“ASSESSMENT STRATEGIES AND APPROACHES TO PAIN MANAGEMENT”
Pain is defined as “an unpleasant emotional situation originating from a certain area, dependent or non-dependent on tissue damage, which is related to the past experience of the person in question” (Merskey, 1986). Acute pain is generally in response to specific injury, experienced for up to 4 weeks (Linton, 2005), and recedes once the injury is treated. In contrast, chronic pain, lasting for longer than 3 months, is multifactorial in cause, changing in response to environmental and psychological factors, and is often resistant to medical treatment (Merskey, 1986).
Pain is the result of responses to stimuli transmitted to the central nervous system (CNS) along afferent nerve fibres, usually in response to noxious stimuli such as tissue damage. Receptors can become sensitized following persistent injury or inflammation, causing pain during previously normal events (Meeus & Nijs, 2007). Additional sensitisation of the CNS can lead to increased perception of tenderness, and pain from other sites. In these cases non-noxious stimuli, such as walking or light touch, can become painful. This process of sensitization is extremely complex, governed by neural plasticity and influenced by a wide range of factors, including the nature of initial physical injuries, and variations in cognitive processing and individual psychology (Meeus & Nijs, 2007). Pain symptoms therefore depend on environmental and psychological factors, and vary widely for individuals experiencing the same disorder (Waldman, 2011).
This essay will evaluate strategies used for assessing chronic pain, considering their value with regard to the full range of factors known to contribute to pain. Evidence for two pain management techniques, acupuncture and aromatherapy, will also be discussed, to evaluate the effectiveness of these techniques for treating chronic pain.
The Cartesian model of pain viewed the body and mind as distinct (Linton, 2005), with pain purely a response to physical damage. Assessment strategies based on this idea focussed simply on physical damage. They ignored broader contributors to chronic pain, limiting success in planning treatments, and reducing the effectiveness of outcomes (Gatchel et al., 1995b). Alternatively, the biopsychosocial model proposed by Robert Gatchel suggests individuals experience pain in a unique way, due to psychological and socioeconomic factors interacting with physical pathology, altering patients’ report of symptoms (Gatchel et al. 2007). Psychosocial factors, including family history, culture, emotion and cognition, may all contribute to chronic pain (Linton, 2005). As an example, patients may fall into a sick role, becoming preoccupied with symptoms and feelings of lack of control over pain and their life (Linton, 2005). Such cognitions predispose patients to depression (Rudy, Kerns, and Turk, 1988), which in turn reinforces these cognitions, and can worsen chronic pain (Gatchel et al., 2007). Pain and depression frequently exist in a mutually reinforcing relationship.
Treatment outcome is strongly dependent on addressing both physical and psychosocial factors underlying pain (Gatchel et al., 1995b) Strategies for assessing pain must assess affective components, and patterns of developing illness behaviours, as well as pain severity and physical impairment (Waddell, 1993), or risk increasing the probability of treatment failure, disposing patients to depression and illness behaviour (Fordyce et al., 1986).
Lebovits (2000) outlines some of the most common tools used to assess pain. Pain intensity scales are often used, verbal (offering choices of words to describe pain), numerical, or visual along a line. Quick to use, and with demonstrated validity, these provide clinicians with a simple score for pain intensity. However, these scales treat pain as “a single, unique quality that varies only in intensity” (Katz & Melzack, 2011), and provide little information on biopsychsocial components.
The McGill pain questionnaire (MPQ) was developed to address shortcomings of simple scales, measuring pain instead against three dimensions: sensory, affective and evaluative. The MPQ has been shown to have remarkable consistency across varied studies (Katz and Melzack, 2011), and has become the gold standard for assessing pain. However, used in isolation the MPQ still focuses on simply measuring pain itself, neglecting the contribution made by underlying psychosocial factors.
The Pain Centre Questionnaire (PCQ) provides an alternative (Lebovits, 2000). It collects information on the pain itself, but also demographic and social information, medical history, and how much the patients’ pain interferes with various life activities. This offers a starting point for structured clinical interviews, which generally assess the same information but allow greater depth and investigation of key areas of interest, and consideration of how patients’ body language and posture may contribute to pain. Given the importance of biopsychosocial factors, the PCQ followed with a structured interview is the best way of assessing chronic pain. Demographic, psychosocial, occupational factors, disability ratings and self-reported pain are all good risk indicators, and can be assessed using simple measurement tools during the interview. Such assessment methods can predict those individuals whose chronic pain will fail to improve with treatment (Gatchel et al., 1995a).
Approaches to Pain Management
Acupuncture is a practice associated with Chinese medicine (Waldman, 2011), following a pathophysiological concept of medicine based on the flow of “qi” energy, which is manipulated by inserting thin needles at specific body points.
Lee et a. (2012) conducted a systematic review of over 160 Random Controlled Trials (RCTs) and Controlled Clinical Trials (CCTs) assessing the efficacy of acupuncture in treating pain. They concluding acupuncture was “promising for pain but with no conclusions able to be drawn”, since the majority of studies found mixed or positive results.
Manheimer et al. (1996) reviewed 17 RCTs (1806 adult participants) studying the efficacy of acupuncture to treat chronic pain associated with Irritable Bowel Syndrome (IBS). In Chinese language trials acupuncture was significantly more effective than pharmacological therapy. 89% experienced improvements in symptom severity as compared to 63% using pharmacological therapy. When used as an adjuvant therapy, 93% of the acupuncture group showed symptom improvement as compared to 79% receiving only medicine. In 5 trials comparing real to sham acupuncture (in which participants believe they receive true acupuncture, but needles either do not pierce the skin or are placed at non-specific points), no significant differences in improvement of either symptom pain or quality of life were found.
Deare et al (1996) reviewed 9 trials (395 participants) assessing efficacy of acupuncture to treat chronic fibromyalgia pain. Patients using acupuncture rated their pain “30 points lower on a scale of 0 to 100 (absolute improvement) after 20 sessions of acupuncture”. They conclude acupuncture improved overall well-being, reducing pain and stiffness. Berman et al. (1999) reviewed 7 studies comparing real and sham acupuncture treatment for fibromyalgia, finding evidence for a significant improvement of real over sham acupuncture. However, this finding was based on a single high quality trial, and further trials are needed before robust conclusions can be drawn.
Paley et al, (1996) reviewed 3 RCTs (204 participants) where acupuncture was used to treat chronic pain related to cancer. It was found that in comparison to placebo, acupuncture patients had lower pain scores during follow up after two months, while the other two studies also showed positive effectiveness of acupuncture. However, findings again suggest sham acupuncture is just as effective as real treatment.
Kawakita & Okada (2014) outline possible mechanisms for analgesic action of acupuncture. Endogenous opioids are the main candidate, with increased levels found in cerebrospinal fluid following electro-acupuncture. Different frequencies of electro-acupuncture elicit release of different opioids, and activation of opioid receptors in the CNS and spinal cord.
“There are numerous RCTs, systematic reviews, and meta-analyses of acupuncture in chronic-pain patients that show no significant differences between real and sham acupuncture” (Kawakita & Okada, 2014), suggesting benefits are due not to physiological benefits of needle insertion itself, but to relief of more psychological aspects of pain. This evidence suggests the success of acupuncture may be down to factors shared between real and sham treatment, such as patients’ beliefs and expectations regarding the treatment, and adjuvant properties of the therapy, such as the therapeutic experience itself and opportunities for relaxation. There is also the suggestion that the light touch occurring in both real and sham acupuncture (but not other controls), may elicit a response in afferent nerves, causing pain relief (Lund & Lundeberg, 2006).
Aromatherapy is the use of over 200 essential oils from plants, and is classified as a “Manual Healing” in Alternative Medicine Practice (Waldman, 2011). Oils may be inhaled by way of a diffuser, administered by placing in a potpourri bowl, or diluting with oil and massaging onto the skin. Aromatherapy benefits may include reductions in anxiety, emotional stress, pain, muscular tension and fatigue while topical application may have antibacterial, anti-inflammatory, and analgesic effects (Cook & Lynch, 2008).
Kim et al. (2006), compared groups given either oxygen, or oxygen plus lavender oil, during surgery. There were no significant differences in the need for anaesthetic between the two groups, and no differences in postoperative pain. However, patients in the lavender group did report that they were more satisfied with their pain management then the control group. This was a small pilot study, and a larger trial would be needed to draw firm conclusions.
Kane et al (2004) used lemon or lavender aromatherapy in an RCT, as an adjunct analgesic, with music, to mask bad odours during dressing changes on vascular wounds. No change was reported for pain during the procedure, but patients receiving the lavender therapy (but not the lemon) reported a better score on pain afterwards (Kane et al., 2004). This was likely due to positive affect associated with lavender, since the lemon, (initially expected to have greater analgesic effects) was associated with cleaner used in the hospital. However, the study had an extremely small sample size (8 patients) with varying wounds, and different physicians. A much larger, controlled trial is necessary before conclusions can be drawn.
A systematic review by Cooke & Ernst (20 found that aromatherapy combined with massage had an immediate, but short-term beneficial effect on anxiety levels, but that this was not strong enough to recommend for use in anxiety treatment. There was little evidence of its use for other ailments including pain. However all the studies reviewed were small, with various methodological issues. Improvements and larger trials are required.
Since there is little clinical evidence for the beneficial effects of aromatherapy, there is even less for potential mechanisms. Several have been proposed: positive patient expectation, pharmacologically mediated effects like gamma-aminobutyric acid (GABA) receptor augmentation or inhibition of glutamate binding, and analgesic effects from topical application (Cook & Lynch, 2008). The most common theory is a connection between olfaction and the limbic system, causing mood change and stress relief. Emotional response to odour has been linked to afferent links connecting the olfactory bulb to the amygdala, where emotional significance is attached to stimuli (Clark et al., 2010). Trials indicate improved sleep, psychological well-being and patient-identified symptom relief as results of aromatherapy (Boehm et al., 2012), and Buckle (1999) suggests aromatherapy may “enhance the parasympathetic response through the effects of touch and smell, encouraging relaxation at a deep level.” Aromatherapy may therefore affect emotional and cognitive response to pain, and can therefore be used as a part of an integrated approach to pain management.
There is little robust evidence for effectiveness of aromatherapy for managing pain, since clinical trials assessing aromatherapy are in the early stages. Evidence suggests that aromatherapy is useful as a complementary therapy for managing pain, however there is no central guidance available for introduction and use of aromatherapy in routine healthcare as yet.
Chronic pain is the result of complex biopsychosocial factors, and when assessing pain it is vital to use a method that takes all of these factors into account (Parish, 2002). A detailed clinical history, taken using of simple tools and a clinical interview, allows the gathering of information on both the pain itself and contributing biopsychosocial factors. Treatment can then be planned that is tailored to the whole person, reducing the chances of failure.
Efforts to provide evidence of the beneficial effects of aromatherapy on chronic pain are in their infancy, and much more research, from large, rigorous clinical trials, is required before conclusions can be drawn regarding its effectiveness. In contrast, there is a large amount of high quality evidence that acupuncture has significant benefits in the management of chronic pain. However, the mechanisms behind these effects are relatively unclear, with sham acupuncture often just as effective, suggesting adjuvant aspects of the therapy are key. This is no way diminishes the value of acupuncture for chronic pain. As a therapy it appears to address the social and cognitive aspects of chronic pain in a way that conventional medicine does not. These opportunities can be vital for those living with chronic pain, with impacts far outside those offered by conventional treatment focussing on purely physical damage.
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