Care of the Special Patient
2. Physiology of pain
3. Causes of pain
4. Management of patient with pain and pain treatment
5. Management of pain with children and elderly people
Pain is a very complicated phenomenon that has been a mystery
for many centuries. Even nowadays, it is hardly possible to
estimate that the mystery of pain is fully revealed. Nonetheless,
the modern science has achieved really great results and has
basically managed to reveal the principle causes of pain,
define its physiology. At the same time, the treatment of
pain still remains a serious problem though mankind has a
much larger experience in the problem of treatment of pain
than in the understanding of its essence. It should be said
that people have been attempting to treat pain since ancient
epochs and in the course of time the ways of treatments were
constantly improving. At the present moment, the modern science
has a variety of tools to treat pain which are quite effective
but often specialists face a problem that modern treatments,
including pharmaceutical measures, being generally effective,
sometimes can produce negative effects on human health that
are mainly provoked by the side effect of some medicines.
This is why in recent years, specialists have started to refer
to alternative, non-pharmaceutical measures in the treatment
of pain. In such a situation, it is extremely important to
thoroughly analyze the modern ways of management of patients
with pain and discuss most effective treatments of pain.
Physiology of pain
Before analyzing the management of patients with pain and
effective ways of treatment, it is important to understand
the essence of pain, its physiology in order to clearly realize
what a treatment should actually target at and, what is more,
it can help define what treatment is the most effective.
First of all, it should be said that there exist different
views on pain and it is quite difficult to find a universal
and absolutely unarguable definition of pain but briefly it
can be 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). At the same time, pain is not very precise notion and
nowadays, specialists rather prefer use the term nociception
instead of pain.
In this respect, it is necessary to precise that all nociceptors
are free nerve endings that have their cell bodies outside
the spinal column in the dorsal root ganglion. These sensory
endings are responsible for the perception of pain and serves
as vehicles of its transmission. Traditionally, specialists
define three major kinds of pain: mechanical, thermal and
chemical nociceptors. Basically nociceptors are displaced
in skin but may be also found on internal surfaces of human
organism such as periosteum and joint surfaces. In stark contrast
deep internal surfaces are less exposed to nociceptors and,
as a rule, pain in this surfaces can progress on the condition
that the respective tissue is damaged.
Nowadays, specialists distinguish two types of nociceptors.
On the one hand there are Ao fibers which are responsible
for fast pain. These fibers are able to transmit signal from
the source of pain at average rate between 6 to 30 meters.
Basically, people can feel this kind of pain practically immediately,
though, in actuality, the process of transmission may take
about one tenth of a second. It can be described as sharp,
acute, pricking pain. In general, these nociceptors are responsible
for the transmission of either mechanical or 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. Traditionally,
people perceive this pain as aching, burning, or throbbing.
Often these nociceptors are responsible for the transmission
of chemical pain. Nociceptors do not adapt to stimulus. Also
it should be said that the long stimulation of pain receptors
can led to the condition known as hyperalgesia.
As nociceptors perceive some kind of pain they transmit it
at different rates to the central nervous system. Basically,
the pain is transmitted either through the neospinothalamic
tract, which is used as a transmitter for fast pain, or through
the paleospinothalamic tract, which is used as a transmitter
for slow pain.
It is also should be said that spinal cord d also plays an
important role in the transmission of pain since due to its
neurons the signals are sent to the brain stem and, in such
a way, people perceive the pain. Remarkably that the time
the signal may be transmitted from the source of pain to the
brain stem is not long and on the sensual level the pain is
often perceived as immediate. In such a way, the nervous system
prevent the organism from the further possible damages if
some trauma, for instance, occurs or can occur. Anyway, pain
receptors warn the bran about the potential danger or malfunctioning
of certain organs.
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 sensation 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
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,
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
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
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.
Nonetheless, in spite of recent scientific achievements in
the field of management of patients with pain, it is still
necessary to continue researches of pain and ways of its treatment
in order to improve the quality of health care services and
increase safety of treatment of pain.
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