Pain Management in Oxfordshire

Types of Pain

Acute pain

– is a type of pain that typically lasts less than 3 to 6 months, or pain that is directly related to soft tissue damage such as a sprained ankle or a paper cut. 

Chronic pain

– Longer than 12 weeks or pain that lasts longer than the expected period of healing, or secondary to illness. It can be an illness in its own right, a malfunction of the body’s pain responses.

Each person’s pain experience is a unique combination of influences from various brain areas. They can be influenced by cultural background (your daughter falls over and you run over to kiss the graze better, she learns that falling over hurts and rubbing it makes her feel better, but you may tell your son to “Man up” and get on with it, it’s only a graze.) This kind of conditioning has an effect on how we view pain.

The nervous system is broadly divided into the peripheral nervous system, which covers all of the body areas outside of the brain and spinal cord, and the central nervous system, which includes the nerves and structures within the spinal cord and brain.

Gate Control theory

In 1965 Melzack and Wall developed the Gate Control Theory of pain, which both peripheral and central nervous system influences the experience of pain.

There is no pain centre in the brain, but multiple integrated networks which contribute to the overall experience of the pain.

Pain also does not transmit directly, like an electrical diagram, where a battery sends an electric current down a wire to light a lightbulb, it’s a 3-dimensional experience, so pain messages are being radiated outwards.

It can be classified broadly into 3 types:

• Neuropathic pain (resulting from a cut or disease)
• Nociceptive pain (pain which is non-neuropathic)
• Psychogenic pain (pain resulting primarily from psychological trauma or process).

Consequently, the type of pain which is most prevalent will determine which treatment will be most effective.

NOCIEPTIVE PAIN

Superficial

Superficial is the nociceptors in the skin and superficial tissue, the idea that something is superficial makes it sound as if it’s not important, however, in medical terms it just means it’s near the surface of the body. 

Deep

Deep somatic pain is stimulation of nociceptors in the ligaments, tendons, bones. This is poorly localised and can be pain referred from another area. 

The most common nociceptive pain problems are:

• Headaches
• Lower back pain
• Arthritis
• Strain and injury

Nociceptive pain often increases after activity and people often stop exercising, which can complicate things in the long term. Exercise also increases dopamine and endorphins, as well as keeping our mental health boosted.

 

NEUROPATHIC  PAIN

Peripheral                                        

Peripheral nervous system pain often described as tingling, electric, stabbing, pins and needles.

Central

Central Neuropathic pain comes from the spinal cord.

Neuropathic pain does not respond well to biomedical treatments. As a result, some reduction in pain by opioids has been found but their long-term effects are detrimental to our health (nausea, constipation, increasing dosage as the effects become less, reduce testosterone and lead to dependency)

Most common peripheral neuropathic pain conditions are:

• Shingles
• Injury to peripheral nerves in diabetes.
• Pain caused by toxins or toxic drugs like chemotherapy
• Inflammatory diseases such as Lupus
• Guillain-Barre syndrome
• Phantom limb pain
• Nerve compression
• Carpal tunnel syndrome
• Trigeminal neuralgia
• Charcot-Marie-Tooth disease
• Multiple sclerosis
• Physical trauma.

Self-hypnosis can help decrease neuropathic pain (Jensen, Barber, Romano, Molton 2009) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465776/

Psychogenic pain

Psychogenic pain can be defined as pain resulting from psychological factors, often started by some kind of trauma or underlying medical condition.

Hence, this kind of pain management is a combination of different approaches, including massage, acupuncture and psychotherapy, as well as learning valuable techniques such as mindfulness, progressive muscle relaxation and guided imagery.

Sometimes pain can be included in all three categories such as:

• Complex Regional Pain Syndrome type I (CRPS-I was formerly known as reflex sympathetic dystrophy)
• Fibromyalgia
• Visceral pain (Pelvic pain)

Self-hypnosis, hypnotic analgesia, mindfulness and progressive muscle relaxation and guided imagery can help these cases.

The scientific explanation of pain

The fibres that communicate nociceptive information from the periphery to the central nervous system enter the spine at the Dorsal horn. These fibres end there and connect with nerves that send information up the spine into the brain. Most of the nerves end at the thalamus, which is the primary relay centre in the brain. It’s called the spinothalamic tract (STT) and plays an important pathway for the transmission of information to the brain.

The STT

The response of STT neurons is influenced by activity coming down the spinal cord to the dorsal horn. As a result, the brain is able to make the STT cells less responsive. Therefore, the brain’s ability to change this can create an analgesic response. Stimulation of the periaqueductal grey (PAG) in the midbrain from the insula, the anterior cingulate cortex (ACC) and the sensory cortex (all areas are known to process pain) shows that the brain is hardwired to have the ability to inhibit pain information coming in from the periphery. These brain areas all work together to produce our experience we label pain. Consequently, this can help us in the first stages of pain management.

Survival

The purpose of this system – while having some control over the pain we experience – has much to do with survival and the ability to get ourselves away from danger first.

Consequently, once the danger is far enough away, the somatosensory cortex (which is divided into two parts S1 and S2) can encode the special information, drawing our attention to where the pain actually is on the body.

The ACC

The Anterior cingulate cortex (ACC) lies between the two hemispheres. It’s part of the limbic system and processes a great deal of data. With pain, it processes the emotional conditioning – hence one’s moods, feelings, and attitudes towards pain and how you’re going to cope.

The Pre-frontal cortex (PFC) – the part of the brain that lies at the front of your head behind the forehead is involved in the planning of complex responses. It’s the part of the brain that moderates our behaviour. Therefore it gives meaning to the pain we experience. Consequently, when the prefrontal cortex is more active, we feel less pain. If you are engaged in a situation which is taking all your focus, you stop noticing the severity of the pain.

Plastic brain

Because the brain is so plastic it is constantly changing. Research by Tinazzi and Melzack has found that the experience of pain is a learned response – triggered by the nociception over time. Hence, memories of pain and the context of the person’s life goals need to be addressed. Therefore, this is why we look at the person as a whole, not just the chemistry. How our thoughts and feelings about the pain and our situation can affect how we implement pain management effectively.

Perception’s role in pain management.

Psychological factors influence our experience of pain, anxiety and depression will have an effect and if we catastrophize. Therefore, catastrophizing often focuses our attention on the pain, and ruminating on it will intensify it. You are hypnotising yourself into making the pain worse.

First of all, those who do catastrophize tend to experience more pain than those who do not. Hence they tend to experience more anxiety, depression, distress and disability. Therefore, they tend to guard themselves more, so move slower and stiffer, rest more and often ask for help doing chores. As a result, research has found that discouraging people from catastrophizing is more effective than encouraging coping self-statements.

Beliefs

Pain beliefs are the meanings people place on their pain. Hence, this can have an effect on how they perceive the pain. The fact that we can change our perception of pain is a positive. As a result, you can use cognitive behavioural methods, solution-focused goal setting, mindfulness, self-hypnosis, relaxation techniques. Furthermore, you can control focus and attention, and visual imagery. A pain in one part of the body can be changed from sharp to dull, from heavy to fluid, from red and inflamed to cool and silky.