Understanding and Explaining Pain
Level 2 Pain Training
Fife Integrated Pain Management Service
Aims
• Cross the gap between lab to clinic
• Understand the pain related biology of the patient in front of
you
• Be able begin to reassure, explain and give understanding to a
patient of what is going on
“The fear of pain is worse
than pain itself”
Feedback Burglar & Cat
Thoughts
Behaviour
Feelings
Structure of the Nervous System
(or threat detection system)
Melzack & Wall
AFFECTIVE
Feelings
Fear, anxiety, sleep,
punishment
autonomic changes
Limbic System
SENSORY
Conscious Brain
Thinking
Location
rational
“oh bother”
Muscle tightening
Recruitment
Sensitivity
Sometimes – most of the
time
Spinal cord
Wind-up and long term potentiation
Central sensitization
Timeline of pain
Pain?
Tissue Healing
Time of injury
3 months
Sensitisation
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What is it?
Why does it happen?
How does it happen?
Forms of sensitisation –
– Primary hyperalgaesia
– Secondary hyperalgaesia
• Cold hyperalgaesia – risk factor
– Allodynia
– Wind up
Central Sensitisation
• Highly common in chronic pain syndromes e.g. CLBP, FMS,
CRPS
• How to recognise?
• Sensitive to light, noise, smell, chemicals, to touch, pressure,
vibration
• Is not an indication of harm or damage
• Can be alarming for patient
• Can lead to many investigations, tests, appointments
Mechanisms of Central Sensitisation
• Plasticity Strengthening of existing
synaptic connections
- Formation of new ones
• Hebbian Plasticity
• ‘Nerves that fire together wire together’
• ‘nerves that fire apart wire apart’
• ‘past behaviour predicts future behaviour’
• Disinhibition accounts for spread of pain and other
symptoms.
Neuropathic Pain
• Pain caused by a lesion or disease of the somatosensory nervous
system.
• From peripheral nerve, nerve root (peripheral)
• From spinal cord or brain (central e.g. thalamic pain)
• Pain often described as shooting, electric shock-like, burning –
commonly associated with tingling or numbness
• The painful region may not necessarily be the same as the site of injury
– Pain occurs in the neurological territory of the affected structure
(nerve, root, spinal cord, brain)
Putting it all together!
Copyright Body in Mind 2012
A Unifying Theory of Pain and its Symptoms – the
Neuromatrix
Case Studies
YELLOW FLAGS
• Attitudes & Beliefs - towards the current problem. Does the patient feel that with
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appropriate help and self management they will return to normal activities? The most
common worry is that the patient feels they have something serious causing their
problem. 'Faulty' beliefs can lead to catastrophisation.
Behaviours - adopting disabled role, rest, use & abuse of medication
Compensation - Is the patient awaiting payment for an accident/ injury at work/
RTA?
Diagnosis - or more importantly Iatrogenesis. Inappropriate or confusing
communication can lead to patients not being sure what the problem is, the most
common examples being 'your disc has popped out' or 'your spine is crumbling'.
Emotions - Patients with other emotional difficulties such as ongoing depression
and/or anxiety states are at a high risk of developing chronic pain.
Family - There can be two problems with families, either over protective or under
supportive.
Work – If there are difficulties, people are more likely to develop chronic problems.
Explain Pain Examples
• Steve and Neil demonstrate
Small groups
• Use A3 paper
– Learning intention
– Success criteria
– Ideas board
Thank You!