Abstracts
B vitamins & Pain
A B vitamin mixture was injected into rats to see the effects on electrical brain activity after repeated daily injections. After 1 week of injections there were changes in the power spectra. Particularly there were increases in alpha 1 and beta range from the thalamus.
The pharmacodynamic actions of the vitamin B mixture influence the serotonergic transmitter system. A single dose of .2 mg/kg of morphine prior to the vitamin treatment resulted in a response more sensitive than that with the vitamins alone. Power changes in the beta range were specifically noted.
Results suggest vitamin B mixtures may be valuable in the reduction of the morphine dose for analgesia with repeated injections.
"Influence of Repeated Vitamin B Administration on the Frequency Pattern Analyzed From Rat Brain Electrical Activity (Tele-Stereo-EEG)", Dimpfel, W., et al, Klin. Wochenschr., 1990;68:138-141.
Abdominal Pain
Nontraumatic abdominal pain is a common complaint of adult patients in acute care settings. The causes of abdominal pain are numerous and can be benign or life threatening.
The advanced practice nurse must be able to differentiate abdominal pain from acute and nonacute sources so that rapid and effective treatment can be implemented.
Kelso LA & Kugelmas M: Nontraumatic abdominal pain. AACN Clin Issues, 1997 Aug, 8:3, 437-48.
Acute Pain
Reviewed the topics presented in the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline for Acute Pain Management.
Inadequate acute pain management continues to be recognized as a problem due to limited health professional education on the treatment of pain, inadequate patient empowerment, negative connotations associated with opioid analgesics (e.g., fear of "addiction"), federal regulations associated with prescribing opioid analgesics, and difficulty in assessing pain.
The widespread inadequacy in pain management prompted the development of the Guideline (1992).
Overall, this guideline is a worthwhile general resource to clinicians. It is important, however, for clinicians managing acute pain issues to supplement this guideline with more detailed and current information.
Follin SL & Charland SL: Acute pain management: operative or medical procedures and trauma. Ann Pharmacother, 1997 Sep, 31:9, 1068-76.
Behavior & Pain
Behavioral manifestations of pain
Behavioral manifestations of pain, distress, and suffering have been characterized as pain behaviors. Although acquisition and maintenance of pain behaviors have been considered to occur through reinforcement contingencies, empirical evidence suggests that pain behavior is better understood as a multidimensional entity.
Evaluated the contributions of physical, operant, cognitive, and affective factors to individual differences in pain behaviors.
Analyses revealed that the physical, cognitive, and affective factors, but not operant factors, were significantly related to observed pain behaviors. The set of all factors accounted for 53% of the variance in observed pain behavior.
Results suggest that pain behaviors should be conceptualized as behavioral manifestation of pain based on a complex interaction of various psychological and physical factors.
Turk DC & Okifuji A: Evaluating the role of physical, operant, cognitive, and affective factors in the pain behaviors of chronic pain patients. Behav Modif, 1997 Jul, 21:3, 259-80.
Research & Pain
Contents:
Bias
Biobehavioral research
Bias
Past research has shown response biases to influence the accuracy of results from self-report measures. In pain assessment, where a percentage of patients have financial and other reasons to minimize, or exaggerate, psychological disturbance, it becomes especially important to identify the influence of response bias in self-report of adjustment.
Investigated the susceptibility of three commonly used self-report pain assessment measures to response bias. [Coping Strategies Questionnaire, Multidimensional Pain Inventory, and Pain Beliefs and Perceptions Inventory.]
With few exceptions, asymptomatic subjects scored significantly differently on these measures while portraying themselves as either coping well, or coping poorly. In addition, when using the "coping poorly" response set, asymptomatic subjects reproduced scores similar to those of symptomatic chronic pain patients.
The susceptibility to manipulation appeared constant across the three measures, a finding that highlighted the difficulties clinicians and researchers encounter in accurate interpretation of results from these measures in the absence of validity indicators.
Subjects with sufficient motivation can present themselves in an untruthful and manipulative manner and generate scores that are, on their own, difficult to distinguish from those of a group of typical chronic pain patients.
Robinson ME et al., Bias effects in three common self-report pain assessment measures. Clin J Pain, 1997 Mar, 13:1, 74-81.
Biobehavioral research
In 1994 ten NIH institutes sponsored an interagency workshop focusing on biobehavioral pain research.
The workshop had three major goals:
(1) to review the current status of biobehavioral pain research
(2) to identify critical research needs, and
(3) to enhance interdisciplinary and interagency cooperation in pain research.
The presentations at this meeting and some of the key research recommendations are reviewed.
Research topics addressed include:
(a) understanding critical interfaces between biology and behavior;
(b) pain, suffering, and emotion;
(c) pain and behavior;
(d) behavior-related interventions;
(e) commonalities and differences in pain expression, experience, and treatment; and
(f) pain in special populations.
Keefe FJ et al., Biobehavioral pain research: a multi-institute assessment of cross-cutting issues and research needs. Clin J Pain, 1997 Jun, 13:2, 91-103.
Risk factors for Pain
Potential risk factors for Chronic Pain
Explored the role of potential risk factors in predicting the development of chronic pain.
Patients who developed chronic pain reported a higher pain intensity, higher anxiety and distress, less certainty that their pain would resolve, longer hospitalization, less independence in ambulation, a diagnosis of trauma, and less need for surgery.
Recognition of these factors could lead to early identification of those individuals with acute pain who are at risk for developing chronic pain.
White C et al., Predictors of the development of chronic pain. Res Nurs Health, 1997 Aug, 20:4, 309-18.
Walking & Pain relief
Evaluated a practical exercise program for elderly people with chronic musculo-skeletal pain.
Subjects (# 33, mean age, 73 years; 69% back pain; 24% knee pain; 9% hip pain) were randomly assigned to one of three groups.
Group 1 received 6-week supervised program of walking.
Group 2 received a pain education program that included instruction and demonstration of use of heat, cold, massage, relaxation and distraction.
Group 3 received usual care.
Attendance was 100% for the education sessions and 93% for walking sessions. No injuries were sustained. Both intervention groups demonstrated significant improvements in pain and performance-based measures of functional status, while the control group had no changes.
Data suggest that patient education and fitness walking can improve overall pain management and related functional limitations among elderly people with chronic musculo-skeletal pain.
Ferrell BA et al., A randomized trial of walking versus physical methods for chronic pain management. Aging (Milano), 1997 Feb-Apr, 9:1-2, 99-105.
Vibration & Pain
Spatial summation of thermal pain crosses dermatomal boundaries.
Examined whether a vibrational stimulus applied to adjacent, or remote, dermatomes affects thermal pain perception to the volar forearm.
Contact heat at 2 degrees C above thermal pain threshold was applied, and a Visual Analog Scale (VAS) was used for pain assessment.
There was a significant decrease in mean VAS rating when simultaneous vibratory stimuli were given to the dermatome adjacent to that receiving thermal stimulation, or to the same dermatome on the contralateral side.
There was no change in VAS rating when vibration was given two or more dermatomes away. Vibration within the same dermatome also did not yield a significant change in VAS rating, possibly due to difficulty in magnitude assessment of stimuli given simultaneously within a single dermatome. This may allow for more flexible design of stimulation therapy for pain.
Yarnitsky D et al., Vibration reduces thermal pain in adjacent dermatomes. Pain, 1997 Jan, 69:1-2, 75-7.
Terminally ill
Terminally ill - Cancer
Determined the frequency of symptoms of hunger and thirst in a group of terminally ill patients and whether these symptoms could be palliated without forced feeding, forced hydration, or parenteral alimentation.
Of the 32 patients monitored during the 12 months of study, 20 patients (63%) never experienced any hunger, while 11 patients (34%) had symptoms only initially. Similarly, 20 patients (62%) experienced either no thirst, or thirst only initially, during their terminal illness.
In all patients, symptoms of hunger, thirst, and dry mouth could be alleviated, usually with small amounts of food, fluids, and/or by the application of ice chips and lubrication to the lips. Comfort care included use of narcotics for relief of pain, or shortness of breath in 94% of patients.
McCann RM et al., Comfort care for terminally ill patients. The appropriate use of nutrition and hydration [see comments]. JAMA, 1994 Oct 26, 272:16, 1263-6.
Non-drug approaches
Pain is a complex process, in part because it is mediated by so many different variables. However, because pain is the primary reason for seeking medical treatment and often a barrier to compliance, therapists treating painful disorders, or injuries, need to be familiar with those factors that influence pain perception and treatment approaches.
How individuals perceive pain, and hence how clinicians treat it, depends upon a wide variety of psychosocial factors, including mood, age, gender, expectations, social support, and perceptions of control.
Even the manner with which therapists interact with patients can minimize the pain experience and ultimately impact compliance and recovery rates.
Outlined how psychologic variables impact pain experiences. In addition, reviewed a number of nonpharmacologic techniques and approaches (i.e., distraction, imagery, relaxation, biofeedback) that are available for assisting patients in dealing with pain.
DePalma MT & Weisse CS: Psychological influences on pain perception and non-pharmacologic approaches to the treatment of pain. J Hand Ther, 1997 Apr-Jun, 10:2, 183-91.
Cancer & Pain
Cancer
Nutritional care of cancer patients should always be considered supportive, whether the oncologic aim is cure or palliation.
The goals of nutritional care are:
· to support nutritional status,
· body composition, functional status, and
· quality of life.
Proactive nutritional assessment and early intervention are the cornerstones of success.
Failure to address nutrition is associated with:
· longer hospital stays,
· increased risk of complication and death, and
· higher health care costs.
Supportive nutritional intervention mandates standardized, cost-efficient assessment and aggressive symptom management. The latter includes nutrition-impact symptoms along the entire gastrointestinal tract, sensory changes, psychologic distress, pain, and anorexia.
Components of pharmacologic and behavioral intervention are discussed in the context of supportive nutrition of the patient with cancer.
Ottery FD: Supportive nutrition to prevent cachexia and improve quality of life. Semin Oncol, 1995 Apr, 22:2 Suppl 3, 98-111.
Children & Pain
Contents:
Children - Iceland
Children & injections
Children - pain memory
Children - Iceland
The prevalence of pain combinations among school children is addressed in view of earlier findings of high pain prevalence in this population.
Considered the prevalence of combinations of 3 common pains: headache, stomach pain and back pain.
There is a 78% prevalence of monthly pain. One or more instances of weekly pain is experienced by 40% of the children, and 16% experience two or three pains weekly.
Relevance of gender is greater when dealing with combinations of monthly than weekly pain. Combinations of weekly pains are more gender related than single weekly pains. Girls have significantly more frequent overall pain than boys. The distribution of pain combinations varies by age but not overall pain.
Kristjansdottir G: Prevalence of pain combinations and overall pain: a study of headache, stomach pain and back pain among school-children. Scand J Soc Med, 1997 Mar, 25:1, 58-63.
Children & injections
Compared the utility of the Faces Pain Scale (Bieri et al., 1990) with 3 alternative self-report measures of pain intensity in children, as well as with pain ratings based on observations of the child's behavior.
[Faces Pain Scale; Poker Chip Tool; Visual Analogue Toy; Verbal Rating Scale.]
The Faces Pain Scale was simple to use, readily understood by the children, and showed a realistic distribution of scores with respect to the type of pain being measured. With the exception of verbal reactions (which were not meaningfully related to self-report), observer ratings based on detailed coding of the child's behavior correlated only poorly to moderately well with self-report scores.
Similarly, although confident in their judgments, the nurses' ratings showed only moderate agreement with those of the children.
In estimating the child's pain, all observers appeared to appropriately weigh changes in the child's facial behavior, which showed evidence of being the most sensitive behavioral index to the intensity of short sharp (needle) pain in 4 to 6 years olds.
Goodenough B et al., Pain in 4- to 6-year-old children receiving intramuscular injections: a comparison of the Faces Pain Scale with other self-report and behavioral measures. Clin J Pain, 1997 Mar, 13:1, 60-73.
Children - pain memory
Despite its importance in clinical practice, little research has examined memory for pain in children.
(a) Investigated the accuracy of children's recall of their worst and average pain intensity when controlling for the effects of repeated pain measurement and
(b) Examined the influence of children's anxiety, age, general memory ability and pain coping strategies on this accuracy.
[Bieri's Faces Pain Scale.]
The accuracy of children's recalled pain intensities was high and showed little decrement over 1 week. Older children had more accurate recall of their worst pain intensity. Anxiety, general memory ability and pain coping strategies were not related to accuracy of recalled pain intensities.
Zonneveld LN et al., Accuracy of children's pain memories. Pain, 1997 Jul, 71:3, 297-302.
Capsicum for Pain
High-Dose Capsaicin
In 10 patients with peripheral neuropathy who coated their lower legs and feet with a cream containing 7.5%-10% capsaicin over the course of several weeks, there was a greater than 50% pain relief reported in 6 of the patients whose pain was associated with diabetes mellitus, postherpetic neuralgia, HIV infection, or complex regional pain syndrome. The patients received epidural anesthesia during the 3-hour application of the cream which causes an acute burning sensation.
Nidecker, Anna: High-Dose Capsaicin Eases Neuropathic Pain, Family Practice News, January 15, 1998;11.
Capsicum (1)
The spice Capsicum is the fruit of the cultivated species of the genus Capsicum (family, Solanaceae), C. annuum principally, and C. frutescens L. to a lesser extent.
Part IV reviews the significant preference of the spice for initially evoking an aversive response, its potent physiological and pharmacological effects, and the aspects of structure-activity relationships of the pungent stimuli of the capsaicinoids.
The beneficial effects particularly associated with long usage by some ethnic groups and its safe consumption levels, with a critical review of the studies on the gastrointestinal tract, the cardiovascular system, the sensory system, thermoregulation, nutritional impacts, and an overview of the five series is also detailed.
Govindarajan VS & Sathyanarayana MN: Capsicum--production, technology, chemistry, and quality. Part V. Impact on physiology, pharmacology, nutrition, and metabolism; structure, pungency, pain, and desensitization sequences. Crit Rev Food Sci Nutr, 1991, 29:6, 435-74.
Capsaicin (2)
Capsaicin, the most pungent ingredient in red peppers, has been used for centuries to remedy pain. Recently, its role has come under reinvestigation due to evidence that the drug acts selectively on a subpopulation of primary sensory neurons with a nociceptive function. These neurons, besides generating pain sensations, participate through an antidromic activation in the process known as neurogenic inflammation.
The first exposure to capsaicin intensely activates these neurons in both senses (orthodromic: pain sensation; antidromic: local reddening, oedema etc.). After the first exposure, the neurons become insensitive to all further stimulation (including capsaicin itself). This evidence led to the proposal of capsaicin as a prototype of an agent producing selective analgesia. This perspective is radically different from previous 'folk medicine' cures, where the drug was used as a counter-irritating agent (i.e. for muscular pain).
The new concept requires that capsaicin be repeatedly applied on the painful area to obtain the desensitisation of the sensory neurons.
Capsaicin has been used successfully in controlling pain in postherpetic neuralgia, diabetic neuropathy and other conditions of neuropathic pain. Capsaicin could also control the pain of osteoarthritis.
Finally, repeated applications of the drug to the nasal mucosa result in the prevention of cluster headache attacks. On the basis of this evidence, capsaicin appears to be a promising prototype for obtaining selective analgesia in localised pain syndromes.
Fusco BM & Giacovazzo M: Peppers and pain. The promise of capsaicin. Drugs, 1997 Jun, 53:6, 909-14.
Causes of Pain
Four factors were derived that account for the causes of chronic pain. These are reported as the patients' account, the professionals' account, the scientists account and the alternative practitioner's account.
Common themes are: responsibility, blame and the need to protect identity. It is argued that in all accounts responsibility is repositioned away from the sufferer, or the healer.
In all of the accounts blame is resisted or deflected away from individual ownership.
Finally, it is argued that when pain is no longer useful as a symptom, identity is challenged, weakened and at risk for both chronic pain patients and pain professionals. Implications of this study for chronic pain research and treatment are discussed.
Eccleston C et al., Patients' and professionals' understandings of the causes of chronic pain: blame, responsibility and identity protection. Soc Sci Med, 1997 Sep, 45:5, 699-709.
Dental Pain
Dental - Verbal rating scales
Verbal rating scales (VRS), composed of ranked pain descriptors, are often employed in pain research. Factors that may influence the subjective pain intensity values, however, are not well established.
5 common pain descriptor adjectives were represented on a visual analogue scale (VAS).
The descriptors did not divide the analogue scale into equal segments. 71% of all subjects gave the adjective "mild" a lower pain intensity representation than the adjective "weak", while the order was reversed among remaining subjects.
Findings cast doubt on the reliability of VRS and the data handling methods commonly adopted in clinical pain research.
Tammaro S et al., Representation of verbal pain descriptors on a visual analogue scale by dental patients and dental students. Eur J Oral Sci, 1997 Jun, 105:3, 207-12.
Elderly & Pain
Chronic pain in elderly people has only recently begun to receive serious empirical consideration. There is compelling evidence that a significant majority of the elderly experience pain which may interfere with normal functioning. Nonetheless, a significant proportion of these individuals do not receive adequate pain management.
This may be due to three significant factors:
(1) lack of proper pain assessment;
(2) potential risks of pharmacotherapy in the elderly; and
(3) misconceptions regarding both the efficacy of nonpharmacological pain management strategies and the attitudes of the elderly towards such treatments.
The most commonly used assessment instruments and patterns of age differences in the experience of chronic pain are described and evidence for the efficacy of psychological pain management strategies for this group is reviewed.
Gagliese L & Melzack R: Chronic pain in elderly people. Pain, 1997 Mar, 70:1, 3-14.
Depression from Pain
Depression (1)
Data from 2 surveys conducted by the United States Center for Health Statistics at an interval of 8 years: the 1st National Health and Nutrition Examination Survey (NHANES-1), and the National Health and Nutrition Epidemiologic Follow-up Study (NHEFS).
The definition of pain used in the NHANES-1 survey identified 15% of the (#2,341) subjects as suffering from persistent pain. Using a different pain definition, in the NHEFS, the frequency of subjects with chronic pain was 33%. Applying this second definition, the percentage of subjects with chronic pain in the NHANES-1 had risen from 15 to 20%.
Some subjects (32.5%) who originally had chronic pain were free from pain at the time of follow-up; 59% of the subjects with chronic pain on follow-up did not have it initially.
Those with chronic pain comprised significantly more females, older people, and people with lower income.
The strongest relationship found at the NHEFS between the variables examined was between chronic pain and depression.
Magni G et al., Chronic musculoskeletal pain and depressive symptoms in the National Health and Nutrition Examination. I. Epidemiologic follow-up study. Pain, 1993 May, 53:2, 163-8.
Depression (2) - Hispanic Americans
Data on abdominal pain and depression from a survey of Hispanic Americans by the United States National Center for Health Statistics.
The point prevalence rates of chronic abdominal pain were 5% in Mexican Americans and 6% in Cuban Americans in a total of 4,175 subjects. The rate was 8% among 1,323 Puerto Ricans.
Using the Depression scale of the Center for Epidemiologic Studies (CES-D), 19% of Mexican and Cuban Americans with pain were found to be depressed to an extent likely to require intervention, and 41% of Puerto Ricans were so affected.
The Diagnostic Interview Schedule (DIS) gave more conservative figures for major depression in terms of DSM-III, viz., 7% for Mexican and Cuban Americans with chronic pain, and 13% for Puerto Ricans.
The most consistent relationships for depression were with chronic pain, female sex and the single state.
Results confirm the strong relationships between chronic pain, mood and female gender, and other socio-demographic variables.
Magni G et al., Chronic abdominal pain and depression. Epidemiologic findings in the United States. Hispanic Health and Nutrition Examination Survey. Pain, 1992 Apr, 49:1, 77-85.
Depression (3)
Determined the current status for the association of chronic pain and depression and reviewed whether depression is an antecedent, or consequence, of chronic pain (CP).
191 studies that related to the pain-depression association were reviewed.
Depression is more common in chronic pain patients (CPPs) than in healthy controls as a consequence of the presence of CP. At pain onset, predisposition to depression (the scar hypothesis) may increase the likelihood for the development of depression in some CPPS. Because of difficulties in measuring depression in the presence of CP, the reviewed studies should be interpreted with caution.
Fishbain DA et al., Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. Clin J Pain, 1997 Jun, 13:2, 116-37.
Muscle Pain
Fibromyalgia
Pain was analyzed in patients with fibromyalgia (FM).
Thirteen patients responded to one or several of the drugs, but not to placebo. Two patients were placebo responders responding to all 4 infusions. Three were nonresponders responding to no infusions. Seven of the responders had a reduction in pain for 1-5 days. Pressure pain threshold and pain tolerance increased significantly in responders.
FM diagnosed according to the American College of Rheumatology criteria seems to include patients with different pain processing mechanisms. A pharmacological pain analysis with subdivision into responders and nonresponders might be considered before instituting therapeutic interventions or research.
S”rensen J et al., Fibromyalgia--are there different mechanisms in the processing of pain? A double blind crossover comparison of analgesic drugs. J Rheumatol, 1997 Aug, 24:8, 1615-21.
Muscle pain
Intramuscular injection of hypertonic saline is a good model to study human muscle pain (Kellgren 1938). The present study concerns the intramuscular (i.m.) pain mediators in saline-induced muscle pain.
The muscle pain intensity was assessed by continuous recordings on a visual analogue scale (VAS). Intramuscular electromyography (EMG) and pressure were assessed in the area of the infused saline.
The infusion of hypertonic and isotonic saline created a visible saline-pool on the MRI scans. These saline-pool volumes were stable and not correlated to the pain scores.
Infusion of isotonic saline produced little pain compared to infusion of hypertonic saline. Maximal pain was reported after the first infusion of hypertonic saline and thereafter the pain gradually decreased with subsequent infusions of hypertonic saline. During infusion of hypertonic saline the i.m. sodium and potassium concentrations increased significantly, i.m. magnesium concentration tended to be increased, and the i.m. PGE2 concentration tended to be decreased although these changes were not significant.
The i.m. EMG was smaller during and after infusions of hypertonic saline compared with isotonic saline. The i.m. pressure was not different during the infusions of hypertonic and isotonic saline but was increased between the infusions of hypertonic saline.
I.m. infusion of hypertonic saline produced a saline-pool, causing the i.m. pressure to increase. Possibly, pain activation and cessation are related to increased intramuscular sodium and potassium content respectively.
Graven-Nielsen T et al., In vivo model of muscle pain: quantification of intramuscular chemical, electrical, and pressure changes associated with saline-induced muscle pain in humans. Pain, 1997 Jan, 69:1-2, 137-43.
Food & Pain perception
Investigated if food could reduce pain perception and explored the differential effects of macronutrient composition on the response to cold-induced pain.
Maximum reduction in pain occurred 1.5 h after ingestion, and a significantly greater effect was exerted by the high-fat low-CHO meal compared with the high-CHO low-fat meal.
Results demonstrate that food, particularly when rich in fat, significantly reduces the pain induced by the cold pressor stimulus in healthy human subjects.
Zmarzty SA et al., The influence of food on pain perception in healthy human volunteers. Physiol Behav, 1997 Jul, 62:1, 185-91.
Laser treatment
Assessed the putative analgesic effect of low intensity, near-infrared laser irradiation (830nm; 1.5 & 9.0J/cm2; continuous wave).
Irradiation was applied to ten points on the ipsilateral Erb's point immediately prior to the pain induction procedure: For the placebo condition, sham "irradiation" was delivered by applying the laser unit without activating the probe.
Pain was measured using computerised visual analogue scales and McGill Pain Questionnaires to assess "current pain intensity" and "worst pain experience," respectively.
Whereas analysis of variance and appropriate post hoc tests showed a trend toward hypoalgesia at a radiant exposure of 1.5J/cm2, no significant effects of laser therapy were found.
Results do not provide convincing evidence for the clinical potential of low intensity laser irradiation as a pain relieving modality, at least at the parameters used.
Lowe AS et al., Failure to demonstrate any hypoalgesic effect of low intensity laser irradiation (830nm) of Erb's point upon experimental ischaemic pain in humans. Lasers Surg Med, 1997, 20:1, 69-76.
Low Back & Pain
Low back pain - Netherlands
Examined the associations of low back pain symptoms with waist circumference, height, waist to hip ratio and body mass index, and tested the interactions between
(1) waist circumference and height, and
(2) waist to hip ratio and body mass index.
Prevalences of low back pain in men and women in the past 12 months were 46% and 52%, of whom 17% and 21% had low back pain for a total of 12 or more weeks, and 13% and 18% had symptoms suggestive of intervertebral disc herniation.
Women who are overweight or with a large waist have a significantly increased likelihood of low back pain. There are no significant interactions between waist and height, or waist to hip ratio and body mass index on low back pain symptoms.
Han TS et al., The prevalence of low back pain and associations with body fatness, fat distribution and height. Int J Obes Relat Metab Disord, 1997 Jul, 21:7, 600-7.
Newborns & Pain
Pain is not a subjective experience, it is, particularly in children, an emotional issue.
Self report has been the 'gold standard' of pain measurement but even in co-operative adults this has inherent weaknesses/biases related to the person and their situation (both the feelings and the reporting of pain are context sensitive).
In some clinical areas, subject report is clearly impossible e.g. the psychogeriatric population, the mentally retarded and in preverbal children. However, even in these groups, there are usually behavioural responses to acute pain that are reasonably interpretable by their caregivers.
McIntosh N: Pain in the newborn, a possible new starting point. Eur J Pediatr, 1997 Mar, 156:3, 173-7.
Chronic Pain
The pathophysiology and management of chronic pain are reviewed in this two-part article, with an emphasis on pharmacological therapies and surgical interventions.
Despite the development of new instruments and treatments to assess and manage pain, chronic pain is often poorly understood and inadequately addressed. Caregivers often lack sufficient skills to intervene promptly and effectively.
Traditionally, drug therapy has relied on the nonsteroidal antiinflammatory drugs (NSAIDs) and opioid analgesics for chronic nociceptive pain. A newer analgesic choice for moderate to moderately severe pain is tramadol, a centrally acting agent with at least two complementary mechanisms of action and minimal gastrointestinal, or renal, toxicity.
Adjuvant agents, including tricyclic antidepressants (TCAs), anticonvulsants, and local anesthetics, also help manage chronic neuropathic pain.
Although significant advances in the understanding of chronic pain and its pathophysiological mechanisms and newer techniques (noninvasive and invasive) for chronic pain management have become available, reduced patient morbidity and improved quality of life may only be realized with an improved understanding of available resources.
Garcia J & Altman RD: Chronic pain states: pathophysiology and medical therapy. Semin Arthritis Rheum, 1997 Aug, 27:1, 1-16.
Pain therapies
Pain - therapy
A therapist may help a patient to deal with pain at three levels.
One is at the level of peripheral nerve endings, where pain is triggered by a wide variety of physical stresses which have in common the fact that living tissues begin to be damaged. The therapist needs to accept the patient's evaluation of what hurts while using objective signs to keep track of inflammation in the tissues and modifying the stresses of treatment so as to minimize pain.
Higher in the nervous system, but still below consciousness there is a level defined by Melzack and Wall as the Gate, where there is a sort of triage of sensory information entering the brain. Moderate pain messages are crowded out when there is heavy traffic of other sensations. Patients who keep busy find that sensory and other distractions relieve pain.
It is in the cortex, in the conscious mind, that pain is recognized as pain, and it is here that it is often made worse by fear, by anger, or by a sense of isolation. The pain may be diminished if the patient understands the cause and loses his fear.
This is a great opportunity for the therapist. To be a successful pain reliever, one needs to be relaxed, non-threatening, and open. Patients should feel free to express fears and to ask questions they were too shy to ask the doctor.
Brand P: Pain--it's all in your head: a philosophical essay. J Hand Ther, 1997 Apr-Jun, 10:2, 59-63.
Aging & Pain
Middle to old age - Swedish
Described patterns of pain reporting over a span of 24 years (interviewed in 1968, 1974, 1981, 1992).
Self-reported pain in the chest, abdomen, and musculoskeletal system (back or hips, shoulders, hands, elbows, legs, or knees).
Less than 1% reported chest or abdominal pain on all 4 occasions.
Whereas 22% reported musculoskeletal pain on all 4 occasions.
More than 50% reported some kind of pain on 3 or 4 occasions.
Women reported more severe and more persistent pain compared with men.
More people developed pain during the 24-year period than there were who became pain free. An increase in pain was equally common for chest and musculoskeletal pain, but a decrease in pain was much more common for musculoskeletal pain than chest pain.
Demonstrated different patterns for men and women and for different pain localities.
Brattberg G et al., A longitudinal study of pain: reported pain from middle age to old age. Clin J Pain, 1997 Jun, 13:2, 144-9.
Palliative care of Pain
Despite the lack of evidence for improvement in symptom relief, quality of life, or length of survival, patients who are terminally ill often are subjected to unnecessary invasive procedures and denied the symptom relief that modern technology and pharmacology make possible.
Nursing administrators are in an ideal position to initiate interdisciplinary policy changes in this area and are encouraged to become familiar with the principles of palliative care. A recently developed policy is described and a review of supportive literature is given.
Jett LG: Comfort at the end of life: palliative care policy. J Nurs Adm, 1995 Nov, 25:11, 55-60.
Outcome measures of Pain
Outcome measure - Patient visits
The treatment of chronic pain is costly and frustrating for the patient, health care provider, and health care system. This is due, in part, to the complexity of pain symptoms which are influenced by behavior patterns, socioeconomic factors, belief systems, and family dynamics as well as by physiological and mechanical components.
Assessment of treatment outcomes is often limited to the patient's subjective, multidimensional, self-reports. Outcome measures based on data about return to work or clinic use can provide more objective assessments of intervention benefits.
Report a 36% reduction in clinic visits in the first year postintervention. Decreased clinic use continued following 2 years postintervention. Decreased use projected to an estimated net savings of $12,000 for the first year of the study posttreatment and $23,000 for the second year.
Caudill M et al., Decreased clinic use by chronic pain patients: response to behavioral medicine intervention. Clin J Pain, 1991 Dec, 7:4, 305-10.
Abutilon indicum
Abutilon indicum
Eugenol, a chemical derived from the Abutilon indicum plant, may exhibit analgesic activity. Rats were given eugenol in doses of 10, 30 and 50 mg/kg body weight, which reduced acetic-acid induced writhing by 21.3%, 42.25%, and 92.96%, respectively. Abultilon indicum has a variety of folk-uses in several countries, including India and the Philippines.
Ahmed M, et al: Analgesic principle from Abutilon indicum, Pharmazie 2000 Apr;55(4):314-6
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