Pain Management Research Paper


Pain always accompanied the existence of living beings and as a rule, pain indicates at certain problems that an organisms suffers from. At the same time, the nature of pain and its treatment have remained unknown for a long period of time and it is only due to recent scientific achievements that the secrets of pain were partially uncovered and quite effective methods of its treatment were developed. Nonetheless, pain is still a great problem, especially in post-operative care, when patients need a particular attention and health care should be of the highest quality. On the other hand, it is necessary to remember that there are various types of pain and different methods of its treatment varying from traditional to quite unusual, some of which are not very reliable. This is why it is necessary to carefully examine the physiology and basic causes of pain in order to better understand the most effective ways of management of patients with pain.

Physiology of pain

Speaking about physiology of pain, it is primarily necessary to briefly define the notion of pain. Traditionally, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Lilley et al 1999). However, it should be pointed out that modern researchers rather prefer to use the term nociception, instead of pain, in order to clearly distinguish detection of noxious event or a potentially harmful event and the psychological responses to it.

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In such a context it should be said that all nociceptors are free nerve endings that have their cell bodies outside the spinal column in the dorsal root ganglion. These sensory endings look like branches of small bushes. There are mechanical, thermal and chemical nociceptors. They are found in skin and on internal surfaces such as periosteum and joint surfaces. Deep internal surfaces are only weakly supplied with pain receptors and will propagate sensations of chronic, aching pain if tissue damage in these areas occurs.

Basically, it is possible to single out two main types of nociceptors, notably Ao and C fibers, which mediate fast and slow pain respectively. Thinly myelinated type Ao fibers, which transmit signals at rates between 6 to 30 meters per second mediate fast pain. This type of pain is felt within a tenth of a second of application of the pain stimulus. It can be described as sharp, acute, pricking pain and includes mechanical and thermal pain.

In contrast, slow pain is mediated by slower, unmyelinated or ‘bare’ type C pain fibers that send signals at rates between 0.5 to 2 meters per second. This type of pain is an aching, throbbing, burning pain. For instance, chemical pain may be viewed as a sample of slow pain. Nociceptors do not adapt to stimulus. Also it should be said that, in some conditions, excitation of pain fibers becomes greater as the pain stimulus continues, leading to the condition known as hyperalgesia.
Naturally, an individual can feel pain only if it is transmitted in the central nervous system. In this respect, it should be said that there are two pathways for transmission of nociception in the central nervous system. To put it more precisely, these are the neospinothalamic tract, which is used as a transmitter for fast pain, and the paleospinothalamic tract, which is used as a transmitter for slow pain.

Basically, fast pain travels via type Ao fibers to terminate on lamina I of the dorsal horn of the spinal cord. Second order neurons of the neospinothalamic tract then take off and give rise to long fibers which cross the midline through the grey commisure and pass upwards in the contralateral anterolateral columns. These fibers then terminate on the reticular formation, Ventrobasal Complex (VBC) of the thalamus. From here, third order neurons communicate with the somatosensory cortex. Fast pain can be localized easily if Ao fibers are stimulated together with tactile receptors.

As for slow pain, it is transmitted via slower type C fibers to laminae II and III of the dorsal horns, together known as the substantia gelatinosa. Second order neurons take off and terminate in lamina V, also in the dorsal horn. Third order neurons then join fibers from the fast pathway, crossing to the opposite side via the grey commisure, and traveling upwards through the anterolateral pathway. These neurons terminate widely in the brain stem, with one tenth of the fibers stopping in the thalamus, and the rest stopping in the medulla, pons and tectum of midbrain misencephalon, periaqueductal grey. Unlike fast pain, slow pain is poorly localized.

Furthermore, when the nociceptors are stimulated they transmit signals through sensory neurons in the spinal cord. These neurons release glutamate, a major exicitory neurotransmitter that relays signals from one neuron to another. If the signals are sent to the reticular formation of brain stem, thalamus, then pain enters consciousness, but in a dull, poorly recognized manner. From the thalamus, the signal can travel to the somatosensory cortex in the cerebrum, when the pain is experienced as localized and having more specific qualities.

It is worthy of mention that Feinstein and his colleagues (1954) found that nociception could also “activate, generalized autonomic responses independently of the relay of pain to conscious level” causing “pallor, sweating, bradycardia, a drop in blood pressure, subjective faintness, nausea and syncope” (147).

Causes of pain

Basically, there may be different causes of pain which often related either to some trauma or disease of certain organs. It should be pointed out that visceral pain sensations is often referred by the central nervous system to a dermatome region which may be faraway from the originating organ. These correlate to the position of the organ in the embryo. For instance, the heart, which actually originates in the neck, can produce the classical pain and arm pain experienced during acute cardiac pain.

Speaking about the pain in different organs and parts of the body, it should be said that the pain in head and neck may be provoked by trauma, temporal arteritis, otitis media or externa, glaucoma, migraine, tension headache, cluster headache, etc. The pain in thorax, may be provoked by trauma, cancer, pulmanory embolism, cholecystitis, perimenstrual, etc. The pain in the abdomen may be caused by cancer, peptic ulcer disease, gastroenteritis, abdominal aortic aneurism, appendicitis, ectopic pregnancy, pelvic inflammatory disease, etc. The pain in the back may result from muscle strain, cancer, spinal disc herniation, degenerative disc disease, coccyx. Furthermore, the pain in limbs may be caused by muscle strain, deep vein thrombosis, peripheral vascular disease, spinal disc herniation, sciatica. Finally, the pain in joints can be provoked by osteoarthritis, rheumanoid arthritis, gout pseudogout, osteonecrosis, trauma, hemarthrosis, inflammatory bowel disease, psoriatic arthritis, Reiter’s syndrome.

Management of patient with pain and treatment of pain

Unquestionably, patient with pain should receive a very serious and careful treatment. Primarily, it is necessary to underline that it is important to avoid the unnecessary disturbance of the patient and provide him/her with the sufficient amount of rest time so that he/she could repose and gradually recover from the disease or problem that have actually caused the pain.

However, before starting the treatment itself, it is necessary to properly assess the pain according to the pain scale that will provide an opportunity to select the most effective way of treatment of the patient. It should be said that there are different pain scales which are basically used as tools that can help health care providers not only measure but also diagnose a patient’s pain intensity.

Traditionally, among the most widely spread pain scales may be named three forms of scales such as visual, verbal, numerical. Other scales mainly represent the combinations of the three mentioned above. Nowadays, one of the most widely spread pain scales is the Wong-Baker Faces Pain Rating Scale which actually combines all three forms of scales since it uses five images of faces depicting different emotions from the normal state to acute or unbearable pain. Basically, the scale goes from 0 to 5 and each number is accompanied by the respective image of a face. At the same time, both numbers and faces are accompanied by verbal correspondences: 0 – no hurt, 1 – hurts a little bit, 2 – hurts a little more, 3 – hurts even more, 4 – hurts a whole lot, 5 – hurts worst.

As a rule, in order to ease pain, especially acute one, pharmacological measures are undertaken. Traditionally, analgesics such as narcotics or NSAIDs and pain modifiers such as tricyclic antidepressants or anticonvulsants are used. In this respect, it is worthy of mention that some analgesics can cause negative side effects that can be potentially quite dangerous for the patient’s health. This is why it is necessary to be very careful while using analgesics and before applying such a treatment it is necessary to find out whether it is safe for the patient. In the case, if the treatment has been already started and unexpectedly some side effects have been revealed, t is highly recommended to stop the use of the analgesics and substitute them using a different pharmacological substance or even use an alternative way of treatment.

In fact, in such a situation, non-pharmaceutical measures may be also undertaken. Among the most effective non-pharmaceutical measures may be named the following: interventional procedures, physical therapy and physical exercise, application of ice and/or heat. Also, many specialists underline that the use of psychological measures, such as biofeedback and cognitive therapy, may be often quite effective.

Management of pain with children and elderly patients

Analyzing the problem of pain, it is extremely important to pay a particular attention to children and elderly patients since these two categories of patients are particularly exposed to the higher risk of the treatment of pain.

First of all, it should be said that managing of pain with children the first problem a doctor can face is the localization of pain. In other words, it is quite difficult to clearly understand where the pain is actually localized and, what is more, often children, especially very young ones, cannot simply explain what kind of pain they have. In such a situation verbal description of the pain may be absolutely ineffective and this is where the Wong-Baker Faces Pain Rating Scale may be extremely helpful as it can visualize the rate of pain and such visualization may be more comprehensible to children.

It is worthy of mention, that some elderly people may have similar problems with identification of pain as their senses gets to be less sharp and neuron transmission is not so effective as younger people have. Moreover, elderly people also have a number of limitations concerning the use of pharmacological measures as well as children have. Practically, it means that it is necessary to be very careful while selecting pharmacological measures.

As for possible alternatives, such as non-pharmacological treatment it is also not always applicable to children and elderly people as sometimes they cannot physically afford such a treatment.

Furthermore, it is necessary to remember that a doctor should be particularly careful about the management of pain with children and elderly people as they are more vulnerable to negative effects of treatment as well as pain itself.


Thus, taking into account all above mentioned, it is possible to conclude that management of patient with pain is an extremely complicated process. To treat the pain effectively, it is necessary to have a profound knowledge of physiology of pain and be bale to clearly define what exactly have caused the pain in the particular case of management of a patient with pain. At the same time, it is equally important to know the effective ways of treatment of pain among different categories of patients, i.e. children, adults, elderly people and, what is more it is necessary to be able and modify measures undertaken in the process of treatment depending on the state of a patient.

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