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What is Pain?

Pain is the unpleasant sensation that is experienced following an injury.

 

It’s the sensation that the body creates to signal the injured person that the body has sustained damage. The aversive nature of the pain experience is one of the factors that motivates us to prevent injury and care for our injuries.

 

Pain is the most frequent reason for consulting a physician or receiving emergency medical care. It is also the most frequently cited reason for taking sick leave from work. The health care resources that are used for treating pain, and the enormous societal costs associated with occupational disability make pain the most costly of all symptoms that arise following injury.

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Pain Types

Pain is not specific to any particular injury. Any injury that damages the body can lead to the experience of pain. Whether someone has sustained a whiplash injury, a head injury, a spinal cord injury, a fracture, contusions or lacerations, it is likely that symptoms of pain will be experienced.

Whiplash Injury Pain

A wide range of pain symptoms might be experienced following whiplash injury which often causes pain in the area of the neck. Pain symptoms in the shoulders and upper arms can also be experienced and might be the result of direct injury, or could be due to the ‘spreading’ of pain from the injured neck tissues.

At times, uncomfortable sensations might be felt down the arms and in the fingers. These uncomfortable sensations can take the form of tingling, temperature changes or numbness and can be of sufficient intensity, such that they might feel painful.

Individuals with whiplash injuries might also experience headaches which differ from usual headaches. Individuals will describe headaches that seem to originate at the top of the spine or the base of the skull, that might spread up the back of the skull to the top of the head. These headaches are referred to as ‘occipital headaches’ or ‘cervicogenic headaches’.

The Pain of Low Back Injury

Low back injuries can result from excessive strain, falls or motor vehicle crashes. It can be experienced as a dull, constant aching sensation, or a sudden, sharp sensation. It can also have a sudden onset after an injury or strenuous activity, or it might also develop slowly over time, even in the absence of injury.

At times, uncomfortable sensations might be felt down the legs, and in the foot and toes, and can take the form of tingling, or numbness and can be experienced with sufficient intensity that they will feel painful. These sensations radiating down the leg might represent a condition known as ‘sciatica’, sometimes the result of irritation or pinching of nerves at the lower (lumbar) part of spine.

‘Mechanical low back’ is the term used to describe low back pain that is not associated with a disease process and is not expected to worsen over time. Most episodes of mechanical low back resolve within a few days of onset. Typically, no special treatment is required.

The Pain of Spinal Cord Injury

Individuals with spinal cord injuries (SCI) must adapt their means of mobility in order to move about their environment. The shoulder muscles will be implicated in propelling a manual wheelchair, and in effecting transfers in and out of a wheelchair. These increased demands on the muscles of the shoulder can lead to symptoms of pain, the most frequent type of pain reported by individuals with SCI.

‘Central pain’, or ‘central neuropathic pain’ are terms that have been used to describe symptoms of pain experienced at or below the level of the spinal cord injury. It is estimated that approximately half of individuals with a SCI will experience central pain which may be described by such terms as sharp, shooting, throbbing, squeezing or burn­ing.

There are few treatments that have been shown to be effective in reducing the severity of central neuropathic pain. As a result, some individuals with SCI might endure distressing symptoms of pain for many years. Researchers believe that central neuropathic pain might be the result of miscommunication between the spinal cord and the brain caused by damaged nerves. 

‘Visceral pain’ is the term used to describe pain experienced in the abdomen or pelvis and is often described as dull or cramping. Like central neuropathic pain, visceral pain might be the result of miscommunication between the spinal cord and the brain caused by damaged nerves. It might also be caused by disease processes such as urinary tract infections, inflammation or bowel impaction.

The Pain of Brain Injury

Headache is one of the most common and persistent pain symptom following a traumatic brain injury (TBI). ‘Post-traumatic headache’ is the term often used to describe the headaches of individuals with TBI.  Approximately one third of individuals with TBI will experience persistent headache symptoms following their injury. For the majority with post-traumatic headaches, headache symptoms will be episodic; in other words, the symptoms will recur on a regular basis, but there will be periods when the individual is free of headaches.

By definition, post-traumatic headaches have their onset within 7 days of injury. Although the cause of post-traumatic headaches is not known, these headaches share many of the features of migraine and tension headaches. The experience of migraine is often described as throbbing or pulsating pain, usually only on one side of the head, and is often accompanied by nausea.  Migraine headaches can be aggravated by light, sound and physical activity. The experience of tension headache is often described as a squeezing or tight painful sensation, usually on both sides of the head.

Fracture Pain

Fractures are common occurrences in injuries sustained in the workplace, sporting activities or motor vehicle crashes and will tend to be associated with significant pain immediately following injury, and for several weeks afterwards. Such pain will tend to be restricted to the bodily region where the injury has been sustained. The pain sensations experienced following a fracture will be due either to the damaged bone itself or to inflamed tissues surrounding the damaged bone.

Post-Surgery Pain

Individuals who have sustained serious injuries might require surgical intervention. For example, surgery might be required to repair a fracture of a limb, to treat damage to internal organs, or remove penetrating objects.

While the treatment objective of surgical interventions is to improve function and decrease pain, such interventions can also be the cause of pain. One of the side effects of surgery is damage to nerves at the incision site. It is not uncommon for people to experience long-term changes in sensation at the incision site of their surgery. The nerve damage can lead to symptoms of persistent pain in approximately 20% of individuals. Post-surgical pain is not considered to be part of any disease process. Researchers believe that post-surgical pain is the result of miscommunication between the damaged nerve cells and the brain.

Other Problems Associated with Pain

Many people who experience pain following an injury, report sleeping problems such as interference with a person’s ability to fall asleep, to stay asleep, or to feel rested after sleeping. Persistent sleep problems can also lead to fatigue and problems with concentration and memory.

Pain symptoms can increase in intensity as a result of physical activity. Consequently, some people with pain conditions discontinue many physically demanding activities of their lives. Although activity reduction might be associated with some pain relief in the short-term, it usually leads to a worsening of the pain condition in the long-term. Activity reduction can lead to physical deconditioning and slows the pace of recovery.

Pain is a distressing symptom that can contribute to mental health problems. Approximately one third of individuals with chronic pain conditions will experience symptoms of depression. For individuals whose injury occurred in the context of a traumatic event, some might experience symptoms of post-traumatic stress disorder. Others might develop symptoms of anxiety or become phobic of situations, places or activities that remind them of the accident.

The time course for different pain conditions vary widely. For a particular individual, and a particular type of pain, it is difficult to predict with any accuracy how long the pain will last. Most forms of pain that arise as a consequence of injury will only last a short period of time. This type of pain is typically the result of bodily damage, and the severity of pain will decrease as the injury begins to heal. There are cases, however, where pain will persist even after the injury has healed. When pain persists beyond the normal healing period, the term ‘chronic’ is used to describe the pain condition. Once pain becomes chronic, it can persist for years after the injury has been sustained.

The pain associated with low back pain or fractures will tend to resolve within one to two months following injury. The pain of whiplash injury will resolve rapidly for many individuals, but approximately half of individuals with whiplash injuries will continue to experience pain symptoms for as long as one year after the injury. Some types of pain emerge only months or even years following injury. For example, the visceral pain experienced by individuals with SCI will tend to emerge several months or even years after injury. Other types of pain, such as post-traumatic headaches, will be intermittent but can also continue to be experienced years after the injury.

It is important to understand that chronic non specific pain (that is pain more than three months after injury) occurs in the absence of a continuing specific injury. The injured diseases have healed but there is continuing sensitisation of the spinal cord or brain that maintains the pain. It is important to understand that the principles of management of chronic pain are completely different to acute pain. In chronic pain it is important to maintain usual activities in spite of the presence of pain. Medications have a very limited role in treatment of chronic pain.

 

Disability Associated With Pain

When severe, the symptoms of pain can interfere with an individual’s ability to engage in many activities of daily living. Reductions in participation in important life activities can contribute to a lowering of quality of life. In some cases, pain can also contribute to work disability. Prolonged work absence can complicate the recovery process as a result of stresses brought about by loss of independence and the loss of financial security.

Paradoxically, some treatments used in the management of pain can also contribute to disability. Medications used in the treatment of pain can cause side effects such as drowsiness, confusion and fatigue. The experience of these side effects can interfere with a person’s ability to participate in important life activities. In other words, some medications might reduce pain at the expense of increasing disability. The ideal pain medication regimen is one that will effectively control pain symptoms without producing side effects that increase disability.

 

The Psychology of Pain

The way people react or think about their pain can influence its severity, the time it will take to recover, and how disabled they will be as a result of their pain. Over the past 20 years, several research investigations have revealed that psychological factors can influence both the experience of injury and the path of recovery.

‘Optimism’, or the tendency to focus on the positive side of life appears to contribute to decreases in pain experience and to a more rapid recovery following injury. On the other hand, individuals who tend to focus on the negative aspects of their conditions experience more intense symptoms of pain and are slower to recover following injury

Fear also affects the path of recovery following injury. Some people avoid participating in activity because they fear that their pain might increase. Since activity participation is necessary to promote recovery, fear can prevent people from engaging in activities to maximise their recovery.

How people think about the future of their pain condition can also play an important role in recovery. People who expect that their condition will improve are actually more likely to improve than people who expect their condition to worsen. Researchers believe that positive expectations can increase the motivation and drive to participate in treatments or programs designed to promote recovery. On the other hand, negative expectations reduce an individual’s motivation or engagement in treatment, and in turn, the benefits of treatment are compromised.

It is important to remember that while psychological factors can influence recovery, psychological factors are not considered the cause of ongoing pain disability. If psychological factors were the primary cause of ongoing pain and disability then a simple change in thinking would be all that was needed to cure pain and disability. Changes in thinking might reduce the severity of pain and disability to some extent, but changes in thinking do not cure pain and disability. For example, optimism or positive expectations might lead to a reduction in the severity of pain, but optimism or positive expectations will not mend a severed spinal cord or repair damaged bones, muscles or tendons.

The Treatment of Pain

Several physical, psychological and pharmacological interventions have been used to treat the symptoms of pain.

The treatments described in this section are provided only for the purpose of information and should not be interpreted as endorsements.

Pharmacological Interventions

Pharmacologic management of pain in individuals who have sustained injuries is complex. Different approaches for the management of pain will be required for different types of pain. Given the complexity of the effective and safe management of pain, decisions about how to proceed should always be made in consultation with a medical professional.

There are a number of different types of pain medications that might be considered in the treatment of pain associated with injury. These include non-steroidal anti-inflammatories, analgesics, and anti-convulsants. Medications typically considered for the treatment of mental health problems such as depression are sometimes also used to treat pain. Pain medications might be administered orally, topically or by injection, and might also be combined with other medication in order to achieve optimum pain relief or minimize side effects. Like all forms of medication, pain medication will be associated with certain side effects, and long-term use must be considered with appropriate caution.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Non-steroidals anti-inflammatory drugs (NSAIDs) are some of the most widely used medications to treat pain conditions that arise consequent to injury. NSAIDS work by blocking the production of one of the body’s neurochemicals called ‘prostaglandin’. Following injury, the body produces prostaglandin, which in turn, stimulates swelling and causes pain. Blocking prostaglandin production reduces the pain caused by swelling.

Some of the most common NSAIDs used in the treatment of pain include aspirin, ibuprofen and naproxen. Gastrointestinal problems can arise with long-term use of NSAIDs. In high or prolonged doses, NSAIDs might cause stomach upset, bleeding and ulcers. NSAIDs should not be used by people with kidney or heart disease.

Paracetamol

Paracetamol is another commonly used medication to treat pain. Paracetamol does not have anti-inflammatory properties. Researchers believe that paracetamol relieves pain be increasing the body’s pain threshold. Paracetamol can be effective in relieving the pain of headaches, and minor aches and pains. Paracetamol is sometimes used in combination with narcotic pain medication (opioids). Combining paracetamol with narcotics can reduce the amount of narcotic medication that will be required to control severe pain.

Opioid Analgesics (Narcotics)

Opioid analgesics are often prescribed for the management of moderate to severe pain. Opioids are produced from ‘opium’, which comes from the poppy plant. Today, many opioid drugs are made synthetically. Opioid drugs relieve by blocking pain signals so they do not reach the brain.

Although opioids are effective in reducing pain, they are also associated with a number of negative side effects. Opioids can cause drowsiness and confusion, nausea, constipation and itching. They can also interfere with breathing and urination. Additional medication might be required to reduce the severity of these side effects. At times, opioids might be combined with anti-inflammatories or paracetamol to reduce the amount of opioid medication required to control pain, in turn, reducing the side effects caused by the opioid medication.

Opioids can also cause ‘dependency’. This term is used to describe a situation where progressively higher doses of a medication are needed to maintain the same analgesic effect. When the dose of opioid medication is increased, the severity of side effects is also increased. Many physicians consider opioid medication to be useful in the short-term management of severe pain. With long-term use, the benefits rarely outweigh the costs.

Anticonvulsants

Anticonvulsants are drugs that have traditionally been used to control seizures in people with epilepsy. These drugs have also been shown to be effective in the treatment of neuropathic pain conditions like those that might be experienced following spinal cord injury, traumatic brain injury, or surgery. Gabapentin, carbamazepine and pregabablin are the most commonly used anticonvulsants used in the treatment of neuropathic pain conditions.

Common side effects of anti-convulsants include nausea, vomiting, headache, dizziness, drowsiness and fatigue.  These side effects are usually temporary.

Anti-depressants

Some types of antidepressants are also used to treat pain conditions. One class of antidepressants known as ‘tricyclics’ might be included in the medication regimen use to treat pain.  Tricyclics have an effect on neuropathic pain symptoms and might be combined with other pain medication when sleep problems are severe or if the individual is experiencing considerable anxiety.

Pain Interventions

Physical Interventions

Physiotherapy interventions are used to treat a wide range of problems associated with painful injury. Physiotherapy does not refer to a specific treatment. Rather, a physiotherapist might use a range of techniques that can assist in the recovery and rehabilitation of different pain conditions. Exercise and other movement techniques are usually prescribed for the treatment of a painful injury. Other techniques might include manual therapy or modalities such as heat, cold or acupuncture with the aim of reducing pain so that movement and exercise can be more effective. Following a comprehensive examination, a physiotherapist determines which treatment techniques might be best suited for a particular pain condition. Physiotherapists will also provide as to how best to manage your condition yourself and regarding practices and postures at work.

Psychological Interventions

Psychological interventions have been used primarily for ‘pain management’ as opposed to pain relief. There are a number of psychological techniques that have been used for tension reduction when individuals suffer from pain conditions. These include relaxation training, biofeedback, and hypnosis. If a pain condition is worsened by tension, then these tension-relief techniques might be useful in reducing the intensity of pain as well.

Emotional control techniques might also be included in a psychological pain management program. The experience of negative emotions such as anxiety, fear and depression are common following the onset of a pain condition. The experience of these emotions is known to be associated with more severe pain symptoms.  By learning to control these negative emotions, it might also be possible to reduce the intensity of pain symptoms.

Psychological techniques might also be used to examine how the individual might be able to lead a productive and satisfying life in spite of the fact that pain symptoms persist. Techniques such as acceptance, problem-solving and goal-setting might be used to maximize an individual’s engagement in activities most likely to contribute to an enhanced sense of well-being and a higher quality of life.

Rehabilitation

The treatment of pain is not just about reducing the severity of symptoms. Full participation in important life activities is as important as reducing the severity of symptoms.  Pain symptoms might persist for a long period. New research findings indicate that individuals with pain can resume important family, social and even occupational activities in spite of fact that some symptoms persist. Rehabilitation interventions can be useful to help individuals resume important activities of their lives even though they continue to experience symptoms of pain.

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