Pain  Other Symptoms

Many serious diseases, such as cancer and AIDS, cause pain. Pain can be intermittent or constant, and can vary in severity from mild to severe. It can have many different qualities, such as burning, shooting, aching, piercing or pinching. Many factors influence the perception of pain, including mood, activity level, stress, and the availability of pain-relieving therapies.

Pain can be caused by:

	The activation of pain receptors by something that injures pain-sensitive tissues (nociceptive pain). Tissue damage from a mass (like a tumor) or from inflammation, for example, can cause this type of pain
	Nerve damage (neuropathic pain) from a virus, chemotherapy, trauma or a disease such as multiple sclerosis

	Experience depression
	Experience disruptions in activity, appetite and sleep
	Feel helpless and anxious
	Give up hope
	Reject treatment programs
	Stop participating in life to the fullest extent possible

	Tumors pressing on organs, nerves or bone
	Treatment such as surgery, chemotherapy or radiation
	Other conditions related to the cancer, such as stiffness from inactivity, muscle spasms, constipation and bedsores
	Conditions unrelated to the cancer, such as arthritis or migraine

	Surgery, radiation or chemotherapy to shrink tumors causing pain
	Antibiotic therapy or drainage for pain caused by infection
	Psychological therapies, and social and spiritual support, to influence the perception of pain
	Other pain treatments

	A nonopioid analgesic, such as acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID)
	Adjuvant drugs if a specific indication exists

	An opioid conventionally used for moderate pain (usually codeine, hydrocodone, dihydrocodeine, oxycodone, propoxyphene, or tramadol)
	A nonopioid analgesic, such as acetaminophen or an NSAID
	An adjuvant drug in some cases

	An opioid conventionally used for severe pain, such as morphine, oxycodone, hydromorphone, methadone, levorphanol or fentanyl
	A nonopioid analgesic in some cases
	Adjuvant drugs in some cases

	Pain due to nerve damage, such as peripheral neuropathy and postherpetic neuralgia
	Headaches from meningitis
	Abdominal pain from gastrointestinal disease
	Chest pain from pneumonia
	Muscle pains

To find an appropriate treatment, a doctor should perform a detailed assessment.

	Non-opioid pain relievers
	Opioids
	Adjuvant medications (drugs whose primary purpose is not for pain but rather for other conditions)
	Topical treatments (drugs are applied directly to the skin, as a patch, gel, or cream)

	Strengthen weak muscles
	Mobilize stiff joints
	Help restore coordination and balance
	Promote a sense of well-being
	Decrease anxiety and stress
	Keep the heart healthy
	Help maintain an appropriate weight

	Increase the blood flow to the skin
	Dilate blood vessels, increasing oxygen and nutrient delivery to local tissues
	Decrease joint stiffness by increasing muscle elasticity

	Deep breathing. In this simple technique, the patient focuses his or her attention on breathing deeply. This may shift attention away from the source of pain.
	Progressive muscle relaxation. In this technique, developed in the 1930s, patients contract, then relax, muscles throughout the body, group by group. Progressive muscle relaxation can help patients learn about the tension in their body and the contrast between tense and relaxed muscles.
	Imagery. In this technique, patients focus on pleasant thoughts, for example waves gently hitting a sandy beach. One variation is to think of an image that represents the pain (such as a hot, blazing concrete sidewalk), then imagine it changing into an image representing a pain-free state (a pretty, snow-covered forest).
	Meditation. In this technique, practiced routinely in Asia, the individual aims to empty his or her mind of thoughts, focusing instead on the sensation of breathing and the rhythms of his or her body.
	Biofeedback Therapy. Biofeedback is a method in which people learn to reduce their body's unproductive responses to stress, and thus decrease their sensitivity to pain. Children are particularly quick to learn from biofeedback. In biofeedback, electrodes are placed at various points on the patient's skin to measure: Muscle tension. As a muscle contracts, electrical activity increases Temperature. The stress response is related to blood flow in the hands or feet, and blood flow determines temperature Heart beat Sweating Patients watch the monitor and listen to the tones measuring their stress indicators. They use these as a guide in learning to release tension throughout their body.
	Distraction. Distraction is a pain management technique in which patients focus their attention on something other than their pain and negative emotions. To distract themselves, patients can: Sing Count Listen to music Watch TV Listen to the radio Talk to friends or family Read Listen to stories being read Reframing. Reframing is a pain and stress management technique that teaches patients to monitor negative thoughts and images and replace them with positive ones. Patients can learn to have a more positive outlook by recognizing some counterproductive thought patterns, such as: Blaming, in which the individual avoids taking responsibility. Thoughts such as "It's my boss's fault I have this headache" can be replaced with "I'm going to focus on what I can do to feel better." "Should" or "must" statements, which imply that someone has failed to live up to an arbitrary standard. Statements such as "I should have been more careful" can be counteracted with "I do not have to be perfect" or "I made the best decision I could have at the time." Polarized thinking, in which everything is black or white, with no shades of gray. Statements such as "I'm still in pain, so this program is useless" can be counteracted with "I wish I could be free of pain, but I have made some progress. Sometimes small improvements add up." Catastrophizing, in which the person imagines the worst possible scenario then acts as if it will surely come true. Statements such as "This pain must mean I am going downhill" can be counteracted with "I am jumping to conclusions" or "I'll find a way to cope with whatever happens." Control fallacy, in which the person sees him or herself as completely controlled by others (or controlling everything). Thoughts such as "My spouse doesn't think I need to see a counselor, so I can't go" can be counteracted with "I am not a helpless victim" (or thoughts such as "My family will fall apart without me" can be counteracted with "Members of my family are not helpless"). Emotional reasoning, in which the individual believes that what he or she feels must be true. Statements such as "I'm so frightened the pain will never stop, I know it never will" can be counteracted with "I'm scared, but that does not give me an accurate view of the situation" or "When I calm down, I will think about what this means." Filtering, in which people focus on one thing (such as pain) to the exclusion of any other experience or point of view. Statements such as "I can't take it"" can be replaced with "I have coped before and can cope again." Entitlement fallacy, in which individuals believe they have the right to what they want. Statements such as "Life is so unfair" or "I have been cheated" can be counteracted with "No one promised me a rose garden. I will focus on finding ways to make things better." Psychotherapy and Social Support Psychotherapy and social support can help a patient cope with pain. Psychotherapy may be useful for anyone whose pain is difficult to manage, who has developed clinical depression or anxiety or who has a history of psychiatric illness. Among the goals of psychotherapy are the following: Emphasize the patient's past strengths Support the patient's use of previously successful coping strategies Teach new coping skills Establish a bond to decrease a patient's sense of isolation Foster a sense of self-worth Psychological Approaches Group Approaches: Peer groups, in which a patient meets with others with the same condition, can help by Providing support Showing the patient how others have coped effectively Helping the patient maintain a social identity Providing access to information and material aid Spiritual leaders are another potential source of support for patients. Complementary/Alternative Approaches Acupuncture Acupuncture is an ancient method for relieving pain and controlling disease, used in China for thousands of years. It appears to be effective for some patients with chronic pain. Thin gold or metal needles, gently twirled for ten to twenty minutes, can be used to stimulate acupuncture points, which relieve pain in specific parts of the body (for example, a point on the leg targets stomach pain). Patients usually feel a tingling, warm sensation, similar to that of transcutaneous electrical nerve stimulation. Acupuncture points can also be stimulated with deep massage (acupressure), electric currents (electroacupuncture), or lasers. The risk of side effects is low. Side effects can include post-needling pain, bleeding, bruising, dizziness, fainting, and local skin reactions. Rarely, organ damage can occur with deep needling techniques. Infection because of inadequately sterilized needles is a hazard; disposable needles are recommended. Acupuncture is not recommended for patients with serious blood clotting problems. Acupuncture should be used with caution by pregnant women. Massage Massage can be a useful addition to a pain management program, especially for patients who are bedridden. Massage can: Stimulate blood flow Relax muscles that are tight or in spasm Promote a feeling of well-being Muscles can be stroked, kneaded or rubbed in a circular motion. A lotion can reduce friction on the skin. Massage is not recommended in cases of swollen tissue. It should be used in addition to, and not instead of, exercise by patients who can walk. Anesthesiologic Approaches For patients with pain who fail conservative therapies, simple to complex interventional therapies such as nerve blocks, epidural steroid injections, intraspinal drug administration, or trigger point injections may be helpful. These therapies are typically provided by anesthesiologists with advanced training in pain management. Nerve Blocks and Epidural Steroid Injections Nerve blocks can relieve pain by inhibiting the impulses that travel along specific nerves in the body. To achieve a block, the doctor usually injects a local anesthetic along the course of a nerve or nerves. Although this is called a "temporary" block, in the best outcome, pain relief lasts for a long time. In very selected cases, the doctor can inject a solution that damages the nerve and produces a more permanent block. Sympathetic nerve blocks inhibit the nerves of the sympathetic nervous system, which are responsible for increasing heart rate, constricting blood vessels and raising blood pressure in response to stress. Sympathetic nerve blocks can be useful in treating some pains due to nerve damage, such as some types of complex regional pain syndrome (also called reflex sympathetic dystrophy or causalgia). Blocks of somatic nerves can be targeted to any area of the body. In some cases, nerve blocks fail to provide pain relief, or provide only a brief respite. Epidural steroids, administered through injection, can help to interrupt the passage of painful impulses through nerves. Spinal Infusion Intraspinal drug administration involves the delivery of low doses of analgesic drugs, such as morphine or clonidine, through a catheter inserted directly into the spine. This approach is used often to manage cancer pain. Triggerpoint Injections Invasive Stimulatory Approaches Invasive Nerve Stimulation Invasive nerve stimulation can provide pain relief for some patients who have not responded to other therapies. In this technique, electrodes are implanted in the patient's body to send a gentle electrical current to nerves in the spinal column or the brain. Spinal cord stimulation has been used for chronic back and/or leg pain following lumbar surgery, pain due to nerve damage (complex regional pain syndrome and postherpetic neuralgia) and intractable angina. Few controlled studies of this method exist. Deep brain stimulation may help as many as half of patients with central pain, a challenging condition that can develop as a result of damage to the central nervous system from stroke. Disadvantages of this therapy include its high cost, risks of an invasive treatment (such as infection), and difficulty predicting before a trial which patients will benefit. Surgical Approaches Surgery to treat pain (rather than the underlying disease) is only appropriate in cases where more conservative approaches have failed and where trained neurosurgeons and follow-up care are available. A surgeon can cut a nerve close to the spinal cord (rhizotomy) or bundles of nerves in the spinal cord (cordotomy) to interrupt the pathways that send pain signals to the brain. In the best possible outcome, surgery relieves pain and the need for most or all pain medication. However, surgery carries the risk of: Stopping the pain only briefly Creating new pain from nerve damage at the site of the operation Limiting the patient's ability to feel pressure and temperature in the region, putting him or her at risk for injury

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