PAIN(types, pathways, pharma and non-pharma management)

1. SUBMITTED BY:
SANTIAGO, LOVELY
TRASMONTE, APRIL ALLISON
TUBO, MAVERICK

2. PAIN
Is an unpleasant sensory and
emotional experience associated with
actual and potential tissue damage, or
described in terms of such damage.
(American Pain
Society[APS],2003;Gordon,2002)

3. IMPORTANT
IMPLICATIONS
Pain is physical and emotional experience,
not all in the body or all in the mind.
It is in response to actual or potential tissue
damage, so there may not be abnormal lab
or radiographic reports despite real pain.
Pain is described in terms of such damage.

5. LOCATION
Classifications of pain based on where it is
in the body may be useful in determining
the client’s underlying problems or needs.
Complicating the categorization of pan by
location is the fact that some pains
radiate(spread or extend) to other areas.

6. DURATION
Acute pain- lasts only through the expected recovery
period whether it has a sudden or slow onset and
regardless of intensity.
Chronic pain- is prolonged, usually recurring o
persisting over 6 months or longer, and interferes
with functioning.
Mild to severe, constant or recurring without an
anticipated or predictable end and a duration of
greater than 6 months. (Ackley&Ladwig, 2006)

7. INTENSITY
Classified using a standard 0(no pain) to
10 (worst possible pain) scale.
Mild pain- rating of 1-3
Moderate pain- rating of 4-6
Severe pain- reaching 7-10 and is
associated with worst outcome.

8. ETIOLOGY
Physiological pain- experienced when an intact,
properly functioning nervous system sends signals that
tissue are damaged, requiring attention and proper
care.
Somatic pain- originates in the skin, muscles, bones
or connective tissue with sharp sensation of a paper
cut or aching of sprained ankle.
Visceral pain- poorly located and may have
cramping, throbbing, pressing, or aching quality.
Often associated with feeling sick.

9. Neuropathic pain- experienced by people with
damaged or malfunctioning nerves.
Peripheral neuropathic pain- follows damage
and/or sensitization f peripheral nerves.
Central neuropathic pain- results from
malfunctioning nerves in Central nervous
system.
Sympathetically maintained pain- occurs
occasionally when abnormal connections
between pain fibers and the sympathetic
nervous system perpetuate problems with both
the pain and sympathetically controlled
function.

10. CONCEPTS ASSOCIATED WITH PAIN
Pain threshold- least amount of stimuli that is
needed for a person to label sensation as pain.
Pain tolerance- maximum amount of painful
stimuli that a person is willing to withstand
without seeking avoidance of the pain or relief.
Hyperalgesia and Hyperpathia- used
interchangeably to denote heightened response
to a painful stimuli.
Allodynia-non-painful stimuli produce pain
Dysesthesia- unpleasant abnormal sensation

11. PHYSIOLOGY OF PAIN
How pain is transmitted and perceived is
a complex in part because of the nature
of the fully integrated constantly changing
structure of the central nervous system,
and the symphony of chemical mediators,
only a fraction of which are understood.

12. NOCICEPTION
The peripheral nervous system includes primary
sensory neurons specialized to detect mechanical,
thermal or chemical conditions associated with
potential tissue damage.
The signals, when these nociceptors are
activated, must be transduced and transmitted to
the spine and brain where signals are modified
before they are ultimately understood or “felt”.
4 physiologic processed involved ( transduction,
transmission, perception, and modulation)

13. TRANSDUCTION
During this stage, noxious stimuli ( with
potential to injure tissue) trigger the release
of biochemical mediators (prostaglandins,
bradykinin, serotonin, histamine, substance
P) that sensitize nociceptors. Noxious or
painful stimulation also causes movement of
ions across cell membranes, which excites
nociceptors.

14. Pain medication can work during this
phase by blocking the production of
prostaglandin(e.g., ibuprofen or aspirin)
or by decreasing the movements of ions
across the cell membrane (e.g., local
anesthetic) . topical analgesic capsaicin (
Zostrix) depletes the accumulation of
subtance P and blocks transduction.

15. TRANSMISSION
Includes 3 segments.
First segment- pain impulse travels from the
peripheral nerve fibers to the spinal cord.
Second segment- transmission from the
spinal cord and ascension via spinothalamic
tracts, to the brain stem and thalamus.
Third segment- involves transmission of
signals between thalamus to the somatic
sensory cortex where pain perception
occurs.

16. Pain control can take place during
this second process. Opoids
(narcotic analgesics) block the
release of neurotransmitters,
particularly substance P, which
stops the pain at the spinal level.
Capsaicin may also deplete
substance P that could inhibit the
transmission of pain signals.

17. MODULATION
Often descibed as “descending System”
Occurs when neurons in the thalamus
and brain stem send signals down to the
dorsal horn of the spinal cord. These
descending fibers release substances
such as endogenous opoids, serotonin,
and norepinephrine which can inhibit the
ascending noxious(painful) impulses in
the dorsal horn.

18. PERCEPTION
Is when the client becomes
conscious of the pain. Pain
perception is the sum of
complex activities in the Central
Nervous System that may shape
the character and intensity of
pain perceived and ascribe
meaning to the pain.

19. GATE-CONTROL THEORY
According to Melzack and Wall’s gate theory,
small diameter(A-delta,or C) peripheral nerve
fibers carry signals of noxious stimuli to dorsal
horn , where these signals are modified when
they’re exposed to substantia gelatinosa.
Peripherally, large diameter (A-delta) nerve
fibers, which typically send messages of
touch, or warm or cold temperature, have am
inhibitory effect on substantia gelatinosa and
may activate descending mechanism or inhibit
transmission of pain impulses.

20. Higher centers in the brain, esp. those
associated with affect and motivation,
are capable of modifying the substantia
gelatinosa and influence the opening or
closing of gates.

21. RESPONSE TO PAIN
The body’s response to pain has both
physiologic and psychological aspects.
The sympathetic Nervous System
responds, resulting in fight-or-flight
response, with noticeable increase in
pulse and blood pressure. The person
may hold his breath or have short,
shallow breathing,

22. Pain interferes with sleep, affects
appetite and lowers quality of life for
clients and their family members.
Natural response is to stop activity,
tense muscles, and withdraw from
the pain-provoking activities which
reduced mobility that may produce
muscle atrophy and painful spasm.

23. Uncontrolled pain impairs
immune function, which slows
healing and increase susceptibility
to infections and dermal ulcers.
This short, shallow breathing that
accompanies pain produces
atelectasis , lowers circulating
oxygen and increase cardiac load.

24. Factors affecting Pain
Ethnic and cultural values
Developmental stage
Environment and support people
Past-pain experience
Meaning of pain

25. NURSING MANAGEMENT
ASSESSING- pain history, location, pain
intensity with pain scale, pattern.
Precipitating factors, alleviating factors,
associated symptoms, effect on daily
activities, coping resources, affective
response.
DIAGNOSING- acute or chronic pain.

26. BARRIERS TO PAIN MANAGEMENT
Attitude of nurses or clientsand knowledge
deficits.
Clients may not report pain because they
expect nothing can be done.
Fear of becoming addicted especially in
long-term opoid use is prescribed.
Pseudoaddiction- results from
undertreatment of pain where clients may
become focused on obtaining medication.

27. KEY STRATEGIES
Acknowledge and accepting client’s
pain.
Acknowledge possibility of pain, listen
attentively, convey that you need to
ask about pain, attend to client’s
need promptly.
Reducing misconceptions about pain.
Assisting support persons.
Reducing fear.
Preventing pain.

29. Mild pain
Paracetamol (acetaminophen), or
a non steroidal anti-inflammatory
drug (NSAID) such as ibuprofen or
aspirin. NSAIDS have antiinflammatory, analgesic and antipyretic effects. The antiinflammatory action relieves pain
by interfering with cyclooxygenase.

30. Mild to moderate pain
Paracetamol, an NSAID and/or
paracetamol in a combination product
with a weak opioid such as hydrocodone,
may provide greater relief than their
separate use. Also combination of opioid
with acetaminophen can be frequently
used such as Percocet, Vicodin, or Norco.

31. Moderate to severe pain
When treating moderate to severe pain, the
type of the pain, acute or chronic, needs to be
considered. The type of pain can result in
different medications being prescribed. Certain
medications may work better for acute pain,
others for chronic pain, and some may work
equally well on both. Acute pain medication is
for rapid onset of pain such as from an
inflicted trauma or to treat post-operative
pain. Chronic pain medication is for alleviating
long-lasting, ongoing pain.

32. Morphine - is the gold standard to which all narcotics are
compared.
Fentanyl - has the benefit of less histamine release and thus fewer side
effects.
Oxycodone - is used across the Americas and Europe for relief of serious
chronic pain.
Pethidine - known in North America as meperidine, is not recommended
for pain management due to its low potency, short duration of action,
and toxicity associated with repeated
Pentazocine- dextromoramide and dipipanone are also not
recommended in new patients except for acute pain where other
analgesics are not tolerated or are inappropriate, for pharmacological
and misuse-related reasons.
Amitriptyline- is prescribed for chronic muscular pain in the arms, legs,
neck and lower back. While opiates are often used in the management
of chronic pain, high doses are associated with an increased risk
ofopioid overdose.

33. Opioids
Opioid medications can provide a short,
intermediate or long acting analgesia
depending upon the specific properties of
the medication and whether it is
formulated as an extended release drug.
Opioid medications may be administered
orally, by injection, via nasal mucosa or
oral mucosa, rectally, transdermally,
intravenously, epidurally and intrathecally

34. Although opioids are strong analgesics, they do
not provide complete analgesia regardless of
whether the pain is acute or chronic in origin.
Opioids are efficacious analgesics in chronic
malignant pain and modestly effective in
nonmalignant pain management. However,
there are associated adverse effects, especially
during the commencement or change in dose.
When opioids are used for prolonged
periods drug tolerance, chemical
dependency, diversion and addiction may occur

35. Commonly-used long-acting opioids:
Oxycontin (oxycodone)
Exalgo (hydromorphone)
Opana ER (oxymorphone)
Duragesic patch (fentanyl)
Nucynta ER (tapentadol)
Methadone (methadone)*

36. Non-steroidal anti-inflammatory drugs
The other major group of analgesics are non-steroidal antiinflammatory drugs (NSAID). Acetaminophen/paracetamol is
not always included in this class of medications. However,
acetaminophen may be administered as a single medication
or in combination with other analgesics (both NSAIDs and
opioids). The alternatively prescribed NSAIDs such
asketoprofen and piroxicam, have limited benefit in chronic
pain disorders and with long-term use is associated with
significant adverse effects. The use of selective NSAIDs
designated as selective COX-2 inhibitors have significant
cardiovascular and cerebrovascular risks which have limited
their utilization.

37. Antidepressants and antiepileptic drug
Some antidepressant and antiepileptic drugs are used in
chronic pain management and act primarily within the pain
pathways of the central nervous system, though peripheral
mechanisms have been attributed as well. These mechanisms
vary and in general are more effective in neuropathic pain
disorders as well as complex regional pain syndrome. Drugs
such as gabapentin have been widely prescribed for the offlabel use of pain control. The list of side effects for these
classes of drugs are typically much longer than opiate or
NSAID treatments for chronic pain, and many antiepileptics
cannot be suddenly stopped without the risk of seizure.

38. Cannabinoids
Chronic pain is one of the most commonly
cited reasons for the use of medical
marijuana. A 2012 Canadian survey of
participants in their medical marijuana
program found that 84% of respondents
reported using medical marijuana for the
management of pain.

39. Other analgesics
Other drugs are often used to help analgesics combat various types of
pain, and parts of the overall pain experience, and are hence
called adjuvant medications. Gabapentin — an anti-epileptic — not only
exerts effects alone on neuropathic pain, but can potentiate
opiates. While perhaps not prescribed as such, other drugs such as
Tagamet (cimetidine) and even simple grapefruit juice may also
potentiate opiates, by inhibiting CYP450 enzymes in the liver, thereby
slowing metabolism of the drug. In
addition, orphenadrine,cyclobenzaprine, trazodone and other drugs
with anticholinergic properties are useful in conjunction with opioids for
neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle
relaxants, and therefore particularly useful in painful musculoskeletal
conditions. Clonidine has found use as an analgesic for this same
purpose, and all of the mentioned drugs potentiate the effects of
opioids overall.

41. NON - PHARMACOLOGIC
Non-pharmacological pain
management is the management
of pain without medications. This
method utilizes ways to alter
thoughts and focus concentration
to better manage and reduce pain.
Methods of non-pharmacological
pain include:

42. Bed Rest
The use of prolonged bed rest in the treatment of
patients with neck and low back pain and associated
disorders is without any significant scientific merit. Bed
rest supports immobilization with its deleterious effects
on bone, connective tissue, muscle, and psychosocial
well-being. For severe radicular symptoms, limited bed
rest of less than 48 hours may be beneficial to allow for
reduction of significant muscle spasm brought on with
upright activity. Patients should be instructed to avoid
resting with the head in a hyperflexed or extended
position. The proactive approach emphasizes activity
modification as opposed to bed rest and immobilization.

43. Manipulation and Mobilization
Manipulative treatment is commonly used in the
treatment of patients with neck pain and
associated disorders. Many different types of
manual treatment exist, including soft tissue
myofascial release, muscle energy/contract-relax,
and high-velocity low-amplitude manipulation. Soft
tissue myofascial release may include various
techniques, including effleurage, pétrissage,
friction, and tapotement. It has been shown to
improve flexibility, decrease the perception of pain,
and decrease the levels of stress hormones.

44. Traction
Cervical traction is a therapeutic modality that can be
administered with the patient in the supine or seated position.
Traction may reduce neck pain and works through a number of
mechanisms including passive stretching of myofascial
elements, gapping of facet joints, improving neural foraminal
opening, and reducing cervical disc herniation. It has been
found to reduce radicular symptoms in individuals with
confirmed radiculopathy and localized neck pain in individuals
with cervicogenic pain and spondylosis. Cervical traction may
be initiated during physical therapy with the patient properly
instructed in home use. It is not a stand-alone treatment
modality and should be done in conjunction with range-ofmotion (ROM) exercises, appropriate strengthening, and
correction of postural issues.

45. Therapeutic Modalities
Therapeutic modalities should be
considered an adjunct to an active
treatment program in the management of
acute low back pain. They should never be
used as the sole method of treatment. The
prescribing physician should first be aware
of all indications and contraindications for
a prescribed modality and have a clear
understanding of each modality and its
level of tissue penetration.

46. Transcutaneous Electrical Nerve
Stimulation
Transcutaneous electrical nerve stimulation (TENS) has been
used to treat patients with various pain conditions, including
neck and low back pain. Success may be dictated by many
factors, including electrode placement, chronicity of the
problem, and previous modes of treatment. TENS is
generally used in chronic pain conditions and not indicated
in the initial management of acute cervical or lumbar spine
pain. Overall, research is limited in regard to the isolated use
of TENS in the treatment of patients with acute cervical and
lumbar spine disorders, though it has been used in
combination with ROM exercises, spray and stretch, and
myofascial release.

47. Superficial Heat
Superficial heat can produce heating effects at a depth
limited to between 1 cm and 2 cm. Deeper tissues are
generally not heated owing to the thermal insulation of
subcutaneous fat and the increased cutaneous blood flow
that dissipates heat. It has been found to be helpful in
diminishing pain and decreasing local muscle spasm.
Superficial heat, such as the hydrocollator pack, should be
used as an adjunct to facilitate an active exercise program. It
is most often used during the acute phases of treatment
when the reduction of pain and inflammation are the
primary goals.

48. Cryotherapy
Cryotherapy can be achieved through the use of ice, ice
packs, or continuously via adjustable cuffs attached to
cold water dispensers. Intramuscular temperatures can
be reduced by between 3 °C and 7 °C, which functions to
reduce local metabolism, inflammation, and pain.
Cryotherapy works by decreasing nerve conduction
velocity, termed cold-induced neuropraxia, along pain
fibers with a reduction of the muscle spindle activity
responsible for mediating local muscle tone. It is usually
most effective in the acute phase of treatment, though it
can be used by patients after their physical therapy
sessions or their home exercise program to reduce pain
and the inflammatory response.

49. Exercise
Correction of posture may be the simplest technique to
relieve symptoms in patients with nonspecific neck or
low back pain, though it is extremely difficult to change
habits. The physician should instruct patients to assume
their worst postural “slump position” with forward
protrusion of the head, flexion of the neck, rounding of
the shoulders, and increased thoracic kyphosis and
reversed lumbar lordosis while sitting. Next, the
physician should instruct patients to correct these
postural abnormalities through retraction and extension
of the head, retraction of the shoulders, extension of the
thoracic spine, and return of the lumbar lordosis.

50. Electrical Stimulation
High-voltage pulsed galvanic stimulation has been used in
acute neck pain to reduce muscle spasm and soft tissue
edema. It is commonly used despite the lack of hard
scientific evidence for its efficacy. Its effect on muscle
spasm and pain is thought to occur by its counterirritant
effect on nerve conduction and a reduction in muscle
contractility. Use of electrical stimulation should be limited
to the initial stages of treatment, such as the first week
after injury, so that patients may quickly progress to more
active treatment that includes restoration of ROM and
strengthening. Electrical stimulation often may be
combined with ice or heat to enhance its analgesic effects.