Pain




© Springer International Publishing Switzerland 2017
Maggi A. Budd, Sigmund Hough, Stephen T. Wegener and William Stiers (eds.)Practical Psychology in Medical Rehabilitation10.1007/978-3-319-34034-0_44


44. Pain



Philip Ullrich1  


(1)
Department of Rehabilitation Medicine, School of Medicine, University of Washington, 410 9th Ave., 4th Floor, Seattle, WA 98104, USA

 



 

Philip Ullrich

Email:


Keywords
PainPain assessmentPain treatmentBiopsychosocial model



Topic


Pain is a complex, treatment-resistant condition with negative impact on functioning and well-being. Unfortunately, pain is also common enough to be an expected complaint among most populations treated by rehabilitation psychologists.


  1. A.


    What is Pain?

    Pain is a biopsychosocial phenomenon. It involves the nerve signals triggered by injury (nociception) that travel from the point of injury to the brain, as well as the subjective suffering brought on by pain, and the pain behaviors that influence the social environment [1]. A broad biopsychosocial model of pain recognizes the complex, bidirectional interactions among physical, psychological, and social factors that cause and maintain the pain experience [2]. Specifically, pain has origins in biological nociceptive and hypothalamic–pituitary–adrenal axis activity, with immediate perceptual and emotional reactions that are influenced by cognitive processes [3]. Pain-related cognitions can then provoke emotional and behavioral reactions that aggravate pain, distress, and disability [3].

     

  2. B.


    Important Definitions


    1. 1.


      Acute pain versus chronic pain

      Acute pain arises from current damage to the body. Chronic pain is typically defined simply by duration, i.e., pain present for more than 3 months. Chronic pain is considered to be the product of repeated episodes of acute pain, and is likely to have bidirectional relationships with psychosocial factors.

       

    2. 2.


      Musculoskeletal versus neuropathic pain

      Musculoskeletal pain is due to damage to tissue or bone. In contrast, neuropathic pain is due to nervous system damage or disease.

       

     


Importance





  1. A.


    Pain is Common

    Many individuals seen by rehabilitation psychologists will experience clinically significant pain throughout their lives. About 58 % of persons with traumatic brain injury (TBI ) report pain concerns, with the prevalence rates being higher among those with mild (75 %) versus moderate or severe (32 %) TBI [4]. Among patients with TBI plus additional disabling injuries (e.g., burns, amputation, spinal cord injury (SCI) ) the prevalence of significant pain may be over 80 % [5]. Headache pain is, of course, experienced after TBI but most patients with these conditions report multiple pain problems, especially shoulder pain [6]. Pain problems can worsen over time among persons with TBI [6]. Over 75 % of patients with SCI report some pain, with severe, disabling pain conditions occurring in about one-third of persons with SCI [7]. Musculoskeletal pain is the most common variety of pain after SCI, but neuropathic pain tends to be the most severe [8, 9]. Longitudinal studies show that pain conditions after SCI are likely to assume a chronic course [9–11] with a chance of worsening over time in spite of active treatments [12, 13]. Similarly, Over 60 % of patients with MS experience pain and pain conditions have been shown to endure or worsen over time as the disease progresses [14, 15]. Pain is one of the most common complications to follow stroke [16, 17].

     

  2. B.


    Pain Negatively Impacts Function

    Pain problems aggravate and amplify the functional difficulties experienced by patients with disabling conditions, from the time of inpatient rehabilitation to long after an acute injury. Pain has been shown to reduce the frequency of rehabilitation therapies [18] and is the most frequently cited factor complicating rehabilitation treatments; more than fatigue, spasticity, or other medical complications [19]. Pain interferes with daily activities and work roles among numerous populations with physical impairments [16, 20–22]. Among survivors of burn injury, 66–75 % report pain interference with work and other functional activities years after initial injury [23].

     

  3. C.


    Pain is Associated with High Levels of Psychological Distress

    Robust positive associations between pain, psychological distress, and functional disability are very well-documented in many medical populations [24–26]. Studies in rehabilitation settings have found pain and depression to co-occur among 19–27 % of patients [12, 27, 28]. In some studies, co-occurrence rates are elevated such that patients experiencing co-occurring pain and psychological distress outnumber those with individual syndromes [5, 27, 29, 30]. Pain and distress levels tend to be more severe and enduring when conditions co-occur [12, 25]. Also, co-occurring conditions are more resistant to treatment and have additive negative effects on functioning [25].

     


Practical Applications





  1. A.


    Pain Assessment

    Basic principles :



    • Pain assessment should progress sequentially from basic screening, to assessment of biopsychosocial aspects of pain, to more detailed analysis, as determined by the practice environment and the apparent importance of the pain problem [31].


    • Most people with physical disability have numerous pain problems; three or more on average [32, 33]. If numerous pain problems exist then the worst three pain problems should be assessed.


    • Use consistent, standardized assessment. Consider time of measurement, measurement approach, and use of medication when conducting and interpreting pain assessments.


    • How you assess pain helps establish your patients’ pain “point-of-view”, an important foundation of any treatment.



    1. 1.


      Pain screening: Intensity and interference

      Pain presence and intensity should be screened with the 0–10 Numerical Rating Scale (NRS): “On a scale from zero to ten where zero means no pain and 10 means the worst possible pain, what is your current pain level?” Pain levels are classified as follows: mild (1–3), moderate (4–7), and severe (8–10). Pain levels of 4 or greater are generally considered to indicate need for additional assessment and likely treatment [34, 35]. Wording of the NRS can be altered to cover pain averaged over a time period, e.g., “the past week”, and to understand “least” and “worst” pains over a specified time period. A “Faces” pain scale provides pain intensity measurement equivalent to NRS among persons with cognitive impairment [36].

      Pain interference should also be screened with a NRS: “On a scale from zero to ten where zero means did not interfere and 10 means completely interfered, how much has pain interfered with activities in the past week?”

       

    2. 2.


      Detailed assessment

      When clinically significant pain is detected through screening then subsequent pain assessment should include a pain interview, a multidimensional pain measure, and measures of psychological distress. In addition to quantifying the pain experience, these assessments help clarify the environmental, cognitive, emotional, and behavioral variables that can be targeted for treatment [37]. Environment assessment should help understand the reinforcers and punishers of pain and wellness behaviors. For example, functional analysis can identify the antecedents and consequences of pain, e.g., social responses, avoidance, de-activation. Behaviors such as guarding, resting, asking for assistance, and task persistence are important to assess. In terms of cognitive variables, beliefs about pain and self-efficacy for pain self-management should be assessed. Cognitive reactions and coping strategies should also be understood, for example, focusing on or ignoring pain, rumination, catastrophizing, and acceptance.


      1. (a)


        Pain interview

        A detailed pain interview is vital for understanding the patient’s pain experience and pain-related features of the environment. The interview should address pain features such as location, distribution, descriptive qualities, temporal trends, and duration. Circumstances of pain onset should also be understood: when does pain occur and under what conditions? What makes pain worse or better? For example, movement, heat, cold, pressure, stress, social factors, and/or mood?

         

      2. (b)


        Multidimensional pain measures

        A multidimensional pain measure should be used to quantify psychosocial aspects of the pain experience. The following readily-available pain measures have good empirical records of reliability and validity in numerous populations, while also being brief and easy to use:



        • The Short Form McGill Pain Questionnaire [38] is a 17-item measure involving descriptive pain words that patients rate in terms of severity. The measure yields sensory, affective, and total scales of pain intensity and interference.


        • The West Haven-Yale Multidimensional Pain Inventory (WHYMPI/MPI) [39] is a 52-item scale that yields the following scales: intensity, interference, negative affect, control, social support, social responses, and activities. The MPI has also been adapted for patients with SCI [40].


        • The Brief Pain Inventory (BPI) [41] is a 36-item measure that yields pain intensity and pain interference scales. The measure also provides information on location of pain, pain medications and amount of pain. The BPI includes a diagram that is used to mark areas of pain on the body.


        • The Pain Outcomes Questionnaire-VA (POQ-VA) [42] is a set of pain measures designed to be used at various stages of pain treatment: intake (45 items), post-treatment (28 items), and follow-up (36 items). The POQ-VA was developed specifically to be a comprehensive pain outcomes measure assessing all pain-related domains of functioning identified by the Rehabilitation Accreditation Commission [43]. Its scales include pain intensity, pain interference, negative affect, activity level, pain-related fear, vocational functioning, patient satisfaction, and healthcare utilization.

         

      3. (c)


        Measures of psychological distress

        Diagnostic assessment should also identify psychological conditions. Depression and anxiety are the most important distress constructs to be measured as part of pain assessment. Some multidimensional pain measures include assessments of negative affect, i.e., the WHYMPI and the POQ-VA. If those measures are not used, a number of brief and psychometrically sound options are available. The Patient Health Questionnaire 9 [44] is a 9-item depression measure based on the nine diagnostic criteria for major depressive disorder. Other commonly used distress measures include the Center for Epidemiological Studies Depression scale [45], the Beck Depression Inventory [46] the Beck Anxiety Inventory [47], the State-Trait Anxiety Inventory [48] and the Tampa Scale of Kinesiophobia [44].

         

      4. (d)


        Additional assessments

        With more complex or chronic pain conditions it may be helpful to assess pain coping strategies with a measure such as the Chronic Pain Coping Inventory [49] or the Coping Strategies Questionnaire [50]. An in-depth appraisal of personality and psychopathology could be gained with measures such as the Schedule for Nonadaptive and Adaptive Personality [51] or the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) [52]. Guides for using the MMPI in the context of chronic pain treatment are available [53, 54].

         

       

    3. 3.

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Jun 25, 2017 | Posted by in PSYCHOLOGY | Comments Off on Pain

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