WHAT IS PAIN?
by Dr NAGNATH KHADKE

Pain is one of the fundamental entity / perception that exists. However its application is strictly subjective.
Pain as such is defined scientifically as- An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage... pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life.

In simple terms pain is -
an uncomfortable feeling that comes from injury, disease or damage to your body. pain is sometimes a nuisance or it may be a signal that something is wrong.
PAIN is THE most common symptom that brings patient to physician attention.

In rheumatology pain is the most common presenting complaint of a patient.
Is there any reason /function for pain?
Yes. Pain is an important perception which many a times has protective function.
For example - inadvertently touching a hot object and immediately removing hand because of pain. Here pain has important protective function. That means pain is an important part of one's defence system.
However when pain is out of context and in excess than required, it becomes a dominant perception invoking suffering and incapacity, which has to be managed effectively, to control further damage.

How is pain produced?
In scientific language pain is nothing but a Stimulus with specific characteristics. Pain stimulus is a perception which can originate at various different points and that stimulus is conveyed to the brain through nervous system. In brain the stimulus would be interpreted differently, one of the interpretation is " PAIN".
In simple terms different stimuli can cause pain - like (excess of) heat, cold, temperature, vibration, mechanical force, pressure, inflammation and emotions.

In arthritis patients, pain is mostly due to excessive inflammation.
What are types of pain?
Pain can be differentiated in to various types like acute or chronic, neuropathic or non-neuropathic, inflammatory or mechanical.

What are different types pain that are possible in Rheumatological diseases ?
Inflammatory pain -
This is a most common type of pain produced due to various pro inflammatory factors.
Some rheumatological diseases like CRPS or Fibromyalgia have been recognised to have different etiology, mechanisms and characteristics of the pain.

CRPS -
Also called as "Algoneurodystrophy", this chronic pain syndrome containing features of both nociceptive and neuropathic pain. Allodynia, hyperalgesia as well as vasomotor and cutaneous changes are common clinical features. This pain is an aberrant tissue response associated with neuronal changes following injury.

What is Fibromyalgia?

• Patients suffering from arthritis, apart from having inflammatory pain of joints can also suffer from soft tissue pain / fibromyalgia.
• There are still many controversies regarding various aspects of Fibromyalgia.Though exact cause is unknown, it involves psychological, genetic, environmental and neurobiologic factors.
• People with this syndrome usually can have symptoms involving most of the organ systems like, Respiratory, Cardio-vascular, Neuronal, Genito-urinary, Gastro-intestinal systems. However fibromyalgia is neither fatal nor progressive
• It can be managed with the help of various pharmacological and non pharmacological treatments.
• Pharmacological treatment involves use of simple analgesics like paracetamol, Non antiinflammatory drugs, mild opiod druds, anti depressants and anti psychotic medicines.
• Non-pharmacological treatments includes CBT (cognitive behavioural theorapy), psychological counselling, stress reductions mechanisms etc...
• Management of pain
• The first and foremost aspect is to give due importance to the presence of "pain". Negligence will only lead to worsening and suffering, so no matter how benign it may feel, pain should not be neglected at any cost.
• "A stich in time saves nine"-pain should be dealt as early as possible.
• Treating pain early is easier, one doesn't require high degree of medication and duration of treatment will also be short. Treating pain early is also more beneficial in a way, you do not lose out on your working hours.
• If not managed early and properly "pain" can become a disease in itself. At this point, management of pain would become complicated and protracted.
• One must also understand when to take help of a physician in dealing with pain. Occurrence of pain in any disease process has to be looked from different clinical point of views and is best done by your physician.
• Patients having rheumatological diseases especially should seek help from rheumatologist early in case of new advent of pain.

Assessment of pain
Important elements of an initial assessment for pain include the following:

1.Patient History
2.Physical Examination
3.Functional assessment
4.Pain assessment
5.Psychosocial Evaluation
6.Diagnostic Evaluation
7.Documentation and recording

Pain is a personal, subjective experience influenced by cultural learning, the meaning of the situation, attention, and other psychological variables. Because of so many variables affecting it , pain measurement is an extremely difficult task. There is no one reading or measurement for holistic measurement of pain. Therefore physician has to depend upon his skills, as well as patients perception.
Approaches to the measurement of pain include verbal and numeric self-rating scales, behavioral observation scales, and physiologic responses. The complex nature of the experience of pain suggests that measurements from these domains may not always show high concordance. One must also take into consideration the psychosocial aspects related to pain. Many a times though the initial stimulus producing pain is pathologic, the persistence or perception of pain which is out of proportion is mostly because of psychological reasons.
Because pain is subjective, patients' selfreports provide the most valid measure of the experience.

Creating the pain treatment plan
A comprehensive treatment plan should be developed and customized to the needs of the individual patient.
The treatment plan should include the types of therapies planned, the goals of treatment, and an explanation of the patient and prescriber roles and responsibilities.
The treatment plan should also include goals related to pain interfering with life activities such as school, work, and social activities.

Components of an effective treatment plan The goals of treatment -
It is important to establish a set of goals early in the course of treatment, including expectations about the following:

The degree of improvement in pain.
The degree of improvement in function, where relevant.
The correct treatment of the pain always involves treating the root cause of pain whenever / wherever possible. That is in case of pain due to aggravation of RA disease activity, one has to treat with drugs for decreasing RA activity, so all the symptoms including pain are also managed. Treating with pain relief medication only, without treating the underlying cause, would not only be naive but can also lead to further damage, suffering and severe complications.

Pharmacological Theorapy

1.Opioid analgesics
2.Anti inflammatory drugs
3.Adjuvant medication

Opioid analgesics

The pain relieving effects of opium, derived from the poppy Papaver somniferum, were recognized by ancient healers. Our current therapeutic opioids are all derivatives of morphine.

Derivates of opium are called opiates, and synthetic analogues are called opioids. In clinical use, opioids are the most powerful analgesics available and their use is of immense therapeutic value. However, they are also associated with known pharmacological side effects.

In common rheumatological conditions, they are not first line choices because most patients respond adequately to other available pain relieving medication.

While prescribing opioids one should be aware of the common side effects like dizziness that may lead to falls and fractures and interactions with other commonly prescribed drugs, like with benzodiazepines.

Dose-dependent side effects include respiratory depression, euphoria, feeding, reduced gastrointestinal transit, effects on anxiety as well as endocrine and immune effects. Prolonged use can, however, produce "tolerance", a physiological phenomenon resulting in a diminished analgesic effect or "dependence", the necessity for continued drug intake in order to prevent the symptoms of opioid withdrawal.

One must also know the management of Opioid withdrawl and overdosage.

Non steroidal anti inflammatory drugs and Acetaminophen

Cyclooxygenase inhibitors are used routinely in clinical practice for their antipyretic as well as analgesic effects. Their main mechanisms of action is inhibition of cyclo-oxygenase enzyme leading to inhibition of prostaglandin synthesis. Prostaglandins are important mediators of inflammation which produces pain.

They are of two types, COX I & COX II inhibitiors. Early NSAIDs were non selective (that is inhibiting both COX I & COX II to various extents, while later on COX selective inhibitors were developed like selective COX II inhibitors. Based on the roles of COX-2 in inflammation, COX II inhibitors are expected to show a somewhat better therapeutic profile. Also there is relatively less gastrointestinal toxicity, but relatively more cardiovascular side effects (stroke, myocardial infarction, thrombosis). However this notion has been somewhat countered by one of the newer studies.

PARACETAMOL

Paracetamol (acetaminophen) as an analgesic, is less potent than NSAIDs and has to be given at relatively large doses with relative safety.

Its main toxicity is on the liver. It has recently become obvious that paracetamol not only shares all side effects of NSAIDs, but in addition induces liver damage at therapeutic doses.

Hence patients must now realize that 'paracetamol is no more the absolutely safest drug as considered earlier.

What precautions one must take while taking these medicines?

Are there any contra indications to these medicines?

Though these are excellent medicines to decrease inflammation and pain, they are not devoid of side effects. Side effect profile of most of the NSAIDs is similar, most important being gastrointestinal, renal, cardiovascular, and the central nervous system side effects.

According to recent guidelines, COX II inhibitors are contraindicated in patients with known high risk cardiac conditions while traditional non-selective NSAIDs are contraindicated in patients who have had two or more GI bleeds, and should be used with caution in patients with known cardiovascular risks.

Though most of these medicines are available as "over the counter" medicines (OTC) (medicines one can have without strict rules on prescription), one must always take these medicines with doctors advise and care, to avoid any possible side effects.

"Never treat your pain on your own"

Adjuvant Medicines

1.Antiepileptic drugs
2.Antidepressants
3.Anti psychotics
4.Anti convulsants
5.Local and regional anesthetics
6.Other miscellaneous adjuvant medications

These are few types of drugs which can be utilized as medicines for pain suppression in special cases. However these are not commonly used medicines for pain management and should strictly be taken under doctor care.

NON-PHARMACOLOGIC THERAPIES

• A number of non-pharmacologic therapies are available that can play an important role in managing pain, particularly musculoskeletal pain and chronic pain.
• Psychological approaches - e.g., cognitive behavioural therapy
• Physical rehabilitative approaches - e.g., physical therapy, occupational therapy
• Surgical approaches - e.g., use of nerve blocks, sympathectomy
• Complementary therapies - e.g., acupuncture, chiropracty

Patient / Family Education

Educates the patient along with the family in different types and causes of pain, when to take help for pain relief, different aspects of pain management, and most importantly learning ways to control pain using various healing techniques.

Community Support Groups/Educational Programs
Help patients learn more about their diagnosis, how to handle their disease and control pain through support of others dealing with the same problem.

Sharing your problems and ideas in a group of similar people help in creating a positive environment and positive mindset to deal with pain.

Exercise

Exercise in any form, like Yoga, Tai Chi, or even simple Walking helps reduce tension, anxiety, depression and fatigue.

Active exercises will help in restoring muscle mass and preserve the normal range of joint motion.

Complementary theorapies

There are number of such theorapies, of which commonly practiced are Acupuncture / Acupressure / Biofeedback systems / matrix rhythm theorapy / Reiki / Heat & sauna bath / Ice / Massage ( Unani / ayurvedic ).

There are many such theorapies which are being developed newly from time to time. However the fundamental science behind each one of them is still to be understood completely and is under research.

One must understand that these are not the core theorapies but only supportive/complementary, as the name suggests, and can never substitute for the proper medical management under the guidance of your treating doctor.

How one can help himself in fighting pain?

Distraction-

Changing your attention to something else such as reading, music, walking or talking to a friend.

Meditation-

Opening your mind to bring awareness to breathing, body sensations, and feelings to deal with chronic pain, panic disorders and anxiety. Humor / Music / Prayer.
Few simple tips to combat pain

Staying ahead of pain-

Staying ahead of the pain means not waiting until your pain is severe before you take your medication.
If you wait until your pain is severe or increasing, it will be more difficult to control your pain.

Get enough sleep-

Sleep is one of the most important things you can do to control your pain.
Adequate sleep improves your ability to cope with pain, speeds healing, and can actually reduce pain.
The trick is to reduce your pain enough to sleep well, which may require medication along with proper positioning.

Physical activity-

What feels good when you are doing it may not feel very good a few hours later. So always remember "slow and steady wins the race".
Always increase your physical activity gradually.

Always remember the golden rule that, "a joint with swelling should always be rested and never be exerted. "
Don't seat too long -
Sitting or lying in one place for too long can lead to more pain.

Getting up and walking every hour or two during the day helps keep you from getting stiff.

Reduce stress -
Stress is the enemy of good pain control. An increase in stress can and often does increase pain.

Surgery is a type of physical stress, and while that cannot be avoided, emotional stress can be minimized.
Try to avoid situations and even people who tend to increase your stress level in the early days of your recovery.

Stress reduction techniques, such as deep breathing and relaxation exercises, can be very beneficial.

Avoid aggravating factors -
There is an old joke that goes something like this:

• Patient: "Doctor, it hurts when I do this!"
• Doctor: "Stop doing that!"

Pain is an excellent indicator of activities that you should avoid or limit during your recovery. The "no pain, no gain" adage does not apply to ALL THE TIME.

However some pain may be unavoidable, such as during physical therapy, an essential component of recovery.

In the end always remember "there in no one recipe or secret for good pain control."

Rather it is a mixture of all the various ways and modalities that we have discussed above in a correct manner under a care of a good doctor.