Overview of pain, common pain management strategies and their effects on wellbeing. Side effects, effects on wellbeing, Covers Pain cycle, Persistent or chronic pain, pain gate theory, pharmaceutical and non-pharmaceutical or pain treatments, including complementary therapies, electrotherapies, psychological therapies for pain. Written for student OT conference 'Perspectives on Wellbeing' Feb 2016

1.  
And their effects on wellbeing

5.  Almost all your clients will potentially have pain
 Neuro – large percentage have pain
 Case management
 Running pain management programs
 People with chronic pain often face work related issues
 Palliative care
 Many that I don’t know!!

6.  Definitions of pain
 Classification of pain
 Persistent pain
 The Pain Cycle
 Pain gate theory
 Common analgesic treatments & effects on wellbeing
 Common non-pharmarceutical treatments & effects
 Branching out
 Our experiences with APS Therapy

7.  ‘an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage’
-International Association for the Study of Pain 1979
 ‘Pain is whatever the experiencing person says it is,
existing whenever the person says it does’
-McCaffery 1968

9.  Neuropathic pain may arise as a consequence of a
lesion or disease affecting the somatosensory system

13. Short-lasting (up to 3 months)
Associated with tissue damage eg wound,
surgery, injury
Warning of potential damage
Healing process
Usually relieved by treatment

14. Long-lasting – more than 12 weeks
May be ‘maladaptive’ or have no biological
usefulness
May not respond to standard treatments
Impact on individual – physically,
emotionally, socially, financially,
psychologically – Pain Cycle

16. Pain Proposal, Improving the
current and future
management of chronic pain.
A European Consensus
Report
Baker et al. 2010

19. National Pain Audit 2011

20.  Usually, once healing has occurred, the pain signals fade
and go away completely
 Sometimes, the pain signal fails to decrease, even after
an injury has healed
 The nervous system has ‘learnt’ the pain, and the pain
messages continue to travel to the brain

21. Not well understood
- IASP Factsheet – Mechanisms of Neuropathic pain

22.  Melzack and Wall 1965
 ‘Gate’ in the spinal cord which can be opened or closed
– controls how much pain your brain is aware of
 Designed to block pain if it will affect you badly eg in an
attack

24.  The Gate can also cause increased awareness of pain
during healing process – eg inflammatory stage,
encouraging protection of injured area
 Regeneration stage – relies on gradual but steady return
to normal activities

25.  Physical factors:
 Extent of injury
 Inappropriate activity level
 Emotional factors:
 Fear, stress, anxiety, depression
 Mental factors:
 Concentrating on the pain
 Boredom
 Gate is opened, increasing perception of pain

26.  People commonly try to protect painful areas by not
using them – muscles de-condition, causing weakness
and loss of stamina
 This means eventually a usually non-painful sensation
such as stretching, can be perceived as painful

27.  Positive emotions – happiness, interest, excitement
 Concentrating on something else / distraction
 Analgesics / treatments
 Relaxation techniques
 Counter stimulation – eg heat, massage
 Activity/exercise/stretching

30. - Pain Proposal, Improving
the current and future
management of chronic pain.
A European Consensus
Report 2010

31.  No one careplan – pain is individual
 Improved access to pain services with md team
 Improved physician training
 No current national clinical guidelines for management of
persistent pain
 Apart from Neuropathic - NICE Guidelines
 Health Improvement Scotland – management chronic
pain

35.  Acceptance
 Engagement & building support team
 Pacing
 Planning & prioritising
 Goals & action plans
 Being patient with self
 Relaxation skills
 Stretching & Exercise
 Diary
 Set-back plan
 Keeping it up

36. Step One
Step Two
Step Three
Simple analgesia e.g. paracetamol +/- NSAID
Opioids suitable for mild/moderate
pain (codeine, dihydrocodeine,
tramadol)
+ simple analgesia
Opioids for use in severe
pain (morphine, oxycodone,
fentanyl)
+ simple analgesia
Step One
Step Two
Step Three
Simple analgesia e.g. paracetamol +/- NSAID
Opioids suitable for mild/moderate
pain (codeine, dihydrocodeine,
tramadol)
+ simple analgesia
Opioids for use in severe
pain (morphine, oxycodone,
fentanyl)
+ simple analgesia

37. Relieving Persistent Pain, Improving Health
Outcomes – UCL School of pharmacy

38.  ‘by the clock’ vs ‘as & when’
 Standard release – absorbed within 30min-1hr, lasts for 4-6
hours (liquid acts faster than tablets)
 Slow release (SR, MR, PR) – slower acting, last usually for 12
hours therefore twice daily dose. Sometimes XL or LA – last
24 hours
o Smoother drug release / side-effect profile
o Lasts through the night
o Less flexibility
 Creams & gels
 Anti-inflammatory
 Heat rub
 Patches

39.  Taken ‘as and when’ not very effective for chronic pain
 Need to take regularly , 2 tablets x 4 times every day for
at least 7-14 days to see effect
 Provides a good foundation for other drugs if needed
 Effects on wellbeing:
 Side-effects very rare; safe (no damage to organs at
normal doses)
 Very toxic in overdose; higher doses do not give better
pain relief (check OTC meds)
 Realistic expectation – may reduce pain by 1-2 points

40.  Ibuprofen, diclofenac, naproxen, others
 Short term for acute pain and for conditions with
inflammation they can work well
 For most people paracetamol will work just as well
 Long term need to weigh up risk and benefit (some are
safer than others)
 Effects on wellbeing:

42.  Morphine type drugs
 Block pain receptors
 Effects on wellbeing:
 30% of pain in 30%
 Increase feelings of pleasure
o Constipation (may need to modify diet/use laxative)
o Drowsiness, dizziness, confusion
o Nausea
o Hallucinations (particularly with tramadol)
o Long term effects on hormones and immune system

43.  Addiction
o Opioids have the potential to be addictive
o Addiction is relatively uncommon during treatment for chronic pain
o Addiction is a behaviour – compulsive use of the drug for non-
medical reasons, craving its mood altering effect not pain relief
o Commonly mistaken for dependence and tolerance
 Physical dependence
o Physiological adaptation of the body to the opioid
o Reason that people suffer withdrawal if they stop suddenly
o Withdrawal effects are unpleasant but not life threatening and
include anxiety, insomnia, pain, sweating, diarrhoea, abdominal
cramp, nausea, vomiting (cold turkey)
 Tolerance
o Decrease in the effect of the drug over time
o Sometimes need a higher dose to get the same effect or may need
to switch to a different drug

44. • Pregabalin:up to 600mg
• Gabapentin: up to 3,600mg
Anticonvulsants
• Amitryptilline – 10 – 150mg
• Duloxetine – 60mgAntidepressants
• Localised pain, & cannot
tolerate/wish to avoid drugs
Topical capsaicin

45.  Anticonvulsants: somnolence, weight gain, dizziness,
peripheral oedema, headache, dry mouth, blurred vision,
diploplia, dysarthria, abnormal co-ordination, parasthesia
 Also: sexual dysfunction, constipation, vomiting,
flatulence, memory impairment, vertigo, increased
creatine kinase level, memory impairment, increased risk
of depression & suicidal thoughts and behaviours.

46.  common : dry mouth, constipation, dizziness, blurred
vision, urinary retention, drowsiness, palpitations,
orthostatic hypertension, sweating.
 Also linked to: cognitive disorders, confusion, gait
disturbance, falls
 Recent research shows causative link to dementia in
long term use ( 2 years low dose)
Cumulative Use of Strong Anticholinergics and Incident Dementia A Prospective Cohort Study
Shelly L. Gray,et al JAMA Intern Med. Published online January 26, 2015. doi:10.1001/jamainternmed.2014.7663

47.  One of 3 main physiotherapy modalities;
 manual therapy, exercise therapy, electrotherapy.
 Electrical stimulation agents, including
Transcutaneous Electrical Nerve stimulation (TENS),
Interferential Therapy (IFT), Functional Electrical
Stimulation (FES), and Microcurrent therapy (MCT),
Action Potential Simulation Therapy (APS Therapy)
 Thermal modalities, including Infra red Irradiation
(IFR), Therapeutic Ultrasound and Laser Therapy, and
 Non Thermal Modalities including Pulsed Ultrasound,
Pulsed Electromagnetic Fields (PEMFs) and
Microcurrent Therapy (MCT)

48.  Depend on therapy being used
 Mixed effectiveness
 Some (eg TENS) have poor carry-over and adaptation
 Some (eg micro-current) possible initial detox reactions,
but more beneficial effect on general wellbeing
 Prices vary, from TENS ( cheap) to SCENAR (
expensive)
 Some can self-manage = empowering, others involve
treatment by physio/practitioner
 Generally extremely safe

49.  Counselling/Talking therapies
 Cognitive Behavioural Therapy
 Neuro-Linguistic Programming/ ‘The Journey’/ EMDR
 Hypnosis/self-hypnosis
 Mindfulness / EMG Biofeedback
 Effects on wellbeing
 Vary with skill of practitioner, receptiveness of client
 And effectiveness of strategy… can go in circles
 Can be profound & lead to excellent self-management
 And real reduction in pain
 Availability as free service/cost implications

50.  Physiotherapy/hydrotherapy
 Massage
 Osteopathy/cranial osteopathy
 Chiropractic
 Bowen technique
 Kinesiology
 Acupuncture
 Myofascial release/trigger point therapy
 Shiatsu
 Reflexology

51.  Generally beneficial
 Generally safe
 Interaction with practitioner
 Human touch
 Assistance in manual lymph drainage, intracellular
communication
 Effectiveness varies depending on therapy, condition &
skill
 Price considerations and possibility of exploitation

52.  Massage balls/ self-massage
 Acupressure/reflexology stimulation points
 Home-use electrotherapies
 Exercise: Yoga, Pilates, core strengthening, stretching,
Wii fit, aquarobics, swimming, exercise equipment,
senior movement/keep fit, Tai Chi
 Supplements – vitamin D etc within safe limits
 Effects of wellbeing:
 Excellent – increases self-efficacy

53.  Lidocaine infusions ( local anaesthetic)
 Epidurals
 Nerve blocks – injections ( local anaesthetic and steroid)
 Surgery eg spinal fusion
 Spinal cord stimulation
 Deep brain stimulation
 Patient controlled analgesia (PCA) pump – palliative
 Wellbeing – waiting time, funding, rejections, short term,
unrealistic expectations, tolerance, and risks.

54.  Keep learning, keep an open mind
 Lots out there – one site I liked recently
 www.painscience.com
 https://www.painscience.com/articles/pain-
tips.php#sec_drs

55.  Be aware: doctors may not know their aches & pains medicine
 2.2 Trigger point massage: the best “secret” weapon, useful even when muscle pain is not the main problem
 2.3 Learn your perfect spots for pressure: a few key points go a long way
 2.4 The bath trick: give yourself a back rub with a ball in a bath
 2.5 Prevention: important even after you’ve been hurt
 2.6 Microbreaking: mobilizations at work
 2.7 Endurance training: under-rated but vital therapeutic exercise
 2.8 Strength training: better, easier than you thought
 2.9 The scientific 7-minute workout
 2.10 Stretching is most over-rated! But it may be useful for a few specific problems
 2.11 Heating: the most basic comfort
 2.12 Raw icing and power icing: for acute and chronic injuries
 2.13 An important icing exception: please (almost) never ice low back pain!
 2.14 Contrasting with heating and cooling: well worth a shot
 2.15 Epsom salt baths: the bath is nice, but the salt is useless
 2.16 Extra water intake? Don’t worry about it
 2.17 Get more sleep! If you’ve got insomnia, start looking seriously for solutions
 2.18 Tactical resting: the underestimated art of taking it easy
 2.19 Nutrition for healing: possibly helpful for serious chronic pain
 2.20 Vitamin D: the most likely of all supplements to be useful for pain
 2.21 Avoid most nutraceuticals, especially chondroitin and glucosamine: they are a waste of your money
 2.22 Try creatine & bromelain
 Minor update Jan 14 '15 Minor update (Jan 14 '15) — Made the tip more concise, and linked out to a new short article about
smoking and pain.
 2.23 Quit smoking: it’s not just for your lungs
 2.24 Postural correction: difficult and usually not very important, but still …
 2.25 Tits up! Use “power poses” to reduce pain sensitivity
 2.26 Reduce postural strain with ergonomics: not just about your keyboard height
 2.27 Use a wobble cushion: an unstable recovery?
 2.28 If you sit a lot, get a great chair, probably an Aeron

56.  2.29 Crunch! Self “adjust” your spine
 2.30 The confidence cure: rational, informed confidence can probably reduce pain
 2.31 Be kind to your nervous system: create pleasant, safe sensory experiences
 2.32 Orthotics: slip into something more comfortable
 2.33 Do not get a joint lube job: avoid artificial synovial fluid injection
 2.34 Heal by growing up: sometimes sweeping personal changes will also affect pain
 2.35 Hyperventilate: an unusual and powerful tool for changing your state
 2.36 General activity increase: do something, anything!
 2.37 Blow off steam: breathe and shake stress away
 2.38 Don’t be a pain drama queen! Tear up that one-way ticket to hell
 2.39 Exercise classes: aerobics, yoga, Pilates, taijiquan, boot camp, etc …
 2.40 Progressive training: break up the challenge into baby steps
 2.41 Friction massage (for tendonitis only)
 2.42 Pain-free ROM exercises after injury: use it (thoroughly) or lose it
 2.43 Mobilizations: massaging yourself with movement
 2.44 Don’t bother with hip strengthening: “weak hips” is a poor scapegoat for chronic leg injuries
 2.45 Try Voltaren: anti-inflammatory medication only where you need it
 2.46 The most popular of all “herbal” pain creams has precious little herb in it
 2.47 Check your drugs! Pain can actually be a side effect — even of pain killers!
 New Jun 27 '15 +New (Jun 27 '15) —
 adjustments (Sep 10 '15) — Small but meaningful improvements regarding safety and efficacy.
 2.48 Master over-the-counter pain medications
 2.49 Get in the pool! Water is a really good place for rehab and pain
 2.50 Relaxation massage: not just fluffy
 2.51 Novel sensory input: change how it feels with taping, bracing, or other tricks
 2.52 Don’t knock “masking” symptoms

57. Miranda Olding RGN MSCN MCMA
www.painfreepotential.co.uk www.mirandasmsblog.com
01908 799870
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