Permanent End To Chronic Pain
In summary, CBT has strong empirical support as an effective treatment for chronic pain clients. More research is needed to explore whether cognitive therapy or behavior therapy is superior with chronic pain clients in general and for what types of problems or outcomes. In addition, the benefits of adding CBT to active treatments for chronic pain clients, especially low back pain clients, demand further exploration. Some of the criticisms of the research on CBT or behavioral therapy with chronic pain clients include the intraparticipant variability in chronic pain conditions, small sample sizes, attrition, the short-term nature of the therapy (see Keefe & Van Horn, 1993 Parker, Iverson, Smarr, & Stucky-Ropp, 1993), and the use of primarily Caucasian samples in these studies. In addition, CBT methods vary considerably from study to study (i.e., lack of uniformity in therapy protocols different models and techniques emphasized). Therefore, what is meant by CBT may be unique to each...
MYOFASCIAL HEADACHES AND TRANSFORMED MIGRAINE Myofascial headache is a variant of tension headache and is characterized by the presence of trigger points on the scalp constant, squeezing pain and occasionally shooting pain. Nausea, vomiting, neck pain, and neck tenderness may be present. It is important to differentiate this disorder from common tension headache because myofascial headache may benefit from referral for injection of trigger points. Transformed migraine is a syndrome in which classic migraine headaches change over time and develop into a chronic pain syndrome. One cause of this change is frequent treatment with narcotics.8 In this regard, patients who initially have vascular symptoms eventually have predominantly muscular symptoms nonthrobbing, squeezing, bandlike pain associated with muscle tenderness and tension. Nausea and vomiting or failure of oral antimigraine medications often prompts an ED visit.
Substance abuse is a frequent problem in chronic pain patients. Patients referred to chronic pain clinics meet Diagnostic and Statistical Manual of Mental Disorders, third revised edition (DSM III-R) criteria for active substance abuse disorders in 12 to 24 percent of cases, while 9 percent meet criteria for remission diagnosis. 67 Drug detoxification is often the first step of the therapeutic plan for new patients referred to a pain clinic. Objective findings of acute pain include tachycardia, hypertension, diaphoresis, and muscle spasms on stimulation. Objective evidence of chronic pain includes muscle atrophy in the distribution of pain due to disuse, skin temperature changes due to the effects of the sympathetic nervous system after disuse or secondary to nerve injury, and trigger points, which are focal points of muscle tenderness and tension. However, these findings do not have to be present for the pain to be factual. Signs and symptoms of chronic pain syndromes are summarized...
Chronic pain is defined as a painful condition that lasts longer than 3 months. 1 Chronic pain can also be defined as pain that persists beyond the reasonable time for an injury to heal or a month beyond the usual course of an acute disease. There are four basic types of chronic pain (1) pain persisting beyond the normal healing time for a disease or injury, (2) pain related to a chronic degenerative disease or persistent neurologic condition, (3) cancer-related pain, (4) pain that emerges or persists without an identifiable cause. Chronic pain differs from acute pain in its function. Acute pain is an essential biologic signal to warn the individual to stop a potentially injurious activity or to prompt one to seek medical care. Chronic pain serves no obvious biologic function. Chronic pain patients presenting to the emergency department (ED) have not been well studied, despite their apparent numbers. Complete eradication of pain is not a reasonable end point in most cases. Rather, the...
There is firm evidence in the research literature that both cognitive-behavioral and behavioral treatments are superior to no-treatment control conditions on a variety of outcomes (e.g., reducing pain levels, use of pain medications, negative thoughts, extent of physical disability as well as enhancing pain control, psychological adjustment, physical functioning and health status and psychosocial functioning) and these effects are maintained at follow-up for a variety of chronic pain clients (see meta-analysis studies by Morley, Eccleston, & Williams, 1999, and van Tulder et al., 2000). In addition, multidisciplinary pain treatment programs that incorporated CBT and behavioral therapy approaches were significantly more successful than unimodal treatment or no-treatment controls (see meta-analysis studies by Cutler et al., 1994, and Flor, Fydrich, & Turk, 1992). Overall, it appears that the cognitive-behavioral approach has a positive additive effect to active treatments (e.g.,...
Chronic pain is difficult to understand. Often the pain continues long after the original injury has healed, leaving other people to wonder why you're not better. For example, Didn't your surgery fix all that is a typical attitude from uneducated family and friends. So what exactly is chronic pain The next step Know what works for you. Everyone responds differently to pain medication, and chronic pain can change the way you respond to medications that you may have used effectively in the past. When pain becomes chronic, you may need to increase the dose of medications you take, try new medications, or move up to prescription-strength medications.
Elderly patients frequently complain of chronic pain. Unfortunately, many of the commonly used medications for pain have higher complication rates in the elderly. In particular, the nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with higher rates of gastrointestinal bleeding and renal disease in the elderly. Opioids also may cause debilitating sedation and or constipation in the elderly however, opioids may have less debilitating side effects than NSAIDs. Doses of many agents should be reduced when treating the elderly, to avoid side effects, and it is essential that a follow-up plan be in place at the time of discharge. There is a perception that the elderly are undermedicated for pain control. While this may be true, the elderly do not seem to be undermedicated more than other age groups. 14
Chronic post-thoracotomy pain requires a history of persistent pain for two months postoperatively at the incision site or along the intercostal nerve der-matome.10 Factors associated with the development of post-thoracotomy pain include intercostal neuromas, rib fracture, local infection, costochondritis, displacement of costochondral joints and local tumor recurrence. The most common cause is an intercostal neuroma secondary to rib spreading from retractor trauma. VATS performed through small incisions with less muscle trauma and little intercostal spreading should theoretically induce less chronic pain.18 However, careless insertion and manipulation of trocars during VATS can produce severe injuries to intercostal nerves with subsequent pain.35 Landreneau et al emphasized meticulous intercostal dissection with minimal cautery to avoid compression and injury to intercostal nerves and rib structure.5 In a retrospective study comparing VATS to thoracotomy, Landreneau noted a...
RETAINED FOREIGN BODIES Retained (nonreactive) foreign bodies such as glass can pose a problem. Chronic pain, especially during walking, can occur if the material is not removed. In the absence of chronic discomfort, inert foreign bodies can remain in the foot. The material typically becomes encapsulated, as is sometimes seen with insulin needles retained in the foot of patients with diabetic neuropathy. Obviously, organic material must be aggressively sought. Deep foreign bodies in the foot can be extremely difficult to remove in the ED. Surgical consultation and removal under fluoroscopy can be required.
Nevertheless, it has advantages in terms of reduced postoperative pain, lower wound morbidity, a more rapid return to normal activity, and less chronic pain and numbness than open repair. The benefits that are realized to the individual patients can be expanded into the societal advantages because these patients are returned to the work force more rapidly. Many surgeons are finding this technique more beneficial for the patients with bilateral and or recurrent hernias. These advantages need to be balanced against increased costs and a high recurrence rate in the learning curve period.
Phenytoin has been employed in the management of chronic pain syndromes. Historically, it has also been used as an antidysrhythmic agent, especially in the setting of digoxin toxicity, but it is no longer considered a first-line agent. Morbidity or mortality is unusual following intentional phenytoin overdose if good supportive care is provided. Most phenytoin-related deaths have been caused by rapid intravenous administration or hypersensitivity reactions.
Review of the medical record may reveal frequent emergency department visits for a variety of complaints, including both trauma and nontrauma presentations. Extensive workups for chronic pelvic pain or other chronic pain syndromes may also suggest a history of domestic violence.
Ischial Tuberosity This fracture results from forceful contraction of the hamstrings (such as with kicking), and the fracture is seen in youths whose apophyses are not united. Symptoms and signs include acute or chronic pain with sitting or on flexing the thigh with the knee extended. Rectal examination reveals tuberosity tenderness. The roentgenogram shows detachment of the apophysis from the ischium with minimal displacement. The apophysis closes between ages 20 and 25 years.
At first glance, you may think this section is in the wrong chapter. How can taking prescription antidepressants help with pain Actually, antidepressants can help decrease chronic pain in several ways. The two most obvious ways are i Decreased depression, which is a common side effect of chronic pain (Check out Chapter 15 for more information about depression and your emotions.) However, there's much more to this story. Many studies have shown that some classes of antidepressants have analgesic properties and have reduced chronic pain in more than 50 percent of the people studied. SNaRI antidepressants are some of the most investigated of the new drugs shown to be effective in the treatment of different kinds of pain, and appear to have fewer side effects than TCAs. Duloxetine (Cymbalta) and venlafaxine (Effexor) have both been found to be effective in treating chronic pain. Mirtazapine (Remeron) is an NaSSA that is more sedating than some of the other antidepressants and may be...
Concerns have been raised about delayed-release transdermal formulations, because of delayed onset and prolonged duration of action. Transdermal fentanyl preparations are used in the chronic pain and oncology setting. Generally, transdermal fentanyl should be avoided for acute pain management.
The legend of Umay Ene, a female deer, tells what happened that when the forest burned (in Siberia) and only one child survived, who was raised by Umay Ene. Considered to be the grandmother of all Kyrgyz and the spirit who protects children and animals, many women pray to Umay Ene. When shamans (many of whom are women) perform a healing on a child they often say, It is not my hand but the hand of Umay Ene who heals. During the harvest or when cattle and sheep gave birth to calves and lambs, the Kyrgyz say Umay Ene's breast gives us milk. Female Kyrgyz shamans also officiate at life cycle celebrations, such as birth and marriage, and conduct funeral services, but central to their role in the Kyrgyz community is the performance of public and private healing rituals. These usually include the chanting of Muslim prayers, as well as prayers to the deceased or to animal spirits. Infertility and chronic pain are typical reasons for seeking out a shaman....
Over the past 5 years an increasing number of studies conducted to test CBT approaches have been published. This growing literature has shown that CBT is a promising insomnia treatment for a various types of insomnia sufferers. Specifically, these studies have shown that CBT produces clinically significant sleep improvements among those who suffer from either sleep onset or sleep maintenance difficulties. Furthermore, studies have shown that this modality is effective among insomnia patients who additionally suffer from significant sleep-confounding medical (e.g., chronic pain syndromes) and significant psychiatric (e.g., depression) disorders. Moreover, some very recent research has shown that paraprofessionals can be trained to administer effectively these treatments in real world
Patients should be examined for signs of intravenous drug addiction, including needle marks and healed or active superficial cutaneous abscesses, and the heart should be examined for evidence of a new murmur and other signs of endocarditis. Patients attempting to simulate nephrolithiasis can falsify hematuria by biting their buccal mucosa and spitting into the urine sample or by pricking their finger and dipping it into the urine sample. Patients who are suspected of factitious hematuria should be examined for these findings. Patients with factitious acute injury may massage old deformities to create the appearance of erythema and swelling, but this will dissipate over time if the clinician stops the patient from holding the extremity. Patients may self-mutilate, usually with the dominant hand, and seek narcotics. Patients may have evidence of chronic pain or, most commonly, have completely normal physical examination findings. Finally, it is widespread anecdotal experience that such...
Relative to other treatment approaches, CBT for children has received strong empirical support. Today CBTs are applied to a wide range of childhood problems and disorders including anxiety and phobic disorders, depressive disorders, aggressive and disruptive behavior problems, substance abuse and eating disorders, as well as pediatric or medical concerns (e.g., coping with painful medical procedures, enuresis, and irritable bowel syndrome). Although reviews clearly highlight the need to develop more and better empirically supported treatments for youth, CBTs for children and adolescents stand out in that they have led the way in doing so. For example, a recent review of the empirically supported treatment literature finds support for CBTs in the treatment of anxiety disorders and phobic disorders, conduct disorder oppositional defiant disorder, chronic pain, depression, distress due to medical procedures, and recurrent abdominal pain (Chambless & Ollendick, 2001). In addition,...
The goals of intervention are behavioral, cognitive, and or emotional change. Specifically they aim at the reduction of stress and anxiety responses, depression, eliminating panic responses, reducing bulemic behavior losing weight, the resolution of phobic disorders, ameliorating agoraphobia, effective management of chronic pain, improving general social functioning, abstinence from risky sexual activity, and increasing self-control in the area of drug and alcohol abuse. (A comparable program has been described by Rose in 1998 for use with disturbed children and adolescents.) In the model proposed in this article the clients make use of the conditions of the group to enhance the clients' learning and motivation. Most CBGT models teach specific skills for coping with and resolving unique problem situations. Skills are usually developed for coping effectively with situations that trigger stress, anxiety, pain and or anger through the use of various cognitive...
TABLE 2911 Common Reasons Why Physicians May Not Diagnose Domestic Violence in the Emergency Department
Another important reason for failure to diagnose is the failure to consider domestic violence in cases with nontrauma chief complaints. Battered women seek care in emergency departments for a wide variety of medical complaints, including anxiety, hyperventilation, depression, drug and alcohol intoxication, chronic pain syndromes, and symptoms suggestive of posttraumatic stress disorder (PTSD).
It is generally accepted that what defines a treatment setting as acute is the medical status of the patients in it rather than some characteristic of the facility. Thus, patients in an acute care setting are medically unstable and likely to experience rapid changes in status. The NICU and medical stabilization floors are good examples of acute care settings. Patients at this level are not able to tolerate several hours of therapy. Rather, the patient takes part in bedside rehabilitative therapy in an effort to minimize the effects of physical deconditioning so that the transition to formal rehabilitation is as smooth as possible. Upon medical stabilization, patients are transferred to a rehabilitation setting. Such environs take many forms, ranging from highly medicalized centers attached to large tertiary care hospitals to freestanding outpatient clinics that may provide a broad range of services to a general patient population (e.g., PT clinic) or specialty services to a particular...
There are few controlled studies on drug-seeking behavior. Although it is known that approximately 10 percent of patients seeking treatment for drug addiction identify a prescription drug as the principal drug of abuse,20 there is no statistical documentation of the problem in the ED. The spectrum of drug-seeking patients includes those who have chronic pain and have been advised to avoid taking narcotics, the drug addict who is trying to supplement his or her habit, and the hustler who is obtaining prescription drugs to sell on the street. Patients may move from chronic pain patient to addict to hustler as their social and financial support deteriorates.
Behavioral strategies and lifestyle modifications are paramount to managing sleep disorders and their sequelae. In addition to sleep hygiene, utilizing a cognitive-behavioral approach and conceptualization may produce additive benefit. Similar to helping patients with medical conditions, such as chronic pain or cardiovascular disease, examining the beliefs, attitudes, thoughts, and emotional responses of patients with sleep disorders is likely to provide an even greater understanding and treatment development compared to solely taking a medical-model approach. Charles Morin and colleagues address these factors in patients with insomnia and have achieved considerable success. Extending and combining these principles for patients with other sleep disorders may similarly provide a more comprehensive management compared to medical recommendations alone. While some strategies, such as systematic desensitization or exposure therapy, for CPAP users await further empirical validation,...
Sometime, during the course of therapy, clients learn assertiveness training skills. Learning how to communicate openly and directly without offending others is a very important skill for this client population given the number of health care professionals involved in their care. In addition, other people may not understand how clients experience pain and how it affects them. Therefore, communicating these experiences to others helps chronic pain clients feel more supported and understood than before.
Future directions in CBT with chronic pain clients could include the incorporation of additional approaches to the current theoretical model, for example, the stages of motivation to change model (motivational interviewing), acceptance-based interventions (see McCracken & Turk, 2002), schema therapy, and multicultural counseling interventions. More attention will be given the therapist factors (e.g., individual characteristics age, gender, race , personality, commitment, optimism, and flexibility) that interact with client factors (e.g., individual characteristics, personality, motivation to change, acceptance of their chronic pain condition) in promoting positive changes for chronic pain clients. More research will explore the effectiveness of CBT with chronic pain clients in other settings besides mul-tidisciplinary pain treatment centers, and with more diverse groups of chronic pain clients. The wave of the future will be therapists providing cognitive-behavioral pain management...
To a particular disease is therapeutic or investigational. Historically, a treatment has moved from investigational use to therapeutic use when it is shown to relieve the symptoms it is intended to relieve with an acceptable degree of risk and when a significant proportion of physicians, especially those working in the field, are convinced that the intended outcome will appear without adverse long- or short-term effects that outweigh the benefits. This delineation between research and therapy has implications for the informed-consent process and the ability of surrogates to provide consent for DBS when a patient or subject lacks decisionmaking capacity. In the early twenty-first century DBS is recognized as therapeutic for the management of chronic pain, Parkinson's disease, and other movement disorders. It remains investigational for other indications.
The hypermobility type of EDS (the former EDS type III) is inherited as an autosomal dominant disorder it is characterized by severe generalized joint hypermobility, as assessed by the Beighton scoring system, and associated signs, such as recurring (sub)luxations, swellings, and tendinitis. This results in early-onset, chronic, generalized joint pain, which is often debilitating. In particular, temporomandibular and sternoclavicular joints, wrist, shoulder, and patella dislocate frequently. The skin is involved, with smooth, velvety skin, or mild atrophic scarring. Hypermobility type of EDS has to be distinguished from familial articular hypermobility syndrome (FAHS), also called benign joint hypermobility syndrome (BJHS), a separate autosomal dominant condition, which is characterized by severe joint laxity, joint dislocations, and chronic pain, but no skin changes. It is currently under discussion whether BJHS is a mild form of a heritable disorder of connective tissue, and is in...
Oftentimes people living with physical pain can develop emotional problems, such as depression and anxiety (check out the next two sections). And these emotional problems can even cause the physical pain and symptoms of endometriosis to worsen. Sometimes, though, differentiating between chronic pain and emotional pain isn't easy because many of the symptoms of chronic pain are also symptoms of depression.
Severe, immediate, and permanent.11 Immediate but transient symptoms include confusion and amnesia, loss of consciousness, temporary lower extremity paralysis, and temporary upper extremity paralysis.10 Lower extremity paralysis (keraunoparalysis) is often a consequence of step-voltage injury and is usually associated with paleness, sensory loss, loss of pulses, and vasomotor changes.12 These immediate but transient symptoms typically resolve within 24 h. Delayed and usually progressive disorders include seizures, spinal muscular atrophy, amyotrophic lateral sclerosis, parkinsonian syndromes, progressive cerebellar ataxia, myelopathy and neuropathy, paraplegia and quadriplegia, paresthesias, and chronic pain syndromes.
OTHER PHARMACOLOGIC AGENTS Topical preparations of NSAIDs are being introduced. These preparations are analgesics, not anesthetics. Topical NSAIDs have relatively lower efficacy than oral NSAIDs but also have lower systemic side effects. Another topical agent currently used for chronic pain management that may also have a role in local acute pain management is capsaicin cream, which blocks substance P. There are a number of allopathic preparations available without prescription for topical analgesia, such as aloe and tea-tree oil. Scientific evidence supporting the effectiveness of these preparations is limited. Tea tree oil is toxic if ingested.
Figuring out chronic pain Going over the counter Moving to prescription drugs Trying creams Looking to exercise Melting away with heat therapy Chronic pain can drive you to despair. When you suffer from acute pain, say from a bad infection, you know it will eventually end and you'll feel better. But chronic pain gives you no such assurances. You can only hope the pain lessens after treatment or that some medication can keep it at bay.
Depression is common in the general population, never mind people with chronic pain. In fact, depression may affect as many as 50 percent of all chronic pain sufferers because depression can be a normal response to the losses that come with chronic pain. When we also figure in the high percentage of women compared to men up to three times as many who suffer from depression (at least in the years before menopause), the potential for a woman with endometriosis to experience depression is very high.
In addition to being a direct cause of traumatic injury, domestic violence also contributes to other conditions frequently seen in emergency departments, such as depression, anxiety, hyperventilation, substance abuse, suicide attempts, sexually transmitted diseases (including HIV), complications of pregnancy, and headaches and other chronic pain syndromes.18 Both batterers and their victims may abuse alcohol and drugs. Abused individuals with chronic medical conditions may present with exacerbations of their illnesses because the batterer withholds their medications or because they are not allowed to keep appointments with their office-based physician. A history of exposure to violence in the home during childhood has recently been associated with an increase in health risks and health-risk behaviors in adults (such as depression, substance abuse, and high-risk sexual behaviors).19 It should be considered, therefore, a contributing factor to many conditions commonly treated in...
COMPLICATIONS Early emergency visits usually involve wound problems. Diagnosis of an infection is supported by the presence of severe pain and an elevated temperature, white blood cell count, and erythrocyte sedimentation rate. Painful acute implant failure is not common, but Harrington-type hook implants may disengage. The patient usually notes an acute pop and an immediate increase in pain. This is usually best demonstrated on the lateral radiograph because the hook will no longer be under the vertebral lamina ( Fig. 272z18). Rod breakage is usually a late occurrence due to failure of the fusion to prevent motion. Patients greater than 3 months postoperative usually will not have instability. Rod breakage should be easily detectable on standard anteroposterior and lateral radiograph views. Pain complaints from spine surgery patients are commonly encountered in the emergency department. Narcotics should be given sparingly, and communication with the orthopedic surgeon is often...
These disorders are constituted by the deregulated proliferation of hematopoi-etic lineage cells within the bone marrow, but also may result in proliferation of blood components in former extramedullary sites of hematopoiesis, namely the liver and spleen. Myeloproliferative disorders can result in splenomegaly due to increased splenic blood flow, but can also be secondary to portal hypertension from obstructive hepatic fibrosis due to proliferation of myeloid hema-topoietic components in the liver. The treatment of myeloproliferative disorders involves the use of alkylating chemotherapeutic agents and periodic blood product transfusions. Splenectomy is indicated for symptomatic splenomegaly, chronic pain from splenic infarcts, or for the management of severe anemia or thrombocytopenia necessitating frequent transfusions or precluding chemotherapy.
PHS policy sets forth several criteria to be followed by the IACUC in reviewing protocols. These criteria go beyond mere care and housing guidelines. The care and use of animals in proposed research must be consistent with the NRC guide, unless acceptable scientific justification is provided for any deviation. The investigator must explain the rationale for using animals at all in the proposed research as well as the appropriateness of the species to be used, the number of animals, and their proposed use. PHS policy stipulates requirements for the use of sedatives, analgesics, and anesthetics if the proposed procedure might cause more than slight pain or distress it also requires prompt euthanasia at the end of (or, when appropriate, during) a procedure for animals that would otherwise suffer severe or chronic pain or distress that cannot be relieved and imposes methods of euthanasia consistent with American Veterinary Medical Association (AVMA) guidelines. All personnel involved in...
Pain must be controlled before physicians can assist patients with the myriad of physical, psychological, and spiritual problems at end-of-life. Yet, physicians frequently fail to apply accepted standards of care for acute or chronic pain management. Moreover, it is clear that despite a multitude of clinical guidelines, position papers,
OTC medications often aren't enough to treat chronic pain. You may also need to take prescription pain medication, at least at certain times of the month. However, you may find that taking pain medication on a schedule is more effective than waiting until the pain builds up.
Despite the emphasis on biological processes, several people are noted for introducing psychological techniques and theory into the understanding and practice of medicine. In the 1600s, Thomas Sydenham used clinical observation to gain a better understanding of his patients and the manifestations of their diseases. He believed that external emotional events could affect the animal spirits of the body, which, in turn, caused hysteria (Shorter, 1991). In 1770, John Gregory wrote about chronic pain in nervous patients. The connection between nervous patients and chronic pain indicates recognition of a correlation between disturbed mental states (as it was referred to at that time) and somatic complaints. Yet, the formal acknowledgment of psychosomatics does not appear for another century.
To better define the psychology of chronic pain, psychiatrists have divided patients' characteristics into two groups. 4 The first group has normal psychologic function at baseline. However, continued pain and its effects, such as inability to work or altered body image, result in psychological dysfunction. The second group has primary psychopathology that predates the onset of chronic pain. Hypochondriacal, hysterical, pain-prone, and depressive personalities are included in this group. The seven D's (T bj , 34-1) summarize the clinical features of these groups.5
Unlike ablative surgery that results in irreversible damage of brain tissue from the intentional destruction of targeted areas, the effects of DBS are reversible. The stimulator can be turned off, and the electrodes can generally be removed without any significant aftereffects. DBS differs from other methods that employ electrical stimulation of the central nervous system. Electroconvulsive therapy (ECT), primarily used to treat severe depression, stimulates the brain using electrodes placed on the scalp. Transcranial magnetic stimulation induces electrical currents in the brain using external magnetic coils. Electrical stimulation in the neck of the vagus nerve has been demonstrated to reduce epileptic seizures. Cortical stimulation of the brain is also employed as a treatment for chronic pain disorders (Greenberg).
One trouble with chronic pain is that it never seems to end. If you have a broken leg, at least you can look forward to the day your cast comes off and you're good as new. Chronic disease, on the other hand, doesn't give you anything to look forward to except more pain. You may not be feeling depressed about your condition, but you may have chronic anxiety. This section looks a little closer at anxiety.
Keywords pain, chronic pain Everyone has been in pain at some point in his or her life. However, unrelieved chronic pain is perhaps one of the most challenging problems faced by health care consumers as well as practitioners and providers. It is estimated that 75-80 million people in the United States suffer from some sort of chronic pain, at an annual cost of 65-70 billion (Tollison, 1993). There are a number of personal, social, and environmental consequences of having unrelieved, chronic pain (see Gatchel & Turk, 1999) that may be very difficult for clients to deal with including physical suffering, emotional distress, negative thoughts, behavioral problems (e.g., inactivity, seeking attention), and psychosocial stress (e.g., life role changes, relationship issues, legal problems). Given these experiences, psychological interventions are important for clients who have chronic pain. Behavioral therapy approaches with the chronic pain population were introduced in the late 1960s and...
Keywords pain, chronic pain, stress Pain is a universal stress encounter. Despite advances in the understanding of the physiological process, pain continues to be a source of distress for patients, caregivers, and physicians. Chronic pain, that is, pain which persists a month beyond the usual course of the acute disease or reasonable time for an injury to heal or that is associated with chronic pathological process that causes continuous pain or pain that recurs at intervals for months or years (Bonica, 1990, p. 19), is considered to be an illness itself, which generally does not remit. Patients with chronic pain experience physical, psychological, and social factors as sources of distress. The biomedical model, which dates back to the ancient Greeks, views pain as an objective biological event and fails to address the roles of psychological and psychosocial variables in health and disease. Patients with chronic pain often experience a wide range of distressing emotions including...
Patients reported a greater self-reported frequency of hallucinations, but rated the hallucinations as less distressing than the psychoeducational intervention patients. In contrast, the patients undergoing psychoeducational treatment reported significantly fewer hallucinations, but significantly more distress associated with the hallucinations. ACT interventions have also been shown to have a significant effect with such diverse problems as chronic pain, occupational stress, and high medical utilization.
As a result of such systematic violation of their physical and psychological (animal scientists prefer the word behavioral ) needs, animals suffer psychologically as well as physically. Many animals in confinement show chronic signs of long- and short-term stress, which can lead to both disease and behavioral problems. Cannibalism among chickens increases in the absence of either space to flee or small enough numbers to establish a pecking order to prevent cannibalism, producers debeak chickens with a hot blade and without anesthesia, sometimes producing chronic pain. Similarly, pigs are tail-docked to prevent tail-biting, a stress-induced result of confinement. Confined animals also show many bizarre, stereotypical behaviors that seem to result from the thwarting of natural inclinations and from boring, austere environments.
Finally, it has been extensively described that the interplay between the neural activity of the hypothalamus and the neural activity of higher centers results in emotional experiences that we describe as fear, anger, pleasure, or satisfaction. For example, the behavior of patients from whom a part of the limbic system (frequently the prefrontal cortex) has been removed supports this idea. Indeed, these patients are no longer bothered by chronic pain or, alternatively, when they do perceive pain and exhibit appropriate autonomic reactions the perception is no longer associated with a powerful emotional experience.
Guanethidine was originally used as an anti-hypertensive but is now mainly used in the management of chronic pain. It is transported by the uptake 1 mechanism and accumulates in the nerve terminals. Initially it causes release of noradrenaline from the vesicles and then inhibits release of the diminishing levels of noradrenaline. Debrisoquine, bretylium and bethanidine have a similar mode of action. Guanethidine is used to treat reflex sympathetic dystrophy by IV regional sympathetic block (chemical sympathectomy) in which guanethidine is injected intravenously into an isolated limb.
Localized paravertebral pain can be associated with an acute facet syndrome. Plica entrapped within the thoracic zygapophyseal joints can produce severe and disabling pain. Radicular pain and localized stiffness associated with osteoarthrosis of these same vertebral joints cause chronic pain and can result in narrowing of the neural and spinal canals. The latter can lead to signs and symptoms of thoracic spinal stenosis.
PROGNOSIS OF LIGAMENTOUS INJURIES The long-term complications of ankle sprains include functional instability (a subjective sensation of giving way without mechanical instability), mechanical instability (a demonstrable laxity), chronic pain, stiffness, and recurrent swelling. The documented incidence of complications is highly variable, and varies from 6 to 40 percent.1922 The long-term sequelae can be reduced with early rehabilitation. Physical therapy should be directed initially at active and passive range of motion exercises followed by early mobilization, strengthening exercises, proprioceptive training and, finally, restoration of normal activity.
Feather-pecking occurs frequently among turkeys and can begin at 1 day of age. This behavior is thought to be redirected foraging behavior, caused by providing birds with an impoverished foraging environment. To reduce feather-pecking, turkeys are often beak-trimmed, which causes acute and possibly chronic pain. Feather-pecking can be considerably reduced, at least in small groups (e.g., 100 birds), by providing supplementary ultraviolet radiation (turkeys are visually sensitive to UV humans are not), pecking substrates (e.g., straw), and visual barriers to reduce social transmission of this behavior. 5-Other pecking substrates include chains, twine, vegetable matter, or food scattered in the substrate. UV-reflective markings appear on young birds at the same time as feather-pecking becomes targeted toward these areas. 6
CT has also been applied to medical problems on an inpatient basis. When used during inpatient treatment, CT was shown to have positive effects for individuals suffering from chronic pain and positive effects on musculoskeletal pain (Johansson, Dahl, Jannert, Melin, & Andersson, 1998). A 10-week cognitive-behavioral treatment program for obese individuals was studied to assess long-term outcome. At the 18-month follow-up, there was a general reduction in both eating and a broad spectrum of psychopathology (Leibbrand & Fechter, 2002).
The majority of studies addressing outcome in somatoform illness have concentrated either on conversion disorder or on somatization disorder, and research explicitly addressing other forms of somatoform illness is rare. It is nevertheless likely that studies investigating the outcome of conditions such as chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and chronic pain conditions are implicitly addressing other aspects of somatoform illness. A review of the substantial literature concerning these conditions is beyond the scope of this article.
Pain as defined by the International Association for the Study of Pain is 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage'. Nociception (perception of a painful stimulus) elicits physiological responses even in anaesthetized individuals and minimization of pain can improve clinical outcomes. An individual's response for months after injury may be determined by processes that occurred during the initial phases of the injury. Even brief intervals of acute pain can induce long-term neuronal remodelling and sensitization ('plasticity'), chronic pain and lasting psychological distress. Factors which influence postoperative pain include the
Most laying hens are beak-trimmed to reduce injuries and mortality associated with feather pecking and cannibalism. These are abnormal behaviors whose causes are still incompletely understood, but large group size (as in free-range and barn systems) and lack of foraging opportunity (as in cages) are both contributing factors.1-1-1 Beak trimming involves removal of one-third to one-half of the upper beak. Birds explore their environment using their beaks, and consequently the beak is highly enervated. Although cannibalism is a serious welfare issue, beak trimming causes acute pain and can also cause chronic pain if the bird is trimmed when older. 5 Genetic selection for hens that do not show these behaviors has been successful experimentally, and it may be possible for the industry to discontinue beak trimming by using selected stocks. 2,5
Beak trimming, which is routinely used to reduce injuries and mortality associated with feather pecking and cannibalism in both cage-housed and more extensively housed hens, also poses a welfare problem. Approximately one-half of the beak is removed using either a hot cauterizing blade or a precision trimmer. The latter makes a small hole in the beak, causing the tip to fall off several days later. Although the pain* associated with beak trimming was once thought to be minor and of short duration, it is now known that hens that have their beaks trimmed using a hot blade experience both acute and chronic pain.
In 1985 this situation changed with the publication of Relapse Prevention Maintenance Strategies in the Treatment of Addictive Behaviors by G. Alan Marlatt & Judith Gordon (Marlatt and Gordon, 1985). Marlatt and Gordon presented the first cognitive-behavioral approach to maintaining behavior change. While the book focused primarily on substance use disorders, the applicability of relapse prevention (RP) strategies to other behavioral problems was readily apparent. Within the next 10 years RP approaches had been developed to sustain change following treatment of a variety of behavioral problems, including a variety of nonaddictive disorders, such as depression and agoraphobia, marital distress, stuttering, and chronic pain (Wilson, 1992). RP also stimulated a substantial body of research into its efficacy and the processes that both contributed to the persistence of addictive behaviors and made it so apparently difficult for treated individuals to maintain those changes.
From the effort to articulate that disruption, as well (G. Becker, 1997). The difficulty of putting suffering into words is especially noted in the literature on chronic pain (Garro, 1992 M. J. Good, Brodwin, Good, & Kleinman, 1992 J. Jackson, 1994 Kleinman, 1992). Phenomeno-logical approaches have also been used to interpret the experience of specific illness syndromes such as nervios (Low, 1994), susto and fallen fontanelle (Castro & Eroza, 1998), and calor (Jenkins & Valiente, 1994).
Pain is a subjective, unpleasant experience that can usually be localized. There is a strong affective component to pain in the form of a subjective emotional response which is determined by the current psychological state, anticipation and past experience of tissue damage. Pain has a protective function and may or may not be associated with tissue damage. The pain response to a noxious stimulus is not necessarily consistent. A situation can arise when the initial stimulus has disappeared but the site of injury becomes hypersensitive to stimuli of lower intensity in the presence of inflammatory mediators. This is a chronic pain syndrome, known as hyperalgesia and is thought to be due to sensitization of previously 'dormant' nociceptors. There is a good practical reason for this since continued function may exacerbate the injury, the injured tissue is compelled to rest to facilitate the reparative process. Prolonged experience of pain can lead to other recognized chronic pain phenomena...
People can have negative, unrealistic thoughts and beliefs about their pain (e.g., My pain is untreatable, I shouldn't have pain all of the time ), themselves (e.g., I am powerless, I am vulnerable, I shouldn't be so needy ), their personal world (including their relationships with others and life roles My doctors don't care about my pain, People will criticize me ), and their future (e.g., I am doomed to be pain-ridden ) given their chronic pain condition.
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Peace in Pain
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