Category: Pain

Introduction

Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (12). Neuropathic pain is solely linked to damaged nerve or the nervous system. Similarly, Nociceptive is often an acute pain caused by a physical pressure or an inflammation which is detected by a nociceptor. Chronic pain can be perceived as a disease itself as it is an amalgam of nociceptive pains (such as visceral, somatic and chemical) and psychogenic pain that triggers or develops to a be persistent chronic pain. Hence it is pragmatic to acknowledge the strong correlation between nociceptive, psychogenic to chronic pain as one might trigger the other. It is also better to acknowledge and accept that some widespread, unidentifiable chronic pain is caused and generated by the central nervous system.

Moreover, assessing chronic pain has been a challenge and almost philosophical to scientist, pain researchers, patients and the public. This is because it is much easier to assess chronic pain as an output caused by a stimulus or an injury which is externally controlled by the peripheral nervous system. It becomes strenuous to peruse and denominate a cause to chronic pain that does not stem from damaged tissue nor a physical injury. Consequently, our study comprises of healthy subjects wearing a virtual reality headset responding to videos of a patients who show a visible chronic pain; as well as having a patient with chronic pain responding to healthy subject reaction or exposure to them. This allows us to explore and correlate the activation of the pain matrix in a health subject to a person experiencing chronic pain such as Fibromyalgia and arthritis. Both of these chronic pains are neither neuropathic nor nociceptive which makes them useful in exploring their potential causes. This is also useful in showing the foundation of chronic pain and its stimulation in the brain from the early stage, hence design treatment which reverses this brain stimulation.

The virtual reality headset has been used previously to reduce the level of pain on patients with acute pain (13). However, with my investigation I would like to deviate from attenuating acute pain to chronic pain. I would like to explore the effectiveness of using VR on patients with chronic pain and the possibility of reversing the brain stimulation of pain in them. Using VR is widely viable in various regions of the world, and could be used in various hospitals as a cheap effective method for pain management. This addresses the economic concerns of the study and its overall implementation.

This investigation is important because chronic pain is often pervasive and undertreated due to the lack of knowledge and scientific trace of the foundation or the causation of chronic pain. This has a huge economic impact, especially when statistics show that just in the UK nearly 50% of adults experience chronic pain (1). Additionally, the NHS spends £8000 per adolescent annually and “cost-of-illness to UK society of an approximately £3840 million” per year (2). In the USA 100 million experience chronic pain mostly untreated and unrecognised medically. Therefore, the economic impact of chronic pain is phenomenally too high and undoubtably a national economic burden. This outlines the desperation and the necessity to design a disease modifying drugs which target specific cells like glial cells (3) that are endemic in triggering pain. It is important to design an investigation which is embodies scientific knowledge and propound new opportunities for treatments and medicine that cures chronic pain itself rather than its symptoms, which reduced the economic impact. Overall, this investigation should obtain results that had ecological validity but also be devoid from ethical controversy and confounds.

To continue with this idea, as an investigator, we will conduct an experiment which uses an epidemiological methodology (1) rather than clinical and laboratory approaches. This is because using epidemiology aims to consider chronic pain’s variation, exposure intensity and prevalence in a population. This is also useful because understanding chronic pain requires the elimination of mutually exclusives probability which disregards various causes to chronic pain. Leading to a study which has ecological validity.

Additionally, the use of two neuroimaging techniques increases the reliability and accuracy of the data. This is very pragmatic because pain is a complex composition which involves and impacts several networks. This might be exploited to predict the behaviour and the intensity of pain, allowing for the invention of specific targeting treatments. chronic pain such as Fibromyalgia correlates much to the phantom pain theory which concludes that the unknown cause for widespread pain must be generated from the central nervous system. Evidently the outcomes of this investigation must indicate that chronic pain must not be caused or correlate to neuropathic (damaged tissue) all the time. Therefore, the investigation outcomes should present the limitations and travesty of Cartesian model of pain perception as the only role of the brain.

The Cartesian model simply claims that the brain is solely responsible for the perception of pain hence, cannot be a cause to chronic pain (4)(5).The complexity of chronic pain has endless impacts on discovered and undiscovered body mechanism such as on the peripheral nervous system, the central nervous system, endocrine, environment, immunity, cognitive process and the respiratory system (figure1). As part of investigating team, we would like to create a study which challenges incorrect theories such as the Cartesian model as well as completing previous studies with more intense research and evidence.

Rationale

Mainly, this study is important because it proposes theories and potential evidence which could affect families, patients and the future generation’s quality of lives. As an investigator, we hope to bring a new life to patients with chronic pain. In the same way DBS was able to control motor symptoms of Parkinson’s disease which brought a new life to patients (14). We know that Chronic pain is a disease which cannot be controlled mainly due to the lack of knowledge and successful studies. With our investigation we hope to achieve and establish a similar outcome to herd immunity vaccination. This research and study also impact medical education which could set a precedent for the exponential decline for patients who experience chronic pain not just in the UK but in the world. Therefore, it is our responsibility to address and resolve the NHS economic burden and stress in dealing with chronic pain. But also develop our current, sufficient knowledge of chronic pain. Therefore, this study has a significant value to everyone as well as ours.

Aim

The purpose of this investigation is to outline that the unknown cause of the chronic pain must be generated from the nervous system through a reliable neuroimaging technique. We will use both FMRI and EEG to investigate regions of the brain which generates pain and its relation with other regions. The FMRI will be used on the patients with chronic pain which measures the blood flow, glucose metabolism and oxygen (6). Typically, an increase glucose metabolism indicates an increase brain activity as active neurons require oxygenated blood. This oxygenated blood will be disproportional in parts of the brain according to the location of pain which will require more energy to activate and fire neurons (6). This shows the pain matrix of the patient and the origination of pain which will reveal the causes of pain. Similarly, the EGG will be conducted on healthy subjects which should show a change of pattern in order to indicate that the causes of chronic pain is due to the central nervous system networks. This is because if we can turn on and off pain, surely, its stimulation must be originated from the central nervous system.

Method hypothesis and null hypothesis

There is a difference in brain stimulation in the health subject and the patient with chronic pain. Also, the patient with chronic pain must temporarily experience no or less pain. The positive outcomes of this investigation should allow us to visually see a stimulation in brain activity from health person at rest and when they are exposed though the virtually reality headset to patients expressing their chronic pain. This is acquired through the EEG exceptional time resolution which records the magnetic potential of activated neurones before and after the exposure. This should assimilate to the phantom pain explanation, in the sense that the health subject that has no association with no chronic pain stills experiences or feels (maybe be with different intensity) the same located pain when exposed to a patient with chronic pain. This would enforce the hypothesis with evidence that the nervous system is not only responsible for deciphering and perceiving pain but it is also a complex almost with its own entity network which can generate pain without a stimulus nor a damaged tissue.

The null hypothesis of this investigation would be that there is no difference in brain stimulation in the health subject hence the lack of sensory nervous system pain generation. This might assimilate to the Cartesian model which outlines that pain is either caused by a stimulus, damaged tissue or the peripheral nervous system. Hence, the negative outcomes of the investigation will indicate that the health subject will not react to the exposure of patients with chronic pain

Participant

The participant will be health subjects and patients with chronic pain, aged from 20 to 40 years old. This is due to the fact that brain plasticity is affected by aging (8), so it is difficult to discern whether the obtained results is exclusively due to the independent variable or to health subjects being to old. Also, the sensitivity and age restriction from the age of 18 and under might limit and misrepresent the results as it alienated a large section of society. Especially when 20% to 35% of children experience chronic pain (9). Moreover, the number of participants will be 60 in total in different age groups: 30 health subjects and 30 patients who experience different chronic pain including fibromyalgia and arthritis; each evenly distributed male and female. All participant must have had a minimum of 4 hours sleep, a meal, no intake of antidepressant 24 hours before. This is to ensure sleep deprivation and starvation does not confound the obtained data. Also, scientifically antidepressant affect the neurotransmitters (10) which affect the obtained result’s reliability and accuracy. They also must have a good eyesight to view and immerse into the virtually reality headset hence responding to their video shown.

Procedure

In my experiment, my participants will be wearing virtual reality headset where they view the experience of patients with chronic pain whilst being connected to a net of electrodes on the scalp (EEG). Externally the patients will be viewing the healthy subject’s reaction to their pain and see if their real pain in inhibited and deflected temporarily whilst being neuroimaged on an FMRI scan.

Expected outcome

This investigation should be useful in seeing what part(s) of the healthy subject brain is stimulated when it views a specific chronic pain. Additionally, the patient with chronic pain should postulate a change in their “sensory nervous system, cognition emotional aspects of pain” which might inhibit the central nervous system from generating pain or deflect and ameliorate pain (7).

Possible directions

If the hypothesis of the investigation equated to the obtained positive results, as an investigator we would carry a series of FMRI on a varied of patients with chronic pain and measure and record the average brain plasticity over a period of time. This will help us to merge the brain plasticity set of results and brain stimulation of a healthy person to create medicine and treatment.

If the null hypothesis of the investigation equated to the obtained negative results. As an investigator this might implore us to carry another investigation which focuses on chronic pain transitions hence pinpoint the starting point. Also, by using SMRI it will help us see and explore how brain plasticity changes with patients with chronic pain, indicating the transition stage.

Ethical consideration

The ethical consideration includes the rights of withdrawal because the health subject might view this investigation as an emotional burden surpassing the tolerance limit. Therefore, it is important to allow healthy subjects and patients to withdraw if it impacts their well beings. Neuroimaging precipitants from different age groups, gender and social life will although be a useful non-invasive it requires steadiness and patience for a maximum of an hour. This is because of the high sensitivity of FMRI and EEG which might impact the obtained results reducing its accuracy.

Additionally, the rights of anonymity will be taking into account and implemented in my investigation. The guidelines of any scientific experiment and investigation (11) is as follows written consent which comprises the nature and the purpose of the investigation the possible risks and future utilisation of the obtained data. This is important because the science of pain is limited and stagnated. Mainly because the term “human experimentation” is dissented in society. Hence reducing the likelihood of pain management which is achieved through experimentations, logical error and deviation from the Cartesian model for unidentifiable causes (3). Therefore, the lack of participant and assessment of patient who experience chronic pain has limited and impeded our understanding of pain.

Conclusion

In conclusion, chronic pain is a multidimensional disease which have many causes both known and unknown. The unknown causes tend to perplex pain scientist which leads to them being classified as idiopathic pain with no treatment (11). our study aims to explore a health subject exposed to chronic patient and a chronic patient exposed to the health subject’s reaction encountering their disease. This study might illustrate brain regions of the health subject being stimulated such as the sensory nervous system. As well as outlining that severity of the chronic pain can decline and ameliorate because if pain can be generated by something as complex as the nervous system it could also control its intensity and suspend it. The number of participants will 60 in total will the same number of females and males but a range of age groups. This is useful in addressing different structure in the whole population. Additionally, The FMRI and the EEG combined will produce a high spatial and temporal resolution which records where active neurons are firing to and originating from. This helps use to produce medicine which can deflect the active neurons from contacting other brain regions which leads to more pain in more regions of the body. As well as stop active neurones from originating themselves.

Reference

1. “Nature of epidemiology”. 13,12,2018. https://www.sciencedirect.com/sdfe/pdf/download/eid/3-s2.0-B9780120887705500484/first-page-pdf
2. Wyatt Redd. 13,12,2018. “Is fibromyalgia a form neuropathic pain or not”. https://www.redorbit.com/neuropathic-pain/
3. Duke university. 13,12,2018. “Is chronic pain gilopathy”. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3858488/ (3)
4. Arne May. 14,12,2018. “Chronic pain may change the structure of the brain” https://www.researchgate.net/figure/Different-levels-of-plasticity-in-chronic-pain-Neuroplastic-changes-change-in-function_fig1_5441677
5. “Specificity to Gate-Control Theory of Pain”. 14,12,2018. https://www.massagefitnessmag.com/whats-the-news/bridging-descartes-to-melzack-and-wall-specificity-to-gate-control-theory-of-pain

This paper will talk about a very important and complex concept, this concept is pain. Pain is a universal concept and common human experience in most of the disciplines especially, nursing discipline. In nursing life and practice, pain one of the most experienced and expressed phenomena by patients. This paper aims to extend the understanding of the concept of pain, to clarify pain concept from its different aspects and to determine its uses, attributes, antecedents, consequences, and finally introduces a real case that represents a model of this concept. This paper follows Walker and Avant criteria (2010) and based on literature from many nursing and other resources. The conclusion as a result for this paper, pain has been identified as a serious problem by both patients and health care providers especially nurses, also nursing studies and literature identified and mentioned the consequences of unrelieved pain, so it’s important to understand the concept of pain in its all aspects and to know that learning about how to relief pain is very important and seems to be an ongoing and multidimensional process, in the way of improving the physical, emotional, and psychological health for patients.

Introduction

“From the brain alone arise our pleasures, laughter, and jests, as well as our sorrows, pain, and grief”.(“Hippocrates quote: Men ought to know that from the brain and from…,” n.d.). The term “pain” as mentioned by Hippocrates perceived by brain, its complex sensorineural concept, has many definitions, and has been widely used in nursing and other human disciplines for many years.

Pain is multidimensional concept, it’s important to be addressed and analyzed, also its important to put in mind that the pain experience is so individualized and highly variable from person to another, so the aim of this concept analysis to understand the pain concept in its all aspects to be all nurses and healthcare providers able to face the challenges during treating the patients pain, so to identify the major characteristics, and attributes of pain.

This analysis will be based on Walker and Avant criteria (2010) and also based on looking thoroughly in the literature, talking about definitions, attributes, antecedents, and consequences, all of that will be explained in details. Finally a model case will mentioned to reflect the term on the real world to articulate and recognize a complete understanding of the concept.

The concept “Pain” definitions and uses

According to the International Association for the Study of Pain (IASP) in 1979, it put a clear definition of pain “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in term of such damage”.(“IASP’s Proposed New Definition of Pain Released for Comment – IASP,” n.d.; Treede, 2018). Also, in 1996 the American Pain Society (APS) defined pain as “Pain as the 5th vital sign”.(Levy, Sturgess, & Mills, 2018).

According to the Medical Dictionary, pain is an uncomfortable feeling occurring as a result of disease or injury usually it’s localized in some parts of body.(“Pain | definition of pain by Medical dictionary,” n.d.). Pain is translated to the brain by sensory neurons system, and is not just a sensation or physical awareness, but it also includes the perception and the subjective interpretation of discomfort, the perception give the information and the characteristics of the pain; location, intensity, nature, and etc…(“Pain | Definition of Pain by Merriam-Webster,” n.d.).

Oxford English Dictionary defined pain as, one when he or she feels hurt in body or mind, suffering that the opposite of pleasure; bodily suffering, mental suffering, and grief.(“Definition The Oxford English Dictionary defines pain in several different ways | Course Hero,” n.d.).

Pain maybe localized or generalized, its complex sensation that causes mild to severe physical discomfort or emotional distress, also pain can be helpful in diagnosing a problem that needs treatment.(“Pain | MedlinePlus,” n.d.).

The world pain is derived from the Latin “Poena” meaning a penalty or punishment, it’s an abstract concept, which refers to a personal, individualized sensation of hurt, also pain acts as an important biological safety and defensive mechanism that warns people when something is wrong. It’s a private, personal, subjective, and multidimensional experience, pain intensity varies according and based on various psychological, physiological, social and cultural factors, and because pain is a private experience, it’s impossible to know accurately and precisely what someone else’s pain feels like.(“Pain management – foundation | Nursing Times,” n.d.).

According to McCaffery`s (1968) pain definition, “Pain is whatever the experiencing person says of is and occurs whenever the experiencing person says if does”.(McCaffery, 1968; “Remembering Margo McCaffery’s Contributions to Pain Management | ONS Voice,” n.d.). The North American Nursing Diagnosis Association (NANDA) defined pain in which an individual experiences discomfort or an uncomfortable sensation, the documenting and reporting of pain can be by verbal communication or by encoded features.(Hanoch Kumar & Elavarasi, 2016; “Welcome to NANDA International | Defining the Knowledge of Nursing,” n.d.).

According to psychology, pain is not just on physical aspect, it also can be emotional, emotional pain result because of disappointment in expectations or relationships, needs to be acknowledged and to deal with it, failure to do that can result in emotional problems and serious mental issues and consequences.(“Pain definition | Psychology Glossary | alleydog.com,” n.d.). Pain identifies who the people are, explains how life is really work, is always a precursor to significant change and to bring maturity and responsibility, athletes and mature persons believe that when no pain, there is no gain. Pain is Gods instrument to produce strength, to learn, grow, and improve, pain is essential to avoid any bad behaviors, and of course pain reminds persons that they need help and need a team, brings all people together because it is main part of everyone story, that is no one is immune.(“15 Benefits Of Pain | Brian Dodd on Leadership,” n.d.).

Pain could be a gift from the universe, it is a massage that there is something wrong, that change some habits, thoughts, emotions, and actions must be done and it’s time to take action, and make lives more and more valuable, pain prepare people for something better in the future and trach them to appreciate anything in the past.(“6 Reasons Why Pain From The Past Is A Gift For You Today,” n.d.).

According to Christian, pain is experience that all people live it, and the natural reaction to pain is to avoid it, or get rid of it, and the importance of the need to realize that God allows pain,. In fact, suffering and pain is a sign of Gods love. Dr. Brand said, “I can tell the health of a human body by its reaction to pain, if body doesn’t react to pain, I know that something there is dreadfully wrong”.(“Pain—- a Christian Perspective | Ben Witherington,” n.d.).

The body is a healthy body when it responds to pain, on another hand if pain persist and not treated related to specific injury, illness, or something else; emotionally reasons for example, it will be hurt, and lead to serious consequences. From the perspective of Islam, “Allah has a purpose for your pain, a reason for your struggles, and a reward for your faithfulness, don’t give up”.(“Even body pain has a divine purpose,” n.d.). So finally, pain is struggler of positive and negative change, is one of the most prevalent motivator of human change and is a provoker of human deterioration.

The philosophical perspective of pain; pain and related perception is influenced by several factors, these factors are; cognitive awareness, interpretation, behavioral dispositions, as well as cultural and educational factors, pain has bodily, psychological, and sociocultural dimensions, pain has been defined as a process as a result of somatosensory perception, later on present in the brain as a mental image and followed by unpleasant feeling as well as changes in the body. Cassell defines pain not just only as a sensation but also “As an experience embedded in beliefs about causes and diseases and their consequences.”(Bueno-Gómez, 2017; Cassell, 2011).

The theoretical perspective of pain, there are four major theories talked about pain, these major theories are; specificity theory, pattern theory, psychological behavioral theory, and gate control theory, the recent one is the gate control theory.

In 1965, Ronald Melzack and Partrick Wall published this scientific theory; the Gate Control Theory; which identified that pain signals can’t reach the brain as soon as the brain generated from injured sites, they need to catch, manage, and be faced with some certain neurological gates at the spinal cord. Therefore, these gates determine if the pain signals should reach the brain or not. So if pain gates give permission to pain signals to go away, pain will perceived. Gating mechanisms can be stimulated by three techniques: cutaneous stimulation, distraction, and anxiety reduction.(Melzack, 1996).

Attributes of pain

Defining attributes is a group of characteristics that are associated with a concept, any concept analysis will contain more than one attribute.(“Walker and Avant offer seven steps for conducting a concept analysis they are,” n.d.).

There are several critical attributes associated with the concept of pain, as identified by Montes-Sandoval (1999), these attributes are:

• An unpleasant, distressful, unwanted, and uncomfortable experience.
• A neurophysiological, socio-cultural, and psychological response to a painful stimulus.
• Subjective and difficult to describe feelings that can’t truly and clearly be measured or accurately perceived by others.
• Individual, unique, and private experience serves as a protective mechanism for self-preservation.
• An adverse sensation to an actual or potential threat of physical or emotional injury or damage.
• Verbal and non-verbal communication.
• Disturbing thoughts resulting from a mental misperception.(Montes-Sandoval, 1999).

Antecedents of pain

Antecedent are the events or incidents that occur before the identify concept, these antecedents help to know further and more and more about the critical attributes of the concept of pain. (Walker & Avant, 2010).

There is many antecedents related to pain such as environmental, personal, and cultural values. Environment is related to the event that arouses pain, these events such as venipuncture, painful stimulus or hospitalization, when they occur, the individual’s body, mind, or both may be affected by these events, which causes actual or potential tissue damage. Also, the individual’s knowledge and attitude related to specific event play an important role, this knowledge and attitude such as past pain experience, may affect the expectations and acceptance of pain on individuals, and later it will affect how the individual copes with pain. (“How to Cope With Chronic Pain by Nelson Hendler M.D. (1993, Paperback, Revised) | eBay,” n.d.).

The personal components consist of, the individual current physical and emotional condition, personality, gender, and socio-economic status.

Firstly, the physical condition contain sleeping pattern, degree of muscle tension, and if the individual is capable of feeling the stimuli. Secondly, emotional condition contain stress and anxiety level, if the individual has increased stress and anxiety, the individual will feel pain more easily. According to personality, when person has a good and positive attitude toward pain he or she will tend to use good and positive methods and techniques to deal with this pain. Regarding to gender, females tend to be more sensitive toward pain and are allowed to express their pain more often than males.(“Pleasure And Pain 7 Inch UK East West 1992: So Damn Tuff: Amazon.fr: Musique,” n.d.).

From a socio-economic perspectives, individuals from different socio-economic classes, may interpret pain differently and in many ways. East (1992) notes that people who have higher socio-economic class tend to express more pain and be more aware of their pain than ones in lower socio-economic classes.

Finally, the cultural aspect of pain, according to Sheridan (1992), culture specify how people and individuals interpret, express, and live with their pain, and how to react to this pain. Therefore, pain and its perception are always culturally shaped.(Sheridan, 1992).

While understanding pf pain is influenced by culture, Zborowski (1969) confirms pain expectancy and pain acceptance to express and discuss the person`s attitude toward pain.(Zborowski, 1969).

Also, according to Montes-Sandoval, the antecedents of pain are:

• Internal or external factors appear, creating harmful and painful stimuli to the nociceptors.
• The individual physical or psychological awareness of the stimuli or discomfort.
• The harmful stimulation or aversive sensation is perceived as pain.(Montes-Sandoval, 1999).

Consequences of pain

Consequences are the events or incidents that happen as results of the concept. (Walker & Avant, 2010). These consequences of pain are; pain reaction and the person`s own interpretation of the meaning of pain.

Firstly, pain reaction is interpreted and viewed as pain behavior, pain behavior is contained two categories; voluntary and involuntary responses.(Swanson, Maruta, & Wolff, 1986). Another consequence of pain is that the individuals have their own interpretation of pain and the meaning of it, this interpretation may be in the positive or negative aspects.(“Nursing Care of the General Pediatric Surgical Patient – Google Books,” n.d.).

Ferrell (1995) described three process for obtaining the meaning of pain, including immediate causes, immediate effects, and ultimate causes.(Ferrell, 1995).

The individuals may or may not aware about the meaning of the pain experience. However, the meaning of pain experience will affect how individual interact with the environment and their relationship with others.(“Pleasure And Pain 7 Inch UK East West 1992: So Damn Tuff: Amazon.fr: Musique,” n.d.).

According to Montes-Sandoval, the consequences are:

• Person with verbal and non-verbal communication, apply neurophysical, psychological and socio-cultural responses to the perception of pain.
• Individual’s responses to the pain may or may not provide relief.
• The pain will remain the same, decrease, or increase.
• Other people will respond to the individual and provide multiple interventions in relieving or coping with the pain.(Montes-Sandoval, 1999).

Modal case of pain

A model case is an example of real life case, which reflects the use of concept critical attributes in the real world. (Walker& Avant, 2010).

Mrs. Sara, 45 years old, married, Sara has been suffering of breast cancer diagnosed three years ago and has undergo chemotherapy and radiation in that period. She is now during recovery period, three days postoperative from a mastectomy. The nurse enters the room to change her dressing, the nurse finds Sara silently crying, nurse started to console her gently, during dressing, Sara avoids eye contact, closes her eyes, turns her head away. The nurse notices that Sara is tense, grimaces, and sweating, her blood pressure and heart rate is elevated. Sara says “I’m not good, I’m very tired, I don’t know exactly what I feel, I’m worrying about what my husband is going to think, and maybe he will not want me anymore, also I’m in pain, I’m in pain”, the nurse provides pain medication, and acknowledges her loss, feelings, fear, and as well as discomfort that related of postoperative pain.

Conclusion

In summary, the concept of pain has been chosen because pain has been recognized as a serious problem for patients and health care provider, it’s helpful and beneficial to nurses and other health care provider in gaining a better understanding of the concept of pain and implementing and providing appropriate nursing interventions to relieve pain.

Pain can be defined as an unpleasant sensation and emotional experience that is generally linked to damaged tissue (IASP, 1994). This feeling of pain occurs when a signal originating at a receptor travels through nerve fibres to the brain for interpretation. The nervous system may also elicit a physical reaction to attempt to prevent further tissue damage.

The most common form of pain is that which arises from damaged tissue (nociceptive pain), however it can also be caused by damage to the nervous system itself (neuropathic pain). A final category, psychogenic pain, is experienced physically but is brought about by some psychological factor. Pain can be described by its severity, ranging from mild to moderate or even substantial. Lastly pain may be either acute or chronic, depending on its longevity, with chronic pain being generated by an ongoing condition and generally lasting a period of many months (Aspinall’s).

All mammals have the capacity to process the impact of negative stimuli on their nervous system. Therefore, it must be assumed that animals experience pain just as humans do, even if they aren’t necessarily able to perceive, understand or communicate their discomfort (MSD manual).

Although animals are not able to accurately convey feelings of pain, this does not negate the possibility of them suffering or their need for analgesia. In fact, this increases the duty of care to veterinary professionals, making it essential for the assessor to be knowledgeable in pain recognition and species-specific behaviours. A familiarity with a species’ normal behaviour makes it easier to identify when pain-induced behaviours are being exhibited. (MSD manual)

Pain varies between species but also between individuals within that species. Like humans, each animal has a different pain threshold and different requirements when it comes to analgesia. To achieve high levels of patient care, patients should be treated individually and holistically (Ambrose, 2013), considering both mental and social factors, rather than just clinical symptoms.

Pain scoring is used to quantify pain by assigning a number to the level experienced for the purpose of monitoring ongoing treatment and correctly prescribing analgesia levels. One of its main uses is the improvement of perioperative pain management and some veterinary professionals even suggest that pain should be viewed as the fourth vital sign (Michelle Richmond). There are several different systems, some adapted for use with animals, but many created specifically for veterinary purposes. Systems consider behavioural changes and patient responses to guide the user towards the calculation of a score.

One of the five freedoms of the Animals Welfare act is the freedom from pain, injury and disease, making the recognition and effective treatment of pain essential (Rutherford 2002). Accurate pain management is vital for every patient to avoid serious health implications. There are safety implications for veterinary staff too as animals in pain can be more aggressive, posing a danger if not carefully controlled.

Another useful clinical system is the application of grimace scales. This is a method of assessing the presence or severity of pain by observing a number of facial action units (FAU). The most successful application of grimace scales has involved horses, rodents and rabbits.

Main body

A common attribute among all mammalian species is the universal ability to experience pain and rabbits are clearly no exception. Unfortunately, recognising the signs of this pain can be difficult as they are a prey species and genetically predisposed to hide common indicators. This is especially true in a veterinary setting which is an unfamiliar, stressful environment. The presence of an observer can be an additional factor causing them to further normalise their behaviour.

Recognising and controlling pain in rabbits is imperative. Varga (2014) states that the effects of pain and stress in rabbits are significant as they can trigger an endocrine stress response which releases several stress hormones. This can lead to a myriad of physiological and metabolic changes which can be more dangerous than the initial cause of the pain. In extreme cases this may lead to heart failure and even death. Staff must be able to identify the existence and severity of pain so it may be correctly alleviated, helping to minimise further risk.

Recognising pain

When dealing with rabbits, pain can be easily confused with stress or anxiety, so distinguishing between the two is crucial for veterinary professionals. Physiological measurements such as temperature, heart rate and respiratory rate can be good indictors of pain in all mammalian species. However, due to a rabbit’s propensity for environmental stress, these should never be used as the sole method of identifying pain. An effective way of identifying pain in rabbits is to closely monitor and understand changes in their behaviour.

Veterinary nurses should gather as much information as possible from owners about what is considered ‘normal’ for their rabbit. However, there are some behavioural signs to look out for right across the species. A normal rabbit will spend much of its day grazing but one of the first signs of pain in rabbits is anorexia. Rabbits are generally inquisitive, active animals but a rabbit experiencing pain may lose interest in their surroundings and hide, hunched in a corner. Much of a healthy rabbit’s day is spent grooming, a behaviour that is greatly reduced in those who are suffering, often leading to a dull, unkempt coat. Other, general signs of pain in rabbits can include bruxism (teeth grinding) and the almost constant licking of painful areas.

Grimace Scales

Traditional pain scoring systems can be inadequate for an accurate assessment of pain in rabbits. However, in recent years the rabbit ‘grimace scale’ has been developed which focuses on five facial action units to accurately identify acute pain. These include orbital tightening, cheek flattening, nose shape, and whisker and ear position. Grimace scales have proven a very reliable method of recognising and assessing the severity of pain in rabbits, but this relies heavily on the user’s experience and interpretation of the different facial changes (Keating, 2012). While considered the best single method, a study by Leach et al (2011) suggests that pain scoring can’t be based on facial expression alone. One of the greatest practical impediments are the time constraints as it’s suggested that pain scale assessments should each last 5-10 minutes and be repeated every 2 hours. Grimace scales are virtually useless when dealing with chronic pain, as the animal becomes accustomed to its level of discomfort, it learns to better hide the signs in its facial expressions.

Inferred pain involves the assumed presence of pain even in the absence of any standard indicators. If a rabbit has a painful condition or has had a procedure that would be deemed painful in another species, then it should be assumed, even in with a lack of behavioural signs, that the rabbit is in pain. Despite pain being present, the animal is exhibiting normal behaviour to avoid predation. (Molly V)

Pre-emptive analgesia involves providing pain relief in the anticipation of some expected future pain. Often, in the case of a planned intervention a preoperative drug will be administered, which, when considering rabbits, makes a lot of sense (Barter, 2011; Weaver, Blaze, Linder, Andrutis, & Karas, 2010). Stress and pain can lead to serious complications, making certain that pain is accounted for, as well as reducing the environmental stress can significantly improve clinical outcomes (Molly V).

Conclusion

An essential skill of a veterinary nurse is that of pain recognition in a variety of animal species. As with all animals, every rabbit is different and may show different behaviours in different stages of pain or show no pain at all. Assessing pain is one of the most challenging aspects of a nurse’s role and pain scoring can be a useful tool in practice but shouldn’t be used alone to diagnose pain. This is largely due to the subjective nature of pain scoring, different vets and nurses may score animals differently resulting in inconsistent approaches to pain management. To negate this issue, scoring should be done regularly and by the same staff member. However, in practice, this is often impossible due to time constraints and staffing issues.

While pain scores are considered a vital part of pain management, veterinary nurses must appreciate the pain score awarded does not provide the definitive, conclusive answer to the question “is this patient in pain?”. However, pain scoring systems can help to improve standards, identify problem areas and optimise patient care (pink book). They are also key in highlighting a need for increased analgesia, which can relieve suffering, helping to meet a patient’s welfare needs.

Analysing behaviour is a vital tool in pain recognition, but it must be remembered that virtually all behaviours indicative of pain in rabbits can also be caused by stress. Some behaviours may not even be noticed in a veterinary setting, with many animals reacting completely differently to their home environment.

Overall, it’s clear that due to the nature of prey species such as rabbits and their reactions to environmental stress that a combination of methods should always be applied. Measurements such as temperature, heart rate and respiratory rate are good indictors of pain in all mammalian species. However, in the case of rabbits these should only be used to confirm a diagnosis reached using behavioural analysis, clinical symptoms and grimace scales.

INTODUCTION TO PAIN

The International Association for the Study of Pain (IASP) defines pain as a highly unpleasant physical and emotional experience related to actual or potential tissue injury (Kumar and Elavasari, 2016). Pain is very subjective and specific to every individual person. Nurses are invited by McCaffery and Beebe (1989) to recognise that ‘pain is what the patient says it is’ providing they are able to express or verbalise this.

Pain is a distressing experience that affects everybody at sometime in their life and is completely unique to each person in that everyone has a different tolerance to pain. Acute pain is short acting, with a sudden onset, and a definitive pathology, usually tissue damage and is treated easily. In contrast, chronic pain is gradual and is usually lasting more than 6 months, this pain serves no purpose and has unclear pathology and is difficult to treat (Mirchandani et al., 2011). The British Pain Society describes chronic pain as the ‘Silent Epidemic’ (The British Pain Society, 2014), with more than 8 million of the UK population suffering from chronic pain with the main complaint being back pain (Fayez et al., 2016).

Pain is often described as nociceptive or neuropathic. Nociceptive dividing into visceral pain relating to internal organ; and somatic pain relating to tissue and musculoskeletal, while neuropathic relating to central nervous system (Goudman et al., 2020).

Total Pain originates from Dame Cicely Saunders idea of a ‘whole-person’ interpretation of pain, incorporating Physical, Spiritual, Psychological and Social elements that are the key aspects of the Total Pain encounter. Taking this multidimensional approach into consideration when assessing patients can give a more accurate and adequate assessment of their pain (Dobson, 2017).

Pain is usually a protective function and is commonly in response to a disease or injury. The sensation of pain involves both peripheral tissue and the central nervous system (CNS), with the CNS controlling other responses. There are four main processes involved in the pain pathway, Transduction, Transmission, Modulation and Perception. Transduction begins when nociceptive receptors in the free nerve cells found in peripheral tissue respond to the stimulation caused by noxious stimuli such mechanical, chemical or thermal injury, their response is releasing chemical mediators (prostaglandins, bradykinin, serotonin, substance P and histamine) which ‘fire’, transmitting the pain impulses to the brain via the dorsal horn in the spinal cord. The dorsal horn being the managing centre for pain fibers (Lodhey, 2015). The pain signal is carried by two different types of fibers to the brain, A-Delta fibers; these are myelinated and carry fast signals are C-fibers; these being unmyelinated and responsible for slow pain signals. The dorsal horn in the spinal cord is the managing centre for and pain fibers enter the spinal cord via dorsal spinal roots, this is where the complex process of Perception takes place, including interpretation and expectation of the specific pain. Modulation mainly takes place in the dorsal horn and can either enable or curb pain (Briggs, 2010). The body modulates the pain experience by emitting endogenous opioids (endorphins, enkephalins and dynorphins) at the end stage of nociception, inhibiting noxious stimulus by curbing neurotransmitter such as Substance P, therefore producing a natural analgesia, known as the descending pathway. Our natural opioids can be released by doing everyday activities like exercise, sex, laughter and mediation (Swift, 2015). This type of concept was highlighted by Melzack and Wall in 1965 who introduced the Gate Control Theory suggesting that psychological factors play a role in the perception of pain. Using the concept of “gates” in the central nervous system to describe how some pain messages are allowed get through and reach the brain, while others are blocked and losing the nerve ‘gate’ to painful stimulus. Although there are many pain theories out there including Specificity, Intensity and Pattern Theory, The Gate Theory revolutionised pain management (Moayedi and Davis, 2013).

PAIN ASSESSMENT STARTEGIES

Pain is a highly subjective multifaceted experience and requires objective standards of care. Accurate pain assessment is crucial, as a suboptimal assessment can be detrimental to pain management. All pain assessments/tools must be appropriate to the individual and should be adapted to specific age, cognitive state and type of pain. Emotion (Fink et. al., 2010). There is an extensive number of pain tools available which include unidimensional and multidimensional approaches

PHARMALOGICAL AND INTERVENTIAL PAN MANAGEMENT STRATEGIES

The stagies of the WHO pain ladder

• medication- analesics and adjuvanta analgesia
• Routes of analgesia and rationale
• Interventional strategies

NON PHARMALOGICAL PAIN MANAGEMENT STARTEGIES

• Pain management programmes and members of the multidisciplinary team
• Supported self management
• Physical- physio exercise heat and col
• Psychological based interventions
• Complementary therapies.;[#

REFERENCE LIST

1. Briggs, E.. (2010). Understanding the experience and physiology of pain. Nursing Standard. 25 (3), p35-39.
2. Dobson, J.. (2017). Dame Cicely Saunders – an inspirational nursing theorist. Cancer Nursing Practice. 16 (7), p31-34.
3. Fayaz, A., Croft, P., Langford, R.M., Donaldson L.J., Jones, G.T.. (2016). Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. British Medical Journal. 6 (6), p1-12.
4. Fink, R. M., Gates, R, A., Jeffers, K. (2010). Oxford Textbook of Palliative care. 5th ed. USA: Oxford University Press. P100-153
5. Goudmanab, L., Marinazzoc, D., Van de Steenc, F., Nagelsbde, A., De Smedtbf, A., Huysmansghijk, E., Putmangh, K., Buyll, R., Ickmansijk, K., Nijsij, J., Coppietersij, I., Moensabm, M.. (2020). Fayaz, A., Croft, P., Langford, R.M., Donaldson L.J., Jones, G.T.. (2016). The influence of nociceptive and neuropathic pain states on the processing of acute electrical nociceptive stimulation: A dynamic causal modeling study . Brain Research. 1733 (0), p1-9.
6. Hanoch, K., Elavarasi, P. (2016). Definition of pain and classification of pain disorders. Journal of Advanced Clinical & Research Insights. 3 (3), p87-90.
7. Lodhey, V, A.. (2015). Pathophysiology of Pain. Journal of the Association of Pysicians of India. 2 (1), p5-7.
8. Mirchandani, A., Saleeb M., Sinatra R. (2011) Acute and Chronic Mechanisms of Pain. In: Vadivelu N., Urman R., Hines R. (eds) Essentials of Pain Management. Springer, New York, NY
9. Moayedi, M., Davis, D. K.. (2013). Theories of pain: from specificity to gate control. Journal of Neurophysiology. 109 (1), p5-12.
10. McCaffery, M., Beebe, A., 1989. Pain : clinical manual for nursing practice. C.V. Mosby, St. Louis.
11. Swift, A.. (2015). Transmission of pain signals to the brain. Nursing Times. 111 (40), p22-26.
12. The British Pain Society. (2014). The silent epidemic – chronic pain in the UK. Available: https://www.britishpainsociety.org/mediacentre/news/the-silent-epidemic-chronic-pain-in-the-uk/. [Last accessed 28th March 2018].

Pain can come in many forms such as burns and aching. Pain tolerance is the amount of pain a person can withhold. Some people describe themselves having a high or low pain tolerance. When having a high tolerance to pain, it means the person can withstand pain more. Low pain tolerance is not being able to cope with pain very well and that they are more sensitive and can feel pain more.

A research was conducted by Margaret Stuber, sherry Duncan, Lisa Libman Mintzer, Marleen Castaneda, Dorie Glover and Lonnie Zeltzer. This was a correlation study. They defined as a behavioural measure and to how long people react to the pain stimulant. (2007). There were two phases during this research. During the first phases, 37 children from the ages of 7 to 13 took part. These children were all from local schools. It started as four groups of children watched a series of short videos. After watching these, the children would rate the video from 1 to 4. By doing this, it gave the second phases more validity. Going on to the second phase, it was carries out on 18 children and adolescences from the ages of 7 to 16 (12 boys and 6 girls). They recruited these children through IRB approved flyers that described the study.

Before these children took part they had a screening done to ensure that, they had no illnesses that would affect their pain tolerance during the research. On the day each child and their parent was taken in to the laboratory and shown all the equipment and was reminding again what was going to happen, after this the child and parent were asked to complete a written consent form. During the three trials that took place the parent waited outside. Before each trial started the child was informed that the water was cold, what position they should hold their hand (palm of hand facing upwards) and that they can take their hand out at any time if becomes uncomfortable and afterwards they would warm their hand. (2007). During all the trials the child used the same hand and were recorded in seconds of how long they held their hand in the water. During the first trial, they did not watch any videos and kept their hand in the water for a maximum of 3 minutes.

Afterwards a towl warmed the child’s hand up to 5 minutes before starting the next trial, during this time the child was asked to rate the pain on the VAS scale. On the second trial the child was shown a video of 15 minutes, their laughter was recorded and was asked to rate how funny the video was. When it come to the third trial, the child was asked to pick a video they saw in the second trail, the video watched was only 3 minutes long in the third trial. The results shown found that pain tolerance increased each time over the trials, when not watching a video they found the children had lower pain tolerance than when they were watching the video while they had their hand in the water. However, they did find that there was not much of a difference made between trial 1 and 2 and that the subjective ratings did not change over the trials. There were many limitations in this study, which were that in the first trial some children could have just been laughing because other children were laughing. In the second phase, the children could have built up a tolerance for the cold water, which is why they had a higher tolerance. The sample size was very small due to it only being a piolet study this meant that there was not a big sample size for gender and that a lot of the children was from the same location which could affect the validity of the research and also they couldn’t guarantee that what the children was saying was valid.

Introduction

For centuries, animals are used to study multitudes of phenomena for furthering scientific knowledge. According to UK Home Office, 3.79 million procedures were conducted on animals for research in 2017 (Speaking of Research, 2018). These animals include mice, fish, rats, birds, dogs, among others. The use of massive number of animals in research pushed forth regulations for animal welfare. Animal welfare came a long way from public discourse of vivisection to the foundation of five freedoms. It was only on the past few decades that animal welfare started to change its perspective from the absence of disease and pain to promoting positive and natural behavior (Broom, 2011).

One of the main challenges in animal welfare is alleviating pain not only due to a lesser pharmacological armamentarium for analgesia per species but also due to the lack of an absolute effective method to assess pain among different animals. Historically, pain assessment method have been very subjective like the Visual Analog Scale (VAS). In a survey conducted by Hawkins (2002), they have concluded that although there is a basic understanding that procedures will introduce pain or suffering; each institution applied varying techniques for pain assessment and a team approach is the best way to guarantee consistency and efficiency. The great discrepancies in subjective assessment of pain have resulted to more research on objective quantification system with the use of pain behaviors (Roughan and Flecknell, 2006). Different pain assessment models have been developed in large animals mostly companion animals, cattle and horses to study pain and efficiency of intervention therapy after procedures (Gigliuto et al., 2014)

This study was done to evaluate the Visual Analog Scale in comparison to Quantitative Behavior Analysis for pain assessment in laboratory rats. It was conducted to prove the hypothesis that short-term training for objective detection and quantification of pain behavior would improve the pain severity assessment in post-operative rats among students.

Materials and Methods

The study participants were 126 master degree (MSc) students with different background experience on animal handling and behavior from 2017 to 2019. This study was conducted in Roslin Building, University of Edinburgh, Scotland.

The students were given instructions to watch 5-minute video clips. Each clip presented a rat that underwent laparotomy for surgical implantation of tumor cells in the bladder. The rats were categorized to four treatment groups: one control and three experimental groups. The control group was given saline solution (T1) 1 hour prior to procedure while the experimental groups were given a non-steroidal anti-inflammatory drug, meloxicam, of varying dosage namely 0.5mg/kg (T2), 1mg/kg (T3), 2mg/kg (T4). The study was performed in two phases with Phase 1 (Visual Analog Scale) done prior to Phase 2 (Quantitative Behavior Analysis).

In Phase 1, the participants were given a sheet that contains a 10-cm line, with 0 as no pain and 10 as severe pain, of the Visual Analog Scale. They were presented with four video clips of the rats in random order and were blinded to the treatment groups. However, they were informed that all of the animals underwent laparotomy. After watching each clip, the participant made a mark in the scale that indicated the severity of pain the rat experienced.

In Phase 2, participants underwent training as a group using video clips for detecting and noting pain behaviors in rats. The pain behaviors emphasized in these clips were back arching, falling/staggering, and twitching. This training lasted for approximately 10 minutes. Thereafter, the participants were handed a sheet with boxes to score the occurrence of each pain behavior per animal. The four video clips were shown in random order to the participants in the same manner as phase 1. They were also blinded to the treatment groups. The participants were asked to tally the number of times they saw the pain behavior for each animal and made a total score for each clip. The total score indicated the severity of pain the rat experienced in the clip.

Data analysis

Due to the different nature of the scores produced using the VAS and Behaviour quantification, direct comparison between the two scoring systems was not possible. In order to assess the relative agreement of the observers with the hypothesised pattern of pain severity, success rates for both VAS and Behavioural Quantification were calculated as the proportion of individual scores that conformed to predictions, based on Roughan and Flecknell (2006) (i.e. salineM2 and M1>M2). VAS scores and behaviour scores for these specific pairs of treatments were compared using the Wilcoxon test (two-tailed).

Results

Success rates are described in Table 1. Overall, when using VAS scores success rates were lower than when using behavioural quantification (e.g. using VAS, 61.9% of observers were able to identify a higher perceived pain level in the saline-treated rat compared to the rat given 2 mg/kg meloxicam, whilst 95.5% of observers were able to discriminate between those treatments using behavioural quantification). No statistically significant difference was identified between VAS scores obtained for the saline treatment and those for 0.5 mg/kg meloxicam (p=0.63; Table 1) and observers also failed to identify a difference between 1 and 2 mg/kg meloxicam (p=0.11). However, VAS scores for saline were significantly different than those for 2mg/kg meloxicam (p

Table 1: VAS and cumulative behaviour scores generating by MSc students (2017-2019, n=126) observing video clips of rats treated with varying levels of Meloxicam (0.5, 1, 2, mg/kg) or with saline following laparotomy.

VAS (quartiles) Behaviour (quartiles) Wilcoxon test Success Rate (%)

Treat Q1 Median Q3 Q1 Median Q3 VAS Beh. VAS Beh.

T1.

Saline 50.0 69.0 80.0 13.0 16.0 20.0 T1vs.T2

W=2869

p=0.63 T1vs.T2

W=1982 p=0.007 T1T4 =61.9 T1>T4 =95.5

T3.

M1 32.0 51.0 68.0 6.0 10.0 12.0 T3vs.T4

W=1942.5

p=0.11 T3 vs.T4

W=4173.5 p=0.002 T3>T4 =31.2 T3>T4 =76.3

T4.

M2 29.0 63.0 80.0 7.0 9.0 12.0

Figure 1: Student Behavioural Scores (Median and Inter-quartile Range, n=126) and a single expert score taken from Roughan and Flecknell (2006).

Discussion

The results of this study showed that Quantitative Behavior Analysis was more accurate than the Visual Analog Scale in the evaluation of pain. Furthermore, the short-term training in pain behaviors enabled students of varying background experiences to assess pain in these animals more effectively.

The output of this study were not directly compared to each other but rather compared to an expert opinion handed out by (Roughan and Flecknell, 2006). As indicated, this expert opinion serves as a gold standard for which the observations were compared. It is important to note that using the VAS method, observers have significantly identified (p The Visual Analog Scale is one of the most widely used subjective method for assessing pain. Nevertheless, the results vary widely among institutions, observer experience and field of study. It is a simple psychometric measurement that is widely used in human medicine to assess the effectiveness of intervention therapy and monitor chronic diseases especially in respiratory conditions (Klimek et al., 2017). However, they were highly variable when applied in veterinary practice (Welsh et al., 1993). Moreover, keeping good records of highly experienced laboratory technicians can give valuable information of the welfare of laboratory animals especially when correlated with other assessment tools (Hawkins, 2002). However, subtle differences in between experimental groups given increasing dosage of meloxicam did not differ significantly. These minimal differences would need a better-equipped personnel or a more efficient tool to evaluate pain and assess the response to therapy.

The Quantitative Behavior Analysis was introduced by (Roughan and Flecknell, 2006) for an objective behavior-based scoring system for pain evaluation. This was a product of series of studies conducted by their group in Newcastle to formulate a more efficient tool in looking at highly prevalent pain behaviors in a limited amount of time. It stemmed from the notion that the use of simpler methods will be more beneficial when considering assessments in a shorter period. In addition, detection of these predominant pain behaviors do not require extensive training and experience to be applied on a day-to-day basis. Using this method, individuals of different backgrounds can be trained in approximately 10 minutes with the use of audiovisual aids in detecting these key behaviors to improve pain assessment in rodents.

In comparison to VAS, it not only accurately identified the control group from the experimental group with the highest dose of meloxicam (p It was implicated in previous research that the major study bias was derived from the fact that the Visual Analog Scale was done prior to behavior-scoring system (Roughan and Flecknell, 2006). However, this bias cannot be addressed since training the individuals first would greatly affect the respondent’s subjective assessment. Also, the two methods cannot be carried out simultaneously by the participants. The study also address only acute post-operative period. As such, it should be interpreted for that duration only and duration of analgesic effects should be taken into account (National Research Council (US) Committee, 2009). Use of opioid analgesics may greatly alter the behavior in rodents even in healthy, pain free animals (Roughan and Flecknell, 2000). Also, behavioral changes caused by non-analgesic effect can be caused by some drugs like buprenorphine (Hayes et al., 2000). It is important to note that rats are basically prey species and would might also mask certain behaviors in response to threat

Newer studies have compared behavior-based scoring with Rodent Grimace Scale (RGS). In the study of (Klune et al., 2019), they have found out that these methods have different sensitivity and it has potential to discriminate the effects of different types of analgesic. On the other hand, (Leach et al., 2010) indicated that in assessing post-operative pain after laparotomy among rabbits, facial observations were of lesser value than behavior-based scoring. Behavior-based scoring were also adapted to the evaluation of post-operative efficacy of analgesia for surgical procedures in the orofacial region which showed consistent and efficient results in determining the relief of pain (Ramirez et al., 2015).

Conclusion

This study demonstrated that the Quantitative Behavior Analysis was more accurate than the Visual Analog Scale in assessing pain severity among post-operative rats who underwent laparotomy. Moreover, even untrained individuals can efficiently carry out this method after a short period of training for detecting pain behaviors. This method was also sensitive in discriminating between severe and moderate types of pain and response to analgesia. The method has been applied mainly in rodent research. Further studies in other laboratory animals, different surgical procedures and different analgesics would elucidate some of the limitations of this study. Improving pain assessment and proper pain intervention in laboratory animals would greatly improve animal welfare and the quality of animal research.

Introduction

Medial collateral ligament (MCL) is the most common injured ligaments in the knee accounting up to 40% of all knee injuries (Andrews et al., 2017). Its frequent in sports involving valgus knee loading such as football. Knee braces have been studied for their benefits as they can provide 20-30% greater resistance to lateral blows and ACL is further protected (Albright, Saterback and Stokes, 1995). However other studies have shown how it can decrease performance. Najibi and Albright (2005) showed knee braces can reduce straight-ahead sprint speed, cause early fatigue and increase oxygen consumption and heart rate. Big Ten Sports Medicine Committee conducted a 3-year analysis of MCL sprains amongst college football players. They found individuals who wore braces often increased injury to their fellow unbraced players and players were two times more vulnerable during practice. So, the use of bracing can prevent further injuries but also can restrict performance.

Classification

Classification of MCL injuries is based on the patient’s ability to relax and the clinician’s ability to find an end feel during knee examination. Grade 1 involves tears of few fibres and localised tenderness but no instability. Grade 2 involves localised tenderness and partially torn MCL and posterior oblique fibres and no instability. Grade 3 is a complete tear of the fibres with instability. Grade 3 is also considered as a chronic valgus instability because the MCL injury fails to heal. Avulsions (skin and tissues completely or partially torn) can lead to the MCL being trapped into the joint which can prevent healing (Chen et al., 2008).

This case study suggests the patient occurred left medial knee pain 2 days ago when they went for a tackle during football. They complained of Lock of control over knee with feeling it could away. Andrews et al., (2017) states one of the signs of MCL injury is the sensation of knee giving away. One of the positive findings are valgus stress and tenderness when palpating along the medial part of the knee. Pain, swelling and tenderness can show with 12 hours of injury (hemarthrosis- bleeding in the joints) (Phisitkul et al., (2006). Miyatomo, Bosco & Sherman, (2009) mention first-degree sprain showed tenderness over the MCL but no instability. Based on the information given it has been hypothesized that the patient has acute grade 1 MCL sprain.

Studies have shown grade 1 injuries can be treated non-operatively using exercise therapy for early range of motion (ROM), and Cryotherapy (cold therapy) during the first 24-48 hours. Phistikul et al., (2006) found ROM exercises and strength training showed high rate of return to play (RTP). Cold therapy decreases tissue blood flow and due to vasoconstriction reduces inflammation (Degrace & Thomas., 2013). The initial goal is to reduce pain and swelling.

Main body

Exercise therapy has been used for patients of all ages. It can increase function and reduce pain, improve walking, muscle strength and joint ROM (Holden et al., 2012). Phistikul et al., (2006) reviewed different treatments for MCL injuries and created a rehabilitation programme for athletes who have had collateral ligament sprains. It promoted weight bearing as tolerated using crutches as an initial treatment and active ROM exercises such as active knee flexion and extension as a subsequent treatment. Early ROM protocols improve healing and biomechanical properties of the MCL (Wijdicks et al., 2010). Chen et al., (2008) mentions a person can RTP in 20 days with grade 1 or 2 MCL injury with (Gelber & Oerelli 2018) showing earlier RTP at 11 days indicating exercise therapy is beneficial. Muller & O`Brien (2018) state PROM of 0-900 for 2 weeks and then full ROM has shown a safe ROM restriction for all ligamentous injuries. Some studies have discouraged using immobilization such as knee brace or cast because of stiffness and Miyamoto, Bosco & Sherman (2009) mentions immobilization as hinderance to ligament healing. Gelber & Pirelli (2018) mentioned immobilization techniques can be used for a short period such as crutches but doesn`t mention exactly for how long. Phusitkul et al., (2006) advices crutches can be discontinued when a person can start walking without a limp and Duffy & Miyamoto (2010) state it can be used acutely so basically its self-dependent. Chahla et al., (2017) have written a guide for RTP and state initial management should focus on improving gait abnormality and because our case study involves patient with a limp gait it`ll be beneficial to them for restoring ROM. Abnormal gait pattern occurs because of high tensile stress placed on the healing tissues which can interfere with the healing process (Paterno & Hewett, 2008). Another reason is lack of quadriceps muscle strength so the clinician should focus on strengthening this. Strength exercises can only be encouraged if knee motion is greater than 1150 and performed without any extension lag (Logan, O`Brien & LaPrade, 2016). Chahla et al., (2017) set up a 6-week programme divided into smaller phases (periodization) where reaching goals are manageable. For muscular strength single leg press and squat 12 reps, 3 sets with 90s rest in between for 3-4 sessions a week was set to improve early ROM and target quadriceps.

Hudes (2011) studied a case which was similar to our case study involving 16-year-old male football player with right medial knee pain of 2 days after been tackled during practice from left side. With similar PC (presenting condition) the patient was diagnosed with right MCL grade 1 sprain with possible meniscus tear. A 2-week rehab programme was given involving VMO (vastus medialis oblique) and wobble board exercises with progression to second week. VMO exercises involved sitting with knee bent and approximately 4 inches off the floor and then straighten leg without moving the thigh. Wobble board exercises included double and single leg balancing squats with instruction to perform 15 reps 3 times/day. After two weeks the patient reported no signs of pain unless running at full speed, but approaching third week even this was gone and the patient was able to play football with ease. Chahla et al., (2017) transitions from musclar strength to muscular power after 6-weeks using squat progression and calf raises.

Cryotherapy involves using any substance or physical medium to the body which can remove heat and decrease temperature. It’s mainly used for acute injuries, muscle spasms, inflammation, oedema and is part of R.I.C.E protocol (Malanga, Yan & Stark., 2014). Cryotherapy can reduce pain and control inflammation (Kim, Sung & Lee., 2017). Ice packs, gel packs, ice massage or ice bath are types of cryotherapy but they all have different physiological effects. Nadler, Weingand and Kruse., (2004) states ice massage cools faster than ice pack. They also found ice packs aren`t effective after 20 minutes of application whereas ice bath continuously dropped the temperature. They have stated ice packs and ice massage are effective for quick recovery such as immediate RTP whereas ice bath is effective for long-term cooling. Malanga, Yang & Stark., (2014) looked at intermittent cold therapy (10-minute ice, 10-minute room temperature) every 2 hours and suggested patients had less pain compared to standard 20-minute icing protocol. Kim, Sung & Lee., (2017) used this type of cryotherapy before patients underwent instrument-assisted mobilization.

Conclusion

Exercise therapy has shown to be very effective in restoring muscular strength and improving ROM but it’s worth mentioning these treatments aren`t effective on their own. Chahla et al., (2017) mentions the importance of patellar mobilization alongside exercise because hypermobility of the proximal end of patella can affect extensor mechanism which can reduce ROM and quadricep strength. Logan, O`Brien & LaPrade, (2016) stated deficits larger than 100 in knee flexion and extension can affect muscular strength and running speed. Therefore Chala et al., (2017) advises patellar mobilisation 3-4 times/day during first 6 weeks which is great for our patient as they lack 100 extension.

Some studies have used alternative approaches such as (Andrews et al., 2017) using NSAIDs and (Hudes.,2011) using TENs and laser therapy. NSAIDs are not bengin agemts so if taken incorrectly can result in harmful side effects (Warden., 2010). NICE guidelines recommend using Iboprufin (1200mg/day) and Paracetamol 0.5-1g/day 48 hours after injury. Having two or more NSAIDs at a time can increase risk of gastrointestinal problems (Atchhinson, Herndon & Ruise, 2013).

TENs and laser therapy have been used by (Hudes, 2011) however they seem to be non-effective and further research needs to done (Hanada,2003). Plus, laser treatment is scarce and expensive.

The effects of Cryotherapy are poor. Hawkins & Hawkins, (2016) state there isn`t any randomised clinical trials which mention decrease in temperature limits pain. The use of cryotherapy is based on a few papers and need further clarity. Use of cryotherapy instead of other treatments has been questioned because the effect on acute injuries have not been fully investigated. Therefore, it’s difficult to make any recommendations. Malanga et al., (2015) stated many studies were not blinded so were subject to bias and potential overestimation. But the guidelines remain that ice can be applied during initial 48-72 hours but after 72 hours there is little evidence for its benefit.

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15. Hudes, K. (2011). Two cases of medial knee pain involving the medial coronary ligament in adolescents treated with conservative rehabilitation therapy. Journal of the Canadian Chiropractic Association . 2 (55), p120-127.
16. Kim, J., Sung, D., Lee, J. (2017). Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. J Exerc Rehabil. 13 (1), p12-22.
17. Logan, C., O`Brien, L., LaParade, R. (2016). POST OPERATIVE REHABILITATION OF GRADE III MEDIAL COLLATERAL LIGAMENT INJURIES: EVIDENCE BASED REHABILITATION AND RETURN TO PLAY. International Journal of Sports Physical Therapy. 7 (11), p1177–1190.
18. Malanga, G., Yan, N., Stark, J.. (2014). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Journal of Postgraduate Medicine . 127 (1), p1-9.
19. Miyamoto, R., Bosco, J., Sherman, O. (2009). Treatment of Medial Collateral Ligament Injuries. Journal of the American Academy of Orthopaedic Surgeons. 17 (5), p152-159.
20. Muller, B., O`Brien, L. . (2018). Multi ligament knee injuries in athletes, is it possible to return to play? —a rehabilitation perspective. Annals of Joint. 3 (92), p1-6.
21. Nadler, S., Weingand, K., Kruse, R. (2004). The Physiologic Basis and Clinical Applications of Cryotherapy and Thermotherapy for the Pain Practitioner. Pain Physician. 7 (3), p395-399.
22. Najibi, S., Albright, J.. (2005). The Use of Knee Braces, Part 1: Prophylactic Knee Braces in Contact Sports. The American Journal of Sports Medicine. 33 (4), p602-611.
23. Paterno, M., Hewett, T. . (2008). Biomechanics of Multi-ligament Knee Injuries (MLKI) and Effects on Gait. North American Journal of Sports Physical Therapy. 3 (4), p234-241.
24. Phisitkul P, James SL, Wolf BR, Amendola A. MCL injuries of the knee: current concepts review. Iowa Orthop J. 2006;26:77–90.
25. Turner, T., Denegar, C.. (2004). Does Cryotherapy Improve Outcomes With Soft Tissue Injury?. Journal of athletic training. 39 (3), p278-279.
26. Warden, S. (2010). Prophylactic Use of NSAIDs by Athletes: A Risk/Benefit Assessment. THE PHYSICIAN AND SPORTSMEDICINE. 38 (1), p1-4.
27. Wijdicks, C., Griffith, C., Johansen, S., Engebretsen, L.. (2010). Injuries to the Medial Collateral Ligament and Associated Medial Structures of the Knee. The Journal of Bone and Joint Surgery. 92 (5), p1266-1280.

While killing someone in an attempt to defend ‘self’ is acceptable by law, mercy killing is seen as an act that is highly immoral in nature. The motive of euthanasia is to ‘aid-in-dying’ painlessly and thus should be considered positively by lawmakers.

Euthanasia should be a natural extension of a patient’s rights allowing him to decide the value of life and death. Continuing life support scheme alongside the patient’s desire is measured as immoral by law as well as medicinal beliefs. If the sufferer has the right to cease treatment, why would he not have the right to cut down his life span to flee from agony? Is not the pain of waiting for death more traumatic?

Family heirs who would misuse euthanasia as a tool for wealth inheritance do not hold true. The reason is, the relatives can withdraw life support leading to the early death of the said individual even in the absence of legalized euthanasia. Here they are not actively causing death but passively waiting for it without the patient’s consent. This is passive involuntary euthanasia that is observed approximately even without authorized hold.

Health care expenditure is and will always be a concern for the family irrespective of the euthanasia laws and only those who can afford a prolonged unproductive treatment will continue to do so. A selection of those in support of mercy killing often asked whether it is rational to keep a person- who has no hopes of survival, alive on a support method when the medicinal infrastructure by now is under enormous stress.

Here are some cons of euthanasia:

1. Mercy killing is morally incorrect and should be forbidden by law. It is homicide and murdering another human and it cannot be rationalized under any circumstances.
2. Human life deserves exceptional security and protection. Advanced medical technology has made it possible to enhance human life span and quality of life. Soothing concern and healing centers are good alternatives to aid the disabled close to demise, live an ache-free and improved life.
3. Family members would take undue advantage if euthanasia was legalized by influencing the patient’s decision into it for personal gains. Also, there is no way one can really be sure if the decision towards assisted suicide is voluntary or forced by others
4. Even doctors cannot firmly predict the period of death and whether there is the possibility of remission with advanced treatment. So, executing euthanasia would denote many illegal deaths that could have well-survived afterward. Decriminalizing euthanasia would be similar to authorizing law abusers and rising to disbelieve of patients in the direction of physicians.
5. Mercy killing would lead to the ‘slippery slope effect; which is when those who are unable to voice their desires, are put to death because of no fault of theirs’, like a baby or someone in a coma or in case of animal euthanasia. It would cause repudiation in healthiness and cause persecution of the most susceptible sections of humanity. Possibly, mercy killing would convert itself from ‘right to die’ to ‘right to kill’.
6. Moreover, all religions believe euthanasia to be an act of murder, with no one’s right to end life or be the judge of what happens next. Apart from these reasons, there is a greater possibility of euthanasia being messed up with.

Thus, morally and ethically, a medical professional has vowed to give and protect life. Taking away the life of a patient is an act, totally against the very basic principles of the medical profession. Also, the person asking for any of the acts of killing is considered to be in a state of comprised mental ability. This makes them unnecessarily ask for death to be freed from the depression and loss of freedom due to the inability to carry out physical activities.

I believe that it is better to die with dignity than to live with soreness or ache. Euthanasia is one of the diverse ways to die with dignity. In addition, organ donation is a very sacred way for a person to die. If the person is living with pain or ache and there is no possibility to save him, then he must go for medically assisted dying. In present-day society, people choose to donate their organs as a helpful gesture for the others who required them.

Conclusion And Suggestions

The issue of Euthanasia is an extremely contentious and disruptive matter, raising an array of complicated ethical, fair, societal, thoughtful, lawful, and spiritual concerns. There is two major points of view deployed alongside euthanasia. The first group is religious: many religions, notably Christians, do not recognize a right to die, believing life to be a divine gift. Christians also regard suicide as a sin.

The second group relates to the requirement of consent. The capacity of terminally- ill patients to give informed consent for their own killing is questioned. Sometimes the doctors and relatives may press people into accepting euthanasia against their will and for reasons not related to their welfare.

In the United States, Dr. Jack Kevorkian – known as ‘Dr. Death’ – successfully challenged the law on euthanasia, avoiding prosecution for conducting medically – assisted suicides die.

Pain is an adaptive, but unpleasant, sensation and emotional experience which acts as an early warning to protect the body from tissue damage; it allows the body to prevent further injury. People experience pain as signals from the stimuli are sent to the brain for interpretation via nerve fibres. Maladaptive pain is when the pain is out of proportion to the damage done to the tissues. Pain tolerance is the intensity or duration of pain that a person can bear before taking action and it is different in everybody as it increases with age, modified emotions and mental state. There are seven different types of pain: nociceptive; acute; chronic; somatic; visceral; inflammatory; neuropathic.

Nociceptive pain is activated only by harmful stimuli acting on sensory receptors. Nociceptors (pain receptors) are nerve endings that respond to a variety of stimuli that have the potential to cause damage. Nociceptor Ad and C afferent stimuli into action potentials that are conducted to the dorsal horn in the spinal cord. A reflex response occurs, causing involuntary muscle contractions. Somatic pain is a type of nociceptive pain which includes pain in skin, tissue and muscles. Somatic pain produces a persistent aching sensation, for example a bone fracture. Another form of nociceptive pain is visceral pain, which is the result of nociceptors in the thoracic, pelvic or abdominal organs being activated by a stimulus. Visceral pain is sensitive to over stretching, inflammation and ischaemia but not effected by stimuli which promote common pain such as burns or cuts. Acute pain is a sudden, sharp, prickling pain which is carried across the A fibres but not felt in deep tissues. It has a short duration and resolves itself as the tissue heals for example, touching a hot stove or a paper cut. Chronic pain is more persistent and has a slower response rate than acute pain. Chronic pain tends to last months and is associated with underlying conditions such as arthritis. Impulses from stimuli are carried by C fibres and may be burning, intense or throbbing pain that can arise in skin, deep tissues and organs. Neuropathic pain is caused by primary lesion or dysfunctions within the nervous system. Signals are sent through peripheral fibres and central neurons. It can be associated with abnormal sensations within stimuli such as allodynia and dysesthesia. Neuropathic pain can be peripheral (diabetic neuropathy, PHN, TN, scar pain) or it can be central (post stroke). Another example is phantom limb pain, which is a continuous painful sensation felt from a limb that is no longer there. Neuropathic pain is perceived differently; it can be a stabbing pain or a chronic prickling, tinging or burning sensation. Inflammatory pain is a response to the noxious stimuli that are triggered during an inflammatory or immune response. People may feel stiffness, distress and potentially intense pain during inflammation. It is associated within the deep tissues. Some mediators directly activate nociceptors for pain and others work together to produce a response of the somatosensory nervous system.

Current methods to control pain which are often used include relaxation therapy, applications of heat or cold, massages, acupuncture, stress reduction, hypnosis and exercise. Opioid receptors are activated by endorphins, which are released by neurons. Opioid receptors can also be exogenously activated via alkaloid opiates, such as morphine. Opioid analgesics bind to neuroreceptors and block the pain messages from being passed from the body to the brain. By acting at these receptors, opiates are enormously potent pain killers however, they are highly addictive. The non-opioid drugs, such as paracetamol and ibuprofen (and other NSAIDs), are predominantly appropriate for pain in musculoskeletal conditions, whereas the opioid analgesics are more suitable for moderate to severe pain, in particular visceral pain. NSAIDs reduce the production of prostaglandins, which promote inflammation, pain and fever. Cyclooxygenase (COX1 + COX2) are enzymes which produce prostaglandins. COX1 inhibition prevents gastric ulcers, bleeding and acute renal failure. COX2 inhibition reduces inflammation, pain and fever. Opioids also have proven to work in nociceptive and cancer related neuropathic pain. Tramadol is a narcotic-like pain relief medication that works by modifying the pain signals which travel from nerves to the brain. Tramadol has numerous different targets within the nervous system which each contribute to pain relief and mood-changing properties. As well as tramadol, medications used to help diabetic nerve pain include reuptake inhibitors (lamotrigine), tricyclic antidepressants (desipramine) and anticonvulsants (carbamazepine).

Inhibitory effects antidepressants have for neuropathic pain appear quicker than their antidepressant effects. This suggests that the main mechanism of antidepressants that inhibit neuropathic pain increase the noradrenaline in the spinal cord. This then acts on the locus coreleus, therefore inhibiting pain. Dopamine and 5-HT also increase in the CNS which may also enhance the inhibitory effects of noradrenaline. Anticonvulsants are extremely effective in treating diabetic neuropathy as they inhibit sodium channels and block spontaneous neural discharges. Anticonvulsants acting at voltage gated calcium channels can also treat neuropathic pain. Pregabalin and gabapentin are both from GABA however they do not have an effect on the GABAergic system. The bind to voltage gated calcium channels within the CNS, which are located on presynaptic terminals, where they can control the release of neurotransmitters.

Future therapeutics can research the importance of genes in pain, as different pain tolerances may be linked to the individual’s pain genes. Insensitivity to pain is inherited as a mutation which includes a loss of function in voltage gated channels The gene which is affected is called SCN9A and is a voltage gated sodium channel, recessive gene. Over ten new alternatives to this gene have been discovered recently which cause channel-associated insensitivity or indifference to pain. Other variations of this gene cause excessive feelings of pain. The use of CRISPR technology to ‘edit genes’ and develop human gene therapies may be an early stage and the first to undergo human clinical trials. This could be used to treat patients who suffer from chronic pain.

Introduction-

Cancer is a major public health problem in the US and many other countries of the world. It is one of the leading causes of morbidity and mortality worldwide.

Cancer is expected to the most important barrier to increasing life expectancy in the 21st century. According to estimates from the World Health Organization in 2015, cancer is the first or second leading cause of death before age 70 years in 91 of 172 countries, and it ranks third or fourth in an additional 22 countries. There will be 18.1 million new cases and 9.6 million cancer deaths worldwide in 2018. Incidence is the number of new cases occurring in a specified period and geographic area, conveyed either as an absolute number of cases per annum or as a rate per 100,000 persons per year1.

Ayurveda describes cancer as ‘Vriddhi’ or ‘Arbuda’. In this condition, the blood becomes impure due to aggravation of one or more Dosha. This impurity of the blood is actually related to subtle part of blood (Rakta Dhatu), and is not detected by physical tests. The impure blood along with aggravated Dosha circulated in the whole body and relocates in a region that has week immunity.

Due to localization of improper Rakta Dhatu, Prana reaching the cells of that particular region also becomes impure. This leads to improper cell division termed as cancer2.

Pain-

– Pain is unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain has two dimensions-

1. Unpleasant sensory (Physical)
2. Emotional experience (Psychological)

Pain is a multifaceted phenomenon that involves biological, psychological, and social consequences like as unrelieved severe pain may associated with disturbed sleep, redused appetite, irritability and depression3.

Pain In Cancer-

Pain occur in estimates indicate that 50% of patients during process and in upto 75% of patients with advanced cancer. According to the International Association of Nurse in Cancer Care, 90% of pain could be treat with standred measure4. Observational data on the incidence of cancer pain survivalance indicate that a patients experience pain at some point during their course of treatment, and that pain impairs quality of life. For many cancer patients and survivors, the occurrence of pain firstly may raise concerns about disease progression and Second, biological factors e.g., tumor progression and invasion, or related treatments, it often persists after patients are believed to be cured of their cancer. Finally, because patients and health care professionals underestimate the impact of psychological distress on cancer pain and do not consider the potential benefits of using psychological treatments to manage cancer pain. Untreated pain leads to unnecessary hospital admission, emergency visits and requests for physician-assisted suicide.

Pain is one of the most feared and burdensome symptoms in cancer patients and often has a negative impact on patients functional status and quality of life. Supported attention to pain is the first priority to established quality improvement efforts. Being diagnosed and living with a life-threatening illness such as cancer is a stressful event that may affect of an individual’s life. Pain in patients with cancer is a stressful event which can affect patients life style also cause discomfort, loss of control, fatigue, and sexual activity, loss of interpersonal relationships and the concept of life, reduced performance, sleep and daily activities in them which has a negative impact on their recovery process Evaluating the severity, characteristics, and impact of pain is the effective treatment to manage pain in cancer patients. Proper pain management may require a multidisciplinary approach5.

Relation of Psychological Distress with pain-

Researchers have conducted numerous studies showing that there is a strong association between cancer pain and psychological functioning. Some of the major findings of these studies are as follows:

• Loss of work Social & Familial
• Financial concern Spiritual state
• Physical disability & disfigurment Fear of death & Pain

These findings indicate that the cancer pain is linked to high levels of psychological distress, including higher levels of depression, anxiety, fear, and negative mood and fear of the future or pain progression. Effective relief of pain is depends upon a comprehensive assessment to identify physical, psychological, social, and spiritual aspects and multidisciplinary interventions. Healthcare providers working with cancer patients need to be alert to signs of psychological distress. Careful assessment and management of psychological distress represents an important component in cancer pain management6.

According to National Cancer Institute stress also can be lead to unhealthy behaviours, such as smocking or alcohol, that may affect cancer risk but can stress be a cause in and of itself. So along with herbal medicine patient will be treated with various unconventional therapies to control the defect in brain controlling mechanism.

Principles of Management in Ayurveda-

The living body is considered as amalgamation of earth, water, fire, air and space and they make not just the physical composition but also the mind and the soul7. So, the body as a whole includes mind, soul, behaviour and consciousness of an individual where the environment also plays a major role in making of a person. The body is combination of Sharir, Indriya, Satva, Aatma. If any of these components are imbalanced or unconnected it can cause negative effect, such as disease. Charaka Samhita states that Satva or mind, Aatma or soul and Sharira or body are just like the legs of tripod, on which the world rests8. Five elements combine with each other to give rise to three functional bio static energies(humour) of the body. These are responsible for all the physical, psychological function of body and mind.

Ayurvedic system is the first system to emphasize health as the perfect state of physical, psychological, spiritual component of Human being. It is important to maintain the strength of the patient during treatment. Cancer is not just a physical disease It is a disease of the mind and souls much as it is of the body.

The principle of Ayurveda believe that in the case of Cancer, the root cause may not necessarily be inside the body, factor could be the external factor. Cancer patients deal with various problems in different individual, family and social areas and also with the reduced life quality

Nonpharmacologic interventions are important adjuncts to treatment modalities for patients with cancer pain. A variety can be used to reduce pain and concomitant mood disturbance and increase quality of life. The experience of pain is widely accepted as a major threat to quality of life, and the relief of pain has emerged as a priority in cancer.

Shadchakras-

The word Chakra literally means as wheel or disc and a spinning sphere of energetic activity emanating from the major nerve ganglia branching of the spinal column. The Chakras are considered to be a point or nexus of biophysical energy are arranged along the spinal cord from bottom to top of the human body. The cerebrospinal system with nerve is the power supply system for the factory of the humen body and the main switch in chakras.

Chakras

Sthana

Elements

Vayu

Senses

1

Muladhara chakra

(Pelvic plexus)

Guda

Prithivi

Apana

Rasana

2

Swadhishthan chakra

(Hypogastric plexus)

Pedu

Jala

Vyana

Netra

3

Manipura chakra

(Coeliac plexus)

Nabhi

Agni

Samana

Twaka

4

Anahata chakra

(Cardiac plexus)

Hridaya

Vayu

Prana

Karna

5

Vishuddha chakra

Kanth

Akash

Udana

6

Agya chakra

Bhrumadhya

Mahattatva

7

Sahasrara chakra

Kundalini is the coiled serpent power that is supposed to be awokened through the practice of meditation. According to ancient science prana changes in consciousness, operate through the two canal of ‘ida and pingala’ in humen being9.

Intervention Of Shadchakra Healing In Purview Of Epigenetics-

Epigenetic is the study of the expression of genes without changing the sequence of the DNA or the genetic code. “Epi” word comes from the Greek word meaning over. Epigenetic (Lifestyle) is a new biological field that is exploring the Effect of the environment on cells. The environment includes one’s physical, social, and electromagnetic environment as well as confidence, awareness, lifestyle, habits, behaviors, and mind-body practices such as Pranic healing. If your environment can change your genetic expression, then it seems wise to surround yourself with a healthy environment rich in peace, love and delight rather than stress, brutality and weariness10. In Ayurveda individual prakriti roughly resembles our DNA, or our genes. According to Ayurvedic concepts Each us of is born with a unique constitutional balance and the individual constitution or Prakruti, is based on physical and psychological characteristics (Vata, Pitta, Kapha, Sattva, Raja, Tama)

In cancer survivals Radiations, Chemicals, Poor life style, Mental Stress, Oxidative stress cause disturbance the energy field (Shadchakras) and weakimmunity

• Disturbs the Prakriti (Genotype) due to disturbance of
• (Phenotype)Vata, Pitta, Kapha Satwa, Raja, Tama
• DNA mutation
• Cancer

Management Of Cancer Pain-

Radiological, chemotherapy, harmones, and surgery all used to treat and palliate cancers, Combining these treatments with pharmacological and non-pharmacological methods of pain control. Cancer treatments, such as surgery, chemotherapy, radiation therapy, cause suffering and distress that lead to impaired quality of life for cancer survivors.

Complementary and alternative medicine (CAM) is a group of medical and health care systems, practices, and products that are not currently considered to be part of conventional medicine Personal belief and appraisals, emotional reaction, coping behaviors and social contextual factor are the primary targets of psychological interventions.

A combination of pharmacologic and nonpharmacologic treatment modalities for cancer pain is the standard of care, as presented in World Health Organization guidelines.

Nonpharmacologic interventions are important adjuncts to treatment modalities for patients with cancer pain. It can be used to reduce pain and concomitant mood disturbance and increase quality of life.

In the classification of complementary medicine, energy healing class includes treatments in which the energy emanates from the human body (biofield) or is originated from an external source such as therapeutic touch, Reiki, shadchakras healing etc. (10)

These Chakras are very important for energy balance and perfect synchronization of interior and exterior rythmus or HEF (Human Energy Field) and UEF (Universal Energy Field)11.

Human beings are systems of energy and that the energy field extends a few inches beyond the skin’s surface. Shadchakras energy healing process is a standardized biofield therapy that uses in the patient’s “energy field” with the goal of restoring balance in the patient’s energy system and strengthening the patient’s “healing capacity”(35) and to reduce distress and fatigue during chemotherapy (24).

* Shadchakras energy healing process –

Scientific evidence provide tangible proof of the existence of body’s energy and its relation to the health & well being.(Article -Discovery of existence of Human energy field-Unique journal of Ayurveda and herbal medicine) Energy Healing is an important component in the treatment of cancer. stress can damage the aura, causing gaps and interrupting Prana, the life-force. Clearing balancing and energizing the subtle body facilitates in restoring health12.

Shadchakras have close relation with nervous system & collaboration with Yogic nadis Ida, Pingala & Sushumna and perform essential physical, mental and autonomus function. These nadis are tubular organ of the body like an artery or vein and medium for flow of pranic energy. Everyone practically experience various changes in the mental state like emotions, peaceful mind, excitation, remembrance etc. Due to dominance of Ida- Pingala activities. In pranic healing exercise both are equally flowing, balanced, sympathetic and parasympathetic activities is established13.

Chakras are the switches in path of energy flow, If these switches are off in normal person, they obstract the flow of energy, but when they are on, energy can ascend in susumna nadi. A normal developed and opened Chakras always spins clockwise and gains pranic energy from UEF while counterclockwise movement of a Chakras makes energy flow out which makes a Chakra closed, sick and abnormal.

The activities of the human body in the form of vayu. Pranavayu flows continuously in Ida, Pingala, and Sushumna14. The energy is situated in muladhara chakra called Kundalini shakti, it is static energy, make it kinetic by arousing with meditation and spiritual practice and ascends in opened chakras and reach to sahasrara through these following processes-

1. Activation of the chakras- Balancing and activating the chakras restores the natural healthy equilibrium of the body. divine spiritual energy run through the entire body, activating Chakras.
2. Treatment of the infection- the infection is treated from its roots. The immune system of the body is boosted. Body’s normal functioning is restored and any abnormality in the biological processes is corrected by divine spiritual energies.
3. Healing including regeneration of the cells and the damage caused by the infection or abnormality is treated. This final stage of healing oversees the complete renewal of the body’s infected systems.

Each and every cell in the body requires the right quota of its Prana to carry on its biochemical processes in an efficient way. Prana is meta-physical energy that is responsible for living activities. Prana can be described as vital energy that flows continuously inside the body and keeping us alive. It is fire of life (Jeevan Agni) that manifests in the vitality. According to Yogic texts, the energy back up required for live cellular activity is supplied from the six energy centres (Shad chakra). This Prana energy influences our Neuro-hormonal system to balance hormonal profile and regulates different physiological functions in a living body. Prana and plays a vital part in all psycho-physical processes.

Prana influence our Central nervous system by acting on subtle tasks such as perception, planning, execution, learning and memory. It increases alertness along with relaxation. Prana is stored up in the Shad-Charkas and shows a reduction in sympathetic activity, it is key management of stress related disorders.

The human aura has layers of physical, emotional, mental and spiritual elements. One aura are made up of many colours and many shades of colores that are constantly changing and change colour depending on the emotion an individual is experiencing16. If patient have detected such energy impurities in the aura of patient, they may be cleared out and removed from patient patient’s field using an shadchakras energy healing procedure known as aura clearing in the following way-

As patient lay the hands on the chakra point during the normal course of treatment- visualise the energy that is following upward through the spine, at that chakras, flowing through the chakra, the blockage in the chakras being removed.

• Pain management through spirituality: SHADCHAKRA
• Yogic healing is an ancient spiritual skill achieved by the yogis through countless years of meditation & spiritual practice.
• The concept of body according to Tantra shastra is the Atisukshma (finest) form.

Tantra shastra is the minutest and most powerful way of understanding the human body. It focuses at the finest level of creation and deals mostly at the level of the mind, which is closest to the Atman. The language and expressions of tantric textbooks are filled with symbolizations, ritualism and has numerous esoteric meanings. The five Mahabhoota, mind and soul are represented in the form of seven energy centers in the central axis of the body. The concept of Chakra have been used in the management of various disorders by means of Daivavyapasraya chikitsa and by means of various systems of sadhana. The seven Chakra respectively symbolizes the five Mahabhoota, the mind and the self, the seven levels of existence. The various letters of Sanskrit alphabet associated with the Chakra represent various frequencies of the matter energy wave which expresses itself as the world. The mastery over this is called as Mantra Shastra and the physical expression of these frequencies is known as Yantra Shastra17.

The concept of a chakra system of energy or consciousness centers exists in many forms in different indigenous systems including Egyptian, Chinese, Native American, Su, and Kabbalah. The chakras have been discussed both from religious and psycho-spiritual perspectives for several thousand years18..

Conclusion-

Ayurveda describe three modalities of treatment namely the Daivavyapasraya, Yuktivyapasraya and Satvavajaya respectively correspond to these three levels of interference into the nature of living systems. Based on this review, A statement can be made regarding the use of shadchakra healing as a non-invasive intervention for improving the health status in patients with cancer. It seems that this method can be used as a safe method in the management of physical function, pain, anxiety, depression and nausea in cancer patients and increasing a sense of well-being. those interested to the field can possibly be of great help in caring for cancer patients and reducing complications of the disease. However, further studies are needed to explore the impact of shadchakras healing on additional clinically relevant measures.