Biobehavioral Measures for Pain in the Pediatric Patient

Pain is a complex biobehavioral phenomenon. The quantification of pain involves the incorporation of many factors, including physiologic, behavioral, and psychologic factors. Recognition of pain relies heavily on the expression of the patient as well as the interpretation of the caregiver. There are many studies published on biobehavioral pain assessment tools, such as neuroimaging, neuromuscular, biomarker, and behavioral pain assessment scales. These tools present a clinical challenge to appropriately assess and manage pain in the noncommunicative pediatric patients, such as infants, preverbal toddlers, and intubated and/or unconscious or cognitively impaired patients. Pain is a combination of physiologic, behavioral, and psychologic interactions. Any tool that incorporates the measurement of only one of those domains is inherently incomplete in the assessment of pain. Therefore, the purpose of this literature review was to provide a comprehensive overview of these biobehavioral pain assessment tools used in pain assessment in the noncommunicative pediatric population.     

A Biopsychosocial-Spiritual Model of Chronic Pain in Adults with Sickle Cell Disease

Chronic pain in adults with sickle cell disease (SCD) is a complex multidimensional experience that includes biologic, psychologic, sociologic, and spiritual factors. To date, three models of pain associated with SCD (i.e., biomedical model, biopsychosocial model for SCD pain, and Health Beliefs Model) have been published. The biopsychosocial multidimensional approach to chronic pain developed by Turk and Gatchel is a widely used model of chronic pain. However, this model has not been applied to chronic pain associated with SCD. In addition, a spiritual/religious dimension is not included in this model. Because spirituality/religion is central to persons affected by SCD, that dimension needs to be added to any model of chronic pain in adults with SCD. In fact, data from one study suggest that spirituality/religiosity is associated with decreased pain intensity in adults with chronic pain from SCD. A biopsychosocial-spiritual model is proposed for adults with chronic pain from SCD, because it embraces the whole person. This model includes the biologic, psychologic, sociologic, and spiritual factors relevant to adults with SCD based on past and current research. The purpose of this paper is to describe an adaptation of Turk and Gatchel’s model of chronic pain for adults with SCD and to summarize research findings that support each component of the revised model (i.e., biologic, psychologic, sociologic, spiritual). The paper concludes with a discussion of implications for the use of this model in research.     

Spinal cord injury pain: the influence of psychologic factors and impact on quality of life

OBJECTIVES: To examine chronic pain prevalence in a spinal cord injury (SCI) population, and to determine the influence of psychologic factors on SCI pain and impact of SCI pain on quality of life. METHODS: Five hundred seventy-five persons with SCI were asked to participate in the study. Demographic, SCI, and pain characteristics were obtained. The Chronic Pain Grade, anger items of the Profile of Mood States, Illness Cognition Questionnaire, Pain Coping and Cognition List, and Patient Health Questionnaire were used. General health and well-being were assessed with 0-10 scales. The influence of psychologic factors was assessed with regression analyses controlling for person and injury characteristics and pain intensity. RESULTS: Response rate was 49%. SCI pain prevalence was high (77.1%). More internal pain control and coping, less catastrophizing, higher level of lesion, and nontraumatic SCI cause were associated with less pain intensity. More pain was associated with higher pain-related disability. Lower catastrophizing was related to better health. Less SCI helplessness and catastrophizing, greater SCI acceptance and lower anger levels were related to higher well-being. Higher levels of SCI helplessness, catastrophizing, and anger were related to higher depression levels. Pain intensity showed no independent relationships with health, well-being, and depression in the regression analyses. DISCUSSION: Chronic SCI pain and quality of life were both largely associated with several psychologic factors of which pain catastrophizing and SCI helplessness were most important. Psychologic intervention programs may be useful for persons suffering from chronic SCI pain to improve their quality of life.     

Jayne's story: healing touch as a complementary treatment for trauma recovery

Healing touch has potential as a complementary therapeutic option for trauma recovery. Healing touch and its predecessor, therapeutic touch, effectively and holistically improve physiologic and psychologic complaints, health perception, and well-being. Support for the incorporation of healing touch therapy in the recovery regime of individuals recuperating from trauma is suggested.     

Chronic Neuropathic Pain in Women After Breast Cancer Treatment

Chronic neuropathic pain affects between 20% and 50% of women after their breast cancer treatment. The Human Response to Illness (HRTI) model provides a comprehensive theoretic framework to guide the assessment and management of this pain in women with breast cancer. Knowledge of the physiologic, pathophysiologic, behavioral, and experiential perspectives, as well as personal and environmental factors, will assist nurses and other health care professionals to develop better assessment tools and improve interventions and treatment modalities. This will provide guidance for nursing practice, education, and research and ultimately improve the quality of life, optimize outcomes, and reduce the incidence of chronic neuropathic pain in the breast cancer population.     

Pain Management for Older Persons Living in Nursing Homes: A Pilot Study

Because the prevalence of chronic pain among the elderly in nursing homes is high and decreases their quality of life, effective nonpharmacologic pain management should be promoted. The purpose of this quasiexperimental pretest and posttest control design was to enhance pain management in nursing homes via an integrated pain management program (IPMP) for staff and residents. Nursing staff and residents from the experimental nursing home were invited to join the 8-week IPMP, whereas staff and residents from the control nursing home did not receive the IPMP. Baseline data were collected from nursing staff and residents in both groups before and after the IPMP. The IPMP consisted of eight lectures on pain assessment, drug knowledge,and nondrug strategies for the nursing staff, and 8 weeks of activities, including gardening therapy and physiotherapy exercise, for the residents. There were 48 and 42 older people in the experimental and control groups, respectively. No significant differences were found in their educational level, sleep quality, bowel habits, past and present health conditions, pain conditions and psychologic well-being parameters (p > .05) at baseline. After the IPMP, the experimental nursing staff showed a significant improvement in their knowledge of and attitudes to pain management (p < .05), and the experimental residents reported significantly lower pain scores and used more nondrug strategies for pain relief compared with the control group (p < .05). Moreover, the psychologic well-being parameters, including happiness, loneliness, life satisfaction, and geriatric depression, had significantly improved among the experimental residents (p < .05). The IPMP was effective in enhancing the knowledge and attitudes of nursing staff, as well as reducing pain conditions and enhancing psychologic well-being for older persons in nursing homes.     

Biological mechanisms related to the effectiveness of guided imagery for chronic pain

Specific aims of this pilot study were to (a) determine the effect of a guided imagery (GI) intervention over an 8-week period on pain and pain disability in a sample of persons with chronic noncancer pain (CNCP) and (b) analyze the mediating effects of neuroendocrine and neuroimmune functioning on the effectiveness of GI on outcome variables. A simple interrupted time-series design (12-week period) was used. GI was introduced at Week 4 and used daily by 25 participants for the remaining 8 weeks. Measures of pain and pain disability were obtained at the beginning of the study period and at six repeated 2-week intervals. Measures of hypothalamic-pituitary-adrenal (HPA) axis activation (plasma cortisol), immune-mediated analgesia (lymphocyte subset counts and proliferation), and immune-mediated hyperalgesia (interleukin-1β) were obtained at the beginning of the study and at Week 11. Usual pain levels were lower after the introduction of GI at Week 4 (Wilks' λ = 52.31; df = 2, 22; p = .000). Pain disability levels were lower after the introduction of GI at Week 4 (Wilks' λ = 5.98; df = 6, 18; p = .001). Correlation coefficients between change scores of dependent variables and mediating variables were not significant. GI was effective in reducing pain intensity and pain disability over an 8-week period; however, the results did not support the expected effects of decreased HPA axis activation, improved immune-mediated analgesia, and reduced immune-mediated hyperalgesia in mediating these outcomes. These findings may be related to procedural and theoretical issues and limitations related to the study design.     

Caring for Special Populations: Total Pain Theory in Advanced Heart Failure: Applications to Research and Practice

TOPIC.  Total pain theory.
PURPOSE.  Describe total pain theory and apply it to research and practice in advanced heart failure (HF).
SOURCE OF INFORMATION.  Total pain theory provides a holistic perspective for improving care, especially at the end of life. In advanced HF, multiple domains of well-being known to influence pain perception are adversely affected by declining health and increasing frailty. A conceptual framework is suggested which addresses domains of well-being identified by total pain theory.
CONCLUSION.  By applying total pain theory, providers may be more effective in mitigating the suffering of individuals with progressive, life-limiting diseases.     

Pain in multiple sclerosis: a biopsychosocial perspective

Clinically significant pain has been found in as many as 65% of persons diagnosed with multiple sclerosis (MS). Acute pain conditions include trigeminal neuralgia, painful optic neuritis, and Lhermitte's syndrome. Chronic pain conditions such as dysesthesias in the limbs, joint pain, and other musculoskeletal or mechanical pain problems develop as a function of spasticity and deconditioning associated with MS. These painful conditions may respond to pharmacological, surgical, rehabilitation, and psychological interventions. However, unresolved pain, associated disability, and affective distress are common. In addition, efforts to manage MS and its associated symptoms, for example, may inadvertently cause osteoporosis and headache or other symptoms that may exacerbate pain and pain-related disability. Conversely, efforts to manage pain may have negative effects on the symptoms of MS (e.g., increased fatigue). A multidimensional approach to assessment and management that is guided by a comprehensive biopsychosocial model is recommended. Such an approach needs to consider the exacerbating nature of MS, MS-related pain, and interventions aimed at their management. Suggestions for future research on MS-related pain conclude the article.     

Toward a Theoretical Model for Mindfulness-Based Pain Management

Mindfulness, as both a process and a practice, has received substantial research attention across a range of health conditions, including chronic pain. Previously proposed mechanisms underlying the potential health-related benefits of mindfulness and mindfulness-based interventions (MBIs) are based on a strong theoretical background. However, to date, an empirically grounded, integrated theoretical model of the mechanisms of MBIs within the context of chronic pain has yet to be proposed. This is a surprising gap in the literature given the exponential growth of studies reporting on the benefits of MBIs for heterogeneous chronic pain conditions. Moreover, given the importance of determining how, and for whom, psychological interventions for pain management are effective, it is imperative that this gap in the literature be addressed. The overarching aim of the current theoretical paper was to propose an initial integrated, theoretically driven, and empirically based model of the mechanisms of MBIs for chronic pain management. Theoretical and research implications of the model are discussed. The theoretical considerations proposed herein can be used to help organize and guide future research that will identify the mechanisms underlying the benefits of mindfulness-based treatments, and perhaps psychosocial treatments more broadly, for chronic pain management.PerspectiveThis focus article presents an initial framework for an empirically based, theoretical model of the mechanisms of MBIs for chronic pain management. Implications of the framework for refining theory and for future research are addressed.     

Selected Nonpharmacological Therapies for Chronic Pain: The Therapeutic Use of the Placebo Effect

Chronic pain is a common problem requiring a multidisciplinary approach. Nursing can offer diverse therapies complementary to the medical-surgical approach. Guidelines for practice and challenges for research are outlined for selected nonpharmacological chronic pain therapies. This article discusses the placebo effect, which is common to all therapies. Placebos can therapeutically empower patients to stimulate their psychophysiologic self-regulation abilities. Effects, theories, ethics, and therapeutic methods of stimulating the placebo effect are explored.     

Relaxation and Imagery for Chronic,Nonmalignant Pain: Effects on Pain Symptoms,Quality of Life,and Mental Health

Nonpharmacologic treatments are being increasingly adopted as alternative or primary approaches to chronic pain management. We present results of a pilot study examining the effect of a 6-week combined abbreviated progressive relaxation technique (APRT) and guided imagery (GI) intervention for the management of chronic pain (N = 19) and, using power analysis, explore recommended sample sizes for future clinical trials. Results indicated consistent and clinically significant trends of improvement on pain (McGill Pain Questionnaire, visual analog scale), mental health (Depression Anxiety and Stress Scale), all domains of quality of life (RAND-36 Health Survey), and sleep for the treatment group only. Owing to inadequate power in this study, these results were not statistically significant. Methodologic concerns, along with suggestions for an improved intervention protocol, are discussed. It is concluded that there is strong preliminary evidence for the efficacy of APRT and GI as an adjunct to conventional treatment options for chronic pain.     

Healing touch: applications in the acute care setting

Nursing has been dedicated throughout its history to addressing the physical, psychologic, and spiritual aspects of the patient that influence the healing process. Current nursing practice in acute care is focused increasingly on monitoring equipment, giving medications, and administering medical treatments in a fast-paced environment that affords few opportunities for the deeper human connectedness between the nurse and the one who is ill and suffering. Healing touch (HT) is an energy-based complementary therapy fostering that nurse-patient connection. Nurses are beginning to use HT with their patients to assist in easing pain and anxiety, promote relaxation, accelerate wound healing, diminish depression, and increase a patient's sense of well-being. This article reports a conceptual framework for use of HT in acute care settings, describes specific HT techniques, and reviews numerous studies that have reported positive outcomes of HT as a noninvasive complementary therapy.     

Psychologic Aspects of Pain

Suggestion, placebos, and hypnosis can be dramatically effective in breaking up patterns of suffering, thus decreasing some kinds of pain from unbearable to bearable levels. When a pain problem originates from or is complicated by psychologic factors and traditional therapies are unsuccessful, the best alternative is often psychologic counseling.     

Complementary and Alternative Medicine for Pain: An Evidence-based Review

Pain is one of the most prevalent conditions for which patients seek medical attention. Additionally, the number of patients who utilize complementary and alternative medicine as a treatment of pain either in lieu of, or concurrent with, standard conventional treatments continues to grow. While research into the mechanisms, side effect profiles, and efficacies of these alternative therapies has increased in recent years, much more remains unknown and untested. Herein, we review the literature on complementary and alternative medicine for pain, with particular emphasis on evidence-based assessments pertinent to the most common alternative therapies, including acupuncture, herbal therapy, massage therapy, hypnosis, tai chi, and biofeedback.     

Biofield therapies and cancer pain

The public and healthcare professionals have become increasingly aware and accepting of the benefit in physical, psychological, social, and spiritual support for patients with cancer. Patients with cancer often seek nonpharmacologic interventions to complement conventional care and decrease the pain associated with cancer and its treatment. Most often referred to as complementary and alternative medicine (CAM), these supportive therapies consist of a heterogeneous group of modalities used as adjuncts to allopathic health care. Biofield therapies are CAM modalities that involve the direction of healing energy through the hands to facilitate well-being by modifying the energy field of the body. This critical review of studies of biofield therapies emphasizes research using these modalities to decrease pain in patients with cancer. Although the therapies have demonstrated clinical efficacy, additional research is warranted. Oncology nurses should familiarize themselves with biofield therapies so they can offer informed recommendations to patients with cancer experiencing pain.     

Effective Treatments for Pain in the Older Patient

By 2050, the number of older persons across the globe will exceed the number of younger people for the first time in history. Chronic conditions, especially pain, will rise in prevalence as the population ages. Controlling pain in this unique subset of the population demands careful attention to pharmacokinetic and pharmacodynamic factors and their specific impact on pharmacotherapies, relevant complementary and alternative medicine therapies, and interventional strategies.