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Treatment of pain

Management of pain is very important on both patients perspective and economicperspective. Pain is the most important reason people seek medical attention. About80% of the doctor visits are primarily because of some pain problem. An appropriate painmanagement protocol should be made while treating patients who seek medical attention forpain.

An extensive pain protocol plan includes a pain management care path flow chart, a painassessment tool, an opioid Reference Table, an analgesics table, side effects managementsheet, and a non-pharmacologic interventions for psychosocial, spiritual & physical pain flowchart.

The pain therapy depends on the type of pain. As mentioned earlier, for clinical purposepain is divided in to two types neuropathic pain and nociceptive pain. The drugseffective for ain control are different in these two t es of ain.

TREATMENT OF PAIN

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The pain medicines used are categorized in to the following types:

Non steroidal anti-inflammatory drugs

Alpha 2 adrenergic drugs

Steroids

Drugs like antidepressants, muscle relaxant and sleepingpills

Drugs for neuropathic pain treatment

These are some of the commonly used drugs for pain relief.These are mainly effective for nociceptive pa in. Some of thecommonly used drugs are acetaminophen, ibuprofen, naproxen,diclofenac and salicylates.

Some of the side effects of these drugs are, gastritis,worsening of asthma and kidney damage if taken for a longertime. The newer COX 2 inhibitors like valdecoxib androfecoxib have less side effects.

Opioids are effective pain relievers for all types of painincluding neuropathic pain.Morphine is the original drug ofthis class. The other drugs include codeine, fentanyl,meperidine, pentazoc ine and propoxyphene.

Some of the side effects include addiction, respiratory depression and constipation.

These drugs were initially used to hypertension. But these drugs also have sedativeproperties and have been used to treat pain and anxiety. Some of the drugs of this class areclonidine and tizanidine. These drugs can cause fatigue and dry mouth.

Steroids are very potent anti inflammatory drugs and have widespread use inmedicine for bot h anti inflammatory and their pain relieving effec ts. In pain management theyare most commonly take by mouth to relieve the pain of arthritis and by injection along withlocal anesthetics in arthritic joints and in the spinal canal to relive back pain.

Steroids should be used very judiciously. In high doses given for more than a few days,they can have various adverse effects including diabetes, osteoporosis and other damage tobones like avascular necrosis to the femoral head.

As said earlier opioids are effective for neuropathic pain relief. Neuropathic pain was untilrecently believed to be resistant to this class of analgesics.

The conventional treatment consists of drugs like anticonvulsants, local anesthetics,neuroleptics, topical analgesics, menthol, and NMDA antagonists.

These were initially meant to treat seizures. But now they are being used for chronicpain management especially neuropathic pain. Some of the anticonvulsants used arecarbamazepine, clonazepam, valproate, phenytoin, gabapent in, topiramate and lamotrigine.

Local anesthetics given by mouth are useful for neuropathic pain. The most commonlyused one is mexiletine which was ori inall used for heart rh thm abnormalities. Other dru s

Pain killers:

Non steroidal anti inflammatory drugs:

Opioids:

Alpha 2 adrenergic drugs:

Steroids:

Drugs for neuropathic pain treatment:

Anticonvulsants

Local anesthetics

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used are tocainide and flecanide.

Neuroleptics- Neuroleptics are drugs tradionally used for psychotic illnesses. Two drugs ofthis class olanzapine and resperidone are found useful to treat chronic pain.

These includes drugs like menthol, lidocaine, EMLA cream and capsaicin. Brand name ofgood topical analgesic is CryoDerm.

NMDA receptors worsen pain. NMDA receptor antagonists therefore can relieveneuropathic pain. Some of the drugs of this class are methadone, dextromethorphan andketamine.

Pain is so often associated with depression that it is sometimes is unclear which camefirst. Regardless treating depression not only elevates mood but also improves the physicalfunctioning.

Some of the drugs of this class include tricyclic antidepressants like amitryptyline,selective serotonin reuptake inhibitors like fluoxetine.

Muscle relaxants are prescribed for pain stiffness and muscle spasm. They also havemild sedative properties.

Some of the drugs of this class are carisoprodol, methocarbomol and diazepam.

There are also natural muscle relaxants such as valerian and passiflora, as foundin Formula 303.

Topical analgesics

NMDA antagonists

Antidepressants:

Sleeping pills and muscle relaxants:

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Types of pain

1. Acute pain

2. Chronic pain

Acute painis pain of sudden onset, lasting for hours to days and disappears once theunderlying cause is treated. Acute pain has a clear cause. It could result from any illness,trauma, surgery or any painful medical procedures. Hence it is beneficial to the patientbecause but for the pain, the individual will ignore his illness resulting in complications andeven death.

Acute pain signals that there is something wrong and motivates the person to get help.For example- just because the nociception is caused by appendicitis, the person consults adoctor and undergoes surgery to get relieved. If pain is not there he will not seek medicaladvice and his appendix may burst and form a mass which is more difficult to treat. Thusacute pain can be beneficial.

PAIN IS DIVIDED INTO TWO TYPES:

Examples of acute pain include:

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the pain of heart attack

acute appendicitis

bone fracture

muscle sprain

prolapsed intervertebral disc of the spine

Chronic pain is thepain that starts as an acute pain and continues beyond thenormal time expectedfor resolution of the problem or persists or recurs for various otherreasons It is not therapeutically beneficial to the patient.

In acute pain, attention is focused to treat the cause of pain whereas in chronic pain,the emphasis is laid upon reducing the pain to give relief, limit disability and improvefunction.

About 9% of the US population and 18% of the European population suffer fromchronic pain. It is rarely accompanied by signs of sympathetic nervous system arousal. Theseverity and extent of chronic pain may be out of proportion to the original injury and maycontinue long past the period in which the damage tissue has healed. Chronic pain is painthat has outlived its usefulness and is no longer beneficial.

Acute and chronic pains have different treatment goals. The primary goal of acute paintreatment is to diagnose the source and remove it.

With chronic pain, the main goals are to minimize the pain and maximize thepersons functioning. Complete relief of pain is rare in chronic pain. The more realistic goalis to decrease the level of pain to a tolerable level that allows the person focus on everydayactivities.

The treatment of chronic pain is multidisciplinary that blendsphysical, emotional,intellectual and social skills. Returning to work is clearly a desirable goal, but in fact, only

50% percent of patients who undergo comprehensive multidisciplinary painrehabilitation are able to return to work.

1. Nociceptive pain

2. Neuropathic pain

Nociceptive pain is pain arising from damage to tissues other than nerve fibers. It isalso called tissue pain. The undamaged nerve cells called nociceptors carry the sensation tospinal cord from where it is relayed to the brain. It is called somatic pain if it results frominjury to muscles, tendons and ligaments. Somatic pain is usually well localized.

It is called visceral pain if it results from injury to the internal organs like stomach, gallbladder and urinary bladder. Visc eral pain is usually diffuse and non-localizing.

Somatic pain in turn is classified in to cutaneous somatic pain if the pain arises from theskin and deep somatic pain if it is from deeper musculoskeletal tissues. The various causes of

joint pain are grouped under musculoskeletal pain.

Neuropathic pain is thepain caused by t he lesion in the nervous syst emwhen they arestructurally or functionally damaged. It is called central pain if the lesion is the centralnervous system. It is called peripheral neuropathic pain if the lesion is in the peripheralnervous system. The neuropathic pain is described as severe, sharp, lancinating, lightning-like, st abbing, burning, cold, numbness, tingling or weakness. It may be felt traveling alongthe nerve path from the spine down to the arms/hands or legs/feet. It does not respond tothe routine analgesics.

Kee in mind that nocice tive and neuro athic ain can co-exist in the same atient in

Acute & Chronic Pain Treatment Goals

Chronic pain is further divided into:

Nociceptive pain:

Neuropathic Pain:

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certain conditions like Sciatica.

Many other types of pain are also described.

Malignant pain

Breakthrough pain

Allodynia

Hyperalgesia

Paresthesia

Hyperpathia

Complex Regional Pain Syndrome I

Complex Regional Pain Syndrome II

Phantom limb pain

Psychogenic pain

Anesthesia dolorosa

Anginal pain

Idiopathic pain

Malignant pain is the pain suffered by the patients with cancer. The pain can be eitherdue to the disease itself or due to the treatment given for cancer like surgery, radiotherapyand chemotherapy.

When pre-existing chronic pain is aggravated, it results in breakthrough pain needingadjustments in treatment to obtain relief. In other words,breakthrough pain is the pain

that results from the worsening of the previously present chronic pain for which the personis on regular treatment. It usually comes on quickly and may last from a few minutes to anhour. The reason for this worsening of pain cannot be understood or anticipated by theperson. The routine doses of analgesic never help and a readjustment of the analgesic dosesis necessary along with the modification of the physical activities.

Allodynia is a pain that results from the stimulus which does not normally evoke any painsensation. Many people aquire allodynia after they've been in pain for quite some time andthey become hypersensitive to touch.

Hyperalgesia is an increased response to a st imulus which is normally painful.

Paresthesia is abnormal sensation which is described as pins and needles. It can occur

either spontaneously or evoked by certain stimuli.

Hyperpathia is a painful syndrome resulting f rom an abnormally painful react ion to astimulus. The stimulus in most of the cases is repetitive with an increased pain threshold.Pain threshold can be defined as the least experience of pain which a subject can recognize.

Complex Regional Pain syndrome I also c alled as Reflex Sympathetic Dystrophy is acontinuous pain in the form of either allodynia or hyperalgesia in the extremities resultingfrom trauma which is associated with sympathetic hyperactivity. The pain does notcorrespond to the distribution of a single nerve and it is worsened by movement. The personaffected usually complains of cool, clammy skin which later becomes pale, cold, stiff andatrophied.

Malignant pain:

Breakthrough pain:

Allodynia:

Hyperalgesia:

Paresthesia:

Hyperpathia:

Complex Regional Pain Syndrome I:

Complex Regional Pain Syndrome II:

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Complex Regional Pain Syndrome II also called as Causalgia is a burning type of pain alongthe distribution a partially damaged peripheral nerve. The pain extends beyond thedistribution of the nerve. This results from abnormal connections between various nerves.The skin of the person affected is classically cold, moist and swollen, becoming atrophiclater.

Phantom limb pain is the pain that is felt in the amputated part of the body. The brainmisinterprets t he nerve signals as c oming from the amputated limb. The phantom limb pain isdescribed as squeezing, burning, or crushing sensations, but it often differs from anysensation previously experienced.

Psychogenic pain is seen in persons with psychological disorders. They have persistent

pain without any evidence of physical cause of pain. Though it is termed psychogenic theperson suffers f rom real pain. This pain is also called chronic pain syndrome. Sometimespsychogenic factors may worsen a pre-existing physical pain.

Anesthesia dolorosa is the pain that is felt in the part of the body that is numb to anyother sensation.

Anginal pain is the pain of cardiac origin. It is described as a feeling of oppression ortightness. It occurs due to disruption of the blood supply to the heart muscle.

When a reasonable cause for the pain cannot be made out, it is called idiopathic pain.

Phantom limb pain:

Psychogenic pain:

Anesthesia dolorosa:

Anginal pain:

Idiopathic pain:


Pain: definition, theories..

There a re numerous different definitions for pain. The most widely accepted definitionof pain is the one used by The International Association for the Study of Pain. It defines

pain as An unpleasant sensory and emotional experience arising from actual or potentialtissue damage or described in terms of such damage.

The American Academy of Pain Medicine defines pain as An unpleasant sensationand emotional response t o that sensation.

Pain has the dubious distinction of being the commonest symptom for which a personapproaches medical care.

The definition of pain that is most appropriate for use in clinical practice was given byMargo McCaffrey in 1968. He defined pain as whatever t he experiencing person says it is,existing whenever he says it does."

The Web version of the Encyclopedia Britannica defines pain as A complexexperience consisting of a physiological (bodily) response to a noxious stimulus followed byan affect ive (emotional) response to that event. Pain is a warning mechanism that helps torotect an or anism b influencin it to withdraw from harmful stimuli. It is rimaril

VARIOUS DEFINITIONS OF PAIN

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Pain: definition, theories..

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associated with injury or the t hreat of injury, to bodily tissues.

Dr. Don Ranney, in his book Anatomy of Pain defines pain as A perception, notreally a sensation, in the same way that vision and hearing are. It involves sensitivity tochemical changes in the t issues and then interpretat ion that such changes are harmful.This perception is real, whether or not harm has occurred or is occurring. Cognition isinvolved in the formulation of t his perception. There are emot ional consequences andbehavioral responses to the cognitive and emotional aspects of pain.

Dr. Pennal, in his book Personality of Pain defines pain as An abstract conceptwhich refers to:

A personal, private, sensation of hurt

A harmful stimulus which signals current orimpending tissue damage

A pattern of responses which operate to protect theorganism from harm

Theories of Pain

Specificity theory.Von Frey (1895) argued that the body has a separate sensory system for

perceiving painjust as it does for hearing and visionand this system contains its own special

receptors for de:ecting pain stimuli, its own peripheral nerves and pathway to the brain, and its

own area of the brain for processing pain signals. But this structure is not correct.

Pattern theory. Goldschneider (1920) proposed that there is no separate system for perceiving

pain, and the receptors for pain are shared with other senses, such as of touch. According to

this view, people feel pain when certain patterns of neural ctivity occur, such as when

appropriate types of activity reach excessively high levels in the brain. These patterns occuronly with intense stimulation. Because strong and mild stimuli of the same sense modality

produce different patterns of neural activity, being hit hard feels painful, but being caressed

does not.

Gate Control Theory.Melzack has proposed a theory of pain that has stimulated considerable

interest and debate and has certainly been a vasy improvement on the early theories of pain.

According to his theory, pain stimulation is carried by small, slow fibers that enter the dorsal

horn of the spinal cord; then other cells transmit the impulses from the spinal cord up to the

brain. These fibers are called T-cells. The T-c ells can be located in a specific area of the spinal

cord, known as the substantial gelatinosa. These fibers can have an impact on the smaller

fibers that carry the pain stimulation. In some cases they can inhibit the communication of

stimulation, while in other cases they can allow stimulation to be communicated into the central

nervous syst em. For example, large fibers can prohibit the impulses from the small fibers from

ever communicating with the brain. In this way, the large fibers create a hypothetical "gate"

that c an open or close the system to pain stimulation. According to the t heory, the gate can

sometimes be overwhelmed by a large number of small activated fibers. In other words, the

greater the level of pain stimulation, the less adequate the gate in blocking the communication

of t his information.

There are 3 factors which influence the 'opening and closing' of the gate -

1. The amount of activity in the pain fibers. Act ivity in these fibers tends to open the gate.

The stronger the noxious stimulation, the more active the pain fibers.

2. The amount of activity in other peripheral fibersthat is, those fibers that carry

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information about harmless st imuli or mild irritation, such as touching, rubbing, or lightly

scratching the skin. These are large-diameter fibers called A-beta fibers. Activity in A-

beta fibers tends to close the gate, inhibiting the perception of pain when noxious

stimulation exists. This would explain why gently massaging or applying heat to sore

muscles decreases the pain.

3. Messages that desc end from the brain. Neurons in the brainstem and cortex have

efferent pathways to the spinal cord, and the impulses they send can open or close the

gate. The ef fects of some brain processes, such as those inanxiety or excitement,

probably have a general impact, opening or closing the gate for all inputs from any areas

of the body. But the impact of other brain processes may be very specific, applying to

only some inputs from certain parts of the body. The idea that brain impulses influencethe gating mechanism helps to explain why peopie who are hypnotized or distracted by

competing environmental st imuli may not notice the pain of an injury.

Thus we can conclude that our experience of pain is dependent on the condition of 'the gate'.

The more the gate is opened the greater the perception of pain. Melzack suggests that several

factors can open the gate:

Physical factors, such as injury or activation of the large fibres

Emotional factors, such as anxiety, worry, tension and depression;

Behvioural factors, such as focusing on the pain or boredom.

The gate control theory also suggests that c ertain factors close the gate.

Physical factors, such as medication, stimulation of the small fibres;

Emotional fac tors, such as happiness, optimism or relaxation;

Behavioural factors, such as concentration, distraction or involvement in other

activities.


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Shree Sai Dental Clinic

Shivam road, Tilak nagar x roads, opposite to Baby S tore .Hyderabad, Andhra Pradesh 50004408125 360807dentalstrings.comWrite a review

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Dry socket

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download Shillingburg Fundamentals of tooth preparation .pdf

Shilling burg Fundame ntals of tooth preparation .pdf 40.62 Mb

Adult Permanen t Teeth Comi ng In Behind Baby Teeth: Shark Teeth

Many parents become alarmed when they look in their child's mouth and see the permanent teeth growing behindthe baby teeth. What went...

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LUDWIGS ANGINA DEFINITION It is defined as the acute toxic swelling with bilateral involvement ofthe sublingual,submandibular,a...

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surrounding the cervical portion of the tee...

Fordyces Granules

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MOUTHWASHES

A mouthwas h is a solu tion which is us ed to rinse away food particles and plaque from the teeth. It is used afterbrushing the teeth and ...

Impression materials

IMPRESSION Definition : It is the neg ative replica of the s tructures of the oral cavity be it hard(tooth) or soft(gingiva,mucous m e...

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