Pain

●​ “ subjective emotional and sensory experience that arises from an actual or

potential tissue damage”
●​ Pain acts as a signal to let us know that whatever we are doing is potentially
damaging and we should stop and how
●​ Pain influences not only the physical sensations but also the psychological,
emotional and social factors

Types of pain
Pain can be categorised into 2 types : Acute pain and chronic pain
Acute pain
●​ A severe pain that comes on quickly
●​ Lasts of a relatively short period of time at a very specific location of the
body and has an identifiable source.
●​ It is easy to treat with pain medication , changes in the environment or
behaviour , form of therapy.
●​ Can develop into chronic pain if not treated
Chronic pain
●​ Pain that lasts for a long period of time and has a resistance towards
treatment
●​ It can likely be the result of behavioural factors like physical exertion or due
to long term chronic illnesses like cancer.
●​ Since it is difficult to treat it can cause a significant impact on quality of life
, relationships and mental health.
●​ Most commonly found in women and in the elderly
Most common type of chronic pain is Muscoskeletal which is referring to the
muscles , bones , ligaments and tendons in the body

Phantom Limb Pain (PLP) is a common problem for people who lose a limb
even tho the arm or the leg is no longer present , PLP occurs when the individual is
still experiencing pain as coming from the cut off area therefore making it difficult
to treat.
Ramachandran and Rogers- Ramachandran successfully treated patients with
PLP using the Mirror treatment works by placing the remaining arm or leg into a
box with a mirror down to the middle so that when it is viewed at a sight angle it
looks as if the patient has two intact arms/legs leading to a reduction in phantom
limb pain
➢​Example study: MacLachlan et al.(2004)
●​ Case study that reported used the Mirror treatment on a person with lower
limb PLP
●​ 32 year old man named Alan who has a life -saving surgery to remove his
leg at the hip
●​ Lead him to be extremely unwell for weeks and he only was aware of his
amputation 5 weeks later
●​ He began to experience Phantom Limb pain as well as pain at the
amputation point
●​ At the beginning of the day , he would experience mid pain and felt as if his
2 feet were crossed and experience “pins and needles” , as the day
progressed the pain got worse
●​ He experienced a full phantom leg and felt as if the one leg was shorter than
the other as if were in a cast that made the leg stretch backwards
●​ Alan tried pain medication and a course of the TENS machine but it had
little to no effect
●​ Alan follow the procedure of the mirror treatment with ten repetitions each
of ten different exercises which included :
○​ Straightening and bending of the leg
○​ Pointing the foot up and down
○​ Clenching and unclenching the toes
○​ Moving the foot in circles
●​ Exercises were initially done twice a day but after a few days Alan did it 4
times a day and this programme lasted for 4 weeks
●​ Took him 4 session to feel as if he had any control over the phantom leg ,
over the second week the feeling of crossing his toes decreased and end of
the third week there was no sensation of the crossed toes and phantom pain
was minimum
●​ Alan rated the level of phantom pain which was minimal as well as the rate
of the level of phantom pain and stump pain
●​ A the start of the study he rated the rated the phantom pain at a range of 5-9
and stump pain at a 0-2 but at the end of the third week he rated phantom
pain as 0 and stump pain as 1
●​ The sense of control over the leg was increased from 0-3% to a 25-30% after
3 weeks
 ●​ This clearly showed that the mirror treatment was an effective method to
treat phantom leg pain

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Strengths and weakness
case study it allows the research to collect information about one person

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allowing accuracy
The results of the study can’t be generalised to a wider audience and the study
cannot be replicated to check for reliability due to the results being subjective
towards Alan

Qualitative and quantitative measures were used to record data ;

●​ Quantitative data was recorded using a likert scale allowing statistical data
and analysis to be carried out however the problem of using the likert scale
is that these types of scales are subjective as they measure what the
individual feels .
●​ Qualitative data allows for a good understanding about the individuals

Issues and debates ☯️

feelings and allowed for a detailed case study
:
Nature vs Nurture : Nature: The study links phantom limb experiences to
neurological processes in the brain (e.g., cortical reorganisation).
Nurture: It also considers psychological and social factors such as trauma, coping,
and emotional adjustment.
Shows that phantom limb pain is influenced by both biological and psychological
factors → interactive approach.
Reductionism vs Holism : Reductionist elements: Some explanations focus heavily
on biological changes in the nervous system.
Holistic approach: The study also includes emotional, cognitive and social aspects
of coping after amputation.
Overall, it leans toward holism by integrating multiple explanations.
Determinism vs Free Will : Determinism: Suggests that changes in the brain after
amputation determine phantom sensations and pain.
Free Will: Coping strategies, cognitive restructuring and psychological
interventions show people can exert some control.
Highlights the tension between biological determinism and psychological choice.
Individual vs Situational Explanations : Focuses on individual factors such as
personality, coping style, trauma history and mental health.
Also considers situational factors, e.g., the circumstances of the amputation, social
support, post-surgery environment.
Emphasises that both contribute to phantom limb experiences.
Specificity Theory
●​ Specificity theory is one of the first modern
theories for pain.
●​ It holds that specific pain receptors
transmit signals to a "pain centre" in the
brain that produces the perception of pain
●​ Von Frey (1895) argued that the body has a
separate sensory system for perceiving
pain—just as it does for hearing and vision.
●​ Pain is an independent sensation with
specialised peripheral sensory receptors
[nociceptors], which respond to damage
and send signals through pathways (along
nerve fibers) in the nervous system to
target centres in the brain.
●​ These brain centres process the signals to
produce the experience of pain.
●​ It is based on the assumption that the free nerve endings are pain receptors
and that the other three types of receptors are also specific to a sensory
experience.

Gate control theory

●​ Melzack has proposed a theory of pain that
has stimulated considerable interest and
debate and has certainly been a vast
improvement on the early theories of pain.
●​ According to his theory, pain stimulation is
carried by small, slow fibers that enter the
dorsal horn of the spinal cord; then other
cells transmit the impulses from the spinal
cord up to the brain.
●​ These fibers are called T-cells. The T-cells
can be located in a specific area of the
spinal cord
●​ These fibers can have an impact on the
smaller fibers that carry the pain
stimulation.
●​ In some cases they can inhibit the
communication of stimulation, while in
other cases they can allow stimulation to be
 communicated into the central nervous system.
●​ For example, large fibers can prohibit the impulses from the small fibers
from ever communicating with the brain. In this way, the large fibers create
a hypothetical "gate" that can open or close the system to pain stimulation.
●​ According to the theory, the gate can sometimes be overwhelmed by a large
number of small activated fibers. In other words, the greater the level of pain
stimulation, the less adequate the gate in blocking the communication of this
information.
There are 3 factors which influence the 'opening and closing' of the gate
●​ The amount of activity in the pain fibers. Activity in these fibers tends to
open the gate. The stronger the noxious stimulation, the more active the pain
fibers.
●​ The amount of activity in other peripheral fibers—that is, those fibers that
carry information about harmless stimuli or mild irritation, such as touching,
rubbing, or lightly scratching the skin. These are large-diameter fibers called
A-beta fibers. Activity in A-beta fibers tends to close the gate, inhibiting the
perception of pain when noxious stimulation exists. This would explain why
gently massaging or applying heat to sore muscles decreases the pain.
●​ Messages that descend from the brain. Neurons in the brainstem and cortex
have efferent pathways to the spinal cord, and the impulses they send can
open or close the gate. The effects of some brain processes, such as those in
anxiety or excitement, probably have a general impact, opening or closing
the gate for all inputs from any areas of the body. But the impact of other
brain processes may be very specific, applying to only some inputs from
certain parts of the body. The idea that brain impulses influence the gating
mechanism helps to explain why people who are hypnotised or distracted by
competing environmental stimuli may not notice the pain of an injury.

The benefit of this theory is that it provides a physiological basis for the complex
phenomenon of pain.
It does this by investigating the complex structure of the nervous system, which is
comprised of the following two major divisions:
●​ Central nervous system (the spinal cord and the brain)
●​ Peripheral nervous system (nerves outside of the brain and spinal cord,
including branching nerves in the torso and extremities, as well as nerves in
the lumbar spine region)
Measuring pain
Subjective measure :
●​ When patient is first presented with pain the doctor will gather a medical
examination and a clinical interview which involves asking the patient a
range of open and closed question that focus on getting an understanding of
the patients experience with pain
●​ It also analysis a range of factors that influence the patients experience like
behavioural and psychological
●​ “ACT UP” is an acronym that is used for the initial clinical interview
○​ Activities looks at how the pain affected your life in term of eating ,
sleeping , physical activities , relationships etc
○​ Coping looks at how an individual deals with the pain and how has
that made it better or worse
○​ Think looks at the mindset of the patient (Positive or negative)
○​ Upset looks at whether the patient was depressed or anxious
○​ People looks at how people respond when someone has pain

Strength of the clinical interviews Weakness of using a clinical interview

It allows the clinician to gather a good The information solely relies on the
understanding of the patient and their patient giving their opinion and
experiences of pain as it is the only interpretation of things which may not
way to know be accurate as some people might
downplay their pain or exaggerate the
pain in order to get attention or be
taken seriously
It collects qualitative data in depth
detail and thorough understanding
Psychometric measures and visual rating scale
The McGill pain questionnaire is designed to assess the quality and intensity of
subjective pain and can be used by patients over a range of conditions
●​ Consists of 78 words out of which the patient has to choose the word that
best describes their pain
●​ The words are assigned a value based on their severity and the patient is
given a total score from 0 to 78​
MPQ covers over several categories :
○​ Pain descriptors which include words like flickering , sharp searing ,
tender , tugging
○​ Affective which included words like tiring , sickening , terrifying ,
wretched
○​ Evaluation of pain which included words like annoying, troublesome,
intense, unbearable
○​ Miscellaneous which includes words like spreading , numb ,
squeezing
●​ The patients were also asked items like eating, heat, cold, Weather changes,
movement , rest and mild exercise increased or decreased the pain
●​ The MPQ asked a range of questions to measure the strength of the pain
including
○​ How the pain is best described now ?
○​ When is it the worst
○​ When is it the least painful
This was answered using the following responses :
●​ Mild
●​ Discomforting
●​ Distressing
●​ Horrible
 ●​ Excruciating

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Strengths and weaknesses
Can be used to assess changes over time and to assess the effectiveness of pain

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management and treatment
Gather quantitative data which will allow for statistical analysis to be carried

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out and for comparisons to be easily made

✅ Relatively quick and easy to administrate

It involves closed questions which may force the patient to chose an answer that

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might not fully represent how they feel
The lack of open questionnaires means that no qualitative data can be collected
so it’s not possible to get fully detailed information about a patient and their
experiences
The Visual analog scale is an instrument that is used to measure pain and other
symptoms or a continuum from no pain to an extreme amount of pain
●​ It can be presented in multiple ways but the most simplest and commonly
used is the horizontal line (100 mm long)
●​ The patient marks where along the line they feel the best represent their
current pain which is then transformed into numerical values by measuring
the distance from the end point (No pain) to where the patient has marked
●​ Cut off points which are recommended :
○​ No pain : 0-4 mm
○​ Mild pain 5-44 mm
○​ Moderate pain 45-74 mm
○​ Severe pain 75-100 mm

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Strengths and weaknesses
Quick and easy to administrate as it is an effective method of detecting changes

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in pain over a period of time and is more sensitive to small changes
Collected quantitative data which means that analysis can be carried out easily

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and comparisons can be made easily
VAS doesn’t collect detailed qualitative data and doesn’t not gather a range of
items making it relatively limited
 ★​ Key study : Brudvik et al. (2016)
Aim :
●​ To investigate the levels of agreement of pain intensity when it is measured
by children, parents and physicians
●​ To estimate the influence of children age, medical condition and severity of
pain on the difference of pain assessment given by children, parents and
physicians
●​ To find out how pain assessment affect the physicians administer of pain
relief
Background :
●​ Research shows that someone’s pain is subjective and that there is individual
differences in a person’s pain threshold
●​ Research also shows that many measures of pain that we use are not
applicable to children as it is complicated for them to understand which
could lead to them not responding properly
●​ According to Singer et al. (2009) , pain assessment by the parents and
practitioners are generally lower than the pain assessment made by the child
themselves
●​ According to Morrow et al.(2012) , investigated that experience of children
with chronic illnesses and found that the report on quality of life made by
the children differed from the ones made by the doctor and parents
Sample :
●​ 243 children between the ages of 3-15 ; 53% male who attended at
Norwegian emergency department over a 17 day period
●​ 51 physicians ; 57% male and 51% had their own children /Half of them had
over 5 years of medical experience and 30% had speciality in family
medicine
Procedure :
●​ Children aged 3-8 years filled out the Faces pain rating scale -revised
Description of faces pain rating scale revised : 6 faces showing increasing levels of
pain
●​ Children aged between 9-15 used the Visual Analogue scale
Description of Visual Analogue scale : Where they marked on a line where there
was no pain (Green) through to the worst thinkable pain (Red)
●​ Parent and physicians completed the numerical rating scale (NRS) to
estimate the child’s level of pain from 0-10 as well of pain assessments , the
parent’s questionnaire gather demographic information about their medical
experience
●​ The children diagnosis was classified as either infections, fractures , wound
injuries/soft tissue or ligament/muscle injuries (51% had ligament tears,
followed by fractures, infections and wound injuries)
Results :
●​ Doctors assessed the children’s mean pain to be NRS - 3.2
●​ The parent assessment was a mean 4.8
●​ Children own evaluation was a mean 5.5
●​ Therefore parents and doctors assessed the rating scale to be lower for the
younger children but there were slight differences
●​ There was little agreement on the pain assessment between parents and
physician

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Strengths and weaknesses :
Ecological validity : The study was conducted in real clinical settings with
children experiencing actual chronic [Link] means the results reflect real-world

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experiences, not artificial lab conditions.

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Pain catastrophizing was measured using well-established questionnaires.

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This reliability and allows comparison with other research.

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Children may misunderstand questions or exaggerate [Link] can lead

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to response bias, internal validity.
Application to daily life :
●​ Helps clinicians identify children at risk for severe chronic pain : The study
shows that children who catastrophize (exaggerate or fear pain intensely) are
more likely to have worse pain outcomes.
●​ Doctors, psychologists, and physiotherapists can use catastrophizing
questionnaires to spot high-risk patients early.
●​ Guides treatment planning (especially CBT) : Findings show that reducing
catastrophizing can reduce pain intensity and disability.
●​ This helps psychologists design CBT programmes that teach children:
○​ realistic thinking
 ○​ coping skills
○​ reducing fear and avoidance
Making treatment more targeted and effective.
Issues and debates ☯️ :
Individual vs Situational : The study emphasises individual differences (e.g., a
child’s tendency to catastrophize pain) as key predictors of pain intensity and
disability.
However, it downplays situational factors such as family environment, school
stress, and peer influences, which may also shape pain experiences.
Nature vs Nurture : Focus on cognitive patterns (catastrophizing) suggests a
nurture explanation as pain responses are learned or influenced by experience.
However, there may also be a biological predisposition to anxiety or heightened
pain sensitivity that the study does not fully address.
Reductionism vs Holism : Pain catastrophizing simplifies complex pain
experiences to a single psychological factor, which is somewhat reductionist.
Chronic pain, however, is influenced by biological, emotional, and social factors
(biopsychosocial model), so multiple layers may be missed.
Behavioural measures
University of Alabama pain behavioural scale (UAB)
●​ It is a scale that consists of ten target behaviours which the person who is
living with the patient has to observe and not the severity, frequency or
intensity of each behaviour everyday
●​ Each behaviour was assigned either 0,1/2 or 1 mark and the total score is
calculated out of 10 ( A high score indicates a more marked pain associated
behaviour and a greater level of impairment)

Strengths Weaknesses
It is a useful tool as it gathers It relies on interpretation of the person
information about outward signs of completing the scale , the observer
pain which can be observed by might not witness the extent of the
someone else behaviour that are expressed or they
may not interpret the behaviours
accurately

The behaviour scale doesn’t correlate

well with the McGill pain questionnaire
suggesting that outward display of pain
-related behaviours are no closely
related to subjective experience of pain
Management and controlling pain
Biological treatments
Analgesics :
●​ It is medication that is used to relive pain
●​ They differ in terms of how they work and their potency differs in terms of
how they work and their potency strength
There are 2 groups of Analgesics :
●​ Nonsteroidal anti-inflammatory drugs (NSAIDs) :
○​ NSAIDs are a group of pain-relieving (analgesic) and
anti-inflammatory medications that work by reducing inflammation,
pain, and fever in the body without using steroids.
○​ NSAIDs work by blocking the enzymes COX-1 and COX-2 which are
responsible for producing prostaglandins, which cause inflammation,
pain, and fever
○​ They do this by reducing prostaglandin production, NSAIDs decrease
pain, swelling, and temperature.
○​ Common example of a NSAID’s is Aspirin
○​ It is used to treat headaches, muscle pain, arthritis, menstrual pain, and
minor injuries.
○​ Side Effects include
■​ Stomach irritation or ulcers
■​ Increased risk of bleeding
■​ Kidney problems (with long-term use)
●​ Opioids :
○​ Opioids are powerful pain-relieving drugs that work by binding to
opioid receptors in the brain and spinal cord to block pain signals and
produce feelings of relaxation or euphoria.
○​ Opioids attach to opioid receptors in the central nervous system
(CNS).This blocks pain messages from reaching the brain.
○​ They can also slow breathing and create a calming effect, which
makes them effective for severe pain but also potentially addictive.
○​ Common example is Morphine
○​ Side Effects:
■​ Drowsiness
■​ Constipation
■​ Respiratory depression (slowed breathing)
 ■​ Addiction and dependence (with long-term use)

Psychological treatment :
Attention Diversion :
●​ It is a cognitive pain management strategy that involves a person finding
ways to shift their attention away from the pain and onto something else
●​ It doesn’t remove the pain but it does stop it from being the whole focus of
attention which makes the pain easier to manage
●​ It works because it involves competition for the attention between the pain
and a consciously directed focus on some form of informed processing
activity
●​ Activities include :
○​ Puzzles
○​ Massage
○​ Stress ball
○​ Crafting
○​ Audio books or music
○​ Counting
○​ Deep breathing

Non- pain imagery :

●​ It involves the person thinking about a calm and relaxing situation or scene
and focusing on this rather than the pain
●​ The individual is more likely to able to slow their breathing , reduce their
heart rate and lower their blood pressure and they help to manage their pain
●​ It can be achieved through the use of auditory recording or talking to the
individual through a relaxing scene and how to focus on different aspects of
the imagery
●​ Practise is required to achieve a full sense of relaxation and calm to engage
all the senses

Cognitive redefinition :
●​ It involves the patient replacing threatening or negative thoughts about the
pain with more rational or positive thoughts
●​ The pain doesn’t go but it allows them to manage the pain better as a result
of changing the way they think about the pain
●​ Types of self - statement for managing pain :
○​ Coping statements : they emphasise the person’s ability to tolerate the
pain
 ○​ Reinterpretative statements : These help to remove the negative
association with pain
The strength of all 3 cognitive strategies is that they don’t have any negative
side effects and they can be learned easily and practised and used without
professional help

Alternative Treatments :

Acupuncture :
●​ Acupuncture is a form of traditional Chinese medicine that involves
inserting very thin needles into specific points on the body (called acupoints)
to relieve pain, reduce stress, and promote healing
●​ From a psychological and physiological perspective, acupuncture works by:
○​ Stimulating sensory nerves under the skin and in muscles.
○​ This triggers the release of natural pain-relieving chemicals in the
brain, such as endorphins and serotonin.
○​ These chemicals help reduce pain perception, promote relaxation, and
improve mood and wellbeing.

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●​ Advantages:
Non-drug, natural treatment option

✅ Can reduce chronic pain and stress

Few side effects when done correctly

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●​ Disadvantages:
Effectiveness varies between individuals

❌ Difficult to measure scientifically (placebo effect possible)

Must be done by a trained professional to avoid injury

Transcutaneous electrical nerve stimulation (TENS) :

●​ It is a small machine that uses electrodes to deliver mid electrical current to
the painful area
●​ The electrical current is experienced as a tingling sensation on the skin
●​ The electrical impulses work by reducing the pain signals that go to the brain
and spinal cord , helping to relieve pain and relax the muscles
●​ The electrical impulses stimulate the production of endorphins
●​ It can be used to to reduce pain associated with a range of conditions
including arthritis and sports injuries
●​ TENS is a reliable method of reducing pain