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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: At a Glance
- Sprache: Englisch
Pain Medicine at a Glance
The market-leading at a Glance series is popular among healthcare students and newly qualified practitioners for its concise, simple approach and excellent illustrations.
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Everything you need to know about Pain Medicine... at a Glance!
Pain Medicine at a Glance is a user-friendly, visual introduction to the impact of pain in various clinical care settings, focusing on primary care needs. Aligned with learning objectives developed by the Johns Hopkins School of Medicine, this authoritative guide covers the basic forms and pathophysiology of pain, the clinical skills necessary for delivering excellent care, pharmacological and non-pharmacological treatments, and a variety of special cases such as healthcare ethics, integrative care, and treatment planning for chronic pain self-management therapy and the management of pain in children and older adults.
A new addition to the market-leading at a Glance series, the text offers concise and accessible chapters, full-color illustrations, self-assessment questions, and easy-to-follow diagrams. Topics include pain assessment, cognitive factors that influence pain, applying behavioral perspectives on pain, managing opioids and other pharmacological therapies, treating acute pain in patients with substance abuse issues, and more. Perfect for learning, revision, and teaching, this book:
- Provides a foundation of clinical and basic science knowledge about pain and its mechanisms
- Describes major forms of pain, including surgical, orofacial, musculoskeletal, and obstetric pain
- Offers advice on fostering empathy and compassionate practices in pain medicine
- Covers non-pharmacological treatments such as physical therapy, hydrotherapy, meditation, acupuncture, massage, and various focal treatments
- Includes discussion of recent advances and new discoveries in pain science
Pain Medicine at a Glance is the ideal companion for medical and healthcare students, junior doctors, advanced practice providers, nurse practitioners, and others involved in diagnosing and treating pain-associated illness.
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Veröffentlichungsjahr: 2021
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Table of Contents
Cover
Title Page
Copyright Page
Dedication Page
Preface
Foreword
Acknowledgment
1 What is pain and how do we assess it?
References
2 Nociceptive processing
Transduction
Transmission
Perception
Modulation
References
3 What are the major types of pain?
References
4 How prevalent is pain and what are the common forms?
References
5 Pain and ethical practice
Beneficence
Non‐maleficence
Autonomy
Distributive Justice
References
6 Advanced skillfulness in clinical practice
References
7 Cognitive factors that influence pain
References
8 Approach to the patient with pain
Balancing treatment and diagnosis: parallel pathway model
Understanding pain and choosing rational pharmacotherapy: mechanism based‐classification
Patient‐centered care vs. disease‐centered care
Biopsychosocial model
References
9 The pain‐focused clinical history
Emotional impact
Sleep
Function
Biopsychosocial model
Openness to treatments – foundations of MI
Social history and work–life
References
10 Assessing pain in those with communication barriers
Speech barriers
Hearing barriers
Language barriers
Socioemotional barriers
Managing affect and negotiating boundaries with pain patients
References
11 Examination skills I
Observation
Affect
References
12 Examination skills II
Inspection
Palpation
Range of motion
Motor testing
Sensory testing
Reflex testing
Provocative testing
References
13 Integrating knowledge, skills, and compassionate practices
References
14 Motivational interviewing and shared decision‐making
References
15 Communication and interprofessional teams caring for patients with pain
References
16 Planning therapy
References
17 Basic considerations for pharmacological therapy – balancing mechanisms of drugs and disease
References
18 Over‐the‐counter analgesia
References
19 Neuromodulating agents
References
20 Opioids – the basics and use in perioperative pain care
References
21 Opioids – the details
References
22 Opioids – advanced practice – alternative delivery routes
References
23 Focal treatments for pain in primary practice
Anatomy and innervation
Selected agents and therapies
References
24 Interventional treatments and surgery for pain
References
25 Activating therapies
References
26 Mind‐based therapies
References
27 Manual therapies: massage; trigger points, acupressure, chiropractic, stretching, inversion
References
28 Therapies that utilize descending pain pathways: meditation, vocation, games, music, and others
References
29 Acute and chronic pain: the basics
Reference
30 Surgical and procedural pain
References
31 Musculoskeletal pain
Reference
32 Orofacial pain
Anatomy and innervation
Common and relevant conditions
33 Neck pain, cervical, and thoracic spine pain
Anatomy and innervation
References
34 Arm and hand pain
Anatomy and innervation
Common and relevant conditions
References
35 Low back pain
36 Back pain emergencies
Common and relevant conditions
Reference
37 Radiating leg, buttock, and groin pain
Anatomy and innervation
Common and relevant conditions
References
38 Knee pain
Anatomy and innervation
Clinical assessment
Basics of treatment
References
39 Foot and ankle pain
Anatomy and physiology
Clinical assessment
Basics of treatment
References
40 Headache emergencies
References
41 Headaches
Basic evaluation
Tension type headache
Migraine headache
Occipital neuralgia
Secondary headache
References
42 Headache – chronic pain and the acute flare
General features and diagnostic guidance
Common and relevant conditions
References
43 Visceral pain
Anatomy and innervation
44 Pelvic pain
Anatomy and physiology
45 Exceptional causes of severe, chronic pain
46 Management of pain in those with substance abuse
References
47 Pain at the end of life, opioid rotation
Opioid rotation
References
48 Opioids for chronic pain: preventing iatrogenic opioid use disorders
References
49 Tapering opioids in patients with pain
References
50 Pain in infants, children, and adolescents
References
51 Pain in older adults
Reference
52 Tailoring pharmacotherapy in aging, renal, liver, and other metabolic dysfunctions
References
53 Pain in pregnancy and the puerperium
Anatomy
Common and prevalent conditions
References
References
Appendix I: Sample exam sheet
Appendix II: Sample pain diary worksheet
Appendix III: Glossary
Sources
Appendix IV: Daily stretching guide – essential for pain prevention
Appendix V: Patient packet – your power over pain
Multiple choice questions
Answers
Index
End User License Agreement
List of Tables
Chapter 9
Table 9.1 Pain alphabet.
Table 9.2 Pain functional interference.
Table 9.3 Biopsychosocial model: with examples for each Bio – Psycho – Social...
Chapter 11
Table 11.1 Pain behaviors by temporal phase.
Table 11.2 Management of affect NURSE acronym.
Chapter 12
Table 12.1 Range of motion of commonly tested parts.
Table 12.2 Selected muscle name and innervation levels.
Table 12.3 Reflex testing.
Chapter 14
Table 14.1 Behavior change in healthcare: comparison of models.
Table 14.2 Motivational interviewing summary.
Chapter 15
Table 15.1 Strategies for acute pain care management.
Table 15.2 Key messages from The Joint Commission about pain.
Table 15.3 The Joint Commission: standards for pain care.
Table 15.4 How to communicate with other providers about pain.
Table 15.5 Maintaining an excellent reputation.
Chapter 18
Table 18.1 Selected NSAIDs and relative potency for COX1 and COX2.
Chapter 19
Table 19.1 Selected features of pain‐active neuromodulating agents: anti‐depr...
Chapter 20
Table 20.1 Abbreviated guide to appropriate opioid prescribing scenarios.
Chapter 21
Table 21.1 The basic principles of safe opioid use are embodied in the CDC an...
Table 21.2 Opioid potency relative to morphine, and receptor subtype activati...
Table 21.3 Opioid receptor types and actions.
Chapter 23
Table 23.1 Over‐the‐counter topical agents and preparations.
Table 23.2 Prescription topical agents.
Chapter 25
Table 25.1 Daily sleep countdown.
Table 25.2 Common sleep questions.
Table 25.3 Daily sleep countdown.
Chapter 26
Table 26.1 Elements of cognitive behavioral therapy.
Table 26.2 Errors of thought contributing to pain perpetuation.
Table 26.3 Six elements of acceptance‐commitment therapy.
Chapter 30
Table 30.1 Potential harms and side effects of inadequate pain control in the...
Table 30.2 Number of common U.S. surgical procedures, selected procedures as ...
Chapter 39
Table 39.1 Incidence of sprains of the lower quarter.
Table 39.2 Distinguishing features of pain syndromes in the foot and ankle.
Chapter 40
Table 40.1 Typical temporal course and major exam findings of major headache ...
Table 40.2 Highlights of testing, imaging, and clinical notes for major heada...
Chapter 48
Table 48.1 Potential harms and benefits of opioids.
Chapter 49
Table 49.1 Opioid WITHDRAWAL mnemonic – FLAPPY HANDS.
Table 49.2 Opioid OVERDOSE mnemonic – MORPHINE.
Table 49.3 Features of opioid tapering: paradigmatic scenarios.
Table 49.4 Naloxone – CDC‐NIOSH recommendations.
Chapter 50
Table 50.1 Neonatal/Infant pain scale.
Table 50.2 Infant positioning for vaccination influences assessed pain. (a) T...
Table 50.3 Soothing and pain‐relieving activities, by age group.
Chapter 53
Table 53.1 Eclampsia: symptoms and signs.
Table 53.2 Peripartum headache differential diagnosis.
List of Illustrations
Chapter 1
Figure 1.1 Pain has sensory‐discriminative and emotional‐motivational compon...
Figure 1.2 Interindividual variability in pain showing tremendous variabilit...
Figure 1.3 Standard pain assessment: the pain ‘Alphabet’.
Figure 1.4 The numerical rating scale of pain severity (intensity).
Figure 1.5 Pain interferes with function in multiple domains of daily functi...
Chapter 2
Figure 2.1 Simplified overview of nociceptive processing in the nervous syst...
Figure 2.2 Transmission and modulation events in the spinal dorsal horn. Inf...
Chapter 3
Figure 3.1 The basic mechanisms of pain.
Figure 3.2 How basic pain mechanisms interact.
Figure 3.3 Stimulus response curve: normal and abnormal pain perception.
Chapter 4
Figure 4.1 (a) Pain is highly prevalent, present in about 38% of the populat...
Figure 4.2 Access to pain‐relieving medication varies widely with location. ...
Chapter 5
Figure 5.1 Healthcare ethics rests on the “four pillars.”
Figure 5.2 Each of the four pillars has distinctive aspects that shape ethic...
Chapter 6
Figure 6.1 Pain patterns, examples. Pain can present with many different pat...
Figure 6.2 Qualities of pain, examples.
Chapter 8
Figure 8.1 Parallel pathway model. Diagnosis and initiation of treatment pro...
Figure 8.3 Balancing knowledge of disease with patient‐centered understandin...
Figure 8.4 (a) Normal functioning demonstrating processes of eudynia; (b) Am...
Figure 8.2 Mechanism‐based classification of pain overview: rationale for de...
Chapter 9
Figure 9.1 The numerical rating scale.
Figure 9.2 In the effective patient‐provider relationship, there are many fo...
Chapter 10
Figure 10.1 Affect and cognition are both communicated in the pain‐focused c...
Figure 10.2 Recognizing and modulating the emotional range of a pain‐focused...
Chapter 11
Figure 11.1 Aspects of emotional development.
Chapter 12
Figure 12.1 Anatomical posterior view of the torso.
Figure 12.2 Dermatomes on male figure. Developed by the author (BBH) from pu...
Chapter 13
Figure 13.1 Epstein and Hundert model of professional competence is based on...
Figure 13.2 Dimensions of emotional competence: applied to pain care.
Chapter 14
Figure 14.1 Action items for each stage of stages of change model.
Chapter 16
Figure 16.1 Comprehensive pain management involves incorporation and coordin...
Figure 16.2
Exploring therapy options:
providing patients with prompts and r...
Chapter 17
Figure 17.1 Schematic for rational selection of agents for pain based on bas...
Figure 17.2 Treatment according to pain type, summary notes.
Figure 17.3 Efficacy (NNT) of selected agents.
Chapter 18
Figure 18.1 Structure and pharmacokinetics of Acetaminophen and Ibuprofen.
Chapter 19
Figure 19.1 Structure of selected neuromodulating agents.
Chapter 20
Figure 20.1 Representations of opioids in antiquity.
Figure 20.2 Consumption of opioids in the U.S. compared with other global re...
Figure 20.3 Opioid precautions.
Chapter 21
Figure 21.1 Preclinical studies show that there can be very rapid tolerance ...
Chapter 22
Figure 22.1 Drawing of the neuroaxis showing potential sites of opioid deliv...
Chapter 24
Figure 24.1 Spinal column views with (a) herniated disc compressing nerve ro...
Figure 24.2 Spinal cord stimulator illustration.
Figure 24.3 Spinal cord indwelling pump illustration.
Chapter 25
Figure 25.1 Estimated relative pain Score impacts for chronic pain.
Figure 25.2 Examples of activating therapies.
Chapter 26
Figure 26.1 CBT: a situation leads to thoughts which produce feelings that l...
Figure 26.2 The six “pivots” of ACT, adapted from Stephen Hayes. In ACT, the...
Chapter 27
Figure 27.1 Massage therapy – trigger points, X indicates location of trigge...
Figure 27.2 Example of acupressure points in forehead.
Figure 27.3 Lunge stretch illustration, stretching routines should be person...
Figure 27.4 Inversion table illustration, please observe appropriate clinica...
Chapter 28
Figure 28.1 Meditation – evidence supports the use of mindfulness‐based stre...
Figure 28.2 Vocational engagement – engaging in meaningful and purposeful ac...
Figure 28.3 Video games and virtual may help reduce stress and pain, however...
Figure 28.4 Connecting with nature is very therapeutic for some.
Chapter 29
Figure 29.1 Chronic vs. Persistent pain: conditions and associated recovery ...
Figure 29.2 In chronic pain, allodynia and hyperalgesia are more prevalent a...
Figure 29.3 Acute vs. Chronic pain: how pain types shift in importance betwe...
Chapter 30
Figure 30.1 Flow diagram for enhanced recovery after surgery protocols. Adap...
Figure 30.2 Prevalent factors that impact outcomes.
Chapter 31
Figure 31.1 Chronic vs. Persistent pain: conditions and associated recovery ...
Figure 31.2 Selected nonpharmacological therapies for musculoskeletal pain c...
Chapter 32
Figure 32.1 Segmental (dermatomal) innervation of face and head, lateral vie...
Figure 32.2 Innervation of the tongue.
Figure 32.3 Pulpitis typically resolves rapidly and completely with denervat...
Figure 32.4 Pain of TMD can involve large areas of the face.
Chapter 33
Figure 33.1 Sagittal view of the neck, illustrating structures of anterior n...
Figure 33.2 Anatomy of cervical spine with a level showing some features of ...
Figure 33.3 Cross‐sectional view of cervical spinal column, muscles removed....
Chapter 34
Figure 34.1 Diagram of arm with major nerves: median, ulnar, and radial; ill...
Figure 34.2 Diagram of shoulder with muscles and tendons of rotator cuff.
Figure 34.3 Diagram of wrist and hand illustrating location of carpal tunnel...
Figure 34.4 Medial elbow, illustrating location of ulnar nerve compressive n...
Figure 34.5 Comparison of pain patterns in hand.
Chapter 35
Figure 35.1 Pain patterns often associated with common causes of low back pa...
Figure 35.2 Lumbosacral spine sagittal MRI. Degenerated, desiccated disc is ...
Figure 35.3 Schematic diagram illustrating changes associated with disc dege...
Figure 35.4 Diagram illustrating SI joint in posterior pelvis/lateral low ba...
Chapter 36
Figure 36.1 Comparison of Type I and Type II red flags for low back pain eme...
Figure 36.2 Imaging modalities and spinal abnormalities. (a) CT of lumbosacr...
Chapter 37
Figure 37.1 Diagnostic prevalence of radiculopathy in older adults by spinal...
Figure 37.2 Patterns of common lumbar radicular pain, L3 (least common), L4,...
Figure 37.3 Illustration of sciatic nerve passes between piriformis and geme...
Figure 37.4 Illustration of meralgia paresthetica (MAYO – need substitute)....
Chapter 38
Figure 38.1 Two views of the knee, anterior anatomical view with muscles, me...
Figure 38.2 Interior view of the knee from above with femur remove, illustra...
Figure 38.3 Common knee injuries with provoking activities and examination n...
Chapter 39
Figure 39.1 Bones and ligaments of the foot and ankle, with (a) anterior, (b...
Figure 39.2 Diagram illustrating selected common foot ailments. Kiel J (2020...
Chapter 40
Figure 40.1 Classic CSF appearance, varies with diagnosis, may visualize at ...
Figure 40.2 Subarachnoid blood in SAH.
Chapter 41
Figure 41.1 Headache calendars are essential for gathering sufficiently deta...
Figure 41.2 Headaches are principally subjective; patient‐reported features ...
Chapter 42
Figure 42.1 Comprehensive pain management is highly effective for chronic he...
Figure 42.2 Chronic headaches can be very impairing: perturbing focus or in ...
Chapter 43
Figure 43.1 Visceral pain often manifests with “referred pain,” pain perceiv...
Figure 43.2 Peripheral and central structures may contribute to the phenomen...
Chapter 44
Figure 44.1 Skeletal anatomy of the pelvis with bones, ligaments, and lumbos...
Figure 44.2 Anatomy of posterior pelvic wall illustrating course of femoral,...
Chapter 45
Figure 45.1 (a) Early phase CRPS: the left hand is edematous, discolored and...
Figure 45.2 Tapping distal phalanx of great toe with a sharp stick to test s...
Figure 45.3 Potential causes and preliminary testing for small fiber neuropa...
Figure 45.4 Comparison of nerve biopsy and skin biopsy for assessment of neu...
Chapter 46
Figure 46.1 There is a complex interplay between pain, substance use disorde...
Figure 46.2 Opioid risk tool elements.
Figure 46.3 The four A's of balanced analgesia: It is important to assess an...
Figure 46.4 Elements of COWS assessment for opioid withdrawal (Clinical Opio...
Chapter 47
Figure 47.1 Many symptoms are associated with end‐of‐life; pain is the most ...
Figure 47.2 Palliative care occurs as a spectrum from focusing of symptom‐ma...
Figure 47.3 Patients have many needs, as exemplified by the layers shown her...
Chapter 48
Figure 48.1 Can your patient or their caregiver be expected to meet the foll...
Figure 48.2 Opioids have a decline in analgesic efficacy over time that is a...
Figure 48.3 Opioids have multiple receptors that manifest different properti...
Chapter 50
Figure 50.1 FLACC infant and small child pain scale.
Chapter 51
Figure 51.1 Common and less common pain conditions in older adults (total Me...
Figure 51.2 Adaptations to pain treatments for older adults.
Figure 51.3 Bird‐watching is an example of an activity that utilizes diverse...
Chapter 52
Figure 52.1 Moderate renal failure diagnosis increases with age, U.S. Medica...
Figure 52.2 Diagnostic prevalence of chronic renal failure by stage, adults ...
Figure 52.3 Diagnostic prevalence of common conditions of older adults. Seve...
Chapter 53
Figure 53.1 Comprehensive pain treatment planning for pregnancy and puerperi...
Figure 53.2 Graphic of basic analgesia medications, in pregnancy and breastf...
Guide
Cover Page
Title Page
Copyright Page
Dedication Page
Preface
Foreword
Acknowledgment
Table of Contents
Begin Reading
References
Appendix I: Sample exam sheet
Appendix II: Sample pain diary worksheet
Appendix III: Glossary
Appendix IV: Daily stretching guide – essential for pain prevention
Appendix V: Patient packet – your power over pain
Multiple choice questions
Answers
Index
Wiley End User License Agreement
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Pain Medicine at a Glance
BETH B. HOGANS
The Johns Hopkins School of Medicine and Veterans Affairs Maryland Health Care System Baltimore, USA
This edition first published 2022© 2022 John Wiley & Sons Ltd
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The right of Beth B. Hogans to be identified as the author of this work has been asserted in accordance with law.
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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication Data
Names: Hogans, Beth B. (Beth Brianna), 1964– author.Title: Pain medicine at a glance / Beth B. Hogans.Other titles: At a glance series (Oxford, England)Description: First edition. | Hoboken, NJ : Wiley‐Blackwell, 2022. | Series: At a glance series | Includes bibliographical references and index.Identifiers: LCCN 2021007910 (print) | LCCN 2021007911 (ebook) | ISBN 9781118837665 (paperback) | ISBN 9781118837658 (adobe pdf) | ISBN 9781118837641 (epub)Subjects: MESH: Pain | Pain Management | HandbookClassification: LCC RB127 (print) | LCC RB127 (ebook) | NLM WL 39 | DDC 616/.0472–dc23LC record available at https://lccn.loc.gov/2021007910LC ebook record available at https://lccn.loc.gov/2021007911
Cover Design: WileyCover Image: © Science Photo Library ‐ SCIEPRO/Brand X Pictures/Getty Images
Dedicated to E.B. and R.A.
With thanks to my patients and colleagues.As we meet reality, we must learn to embrace it as a profound set of contingencies in which we are embedded, and whose meaning is unknown.
Polly Young‐Eisendrath
The Present Heart
Preface
Fifteen years in the making, this book was first conceptualized as one of the potential outgrowths from the first‐year medical student course in pain at Johns Hopkins assembled by an interprofessional team of pain experts. In the ensuing years, tremendous changes have swept the globe impacting the practice of clinical care: The North American opioid crisis has raised awareness about the perils of medication‐based approaches, especially when drugs impacting the reward pathways are used; revisions in healthcare financing, delivery, and education have increased the representation of nurse practitioners and physician assistants in primary care roles; and the gathering of large interprofessional working groups and creation of interprofessional curricula have endeavored to meet to the above needs. This text is responsive to the guidance of the Interprofessional Education Collaborative which recommends that curricula are based on teamwork, shared values, professional roles, and communication, centered on the patient and family, and informed by community and population. The concepts in this book are firmly rooted in the work of the International Association for the Study of Pain but some adaptations are present. The primary target audience of this book is the primary care provider, or nonpain specialist, seeking quick guidance about pain, within the context of an integrated, whole‐person approach.
This book springs from my passion for teaching and my profound belief in visual learning. My goal is to change how you think, and feel, about pain – to illuminate the reasons behind pain experience, the events of peripheral nociception, the impacts of pain on the person, and the outlines of how manage pain in the most holistic manner possible, with compassion and concern for best long‐term outcomes. With Pain Medicine at a Glance, it is my intention to capture the imagination and attention of each person who happens upon the book, to provide a series of visual mental images that imprint “pain logic” on the mind and aid each reader to approach pain with enthusiasm and interest.
My guiding inspiration for this book was to employ visual learning to change how healthcare providers think about pain. As a young person, I spent many weekends with my grandparents, my grandfather was a naturalist, and my grandmother had grown up on the farm but moved to the city as a teenager to study nursing. They both loved the outdoors but approached it as an opportunity to learn as well as to wonder and enjoy. They had a small collection of guidebooks with exquisite illustrations – trees, mushrooms, wildflowers, seashells, and birds came to life in glorious detail. I loved to gaze at the pictures but was awestruck at how much my grandparents had learned about the world around them and the gentle respect for nature that suffused their approach to exploring that world. Pain Medicine at a Glance is my chance to share the special love and wonder I feel for the human body as a physician and pain scientist. In it, I seek to unlock some fundamental knowledge so that students and colleagues can better understand and respond to this physiological system that functions to protect us, but sometimes causes profound suffering. May this book be a useful guide on your journey to helping others.
Beth B. Hogans
Baltimore, Maryland
Foreword
No North American pain educator today is more highly esteemed than Beth Hogans. Her career has been informed not only by her medical and scientific training as a scientist and neurologist, but also by broad interests in literature and the humanities. Dr. Hogans' early work identified, in a series of landmark studies, deficits and gaps in the medical student curriculum related to pain. Together with colleagues, she inaugurated an innovative course at Johns Hopkins for entering medical students about pain. For over a decade, this course has served as a model for other pain educators. It spans not only conventional biomedical content but also the experiential and social dimensions of pain. As the course has evolved, so have the fields of pain research, education, and policy. Throughout this time, Beth led the charge to more broadly advance clinical competence in pain. Working collaboratively, she created a scholarly journal section dedicated to pain education. Through this, she guided her peers in the field, raising the level of scholarship in pain education and supporting the development of clinician‐educators, nationally and internationally, continually seeking to innovate and disseminate academic advances. Central among these advances has been the reaffirmation that pain is a clinically salient subjective experience heavily influenced by social processes such as isolation and stigma that add to suffering.
Advances in educational psychology have been applied by Dr. Hogans and colleagues to render pain education more effective and efficient. The techniques of role‐playing, narrative, re‐enactment of brief pain, such as BandAid removal, have been incorporated into the course. Beth has had a particular interest in harnessing the neurobiology of learning to optimize pain education, whether through ensuring that experiences are of relatively brief duration so as not to overload students' cognitive capacity, and providing copious illustrations to harness other means to convey packets of knowledge, e.g. text. The practical results of such a sophisticated approach are embodied in Pain Medicine at a Glance: focused one‐ to two‐page chapters that convey the essence of a topic or clinical situation in a way that all members of an interprofessional pain care team can quickly absorb and apply. The consistent delivery of linked pieces of knowledge by a single exemplary clinician‐educator‐scientist – with practical dicta such as watching out for their own safety, or displaying compassion and empathy – conveys what it must be like for a student or fellow to accompany Beth in the clinic or on bedside rounds.
I believe that the magic by which Dr. Hogans' presence and style suffuse this book derives from its being a single‐author volume. Those who know Beth or have heard her speak will recognize the prose of the present volume as conveying her voice. Single‐author volumes on complex topics (think Bonica, Beecher, Ballas on sickle cell pain, or Selye on stress) are becoming more and more uncommon as fewer and fewer scholars – particularly clinician‐scholars – have the breadth of knowledge to single‐handedly convey their oeuvre. Two thousand years ago, Horace, the Roman playwright, satirist, and father of literary criticism, in Ars Poetica urged writers to choose their subject judiciously, in harmony with their own interests and abilities. That done, “neither elegance of style nor clarity of expression shall desert the [writer] by whom the subject matter is chosen judiciously.” Devoting her career to becoming an exemplary clinician‐educator, Beth has indeed chosen her subject wisely. Her descriptions of problematic situations and how to manage them (e.g. tapering opioids in a patient reluctant to do so) speak with clinical credibility. This volume is a testament to her mastery of the field of pain, and her own personal approach to interdisciplinary pain education, that call to mind the historical mission statement of a leading Boston hospital: “where science and kindliness unite.”
Daniel B. Carr, MD, DABPM, FFPMANZCA (Hon.)
Professor Emeritus, Tufts University School of Medicine, Boston
Founding Director, Tufts Program on Pain Research, Education and Policy
Past President, American Academy of Pain Medicine
Honorary Member, International Association for the Study of Pain.
Acknowledgment
Many thanks to Anne Hunt, James Watson, Vincent Rajan, Samras Johnson, and Avinash Singh, my editors at Wiley. I appreciate their consistent encouragement and sage advice in preparing this manuscript. The work came together with a breathtaking team effort – my vision of communicating the wonders of pain clinical science, so many years in the making, has now arrived. Thank you.
I would like to acknowledge some of my many great teachers in pain: Jim Campbell, the late John W. (Jack) Griffin, Jennifer Haythornthwaite, Lewis Levy, Steven Waxman, George Richerson, Alan Pestronk, David Cornblath, Vinay Chaudhry, Ahmet Hoke, Andrea Corse, Stuart Goldman, Steve McMahon (Mac), Dan Carr, and Mac Gallagher have taught me so much about pain and nociceptive processing. Paul Hoffman, Dick Meyer, and Tom Brushart were among my exemplars of critical scientific reasoning. Judy Watt‐Watson, Pat Thomas, Margaret Lloyd, Nancy Hueppchen, Andy Levy, Kyle Davis, Beth Nenortas, Christina Spellman, and Rachel Salas are among my great educational role models. I am deeply grateful to David Yarnitsky, Merav Shor, Antje Barreveld, Michelle Taylor, and Bernie Siaton for professional collaborations and sincere friendship. I have been fortunate to have many wonderful students, but some have brought exceptional effort and talent including Aakash Agarwal, Lina Mezei, Joe Nugent, Alexis Steinberg, Zelda Ghersin, and Kolade Fapohunda. Mr. Tim Foley is an extraordinary and talented administrator, and I am most appreciative of Ms. Tina Moore's heartfelt and able administrative support of my academic career. Les Katzel has supported my advanced career development with grace and wit, and John Sorkin has championed my passion for statistics and applied mathematics in the service of clinical medicine. Justin McArthur has always offered encouragement and fostered my passion for neurology and pain. Shelley List, my dear friend, has served unswervingly as a personal ad hoc editor, consultant, and trusted advisor. My father Donald Hogans was an extraordinarily devoted champion; given his 2‐meter stature, from birth, I actually “stood on the shoulders” of a giant. He cheered my efforts to write cogently about pain and to step up to any reasonable opportunity to improve the world. And my children, who have genuinely been my light and joy – so determined, so clever, and so unfailingly kind.
To apportion our days?
But tell us how,
and we shall come to the heart of wisdom.
The Psalm of Moses
Beth B. Hogans
Baltimore, MD
1What is pain and how do we assess it?
Formally defined as an “unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Raja et al. 2020), pain has an enormous impact on clinical outcomes. This formal definition captures several important aspects of pain: first, it is unpleasant, meaning that most people strongly prefer pain relief to continued pain. Second, pain is a sensory AND emotional experience, which means that pain has both sensory‐discriminative qualities, i.e. descriptive features such as burning or stabbing; as well as unpleasantness, i.e. aspects that pertain to suffering (Figure 1.1). The unpleasantness of pain profoundly motivates most people to seek relief. The suffering associated with pain motivated Epicurean philosophers (300 BCE) to observe in that the height of pleasure is reached with the absence of pain.
Figure 1.1 Pain has sensory‐discriminative and emotional‐motivational components.
Essential to survival, pain normally functions as a warning sign of damage to the body. High mortality rates are associated with painless myocardial ischemia; patients who cannot perceive a heart attack won't seek medical care until it is too late. At the extreme end of this spectrum are patients born with genetic mutations that eliminate pain sensing, e.g. SCN9A sodium channel defects, these patients are at increased risk for mutilation and death (Cox et al. 2006).
Perhaps the most important aspect of pain the tremendous variability from one person to another, interindividual variability, Figure 1.2. Due to diverse biology, genetic, and environmental factors, it is truly not possible to “know another's pain.” We must ask people about their pain in order to understand it. In a clinical setting, we call this “pain assessment.”
Figure 1.2 Interindividual variability in pain showing tremendous variability in healthy individuals exposed to pain stimulus.
Standard basic pain assessment includes assessment of: (i) Quality (burning, sharp, etc.), (ii) Region involved (arm, leg, etc.), (iii) Severity (also pain intensity), (iv) Timing (sudden, slow, waxing/waning), (v) Usually associated symptoms (rashes, vomiting, etc.), (vi) the things which make the pain Very much better (medicines, rest), and (vii) the things which make the pain Worse, Figure 1.3. This information, taken together, enables the clinician to formulate a preliminary differential diagnosis. Caring for patients with pain relies on strong basic clinical skills. It is essential to establish a problem list and a working differential diagnosis.
Functional pain assessment includes appraisal of how pain impacts a patient's functioning in daily life. Are they able to: Carry out tasks at home? Work to full capacity? Engage in self‐care? Interact with family and friends? Contribute to society normally? Enjoy life? And What is their quality of sleep? How is pain impacting their mood?
Figure 1.3 Standard pain assessment: the pain ‘Alphabet’.
Limited pain assessment, at a minimum, focuses on pain severity. Through the use of pain intensity scales, it is possible to rapidly and reproducibly ask patients about pain. Clearly subjective, but highly reproducible, the numerical rating scale (NRS) is the preferred pain intensity scale (Figure 1.4). Widely used, it is easy to understand, rapidly explained and scored, does not require literacy, translates well to other languages, and shows robust response properties in clinical practice. Intubated patients can use an NRS presented visually. The NRS is properly referred to as an “11‐point scale” as 0 and 10 are both included. Changes of less than 2 points on the NRS are generally below the “minimal clinically significant change” threshold and not meaningful. Limited pain assessment, focusing on pain severity alone is only appropriate for ultra‐rapid re‐assessment of patients with an established diagnosis. Initial appraisal of a patient with pain should always include the elements of the standard basic assessment, and the functional pain assessment, pain frequently impacts function (Figure 1.5).
Figure 1.4 The numerical rating scale of pain severity (intensity).
Over the years, a number of other pain scales have been used for verbal adults including the ‘verbal descriptor scale’ (mild/moderate/severe), the visual analog scale (a bar with no tick marks), a 100‐point scale, and a pain thermometer. The NRS is currently the most widely preferred scale.
For children, it is important to conduct an age‐appropriate pain assessment. Infants and pre‐verbal children require behavioral pain scales, Chapter 50. For those with communication barriers, cognitive impairments, or dementia, situationally appropriate pain scales are necessary, Chapters 10 and 51.
There are several scales used in research that were designed to assess various aspects of pain. The McGill Pain Questionnaire includes a list of 77 pain descriptors organized into 20 categories that are grouped in major domains of sensory, affective and evaluative in nature, and ranging in intensity (Melzack 1975). For example, pain that is pulsatile, ranges from flickering to pounding. Reviewing this instrument can build awareness of the diverse qualities of pain descriptors. The Brief Pain Inventory (BPI) is another informative and widely validated pain assessment instrument (Cleeland 2017). The BPI asks about pain in terms of impact on various domains of function: sleep, mood, general activity, relationships with others, etc.; as well as rating pain intensity. Both of these scales are available on the web.
Figure 1.5 Pain interferes with function in multiple domains of daily functioning. A patient may experience varying degrees of impairment.
In a nutshell, pain is a major force in life and medicine. It determines many of the choices we make as we navigate potentially hostile and dangerous environments. In the absence of a functioning pain system, we cannot grow to adulthood without repeated traumatic injuries. Conversely, when the pain system goes awry and overamplifies pain, persistent suffering is the result. Through biomedical research and increasing patient‐centeredness in clinical care, tremendous strides in understanding and managing the pain system are occurring with implications for improved healthcare and patient satisfaction. In this book, you will encounter pain in many different aspects, and learn the beginning steps to assessing and treating pain safely and effectively.
Pain is prevalent and impacts all patient outcomes: learning about pain will improve your clinical performance, enhance your career satisfaction, and increase quality of life for you, and for your patients.
References
Cleeland, C. (2017). Brief pain inventory user guide.
https://www.mdanderson.org/documents/Departments‐and‐Divisions/Symptom‐Research/BPI_UserGuide.pdf
(accessed 17 December 2017).
Cox, J.J., Reimann, F., Nicholas, A.K. et al. (2006). An SCN9A channelopathy causes congenital inability to experience pain.
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Melzack, R. (1975). The McGill pain questionnaire: major properties and scoring methods.
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Raja, S.N., Carr, D.B., Cohen, M. et al. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain 2020 Sep 1;161 (9): 1976–1982. doi: 10.1097/j.pain.0000000000001939. PMID: 32694387; PMCID: PMC7680716.
2Nociceptive processing: How does pain occur?
Nociceptive processing is the processing of pain‐related information by the nervous system, occurring at many levels. By understanding how pain is processed in the body, we can better understand patients' pain.
Both neurons and glia participate in nociceptive processing and responses to nociceptive inputs are shaped by genetic and environmental factors, explaining the tremendous variation in pain experience.
The nociceptive processing system is anatomically and functionally divided into four inter‐related components: transduction, transmission, perception, and modulation (Figure 2.1). Normally, nociceptive processing serves to protect an organism. Unfortunately, fidelity in recognizing threats is sometimes lost, and misdirected activation results in aberrant pain sensing (enhancement or loss). In this respect, the pain system is not unlike the immune system which can manifest disorders of excessive or deficient immunity, both causing substantial harm. Excessive pain, persistent pain, and deficient pain perception are all detrimental to health.
Figure 2.1 Simplified overview of nociceptive processing in the nervous system.
Transduction
Pain perception normally begins with a noxious stimulus. Perhaps a thorn is encountered: nerve endings of thinly myelinated and unmyelinated axons respond. Many decades ago, there was vigorous discussion about the “labeled line” hypothesis. The idea was that “pain” was encoded by specific nerve fibers and travelled in a dedicated pain system. With molecular biology, we know now that there are a wide variety of “labeled lines” each carrying signals of a particular flavor or nuance (Stucky et al. 2009; Ringkamp et al. 2013). For example, various transient receptor‐potential (TRP) channels are expressed in sensory neurons responding to high heat, medium heat, low heat, warm, and cold stimuli across the thermal spectrum, similar to the way that rods in the eye respond to different spectral intensities of light (Tominaga et al. 1998; Fernández‐Carvajal et al. 2012). Some of these thermal stimuli are clearly encoded as painful, some require co‐activation of other sensory afferents to produce a painful percept. Transduction occurs in response to different forms of stimulus, e.g. mechanical, thermal, chemical. Signaling ions enter the primary afferent peripheral nerve termination causing small shifts in membrane potential: the “graded potential.” If the graded potential shifts the local membrane potential to threshold, action potentials volley into the afferent axon. Altered transduction by nerve endings in the target organ is an important part of inflammatory pain; mediators such as NGF, bradykinin, and protons can sensitize nerve endings, leading non‐ painful stimuli to produce pain.
Transmission
Nociceptive signals are transmitted as action potentials via multiple structures in parallel and series. The primary afferent neuron, with cell body located in the dorsal root ganglion, extends axons peripherally and centrally from the sensory ganglion. Many nociceptive signals are transmitted by small nerve fibers of varying caliber. “First pain,” for example, is signaled by thinly myelinated a‐delta fibers that conduct action potentials at about 20 m/s. This means that an adult leg can be traversed in under 50 ms. So‐called “second pain” is signaled by unmyelinated C fibers that conduct at 1 m/s and arrive at the spinal cord much later. Both fast and slow signals are transmitted to second order neurons in the spinal dorsal horn. The synapses are principally located about two anatomical levels rostral to the entry of the root into the spinal cord. Lumbar and sacral spinal roots terminate far rostral to the corresponding vertebra, with implications for spinal lesion localization. Cervical roots are much shorter. Altogether, nerves, spinal cord, brain stem, and cortical white matter are all involved in transmission.
Perception
The perception of pain is multidimensional and occurs in several cortical sites. S1 and S2 are associated with the sensory‐discriminative features of pain. The earliest activation of cortex in response to pain is in the “S2” sensory‐discriminative area (Granovsky et al. 2008). The medial limbic cortex, (rostral anterior cingulate cortex) mediates the affective, motivational aspects of pain. Other structures contribute to the impact of pain on motor behavior (basal ganglia and cerebellum), sympathetic tone (insula), and alertness (periaqueductal gray) (Liu et al. 2011). It is arguable whether all are properly referred to as “perception” but a better term has not arisen. Perception occurs as a complex temporal and spatial series of events varying with the type, severity, and persistence of pain. Neuropathic pain results in strong activation of affective and motivational centers in the brain. Unfortunately, persistent pain may be associated with brain atrophy (Baliki et al. 2011).
Modulation
Pain modulation occurs at every level of the nervous system including end‐organs, peripheral nerve, spinal dorsal horn and rostral centers. Key modulation events occur in the dorsal spinal cord where descending fibers, especially from the nucleus raphe magnocellularis (NRM) synapse and control the transmission of nociceptive signals from primary afferent neurons onto second order neurons (Figure 2.2). This is an important form of gating which has the potential to constrain “pain from accessing the CNS.” The NRM is situated in the ventral midline at the pontomedullary junction. It contains both “ON” and “OFF” cells. ON cells have the capacity to sensitize an animal to noxious stimuli, effectively turning the pain system “on,” whereas OFF cells have the capacity to decrease the transmission of nociceptive signals from primary to secondary afferent, effectively turning pain sensitivity “off.” More recently, a role for non‐neuronal cells has been recognized in nociceptive modulation (see Chapter 29).
Figure 2.2 Transmission and modulation events in the spinal dorsal horn. Influences on nociceptive processing include: descending inhibition and facilitation, afferent inputs from the periphery and local inhibitory circuits. This is a key site of drug action.
In summary, pain experience arises from the normative functioning of the nociceptive processing system, a complex sub‐system of the nervous system including both neuronal and non‐neuronal elements. Understanding the component elements of the pain processing system: transduction, transmission, perception, and modulation, may aid clinicians in thinking about patients with pain, and lead them to develop more effective diagnostic and treatment plans.
References
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3What are the major types of pain?
The best approach to understanding and designing effective treatment plans for pain is to view the origins of the problem in terms of basic pain mechanism. This is because the pain mechanism has a major impact on: (i) the potential to diagnose a specific condition, (ii) choose an effective treatment, (iii) prognosticate the patient's course in therapy, and (iv) guide the patient in self‐management. There are three major mechanism‐based types of pain: nociceptive, inflammatory, and neuropathic (Figures 3.1 and 3.2).
Figure 3.1 The basic mechanisms of pain.
Figure 3.2 How basic pain mechanisms interact.
Nociceptive pain is pain arising from acute injury. It is signaled by the normal functioning of the nociceptive processing system (Chapter 2). Primary afferents in the various parts of the body are activated by peripheral signaling molecules or direct energy transfer. Currently we know that all of the body is innervated by afferents with some exceptions: the nucleus pulposus of the vertebral disc, the brain parenchyma, and cartilage. Signaling molecules involved in nociception include: protons, bradykinin, histamine, acetylcholine and others (Ringkamp et al. 2013). Direct energy transfer can occur from pressure‐type stimuli, thermal stimuli (hot and cold), or electric shock. A specific nociceptive stimulus may be sensed by multiple primary afferents, as there is no one afferent that is exclusively responsible for pain. Thermal stimuli are sensed by multiple fiber types, for example when touching a hot stove, there is “first pain” that provokes an immediate withdrawal response, mediated by Aδ fibers, and “second pain
