Go behind the scenes and watch why we developed this course on pain.
No two people experience pain the same, and no two instances of pain warrant the same treatment protocol. Perhaps this is why the study of pain and pain management can prove so perplexing. Unless we treat pain as the messenger, that it is, we will undoubtedly jump to conclusions based on our own experiences. Our individual acquaintance with pain may be of little help to the individuals that we serve. And this is why we must first interrogate the messenger, pain. The first step in navigating the topic of pain is education–We trust you’ll find this course a good place to start.
Upon completion of this course you will be able to:
- Understand the history and significance of pain
- Have a clear definition of pain
- Know the different ways pain is categorized
- Understand some of the various causes of pain
- Be aware of the various effects of pain on others as well as on ourselves as healthcare and human services workers
- Understand the history and philosophy of pain management
- Understand different pain management interventions
- Be aware of cultural considerations in regard to pain and its management
Course Instructor Profile:
Donn Kropp founded CLiCKPLAY Continuing Education University out of a desire to bring others to greater levels of health and wellness. With over ten years of emergency and trauma room experience, Donn brings a seasoned, yet fresh approach to continuing education.
- CA Board of Registered Nursing: CA Provider # CEP 15849
- District of Columbia Board of Nursing: CE Provider #50-14108
- California Board of Vocational Nursing Provider # V10810
- Psychiatric Technicians Provider # V10806
- DSS/CCL Division for Adult Residential Facilities (ARF) Vendor Approval # 2000149-735-2: Course Approval #149-0212-25088
- DSS/CCL Division for Residential Facilities for the Elderly (RCFE) Vendor Approval # 2000149-740-2: Course Approval #149-0212-25082
- DSS/CCL Division for Group Homes (GH) Vendor Approval # 2000149-730-2: Course Approval #149-0212-25080
- Far Northern Regional Center
Pain: Friend & Foe
1. INTRODUCTION & OBJECTIVES
I’m Donn Kropp. Welcome to the course, Pain: Friend & Foe. The profession of healthcare and human services is a culture fixated with pain—primarily with how to deflect it, diminish it, or delete it from our lives or the lives of the people we serve. But is pain really an enemy to annihilate? The saying, “Don’t shoot the messenger” may very well be the key that unlocks the role of the health professional in the study of and approach to pain. A patient steps up onto the exam table and announces, “My back hurts.” Should x-rays be ordered right away? Should pain relievers, muscle relaxers, or anti-inflammatories be prescribed? Should bed rest or physical therapy be started? Should we recommend the patient be seen by a surgeon or chiropractor? Pain is as individual as a fingerprint. What hurts you, may feel good to your client. And what feels good to your client, might send your coworker screaming through the halls.
No two people experience pain the same, and no two instances of pain warrant the same treatment protocol. Perhaps this is why the study of pain and pain management can prove so perplexing. Unless we treat pain as the messenger, that it is, we will undoubtedly jump to conclusions based on our own experiences. That being said, our individual acquaintance with pain may be of little help to the individuals that we take care of. And this is why we must first interrogate the messenger, pain.
The first step in navigating the topic of pain is education. I trust you’ll find this course a good place to start. So sit back and enjoy. Maybe get some popcorn or something.
When you’re finished with this course, you will:
- Understand the history and significance of pain
- Have a clear definition of pain.
- Know the different ways pain is categorized.
- Understand some of the various causes of pain.
- Be aware of the various effects of pain on others as well as on ourselves as healthcare and human services workers.
- Take a peek into the history and philosophy of pain management.
- Understand different pain management interventions.
- Be aware of cultural considerations in regard to pain and its management.
2. HISTORY & SIGNIFICANCE OF PAIN
To understand any topic it’s important to have a fundamental understanding of that subject’s history and significance. Our study of pain is no different. The history of pain can obviously be traced back to man’s beginning. As long as we have walked the face of this earth,we have experienced both pleasure and pain. Every stimulus, whether physical, mental, or emotional, has an effect on the body and the psyche. When an object, a person, or a thought activates our pain sensors, we must interpret, express, and ultimately attempt to mitigate or eliminate that pain. It’s clearly shown by research that the meaning attached to pain by a group or an individual has drastic effects on how it’s felt, how it’s expressed, and whether an individual chooses to endure that pain or make attempts to eradicate it.
The Ancient Greeks spoke of the ‘passions of the soul’– pain and pleasure, as intimately linked. They believed that the absence of pleasure led directly to pain. This could very well have been the primary motivating factor for the pleasure-seeking behaviors the Ancient Greeks are so famous for, and it certainly accounts for why philosophers were so keen on discovering the inner workings of the human body. Our English word pain finds its origins in Latin, Old French, and Ancient Greek. The Greek word poine relates to penalty, and the Latin word poene means ‘to punish.’ In their mythology, the Ancient Greeks expressed that pain was a punishment from the gods. Wow, what was that all about? While many cultures across the ages have believed, as the Ancient Greeks did, that pain is a punishment, most experts in the West agree that pain is not so much an enemy to be exorcised or a punishment to endure. Rather, they understand pain to be a messenger, an alarm bell ringing to alert the brain and the psyche that something bad is about to, or already has happened.
The Greeks were not the only people groups to believe that pain came from punishing gods. Many ancient cultures practiced appeasement rituals, such as animal sacrifices or scapegoat rituals, which they believed eradicated the sins of the people and thereby mitigated pain. An equally mystical belief of other ancient cultures was that pain was caused by evil spirits. Many of these tribes or people groups appointed shamans or medicine men, who formulated incantations and herbal potions to exorcise the spiritual forces that caused misery and discomfort. Still other ancients believed that pain made a person stronger—that it was a necessary part of life to learn from and to endure. In fact, many of these cultures believed in several different origins of pain, perhaps a combination of two mentioned notions, or maybe even all three. And some of them even inflicted pain as part of initiations, coming of age rituals and other rites of passage. And really—have things changed all that much throughout the millennia–as to the ways man attempts to attach meaning to pain–there’s really been very little deviation from these three explanations of pain. What are even more compelling than myths of the history of pain are the philosophical and scientific theories about pain throughout Western history. It’s really these theories that lay the foundation for modern Western medical practices in the management and treatment of pain. Moving into the 11th century, Avicenna, a Persian, was particularly enthralled by Aristotle’s writings about existence, being and the natural world. As a teenager Avicenna spent hours in prayer and study in an attempt to reconcile his thoughts with those of Aristotle. By the time he was 16, Avicenna turned his full attention to the study of medicine and the human body. He was the first to put forth the foundations for the Theory of Specificity. He proposed that there were many feeling senses, not limited to Aristotle’s theories about the five senses of taste, touch, sight, sound, and smell.
Avicenna added to the list a sense of pain and a sense of titillation-that’s just a fancy word for pleasure. Though these were the first steps toward understanding the pain mechanism, it would be a long time before the shift toward the human body as a machine would open the way to confirming pain as a complex bodily system. Although it was the Ancient Greeks and Romans who first proposed the theory that the brain and nervous system played a role in the sensation and perception of pain, it wasn’t until the Renaissance, the 14th through 16th,centuries that philosophers, who were the primary students of anatomy and the human body, began to take the evidence, which had been rolling in steadily since the Middle Ages, and apply it to the understanding of the physiology of pain. It wasn’t until well into the 17th century that philosophers began to take hold of the revelation that the body responded to pain like a machine and that pain was associated with disturbances of nerve fibers that sent messages to the brain. Until this time, it was firmly believed that the heart was the seat of emotion where the pain center existed. In the early 1800s several theories began to build momentum toward a true breakthrough in pain theory. These theories postulated that a single stimulus type such as an electrical current or blunt trauma could elicit different sensations, depending on the type of nerve stimulated. In 1965, centuries of study, countless theories and hypotheses paved the way for the landmark Gate Control Theory put forth by Ronald Melzack, a Canadian psychologist, and Patrick Wall, a British neuroscientist. Melzack and Wall proposed the existence of a synapse that modulated the transmission of pain signals to the spinal cord. They believed that thin pain nerve fibers and large-diameter, touch, vibration, pressure, fibers both carry information from the site of injury to the spinal cord. They postulated that thin fibers carry transmission cells to the brain, while large-diameter fibers carry inhibitory interneurons that intercept the transmission cells on their way to the brain. They concluded that we rub a slap because rubbing activates the large-diameter fibers which diminishes the pain signals, that in turn diminishes the amount of pain felt. Melzack and Wall’s theory has led directly to most pain theories in the 21st century. Interestingly, even in our day and age of knowledge researchers agree that such phenomenon as phantom pain, idiopathic pain, and most chronic pain poke holes in even today’s theories of how pain is processed and perceived. Research is now underway in the areas of the roles of neurotransmitters and hormones in the pain system, as well as continued clinical study of the physiology behind pain. Let’s now turn our attention to defining pain.
3. PAIN DEFINED
Now that we have gone through a brief history of pain let’s delve into some of the definitions and theories of this era. The standard and generic definition of pain is, “An unpleasant, subjective, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” That definition though doesn’t do the subject of pain justice. In 1968, a registered nurse and pioneer in the field of pain management named Margo McCaffery defined and highlighted pain’s subjective nature. She stated that pain is, “Whatever the experiencing person says it is, existing whenever he or she says it does”. That’s a pretty broad and seemingly subjective definition, particularly by professional medical and health standards but it’s a key definition because pain is such an elusive concept that isn’t as cut and dry as it appears. However, while the clinical definition of pain has evolved since the 60’s, today’s definition of pain still encompasses and allows for individual expression and experience of pain for every individual. Today’s pain mantra in healthcare and human services should be “Only the person who is experiencing the pain can describe it properly.” As recently as 2009, the American Pain Society reported that “pain is a subjective experience without objective tests to measure it.” There are many ways to define pain, but there is one thing everyone agrees on: Pain is a unique and individual experience, and each person has an inherent right to define and describe it according to their own understanding and experience.
At the most basic level, pain is an unpleasant sensory experience which also has unpleasant psychological components. Without the early warning signal and protective mechanism that pain provides we might be in danger of leaving our fingers too long on a hot burner or stretching our necks or backs too far, resulting in damaged tissues, ligaments, or bones. Aw, I just pulled something! Without pain’s message to stop and take stock of our situation, we might plummet ahead to serious injury or even death.For those of us with fully functioning pain responses, we react quickly and efficiently to pull our fingers away from danger, stop what we’re doing, or straighten up and rub an aching muscle or joint. Most of us know to stop and rest, grab some ice or pop a few anti-inflammatories, and rest. Unfortunately those with altered and diminished pain responses can lead to serious injury, amputation or worse. We see this commonly in individuals suffering from diabetes who have altered pain responses especially in their legs and feet. This diminishment in feeling can lead to ulcers and repeat injury. So what happens when pain persists past home remedies? What if it just goes on and on? When pain starts cutting into life then we need to start thinking about pain management. Pain management is a huge topic. While many advancements have been made in the treatment of pain since the Ancient Greeks first ascribed it to angry gods, the potential for pain to become a destructive force in someone’s life must spur us forward toward understanding how to address the individual nature of pain and how to best alleviate the suffering of others. Before we begin to delve into pain management we have to understand the various forms and types of pain first.
4. TYPES OF PAIN
The first step in knowing how to help individuals in pain is to understand the different ways clinical pain is classified. Each type of pain has unique origins, resulting in a unique experience for everyone which-in-turn requires us to implement different modalities and methods for treatment. Just as pain is multi-faceted in its definition, it’s also multifaceted in its classification. One person might present with physiological or psychological pain. Another individual might describe acute or chronic pain. Still someone else might describe nociceptive or non-nociceptive pain. You could also have a patient or client come to you and be complaining simultaneously about every one of those types we just mentioned. Wait..what…you don’t know what nociceptive and non-nociceptive means..don’t you worry we’ll cover that in a few moments. To fully differentiate the types of pain, it helps to begin with the distinction between acute and chronic. All pain, including that which is psychological, will fall under the heading of either acute or chronic. A woman presenting for Valium the day after her husband died in a fatal car crash is suffering from acute psychological pain. The football player who presents with a broken arm the day after he’s been crushed in a dog pile is suffering from acute pain. Acute pain can be excruciating, but it’s by nature relatively short in duration, lasting only until the injury has healed. This time frame can be anywhere from a few hours to a few months. The duration for acute psychological pain can be greater. Depending on the source it could take from three months to a year to fully recover emotionally. In contrast, pain that persists past the healing of an injury is considered chronic. Clearly, in the case of psychological pain, chronic pain is the result of suppression of feelings, or of grief & loss, or unresolved stress or strain. Acute physical pain is most commonly precipitated by damage to soft tissues, bones, or organs. It’s typically felt as a sharp, aching, or throbbing sensation which comes on suddenly and resolves once the injury has healed. The sharp ache or throbbing is followed by swift reflexes which cause a person to jerk back and protect the injured site from further harm. Typically, a person engages in other pain behaviors that further encourage healing. These include such actions as running a burning fingertip under cold water or squeezing a thumb after it’s been smashed by a hammer. Both promote healing through increasing circulation and by easing the burning or throbbing in the digits.
On the flip-side, chronic physical pain persists beyond the expected healing time for tissue damage. It can be felt consistently or intermittently, and it’s often resistant to treatment. Chronic pain often serves as a signal that the nervous system is no longer functioning properly.While it can be attributed to damaged tissue, it’s often really a result of nerve damage or prolonged psychological stress. In a few minutes, I’ll explain the difference between tissue and nerve damage and demonstrate how the different types of pain are experienced by the central or peripheral nervous system.. For now, it’s enough to remember that chronic pain is any discomfort lasting more than three to six months, which most often begins with an identifiable acute injury. The next tier of classification takes into account only physiological pain. All pain resulting from injury to the physical body falls into one of two categories: Nociceptive and Non-Nociceptive. Nociceptors are thin nerve fibers in the peripheral nervous system that serve as pain receptors in the skin, muscles, and other soft tissues. These nerve endings are able to differentiate between harmful and benign stimuli. When they detect an unpleasant stimulus, they signal the brain to release several substances, including hormones and neurotransmitters, which relay the pain messages from the peripheral nervous system to the central nervous system AKA the brain and spinal cord. Most physical pain is caused by tissue damage and is therefore nociceptive pain, meaning that the pain receptors in the region of damage are stimulated by the injury and send a signal to the brain which alerts a person to the harm or potential harm. This initiates the reflexive measures which cause someone to remove themselves from further harm and to begin alleviating the pain by rubbing the area, running it under cool water, or shaking it out. This isn’t scientifically proven yet but the nociceptive pain sensors somehow trigger the F-word centers centers in our brain which causes us to shout out profanity and expletives. Let’s take a look at this complex process, shall we. While nociceptors are typically activated only by compelling stimuli, such as a cut or a bruising blow, once tissues are inflamed by damage or infection, nociceptors become far more responsive as a result of the chemicals flowing through the peripheral nervous system. This is the reason why infected ingrown toenails are so excruciatingly painful to the touch and why even the lightest caress of your bedsheets across your sunburned body can be unbearable. This phenomenon has its own medical term—allodynia, a Latin word which means pain caused by something that wouldn’t normally cause pain.
There are two types of nociceptive pain: Somatic Pain and Visceral Pain. Somatic pain occurs when nociceptors in the skin, bones, or muscles are activated by damaging stimuli. These pain receptors respond to changes in temperature, vibration, and stretch in the ligaments or muscles and will signal the brain to the presence of tissue damage. They will also send a signal in the presence of inflammation, such as in the case of an ankle or wrist sprain. Somatic pain is also called musculoskeletal pain and refers to any discomfort felt on the skin or in the joints, ligaments, muscles, or bones. With somatic pain, movement or touch of the affected area will cause worsening symptoms, which typically feels sharp and localized to the area of injury. The other type of nociceptive pain is felt in the chest, abdominal, or pelvic cavities. This type is called visceral pain, and occurs when nociceptors in the organs or other soft tissues respond to inflammation, stretch, or lack of oxygen called ischemia. Visceral pain can be hard to pinpoint and typically manifests as a sharp stabbing sensation, a pressurized vice grip, or a dull diffuse ache. While trauma is the most likely cause of visceral pain, other causes can include gas buildup, uterine cramps associated with menses or labor, and also disease processes such as viral or bacterial infections.
Juxtaposed to nociceptive pain, we have the category non-nociceptive, which includes any type of pain that’s not generated by external stimulation of the peripheral nervous system. Non-nociceptive pain finds its genesis in the central nervous system, which for one reason or another has ceased functioning properly. It’s primarily caused by nerve damage, resulting in abnormal and unstable signals sent to the brain, which interprets the signals as pain. Though there is no evident source of harm or injury, the body tells the brain that it’s been hurt. As I’m sure you’ve already figured out, non-nociceptive is the primary source for most chronic pain issues. Just as there are two types of nociceptive pain, there are also two types of non-nociceptive which is called Neuropathic Pain and Sympathetic Pain. Neuropathic pain, also called nerve pain, is a result of unstable nerves sending faulty signals to the brain in the absence of injury or long after an injury has healed. The brain, interpreting the signals as pain, sends messages to the musculoskeletal system which manifest as burning, itching, tingling, or shooting sensations. Neuropathic pain develops when nerves are damaged by laceration, degeneration, or when they are pinched between bones or ligaments. Nerve damage can be mitigated by several types of treatment which we will discuss a little later on in this course, but it responds very differently than musculoskeletal,nociceptive pain, and so requires different treatment. Nerves between the spinal cord and the brain, the central nervous system, and nerves between the tissues and the spinal cord, the peripheral nervous system, can be damaged by pressure caused by inflammation due to a spinal cord injury or to infection, or they can be damaged by diseases such as multiple sclerosis or diabetes. Neuropathic pain is typically chronic in nature, though it sometimes presents intermittently. It can also strike randomly without warning or provocation, or in ebbs and flows of tingling or prickling sensations.
Sympathetic pain stems from malfunction of the sympathetic nervous system, which regulates response time for the peripheral nervous system and modulates blood flow to the skin and muscles. It also acts as the body’s cooling system, stimulating perspiration with increased temperatures. Initially following a fracture or other critical injury to a limb, the sympathetic nervous system kicks in to increase blood flow to muscles, to release adrenaline and glycogen, and decrease inflammation, all in an attempt to repair and/or protect the injured site. As a result, nociceptors in the skin light up and cause the area around the injury to grow hypersensitive to touch which signals the injured person to guard and protect the area. Generally, as the injury heals this sensitivity will return to normal after healing begins. However, sometimes the sympathetic nervous system goes haywire, resulting in chronic skin, muscle, and joint pain without obvious tissue damage.
The last type of pain we will mention today is Psychogenic Pain. You can probably tell by its name that this type of pain has a psychological factor attached to it. This manifestation of chronic pain is not attributable to nerve or tissue damage. Though often originating at the onset of a physical injury, this type of pain is prolonged by psychological factors such as anxiety, depression, or stress. A little later in the course, we’ll talk more about this phenomenon, which renowned expert on pain research, Dr. Michael Sullivan, calls catastrophizing. This type of pain causes actual physical discomfort but it’s caused, increased, or prolonged by mental, emotional, or behavioral factors. The unfortunate aspect about this pain is that the sufferers are often times stigmatized as “faking it” or making up because there is no test or x-ray that can identify a source or cause of pain. It’s absolutely essential that we take time with the people we serve to ensure they aren’t suffering from pain that is psychogenic in nature. With emotional and mental health services psychogenic pain can be dealt with and mitigated. Now that you have an understanding of the different types of pain and how they manifest in the body, we’ll turn our attention now to the some of the most common causes of pain.
5. CAUSES OF PAIN
Now that you have an understanding of how pain is classified let’s focus and give our attention to some of the causes of pain. The first type of nociceptive pain, somatic pain, usually begins with an injury to soft tissue or bone. Nociceptors in the tissue act like gates. When they are activated by damage, they open up and release a signal to the spinal cord and to neighboring cells, which activate the pain system. The body’s first response to musculoskeletal injury is inflammation stimulated by the release of hormones and neurotransmitters released by the sympathetic nervous system. In response to some of these chemicals, circulation of blood and lymphatic fluid increases to the affected area. Blood circulation nourishes the tissues with oxygen, The heat or “fever” from inflammation kills bacteria that would lead to infection and delayed healing, and the circulation of increased lymphatic fluid dilutes toxins and acts as a flushing mechanism to carry toxins and dead bacteria away. Even after the initial inflammation subsides, pain signals continue to travel to the brain until the injury has completely healed. These signals remind the brain to protect the area and motivate a person to continue taking steps toward healing. Somatic pain is generally caused by trauma such as contusion or laceration, muscle strain or sprain, repetitive motions as in the case of carpal tunnel syndrome, excessive stretching or activity, disuse, misuse, or surgery, to name a few.
Visceral pain is caused by problems in the internal organs, such as distention, perforation, impaction, inflammation, constipation, or infection. It’s typically marked by feelings of malaise, pain, pressure, nausea, and sometimes fever. It can also be caused by trauma or surgical damage to the internal organs, abdominal wall or muscles. Neuropathic pain is the most common form of chronic pain. Though it has various causes, the most common sources are diseases affecting the nerves such as Multiple Schlerosis and cancer, or functional changes within the nervous system caused by trauma or surgery. Sympathetic pain is caused primarily by damage to the peripheral nerves located just beneath the skin and along the muscles. These nerves can be damaged by lacerations, burns, repetitive use, or from structural damage such as dislocation or broken bones. It can also be caused by malfunction in the pain signaling system, often caused by chronic stress or psychological factors. Psychogenic pain is accompanied by a physiological response. The primary culprit for emotional pain is stress. In fact, the primary culprit for physical pain is also stress. Stressors can be physical, such as injury or pressure from carrying a heavy load, or they can be emotional, such as the anxiety or fear that come from work deadlines, interpersonal conflict, financial pressures, or death and loss. In fact, pain itself can cause stress, which can influence negative thoughts and emotions, which have been scientifically proven to heighten one’s experience of pain. Our experience of pain is not merely physiologic in origin. Research has proven that pain can be caused simply by expecting it. One study conducted by Thomas Weiss used functional MRI to observe how 16 healthy people processed words associated with the experience of pain. Scans were taken of each participant’s brain while a clinician read a list of words to them. The list contained a combination of benign words and pain-associated words (such as excruciating and grueling). The results showed that just hearing words associated with pain activated what Weiss called the ‘pain matrix,’ the areas of the brain that process the corresponding sensations.
Try it with me. When I say fuzzy bunny. How do you feel? Nice, relaxed and at peace? When I say idyllic fields of green. What is going on? Now, what happens to you when I say the word grueling, check for a physical response. Did you purse your lips or narrow your eyebrows? Did you hike up your shoulders or hold your breath for a second? Not sure? Let’s try it again….excruuuciating. Bamboo slivers shoved under your finger nails. What is going on….Ok calm down. Go back to fuzzy bunnies. Aww.. Better. Isn’t that astonishing? The researchers behind this study believe that their findings may be especially significant for people who spend a lot of their time discussing their painful experiences with their doctors and nurses, especially those with chronic pain disorders or diseases that cause pain. This idea that talking about your pain intensifies the pain experience is corroborated by the work of Dr. Michael Sullivan, who actually developed a questionnaire designed for health professionals to determine how likely a patient will be to intensify their pain through expecting the worse. He termed this particular behavior—expecting the worse to happen and speaking negatively about it—catastrophizing. Through his work, Dr. Sullivan has been able to show that feeling and verbalizing negative in response to pain stimulates the neural system and causes increased sensitivity to pain, and fosters an environment ripe for anxiety, depression, chronic pain, and even disability. So, choose your words carefully. As a healthcare and human services worker, it’s a good idea to learn what you can to identify those patients and clients who seem stuck in this vicious cycle. Do what you can to compassionately and gently steer conversation away from the topic of pain. Distraction can be a highly effective form of relief from this cycle, as can encouraging and educating others in ways that empower people to follow physician recommendations and take action to regain as many activities of daily living as possible.
6. EFFECTS OF PAIN
Our discussion about the causes of pain has alluded to some of its effects, including depression, anxiety, and chronic pain cycles. However, in this section of the course, I’d like to look a little more deeply into the varied effects pain has, not only on patients and clients, but also on you—the valiant health and human services professional, —who must witness the pain of others on a daily basis. Just as there are many different types of pain, there are many different effects. These effects range from physiological to psychological and even to socioeconomic ramifications. We’ve already discussed in detail the neurological processes involved in the experience of pain, but let’s take a look from a different angle at the effects of pain on the body. Once the pain signals reach the hypothalamus, multiple hormones are released into the bloodstream which affect various body systems. The first of these hormones is cortisol, which is released from the adrenal cortex, primarily acts to decrease inflammation. Two others are epinephrine and norepinephrine, which target the blood vessels, thereby increasing blood. This trio of hormones aides the body in adapting to stress. When this system is working properly, these hormones work together to increase blood pressure, which ups cardiac output, and thus delivers more blood to the vital organs and area of injury. Epinephrine and norepinephrine also increase oxygenation by dilating the passageways of the lungs. Epinephrine is also responsible for the heightened emotional awareness that accompanies stress or injury. In addition to these hormones, the stress response also triggers the release of glucagon, a polypeptide produced by the pancreatic islet cells. Glucagon elevates the metabolic rate and reduces insulin levels, resulting in the breakdown of glycogen in the liver, which releases glucose or energy for immediate use by critical organs, including the heart and brain. For a short duration, this stress response enables a person to remove himself from harm and alerts him to further threat of injury.
As you can imagine, however, this flood of glucose paired with suppression of insulin and the suppression of the immune system quickly turns from helpful to potentially destructive if there is no reduction of the stress response. If a person doesn’t find quick relief from pain, his body will continue to signal for more corticosteroids, leading to hyperglycemia, impaired glucose tolerance- a precursor to diabetes, and carbohydrate, protein, and fat destruction. This increased breakdown of proteins leads to excess toxins, which creates a heavier load on the lymphatic system and a negative nitrogen balance, which can lead to delayed wound healing. That ain’t good. Another hormone associated with the stress response system is vasopressin, which normally acts to increase excretion of water through the kidneys. However, during stress it signals the renal tubules to retain sodium and water for storage in the extracellular fluid. This has a direct effect on blood pressure. At the same time this is going on, the powerful enzyme renin is released to stimulate the release of aldosterone from the adrenal gland, resulting in further sodium reabsorption by the kidneys. Renin also plays a role in arteriole constriction which leads to hypertension when prolonged. Another chemical, interleukin-1 is also released following tissue damage. This powerful substance activates the inflammatory response in the immune system, while at the same time stimulating the release of hormones from the adrenals epinephrine and norepinephrine, which trigger the anti-inflammatory mechanism. All of these powerful reactions in the body increase heart rate, breathing rate, and blood pressure. These physiological changes, if left unmitigated, can lead to gastrointestinal upset, fuzzy thinking, hypertension, hyperglycemia, increased heart rate called tachycardia, and increased risk of coronary events or respiratory distress in patients whose hearts and lungs are compromised by underlying disease processes.
Of course, fear and negative feelings about the pain or the incident that caused the pain can increase stress, thereby increasing the load on the adrenal system for a prolonged time. Anytime the adrenals are stimulated, they continue to release stress hormones into the body. Thus, pain itself becomes a source of stress, and the body becomes locked into a continuous cycle of stress response without relief. Unrelieved pain can also cause depression of the immune system, increased anxiety, sleep disturbances, and adrenal fatigue, all of which can lead to chronic pain, decreased functionality, and increased cognitive impairment, such as disorientation, confusion, and reduced ability to concentrate. Sleep disturbances and cognitive impairment can also lead to decreased serotonin levels in the central nervous system. Since serotonin acts as a modulator for noxious stimuli, decreased levels can lead to neuropathic pain. People suffering from chronic pain may also experience a wide range of adverse social and economic effects associated with long-term bouts of pain. Many who struggle with chronic pain are limited on the job, and some must even quit working altogether. This often triggers the shame cycle, which results in low self-worth, increased stress from financial and social pressures, and eventually unresolved anger from feelings of powerlessness and hopelessness. Inactivity and interruptions in the gastrointestinal system often lead to weight gain and deconditioning, both of which add to the shame cycle while at the same time contributing to increased stress on vital body systems, such as the circulatory and respiratory systems. These effects can, in turn, cause more physical and psychological pain and stress. Chronic pain coupled with low self-image can also lead to relational problems, causing irritability and social avoidance—pulling away from peers out of shame or fear of not being able to participate fully in activities.
Ultimately, these adverse effects can have a direct impact on the suffering person’s outlook. Ensuing negative thoughts and feelings of helplessness and hopelessness can lead to exacerbation of pain and in some individuals can evoke the victim mentality which often leads to narcotics abuse. Patients who have succumbed to this victim mindset will search for an external fix for their problems. These people begin to blame others or themselves, and they quickly become a drain on those around them—looking to you to fix their pain, fix their relationship problems, or fix their finances. They often gripe and complain loudly and yell and make demands when they meet with frustrations. Have any of you experienced these types of clients? I know I have. Some of these folks fall into drug-seeking habits, and it’s this group of people that can be most troubling to you. Clearly they’re in pain and need help, but how much can be done for them, and how much do they need to do for themselves? We will talk more about this a little later in the section called “Call to Action.” While the physiologic and socioeconomic effects of pain are felt only by the person suffering from said pain. It is the psychological impact of pain that has a very real and sometimes profound effect on healthcare and human services professionals. Exposure to the pain of others day-in and day-out makes what can become a lasting imprint on our psyches. All the stories begin to blend into one big tragic story, often without closure or with a bad ending. This is especially true for ER and trauma workers, where time with the patient is often spent swiftly patching them up for transfer to a different floor. This leaves the medical worker with little to no closure and very little opportunity for followup. This scenario clearly lends itself to stress, and we know now that stress can and does lead to pain. It can be very easy to slip into cynicism, burnout and compassion fatigue when working with others who are in pain. It’s vital that you stay on guard against the psychological effects that the pain of others has on your thoughts and emotions. Otherwise, you may be the one sitting on someone else’s table in pain. That’s what happened to me, believe me- don’t let it happen to you.
7. PAIN MANAGEMENT: HISTORY
As the Age of Enlightenment dawned, a shift of monumental proportions was taking place in the study of medicine and human physiology. For millennia, mystics and philosophers held court as the experts on pain and its treatment. Though the shift from the heart to the brain as the source for the perception of pain had begun to shift as early as 500 BC, it was the Renaissance philosophers—scientists, such as Leonardo da Vinci—who began to truly explore the central nervous system and its role in the body. The wonder of the human body captivated philosophers well into the 1660s, and Rene Descartes’ pinnacle description of the “pain pathway” in 1664 paved the way for new developments in pain theory. Descartes proposed that the human body behaved like a machine. He was the first to publicly express the idea that pain was a disruptive message transmitted via nerve fibers to the brain. Descartes’ simple theory caused an earthquake-like shift in the theory of pain, transforming it from a mysterious, mystical experience to a physical sensation, which could now be cured rather than merely endured. It was this shift that paved the way for modern pain management. For the next several hundred years, a new breed of scientists emerged to explore the ramifications of these new theories. By the 1800s, neurologists and physiologists completely dominated the field of pain research. Physicians started popping up all over the place, claiming to have the latest cure for what ailed the people. With very little regulation and limited understanding of the inner workings of the human body, this period of history produced its fair share of quacks.
Peddlers of the latest concoctions and treatment devices went about claiming miracle cures with everything from magnets to Glyco-Heroin, a cough suppressant containing glycerin and heroin. Many of these quacks would take their wares on the road, traveling from town to town like a one-act circus, often taking advantage of the poor and desperate in small villages with no legitimate doctors. Some of their cures did deliver what was promised although with unwanted side effects, and others probably worked on the basis of the placebo effect, but it’s clear that though many of these miracle cures had at least some level of scientific theory backing them, the physicians of the early 19th century still had a lot to learn, not only about the human body’s response to pain, but also about ethics and the humane treatment of the desperate and suffering. Thankfully, the days when just anyone could buy a medical license and call himself a doctor were relatively short in the history of pain, and as regulations and knowledge of the mechanisms of pain increased, so did effective treatments for pain advance. While most of these advancements merely improved on ancient remedies such as the development of morphine and codeine from opium poppies many of the remarkable discoveries made in the late 19th and early 20th centuries are still bringing hope to millions of those suffering from pain.
8. PAIN MANAGEMENT: PHILOSOPHY & PRINCIPLE
If we boil down our jobs and our calling in life and ask ourselves what is the reason we do what we do? 10 out of 10 of us should say our task is to increase the quality of life in the individual’s we serve. All of the tasks we perform should serve that to that end. Our view of pain management shouldn’t be any different. Sadly, a lot of us have seen so much pain and destruction and drug seeking behavior over the years that the agonizing scream of an individual writhing in pain does little to move us. I am gently reminding myself and all of you to renew your vow to compassion and give special attention to how we view those in pain. I’ll get off my soap box now. That being said we need to have standards in our multi-dimensional approach to pain and its management. Fortunately the Joint Commission on Accreditation of Healthcare organizations and the American Academy of Pediatrics have clearly defined standards and guidelines of pain and its management that are applicable to all no matter what setting you are working in.The standards that should govern our approach to our client’s pain is as follows: Each and every person has a right to the assessment and management of pain. That means we just don’t blow off someone’s complaint. We take a good look at them and their complaints. If they are nonverbal we use our eyes and ears to hone in on common displays of pain such as grimacing, groaning, pacing, sweating, etc. Don’t ignore overt or covert signs of pain.
Another principle of pain management is to develop policies and procedures that identify pain which in-turn outline methods and modalities for treatment. What is a policy? A policy just means plan and procedures are steps that you take to achieve the plan. Be aware of the pain plan you have at your place of business and follow steps to achieve your goal of good pain management practices. Another principle or pillar you need to incorporate into your pain management paradigm is education. That’s why we developed this course because it’s such a big topic, unfortunately our understanding of it is often superficial and we just expect a person to pop a pill and they’ll be ok. Education needs to also take into consideration family members, friends and other support personnel of the one who’s in pain. A comprehensive approach to pain management is key to its success. Let’s get down to the nuts and bolts of our standards and guidelines of pain management. As stated before. First, we must recognize the patient or client’s rights to the assessment and management of pain. All people deserve that fundamental right to have their pain taken seriously. Secondly, we must assess the pain and its intensity. After the assessment you must take steps to help alleviate the pain- is it through medications or massage? Comfort measures or surgery? Does the patient or client need diagnostic tests done? After taking the step of implementing pain alleviating measures you have to perform an evaluation of the intervention. Did the pain go down? Did it intensify. What helped. What didn’t? Without this crucial step of evaluation it’s impossible to manage pain. Another crucial step when providing pain management is encourage the patient or client to take an active role in their treatment process. It shouldn’t be a unilateral undertaking. The patient can significantly aid the process of alleviating their pain when taking an active participatory role. In our day and age we want a magic pill to take away all our woes. Our temptation is to sit back and wait until the pill kicks in. This shouldn’t be. We need to encourage and remind individuals that pain alleviation is multi-dimensional. It needs to use a number of different modalities which may include medications, cognitive therapy, behavioral therapy and/or other techniques. In our next section let’s look at some common pain management interventions.
9. PAIN MANAGEMENT: INTERVENTIONS
What does it mean to intervene? The actual definition is, action taken to improve a situation. Pain management works best when the intervention matches the type of pain. We can’t have a one size fits all approach. Both the patient or client as well as you, as the care provider, will quickly succumb to discouragement and frustration if attempting an intervention that is incompatible with the cause of pain. On that note- let’s break down four different types of interventions that can be instituted for the management of pain. First we will discuss Pharmacological Interventions- obviously this approach we are talking about utilizing medications. Secondly we will talk about Non-Pharmacological Interventions. Under the heading of non-pharmacological interventions we will highlight physical, electrotherapy and surgical measures. The third type of intervention we will uncover is cognitive and behavioral pain management interventions and our fourth and final pain management intervention will be Complimentary and alternative methods.
Let’s first look at medicinal or pharmacological agents. Pain medications are called analgesics. This is just a Greek word that means “without” “pain”. Pain Medications are amazing aren’t they. This little guy in my hand can do so much good. Pain pills are all over the place these days. They’re over the counter, under the counter, prescription. There are two primary groups of pain pills opiods and nonopioids. In street terms narcotic and non-narcotic. Let’s talk a little bit about opioids first. If you haven’t figured it out yet the word opioid is derived from the word opium which we will talk about in a moment. Some examples of common opioid medications we hear about today are morphine, codeine, hydrocodone, hydromorphone, oxycodone and many others. Man and opioids have a long history history together. As far back as 3400 BC, Mesopotamians were known to grow opium poppy plants, AKA “joy plants” to help them deal with pain and suffering. In the Middle Ages, a time in Western history when war, plagues, and the feudal system held society in a kind of stasis mode of survival. Very few technological or scientific advances were made, as the bulk of resources was spent on acquiring food and land as well as on advancing weaponry to protect newly acquired land in an ever-shifting struggle for power and dominion. Throughout the Middle Ages, Europeans relied heavily upon the liberal use of various herbs to treat pain. One of the most widely used of these herbal concoctions was called theriac. Though theriac has its origins of use along the Silk Route in the early part of the first century, by the Middle Ages it was formulated as a blend of approximately 64 compounds including viper flesh, castor sacs of beaver, and Dead Sea bitumen reduced into a honey-based tincture. I wonder what that would have tasted like? Hmm…delicious. This theriac was used in conjunction with incantations, potions like theriac which also included opium, valerian, and other powerful substances often induced a trance-like state in patients, which would certainly relieve them of their pain. Gemstones, metals, and minerals were also ground into powders and administered for the treatment of pain and disease. Some of the most commonly reported ingredients to alleviate pain were gold, ivory, and even the mythical unicorn horn.Hmm…the unicorn horn. Got get some of that.
Let’s take a closer look at how opioids work in our bodies. An opioid is a chemical that has psychoactive properties. In laymen’s terms that means it messes with your head. Opioid receptors or antennas in our nervous system love when an opioid comes into our systems because they bind and gives our bodies a decrease in pain perception, decreased reaction to pain and also increase in tolerance of pain as well as a general sense of euphoria. There are some side effects of opioid use such as sedation, constipation, mental and respiratory depression which can be deadly. So be extra careful and vigilant when assisting with administration of opioid medications. Though opium derived medications reign supreme as the king of herbal pain remedies, there is another class of medicinal pain relievers I want to explore called NSAIDs.These types of medications are non-opioid which means they don’t mess with your head and make you loopy. NSAID stands for non-steroidal anti-inflammatory drug. As with opiates, the development of non-steroidal anti-inflammatory drugs begins in ancient times. Ancient Egyptians were known to use the bark from willow trees to reduce pain and fever, and Hippocrates wrote in his journals that both the leaves and the bark were effective for these same conditions. Thousands of years later, in the late 1700s, several researchers in different parts of the world were working to isolate the compound in willow bark that produced these effects when ingested. in 1829, Henri Leroux, a French chemist, succeeded in obtaining the crystalline form of what he termed “salicylic acid” from the willow tree bark. This was the precursor to what we no today as Aspirin. It wouldn’t be until 1838 that Italian chemist Raffaele Piria would convert the crystals into its pure form for use in medication. For the next 15 years, stomachs around the world would make it clear that more work needed to be done. The first chemist to work on buffering the effects of the bitter acid on the gastrointestinal system was a Frenchman named Charles Frederic Gerhardt, who succeeded in neutralizing the acid with sodium salicylate and acetyl chloride, but he soon abandoned his discovery. Enter Felix Hoffman in 1899, the German chemist employed by Bayer, who used Gerhardt’s formulas to provide relief to his father, who suffered from arthritis pain. So effective it was, that Hoffman convinced Bayer to begin manufacturing and marketing the new drug acetyl-salicylic acid which we know today as aspirin.
The history of aspirin is the history of this entire class of non-steroidal anti-inflammatory drugs. Although in some ways a misnomer for aspirin, which does not possess anti-inflammatory properties. NSAIDs are the most commonly prescribed medications for pain related to musculoskeletal injury and inflammatory processes, such as rheumatism. As of this year, there are as many as 20 NSAIDs available by prescription or over-the-counter, including indomethacin, ibuprofen, naprosyn and many others. NSAIDS work by affecting Prostaglandins. Prostaglandins are a family of chemicals that are produced by the cells of the body and have several important functions. They promote inflammation, pain, and fever; support the blood clotting function of platelets; and protect the lining of the stomach from the damaging effects of acid. Prostaglandins are produced within the body’s cells by the enzyme cyclooxygenase (COX). There are two COX enzymes, COX-1 and COX-2. Both enzymes produce prostaglandins that promote inflammation, pain, and fever. Nonsteroidal anti-inflammatory drugs work by blocking the COX enzymes and reduce prostaglandins throughout the body. This in-turn causes ongoing inflammation, pain, and fever in the body to be reduced. There are a ton of medicines out there for pain and suffering but you may be worried about the cost or risk. Today medicines have a million and one side effects. It seems more and more society is getting skeptical and jaded about our pharmaceutical riddled society. If you are one of those jaded ones then this next section is great for you. Let’s talk about some non-pharmacological interventions for pain management. These types of interventions are great because they are often low risk, cheap and can be easily performed. Physical Interventions are great because they can increase an individuals mobility, give comfort, decrease stress and lead to the ultimate goal of decreased pain. Some of the more common physical interventions include, initiating comfort measures. These types of measures include providing clean and smooth sheets, soft and supportive pillows, warm fuzzy blankets, and a soothing and calm environment.
Controlling the environment is an often overlooked but really important comfort and pain alleviating measure. Are there bright fluorescent lights glaring down on your patients or client’s. Is the noise level a thousand decibels too loud. You know what a calm environment is like right? If not pick up a Martha Stewart magazine right now. Creating an atmosphere of calm and peace is a great intervention to do to help decrease stimulation and ultimately pain. Providing position changes and movement are great pain-relieving interventions as well. Moving the body around, even a small amount, helps relieve muscle spasms and provides pain relief. Movement of the body to alleviate pain is so important and effective that, an entire profession has developed specializing in physical therapy. But you don’t need to wait for a specialist to offer these important pain-relieving interventions. Massage is another great way to alleviate pain. A good massage helps with muscle spasms, poor circulation, and provides stimulation to the skin and deeper structures of the body. I need one right now. Ah. I am kind of tight.
Some more pain relieving interventions include advanced technology like the use of a TENS unit. TENS stands for Transcutaneous Electrical Nerve Stimulation. The TENS unit provides a continuous, mild electric current electrodes placed on the skin near a painful site. The stimulator is a small, battery-operated devise worn by the client. Experienced as a tingling sensation, TENS works by stimulating large nerve fibers to close the “gate” in the spinal cord. It also may stimulate endorphin production. TENS may be used for acute postoperative pain or for chronic conditions such as low back pain, phantom limb pain, and neuralgia. Get this! Use of electricity use dates back to 2750 BC. Electricity was used effectively to treat pain even back then. Yes, I did say 2750 BC! That is crazy. Of course, these ancient people didn’t have our modern-day convenience of plugging in a machine, but they did have access to one of nature’s electrical wonders—the torpedo ray fish. These flat electric fish emit electrical impulses between 50 & 200 volts which effectively alleviated pain when applied directly to the affected area. Even as recently as 47 AD, Roman physicians were known to use these same shocking fish as anesthetic for the pain of childbirth or surgery, as well as for pain associated with gout and headache.
Wow, aren’t you glad you live in this day and age! Next let’s talk a little bit about surgical interventions for pain management. It’s safe to say that surgery often times is a last resort-Unless it’s an emergency of course. If a doctor encourages you or your clients to go under the knife first before other pain management interventions are attempted you might want to run the other way. Surgical Interventions may be recommended when the pain is severe and persists despite other pain relieving efforts. Fortunately, today a lot of surgical procedures can be done using minimally invasive techniques with little disruption to unaffected surrounding structures and tissues. In the not so distant past surgeons would open you up stem to stern to access the areas of pain and damage. Some dangers surrounding surgery are the fact that a patient may be left with worsening pain or disability. How many of you out there know someone who had back surgery and now can barely move or racked by pain that was worse then the original. I sure do. Now let’s talk a little bit about Cognitive-Behavioral Interventions in regards to pain management. As the name suggests a cognitive-behavioral approach is using your brain and thoughts to elicit a certain response-in our case a lessening of pain. As discussed earlier negative thoughts and habits can increase pain in our bodies. With changes in our thoughts and behaviors pain can be lessened. Cognitive Behavioral Interventions include the use of relaxation techniques, Meditation, yoga, guided imagery, biofeedback and others relaxation techniques. All of these examples share a common theme of trying to decrease anxiety and stress that can gnaw away at our minds and bodies. This gnawing over time can significantly increase our pain and make us more prone to disease and sickness. Over the last decade it seems that more and more people are becoming cynical with today’s standard medical practices. A staggering number of individuals are subscribing to complimentary and alternative medicine practitioners and therapies. It’s been interesting to see the evolution over the last decade or so . What was traditionally viewed as strange and hippish alternative therapy has now gained traction and aiding in the fight against pain. Practitioners of Complimentary and alternative medicine often use the term holistic because they view health and illness as affecting the whole person—body, mind, and spirit. The major categories of complementary and alternative medicine are: Biologic where they use of herbal mixtures, dietary changes and megadoses of vitamins. Another category is the identification of energy fields and manipulating them accordingly such as in the case of acupuncture, therapeutic touch, chachras and Reiki. Manipulative and body-based practitioners attempt to manipulate the body, bones, muscles and soft tissue to alleviate pain and suffering. Chiropractors are part of the manipulate body-based category. They attempt to align the spine to eradicate subluxations and nerve impingements that can lead to significant pain, discomfort and disability.
Other manipulative and body based practitioners use aromatherapy, deep tissue massage such as shiatsu to help the body heal itself and decrease pain and discomfort. To some of you these alternative therapies may sound strange and weird, but I can speak from experience that they have significantly helped–yours truly. That wraps up some of the schools of thought and techniques available today for the management of pain. But how do we know if all these types of pain alleviating measures are working. I’m so glad you asked because to know if something is working you must evaluate it. That’s a no brainer right. Evaluation is an absolute essential step in our journey to manage pain. Our goal is to have pain decreased either in ourselves or in others to see if we have achieved that goal then we need to make a comprehensive evaluation of the pain mitigating technique. To gather that all-important data is to ask the client or patient about the pain after treatment. Ask questions such as, did it get better, did it get worse, did the quality or location of the pain change, are there any other accompanying symptoms that happened from the treatment. Did the blood pressure drop dangerously low, did the patient or client become nauseated. All this information goes into our database so that we can make better educated choses about the next course of action. Remember our goal is to help alleviate pain so that quality of life can be increased. We can’t do this flying blindly. We must have good, objective data to help those we serve and care for. Does that make sense to you guys? I hope so. Evaluate, evaluate evaluate! It’s so important. Next I want to shift a little and talk about how culture effects our perception and responses to pain.
10. CULTURAL CONSIDERATIONS
As we have discussed pain is subjective response and each experience is highly nuanced and dependent on many factors. One factor that effects and influences our responses to pain is the culture in which we have been raised. Some cultures value pain and see it as a right of passage into the next life. Other cultures view overt displays of pain as a sign of weakness. Yet others try to avoid pain at all costs. We are going to paint with a broad brush right now and split cultures into to two groups. The Stoic type and emotive type. Traditionally Asian and some European cultures view pain stoically or with little visible emotion. Some cultures in Africa view pain as a normal and expected part of life that is to be accepted as a rite of passage and not be shunned or avoided. In other cultures such as in the US we take a more emotive response to pain. Remember the F-word center response in the brain. Shouting expletives and profanity after experiencing pain is a classic emotive response. It’s imperative that we understand the varying cultures we serve. Our role as healthcare and human services workers should be to help advocate for what feels appropriate to our clients for them within the context of their culture. It is dangerous and irresponsible to only look through the lenses of our own life when we approach the subject of pain and its management.
11. CALL TO ACTION
We’re are at the end of our course. What a pity you must be sad, i know that I am. As health and human services professionals, we know that lives depend on us and that our understanding of pain and its effects on the human mind and body can make a difference in the lives of patients suffering from acute or chronic pain. It’s our job to listen to, bring comfort to, and assist in the effective management of pain for every individual we care for. We have learned in this course that pain, when improperly treated, often leads to overactivity of the body’s stress response system, which can lead to chronic pain syndromes as well as a host of other adverse health and psychological effects.
If we are going to be effective in proactively supporting physicians and patients in formulating aggressive and effective pain management plans, we must do four important things. One–Take care of yourself. We must take care of ourselves. Burned out, cynical health and human service workers can’t stand in the gap for their clients, nor can they empower them to fight for their health.
Two–Educate yourself on the issues surrounding pain and pain management. We must learn everything we can about pain and its effects, as well as effective treatment options. You have already taken the initiative by taking this course, but there is more to learn. It is up to you to invest in further understanding the barriers to effective pain management as well as alternative treatments that fall outside the scope of this course. Three–Listen to the people you care for. If you walk into a patient room at the top of your game, fully equipped to manage your own stress and fully aware of the many components involved in providing effective pain management, you will be ready to lend your patients a listening ear and empower them to effectively manage their pain and take back their health one step at a time. And Finally Four–Empower your clients to take back their health. We all need a little encouragement. Don’t enable the people you serve by pandering to their every whim and decision. Be assertive and offer suggestions, recommendations and about the importance of participating in their pain management process. Thanks so much for joining me on this journey toward hope. You can and do make a difference in the lives of the people under your care, often at their greatest hours of need. It’s up to you to do all that you can to ensure that the difference you make alleviates physical and emotional suffering of others and offers hope.You’re so awesome and you do great things for humanity. Yes, you! Say it after me. I am awesome and I do great things for humanity. Now, just say that every day and you will great. I’ll see you next time.
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- Donovan, Arthur, «Lavoisier and the origins of modern chemistry», in Donovan, Arthur (ed.), The chemical revolution. Essays in reinterpretation, Osiris, vol. IV, 1988, pp. 214-231.
In this lesson we’ll introduce our course on pain and go over the objectives.
In this lesson we’ll go over the history and significance of pain.
In this lesson we’ll define pain.
We’ll explore the different types of pain.
In this lesson we’ll the various causes of pain.
In this lesson we’ll look at the effects of pain.
Take a look back into history and see how pain management has evolved over the years.
In this lesson we’ll explore the philosophy and principles that govern pain management.
In this lesson we explore pain management interventions.
Cultural considerations are important when assessing or managing pain.
This lesson concludes our course on pain. Once you are finished watching the course take the final quiz to get your certificate of completion instantly!