Category: Chronic Pain

Chronic back pain is a common disease that affects many people, especially the ones aged 35  55. It is quite difficult to detect the causes of this pain, but it is usually considered to be related to the strain in one of the structural components of the back. A chronic back pain is the one that is lasting longer than a month.

It can be caused by many reasons, such as long period of standing or sitting, having a fall, lifting or carrying heavy objects, stress, overweight, etc. There are several ways of treatment of the chronic back pain, including tacking various medicines, physical therapies, surgery, psychological therapy, complementary therapy.

The Gate Control Theory provides the methods of the chronic back pain therapy based on the work of mind and brain regarding pain perception. In this paper, we are going to discuss the methods of pain control based on the Gate Control Theory and how the Gate Control Theory relates to cultural explanations regarding the sensation of pain. We will also consider a possibility to completely eliminate pain by applying the Gate Control Theory.

The Gate Control Theory was developed by Patrick Wall and Ronald Melzack in 1960s. The theory suggests that there are systems in the central nervous system responsible for the transmitting the pain messages through the brain. These systems can open or close gates that let in or block the pain.

This process can be explained by the work of neurotransmitters: when a nerve impulse comes to the end of the axon and reaches a terminal button releases a chemical courier called a neurotransmitter (Ryan, 2011). The Gate Control Theory describes the phenomena of the mental nature, but with regard to the processes that occur in the nervous system.

Although, there are no detailed explanation of how these processes occur and regulated, the Gate Control Theory help explain why different treatments might be effective to manage the chronic back pain, The effectiveness of nonpharmacological pain-management strategies can be explained by the Gate Control Theory and the processes responsible for the transmission of pain (Simpson and Creehan, 2007). Thus, acupuncture is one of the alternative medicines based on the Gate Control Theory. However, there are also:

Opioid analgesics act on synaptic transmission in various parts of the central nervous system by binding to natural opioid receptors. They inhibit ascending pathways of pain perception and activate descending pathways (Freudenrich, n. d.).

Thought, they can become addictive. The massage is another method of back pain relief. In order to prevent or reduce the back pain, one should combine these methods.

Our sensation of pain can be explained by the Gate Control Theory as it is related to the work of mind. Our cultural background plays an important role. Thus, our beliefs and values, memories of previous pain, upbringing, expectations of and attitudes towards pain affect how we interpret the pain. (Pain and How You Sense It, n. d.).

Thus, the information mentioned earlier suggests that we can eliminate pain by applying the Gate Control Theory. However, in order to do this, a number of various methods based on the Gate Control Theory should be applied during course of treatment.

In conclusion, it should be said that the Gate Control Theory can provide a basis for the treatment of the chronic back pain. Moreover, with its help, we can explain how f cultural background can influence our sensation of pain. In addition, a balanced course of treatment based on the Gate Control Theory can help eliminate pain completely.

List of References

Freudenrich, C. (n. d.) How pain works. Discovery Health. Web.

Pain and how you sense it. (n. d.) For Healthy Australia. Web.

Ryan, M. (Ed.). (2011). Psychsmart. New York, NY: McGraw-Hill.

Simpson, K. R., and Creehan, P. A. (2007). Perinatal nursing. New York: Lippincott Williams & Wilkins.

It is important to note that chronic pain is a major issue, which affects the general population in several layers. The implications can range from mild discomfort to a severe decrease in quality of life as well as impairment. Although the current measures rely on the use of pain killers, the latter also comes with a host of other problems. Other approaches may also primarily utilize ones coping psychology in regards to the given health condition. The given assessment will provide invaluable insight and information as well as justification for the importance of chronic pain, a critical subject.

The topic of chronic pain was selected due to the problem being a highly viable and relevant one since it is a common issue of public health. Historically, it was considered that chronic pain and pain, in general, was a biomedical issue, which required medical solutions since the professional community defined the issue as a mere consequence of tissue damage (New Harbinger, 2019). However, it should be noted that chronic pain is a biopsychosocial problem, which affects a person not only bio-medically but also psychologically and socially (New Harbinger, 2019).

In other words, ones experience of pain can vary depending on his or her mental attitude towards it, and having a social support circle can greatly improve the overall experience of pain (New Harbinger, 2019). Therefore, chronic pain is a highly multifaceted problem, which requires a complex set of measures in order to manage it and minimize its effects on ones life. It can also affect anyone regardless of age, gender, or ethnicity, which, alongside the previously mentioned statements, makes it both an interesting and relevant topic to analyze and understand.

In order to properly and comprehensively discuss holistic alternative therapies, it is important to learn and overview the historical measures used to treat the selected condition. One of the most conventional approaches primarily utilizes medications to relieve the pain, and these might include corticosteroids, antidepressants, anticonvulsants, and opioids. There is a wide range of options in regards to medications due to chronic pain manifesting itself in different types, mainly nociceptive, neuropathic, and sensory (GovInst, 2018). The use of pharmacological measures can be effective at giving an individual an opportunity to manage his or her own chronic pain, but it can also cause other issues, such as addictions. The most dangerous and common one is opioid use disorder or OUD, which is determined by the fact that a person using the drugs adheres to several criteria (GovInst, 2018).

These include having severe cravings for the drug, investing a significant portion of ones time to obtain or recover from the opioids, role failure, recurring use in hazardous situations, and many others (GovInst, 2018). In other words, addiction emerges when a persons life is worsened or burdened by the use of the drug, and adherence to a larger set of criteria makes the addiction case more severe.

There is a number of both old and new theories on chronic pain, which address its nature, implications, and categorizations. One such theory is the concept of biopsychosocial pain, which views the issue in three distinct layers, which are biomedical, social, and psychological (New Harbinger, 2019). The given framework provides an in-depth view of chronic pain, which allows deriving a more complex and multidimensional set of solutions.

In addition, it greatly improves the overall understanding of the issues as well as their implications. According to the biomedical model, comorbid signs of chronic diseases, such as sleep disturbance, depression, psychosocial abnormalities, and pain are considered a response to the disease and are therefore considered secondary. It is assumed that if the disease is healed, then the secondary reactions will evaporate. In such situations, which are common in chronic conditions such as back pain, headache, pain in myofascial pain syndrome, and temporomandibular syndrome, the patients complaints do not fit into the biomedical model (Darnall, 2018). Problems arise when the symptoms and disease are not comparable with the severity of the observed pathology.

Chronic pain is more than a physical symptom, and its persistent presence has many manifestations, including preoccupation with pain. This includes restriction of personal, social, and professional activities, demoralization and mood disorders, and the use of more medication and frequent medical seeking when the person as a whole becomes comfortable with the patient role. Although the importance of such factors has been recognized for some time, it is only in recent years that a systematic attempt has been made to combine these factors into a comprehensive pain model.

The topic deserves more interest and a closer look because its effects can be severe, and the issue can impact many groups. Therefore, there are both epidemiological and public health-related aspects to chronic pain. In addition, it can no longer be categorized as a solely biomedical issue since it has encompassing elements in regard to ones psychology and social life. The latter two factors need more analysis and study in order to design successful treatment protocols and models, which will enable a multidimensional approach towards the issue.

In the case of speculations on the future directions for research with regards to the development of psychological based treatment or holistic alternative therapies respective to the topic, the emphasis should be put on resilience-based approaches. It is stated that one of the key traits to overcoming adversity is that of resilience, which is the ability to withstand both physical and emotional difficulties (Abaci, 2017, para. 2).

In other words, it can provide some form of mental and physical fortitude towards chronic pain. Modern experts in the field also address the topic with a strong recommendation of utilizing an interdisciplinary solution, which can greatly improve the outcomes (TEDx Talks, 2019a). It is suggested that resilience is achieved and implemented through three core strategies, which are an acknowledgment of a problem, selective attention to details, and taking control over the situation (TEDx Talks, 2019b). In other words, resilience-based approaches are built on a systematic process of chronic pain management, which involves addressing and enabling support systems in all three major areas of the biopsychosocial framework of view of the problem.

The information presented indicates that pain syndrome, regardless of the etiology of its occurrence, is the result of not only functional but also structural changes affecting the entire nociceptive system ranging from tissue receptors to cortical neurons. In nociceptive and psychogenic pain, functional and structural changes in the pain sensitivity system are manifested by sensitization of peripheral and central nociceptive neurons, as a result of which the efficiency of synaptic transmission increases and persistent hyper-excitability of nociceptive neurons occurs (Darnall, 2018). In patients with neuropathic pain, structural changes in the nociceptive system are more significant and include the formation of loci of ectopic activity in damaged nerves and pronounced changes in the integration of nociceptive temperature and tactile signals in the central nervous system (Darnall, 2018).

It should also be emphasized that the pathological processes observed in the nociceptive structures of the peripheral and central nervous systems in the dynamics of any pain syndrome are closely interrelated.

Damage to tissues or peripheral nerves, increasing the flow of nociceptive signals, leads to the development of central sensitization. In turn, an increase in the activity of central nociceptive structures is reflected in the excitability of nociceptors, for example, through the mechanisms of neurogenic inflammation, as a result of which a vicious circle is formed that maintains the long-lasting hyper-excitability of the nociceptive system (Darnall, 2018).

Evidently, the stability of such a vicious circle and, consequently, the duration of pain will depend either on the duration of the inflammatory process in the damaged tissues (Darnall, 2018). Therefore, they provide a constant flow of nociceptive signals into the nervous system structures, or on the initially existing cortical-subcortical dysfunction in the nervous system, due to which central sensitization will be maintained, and retrograde activation of nociceptors is achieved.

In conclusion, it is important to consider the fact that chronic pain is no longer a biomedical problem because it has major implications in a persons psychological and social areas of life. Therefore, the topic needs to be illuminated, researched, and developed in order to improve the current systems of chronic pain management. One of such holistic alternative approaches is resilience-centered treatment, which is a multidimensional and procedural process of reducing the effect of chronic pain and its impact on ones life.

References

Abaci, P. (2017). 7 ways to build resilience in the face of chronic pain. Chronicality. Web.

Darnall, B. D. (2018). Psychological treatment for patients with chronic pain. American Psychological Association.

GovInst. (2018). Overview of chronic pain and addiction [Video]. YouTube. Web.

New Harbinger. (2019). How is pain biopsychosocial and what does that mean in terms of how we treat pain? [Video]. YouTube. Web.

TEDx Talks. (2019a). What chronic pain has taught me about resilience | Trung Ngo | TEDxCentennialCollegeToronto [Video]. YouTube. Web.

TEDx Talks. (2019b). The three secrets of resilient people | Lucy Hone | TEDxChristchurch [Video]. YouTube. Web.

Chronic pain can be potentially debilitating, reducing a patients functional status and quality of life. Available treatments for this condition include either multidisciplinary interventions or single-discipline approaches with varying levels of efficacy. Various studies have evaluated the effectiveness of opioid use, alternative medicine, cognitive-behavioral rehabilitation, and other therapies for pain management. This paper reviews scholarly evidence for the efficacy of the existing modes of treatment for chronic pain.

Article Summary

A literature search was conducted to identify three relevant articles for this analysis. Jacobs et al. (2016) assessed the short-term and long-term efficacy of advanced soft tissue release (ASTR) in treating injury-related neck pain. The biopsychosocial treatment is a holistic approach to treating sprain- or strain-type injuries primarily through stretching soft tissues, behavior change, and physical activity. Through a retrospective cohort study, patients with chronic neck pain and receiving therapy at a medical facility were included in the sample.

Patient charts were used to collect demographic information on the subjects age and sex. Additionally, past treatments, symptom type and onset, and visual analog scale (VAS) rating before and after ASTR intervention were obtained from these tools (Jacobs et al., 2016). The VAS pain scores of the patients were taken after a 12-month follow-up period.

The mean pre-treatment VAS rating was 7.51, which dropped significantly to 0.31 at the last ASTR session (Jacobs et al., 2016). At the end of the follow-up period, an average VAS of 0.49 was reported. Additionally, 83%, 84%, and 87% of the patients had no neck pain after the first ASTR, at last treatment, and one-year post-discharge, respectively. The researchers concluded that ASTR is effective in relieving neck pain both in the short and long run.

Kamper et al. (2015) evaluated the long-term effect of holistic biopsychosocial therapy for chronic low back pain (CLBP). This systematic review analyzed randomized controlled trials (RCTs) published in multiple databases, including Medline and CINAHL. Selected studies were RCTs examining multidisciplinary rehabilitation that included physical, mental, and social components and performed by interprofessional teams (Kamper et al., 2015). Forty-one trials were chosen for the analysis.

The combined participants were 6858 and had an average pain duration of over 12 months. Moderate-quality evidence for the efficacy of biopsychosocial therapy in reducing pain was found in 16 RCTs over standard care (pd0.04-0.37). The other studies did not provide sufficient proof that multidisciplinary rehabilitation is better than physical intervention or surgery for treating CLBP. Therefore, biopsychosocial treatments have higher efficacy than standard care in pain management but high-quality evidence is lacking.

In a related article, Rauck et al. (2015) assessed the efficacy of buccal buprenorphine (BBUP) film delivered through the BioErodible MucoAdhesive technology in CLBP management. The study used a multi-center, double-blind randomized design. A sample of 749 opioid-naïve patients received 150-450 microgram dosage of BBUP intravenously after a 12-hour interval (Rauck et al., 2015).

High tolerability was recorded in this group, which was subsequently randomly assigned to BBUP (229 subjects) and placebo (232 participants). The results indicated a pain decrease from severe (7.15) to mild levels (2.81) at week 12 after the initial BBUP titration. Further, pain relief was significantly higher in the BBUP group than in the placebo arm (1.59 vs. 0.94). These findings show that BBUP is effective and well tolerated by opioid-naïve patients with CLBP.

Synthesis

Interventions for treating chronic pain range from single-discipline treatment forms to multidisciplinary methods. Research evidence shows that some therapies are effective compared to others in long-term pain relief and have few adverse outcomes. Titration of low-dose opioids, such as BBUP, seems to decrease chronic pain within a shorter period  12 weeks (Rauck et al., 2015). BBUPs clinical efficacy comes from its prolonged analgesic activity and reduced risk of dependence when administered intravenously.

However, its long-term effect is low compared to other interventions. The biopsychosocial model can produce prolonged CLBP relief for up to one year (Kamper et al., 2015). A typical multidisciplinary rehabilitation program includes physical therapy (heat treatment and acupuncture), psychological aspect (CBT), and a social component delivered by interprofessional teams.

Moderate-quality evidence has shown this holistic model to be more effective for pain relief than usual care or surgery (Kamper et al., 2015). In general, treatments following the biopsychosocial framework appear to produce long-term CLBP reduction and better functioning compared to single modality interventions, such as opioid use.

ASTR, a specialty therapeutic approach that uses the multidisciplinary model, is effective for neck pain relief. It entails working on different aspects meant to treat musculoskeletal and neuromuscular tissue dysfunctions (Jacobs et al., 2016). The intervention holistically tackles scarifications, muscle cramps, fibrosis, behavior, and diet using various ASTR tools, patient training, and exercise. Therefore, ASTR yields quick, long-term relief for neck pain because it addresses diverse factors related to the injury. Consistent with the biopsychosocial model, ASTR tackles social aspects (habits), physical variables (dysfunctional tissues or scars), and psychological (mindset) causes of the pain.

Evaluation

The articles reviewed have some strengths and weaknesses. Jacobs et al. (2016) can be evaluated based on the representativeness of the sample, setting, and procedures. The authors admit that random sampling was not done, affecting the 95% confidence intervals computed for the variables. The largely uniform geographic, demographic, social, and economic conditions may have limited the representativeness of the sample, as the study participants were only drawn from patients attending a physical therapy clinic.

However, the sample size (n=105) seems adequate to make a general inference about ASTRs efficacy in neck pain relief. The unique characteristics of this setting that offers neck injury care may be generalized to other facilities that treat patients with soft tissue problems or orthopedic surgery environments. Both the ASTR protocol and VAS tools used involve procedures that can be replicated in other settings.

Kamper et al. (2015) reviewed RCTs with a combined sample size of 6,858, which can be considered adequate for inferring about the intervention. This meta-analysis provides the strongest evidence (level 1) for the effectiveness of multidisciplinary rehabilitation interventions in treating chronic low back pain.

Thus, it can guide clinical practice in this area. However, the specific domains and configurations of interprofessional teams that would yield optimal results were not identified. Further, only moderate-quality evidence for the efficacy of biopsychosocial treatments over usual care was found.

The study by Rauck et al. (2015) was conducted in 50 different sites and involved 749 randomized patients, which enhanced the extent to which it can be generalized to other population conditions. The randomization process eliminated selection bias, while the double blind, placebo-controlled approach limited to 12 weeks reduced maturation effects that could threaten internal validity.

However, the study sample was restricted to opioid-naïve adults with CLBP. Thus, the findings may not be generalized to other patient populations. Additionally, the study was conducted for 12 weeks, thus, the long-term efficacy of BBUP may not be inferred. The efficacy and tolerability of BBUP were measured against a placebo, not versus other opioids.

Conclusion

Chronic pain affects physical functioning and emotional wellbeing. Multiple treatments exist for reducing pain intensity, ranging from single-discipline interventions to holistic approaches. From the articles reviewed, multimodal approaches that use the biopsychosocial model produce positive long-term outcomes compared to opioid treatment alone. Therefore, individuals with chronic pain can benefit from multidisciplinary care programs that combine multiple treatment options.

References

Jacobs, J., Wilson, J., & Ireland, K. (2016). Advanced soft tissue release® (ASTRA®) long-and short-term treatment results for patients with neck pain. MedCrave Online Journal of Orthopedics & Rheumatology, 5(4), 1-5.

Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & van Tulder,M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. The British Medical Journal, 350(h444), 1-11.

Rauck, R. L., Potts, J., Xiang, Q., Tzanis, E., & Finn, A. (2015). Efficacy and tolerability of buccal buprenorphine in opioid-naive patients with moderate to severe chronic low back pain. Postgraduate Medicine, 128(1), 111.

Introduction

Definition of Pain

Pain is a multidimensional phenomenon; therefore, it is difficult to define. Pain has been defined in many different ways by health care practitioners. (Sternbach, 1999).

Chronic pain: According to NHS Quality Improvement Scotland (2006, p. ix), chronic pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage in cases where pain lasts for more than three months after an injury causing the pain has healed, the patients presentation becomes more complex with biopsychosocial feature. Other characteristics of chronic pain include that it often has an identifiable cause (although the cause may be difficult to determine); is often described using affective terms, such as hateful or sickening; has the qualities of allow pain; and is often much more difficult to treat than acute pain. Health care providers may feel frustrated and incompetent when their attempts to relieve chronic pain are ineffective. However, understanding of the anatomy, physiology and psychosocial aspects of chronic pain is very helpful in management of chronic pain (Mersky, 1996; Hodgkiss, 1997).

Dysvik (2004, p. 68) says that, by looking at chronic pain in a biopsychosocial way it allows the nurse to concentrate on the specific area which is having the largest impact on the patients symptoms.

Holistic Nursing Practice

Holistic nursing practice is about healing the whole person, explicitly recognizing and addressing the interconnectedness of body, mind, emotion, spirit, society/culture, relationships, context, and environment (American Holistic Nurses Association, 2008).This type of practice does assist people to find the much needed well being. It looks at an individual as a bio-psycho-social being and therefore every aspect of ones life is considered during provision of nursing care. Holistic nursing practice starts from the time a patient presents her/himself to the nurse for nursing care and ends when the patient is well. It does not only entail that which has brought the patient or that which has made the patient to seek nursing or medical care but all factors that are involved in the patients behavior to seek nursing assistance. (AHNA, 2008; Frisch, Dossey, Guzzetta, & Quinn, 2000).

Assessment and management of chronic pain in the context of holistic nursing practice is one of the best ways in dealing with chronic pain as it will consider the patient as a bio-psycho-social-spiritual being. All the concerns of the patient and all aspects of his/her life will be considered during assessment and management. Holistic care does not only involve the patient but also his/her surrounding/environment. According to Rudin, (2001), guidelines for assessment and management of chronic pain, chronic pain management is defined as a process wherein physician, and non-physician clinician work together to improve function, reduce pain, develop self-management skills, and maintain those improvements over time. It further states that this process requires active participation by the patient (and significant others in the persons life) and open ongoing communication among all practitioners involved in the treatment process. Holistic care of a patient in chronic pain promotes effective and proper ways of communication, co-operation between nurse and client, shared understanding, health promotion and informed consent (Hamilton & Price 2007, p. 221). Holistic assessment enables the nurse to comprehend of the individuals precise pain. This type of assessment is normally based on deductive reasoning. Diversity of factors that determine bio-psycho-social-spiritual functioning are assessed (Hamilton & Price 2007).

Assessment of Chronic Pain

In order for a nurse to succeed in chronic pain management, holistic assessment must be done accurately and appropriately. The nurse must incorporate the components of holistic assessment which according to Keef and Bonk (1999, p. 88) are, clinical history; general personality trait; current level of somatic concern, depression, anger; report of pain and functional limitations; preliminary behavioral analysis; pain coping strategies; beliefs about injury; pain and treatment outcome; and social and occupational influences on symptom presentation. Holistic assessment of chronic pain recognizes two major parts of the assessment process which are history and examination. The History, when accurately and exhaustively taken, can provide relevant and important information regarding the chronic pain. The history should include pain, treatment and psychological history, patients ideas about the cause of pain and goals for evaluation and treatment. Comprehensive examination should include the following; musculoskeletal examination, neurological examination, psychological examination, assessment of function-abilities and deficits (Wall, 1992; Meinhart, 2000). A detailed symptom analysis is performed as explained herein. In order to get accurate information that will help in holistic management of chronic pain, accurate history is essential. The following aspects are considered during assessment of chronic pain:

Location: to determine the location of the clients pain, the following questions are asked: where in the body is the pain? (A figure of a person is normally used and the client just points to or marks painful areas.), is the pain inside (internal) or on the surface (external)? Is the pain always in these areas? If the pain is in more than one spot, are the pains equal, or does one trigger the others? These questions help the nurse to know the exact spot of the pain and whether the pain(s) is internal or external. The nurse has to know very well the anatomy and physiology of human beings as this will enable her/him to understand deeply the location of pain and the physiology behind it.

Extension and Radiation: in order to determine the extension and radiation of the clients pain the following questions are asked; does the pain extend from where it started? Does it cover a wide area or can you point to where it is? These questions enable the nurse to know the pattern and which parts of the body in particular are affected. This helps in management interventions such as body psychotherapy and also in positioning of the patient in bed in a comfortable way.

Onset and pattern: onset and pattern of chronic pain is very important in designing the management plan and therefore they have to be very clear. These can be determined by asking the patient the following questions; when did the pain begin? Is it a regular pain, or does it varies? Does it occur in cycles, such as at the same time every day, every month, or every spring: What triggers the pain? Are there specific things that always trigger it? Can you identify any particular patterns? Does the pain begin suddenly or gradually overtime? Is it continuous, or does it vary? Are there separate episodes of pain? If so, does the pain go away completely between episodes, or does it just get better? Has the pain pattern change at all since it began? Has your lifestyle changed since the pain began? Onset and pattern of chronic pain is very vital in the planning of care of a patient. The nurse needs to get accurate information about this so that she/he can be able to know the nature of the pain and what aggravates it.

Duration: Duration of a chronic pain is important in holistic care as it enables the nurse to know accurately the types of medication to administer and also to find the most appropriate method on non pharmacological pain control measures. The questions include; Are you free of pain between attacks? Is the pain constant, intermittent, pulsating, or throbbing?

Precipitating factors: These are gotten from the client through asking questions such as what seems to trigger the pain? Can you identify a specific cause or event that always or sometimes precedes the pain? Does anything make it worse, such as smoking, drinking alcohol, eating, heat, or tension? What helps relieve the pain, such as rest, activity, heat or cold, or medications? These questions also helps the nurse in patient education; what to avoid.

Intensity: this is determined by asking questions such as, (When treatment starts, always have the client rate the pain before and after treatment). Note what nonverbal signs of pain the client exhibits, such as grimacing, crying, mourning, sleeping, appearing exhausted, or remaining immobile.

Associate symptoms: This can be achieved by asking the client if there is any other problems caused by his/her pain, if he/she experiences any nausea, restlessness, insomnia, excessive sleeping, or loss of appetite.

Effect on activities of daily living (ADL): The nurse therefore has to enquire from the client his/her pain has affected his capacity and ability to perform ADLs (McCracken, p. 1998, p. 28). The nurse will get these by asking the client questions such as: Does pain interfere with work, sleep, driving, eating, schoolwork, sexual relations, housework, social activity, or other activity? Has the pain caused any changes in your lifestyle?

Methods of pain relief: Ask about both invasive and noninvasive pain relief methods.

Psychological history: This forms an integral part of holistic care and the nurse should screen the client for anxiety, depression, stress coping styles, personality traits, addiction, personality disorders and traits, and psychiatric conditions (Keefe, et al. 2005, p. 601; Weisenberg, 2000, p. 60).

Physical Examination

The Wisconsin medical association recommends a comprehensive examination of each and every patient. Begin the examination by having the client show where the pain is and describe how it feels. Remember that the client is the expert on the pain and is the one who can best described and pinpoint it. This includes the following area: Musculoskeletal examination: posture; gait; joint examination-symmetry, range of motion, size, ligament stability; spinal examination  focal tenderness, symmetry, range of motion, and provocative movements; muscle examination; strength. Neurologic examination: mental status; sensation  touch, pressure, pinprick, heat, cold, vibration and reflexes  deep tendon and pathologic. Functional assessment will depend on patient self report and /or objective evaluation of mobility, self care, and physical performance. Objective signs of pain can be divided into three categories: sympathetic responses, parasympathetic responses, and behavioral responses. These responses are not diagnostic of chronic pain, but they may give clues about its cause. Sympathetic Responses are often associated with low to moderate pain intensity or superficial pain. They signify that body defenses are mobilized and that the fight or flight responses has begun. Objective signs include pallor, increased blood pressure, increased pulse, increased respirations, skeletal muscle tension, dilated pupils, and diaphoresis. Parasympathetic responses are often associated with pain of severe intensity, or with deep pain. In parasympathetic responses, body defenses may collapse in an attempt to lessen the effects of an external threat. In behavioral responses, the client may assume a posture that minimizes pain, such as lying rigidly, guarding, drawing up the legs, or assuming the fetal position; Moan, sigh, clench the jaws or fist, become quiet, or withdraw from others; Blink rapidly; Cry, appear frightened, exhibit restlessness; Have a drawn facial expression; Have twitching muscles; Withdraw when touched; and hold or protect the painful area, or remain motionless (Vasudevan, 2000; Max, 2004).

Examples of tools and assessment domains

The simplest pain assessment tool to use for both nurse and client are the visual analog or visual descriptor scales. These scales can be combined with numbers and verbal anchors. These tools are easy to use and provide the client and nurse a way to quantify pain. Another common assessment tool used to assess pain is the McGill  Melzack Pain Questionnaire. Although this tool is complex and more difficult than others to use, it can be very useful (Taylor, & Herr, 2003, p. 87). Others include the Doloplus-2 scale which assesses somatic, psychomotor and psychosocial reactions, the No Pain-Non-Communicative Pain Assessment Instrument that majorly assesses activity level and pain response, McCaffery and Pasero Initial Assessment Tool, Patient comfort assessment guide, Brief pain inventory and Oswestry disability questionnaire which was developed with the aim of getting information from a patient experiencing back and leg pain on the pain ahs affected their ability to manage every day life. These tools are limited in that they do not cover bio-psycho-social-spiritual nature of human beings and therefor other methods of assessment such as observation and patient verbalization must be used hand in hand with assessment tools.

Management of Chronic Pain

Nursing and Non-Pharmacologic Intervention

Non pharmacologic interventions are those interventions that do not totally involve the use of medicine/drugs in management of pain (Lin, &Taylor, 1999, p. 155). Holistic management of chronic pain requires that all aspects of chronic pain including its effect on the patients life are considered during management. The principle of chronic pain management clearly states that a multidisciplinary team and significant others must be included in the management of chronic pain.

Basic Principle: When caring for a client in pain, the nurse identifies and removes the cause whenever possible. The nurse must work with the client in seeking ways to reduce or remove pain. Listen to what the client thinks will help, and decide with the client and other health care team members what should be done. Allow the client a sense of control over the pain experience, rather than promote a feeling that the client is helpless in the grip of an episode of pain (Rudin, 2001; Lee & Scharff, 2002).

Alleviating Anxiety: the greater the clients anxiety, the greater the suffering associated with the pain. The nurse should stay with the client for a while, allow client cliet to talk and express feelings and fears (Abram, 1990).

Distraction or diversion: this takes several forms such as occupational therapy, conversation, and reading, watching television, listening to the radio, meditation, self-hypnosis, biofeedback, and autosuggestion. It is upon the nurse to choose and initiate the most appropriate form of distraction. The nurse should encourage the client to use any methods that they have found helpful in the past to relieve pain, provided that these methods are harmful or bothersome to others (Loese, & Butter, 2001).

Providing physical care: the nurse should ensure that effective physical care for clients experiencing chronic pain is directed at reducing mechanical, chemical and thermal stressors that lower pain tolerance. This include protecting clients from local irritations or inflammations such as infection or thrombosis, muscle spasm or muscle strain, interference with local blood supply and venous and lymphatic drainage, distension of hollow visceral organs such as the bowel and bladder, and further damage to traumatized tissue (Loese, & Butter, 2001).

Key Principles in Holistic Management of Chronic Pain

McCaffery (1999), states that, the key to successful management of chronic pain is identification of chronic pain, accurate assessment, adequate intervention and frequent evaluation. These enables the nurse to educate the patient on the process, demonstrate understanding, holistic support of the client; socio-environmental impacts, quality of life improvement where possible and encouragement to return to work where appropriate and possible and creating an environment of understanding of a patient in chronic pain.

Analgesic Ladder: Principles and Guidelines

The World Health Organization published a document entitled Cancer Pain Relief which set out principles of cancer pain management based on analgesic three step ladder. The latest version was published in 1996 with the principles of by the mouth, by the clock, and by the ladder (WHO, 1996). According to the principles, the first step begins with non opioid analgesics, plus adjuvants as needed, such as tricyclics antidepressant. The second step uses weak opioids plus or minus (+/-) non opioid analgesics plus or minus adjuvant. The third step uses strong opioids plus or minus non opioid analgesics plus or minus adjuvants. According to Shaun and Richard (2008), patients who have moderate to severe pain when first seen by a clinician should be started at the second or third step of the WHO analgesic ladder. Non opioid analgesics include sallcylates, aspirin, choline magnesium trisallycylate, and other NSAIDS such as acetaminophen. Weak opioids analgesics include codeine, dihydrocodeine, and hydrocodone. Strong opioids analgesics include morphine, oxycodone, fentanyl, methadone and levorphanol (Shaun, & Richard, 2008). Adjuvant analgesics are drugs that are not primarily analgesics but research has shown that they have analgesic properties. They are normally co-administered with analgesics mostly in management of refractory pain. These include diclofenac, Dexamethasone, Prednisilone, gabapentin, and amitriptyline (Ellison, 1993; Brown, & Fleming, 1996). From the above (assessment and management) it can be deduce that there is a relationship between holistic nursing practice and assessment and management of chronic pain in that holistic practice considers all aspects of ones life just as chronic pain has adverse and varied effects on ones life and therefore needs to be viewed in a way that the whole person and all related factors in his/her life are considered during the process of assessment and management. In holistic practice, factors that are not directly involved in a persons disease process such as socio-cultural factors, role and functions, psychological and family issues are addressed. This too applies in assessment and management of chronic pain where by these factors are considered but in a different perspective; how the chronic nature of the pain has affected them (Woolf, 2004, p. 441).

Evaluation and Out Come of Chronic Pain Management

The nurse should always maintain accurate and complete records of pain management as part of nursing care. The following out comes should be used as measures of evaluating the effectiveness of chronic pain management; reduction in pain, improved physical, psychosocial functions, improved sleep with reduced depression and anxiety, change in use of medication in terms of dosage, frequency and completion of dose, increased ability to manage pain without external assistance, the reduction in utilization of health care services as a result of pain and verbalization of the client that he/she is feeling well or better (Turk, 2001; Moskovitz, 2002; Olungalunga, 2000). It is the role of the nurse to continuously monitor recovery progress, liaise with the other health professionals such as physicians, social workers, counselors and others. The nurse also ensures that patient receives his/her medication as prescribed.

Conclusion and recommendations

Holistic nursing care forms an integral part of chronic pain assessment and management. Holistic nursing care views an individual as a bio-psycho-social-spiritual being and therefore all aspects of ones life are considered during assessment and management. Holistic nursing encompasses thorough assessment which involves both history taking and physical examination in order to come up with a proper care plan. The information gained from this paper will be of great help in my future nursing practices as it has opened up a new zeal to acquire more new information on chronic pain.

References

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Chronic pain is a very common type of pain which is affects both physiology and psychology of a person. A pain is considered to be ‘chronic’, if the pain continues beyond the time expected for a painful condition or injury to heal, usually about 3 months or more (The Australian Pain Management Association Ltd. (APMA) , 2018). The constant pain affects the person’s day to day lives, in which it makes the person prone to psychological distress such as depression and anxiety. Furthermore, long term chronic pain can lead to: increase in negative feelings, pain catastrophizing, social stigma, and depression. Chronic pain falls in the category of biopsychosocial model, and numerous treatments have been developed in order to treat chronic pain. The most effective form of psychological intervention to treat chronic pain is the cognitive behavioural therapy, which focuses entirely on practical self-help strategies (Victoria, 2019).

Cognitive behavioural therapy is a psychological intervention that is used to treat the psychological and physiological effects of chronic pain. The primary focus of cognitive behavioural therapy is to change unhealthy and/or unhelpful thoughts, behaviour and coping mechanisms of a person (Healthdirect, 2019). The cognitive behavioural therapy is the combination of two types of therapies: ‘cognitive therapy’ and ‘behaviour therapy’.

The aim of cognitive therapy is to change a person’s way of thinking about an issue which causes concern. This is done by challenging the negative thoughts and maladaptive coping mechanisms of a person and replacing it with healthier coping strategies. A common technique in cognitive therapy is ‘Cognitive reconstructing’, this is when a person learns to identify the negative thoughts and replace them with realistic and positive thoughts (Victoria, 2019). The behaviour therapy identifies a person’s behaviour/s and help change potentially self-destructive behaviour’s. The behaviour therapy functions on the idea of a behaviour is a learned trait, therefore; I can be changed by replacing ‘dangerous’ behaviour with one that is ‘productive or helpful’ to the person (T.J.Legg, 2014).

“The perception of pain is in your brain, so you can affect physical pain by addressing thoughts and behaviours that fuel it”, (bowers, 2016). The cognitive behavioural therapy is an effective form of therapy for those suffering from chronic pain. It changes people’s perception of pain and by recognising pain, the pain becomes insignificant and the pain interferes with a one’s quality of life a little less, thus; optimising their functions in day to day life. Furthermore, cognitive behaviour therapy changes the physical response in the brain which leads to catastrophizing pain. Pain causes stress in a person and the stress increases the production of adrenaline and serotonin, in order to control the chemicals released by the brain “cognitive behaviour therapy reduces the arousal and the impacts of the chemicals” (Hullett, 2011). Consequently, this improves the person’s natural pain relief response. In addition, cognitive behaviour therapy is very effective due to its nature of being self-help, this gives the person coping mechanisms in treating chronic pain and can also help in the future to treat the residual effects of chronic pain such as anxiety or depression.

A study was conducted by Dawn M. Ehde from university of Washington titled ‘Cognitive-Behavioural Therapy for Individuals with chronic pain’, and in this research the treatment of CBT has been shown to present a positive set of results. The results yielded by the study supports the prevalence of the CBT in treating chronic pain, CBT had positive impact on pain, pain-related discomfort, depression, anxiety, and health related quality of life (Hoffman, Papas, Chatkoff, and Kerns, 2007). Furthermore, cognitive behavioural therapy had proven to be effect during post-treatment, the observations were made by the research team and the team observed the patients to have used CBT to treat minor pain related issues (Henschke et al., 2010). Patients using CBT post-treatment highlighted the self-help aspect of the treatment, thus; giving the patient knowledge about their condition and how to treat it effectively.

The treatment of cognitive behavioural therapy has been tested on various groups of test subjects. This ranges from: children and adolescence, and older adults who are suffering from chronic pain (Judith A. Turner, 2014). As each group received CBT treatment for chronic pain the children and adolescence had the clinically significant success rate of >50% improvement in pain post-treatment. However, during one of the test that was conducted a group yielded no significant results from the CBT treatment they had received becoming an outlier (Tiara M. Dillworth, 2014). On the other hand, the adult group whom are suffering chronic pain was also been treated with CBT but the symptoms of chronic pain were prevalent. The adult group that were diagnosed with chronic pain is suffering from wide range of issues caused by chronic pain, such as: pain related distress, depressive symptoms, denial, pain catastrophizing, and low self-efficacy dealing with pain. After cognitive behavioural therapy had been administered nearly half of the patients (44%) made a clinically meaningful improvement at one-month post treatment and the other 42% of the subjects were predicted to make significant improvement over next two to four months (Judith A. Turner, 2014).

There are other approaches to chronic pain such as: opioid medication, nonsteroidal anti-inflammatory medication, and mindfulness. Treatments such as opioid medication and nonsteroidal anti-inflammatory drugs were administered on a group of adults aged 20 – 70, the results yielded by both those treatments were had poor results of mere 22% success rate. In addition, the side effects of the drug treatment showed a small effect on the patients physical functioning, with no statistically significant impact for depression or depressive symptoms and miss use of medicinal drug use (Tiara M. Dillworth, 2014). The mindfulness treatment is closely related to cognitive behavioural therapy which focuses on by increasing the acceptance of pain rather than minimising the pain. The mindfulness therapy revolves around the notion of stress reduction of acceptance of pain. In order to identify which treatment is better (mindfulness vs. CBT) researcher Melissa and her team conducted a study. At the end of the experiment both groups yielded promising results of CBT with (P < 0.01) and mindfulness at (P < 0.05) (Melissa, 2016). Mindfulness treatment was less effective than CBT due to methodological shortcomings and mindfulness does not provide the patient with adequate coping mechanisms compared to CBT.

In conclusion, cognitive behavioural therapy is the most effective form of psychological intervention that is suitable for those suffering from chronic pain but is not limited to chronic pain but can also be used for other problems such as depression and anxiety. CBT is designed as self-help treatment with gives the patient more control and better chances at fighting chronic pain in future.

Pain is the body voice that you need to listen to your body. Chronic body aches really make you suffer a lot; relieve it with natural methods and Ayurvedic remedies and herbs.

“It’s not just pain. It’s a complete mental and emotional assault on your body” – Jamie Wingo.

Popping up pills is surely an instant but not permanent solution to chronic pain and body aches. Over the counter medicines, natural methods and alternative medicine system works wonder to relieve pain. The process makes pain management so much easier that you can do it just by opening the full of treasure cupboard of kitchen and by changing few this and that in your lifestyle.

Ayurvedic herbs or home remedies and altering your lifestyle with good habits help reducing and relieving chronic pain. The method helps you to deal with the pain by going to their root cause and then treat it. You can also go for Ayurvedic treatment in India undertaking detox, massage and other therapies and treatment.

Pain is body’s effective way of altering us that there is imbalance in the body and we needs to change it. Instead of treating it, we suppress it by loading up on medication that can have side-effects both toxic and addictive.

Both over the counter and prescribed medicine increase the risk of stroke and heart attack. These drugs don’t treat the problem, just cover it up by the time our body develops tolerance for the dosage.

Turn towards natural way to heal chronic pain using the mentioned below options.

Natural Pain Reliever

Intake Anti-Inflammatory Diet

Many kind of body pain, even joint aches often caused or triggered due to inflammation Consuming anti-inflammatory diet or foods help relieving the pain. The diet includes nutrient-dense plant food and Mediterranean diet proves to be helpful. In the case, one needs to avoid processed food, gluten, sugary food, alcohol, Trans fat, vegetable oil, etc.

Heal with Yoga and Meditation

Yoga with its different aspects and technique relives chronic pain treating the root cause. Certain yoga poses are designed to reduce body aches increasing the flexibility that relaxes muscles, strengthen bones and enhances range of motion. You don’t need to be a Human Pretzel, resolve the issue even with restorative, easy and simple poses. Mindfulness meditation is a great way to treat the issue naturally. According to a 2017 systematic review and meta-analysis, went through 38 studies and concludes that meditation improve depression, stress, pain symptoms and enhance life quality. Meditate for 10-20 minutes daily to relax the body and mind to get rid of body aches and chronic pain.

Massage Release Stress, Reduces Pain

The other natural and amazing method to reduce pain is massage that release stress, tension, stimulates blood flow and re-energizes the body. Body massage removes toxics, enhance circulation and due to hand therapy it produces energy that heal the body condition. One can undergo Panchkarma treatment in India after consulting doctor, and allow the body for self healing.

Ayurvedic Herbs and Remedies to Rescue

Ginger

Commonly found herb spice, Ginger consists of antioxidants and anti-inflammatory properties and proves to be more effective than over the counter medicines. Ginger is relieves joint pain soothes arthritis, treat stomach pain, reduces stiffness, etc. Consume ginger with your food or drink ginger tea twice daily.

Turmeric

Another common spice herb, Turmeric is widely used in South East Asian cuisines and possesses anti-inflammatory and anti-cancer properties. The magic spice consists of pain reducing properties, and has been used for the same since ancient age. Use turmeric in your food, sprinkle over soup, drink hot turmeric milk before sleeping and can apply turmeric paste on the affected area.

Essential Oil

Sniffing essential oil is again highly beneficial, so keep them on hands in order to calm and relax the mind. Aromatherapy relives stress and often the root of pain. You can use Chamomile, Lavender, Sage, Peppermint, Rosemary, and Eucalyptus Oil onto your temple, sore joints or chest.

Pineapple

This tropical fruit is wonderful in curing chronic pain and aches. It is often used to reduce joint swelling, inflammation, muscle soreness and proves to be useful for people with acute sinus. Bromelain (enzyme in pineapple) tonics are available for body, but it is better to eat the fruit.

Others: White Willow Bark, Devil’s Claw, FeverFew, Boswellia, Valerina Root, Arnica, Capsacian, etc.

These methods and food naturally relieves chronic pain, and for the professional assistance Ayurvedic treatment in India is the amazing option to opt.

This year has been so full of stress and anxiety for just about all of us. Concerns about our health, uncertainty about the future, and the feeling of isolation have made so many of us worse for the wear. It should come as no surprise that chronic pain, which is greatly affected by mental state, may also be reaching an all-time high for many. Physical manifestations of stress and anxiety can be managed. The good news is you may not need to rely entirely on a doctor or stay on pain medication.

That is not to say that it isn’t important to see your doctor and to work with him on a pain management plan; but the difference between acute illness and chronic illness is that with acute illness and pain, you go to your doctor get a prescription and hopefully following his instructions get well. As someone with a chronic illness, I understand that it is important to work with your doctor to get the best possible care and also seeing what you can do to help yourself.

In recent years, researchers, scientists, and theorists have been conducting clinical research on the effects of mindfulness and meditation practices and their findings are confirming the long-term benefits of regular mediation and mindfulness practice. These benefits include, but are not limited to stress reduction, minimizing chronic pain, reducing anxiety, lowering the probability of symptoms of depression, enhancing brain performance, improving sleep, reducing the risk of heart attack and stroke, and improving overall well-being.

According to Sylvia Boorstein, (2012) “Mindfulness is the aware, balanced acceptance of the present experience. It is not more complicated than that. It is opening to or receiving the present moment, pleasant or unpleasant, just as it is, without either clinging to it or rejecting it”.

Kabat-Zinn has defined mindfulness meditation as “the awareness that arises from paying attention, on purpose, in the present moment and non-judgmentally. By focusing on the breath, the idea is to cultivate attention on the body and mind as it is a moment to moment, and so help with pain, both physical and emotional’.

When we examine the definitions of mindful meditation, we can see that it is the opposite of fighting, clinging, or avoiding the thoughts, feelings, and sensations present in the moment. Many of us, especially those struggling with chronic pain, spend large portions of our time consumed with either fighting, clinging, or avoiding our experiences in the present moment and end up missing out on life.

Typically, we are not even aware we are doing this. As Jon Kabat-Zinn, Ph.D., writes in the introduction of The Mindfulness Solution to Pain, “From the perspective of mindfulness, nothing needs fixing. Nothing needs to be forced to stop, or change, or go away”. Kabat-Zinn founded an effective program called mindfulness-based stress reduction (MBSR) in 1979. While today it helps individuals with all sorts of concerns, such as stress, anxiety sleep problems and high blood pressure, it was originally created to help chronic pain patients.

Mindfulness is the opposite of mindlessness. How many of us are guilty of going through our days like a robot? Waking, taking medication, showering, etc, without even thinking. Sometimes we are so mindless that we must honestly think to recall why we walked into a room or what we did the previous day.

Mindfulness is living each day with purpose and intent and the practice of mindfulness would have us engage and be present in every moment of our day…and adapt adjust as each moment changes. Furthermore, mindfulness would have us accept what is…what is present, pleasant, or unpleasant, good, or bad, and let it be. “Mindfulness is not just paying attention to the positive experiences, but also the neutral and negative ones” – Dr. Jackie Gardner-Nix.

Chronic pain can trigger changes in brain structure, such as changes to the limbic system that controls our emotions and the pre-frontal cortex that is the thinking, decision-making, and problem-solving area of our brain. Chronic pain changes the communication between these two areas of the brain, reducing the effectiveness of our pre-frontal cortex and increasing activity in parts of our limbic system. When these changes occur, individuals tend to struggle with concentration, decision-making, and problem-solving, along with being more susceptible to emotional reactivity related to heightened stress Penman, D.

Forming new memories can also be a struggle for people with chronic pain. Consequently, the changes in brain structure produce changes in brain functioning that are linked to depression, anxiety, and impaired cognitive functioning. The good news is that research shows these changes can be reversed when patients are treated for painful conditions. If you are experiencing any of these symptoms, mindful meditation is a way to retrain your brain.

With advances in brain imaging technology, we can see how regular weekly practice of meditation can profoundly change the way different regions of the brain communicate with each other and therefore how we think Ireland, T., Scientific American. With regular mindfulness practice, the emotional response system of the brain the limbic system, specifically the amygdala, which is directly impacted by stress shrinks, while the rational, decision-making part of our brain, which is in control of concentration and awareness, grows Ireland, T., Further, the connections between these two areas of the brain also change. Thus mindful meditation practices seem to reverse the effects chronic pain has on the brain. Mindfulness meditation has been shown in clinical trials to reduce chronic pain by 57%, and some experienced meditators can reduce it by over 90%.

There are many ways to practice mindfulness, but the goal of any mindfulness technique is to achieve a state of alert, focused relaxation by deliberately paying attention to thoughts and sensations without judgment. This allows the mind to refocus on the present moment. All mindfulness techniques are a form of meditation.

• Basic Mindfulness Meditation: Sit quietly and focus on your natural breathing or a word or “mantra” i.e. “quiet,” “relax” that you repeat silently. Allow thoughts to come and go without judgment and return to your focus on breath or mantra.
• Body Sensations: Notice subtle body sensations such as an itch or tingling without judgment and let them pass. Notice each part of your body in succession from head to toe.
• Sensory: Notice sights, sounds, smells, tastes, and touches. Name them “sight,” “sound,” “smell,” “taste,” or “touch” without judgment and let them go.
• Emotions: Allow emotions to be present without judgment. Practice a steady and relaxed naming of emotions: “joy,” “anger,” “frustration.” Accept the presence of the emotions without judgment and let them go.

You can always access several guided meditations on the internet; simply by searching for meditation for pain and sleep, or meditation for pain and stress. “Guided Meditation for Pain”, videos are especially helpful resources. There are also apps available on smartphones that allow access to meditation anywhere.

There is no right or wrong way to meditate. You can start with – minutes a day and then integrate another — minute practice throughout your day. The key is to start right away and not put it off. Like all healthy lifestyle practices, regular and consistent mindfulness meditation practice is crucial to reap the associated benefits.

Bibliography

1. Jackie Gardner-Nix, Ph.D. The Mindfulness Solution to Pain: Step-by-step Techniques for Chronic Pain Management: Step-by-Step Techniques for Chronic Pain.
2. Danny Penman and Vidyamala Mindfulness: A Practical Guide to Relieving Pain, Reducing Stress, Platkus.
3. Ted Talk: How Mindfulness Meditation Redefines Pain, Happiness, and Satisfaction by Dr. Kasim Al-Mashat.
4. Sylvia Boorstein (2012) Wheel: A Recovery from Chronic Pain and Discovery of New Energy Balboa Press.

Chronic pain is a multi-dimensional, distressing experience that can occur with or without tissue damage and persists over extended periods of time (at least 3 months) [1]. This disease is a public health problem worldwide [5]. Specifically, it is currently estimated that chronic pain affects between 20 and 30% of the adult population worldwide [3–8] and up to 70% of adults older than 42 years [9]. As a consequence, chronic pain has become the most expensive disease in the world [10] and accounts for up to 2% of the European Gross Domestic Product annually [11]. Additionally, with the age distribution shifting towards the elderly [12], the economic burden of this disease is likely to increase in the coming years.

In this scenario, various efforts have been made to improve chronic pain treatments in recent decades. However, existing reviews only provide modest support for the most popular chronic pain treatments, including medical interventions, physical therapy, psychological treatment, or a combination of these [13–15]. Several factors, such as patient characteristics, unexplored genetic or biomechanical mechanism factors, or the experience of therapists, could help explain the modest effectiveness of existing treatments for chronic pain. However, some authors have suggested that inadequate monitoring of patient progress and response to treatment is likely to be, at least in part, responsible for the limited impact of current therapies for chronic pain [16,17].

Due to its chronic nature, management of chronic pain often requires prolonged and regular contact with the health care system [18]. In this sense, it is important to note that a move towards self-management will be needed, rather than relying on the care of health professionals [19]. However, in doing so monitoring could still remain a challenge because limited resources and existing waiting lists in public health settings limit the quality of patient monitoring in chronic pain settings [20,21]. For example, pain treatment follow-up is still predominantly discreet during on-site appointments. This is problematic because pain-related variables, such as pain intensity, mood, and fatigue can vary across and within days [22,23], even in patients with chronic pain such as osteoarthritis [24], rheumatic diseases [25], multiple sclerosis [23], and fibromyalgia [26].

The aforementioned variability of symptoms in patients with chronic pain means that a single measure may not be representative of the entire experience. Furthermore, retrospective pain assessment leads to recall bias and reduces accuracy [27]. This could be minimized with paper diaries. However, research has shown that the use of paper diaries is problematic due to participant non-compliance (missing data and back-filling) and errors associated with manual data entry [28,29]. Additionally, neither episodic on-site assessment nor paper diaries permit timely communication and response to undesired events experienced by the patient during the course of treatment [20].

Another problem related to the current model of care in chronic pain refers to decision-making in the face of unwanted events. Specifically, the current approach to care requires patients to judge when an undesired event is problematic and what is the preferred action to take in the face of that event [30–32]. This approach is problematic, as some patients may tolerate serious or even urgent problems (e.g., tachycardia, severe drowsiness, persistent vomiting, diarrhea, or urine retention) for too long, while others may seek care for symptoms that are less urgent or not problematic (e.g., very mild or short-term). For patients with chronic pain, and added problem is that patients combine appointments with their general practitioner, emergency services, and specialized pain clinics for the treatment of their pain and related symptoms [33]. This practice is likely to be problematic, as the alternation of different specialized and non-specialized services could lead to unpredictable treatment plans in response to unwanted events.

Telemonitoring with episodic phone calls, which is becoming an increasingly common practice, also only partially solves the aforementioned problems. First, because undesired events (e.g., side medication effects or decreased treatment effectiveness) can occur at different treatment stages [34], which means that control calls will often occur before or long after unwanted events occur. Additionally, because such phone calls require the active participation of a healthcare professional, which makes this procedure resource-consuming and ineffective [18]. Taking all the previous into account, it has been argued that our societies will not be able to sustain the current model of care for this condition [20,21,35,36], especially due to the ageing of the population and the dramatic increase in the prevalence of this disease in the elderly [9]. Indeed, this appears to be true now more than ever as a result of the COVID-19 crisis, imposed restrictions on circulation, and saturation of health systems [37]. Our team has already achieved some important goals in the design, development, and implementation of a new tool, namely a smartphone app called Pain Monitor, which facilitates regular assessment of patient outcomes using mobile technology and minimal healthcare professional involvement in assessment. The app, which has been developed by a multidisciplinary team including physicians, nurses, psychologists, and engineers following guidelines on pain research and eHealth [38–41], was found to have valid content (i.e., comparable to well-established paper-and-pencil measures) and high patient acceptability (i.e., response rates greater than 70% for daily responses over a period of one month) [42]. While important milestones have been achieved, the utility of the app in terms of increased treatment effectiveness (e.g., further reduction in pain severity and associated symptoms) remains unclear.

In fact, although it has been argued that mobile technology (mHealth), especially the use of smartphone apps, facilitates this paradigm shift towards telemonitoring in chronic pain care, reviews on this topic have evidenced that randomized controlled trials (RCT) evaluating the usefulness of these tools are lacking in the chronic pain literature [39,41,43–45]. Therefore, the current investigation constitutes an important step forward into the literature on this important public health condition. In particular, the goal of the present study is to test whether incorporating the Pain Monitor app into routine medical treatment results in better pain-related outcomes in patients with chronic musculoskeletal pain. As a secondary objective, we want to investigate the opinion of healthcare professionals on the app (the patients’ opinion was already evaluated in the 112 validation study [42]), which is key for future implementation [46]. This RCT will have three conditions, that is usual treatment (TAU) with the usual assessment method (episodic, combined on-site and by phone call), TAU with app-based assessment without clinical alarms, and TAU with app-based assessment with clinical alarms. Eligible patients will be adults with chronic musculoskeletal pain, the most common chronic pain condition, which includes pain in the bones, muscles, nerves, ligaments, or tendons [47]. As recommended in the guidelines, we will focus not only on the effectiveness of mHealth in pain severity levels [38]. In particular, outcomes will also include interference of pain on functioning, fatigue, and mood (depression, anxiety, and anger).

The study goal is to compare the response to one month of usual pain treatment for patients in the three monitoring conditions, namely usual episodic monitoring, monitoring with an app without clinical alarms, and monitoring with an app with clinical alarms. All patients will receive the usual treatment for their pain, so differences in outcomes (pain severity and interference, fatigue, and mood) across outcomes are expected to occur as a consequence of the assigned monitoring condition. Another goal is to investigate the opinion about the app of the health professionals involved in the study (e.g., in charge of disseminating the study, helping download the app, and proposing the treatment).

We expect that the use of the app with alarms that are sent to the healthcare professional in the presence of unwanted clinical events will allow a quick detection of patient suffering (see the alarms in Appendix I), including severe pain levels, side medication effects, high interference of pain on functioning, and psychological distress, as well as a quick reaction to these events. As a consequence of the above, we anticipate that patients in the app+alarm condition (telemonitoring) will report a greater reduction in pain severity, pain interference, fatigue, depressed mood, anxiety, and anger. Additionally, we expect that patients in this condition will also experience unwanted clinical events (e.g., poor treatment response or undesired clinical events associated with treatment onset) for a shorter time compared to treatment as usual or treatment as usual with the app but without alarms. In relation to the professionals’ opinion on the app, we expect that the professionals will experience some burden as they help patients to download the app and respond to alarms. However, we also anticipate that they will perceive the app to be useful and will be willing to use it in the future, preferably the version with alarms.

Abstract:

Chronic pain is a severe disorder which includes fibromyalgia, rheumatoid arthritis, cancer-related pains, etc. Pains are very severe in the age above 60 like arthritis pains. The prevalence of chronic pain is high in developed and developing countries. There is a significant increase in chronic pain prevalence studies in the world. Chronic pain is a severe condition were treatments are offered with NSAIDs, topical formulations, sprays, etc. these medications can offer only a temporary relief. There is no permanent relief for chronic pains. Pain is an immune-mediated disorder which leads to sleeplessness, stress, tired, etc. Normally chronic pains cannot be cured by treatment with modern medicines, but they are available with severe toxic effects. Treatment is available with pain relievers which may give a temporary relief but with severe side effects. Treatments with herbal remedies are available with essential oils as a combination of different essential oils which can be used as an oil bath these oils can relieve pain to some extent and can give a relief to patients with chronic pain. Hence when a plant containing essential oil is selected the plant must contain active constituents which include secondary metabolites etc. The selected plant must be free from side effects and toxicity, should be having better potency and efficacy, and safe to use. Nasal sprays are agents which can deliver medicaments directly to the brain by targeting pain receptors in the brain. Nasal sprays are more efficient way of administering drugs with potential use in crossing the blood-brain barrier. This review mainly focuses on intra-nasal drug delivery and transport of drugs through the olfactory route and also reviews the recent development in nanotechnology and role of Nanoparticles used in the nose-to-brain drug delivery.

Introduction

Chronic pains like fibromyalgia, rheumatoid arthritis, neuropathic pain, etc are most common pain disorders, affecting 5% of the world population. According to the American College of Rheumatology, chronic pain affects between 2 and 4 percent of people. Up to 90 percent of people with the condition are women. Essential oil has been reported to reduce the severity of pain, anxiety, and depression, and improve the quality of sleep, suggesting that it may be useful to treat chronic pain. Chronic pain, a disease of pain perception, is a long-term chronic illness affecting 0.5-2% of general population. Females are 3-7 times more frequently affected than males and 10-16% patients can have an associated rheumatologic condition. The prevalence of the disease is high in developed and developing countries. There is a significant increase in chronic pain prevalence studies in the world. Chronic pain is a severe condition were treatments are offered with NSAIDs, topical formulations, sprays, etc. these medications can offer only a temporary relief. Chronic pains may be muscular disorders which include fibromyalgia, rheumatoid arthritis, and neuropathic pain, symptoms of chronic pain include joint pain, muscle aches, burning pain, fatigue, sleep problems, loss of stamina and flexibility, due to decreased activity, mood problems, including depression, anxiety, and irritability. Causes of chronic pain include osteoarthritis, rheumatoid arthritis, back pain, fibromyalgia, inflammatory bowel disease, surgical trauma, advanced cancer. Chronic pain causes are due to pain disorders like chronic fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction. Some of the most common types of chronic pain include headache, postsurgical pain, post-trauma pain, lower back pain, cancer pain, arthritis pain, neurogenic pain, psychogenic pain. This review mainly focuses on the various pathways involved in intra nasal drug delivery and transport of drugs through the olfactory route and trigeminal pathway and also reviews the recent development in nanotechnologies and Nanoparticles used in the nose-to-brain drug delivery.

Nasal sprays are agents which can deliver medicaments directly to the brain by targeting pain receptors in the brain. Nasal sprays are used to deliver medications locally through the nasal cavities systemically. The nasal delivery route is preferred for systemic therapy because it provides an agreeable alternative to pills or injection. Substances can be administered directly and quickly through the nose.[1] Many formulations exist as nasal sprays for systemic administration e.g. treatments for pain, migraine, osteoporosis, rhinitis, and sinusitis. Nasal sprays are more efficient way of administering drugs with potential use in crossing the blood-brain barrier. The delivery of the drug via an intra nasal route offers various advantages over systemic drug delivery system, as it directly delivers the drug into the brain via olfactory route. A new method of fast-acting pain control, in which patients can administer themselves powerful doses of a pain reliever with a nasal spray, which shows promising effect for people with chronic pain. Nasal sprays are patient-friendly and administration of drug through this route is easy and convenient for the patients. Researchers are testing this method for delivery of short-acting but strong pain relievers hence pain relievers are rapidly absorbed through the nasal route.

Figure 2 Drug deliveries through Nasal route

Intranasal drug delivery system has emerged as an alternative route over the systemic oral and parenteral drug delivery administration through nose to brain drug delivery. Nasal sprays are more efficient way of administering drugs with potential use in crossing the blood-brain barrier. The delivery of the drug via an intra nasal route offers various advantages over systemic drug delivery system, as it directly delivers the drug into the brain via olfactory route. Presence of drug in the olfactory bulb enhances the drug bioavailability in the brain and reduces the side effects, drug degradation, and wastage of the drug through systemic clearance. However, there are also some drawbacks associated with INDD like poor drug permeation through the nasal mucosa and mucociliary clearance. Some factors may affect the rate of drug absorption these factors are formulation of the drug, drug permeation and metabolic stability. Many CNS-associated diseases have already been treated with IN administration of drugs, like Alzheimer’s disease, Parkinson’s disease, Huntington’s Disease, depression, anxiety, autism, meningitis, seizure, addiction, schizophrenia, stroke, etc. Intranasal administration is an alternative option to enteral or intravenous administration. Numerous new promising drugs are under development for IN application for diseases like Parkinson’s disease, depression, anxiety, autism, seizure, addiction, and stroke. Many intranasal medications are still in preclinical phase of development. Some of these studies are targeting memory and learning that show potential treatment for neurodegenerative disorders like AD, PD, epilepsy, and other neurotoxic events like oxidative stress and ischemia, and other diseases.

Figure 3 Route of administration

Essential oil also aids in treating migraine pains, gout pains, rheumatism, and headaches due to cold. Essential oil is also widely used in the healing of muscular spasms. Essential oils have been used for thousands of years for its calming, relaxing, balancing influences, and stabilizing effects. Essential Oil used in Ayurveda and aromatherapy commonly offers a calming and restorative effect due to the high amounts of terpenoids in the oil. Due to these properties, essential oil can be used as an alternative treatment to assist restlessness, sleeplessness, and trauma. During the last three decades, it has been clinically investigated for its relaxing properties. Researchers have pinpointed that terpenes act as active constituents that exert a calming and restorative effect on the central nervous system. Essential oils are used as stress releasing, calming and relaxing, antispasmodic, analgesic, anti-inflammatory, tranquilizer, and temperature-reducing. Essential oil can be effective in treating sleeping disorders such as insomnia and may also be used to relive symptoms caused by PMS such as headaches, diarrhea, stomach cramps, fatigue, migraines, and indigestion. Essential oil is calming and relaxing on the nervous system and can be beneficial for depression, restlessness, anxiety, stress, and emotional trauma. Still it is required to design the formulation having combined advantages such as Nanostructured lipid carriers for intranasal delivery,[25] and in situ nasal gel,[27] chitosan coated nanostructured lipid carrier, etc. Researchers are still searching for new technologies for improve the bio efficacy via IN administration route.

Role of Nanoparticles in Intranasal drug delivery

Nanoparticles play a crucial role in delivering the drug to the targeted site of action through many routes like oral, systemic, parenteral, and other routes. Nanoparticles including, carbon-based nanoparticles, biodegradable nanoparticles, metallic nanoparticles, polyester-based nanoparticles, nanostructured lipid carriers lipid-based nanoparticles, liposomes, nanoemulsions, micelles, and nano complexes exhibit significant advantages in enhancement of brain delivery of intranasally administrated drugs. Nanoparticles with antibodies on the surface have the capability to cross the brain barrier and also provide neuroprotection.

Conclusion

Nasal drug delivery systems is a new technology for pain management, since solid dosage forms like tablets, capsules, gels were commonly used for pain management, transdermal drug delivery systems like transdermal patches was one of the best treatment for managing pain. Transdermal patches are available via the skin into cutaneous and subcutaneous tissues through the semi-permeable membranes into the systemic circulation enhanced permeability increases the efficacy of the drug through these passages. Nanoparticles play a crucial role in delivering the drug to the targeted site of action through many routes like oral, systemic, parenteral, and other routes. Researchers are still working on testing this method for delivery of short-acting but strong pain relievers since pain relievers are rapidly absorbed through the nasal route. Relieving pain through nasal route is an alternative therapy to reduce the side effects increase the potency efficacy and safety using herbal remedies and improve the technology by using new methods to overcome the difficulties in formulating finished products.

References

1. Mills SEE1, Nicolson KP2, Smith BH Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth. 2019 Aug;123(2):e273-e283..
2. María Dueñas,1 Begoña Ojeda,2 Alejandro Salazar,2 Juan Antonio Mico,3 and Inmaculada Failde2A review of chronic pain impact on patients, their social environment and the health care systemJ Pain Res. 2016; 9: 457–467.
3. Krishnan V. Chakravarthy, MD, PhD,*,† Frank J. Boehm,‡ and Paul J. Christo, MD, MBA
4. Nanotechnology: A Promising New Paradigm for the Control of Pain Pain Medicine 2018; 19: 232–243
5. Siavash Beiranvand &Mohamad Masud Sorori Pain management using nanotechnology approaches Artificial Cells, Nanomedicine, and Biotechnology Volume 47, 2019 – Issue 1 Pages 462-468

Abstract

• Introduction: The research understudy aspires to examine and explore the behaviours, views, and experiences of older people in the Scottish Highlands in the management of chronic pain. Precisely, the researcher intends to explore the severity and type of chronic pain as well as its management regimens, evident safety and efficacy, identify issues relating to regimens of chronic pain management and concomitant information in order to identify ways in which management of chronic pain can be improved.
• Methods: The research understudy has collected data via interviews. For this study, qualitative data was collected through interviewing target size predetermined to be around 40 participants.
• Result: The results depict that out of 12, total of 10 (83.3%) participants, who were experiencing a chronic pain took part in the study. The chronic pain management involves pharmacological and non-pharmacological approaches. Similarly, the influences of chronic pain management can include easiness, ability to manage pain and health management. The suggestions being received for services enhancement are making it more local and improving accessibility.
• Discussion: The overall findings of this study depicted that the behaviours, views, and experiences of older people in the Scottish Highlands in the management of chronic pain can vary based on multiple factors. It can be argued that chronic pain is common because majority elderly report pain of moderate or greater intensity. Arguably, the findings are relatable because literature shows that 1 in 5 adults suffers from pain.
• Conclusion: It can be summarised that the chronic pain among elderlies is common and results in substantial morbidity. (253)

Introduction

In the past few decades or so, rural regions have witnessed a higher rise in terms of average age as compared to their urban counterparts. Going forward, the population that is aged at least 65 years is expected to grow by nearly 50% in rural and urban regions from 2016 to 2039. The population of this age group (65 years and above is 11.8 million {{85 Coates, Sarah 2019;}}. Nevertheless, some non-uniformity has been observed in the pattern associated with demographic ageing. To illustrate, the number of people whose age is more than 75 years old in many rural regions of Scotland is significantly higher as compared to the urban regions {{86 Roberts, Anne 2015;}}. When it comes to rural Scotland, it is important for the provision of older adults to address a number of important challenges, such as comparatively few service recipients spread across a wider geographical area as well as the challenges associated with enticing and sustaining specialist workforce {{88 Wilson, N 2009;}}.

Owing to the expected increase in the population of the older age group, there is expected to be a corresponding rise in chronic pain, which impacts between 10.4% and 14.3% of Scotland’s population, and is defined as pain that persists for a minimum of three months {{79 Fayaz, 2016}}. It is particularly problematic for the older people by limiting their independently and making it necessary for them to seek external support. Enhanced pain relief brings about a reactivation of the mental and physical activity of an individual. This reactivation would reduce their increased demand for healthcare and allied services while enhancing the quality of their life (5)

NHS Highland is the UK’s the largest geographical health board, encompassing almost 32 500 km 2 and accounting for 41% of Scotland’s entire land mass. However, the population is below 10% to that of Scotland’s population at 320 000. Just 25.8% of the population of Highland Council resides in urban regions (6) as compared with 69.5% of Scotland’s entire population. Many studies have examined a wide array of problems that are commonly faced concerning healthcare in rural and remote communities, such as trouble in gaining access to care; long distances; centralised healthcare services; long waiting times; high travel costs and service hours; GP relatability; resuming the care process; and utilising emergency and deterioration in health {{84 Alfaqeeh, Ghadah 2017;}}. According to Mezei & Murinson (2011), rural communities also lack access to primary care providers specialising in chronic pain management. Therefore, residents of these areas may need to solely depend on primary care providers that are quite often less equipped to tackle chronic pain management. Furthermore, these studies investigated the access of healthcare in Highland, albeit not in a focused manner. For this reason, the study aimed at examining the severity and type of chronic pain as well as its management regimens, evident safety and efficacy, identify issues relating to regimens of chronic pain management and concomitant information in order to identify ways in which management of chronic pain can be improved. (503)

Methods

This qualitative research project was conducted using individual telephone interviews as method of data generation because this approach allowed for free and open evaluation of thoughts on the part of participants, which cannot be done by using surveys {{82 Szolnoki, Gergely 2013;}}. In this study, participants aged 75 and over who lived in the Scottish Highlands as well as remote areas were targeted. The target sample size was predetermined to be 40 participants based on their availability and willingness to participate. However, only 37 participants responded to the request. All 37 participants divided into groups of students, were then asked to complete the consent form, provide their contact details and set the appropriate time for the telephone interview. Of these participants, only 10 in our group, agreed for telephonic interview. The participants who did agree were provided with the information leaflet after being reviewed by the research supervisor. This project was carried out as per the norms of the Research Governance and Research Ethics at Robert Gordon University. One of the fundamental principles of ethics is confidentiality. In fact, “Confidentiality is the assurance that any information or communication provided by the participant to the researcher would not be shared with anyone else who is not related to the study. Therefore, special codes were generated for each participant prior to contacting the participants.

In order to ensure the rigour of this study, all students were made to prepare their questions beforehand. Subsequently, these were combined and revised using the supervisor’s amendment. Finally, a list of questions was divided into five main areas of open-ended questions which were logically organised from simplest to more complicated questions. A semi-structured interview schedule, which focused on the nature as well as duration of pain, the type of the medical service provided, ways of managing pain and observing personal opinions on making improvements in the quality of services providers was focused on. One telephonic interview was conducted for each participant and a total of 10 interviews were held over a seven-day period. These interviews, which lasted between 20 and 25 minutes, were audio recorded and transcribed. Information was gathered by transcribing interviews in a Microsoft Word document to make sure that all statements made by each of these 10 participants were recorded.

Data analysis process commenced b getting familiar with the entire data set, by rereading transcripts, observing patterns in terms of language use and repetition of certain words {{83 Gibbs, Graham R 2018}}. Team meetings were subsequently held to discuss and develop data codes in order to develop themes and sub-themes. In other words, quotes from interviews were coded via a participant number. Thereafter, the researchers began searching meaningful units within all responses of the participants and then via the information gathered from all respondents. Subsequently, I began to identify new emerging themes as well as subthemes manually from the transcribed records. In addition, new codes were generated for emerging themes that were then added into a list of pre-existing codes that facilitated the development of the ultimate analytical framework, which, in turn, comprised of () codes grouped into 5 categories as per in table 2. (521)

Result

Participants’ Demographics

Out of 12, total of 10 (83.3%) participants, who were experiencing a chronic pain took part in the study. Among these participants, five were accounted for by males whereas the remaining five were comprised by women. As evidenced in Table 1, each participant was assigned a separate code along with deprivation category, urban and rural class cation, gender, age and ethnicity. The ethnicity of all participants was white and the average age of male participants was higher than their female counterparts. It is revealing that participant codes N29, N35, N30, N31 and N44 had the least favourable deprivation category, which has a clear relationship with their age and area of their location. This is not surprising because as mentioned above, chronic pain management in rural areas is less than satisfactory.