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Treatment of pain
TREATMENT OF PAIN
Management of pain is very important on both patients perspective and economic perspective. Pain is the most important reason people seek medical attention. About 80% of the doctor visits are primarily because of some pain problem. An appropriate pain management protocol should be made while treating patients who seek medical attention for pain. An extensive pain protocol plan includes a pain management care path flow chart, a pain assessment tool, an opioid Reference Table, an analgesics table, side effects management sheet, and a non-pharmacologic interventions for psychosocial, spiritual & physical pain flow chart. The pain therapy depends on the type of pain. As mentioned earlier, for clinical purpose pain is divided in to two types neuropathic pain and nociceptive pain. The drugs effective for pain control are different in these two types of pain.
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effective for pain control are different in these two types of pain. Pain killers: The pain medicines used are categorized in to the following types: Non steroidal anti-inflammatory drugs Alpha 2 adrenergic drugs Steroids Drugs like antidepressants, muscle relaxant and sleeping pills Drugs for neuropathic pain treatment Non steroidal anti inflammatory drugs: These are some of the commonly used drugs for pain relief. These are mainly effective for nociceptive pain. Some of the commonly used drugs are acetaminophen, ibuprofen, naproxen, diclofenac and salicylates. Some of the side effects of these drugs are, gastritis, worsening of asthma and kidney damage if taken for a longer time. The newer COX 2 inhibitors like valdecoxib and rofecoxib have less side effects. Opioids: Opioids are effective pain relievers for all types of pain including neuropathic pain.Morphine is the original drug of this class. The other drugs include codeine, fentanyl, meperidine, pentazocine and propoxyphene. Some of the side effects include addiction, respiratory depression and constipation. Alpha 2 adrenergic drugs: These drugs were initially used to hypertension. But these drugs also have sedative properties and have been used to treat pain and anxiety. Some of the drugs of this class are clonidine and tizanidine. These drugs can cause fatigue and dry mouth. Steroids: Steroids are very potent anti inflammatory drugs and have widespread use in medicine for both anti inflammatory and their pain relieving effects. In pain management they are most commonly take by mouth to relieve the pain of arthritis and by injection along with local anesthetics in arthritic joints and in the spinal canal to relive back pain. Steroids should be used very judiciously. In high doses given for more than a few days, they can have various adverse effects including diabetes, osteoporosis and other damage to bones like avascular necrosis to the femoral head.

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Drugs for neuropathic pain treatment: As said earlier opioids are effective for neuropathic pain relief. Neuropathic pain was until recently believed to be resistant to this class of analgesics. The conventional treatment consists of drugs like anticonvulsants, local anesthetics, neuroleptics, topical analgesics, menthol, and NMDA antagonists. Anticonvulsants These were initially meant to treat seizures. But now they are being used for chronic pain management especially neuropathic pain. Some of the anticonvulsants used are carbamazepine, clonazepam, valproate, phenytoin, gabapentin, topiramate and lamotrigine. Local anesthetics Local anesthetics given by mouth are useful for neuropathic pain. The most commonly used one is mexiletine which was originally used for heart rhythm abnormalities. Other drugs

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used one is mexiletine which was originally used for heart rhythm abnormalities. Other drugs used are tocainide and flecanide. Neuroleptics- Neuroleptics are drugs tradionally used for psychotic illnesses. Two drugs of this class olanzapine and resperidone are found useful to treat chronic pain. Topical analgesics These includes drugs like menthol, lidocaine, EMLA cream and capsaicin. Brand name of good topical analgesic is CryoDerm. NMDA antagonists NMDA receptors worsen pain. NMDA receptor antagonists therefore can relieve neuropathic pain. Some of the drugs of this class are methadone, dextromethorphan and ketamine. Antidepressants: Pain is so often associated with depression that it is sometimes is unclear which came first. Regardless treating depression not only elevates mood but also improves the physical functioning. Some of the drugs of this class include tricyclic antidepressants like amitryptyline, selective serotonin reuptake inhibitors like fluoxetine. Sleeping pills and muscle relaxants: Muscle relaxants are prescribed for pain stiffness and muscle spasm. They also have mild sedative properties. Some of the drugs of this class are carisoprodol, methocarbomol and diazepam. There are also natural muscle relaxants such as valerian and passiflora, as found in Formula 303.
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Types of pain
PAIN IS DIVIDED INTO TWO TYPES:
1. 2. Acute pain Chronic pain

Acute pain is pain of sudden onset, lasting for hours to days and disappears once the underlying cause is treated. Acute pain has a clear cause . It could result from any illness, trauma, surgery or any painful medical procedures. Hence it is beneficial to the patient because but for the pain, the individual will ignore his illness resulting in complications and even death. Acute pain signals that there is something wrong and motivates the person to get help. For example- just because the nociception is caused by appendicitis, the person consults a doctor and undergoes surgery to get relieved. If pain is not there he will not seek medical advice and his appendix may burst and form a mass which is more difficult to treat. Thus acute pain can be beneficial. Examples of acute pain include:

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the pain of heart attack acute appendicitis bone fracture muscle sprain prolapsed intervertebral disc of the spine

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Chronic pain is the pain that starts as an acute pain and continues beyond the normal time expected for resolution of the problem or persists or recurs for various other reasons It is not therapeutically beneficial to the patient. In acute pain, attention is focused to treat the cause of pain whereas in chronic pain, the emphasis is laid upon reducing the pain to give relief, limit disability and improve function. About 9% of the US population and 18% of the European population suffer from chronic pain. It is rarely accompanied by signs of sympathetic nervous system arousal. The severity and extent of chronic pain may be out of proportion to the original injury and may continue long past the period in which the damage tissue has healed. Chronic pain is pain that has outlived its usefulness and is no longer beneficial. Acute & Chronic Pain Treatment Goals Acute and chronic pains have different treatment goals. The primary goal of acute pain treatment is to diagnose the source and remove it. With chronic pain, the main goals are to minimize the pain and maximize the persons functioning. Complete relief of pain is rare in chronic pain. The more realistic goal is to decrease the level of pain to a tolerable level that allows the person focus on everyday activities. The treatment of chronic pain is multidisciplinary that blends physical, emotional, intellectual and social skills. Returning to work is clearly a desirable goal, but in fact, only 50% percent of patients who undergo comprehensive multidisciplinary pain rehabilitation are able to return to work. Chronic pain is further divided into: 1. 2. Nociceptive pain Neuropathic pain

ORTHODONTIC TREATMENTS

Nociceptive pain: Nociceptive pain is pain arising from damage to tissues other than nerve fibers. It is also called tissue pain. The undamaged nerve cells called nociceptors carry the sensation to spinal cord from where it is relayed to the brain. It is called somatic pain if it results from injury to muscles, tendons and ligaments. Somatic pain is usually well localized. It is called visceral pain if it results from injury to the internal organs like stomach, gall bladder and urinary bladder. Visceral pain is usually diffuse and non-localizing. Somatic pain in turn is classified in to cutaneous somatic pain if the pain arises from the skin and deep somatic pain if it is from deeper musculoskeletal tissues. The various causes of joint pain are grouped under musculoskeletal pain. Neuropathic Pain: Neuropathic pain is the pain caused by the lesion in the nervous systemwhen they are structurally or functionally damaged. It is called central pain if the lesion is the central nervous system. It is called peripheral neuropathic pain if the lesion is in the peripheral nervous system. The neuropathic pain is described as severe, sharp, lancinating, lightninglike, stabbing, burning, cold, numbness, tingling or weakness. It may be felt traveling along the nerve path from the spine down to the arms/hands or legs/feet. It does not respond to the routine analgesics. Keep in mind that nociceptive and neuropathic pain can co-exist in the same patient in
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Keep in mind that nociceptive and neuropathic pain can co-exist in the same patient in certain conditions like Sciatica. Many other types of pain are also described. Malignant pain Breakthrough pain Allodynia Hyperalgesia Paresthesia Hyperpathia Complex Regional Pain Syndrome I Complex Regional Pain Syndrome II Phantom limb pain Psychogenic pain Anesthesia dolorosa Anginal pain Idiopathic pain Malignant pain: Malignant pain is the pain suffered by the patients with cancer. The pain can be either due to the disease itself or due to the treatment given for cancer like surgery, radiotherapy and chemotherapy. Breakthrough pain: When pre-existing chronic pain is aggravated, it results in breakthrough pain needing adjustments in treatment to obtain relief. In other words,breakthrough pain is the pain that results from the worsening of the previously present chronic pain for which the person is on regular treatment. It usually comes on quickly and may last from a few minutes to an hour. The reason for this worsening of pain cannot be understood or anticipated by the person. The routine doses of analgesic never help and a readjustment of the analgesic doses is necessary along with the modification of the physical activities. Allodynia: Allodynia is a pain that results from the stimulus which does not normally evoke any pain sensation. Many people aquire allodynia after they've been in pain for quite some time and they become hypersensitive to touch. Hyperalgesia: Hyperalgesia is an increased response to a stimulus which is normally painful. Paresthesia: Paresthesia is abnormal sensation which is described as pins and needles. It can occur either spontaneously or evoked by certain stimuli. Hyperpathia: Hyperpathia is a painful syndrome resulting from an abnormally painful reaction to a stimulus. The stimulus in most of the cases is repetitive with an increased pain threshold. Pain threshold can be defined as the least experience of pain which a subject can recognize. Complex Regional Pain Syndrome I: Complex Regional Pain syndrome I also called as Reflex Sympathetic Dystrophy is a continuous pain in the form of either allodynia or hyperalgesia in the extremities resulting from trauma which is associated with sympathetic hyperactivity. The pain does not correspond to the distribution of a single nerve and it is worsened by movement. The person affected usually complains of cool, clammy skin which later becomes pale, cold, stiff and atrophied. Complex Regional Pain Syndrome II:
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Complex Regional Pain Syndrome II also called as Causalgia is a burning type of pain along the distribution a partially damaged peripheral nerve. The pain extends beyond the distribution of the nerve. This results from abnormal connections between various nerves. The skin of the person affected is classically cold, moist and swollen, becoming atrophic later. Phantom limb pain: Phantom limb pain is the pain that is felt in the amputated part of the body. The brain misinterprets the nerve signals as coming from the amputated limb. The phantom limb pain is described as squeezing, burning, or crushing sensations, but it often differs from any sensation previously experienced. Psychogenic pain: Psychogenic pain is seen in persons with psychological disorders. They have persistent pain without any evidence of physical cause of pain. Though it is termed psychogenic the person suffers from real pain. This pain is also called chronic pain syndrome. Sometimes psychogenic factors may worsen a pre-existing physical pain. Anesthesia dolorosa: Anesthesia dolorosa is the pain that is felt in the part of the body that is numb to any other sensation. Anginal pain: Anginal pain is the pain of cardiac origin. It is described as a feeling of oppression or tightness. It occurs due to disruption of the blood supply to the heart muscle. Idiopathic pain: When a reasonable cause for the pain cannot be made out, it is called idiopathic pain.

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Pain: definition, theories..

VARIOUS DEFINITIONS OF PAIN
There are numerous different definitions for pain. The most widely accepted definition of pain is the one used by The International Association for the Study of Pain. It defines pain as An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. The American Academy of Pain Medicine defines pain as An unpleasant sensation and emotional response to that sensation. Pain has the dubious distinction of being the commonest symptom for which a person approaches medical care. The definition of pain that is most appropriate for use in clinical practice was given by Margo McCaffrey in 1968. He defined pain as whatever the experiencing person says it is, existing whenever he says it does." The Web version of the Encyclopedia Britannica defines pain as A complex experience consisting of a physiological (bodily) response to a noxious stimulus followed by an affective (emotional) response to that event. Pain is a warning mechanism that helps to protect an organism by influencing it to withdraw from harmful stimuli. It is primarily

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protect an organism by influencing it to withdraw from harmful stimuli. It is primarily associated with injury or the threat of injury, to bodily tissues. Dr. Don Ranney, in his book Anatomy of Pain defines pain as A perception, not really a sensation, in the same way that vision and hearing are. It involves sensitivity to chemical changes in the tissues and then interpretation that such changes are harmful. This perception is real, whether or not harm has occurred or is occurring. Cognition is involved in the formulation of this perception. There are emotional consequences and behavioral responses to the cognitive and emotional aspects of pain. Dr. Pennal, in his book Personality of Pain defines pain as An abstract concept which refers to: A personal, private, sensation of hurt A harmful stimulus which impending tissue damage signals current or

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A pattern of responses which operate to protect the organism from harm Theories of Pain Specificity theory. Von Frey (1895) argued that the body has a separate sensory system for perceiving painjust as it does for hearing and visionand this system contains its own special receptors for de:ecting pain stimuli, its own peripheral nerves and pathway to the brain, and its own area of the brain for processing pain signals. But this structure is not correct. Pattern theory . Goldschneider (1920) proposed that there is no separate system for perceiving pain, and the receptors for pain are shared with other senses, such as of touch. According to this view, people feel pain when certain patterns of neural ctivity occur, such as when appropriate types of activity reach excessively high levels in the brain. These patterns occur only with intense stimulation. Because strong and mild stimuli of the same sense modality produce different patterns of neural activity, being hit hard feels painful, but being caressed does not. Gate Control Theory. Melzack has proposed a theory of pain that has stimulated considerable interest and debate and has certainly been a vasy improvement on the early theories of pain. According to his theory, pain stimulation is carried by small, slow fibers that enter the dorsal horn of the spinal cord; then other cells transmit the impulses from the spinal cord up to the brain. These fibers are called T-cells. The T-cells can be located in a specific area of the spinal cord, known as the substantial gelatinosa. These fibers can have an impact on the smaller fibers that carry the pain stimulation. In some cases they can inhibit the communication of stimulation, while in other cases they can allow stimulation to be communicated into the central nervous system. For example, large fibers can prohibit the impulses from the small fibers from ever communicating with the brain. In this way, the large fibers create a hypothetical "gate" that can open or close the system to pain stimulation. According to the theory, the gate can sometimes be overwhelmed by a large number of small activated fibers. In other words, the greater the level of pain stimulation, the less adequate the gate in blocking the communication of this information. There are 3 factors which influence the 'opening and closing' of the gate 1. The amount of activity in the pain fibers. Activity in these fibers tends to open the gate. The stronger the noxious stimulation, the more active the pain fibers. 2. The amount of activity in other peripheral fibersthat is, those fibers that carry

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information about harmless stimuli or mild irritation, such as touching, rubbing, or lightly scratching the skin. These are large-diameter fibers called A-beta fibers. Activity in Abeta fibers tends to close the gate, inhibiting the perception of pain when noxious stimulation exists. This would explain why gently massaging or applying heat to sore muscles decreases the pain. 3. Messages that descend from the brain. Neurons in the brainstem and cortex have efferent pathways to the spinal cord, and the impulses they send can open or close the gate. The effects of some brain processes, such as those inanxiety or excitement, probably have a general impact, opening or closing the gate for all inputs from any areas of the body. But the impact of other brain processes may be very specific, applying to only some inputs from certain parts of the body. The idea that brain impulses influence the gating mechanism helps to explain why peopie who are hypnotized or distracted by competing environmental stimuli may not notice the pain of an injury. Thus we can conclude that our experience of pain is dependent on the condition of 'the gate'. The more the gate is opened the greater the perception of pain. Melzack suggests that several factors can open the gate: Physical factors, such as injury or activation of the large fibres Emotional factors, such as anxiety, worry, tension and depression; Behvioural factors, such as focusing on the pain or boredom. The gate control theory also suggests that certain factors close the gate. Physical factors, such as medication, stimulation of the small fibres; Emotional factors, such as happiness, optimism or relaxation; Behavioural factors, such as concentration, distraction or involvement in other activities.

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