Pain

Question 1

3 steps of peripheral sensitisation

Answer 1

Tissue damage -> inflammatory mediators
Activate signal pathways
Receptor (nociceptor) change
- Threshold and kinetics

Question 2

Central Sensitisation of Pain

Answer 2

• Facilitated Excitation and Depressed Inhibition results in an amplified response to noxious and innocuous inputs
• In the dorsal horn after prolonged nociceptive input you get reduced threshold, amplification of pain, spread to non injured areas
• Sub threshold inputs cause action potentials and resulting pain
• mechanism is via NMDA in Dorsal horn

Question 3

Inflammatory Mediators and Peripheral Sensitisation

Answer 3

Prostaglandins –> Cytokines –> Macrophages
Macrophages release Prostaglandins (ILs), TNFalpha, cytokines
Other growth factors cause schwann cell proliferation
- Prostaglandins and cytokines = sensitise nociceptors

Question 4

Interruption / Interference / Identity issues of pain

Answer 4

1. Interruption
   Pain disrupts attention, results in behavioural change at a moment to moment level
2. Interference
   Continued interruption, leading to impaired function
3. Identity
   Repeated interference, impacts views of self and future

** Acute pain leads to interruption and interference but not likely to impact identity

** Anxiety sensitivity refers to a dispositional tendency for patients to be fearful of arousal or somatic related sensations based on the belief that the sensations themselves may have or reflect harmful consequences

Question 5

Catastrophizing Psychology

Answer 5

• Tendency to magnify the potential threat of an experience and to have limited confidence in one’s ability to tolerate it
• Antecedent of kinesiophobia
• Associated with long term pain

Question 6

Kinesiophobia

Answer 6

• Fear/avoidance is a closely related concept in which patients believe that the experience of pain reflects that physical damage is occurring, especially during physical exercise or activity
• Antecedent to depression and disability
• Associated with long term disability

Question 7

Clinical Significance of Pain Related Fear

Answer 7

This lies in its contribution to pain disability beyond that attributable to nociception, and in cases where it exerts a prepotent influence on disability, it becomes evident that mere reduction in the peripheral inflow of nociceptive transmission will not offer clinical improvements in functional outcomes

Question 8

5 Psychosocial Factors of Pain

Answer 8

1. Environment
2. Brain State
3. Cognitive Content “what do you Believe is the source of your pain?”
   - Adaptive (better) -> self efficacy
   - Maladaptive (worse) -> pain = damage, pain relief before function
4. Cognitive coping “what strategies do you use?”
   - Mood/behaviour/pain
   - Adaptive -> ignore pain / coping self statements / acceptance
   - Maladaptive -> catastrophizing
5. Behaviour “what do you do to manage your pain”

Question 9

Psychological Pain Therapy: Behavioural Therapy

Answer 9

Behaviour is a function of 2 factors:

• Reinforcement: Consequences that determine the future probability of a specific behaviour
• Antecedents: Context in which behaviour occurs and includes the presence of discriminative stimuli that signal the availability of reinforcement

Question 10

Psychological Pain Therapy: Operant Conditioning

Answer 10

Learn and Reinforce (pain behaviour)
Goal Setting and Praise (good dog)
Goal: Identify pain behaviour reinforcers, alter them so well behaviours are rewarded and pain behaviours are ignored

Question 11

Psychological Pain Therapy: Classical Conditioning

Answer 11

Exposure and resultant physiological response (pavlov’s dogs)

Question 12

Psychological Pain Therapy: Cognitivie Therapy

Answer 12

Cognitive conditioning

• modify unhelpful thoughts (ie catastrophizing, low self efficacy, fear avoidance)
• not positive thinking (denial)

Question 13

Psychological Interventions: Self Regulatory Treatments and Operant Behavioural Treatment

Answer 13

Self Regulatory Treatments:
- relaxation / biofeedback / hypnosis

Operant Behavioural Treatment:

• Theory is that pain behaviours reinforced by desirable consequences will increase frequency of occurrence and duration of pain and disability
• Method is to identify reinforcing behaviours and alter these behaviours

Question 14

Cognitive Behavioural Therapy and Pain

Answer 14

The term CBT varies widely and may include self instructions, relaxation or biofeedback, developing coping strategies, changing maladaptive beliefs about pain and goal setting, varying selection of these strategies.
- embedded in a more comprehensive pain management program that includes functional restoration, pharmacotherapy and general medical management

• Self management program
• Challenge unhelpful thoughts (fear avoidance)
• Psychoeducation
• Problem solving (flare up plan)