Introduction and Overview
Our agenda is to review the epidemiology of pain, and the ethics and health policy related to pain. We are going to examine what pain is, and define and differentiate acute versus chronic pain. We will review some diagnoses and diseases associated with chronic pain, and discuss the inter-disciplinary necessity for pain management. Next, we will pinpoint the role of speech pathology as it relates to the public health burden of pain. We will share some of the best and most used evaluation tools, in addition to some pain management and integrative techniques that you will find useful. Finally, we will conclude with an overview of how to ensure a quality pain program in your current work setting.
Epidemiology of Pain
The Ethics and Health Policy Related to Pain emphasizes that medical professionals (including allied health professionals) must ask the following questions to effectively manage pain:
- Are the patient’s preferences in pain treatment given the highest priority?
- Does the patient benefit from the pain treatment decisions that the team is making?
- What can I do to decrease harm when deciding on a pain treatment regimen?
- Did I do my best to protect the most vulnerable patient, treating his or her pain in the best possible way with respect and without discrimination?
As of 2010, the total annual cost of health care in the United States due to pain ranged from $560 to $635 billion (Gaskin and Richards, 2012). These figures include the combined medical costs of pain care, and the economic costs related to disability days, lost wages and reduced productivity. It is important to note that more than half of all hospitalized patients experience pain in the last days of their lives. Although therapies exist to alleviate pain for those dying of cancer and other terminal diseases, research shows that 50 to 75% of patients die in moderate to severe pain. Furthermore, an estimated 20% of American adults (42 million people) report that pain or physical discomfort disrupts their sleep a few nights or more per week.
Let's take a look at the prevalence of people who suffer from chronic pain, as compared to other conditions:
- Chronic Pain: 100 million Americans (Institute of Medicine of The National Academies)
- Diabetes: 25.8 million Americans; diagnosed and estimated undiagnosed (American Diabetes Association)
- Coronary Heart Disease (heart attack and chest pain): 16.3 million Americans (American Heart Association)
- Stroke: 7.0 million Americans (American Heart Association)
- Cancer: 11.9 million Americans (American Cancer Society)
According to the Institute of Medicine of the National Academies, 100 million Americans suffer from chronic pain. This far exceeds diabetes, coronary heart disease, stroke and cancer.
The use of prescription opioids to manage pain has quadrupled. In 2014, 1,000 people per day were treated in emergency departments, and almost 2 million people were dependent on prescription medications for pain. The Centers for Disease Control and Prevention (CDC) identified that medication overdose deaths have quadrupled since 1999, involving more than 165,000 people in the United States, with more than 14,000 deaths in 2014 alone. Furthermore, the incidence of adverse drug reactions and drug effects has led to increased admissions to the emergency room and hospital overall. Opioid prescription overdose is now the leading cause of death related to drug overdose, killing more individuals than overdoses of heroin and cocaine combined (DeNoon, 2011).
Facts About Older Adults
Among older adults, 50 to 80% report some degree of pain that interferes with their quality of life. Pain is two times as prevalent in the elderly, with 25 to 50% of community-dwelling geriatric individuals, and 45 to 80% of skilled nursing facility residents experiencing pain. Most frequently the pain is musculoskeletal. After that, common causes of pain are due to headache, cancer and neuralgia. Commonly, older adults will underestimate the level or the severity of their pain, and therefore they go under-treated. Often, they feel that they do not want to bother anyone or become a burden. Therefore, they do not mention it or try to go as long as they can. However, this has consequences. Untreated pain can cause sleep problems, weight loss, depression and certainly reduced life satisfaction. Older individuals with all forms of dementia, Alzheimer's Disease and related dementias are one of the most vulnerable populations. In older individuals with dementia, communication and comprehension difficulties, pain detection and control becomes more difficult. We are up against a lot when trying to alleviate pain in the dementia population.
The International Association for the Study of Pain (IASP) defines pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Margo McCaffrey's person-centered definition of pain is “whatever the person experiencing the pain says it is, existing whenever she or he says it does.”
How Does Pain Happen?
First, the stimulus or the source of pain is identified or occurs. It travels via the spinal cord to the brain. It is perceived by the brain, and the brain communicates the response. Nociceptors are stimulated, nerve transmission occurs via spinal tracts, and then spinothalamic tracks relay the information to the thalamus and brainstem. Within the thalamus we have the perception of pain, and it houses the affect and motivational aspect of pain. At that point, the sensory cortex (which governs touch, pressure, thermal or mechanical stimuli) is impacted. The response is created from this interpretation. Other areas that are involved in pain are the limbic system, which is the emotional component of pain, and the cerebrocortex. Pain is perceived all over the brain. Many different areas are involved.
Pain Neuromatrix Theory
The Pain Neuromatrix Theory was developed by Melzack. He proposed that “pain is a multi-dimensional experience produced by characteristic neurosignatures, or patterns of nerve impulses, generated by a widely distributed neural network called the body-self neural matrix.” Chronic pain is not just influenced by sensory input from the periphery. It is also facilitated by the output of a distribution of neural networks in the brain. You may have heard of phantom limb phenomena, and this is identified by sensory input in the brain from a limb that is no longer present in the body. Based on the communication loops that we just spoke about, and specifically the loop that occurs between the thalamus and the cortex, and between the cortex and the limbic system, pain is perceived in a limb where there is none, where it does not exist.
In review, the following areas of the brain are involved: the thalamus; anterior and posterior insular cortex; lateral and medial prefrontal cortex; anterior, mid and posterior cortex; primary and secondary somatosensory cortex; orbitofrontal cortex; basal ganglia; premotor cortex; midbrain; cerebellum; and posterior parietal cortex.
Chronic Pain Impact on Cognition
A Northwestern University study found that chronic back pain shrinks the brain by as much as 11%. This is equivalent to the amount of gray matter that we normally would lose in 10-20 years of normal aging. That's 1.3 cubic centimeters of gray matter lost for every year of chronic pain. There were 26 participants involved the study, and measurements of the brain were measured by MRI. All of the participants had unrelenting pain for at least one year. They also found that back pain sustained for six months or more is accompanied by abnormal brain chemistry in the areas impacting emotional responses, decision making and controlling social behavior (The Journal of Neuroscience, November 23, 2004).
Acute vs. Chronic Pain
The following outline provides a helpful comparison to differentiate between acute pain and chronic pain.
- Result of an injury to tissues, inflammation or specific diseases
- Sudden onset
- Usually brief in duration
- Limited degree of severity
- Easy to diagnose and treat the cause
- Pain subsides as healing takes place
- If left untreated, will evolve into chronic pain
- Usually of unknown etiology due to co-morbidities
- Lasts for weeks, months and years (4 weeks greater than normal healing time for diagnosis)
- Intensity may range from mild to severe
- Rehabilitation may be slow
- Multiple medication use
- Comprised of both psychosocial and physical conditions
Some diagnoses/diseases associated with chronic pain include: osteoarthritis, rheumatoid arthritis, neuropathic pain and diabetes, PVD, amputations, old strokes and related to contractures (neck, wrist, knee, hip), depression, headaches/migraines, fractures, cancers, and tumors, and pressure ulcers.
The SLP's Role on Interdisciplinary Pain Management Team
The interdisciplinary pain team is comprised of the patient/resident/client, the family, the physician, the entire rehab team, nursing, pharmacology, psychology and social services. With regard to the practice of speech pathology as it relates to the public health burden of pain, our knowledge and awareness of individual pain challenges is based on the chart review, history, and physical. Reviewing the patient's history and physical in the comprehensive chart review helps us identify if a patient is at risk or experiencing chronic pain. We are the professionals who look at non-verbal communication and non-verbal signs and symptoms that are indicative of pain. In fact, the SLP may be the first to report that there are some non-verbal communication signs and symptoms of pain.
Pain impacts our physical, emotional, psychosocial, and spiritual health. Anxiety and fear almost always enhance pain. As speech pathologists, we must help all of our clients identify pain, and deal with the emotional factors within the framework of the inter-disciplinary team model. Asking the individual to describe what they are feeling, what intensifies their pain, and the limitations it causes is key. We are not with our patients 24-7. Therefore, it is critical for us to document our findings in commonly used pain terminology. As SLPs, we also are the discipline to use alternative communication and pain scales with the non-verbal individual, as well as cognitive and sensory stimulation interventions that can help alleviate the pain.
Pain Assessment and Evaluation
When working with people who suffer from pain, it is critical that we are doing an accurate pain assessment. How do we perform an assessment of pain? What do we need to assess and what tools do we have available?
The assessment of pain is a complex process because it not only involves the physical components of pain, but also the emotional and the psychosocial. In many of the EEG studies referred to earlier, they discovered that there were many emotional components of pain, based on where the pain was triggering in the brain during the EEG. Pain is not simply a physical sensation. It affects a person's emotions and psychological well being which is why we see a lot of crying, wincing, grimacing, and other nonverbal indicators.
In 2003, as a response to the growing pain epidemic, a national effort was made to bring together experts from different settings, including home health, rehab, acute, and outpatient, to collaborate on effective pain management techniques. This is when they termed the phrase "pain is the fifth vital sign," because it affects every vital sign that we have. In a person who is experiencing chronic pain, you will see an elevation in blood pressure, temperature and pulse. They may exhibit sweating, nausea and vomiting. Depending how long a person has been in pain, you will observe varying degrees of psychological issues. You may witness depression, sleep deprivation, anxiety and fear, which is often rooted in the fear of movement. A person in pain may start to grimace, and they will be very guarded with their movements. This significantly limits their activities and, thus, become weaker. They get contractures and muscle atrophy because they are not performing in ways that they used to. They also tend to become withdrawn; not wanting to go out in society and disengaging from others. It is important that we get this chronic pain under control. Through use of scales and diagrams, we can properly understand where the pain is located, how it is impacting the patient, and ultimately how it can best be treated.
Patient Evaluation Tools
Many of the scales and tools that we use are intended to increase clinician-patient communication, so we can accurately identify the origin of their pain. Furthermore, we use quality of life scales to determine the degree to which the patient's quality of life is affected: their routines, their function, management of their pain. What have they given up as a result of this pain? We want to help them to get back to that wonderful, engaging life that they used to have.
The American Pain Foundation devised a clever acronym to help us remember the six key steps that we can use when asking our clients about their pain: T-A-R-G-E-T.
T = Talk to your patients about pain
Often, we will ask the patient the closed-ended question, "Do you have pain?" To which their only response is "yes" or "no." The best method is to phrase it as an open-ended statement: "Tell me about your pain today." That allows the patient to create a story about their pain; they will choose words that inform you exactly where the pain is coming from. In this way, we can determine the etiology of the pain to resolve it, and not just treat the symptoms.
A = Ask about current treatments
What is working? What isn't? What have they tried in the past? On occasion, the patient may tell us about a treatment or technique that they believe worked to relieve their pain, when we know that in reality, it is likely just a placebo effect. However, if in their mind, they are convinced that something was effective, why should we take that away? Sometimes the placebo effect can be a great avenue to use.
R = Rate pain intensity and get details
It's important that we use intensity scales that are appropriate for the population. For example, you are not going to use a zero to ten rating scale with someone with dementia or someone who is non-verbal, because they will not be accurate with their scoring. The rating scale must match their cognition and their ability to answer the question.
G = Get details about break through pain (BTP), or short bursts of pain that don’t respond to normal pain meds.
Often, our clients will experience breakthrough pain that occurs between their normal routine pain medications. In those cases, we may prescribe a pain patch to help them with that breakthrough pain so that they can avoid any pain issues.
E = Evaluate limitations on activities
What is it that they are not doing any more? What would they like to do? How long has it been since they have participated in those activities?
T = Treat side effects
As we know, many of our clients experience side effects when they start taking more pain medications. Commonly, we see confusion, sleepiness and light-headedness. Constipation is an area that is of great concern because it could trigger many more issues pertaining to their health if they continue to be constipated. Typically, when they have these side effects, they end up getting another medication to manage the additional side effect. It's a circular pattern. If we can just resolve their pain, we can resolve many of those side effects.