Author: Paulette Tull RGN DipN

Date: 05 July 1998

Email: paulette@olney.demon.co.uk

Assignment Question:

‘ Pain is what the patient says it is’. Discuss.....

In 1980, Margo McCaffery wrote;

This assignment discusses this statement in terms of it’s validity. The first section describes types of pain, pain thresholds, personality types and where it originates. It then gives the physiology of pain, which includes the Gate Control Theory.

The next section looks at psychological aspects - which investigates the spiritual, cultural and related aspects of pain. This is followed by an assessment of experiential pain, which reviews verbal and non- verbal communication, including the use of assessment tools.

It has been agreed generally by pain experts, that pain is subjective and individual. As Atkinsanya (1985) states; "Pain is a totally subjective experience." Merskey (1979) echoes this by saying that pain is always subjective. Steinbach (1968) believes that pain is a personal, private sensation of hurt.

Others have been unable to define pain. Melzack and Wall (1988) have stated that pain has never been defined adequately, as research is not advanced enough to reach an accurate definition, particularly as the experience is so diverse.

According to Champagne and Weisse (1994), pain is now recognised as a complex experience with at least four main components. These are noniception, sensation, suffering or distress and behaviour.

There is some confusion among the general public as to the use of these two categories of pain. The pain threshold or sensory pain refers to the point when stimulation becomes painful. These points vary between individuals and whereas some people may feel pain to a certain stimuli, others may not.

Pain tolerance refers to the reaction to pain, which again varies between individuals and also between cultures. We, as nurses, can only assess the severity of pain by the observation of the patient’s reaction to it. (Niven 1994)

It is generally agreed that pain has an important function. Niven (1994) states that the purpose of pain is to signal to the body of an impending injury or that it needs rest. Hendler (1981) adds that pain warns an organism that something is amiss.

Pain as punishment. Davis (1993) states that those who hold with this belief tends to subscribe to the opinion that ‘a little suffering is good for you’ or that ‘they brought it upon themselves’. In the past, the existence of pain would signify the invasion of the individual by evil spirits or as a punishment for sins.

Pain as a positive experience. For some patients, religion may influence the meaning to which they attach to pain. It may be seen as having a positive value. She quotes Pope John Paul II, in 1984, believed that redemption would be accomplished through suffering. For those who do not have a particular religion, pain can still be viewed as having a positive meaning for self-growth or self-testing. (Seers 1988)

Pain as a pleasure. In 1927, Pavlov experimented with dogs, who he conditioned to approach electric shocks in return for food. In the same way, some people will associate sexual pleasure with certain types of pain.

The origins of pain can be divided into two broad categories. These being organic and psychogenic. Organic or somatogenic pain, refers to pain arising from physical causes such as surgery, trauma or disease. Psychogenic or functional pain, describes pain where no physical findings exist for initiating it and no physical findings account for it’s persistence. (McCaffery 1983)

It has been found that even with organic pain, there is, as Mosby’s Medical and Nursing Dictionary (1983) states, a "psychogenic overlay". It is McCaffery’s (1983) opinion that ‘pure’ physical pain is likely to be as rare as ‘pure’ psychogenic pain.

This is described as being a short-lived and reversible discomfort of less than six months duration. Niven (1994) and McCaffery (1983). There is often a sudden onset and a foreseeable end; for example, in the case of a heart attack. Organic disease or injury is present to account for the pain.

As previously mentioned, acute pain has a useful purpose, in that it signals to the body of impending injury or that it needs rest. Conscious memory of pain as children, reminds us that it hurt when our hands touched a hot iron or plate.

McCaffery (1983) has found that anxiety is the emotion most frequently associated with acute pain.

This is described by Encarta (1996) as being a behaviour state, initiated by a real injury, in which the pain has lasted so long, (six months or longer according to McCaffery in 1983) that it has itself become the disease. Often, there appears to be no foreseeable end. This type of pain nags the sufferer, intruding into his or her life. (Hendler 1981) There is usually intense psychological adjustment to this ‘new’ way of life (Niven 1994) as may patients are dependent on strong pain killing medicines and have fallen into a cycle of pain, depression and inactivity, (Encarta 1996) therefore, the useful purpose of acute pain is somewhat unclear when it is applied to chronic pain.

There are three types of chronic pain. (McCaffery 1983)

• Limited pain - where physical pathology usually exists and is known e.g. cancer pain, slowly healing injuries, such as burns or torn muscles.
• Intermittent pain - where the patient has periods when he is free from pain, e.g. headache such as migraine or back pain.
• Persistent pain - or ‘chronic benign pain’. This usually occurs daily. Examples are; low back pain or arthritic pain.

In psychogenic or functional pain, there appears to be no physical findings in existence for causing or initiating the pain nor do any account for it’s persistence. (McCaffery 1983) The pain, however is real to the patient even though the pain appears to result from purely psychological processes. This does not necessarily mean that just because the pain is not assigned to having a physical cause, there may not be one. In fact, Melzack and Wall in 1982, found that psychogenic pain often originated with tissue damage, which persisted after healing was completed. Neuralgia and causalgia, which are readily provoked by innocuous stimuli, such as cotton wool stroked across the skin, are this type of psychogenic pain. Phantom limb pain is another type.

McCaffery (1983) has suggested that this type of pain poses a problem for those assessing the pain. If the patient realises that a physical cause cannot be found for his or her pain, then this pain is likely to become more intense.

Pain starts with the stimulation of special sense receptors called noniceptors, situated in the skin or internal organs. These receptors receive information of noxious (painful) stimuli produced by intense heat, extreme pressure, pricks and cuts, surgery or ischaemia. (Encarta 1996)

This message of pain is transmitted to the spinal cord, to the substantia gelatinosa of the central nervous system. It is here that an event called the Gate Control Theory takes place. This theory was first proposed by Doctors Melzack and Wall in 1965. From here, the pain messages that are transmitted (as opposed to being blocked) travel to the higher centres in the brain where these are translated into perceptory experiences.

The control mechanism is likened to a gate, in which pain impulses can only pass through it when it is open, not when it is closed.

Pain messages arriving at the spinal cord can be blocked by the neural mechanisms, thus closing the gate. There are two competing pain mechanisms, which influence gate control. (Davis 1993)

In addition to the noxious stimuli carried by the noniceptors, there may be other peripheral stimuli, such as those caused by temperature change or by vibration. These travel along A-beta fibres.

If the noniceptor input exceeds that of the A-beta fibres, then the gate is open and pain is perceived by the brain. However, if the input of the A-beta fibres exceed that of the noniceptors, then the gate is closed and the pain impulse is not transmitted to the brain. Davis (1993) Small A-fibre input can also be exceeded by the larger C-fibres, thus reducing pain perception. (McCaffery 1983)

The gate control theory is indicated in the old adage "of rubbing it (the injured area) makes it better". Transcutaneous electrical nerve stimulation, hot and cold therapies and other skin stimulation therapies are thought to be effective for the same reason.

Descending impulses from the brain can also modify the opening and closing of the gate, such as inhibitory signals from the cortex, due to feelings of confidence and control, which close the gate. In the same way, adverse emotions and anxieties will open the gate. Patients who feel in control of their pain, such as those receiving patient controlled analgesia and who are psychologically preprepared about their forthcoming operation have been found to have significantly faster recovery rates than those who are not. (Davis 1993)

This may explain why there are anecdotes of severely wounded soldiers in battle, who do not complain of pain or athletes, who are injured, but have not perceived their pain until the contest had finished. (Encarta 1996) The immediate phase of pain in the case of the soldiers are over-ridden by more pressing matters, such as avoidance of injury, destruction of an attacking enemy, or the need to seek protection. Thus pain may not be perceived at this time because other stimuli are bombarding the spinal cord in addition to the painful one. (Hendler 1981)

Niven (1994) concludes that the degree of injury is not necessarily proportional to the amount of pain experienced.

When mental events result in pain, this can be just as intense as pain that result from physical stimuli. (McCaffery 1983) As ‘pure pain’ is rare, therefore it is generally a combination of physiological and psychological factors.

Said to be as important to treat as physical pain. Emotional pain is the mental anguish that accompanies or is interwoven with and exacerbating physical pain. The sufferer may feel that he or she has lost their dignity, their sense of humour and are "not themselves" because of the physical pain.

Earlier tragedies and losses, such as divorce or bereavements causes the patient overwhelming anxiety. There may be a feeling of helplessness.(Earnshaw-Smith 1982) Children in hospital can suffer this too due to isolation from family and friends. (Muller, Harris et al 1995) Hendler (1981) has found that previous psychiatric disorders sensitises patients to their pain, which manifests itself by depression or anger.

Empathy and perception on the part of the care team members can alleviate this aspect of pain by encouraging the patient to talk about these feelings.

Like emotional pain, this is a compound factor to physical pain. (1992) patients feel a desolate meaninglessness to their lives. The sufferer’s view of life has been shattered. A common phrase used by sufferers is that "nothing makes sense any more" pieces". The Rev. R Morrison (1992) quotes Frankl’s dictum, "Man is not destroyed by suffering, he is destroyed by suffering without meaning".

This can be brought on by the break-up of a seemingly happy marriage or the loss of a loved one, who the patient cannot imagine living life without.

The patient’s past experience of pain and it’s relief will also affect how they judge that pain and what it means to them. Thus the childhood memory of putting one’s hand on a hot iron and the resultant pain experienced from the burn will contribute to the learning process of avoiding the same mistake again.

Unrelieved pain from a previous operation or if a relative died from the same operation will affect the patient’s view of their current pain. (Seers 1988)

Carter (1994) cites a case where a 29 year old woman, under hypnosis, recalled the pain that she had experienced as a neonate when she was placed on metal weighing scales in the delivery room.

Seers (1988) states that each cultural group has attitudes and behaviours towards the expression of pain, which it considers are normal. She cites Zborowski’s 1952 survey, in which third generation American subjects (Old American) who did not identify with a cultural group, took pride in their ability to control their outward expression of pain. By contrast, the Jewish and Italian Americans felt no compunction to ‘grin and bear’ their pain and thus showed this by moaning and crying.

Seer (1988) has quoted Bond and Pearson’s (1969) research findings on personality and pain. It was concluded that introverts had more intense pain, but complained less than their more extrovert neighbours. Niven (1994) found that patients who were pain-free, were more sociable and less emotional than those having pain. Of those who did not complain of pain, but were nonetheless experiencing it, they were more emotional and less sociable.

Seers (1988) has found evidence that older patients obtained more relief from painkillers than younger patients. It was possible that younger patients had higher expectations of pain relief or that they may not have experienced severe pain before. This may explain why dissatisfaction with pain relief was more common among young patients.

Conversely, Woodrow et al (1972) found that the amount of pain tolerated by patients decreased with age.

McCaffery (1993) and Seers (1988) have found that in most cultures, which includes our own, males, who are experiencing pain, are encouraged to be brave and display a stoical attitude towards it, but females are allowed a greater freedom of expression. Pilowsky and Bond (1969) observed that the men rated their pain as more severe than the women, but were given less sedation.

It is said by Baillie (1993) that pain assessment and control should be a priority within nursing, yet pain may often be under assessed and unrelieved for a variety of reasons. Because of the subjective nature of pain, only patients can measure their own pain accurately.

According to Mosby’s Medical and Surgical Dictionary (1983), pain assessment is an evaluation of the factors that alleviate or exacerbate a patient’s pain. As pain is complex, it is complex to assess, therefore more than one strategy may be employed by the nurse, in order to assess it. It is often the responsibility of nurses to infer that a patient has pain, based on the type of information given by the patient and perceived by the nurse. (Hollingworth 1994)

Schofield (1995) stresses the importance of a good nurse-patient relationship. This aids communication and allows the patient to express his or her pain, thus eliminating previously held assumptions by both parties, e.g., cultural prejudices. Examples of these assumptions which hamper effective management of pain are many, but common beliefs are;-

• Patients assume the nurse automatically know about their pain. (Seers 1988)
• Patients may endure pain if they feel that the staff are too busy to attend to their needs. This may be more prevalent in a culture where pain tolerance is valued highly.
• If the patient has chronic or long-term pain, it may be assumed that he or she will get used to it. (Seers 1988)
• Nurses may ascribe a greater degree of pain to certain diagnoses, e.g., cancer, and a lesser degree to others e.g., haemorrhoids. (Gooch 1989)
• Nurses may withhold narcotics for fear of addiction. (Seers 1988) and (Gooch 1989)

Discussion about the patient’s pain with the nurse will demonstrate to him or her that the nurse believes the patient and can be trusted to help. The result of this will be to reduce fear, anxiety and faster recovery. (Schofield 1994)

This information available to the nurse has two forms; that of verbal communication between the nurse and patient, which may be structured to include an assessment tool, and non-verbal communication.

5.1 Pain Assessment Tools

I have had personal experience of the usage of pain assessment charts whilst working as a bank nurse, on the surgical and coronary care units of my hospital, which is the Milton Keynes General Hospital Trust (MKGH). (See appendix)

These, however, are not a substitute for one to one communication and a thorough nursing assessment. The common types are briefly reviewed below.

The best known of these are McGill’s Pain Questionnaire (MPQ) and the London Pain Chart. The MPQ is widely used (usually non-acute) because of it’s all-encompassing structure, which covers most aspects of pain and related stimuli. The body chart shows single and multi-focal pain. The London Pain Chart is a more modified form of the questionnaire. Large-scale questionnaires rely on the patient to have a good command of the English language and they also need to be alert, awake, and able to concentrate. Children have been found to use different words, when describing pain, than those in the MPQ. Words such as ‘bullet’, ‘upset’, and ‘yukky’ were prevalent among the 5 to 7 year old age group. ‘Dizzy’, ‘disappointed’ and ‘weird’ were additionally used by older children.

Patients, usually children are asked to choose the colour nearest to their pain, e.g., red denotes ‘bad pain’, purple denotes ‘awful pain’, whilst pink or yellow means no pain.

These consists of a 10cm numerically calibrated line. Numbers can be labelled, variously, 0 - 10, 0 - 20 or 0 - 100. At either end are verbal end points.
(See figure 5-1 below)

The patient is asked to mark the line with a cross at a point which represents their current level of pain. (See figure 5-1) The advantage with this is that there are an infinite number of points that can be chosen by the patient.

Like the previous two scales, this is easy to use. It consists of a list of adjectives that describes levels of pain intensity (‘no pain’, ‘mild’, ‘moderate’, ‘severe’ and ‘very severe’). The patient selects a word that describes their pain and other accompanying stimuli, if provision for this is provided. The post operative assessment chart used at the MKGH for patients with patient controlled analgesia (PCA) combines some of the attributes of this type of chart, together with the Visual Analogue Scale. (See Appendix A)

Much favoured on children’s’ wards, (including those at my hospital). The patient chooses a face that corresponds with pain (if any) that is experienced.

The greater challenge to the nursing staff, is assessing pain when it is not what the patient says it is. The commonest reasons for this, in my view as a practising nurse are;-

• The patient is too young to talk.
• The patient is unable to speak or understand English.
• The patient is too weak or ill to talk.
• The patient may feel it is undignified to admit to their pain and thus deny it’s presence.
• The patient has impaired hearing or sight. (Seers 1988)
• The patient may be too embarrassed to admit to pain in certain regions of the body, e.g., the rectum. (Seers 1988)

It is in the interpretation of non-verbal cues received from the patient as regards to their pain, which determines the course of action taken by the nurse. These may be;-

Raised blood pressure, heart rate and respiration’s may be present if a patient is experiencing pain, either inclusively or as single entities.

I have encountered this phenomenon several times whilst working on the surgical unit of my hospital. One particular patient denied the presence of pain, despite the fact that his anaesthetic had worn off several hours previously. He understood the need for analgesia when I informed him of his raised blood pressure and heart rate.

Guarding the painful area is common. It is often seen when people are walking, as they attempt to ‘protect’ the region of the body from becoming more painful. Patients who deny having pain on the surgical unit of the MKGH, are asked to touch the opposite side of the bed with their hand.

Adults may adopt facial expressions such as wincing or grimacing, whilst in pain. In infants and children, this behaviour extends to crying, posture and rigidity of the torso. In neonates, facial expression is measure by tools such as the Neonatal Facial Coding System. Pain expression can be characterised by tightly closed eyes and either an angular squarish mouth or vertical stretch mouth. There may also be a tautness of the tongue. (Carter 1994)

It is common for sleep to be disturbed due to pain. This may be particularly true at night, when there are few distractions, which might focus the patient’s mind away from their pain.

Patient’s who do not or are unable to communicate their pain may have little appetite for food.

It is now recognised that patients who are verbally non-expressive may still have as much pain as their more noisier neighbours. Cultural aspects may influence certain patients to tolerate their pain, instead of making it manifest.

It is concluded that pain is a subjective and individual experience. Acute pain serves as warning of impending danger.. It can be seen as a punishment for past sins or as having a positive value for redemption or self-growth. It may be seen as having pleasurable connotations.

Pain can arise from physical causes or there may not be a physical cause for it’s existence. However, it is believed that ‘pure’ organic pain is as rare as ‘pure’ psychogenic pain. There is nearly always underlying anxiety whenever pain is experienced.

There are two types of pain; these being acute and chronic pain. Anxiety that accompanies acute pain usually subsides in proportion to decreasing intensity, as this is short-lived and has a foreseeable end.

Chronic pain is a long term pain which has endured for six months or longer. Depression often accompanies this type of pain, as there may be intense adjustment by the sufferer to their way of life with little hope of an end to their pain.

The Gate Control theory propounded by Melzack and Wall is said to explain why those who have sustained seemingly horrific injuries during time of intense activity, such as in battle, do not appear to perceive their pain from them.

Psychological aspects of pain include emotional pain, in which the sufferer feels a sense of helplessness and spiritual pain, which leaves the sufferer with a desolate meaninglessness to their lives. The memory of pain will affect how a patient judges their current pain. If this is associated with a tragic incident in the past, then the patient’s anxiety will be increased..

Although pain assessment and pain control are to be a priority within nursing, it is often under-assessed and unrelieved, due to a variety of reasons. These include embarrassment or stoicism on behalf of the patient. Nurses under-judge a patient’s pain if the cause is perceived to be a minor one. There is also a fear of addiction from narcotics. Culture, age, personality and gender can shape patients’ and nurses’ attitude towards the perception and subsequent management of the pain.

Pain assessment tools commonly in use include questionnaires, colour and faces scales, numerical, visual and verbal rating scales. Non-verbal communication perhaps presents a greater challenge to the nurse than verbal communication, as the nurse must translate cues such as raised vital signs and body movements into an expression of pain.

It is found that patients who are fully aware of outcomes of their treatment and can control their pain, subsequently recover faster.

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