pain (pan) [Fr. peine, fr L. poena, a fine, a penalty, punishment]
As defined by the International Association for the Study of Pain, an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. Pain includes not only the perception of an uncomfortable stimulus but also the response to that perception. About half of those who seek medical help do so because of the primary complaint of pain. Acute pain occurs with an injury or illness; is often accompanied by anxiety, diaphoresis, nausea, and vital sign changes such as tachycardia or hypertension; and should end after the noxious stimulus is removed or any organ damage heals. Chronic or persistent pain is discomfort that lasts beyond the normal healing period. Pain may arise in nearly any organ system and may have different characteristics in each. Musculoskeletal pain often is exacerbated by movement and may be accompanied by joint swelling or muscle spasm. Myofascial pain is marked by trigger-point tenderness. Visceral pain often is diffuse or vaguely localized, whereas pain from the lining of body cavities often is localized precisely, very intense, and exquisitely sensitive to palpation or movement. Neuropathic (nerve) pain usually stings or burns, or may be described as numbness, tingling, or shooting sensations. Colicky pain fluctuates in intensity from severe to mild, and usually occurs in waves. Referred pain results when an injury or disease occurs in one body part but is felt in another.
Several factors influence the experience of pain. Among these are the nature of the injury or illness causing the symptom, the physical and emotional health of the patient, the acuity or chronicity of the symptom, the social milieu and/or cultural upbringing of the patient, neurochemistry, memory, personality, and other features. See: table
Many clinicians use the mnemonic “COLDER” to aid the diagnosis of painful diseases. They will ask the patient to describe the Character, Onset, Location, and Duration of their painful symptoms, as well as the features that Exacerbate or Relieve it. For example: The pain of pleurisy typically is sharp in character, acute in onset, located along the chest wall, and long-lasting; it is worsened by deep breathing or coughing and relieved by analgesics or holding still. By contrast, the pain of myocardial ischemia usually is dull or heavy, gradual in onset, and located substernally. It may be worsened by activity (but not by taking a breath or coughing) and relieved by nitroglycerin.
In 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued pain-management standards, in 2001 began surveying for compliance, and in 2004 added patient-safety goals, thus most U.S. health care facilities have devised policies and procedures that require pain-intensity rating as a routine part of care (the fifth vital sign). Pain intensity usually is assessed on a numerical scale, in which 0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, and 7 to 10 = severe pain. However, obtaining a numerical rating of pain intensity is possible only if the patient is able to provide this report of the pain being experienced, which infants, children, the critically ill, and cognitively impaired usually are unable to do. The Wong’ Baker FACES scale, developed for pediatric use, has been used successfully in other patient populations. It uses visual representations of smiles or grimaces to depict the level of pain a patient feels.
Health care professionals must be aware that pain in non-verbal patient can easily be overlooked and must make a conscious effort to ensure that pain in these patients is assessed and treated. Observing subtle behaviors and being sensitive to contextual clues are two pain methods used by health care professionals to try to determine when nonverbal patients are in pain. When this judgment is made, a trial of pain-relieving medication may be used. The responses of the patient and any complications of treatment should be carefully observed and appropriate changes made in dosing or the type of analgesic drug as indicated.
Because pain is a subjective and intensely personal problem, sympathetic care is an important part of its relief. In addition to administering analgesic drugs, health care professionals should use a wide range of techniques to help alleviate pain, including local application of cold and heat, tactile stimulation, relaxation techniques, diversion, and active listening, among others.
Pain that typically is produced by sudden injury (e.g., fracture) or illness (e.g., acute infection) and is accompanied by physical signs such as increased heart rate, elevated blood pressure, pupillary dilation, sweating, or hyperventilation. Acute pain is typically sharp in character. It is relayed to the central nervous system rapidly by A delta nerve fibers. [Then, at the end of this entry please add the SYN:] fast pain Depending on the severity of the underlying stimulus, acute pain may be managed with acetaminophen or anti-inflammatory drugs, immobilization and elevation of the injured body part, or the topical application of heat or ice. Severe acute pain, such as that of broken ribs or of an ischemic part, may require narcotics, often with adjunctive agents like hydroxyzine for relief, or antiemetics. Acute pain should be managed aggressively. Synonym: fast pain
Discomfort arising from the fallopian tubes and ovaries; usually due to inflammation, infection, or ectopic pregnancy.
Pain felt in or along the spine or musculature of the posterior thorax. It is usually characterized by dull, continuous pain and tenderness in the muscles or their attachments in the lower lumbar, lumbosacral, or sacroiliac regions. Back pain is often referred to the leg or legs, following the distribution of the sciatic nerve.
Common causes of back pain include pain caused by muscular or tendon strain, herniated intervertebral disk, lumbar spinal stenosis, or spondylolisthesis. Patients with a history of cancer may have back pain caused by metastatic tumors to the vertebrae and should be evaluated to be certain that damage to the spinal cord is not imminent. Patients with back pain and fever (esp. those with a history of injection drug use, tuberculosis, or recent back surgery) should be evaluated for epidural abscess or osteomyelitis.
Depending on the underlying cause of the back pain, treatment may include drugs, rest, massage, physical therapy, chiropractic, stretching exercises, injection therapy, and surgery, among others. Most nonmalignant causes of back pain improve with a few days of rest, analgesics, and antiinflammatory drugs, followed by 2 to 4 weeks of anti-inflammatory treatment, appropriate muscle strengthening, and patience. Pain caused by an osteoporotic fracture may prove more debilitating and longer-lasting. Back pain produced by a spinal metastasis can improve with corticosteroids, radiation therapy, intravenous bisphosphonates, and/or surgical decompression. Patients with a spinal epidural abscess will need surgical drainage of the infection and antibiotics.
Prolonged bedrest is inadvisable in most patients with back pain. The treatment regimen is explained, implemented, and reinforced. Factors that precipitate symptoms are identified and preventive actions are discussed.
Rectal pressure and discomfort occurring during the second stage of labor, related to fetal descent and the woman's straining efforts to expel the fetus.
Piercing, used to describe pain felt deep within the body.
Transient episodes of pain that occur in patients with chronic pain that has been previously reduced to tolerable levels. Breakthrough pain disrupts the well-being of cancer or hospice patients who have been prescribed regular doses of narcotic analgesics. The painful episodes may occur as a previous dose of pain-relieving medication wears off (“end-of-dose pain”), or after unusual or unanticipated body movements (“incident pain”).
Pain caused near a joint affected with neuralgia when the skin is folded near it.
Pain experienced in heat burns, superficial skin lesions, herpes zoster, and circumscribed neuralgias.
Pain due to a lesion in the central nervous system.
Discomfort felt in the upper abdomen, thorax, neck, or shoulders. Chest pain is one of the most common potentially serious complaints offered by patients in emergency departments, hospitals, outpatient settings, and physicians' offices. A broad array of diseases and conditions may cause it, including (but not limited to) angina pectoris or myocardial infarction; anxiety and hyperventilation; aortic dissection; costochondritis or injured ribs; cough, pneumonia, pleurisy, pneumothorax, or pulmonary emboli; esophageal diseases, such as reflux or esophagitis; gastritis, duodenitis, or peptic ulcer; and stones in the biliary tree.
chronic idiopathic pelvic pain Abbreviation: CIPP
Unexplained pelvic pain in a woman that has lasted 6 months or longer. A complete medical, social, and sexual history must be obtained. In an experimental study, women with this illness reported more sexual partners, significantly more spontaneous abortions, and previous nongynecological surgery. These women were more likely to have experienced previous significant psychosexual trauma.
The pain associated with CIPP should be treated symptomatically and sympathetically. The participation of pain management specialists, complementary medical providers, and the primary health care provider should be integrated. Realistic goals (e.g., the reduction of pain rather than its elimination) should be set. Medroxyprogesterone acetate, oral contraceptives, presacral neurectomy, hypnosis, and hysterectomy have been tried with varying degrees of success.
1. Long-lasting discomfort, with episodic exacerbations, that may be felt in the back, one or more joints, the pelvis, or other parts of the body.
2. Pain that lasts more than 3–6 months.
3. Pain that lasts more than a month longer than the usual or expected course of an illness.
Pain that returns periodically every few weeks or months for many years. Chronic pain is often described by sufferers as being debilitating, intolerable, disabling, or alienating and may occur without an easily identifiable cause. Studies have shown a high correlation between chronic pain and depression or dysphoria, but it is unclear whether the psychological aspects of chronic pain precede or develop as a result of a person's subjective suffering. Chronic pain is the leading cause of disability in the U.S.acute pain
The management of chronic, nonmalignant pain is often difficult and may be frustrating for both sufferer and caregiver. The best results are usually obtained through multimodal therapy that combines sympathetic guidance that encourages patients to recover functional abilities, by combinations of drugs (e.g., nonsteroidal anti-inflammatories, narcotic analgesics, and/or antidepressants), physical therapy and regular exercise, occupational therapy, physiatry, psychological or social counseling, and alternative medical therapies (e.g., acupuncture, massage, or relaxation techniques). Placebos, although rarely employed clinically, effectively treat chronic pain in about a third of all patients. Surgery and other invasive strategies are occasionally employed, with variable effectiveness.
Pain in the oral area, which, in general, may be of two origins. Soft tissue pain may be acute or chronic, and a burning pain is due to surface lesions and usually can be discretely localized; pulpal pain or tooth pain varies according to whether it is acute or chronic, but it is often difficult to localize.
Discomfort accompanying rhythmic uterine contractions during the first stage of labor.
Low back pain resulting from degeneration of an intervertebral disk. Discogenic pain differs from neuropathic pain in that it does not radiate into the extremities or torso.
A mild discomfort, often difficult to describe, that may be associated with some musculoskeletal injuries or some diseases of the visceral organs.
Pain occurring in peripheral structures owing to a lesion involving the posterior roots of the spinal nerves.
Pain located between the xiphoid process and the umbilicus. It may suggest a problem in one of many different organs, including the stomach, pancreas, gallbladder, small or large bowel, pleura, or heart. Synonym: gastralgic pain See: cardialgia
Discomfort during the second stage of labor, associated with bearing-down efforts to expel the fetus. Women may experience a similar pain during delivery of the placenta.
Abdominal discomfort associated with Braxton Hicks contractions, which occur during the last trimester of pregnancy. Characteristically, the woman complains of irregular, lower abdominal pains, which are relieved by walking. Vaginal examination shows no change in cervical effacement or dilation. See: Braxton Hicks contractions
fast painAcute pain.
fulgurant painLightning pain.
gallbladder painBiliary colic.
Pain in the intestines caused by an accumulation of gas therein.
gastralgic painEpigastric pain.
An imprecise term indicating ill-defined pain, usually in the shin or other areas of the legs, typically occurring after bedtime in children age 5 to 12. There is no evidence that the pain is related to rapid growth or to emotional problems. If these symptoms occur during the daytime, are accompanied by other symptoms, or become progressively more severe, evaluation for infection, cancer, and other diseases of muscle and bone should be undertaken. In the majority of cases, this evaluation is not necessary.
The child should be reassured and given acetaminophen or ibuprofen; heat and massage can be applied locally. Children with growing pains benefit from concern and reassurance from their parents and health care providers.
heterotopic painReferred pain.
Pain felt at the point of injury.
Pain in the epigastrum that occurs before meals.
Pain due to a sudden, forceful, unanticipated, or unusual body movement or posture.
Pain in the presence of inflammation that is increased by pressure.
Episodic, localized pelvic discomfort that occurs between menstrual periods, possibly accompanying ovulation. Synonym: midpain See: mittelschmerz
Chronic pain that is difficult or impossible to manage with standard interventions. Common causes include metastatic cancer, chronic pancreatitis, radiculopathy, spinal cord transection, or peripheral neuropathy. Intractable pain may also accompany somatoform disorders, depression, fibromyalgia, irritable bowel syndrome, and opiate dependence. Various combinations of the following management strategies are often used to treat intractable pain: antidepressant medications, counseling, deep brain stimulation, injected anesthetics, narcotic analgesics, neurological surgery, and pain clinic consultations.
Uncomfortable, intermittent, rhythmic, girdling sensations associated with uterine contractions during childbearing. The frequency, duration, and intensity of the events increase, climaxing with the delivery of the fetus.
lancinating painAcute pain.
A sudden brief pain that may be repetitive, usually in the legs but may be at any location. It is associated with tabes dorsalis and other neurological disorders. Synonym: fulgurant pain
Pain in the tongue that may be due to local lesions, glossitis, fissures, or pernicious anemia. Synonym: tongue pain
Sharp pain in the region of the lungs.
mental painPsychogenic pain.
middle painIntermenstrual pain.
Pain that moves from one area to another.
Pain that originates in peripheral nerves or the central nervous system rather than in other damaged organs or tissues. A hallmark of neuropathic pain is its localization to specific dermatomes or nerve distributions. Some examples of neuropathic pain are the pain of shingles (herpes zoster), diabetic neuropathy, radiculopathy, and phantom limb pain.
Drugs like gabapentin or pregabalin provide effective relief of neuropathic pain for some patients. Other treatments include (but are not limited to) regional nerve blocks, selective serotonin and norepinephrine reuptake inhibitors, psychological counseling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy.
Pain that awakens the patient at night or interferes with sleep; may be due to infection, inflammation, neurovascular compromise, or severe structural damage.
Pain induced by some external or internal irritant, by inflammation, or by injury to nerves, organs, or other tissues that interferes with the function, nutrition, or circulation of the affected part. It is usually traceable to a definite pathologic process.
A stinging or tingling sensation manifested in central and peripheral nerve lesions. See: paresthesia
A discrete, well-localized pain caused by inflammation of tissues surrounding a tooth. This may be contrasted with the throbbing, nonlocalized pain typical of a toothache or pulpal pain.
phantom limb pain
The sensation of pain felt in the nerve distribution of a body part that has been amputated. Phantom pain can lead to difficulties in prosthetic training. Synonym: phantom sensation
Phantom limb pain or nonpainful sensations are reported by most amputees. A multimodal or combination approach to management is appropriate. Drugs used to treat neuropathic pain may be helpful, including some anticonvulsant drugs, tricyclic antidepressants, selective serotonin inhibitors, and muscle relaxants. Nerve blockade and/or transcutaneous electrical stimulation may also be helpful. Health care professionals should encourage amputees to move the affected extremity, seek counseling or group therapy, engage in physical and occupational therapy, and use distraction techniques.
Abdominal pain after eating.
Pain felt in the center of the chest (e.g., below the sternum) or in the left side of the chest.
Ineffective contractions of the uterus before the beginning of true labor. See: false pain
The false sensation of movement in a paralyzed limb or of no movement in a moving limb; not a true pain.
Pain having mental, as opposed to organic, origin.
Pain that radiates away from the spinal column through an extremity or the torso resulting from the compression or irritation of a spinal nerve root or large paraspinal nerve. It may be accompanied by numbness or tingling.
SITES OF REFERRED PAIN
Pain that arises in one body part or location but is perceived in another. For example, pain caused by inflammation of the diaphragm often is felt in the shoulder; pain caused by myocardial ischemia may be referred to the neck or jaw; and pain caused by appendicitis may first be felt near the umbilicus rather than in the right lower quadrant, where the appendix lies. See: table Synonym: heterotopic pain; sympathetic pain See: illustration
Pain with temporary abatements in severity; characteristic of neuralgia and colic.
Pain due to ischemia that comes on when sitting or lying.
Cutaneous pain caused by disease of the sensory nerve roots.
Pain that seems to travel like lightning from one place to another.
Pain that is perceived a second or more after a stimulus. It is transmitted to the central nervous system by C (nerve) fibers, which are not myelinated, and therefore conduct sensations more slowly than A delta fibers. Slow pain lasts longer than sudden pain. It is usually perceived by patients as burning, cramping, dull, itchy, or warm.
standards for pain relief
Standards for the Relief of Acute Pain and Cancer Pain developed by the American Pain Society. These are summarized as follows:
1. In order to increase the clinician's responsiveness to complaints of pain, it is now considered by some health care professionals to be the fifth vital sign.2. Acute pain and cancer pain are recognized and effectively treated. Essential to this process is the development of a clinically useful and easy-to-use scale for rating pain and its relief. Patients will be evaluated according to the scales and the results recorded as frequently as needed.3. Information about analgesics is readily available. This includes data concerning the effectiveness of various agents in controlling pain and the availability of equianalgesic charts wherever drugs are used for pain.4. Patients are informed on admission of the availability of methods of relieving pain, and that they must communicate the presence and persistence of pain to the health care staff.5. Explicit policies for use of advanced analgesic technologies are defined. These advances include patient-controlled analgesia, epidural analgesia, and regional analgesia. Specific instructions concerning use of these techniques must be available for the health care staff.6. Adherence to standards is monitored by an interdisciplinary committee. The committee is responsible for overseeing the activities related to implementing and evaluating the effectiveness of these pain standards.
A pain accompanied by muscular spasm during the early stages of sleep.
A sharp stitchlike pain occurring during breathing caused, for example, by an abscess or tumor beneath the diaphragm. When the breath is held, the pain ceases. Pressure against the lower rib cage eases the pain.
subjective painPsychogenic pain.
sympathetic painReferred pain.
A boring or piercing type of pain.
thalamic pain See: thalamic syndrome
Pain caused by heat.
thoracic painChest pain.
Pain found in dental caries, headache, and localized inflammation. The pain is often thought to be caused by arterial pulsations.
tongue painLingual pain.
Pain that throbs or pulses, such as the pain of a migraine headache.
Pain that changes its location repeatedly.
|Generic Name||Dose, mg *||Interval||Comments|
|Acetylsalicylic acid||325–650||4–24 hr||Enteric-coated preparations available|
|Acetaminophen||650||4 hr||Avoid in liver failure|
|Ibuprofen||400–800||4–8 hr||Available without prescription|
|Indomethacin||25–75||8 hr||Gastrointestinal and kidney side effects common|
|Naproxen||250–500||12 hr||Delayed effects may be due to long half-life|
|Ketorolac||15–60 IM||4–6 hr||Similar to ibuprofen but more potent|
|Generic Name||Parenteral Dose (mg)||PO Dose (mg)||Comments|
|Codeine||30–60 every 4 hr||30–60 every 4 hr||Nausea common|
|Hydromorphone||1–2 every 4 hr||2–4 every 4 hr||Shorter acting than morphine sulfate|
|Levorphanol||2 every 6–8 hr||4 every 6 hr||Longer acting than morphine sulfate; absorbed well PO|
|Methadone||10–100||6–24 hr||Delayed sedation due to long half-life|
|Meperidine||25–100||300 every 4 hr||Poorly absorbed PO; normeperidine is a toxic metabolite|
|Morphine||10 every 4 hr||60 every 4 hr|
|Morphine, sustained release||30–90||60–180 2 or 3 times daily|
* By mouth unless indicated otherwise.PO—by mouth only.SOURCE: Adapted from Isselbacher, K.J., et al.: Harrison's Principles of Internal Medicine, ed 13. McGraw-Hill, New York, 1994.
|Oxycodone||—||5–10 every 4–6 hr||Usually available with acetaminophen or aspirin|
|Organ of Origin||Location Felt|
|Head||External or middle ear|
| Nose & sinuses|
| Teeth, gums, tongue|
| Throat, tonsils|
| Parotid gland, TMJ joint|
| Diaphragm||Shoulder, upper abdomen|
| Heart||Upper chest, L shoulder, inside L arm, L jaw|
| Stomach & spleen||L upper abdomen|
| Duodenum||Upper abdomen, R shoulder|
| Stomach & spleen||L upper abdomen|
| Stomach & spleen||L upper abdomen|
| Stomach & spleen||L upper abdomen|
| Colon||Lower abdomen|
| Appendix||Periumbilical and R lower abdomen|
NOTE: L = left; R = right.
| Appendix||Periumbilical and R lower abdomen|