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Pain Mechanisms - Physiopedia (physio-pedia.com)
^ Mechanisms for pain

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The most widely accepted and current definition of pain, established by the International Association for the Study of Pain (IASP), is "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." Although several theoretical frameworks have been proposed to explain the physiological basis of pain, not one theory has been able to exclusively incorporate the entirety of all the aspects of pain perception. The four most influential theories of pain perception include Specificity, Intensity, Pattern and Gate Control theories of pain. However, in 1968, Melzack and Casey described pain as multi-dimensional, where the dimensions are not independent, but rather interactive. The dimensions include sensory-discriminative, affective-motivational and cognitive-evaluate components.

Determining the most plausible pain mechanism(s) is crucial during clinical assessments as this can serve as a guide to determine the most appropriate treatment(s) for a patient. Therefore, criteria upon which clinicians may base their decisions for appropriate classifications have been established through an expert consensus-derived list of clinical indicators. The tables below were adapted from Smart et al. (2010) that classified pain mechanisms as 'nociceptive', 'peripheral neuropathic' and 'central' and outlined both subjective and objective clinical indicators for each. Therefore, these tables serve as an adjunct to any current knowledge and provide as an outline that may guide clinical decision-making when determining the most appropriate mechanism(s) of pain.

Furthermore, being cognisant about the factors that may alter pain and pain perception may assist in determining the most appropriate pain mechanism for a patient. The following are risk factors that may alter pain and pain perception:

Biomedical

Psychosocial or Behavioural

Social and Economical

Professional/ Work-related

Nociceptive Pain Mechanism

Nociceptive pain is associated with the activation of peripheral receptive terminals of primary afferent neurons in response to noxious chemical (inflammatory), mechanical or ischemic stimuli.

Clear, proportionate mechanical/anatomical nature to aggravating and easing factors

Pain associated with and in proportion to trauma, or pathological process (inflammatory nociceptive), or movement/postural dysfunction (ischemic nociceptive)

Pain localized to area of injury/dysfunction (with/without some somatic referral)

Usually rapid resolving or resolving in accordance with expected tissue healing/pathology recovery times

Responsive to simply NSAIDs/analgesics

Usually intermittent and sharp with movement/mechanical provocation; may be more constant dull ache or throb at rest

Pain in association with other symptoms of inflammation (i.e., swelling, redness, heat) (inflammatory nociceptive)

Absence of neurological symptoms

Pain of recent onset

Clear diurnal or 24h pattern to symptoms (i.e., morning stiffness)

Absence of or non-significantly associated with mal-adaptive psychosocial factors (i.e., negative emotions, poor self-efficacy)

Clear, consistent and proportionate mechanical/anatomical pattern of pain reproduction on movement/mechanical testing of target tissues

Localized pain on palpation

Absence of or expected/proportionate findings of (primary and/or secondary) hyperalgesia and/or allodynia

Antalgic (i.e., pain relieving) postures/movement patterns

Presence of other cardinal signs of inflammation (swelling, redness, heat)

Absence of neurological signs; negative neurodynamic tests (i.e., SLR, Brachial plexus tension test, Tinel's)

Absence of maladaptive pain behaviour

Peripheral Neuropathic Pain Mechanism

Peripheral neuropathic pain is initiated or caused by a primary lesion or dysfunction in the peripheral nervous system (PNS) and involves numerous pathophysiological mechanisms associated with altered nerve functioning and responsiveness. Mechanisms include hyperexcitability and abnormal impulse generation and mechanical, thermal and chemical sensitivity.

Pain described as burning, shooting, sharp, aching or electric-shock-like

History of nerve injury, pathology or mechanical compromise

Pain in association with other neurological symptoms (i.e., pins and needles, numbness, weakness)

Pain referred in dermatomal or cutaneous distribution

Less responsive to simple NSAIDs/analgesics and/or more responsive to anti-epileptic (i.e., Neurontin, Lyrica) or anti-depressant (i.e., Amitriptyline) medication

Pain of high severity and irritability (i.e., easily provoked, taking longer to settle)

Mechanical pattern to aggravating and easing factors involving activities/postures associated with movement, loading or compression of neural tissue

Pain in association with other dysesthesias (i.e., crawling, electrical, heaviness)

Reports of spontaneous (i.e., stimulus-independent) pain and/or paroxysmal pain (i.e., sudden recurrences and intensification of pain

Latent pain in response to movement/mechanical stresses

Pain worse at night and associated with sleep disturbance

Pain associated with psychological affect (i.e., distress, mood disturbances)

Pain/symptom provocation with mechanical/movement tests (i.e., active/passive, neurodynamic) that move/load/compress neural tissue

Pain/symptom provocation on palpation of relevant neural tissues

Positive neurological findings (including altered reflexes, sensation and muscle power in a dermatomal/myotomal or cutaneous nerve distribution)

Antalgic posturing of the affected limb/body part

Positive findings of hyperalgesia (primary or secondary) and/or allodynia and/or hyperpathia within the distribution of pain

Latent pain in response to movement/mechanical testing

Clinical investigations supportive of a peripheral neuropathic source (i.e., MRI, CT, nerve conduction tests)

Signs of autonomic dysfunction (i.e., trophic changes)

Note: Supportive clinical investigations (i.e., MRI) may not be necessary in order for clinicians to classify pain as predominantly "peripheral neuropathic"

Central Pain Mechanism

Central pain is pain initiated or caused by a primary lesion or dysfunction in the central nervous system (CNS).

Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/non-specific aggravating/easing factors

Pain persisting beyond expected tissue healing/pathology recovery times

Pain disproportionate to nature and extent of injury or pathology

Widespread, non-anatomical distribution of pain

History of failed interventions (medical/surgical/therapeutic)

Strong association with maladaptive psychosocial factors (i.e., negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviours altered by family/work/social life, medical conflict)

Unresponsive to NSAIDs and/or more responsive to anti-epileptic or anti-depressant medication

Reports of spontaneous (i.e., stimulus-independent) pain and/or paroxysmal pain (i.e., sudden recurrences and intensification of pain)

Pain in association with high levels of functional disability

More constant/unremitting pain

Night pain/disturbed sleep

Pain in association with other dysesthesias (i.e., burning, coldness, crawling)

Pain of high severity and irritability (i.e., easily provoked, taking long time to settle)

Latent pain in response to movement/mechanical stresses, ADLs

Pain in association with symptoms of autonomic nervous system dysfunction (skin discolouration, excessive sweating, trophic changes)

History of CNS disorder/lesion (i.e., SCI)

Disproportionate, inconsistent, non-mechanical/non-anatomical pattern of pain provocation in response to movement/mechanical testing

Positive findings of hyperalgesia (primary, secondary) and/or allodynia and/or hyperpathia within distribution of pain

Diffuse/non-anatomic areas of pain/tenderness on palpation

Positive identification of various psychosocial factors (i.e., catastrophisation, fear-avoidance behaviour, distress)

Absence of signs of tissue injury/pathology

Latent pain in response to movement/mechanical testing

Disuse atrophy of muscles

Signs of autonomic nervous system dysfunction (i.e., skin discolouration, sweating)

Antalgic (i.e., pain relieving) postures/movement patterns

The following clinical vignettes are here to supplement the above information and encourage thinking about plausible pain mechanisms.

Case #1: Patient A is a 58-year-old female, retired high school teacher. History of current complaint, approximately 1 month ago, sudden onset of low back pain after starting a season of curling and has been getting worse with walking. Patient A presents with right-sided low back pain (P1) that is a constant dull ache, 7-8/10, and anterior leg pain stopping above the R knee (P2) that is an intermittent ache for ~10-30 minutes rated at 2/10, with an occasional burning pain above the knee. P1 is aggravated by curling with R knee as lead leg, walking >15 minutes, driving >30 minutes and stairs. P2 is aggravated by sitting on hard surfaces >30 minutes and sustained flexion. Coughing and sneezing does not make it worse and P1 is worse at the end of the day. General health is unremarkable. Patient A has had a previous low back injury approximately 10 years ago, underwent treatment and resolved with a good outcome. What is the dominant pain mechanism?

Case #2: Patient B is a 30-year-old male, accountant. History of current complaint is a sudden onset of an inability to turn neck to right and side bend neck to right 2 days ago. On observation, Patient B has head resting in a position of slight L rotation and L side bend. Patient B reports a low level of pain, 2-3/10, only when trying to move head to the R, otherwise movement "is stuck". Patient B denies any numbness, tingling or burning pain and NSAIDs ineffective. Patient B reported heat and gentle massage to ease any symptoms. Objective findings indicate only right PPIVMs and PPAVMs to have decreased range and blocked. All other cervical spine mobilizations are WNL. What is the dominant pain mechanism?

Case #3: Patient C is a 25-year-old female student. History of current complaint is a MVA 40 days ago while going to school. Patient C was hit from behind, braced and braked with R foot, airbag inflated, checked out of the ER then home on bed rest. Since then, Patient C has had 6 visits of physiotherapy with no improvement and neck pain persisting. P1 is left C2-7 and upper trapezius, rated 3-9/10, and pain varies from a dull ache to sharp pain with occasional pins and needles, depending on neck position. P1 is aggravated by sitting and walking > 30 minutes and turning to the left. P1 occasionally disturbs sleep, particularly when rolling over in bed and coughing/sneezing does not increase pain. P1 is sometimes eased by heat and stretching. NSAIDs have no effect. X-ray day of MVA is negative, negative cauda equina, vertebral artery and cord signs. General health is generally good. Minor sprains and strains in sports, but never required treatment and no previous MVA. Patient C voices concern about fear of driving and has not been driving since the accident. Patient C has also reported an increase in sensitization in her lower extremities. What is the dominant pain mechanism?

1. International Association for the Study of Pain. IASP Terminology. Available from: https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698. [Accessed 19 July 2020]

2. Graven-Nielsen, Thomas, and Lars Arendt-Nielsen. "Assessment of mechanisms in localized and widespread musculoskeletal pain." Nature Reviews Rheumatology 6.10 (2010): 599.

3. Smart KM, Blake C, Staines A, Doody C. Clinical indicators of 'nociceptive', 'peripheral neuropathic' and 'central' mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians. Man Ther 2010;15:80-7. (accessed 1 April 2014).

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The most widely accepted and current definition of pain, established by the International Association for the Study of Pain (IASP), is "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."

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Risk factors | Background information | Chronic pain | CKS | NICE

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories.

CKS content is produced by Clarity Informatics Limited. It is available to users outside the UK via subscription from the Prodigy website.

If you believe you are seeing this page in error please contact us.

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories. CKS content is produced by Clarity Informatics Limited. It is available to users outside the UK via subscription from the Prodigy website. If you believe you are seeing this page in error please contact us.

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I used the biochem lecture

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https://www.youtube.com/watch?v=FwiaoKrdzx4

Great video explaining what chronic fatigue syndrome is and the symptoms, diagnosis and treatment.

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https://www.youtube.com/watch?v=EFLPbA1Rrvk

This video explains what fibromyalgia is, the symptoms, treatment and investigation, I highly recommend it

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https://www.intechopen.com/chapters/62969

This link gives the different types of non-pharmacological pain management, including the physical and psychological interventions.

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Open access peer-reviewed chapter

DOI: 10.5772/intechopen.79689

Abstract

Non-pharmacological pain therapy refers to interventions that do not involve the use of medications to treat pain. The goals of non-pharmacological interventions are to decrease fear, distress and anxiety, and to reduce pain and provide patients with a sense of control. When deciding the most effective non-pharmacological technique, take into consideration the patient's age, developmental level, medical history and prior experiences, current degree of pain and/or anticipated pain. The advantage of non-pharmacological treatments is that they are relatively inexpensive and safe.

chapter and author info

Authors

Ahmed El Geziry*

Department of Anaesthesia, ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar

Yasser Toble

Department of Anaesthesia, ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar

Fathi Al Kadhi

Department of Anaesthesia, ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar

Muhammad Pervaiz

Department of Anaesthesia, ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar

Mohammad Al Nobani

Department of Anaesthesia, ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar

*Address all correspondence to: ageziery@hamad.qa

DOI: 10.5772/intechopen.79689

From the Edited Volume

Pain Management in Special Circumstances

Edited by Nabil A. Shallik

1. Introduction

Non-pharmacological therapies are typically categorized into

1. Physical (sensory) interventions

1. Physical (sensory) interventions typically are patient-specific and inhibit nociceptive input and pain perception.

2. Some measures that can reduce pain intensity and improve the patient quality of life such as massage, positioning, hot and cold treatment, transcutaneous electrical nerve stimulation (TENS), acupuncture and progressive muscle relaxation.

2. Psychological interventions

1. Continuous pain may lead to development of maladaptive status and behavior that worsen day to day function, increase distress, or enhancing the experience of pain. Patients suffering pain tend to show increased vulnerability to a variety of psychiatric illnesses, including depressive and anxiety disorders, and posttraumatic stress disorder. In fact, the relationship between depression and pain is likely to be bidirectional, so that the presence of a depressive disorder has been identified as a key risk factor in the transition from acute to chronic pain.

2. Most commonly used psychological interventions are: cognitive behavioral therapy, mindfulness-based stress reduction, acceptance and commitment therapy (ACT), guided imagery and biofeedback.

3. Others

Spirituality and religion in pain management and music therapy.

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2. Physical (sensory) interventions

2.1. Massage

Pain can complicate the patient condition as it can elevate stress, altering posture, and reduce one's ability to participate in daily activity [ 1]. It is the process of rubbing and kneading parts of the body, especially joints and muscles with hands to relieve pain and decrease tension. Massage can interrupt the patient's cycle of distress. It can increase the blood circulation as well as lymphatic circulation. Massage can also initiate an analgesic effect to the area being rubbed and decrease inflammation and edema. Moreover, it can release muscle spasms manually while increasing endogenous endorphin release, and conflicting sensory stimuli that override pain signals [ 2].

The process of rubbing and kneading soft tissues of the body can lead to relaxation of the tense muscles, increase blood flow to the underlying tissues and decrease pain. The exact mechanism of pain reduction in massage is still unknown; however, there are some studies and expert's hypothesis suggest that the process of massage can lead to an increase in dopamine levels which decrease pain. In addition to that, massage can lead to relaxation of the muscles tension that often arise when pain present [ 3].

There are many benefits of massage as it can reduce stress, promote muscle relaxation, lower blood pressure, improve circulation, help improve posture, and strengthen the body immune system. Moreover, there are some studies suggest that massage had been found to decrease pain and anxiety in many of the surgical and nonsurgical patients [ 3].

Massage can be beneficial in cancer patient as it can improve mood and quality of life among patients suffering from cancer. Both the massage and simple-touch groups had statistically, although not clinically, significant improvements in pain and quality of life over time despite no increases in total analgesic medication use [ 4]. In addition to that, there are some short-term benefits of massage which include improve psychological well-being and, in some cases, reduced severity of physical symptoms. Depression and anxiety have shown significantly improve with massage.

2.2. Positioning

Positioning is a physical intervention that includes maintaining a proper body alignment to reduce stress and anxiety, especially in children.

It helps to prevent further complications, reduces the risk for developing injuries, prevents developing bed ulcers and most importantly reduce alleviate pain. Therefore, positioning the patient correctly and re-positioning can help with the above complications [ 5].

Positioning can help with many patients as it can relieve muscle pain, tension and discomfort. It can improve blood circulation which in turn prevents ulcers from developing. Moreover, elevating extremities while positioning can be beneficial in decreasing pain and prevent edema as well.

2.3. Hot and cold

Several studies have shown reduction in pain, anxiety, nausea and heart rate in patients treated with active warming for pain related to mild trauma, cystitis, urolithiasis, cholelithiasis, appendicitis, colitis, and rectal trauma. This is an inexpensive and easy-to-use therapy with minimal side effects when used appropriately. Cold therapy includes applying a cool substance or device to any part of the body. Numerous studies have reported that cold treatment can increase pain threshold, decrease edema, and suppress the inflammatory process. Cold compresses may be used between 15 and 30 min time periods and up to 2-3 times per day.

Hot and cold therapy has been used for many decades and centuries to relieve pain, which includes muscle pain, joints pain, extremities pain, back pain and arthritis. Some studies show evidence that ice and heat therapies are effective and can reduce pain when compared to over the counter meds such as Paracetamol and Ibuprofen.

One study showed that "superficial heat relieves pain in a number of different ways:

1. Heat stimulates the thermo receptors in the skin and deeper tissues. This can help to reduce pain by closing the gating system in the spinal cord.

2. Heat reduces striated muscle spasm by minimizing muscle spindle excitability and reducing tension in muscle trigger points.

3. By warming joints, heat reduces the viscosity of synovial fluid, which alleviates painful stiffness during movement and increase joint range" [ 5].

Although through history hot and cold-water therapy is frequently used in home environment. However, these home therapies can create some complications such as burns and water leak. Nowadays, mostly in hospital setting, they use wheat-based heat packs and electrical heating pads, which are safer and give the maximum effect of analgesics [ 6].

2.4. Acupuncture

This has been used for around 5000 years, and it is considered one of the world's oldest arts of an empiric body healing. Basically, acupuncture works by putting the needle in specific region of the body, which stimulates the nerve. Each needle will cause no discomfort to little discomfort to the patient, but it will produce a small injury at the insertion area which will stimulate the body and the immune system to increase circulation, wound healing, pain modulation and pain analgesia [ 7].

The number and location of the acupuncture used by Chinese ancient times has changed by the science of modern practitioners, and nowadays they are using clinical and physical observation of the patient and the therapeutic effect of the pricking. According to Lewin (1974) "Two therapeutic modes of acupuncture are used in practice today: (1) acupuncture used for the treatment of many diseases and (2) acupuncture employed as an anesthetic procedure (a more accurate term for this would be surgical analgesia)" [ 8].

Acupuncture can be used to treat many conditions and studies claiming that it can be helpful with allergies, anxiety and depression, chronic back, neck, or shoulders pain, hypertension, insomnia, migraines, morning sickness, strokes and menstrual cramps. In addition to that studies suggest that it can be beneficial with cancer and multiple sclerosis patients as well [ 9]. The benefits of acupuncture can go beyond conditions to go far to help with relaxation and pain management as well. Acupuncture can be helpful as an analgesic effect to patients who experience pain as well [ 7].

2.5. Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation (TENS) is an electrical device used to treat pain. It consists of battery-powered unit and has 2-4 leads connected to sticky pads, which are positioned over the skin to cover or surround the painful area.

The TENS unit delivers a low-voltage electrical impulse to the padded surface electrodes in a series of alternating electrical current impulses.

The larger impulses are postulated to activate large myelinated fibers.

Large nerve fiber stimulation is thought to block small pain-transmitting fibers. Some experts also believe that TENS unit activates the release of natural endorphins at the pituitary level by using alternating low-540 frequency pulses.

It is thought that TENS produce analgesia by stimulating large afferent fibers. It can help those patients with chronic back pain, arthritis, and neuropathic pain. In addition, it can help patients with mild to moderate acute pain.

When the TENS unit is turned on, patient feeling a light tingling sensation over the area where the pads are placed.

The signal intensity also known as pulse width (duration of the pulse) produced from the TENS device can be adjusted, the goal being to produce paresthesia without muscle contraction. At initial use, the patient adjusts the settings to find the most comfortable effective sensation [ 10].

TENS is virtually side effect free, and the mechanism includes activation of descending modulation systems and blocking of sympathetic outflow.

The unit can be attached to the patient's belt for ease of use.

TENS should not be used in patients with cardiac pacemakers or a history of cardiac dysrhythmia [ 11].

2.6. Progressive muscle relaxation

Progressive muscle relaxation is a technique where the participant involved tightens and relaxes different muscle groups throughout the body in a progressive manner that would provoke a sense of relaxation and comfort.

There are many indications to the use of PMR, including back pain, phantom limb pain, headache and stress. PMR is a safe technique with minimal if any adverse effects have been reported.

In a double-blinded randomized clinical trial the use of PMR was found to decrease intensity of pain, tenderness of masticatory muscles and maximum opening of mouth with and without pain in patient with myofascial pain dysfunction syndrome [ 12].

Relaxation techniques have shown positive results for patients with chronic neck pain, tension headache, low back pain and chronic pain related to rheumatologic and non-rheumatologic chronic inflammatory disorders [ 13, 14, 15, 16, 17, 18, 19].

The global spine care initiative for communities with low and medium income supports the use of biofeedback and progressive muscle relaxation techniques as an initial therapy for patient without a serious pathology chronic low back pain and neck pain [ 20].

In a randomized controlled trial, it was found that the use of PMR in combination with guided imagery and phantom exercises were useful in reducing phantom limb pain and phantom limb sensation [ 21].

In an interesting study which looked into deploying relaxation techniques over the Internet was found to be effective for patient suffering from chronic headaches. Other trials are ongoing that utilizes phone applications in other conditions like chronic back pain and neck pain [ 14, 22].

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3. Psychological interventions

3.1. Cognitive behavioral therapy

Incorporating the biopsychosocial (BPS) model to pain management by targeting cognitive responses to pain and maladaptive behavioral in addition to social and environmental factors that may play an important role in modifying reactions to pain [ 23]. Such therapy has shown efficacy for many physical disorders and psychiatric illnesses, as well as pain [ 24]. Cognitive behavioral therapy (CBT) helps to develop important set of coping skills intended to improve psychological functioning, including behavioral activation, structured relaxation exercises, recalling and scheduling of pleasurable events, dogmatic assertive communication, and behavior pacing aiming to avoid prolongation and/or exacerbation of flares of pain. CBT for pain also addresses maladaptive thoughts about pain and pain catastrophizing through formal use of cognitive restructuring.

According to recent meta-analytic studies [ 25], CBT for pain demonstrates small-to-medium effect sizes in a variety of domains and shows effects on pain and functioning compared to standard medical care for pain.

3.2. Mindfulness-based stress reduction

This approach aims to disconnect the link between the sensory elements of pain from the emotional and evaluative elements and enhances uncoupled awareness of both somatic and psychological sensations [ 26]. Because the signal of pain usually cannot be distinguished, such detachment may alter the response to pain [ 27].

Using mindfulness-based stress reduction strategies such as awareness and meditation, different ideas and beliefs about pain may be perceived as an unattached event rather than a sign of an underlying matter that requires lineal and possibly maladaptive reactions.

3.3. Acceptance and commitment therapy

This approach implies that thoughts do not basically have to be changed or targeted but the responses to these thoughts may be altered in a way that the resulting negative consequences are ameliorated [ 28]. ACT approaches can augment the sense of well-being via purposeful and nonjudgmental acknowledgment of mental events like emotions and thoughts, facilitating acceptance of such events, and enhancing the capability of the patients to sustain present and be aware of personally relevant environmental and psychological factors. Keeping this in mind, patients might be able to modify their behavior in a way that is in line with their goals and values, instead of keep focusing on immediate relief from their emotions and thoughts [ 27]. While conducting pain management, ACT can boost purposeful awareness and pain acceptance, hence diverting the focus on decreasing pain and its thought content and re-directing efforts trying to achieve favorable fulfilling behavior.

3.4. Biofeedback

Applied psychophysiology or better known as biofeedback is a technique in which the patient receives extra "extrinsic" information that is not based on what the patient feels, and the information should be in real time and biological in nature, that is, the use of real-time ultrasound biofeedback for patient with pelvic floor muscle dysfunction or low back pain, or the use of electromyography (EMG) in real time for patients with musculoskeletal disorders [ 29]. In simple words by Schawarts and Olsen, "psychophysiology involves the scientific study of the interrelation of physiological and cognitive processes" [ 30, 31, 32].

In a randomized clinical trial, it looked into the difference between hypnosis for chronic low back pain and hypnosis with biofeedback techniques, it showed that biofeedback with hypnosis is significantly more effective than hypnosis alone [ 33].

In a meta-analysis by Sielski, he found that biofeedback led to a small to medium effect when it comes to pain intensity reduction in patients with chronic back pain, also it led to reducing depression, disability, muscle tension, and improved cognitive coping in the same patients' groups [ 34]. Biofeedback was also used successfully in patients with juvenile rheumatoid arthritis, in a randomized clinical trial for children aged 8-13, the use of electromyography biofeedback was associated with reduced pain intensity and improved quadriceps strength [ 35].

3.5. Guided imagery

It is a technique in which an experienced practitioner helps a patient provoke a state of mind or mental images in the absence of that stimuli, defined by Bresler and Rossman as a range of techniques from simple visualization and direct imagery-based suggestions through metaphor and storytelling [ 36]. Recently, it has been increasingly explored in different medical settings, like for managing post-operative pain, fibromyalgia, low back pain or musculoskeletal-related pain.

Those images if they are vivid enough, this may elicit a physiological response, through modulations at the level of the autonomic nervous system, such effects would result in changes of the cardiovascular, respiratory, nervous, endocrine and even immune system [ 37]. Many randomized clinical trials have shown significant reduction in pain scores using guided imagery or hypnosis, but there is a lack of rigors high-quality studies, in a systematic review by Posadzki, he found only nine RCT with quality ranged between 1 and 3 on Jadad scale, eight of them suggested significant reduction of musculoskeletal-related pain, while one showed no significant change from the usual standard of care [ 38].

In another systematic review of randomized clinical trial by Posadzki, he found that 11 trails of the 15 included in his analysis showed significant reduction of non-musculoskeletal pain, while 4 trails showed no significant change from standard of care. Although the evidence remains inconclusive but simply looking at the risk to benefit ratio, we can simply conclude that benefits significantly outweigh the risk [ 39].

Many trials have looked into the efficacy of guided imagery and hypnosis in fibromyalgia cases, were they have shown a clinically significant benefit, moreover, a meta-analysis by Zechhave showed that combined therapy of cognitive behavioral therapy and hypnosis is superior to the use of cognitive behavioral therapy alone in patients with fibromyalgia [ 40].

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4. Others

4.1. Spirituality and religion

In the middle ages, pain was considered a religious matter. Pain was seen as God's punishment for sins, or as evidence that an individual was possessed by demons. Spiritual counseling in such situation can be more of a priority than medical treatment [ 41]. Major parts of Hindu believers consider pain as a God punishment or as a result of personal actions. In Islam, it can be vindictive or Allah's willingness. A common Buddhist belief is that suffering is the price of attachment [ 42]. Spiritual and religious beliefs are important in many individuals' lives. However, religious and spirituality are not the same. These beliefs can influence lifestyle, attitudes, and feelings about life, pain, and death. Spiritual and religious beliefs are important in many individuals' lives. However, religious and spirituality are not the same. These beliefs can influence lifestyle, attitudes, and feelings about life, pain, and death. Spiritual beliefs often place a greater significance at the time of illness than any other time in a person's life.

Both religious and spiritual beliefs help some people accept their own illness and help explain illness for others. Religion can supply the client, the family, and health professionals with a sense of strength, security, and faith during a time of need [ 41, 43].

Pain is an extremely complex phenomenon that involves multiple cascades of behavioral responses, thoughts, and emotions. A lot of non-physiologic factors such as psychological, familial and societal attitudes, life stressors, and cultural, spiritual and religious beliefs contribute significantly how the individuals experience and respond to pain. Emotional distress specifically depression and anxiety plays a vital role in pain experience. Numerous studies have demonstrated that individuals having pain perhaps report more severe pain and disability, if they have anxiety, depression or both. Interestingly, it has been found that fear of pain can cause more disability than that has been already caused by pain itself. There is a cyclical pattern of chronic pain leading to depression and depression causing an increase in chronic pain, creating a mutually reinforcing relationship [ 44, 45].

Since pain experienced in the context of biopsychosocial-spiritual system model (BPSSM), it should be understood that individuals' capacities to cope, tolerate, and accept disease and pain entail multiple levels of experience and thought. BPSSM suggests that illness disrupts the biological, interpersonal, and spiritual relationships unique to the individual. The BPSSM recognizes the potential impact of spiritual and religious variables that may increase or decrease experience of illness.

Spiritual interventions may differ depending on culture background. Generally, prayer is one of the most common daily spiritual activities, which can take variety of forms including gratitude, admission and confession, intercessory prayer or silent communion. The ultimate goal is to become more close to and loved one for God. Pain is often referenced in the context of people's relationships with God. God is responsible for wellbeing and health; therefore, spiritual beliefs are considered one of the most effective ways that influence healing. Individuals suffering pain may practice varieties of spiritual and religious activities including prayer and seeking specialized spiritual support, to cope more effectively with their pain [ 46]. Patients with chronic pain with a variety of conditions (e.g., musculoskeletal pain, cancer, or sickle cell) usually report that religiousness and spirituality are important in their lives [ 47].

4.2. Music therapy

Music has been used since ancient times to enhance wellbeing and reduce pain and suffering. Playing music for patients during or after surgery helps reduce pain and use of morphine and other sedatives, anxiolytics, and analgesics [ 48, 49].

Many randomized controlled studies adopting music therapy for subjects undergoing colonoscopy or sigmoidoscopy have found in comparison with the control group, those who listened to music reported a significant lower pain scores, less sedation and shorter examination times [ 50, 51, 52].

During labor, music has been shown to reduce women perceptions of and responses to pain. The same findings have been reported in premature infants as well as other categories of individuals living with chronic pain [ 53, 54]. Women during labor who enjoyed listening to slow soft music experienced less distress attributed to pain and repotted music as a helpful and effective tool in pain control [ 54]. Elderly patients with chronic osteoarthritis who listened to music daily for twenty minutes for couple of weeks reported decreased pain levels as compared to a control group [ 55]. Cancer survivors reported moderate pain relief upon listening to music, and in many cancer centers, music is offered as an adjunctive therapy [ 56, 57].

One study has been designed to evaluate the effects of including music therapy on pain report, nausea, in addition to the time to engraftment for patients undergoing bone marrow transplant. Among such extremely ill individuals, those who received music therapy alongside with relaxation imagery experienced lower pain scales and less nausea. Moreover, they had faster engraftment [ 58].

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5. Conclusion

The role of non-pharmacological approaches to pain management is evolving, and some non-pharmacological and complementary therapies have an increasingly important contribution to make to holistic patient care alongside analgesics.

Generally, these approaches are relatively inexpensive with high safety profile and low side effects.

There is evidence to support the use of patient education, cognitive behavioral therapy (CBT), relaxation, music, and other modalities. These therapies should be taken into consideration to help and support the standard pharmacological treatment in pain management. While medical drugs are essentially being used for treating the somatic (physiological and emotional) dimension of the pain, non-pharmacological therapies aim to treat the cognitive, affective, behavioral and socio-cultural dimensions of the pain.

These therapies can treat the pain as adjuvant or complementary at middle level and severe pain experiences.

Non-pharmacological approaches help to

Increase the individual ability to control feeling.

Reduce the feeling of weakness.

Enhance the functional capacity and activity level.

Reduces anxiety and stress.

Decrease the pain behavior and focused pain level.

Decrease the dosage of analgesic drugs, subsequently decreasing the well-known side effects of these drugs.

For this reason, research on non-pharmacological approaches to pain management is very important, so that patients are provided with information that ensures them the most effective options for treating their pain.

Ahmed El Geziry, Yasser Toble, Fathi Al Kadhi, Muhammad Pervaiz and Mohammad Al Nobani (November 5th 2018). Non-Pharmacological Pain Management, Pain Management in Special Circumstances, Nabil A. Shallik, IntechOpen, DOI: 10.5772/intechopen.79689. Available from:

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Non-pharmacological pain therapy refers to interventions that do not involve the use of medications to treat pain. The goals of non-pharmacological interventions are to decrease fear, distress and anxiety, and to reduce pain and provide patients with a sense of control.

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https://my.clevelandclinic.org/health/diseases/4798-chronic-pain

This link gives a very detailed summary of chronic pain and it's symptoms, investigation and treatment.

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https://www.everydayhealth.com/pain-management/know-your-risk-for-chronic-pain.aspx

This link gives the different risk factors for chronic pain (biological, psychological and lifestyle).

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https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/behavioralchangetheories6.html

https://social-change.co.uk/files/02.09.19_COM-B_and_changing_behaviour_.pdf

These links provide a great explanation of the Transtheoretical (stages of change model) and the COM-B model.

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https://www.britannica.com/science/human-nutrition/Nutrition-throughout-the-life-cycle

This website gives an idea of the different recommended nutrients humans should be consuming at different stages of their life.

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https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/placebo-effect

The link provides information on what a placebo is, why we use it and the effect it has on the body.

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https://www.england.nhs.uk/blog/ed-mitchell-2/

This website explains what the sick role is and the steps needed to be taken by a sick person.

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https://www.youtube.com/watch?v=JxK5rZxbyQY

This video gives a nice overview of carbohydrates.

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I thought the resource from sofia is useful

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Introduction to the Theory of Planned Behaviour - YouTube
^Go to 2:31 for a summary of Theory of planned behaviour as well as it being applied in the example of exercising

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Introduction to the Theory of Planned Behaviour

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Health Belief Model Example - YouTube
^ An example of the Health belief model being applied

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Transtheoretical Model - YouTube
^ Stages of change model with an example

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Non-Pharmacological Pain Management Therapies for Adults - What You Need to Know (drugs.com)

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This material must not be used for commercial purposes, or in any hospital or medical facility. Failure to comply may result in legal action.

WHAT YOU NEED TO KNOW:

What are non-pharmacological therapies for pain?

Non-pharmacological therapies are ways to decrease pain without medicine. Your healthcare provider will help you choose therapies that are right for you. Your provider will explain the advantages for each treatment and which may work best for the cause of your pain. Non-pharmacological therapies may help decrease your pain or give you more control over your pain. This can improve your quality of life.

What are some common therapies to help control pain?

Heat helps decrease pain and muscle spasms. Apply heat to the area for 20 to 30 minutes every 2 hours for as many days as directed.

Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a towel and place it on the area for 15 to 20 minutes every hour, or as directed.

Massage therapy may help relax tight muscles and decrease pain.

Physical therapy teaches you exercises to help improve movement and strength, and to decrease pain.

A transcutaneous electrical nerve stimulation (TENS) unit is a portable, pocket-sized, battery-powered device that attaches to your skin. It is usually placed over the area of pain. It uses mild, safe electrical signals to help control pain.

A spinal cord stimulator (SCS) is an electrode implanted near your spinal cord during a simple procedure. The electrode is connected to a stimulator (a small box). The stimulator sends mild, safe electrical signals to the electrode. The electrical signals help relax the nerves that cause your pain.

What other therapies may help control pain?

Relaxation techniques can help you relax, relieve stress, and decrease pain. Common relaxation techniques include any of the following:

Aromatherapy is a way of using scents to relax, relieve stress, and decrease pain. Aromatherapy uses oils, extracts, or fragrances from flowers, herbs, and trees. They may be inhaled or used during massages, facials, body wraps, and baths.

Deep breathing can help you relax and help decrease your pain. Take a deep breath in and then release it slowly. Do this as many times as needed.

Tense your muscles and then relax them. Start with the muscles in your feet then slowly move up your leg. Then move to the muscles of your middle body, arms, neck and head.

Meditation and yoga may help your mind and body relax. They can also help you have an increased feeling of wellness. Meditation and yoga help you take the focus off your pain.

Guided imagery teaches you to imagine a picture in your mind. You learn to focus on the picture instead of your pain. It may help you learn how to change the way your body senses and responds to pain.

Music may help increase energy levels and improve your mood. It may help reduce pain by triggering your body to release endorphins. These are natural body chemicals that decrease pain. Music may be used with any of the other techniques, such as relaxation and distraction.

Biofeedback helps your body respond differently to the stress of being in pain. Healthcare providers may use a biofeedback machine to help know when your body is relaxed. You will learn what your breathing and heart rate are when you are relaxed. When you are in pain, you practice getting your breathing and heart rate to those levels. This may help you feel more control over your pain.

Self-hypnosis is a way to direct your attention to something other than your pain. For example, you might repeat a positive statement about ignoring the pain or seeing the pain in a positive way.

Acupuncture therapy uses very thin needles to balance energy channels in the body. This is thought to help reduce pain and other symptoms.

Where can I find more information?

National Center for Complementary and Alternative Medicine, NIH
Information Clearinghouse
PO Box 7923
Gaithersburg , MD 20898
Phone: 1- 888 - 6446226
Web Address: http://nccam.nih.gov

When should I call my doctor?

Your pain does not get better, or you have new pain.

You have questions or concerns about your condition or care.

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your healthcare providers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

© Copyright IBM Corporation 2021 Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or IBM Watson Health

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
Medical Disclaimer

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Non-Pharmacological Pain Management Therapies for Adults - What You Need to Know

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This material must not be used for commercial purposes, or in any hospital or medical facility. Failure to comply may result in legal action. Non-pharmacological therapies are ways to decrease pain without medicine. Your healthcare provider will help you choose therapies that are right for you.

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I used the sofia resource

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I only used the lecture

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https://www.clinicalkey.com/student/content/book/3-s2.0-B9780723438656000072#hl0000441

the resource from Sofia, very helpful

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ClinicalKey Student is an interactive education platform that supports students and faculty with tools to develop and assess the medical knowledge of aspiring professionals.

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https://www.clinicalkey.com/student/content/book/3-s2.0-B9780702062988000591#hl0000043

good summary of the models of disability

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https://www.clinicalkey.com/student/content/book/3-s2.0-B9780323755702002010#hl0000020

https://www.clinicalkey.com/student/content/book/3-s2.0-B978032379006200135X#hl0000216

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ClinicalKey Student is an interactive education platform that supports students and faculty with tools to develop and assess the medical knowledge of aspiring professionals.

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I used the crash course rheumatology and orthopaedics book which presented the information nicely

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https://bestpractice.bmj.com/topics/en-gb/694/history-exam#riskFactors
helpful for the risk factors and general overview of chronic pain

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https://www.clinicalkey.com/stuhttps://bestpractice.bmj.com/topics/en-gb/694/history-exam#riskFactors

talking about the mechanisms and details of chronic pain physiologically

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https://www.nice.org.uk/guidance/ng193/chapter/Recommendations

https://bestpractice.bmj.com/topics/en-gb/694

good info on chronic pain

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Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies

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Objectives There is little consensus regarding the burden of pain in the UK. The purpose of this review was to synthesise existing data on the prevalence of various chronic pain phenotypes in order to produce accurate and contemporary national estimates.

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I thought the lecture gave enough information on this LO

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https://www.youtube.com/watch?v=5XEMqDa92RA
Not essential but very a complete and easy to follow video if you want to revise differently. My main resource was the Medical sciences textbook.

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https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html#:~:text=Impairment%20is%20an%20absence%20of,or%20function%20or%20mental%20functioning.
Provides useful, complete & inclusive definitions of disability and impairment.

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Centers for Disease Control and Prevention

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Impairments, Activity Limitations, and Participation Restrictions

What is disability?

A disability is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions).

There are many types of disabilities, such as those that affect a person's:

Although "people with disabilities" sometimes refers to a single population, this is actually a diverse group of people with a wide range of needs. Two people with the same type of disability can be affected in very different ways. Some disabilities may be hidden or not easy to see.

According to the World Health Organization, disability has three dimensions:

1. Impairment in a person's body structure or function, or mental functioning; examples of impairments include loss of a limb, loss of vision or memory loss.

2. Activity limitation, such as difficulty seeing, hearing, walking, or problem solving.

3. Participation restrictions in normal daily activities, such as working, engaging in social and recreational activities, and obtaining health care and preventive services.

Disability can be:

Related to conditions that are present at birth and may affect functions later in life, including cognition (memory, learning, and understanding), mobility (moving around in the environment), vision, hearing, behavior, and other areas. These conditions may be

Associated with developmental conditions that become apparent during childhood (for example, autism spectrum disorder and attention-deficit/hyperactivity disorder or ADHD)

Related to an injury (for example, traumatic brain injury or spinal cord injuryexternal icon ).

Associated with a longstanding condition (for example, diabetes), which can cause a disability such as vision loss, nerve damage, or limb loss.

Progressive (for example, muscular dystrophy), static (for example, limb loss), or intermittent (for example, some forms of multiple sclerosisexternal icon ).

What is impairment?

Impairment is an absence of or significant difference in a person's body structure or function or mental functioning. For example, problems in the structure of the brain can result in difficulty with mental functions, or problems with the structure of the eyes or ears can result in difficulty with the functions of vision or hearing.

Structural impairments are significant problems with an internal or external component of the body. Examples of these include a type of nerve damage that can result in multiple sclerosisexternal icon , or a complete loss of a body component, as when a limb has been amputated.

Functional impairments include the complete or partial loss of function of a body part. Examples of these include pain that doesn't go away or joints that no longer move easily.

What is the difference between activity limitation and participation restriction?

The World Health Organization (WHO) published the International Classification of Functioning, Disability and Health (ICF) in 2001. The ICF provides a standard language for classifying body function and structure, activity, participation levels, and conditions in the world around us that influence health. This description helps to assess the health, functioning, activities, and factors in the environment that either help or create barriers for people to fully participate in society.

According to the ICF:

Activity is the execution of a task or action by an individual.

Participation is a person's involvement in a life situation.

The ICF acknowledges that the distinction between these two categories is somewhat unclear and combines them, although basically, activities take place at a personal level and participation involves engagement in life roles, such as employment, education, or relationships. Activity limitations and participation restrictions have to do with difficulties an individual experiences in performing tasks and engaging in social roles. Activities and participation can be made easier or more difficult as a result of environmental factors, such as technology, support and relationships, services, policies, or the beliefs of others.

The ICF includes the following in the categories of activities and participation:

Learning and applying knowledge

Managing tasks and demands

Mobility (moving and maintaining body positions, handling and moving objects, moving around in the environment, moving around using transportation)

Managing self-care tasks

Managing domestic life

Establishing and managing interpersonal relationships and interactions

Engaging in major life areas (education, employment, managing money or finances)

Engaging in community, social, and civic life

It is very important to improve the conditions in communities by providing accommodations that decrease or eliminate activity limitations and participation restrictions for people with disabilities, so they can participate in the roles and activities of everyday life.

References

1. World Health Organization, International Classification of Functioning, Disability and Health (ICF)external icon . Geneva: 2001, WHO.

2. US Department of Health and Human Services. The Surgeon General's Call to Action to Improve the Health and Wellness of Persons with Disabilitiesexternal icon . Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2005.

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A disability is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions).

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https://www.youtube.com/watch?v=z16vhtjWKL0
Great video suggested by one of the lecturers. Answers this LO through example of quitting smoking. (12mins long) Would recommend watching to get isight on how to concretely tackle psychological factors.

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What is the Single Best Thing You Can Do to Quit Smoking?

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Also used the Medical Sciences textbook.

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I used just the lectures however this slide was useful to me because it shows clearly how the pathological and the psychological come together when someone experiences pain and it highlights the fact that nociception is only a small part of when we feel 'pain'. therefore I found that this is important to remember as pain is almost entirely subjective.

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I enjoyed the lecture and this slide stuck with me because I feel that it highlights some important points about Talcott's theory.

https://kar.kent.ac.uk/62743/55/Talcott%20Parsons%20and%20the%20theory%20of%20the%20%27Sick%20Role%27%202004.pdf

I also used this link and pages 3-6 were very easy to follow and basically covered this entire LO

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this (blurry) image is a very nice visual way of remembering the 3rd model of disability- 'integrating across model'/'ICF-international classification of functioning model'

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https://www.science.org/content/article/why-do-placebos-work-scientists-identify-key-brain-pathway

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© 2021 American Association for the Advancement of Science. All rights reserved. AAAS is a partner of HINARI, AGORA, OARE, CHORUS, CLOCKSS, CrossRef and COUNTER.

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https://www.jneurosci.org/content/41/47/9794

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Brainstem Mechanisms of Pain Modulation: A within-Subjects 7T fMRI Study of Placebo Analgesic and Nocebo Hyperalgesic Responses

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Pain perception can be powerfully influenced by an individual's expectations and beliefs. Although the cortical circuitry responsible for pain modulation has been thoroughly investigated, the brainstem pathways involved in the modulatory phenomena of placebo analgesia and nocebo hyperalgesia remain to be directly addressed.

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This is the endorphin one, scroll down to the case study

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This is the endorphin one, scroll down to the case study

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https://www.clinicalkey.com/student/content/book/3-s2.0-B9780702062988000451#hl0000103

# data[].attributes.attachment_link.description
ClinicalKey Student is an interactive education platform that supports students and faculty with tools to develop and assess the medical knowledge of aspiring professionals.