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After completing the post test, you can print your certificate PAIN MANAGEMENT A COMPREHENSIVE REVIEW ABSTRACT Pain can be defined as a complex, multi-dimensional provocation. It is one of the major reasons that people seek health care. Pain is a response to noxious stimuli and can function as a protective mechanism of the body to prevent further injury. The sensation of pain as the warning of potential tissue damage may be absent in people with certain disorders, such as diabetic neuropathy, multiple sclerosis, and nerve/spinal cord injury. There are a number of approaches in the management of pain, each with respective advantages and disadvantages. According to a recent medical report titled ‘Relieving the pain in America' published by A Blueprint for Transforming Prevention, Care, Education, and Research, pain is a significant public health problem that costs Americans at least $560-$635 billion annually, an amount equal to about $2,000.00 per person living in the U.S. Consequently, the total incremental cost of health care for controlling pain ranges between $261 and $300 billion, and $297-$336 billion is attributable to a loss in manpower productivity. Ultimately, there should be proper pain management measures in place in order to reduce the root cause of pain, the length of pain, and the effectiveness of pain management. This course aims to offer a comprehensive review of the pain management methods that are currently available, as well as offer some new insight into the modern and innovative measures of pain management. LEARNING OBJECTIVES 1. Define pain 2. Describe the magnitude of pain 3. Enumerate the characteristics of pain 4. Explain the types of pain 5. Describe the negative consequences of pain 6. Describe the pathophysiology of pain 7. Elaborate the theories of pain 8. Identify the factors affecting the pain 9. Demonstrate appropriate use of pain measurement instruments 10. Explain the pharmacological management of pain 11. Describe the non-pharmacological management of pain 12. Explain alternative therapies for the relief of pain 13. Discuss the patient self care method to relieve pain OUTLINE Introduction Pain is considered a “universal disorder” [1] that comes in many forms. Regardless of the form it is seen in, everyone experiences pain, with the perception of pain occurring differently in each individual. In the most benign form, pain serves to warn the individual that something is not quite right. Pain can, however, disrupt productivity, well-being, and indeed, the entire life of the individual experiencing the pain. At its core, pain is complex and differs greatly among individuals, including those who seem to have identical injuries or illnesses. Pain has a long history. Ancient civilizations recorded accounts of pain and the various treatments and cures used on stone tablets. Early humans also related pain to magic, demons, and evil. In early times, the responsibility of pain relief fell on shamans, priests, and sorcerers, who utilized herbs, rites and ceremonies to treat pain. The Romans and Greeks were the first peoples to advance the idea that the brain and nervous systems are key in producing pain sensations. However, evidence was not available to support this theory until well into the Renaissance in the 1400 and 1500s. It was not until the 19th century that real advancements in science led to advancements in pain treatment. Physicians discovered that such drugs as morphine, codeine, cocaine, and opium could be used to treat pain. These drugs then led to the development of aspirin as a pain treatment; even today this is the most commonly utilized pain reliever. Finally, anaesthesia advanced and became the standard for surgery. As we have moved into the 21st century, scientists and physicians are gaining an ever greater understanding of pain and pain treatment [1]. Pain today is a costly and very serious public health issue [2]. It is also a challenge for friends and family as well as health care practitioners there to offer support to the individual suffering from the pain. Pain related issues currently account for approximately 80% of doctor’s visits [3]. There are many things that affect how pain is felt. One is the type and extent of the injury itself. Another big thing that affects how pain is felt is the emotions the individual feels during the injury and recovery periods. Emotions strongly affect the perception of pain. Pain is not something that has any unit of measure. While practitioners can measure the extent of severity of an injury, there is no way for them to measure how or why some people feel more or less pain than others with the same injury [4]. However, there are a number of ways to address pain conditions, from pharmacological to nonpharmacological options as well as alternative therapies. It is also important to address the education of both practitioners as well as the individual, friends and family to ensure that pain is managed effectively. The better practitioners communicate with and educate their patients, the more likely that pain will be effectively addressed and managed. Additionally, there is a treatment gap that exists in pain management, which cannot be ignored. Women, children and older adults are at greater risk of being negatively affected by chronic pain and frequently end up receiving treatment that falls short. Understanding why this happens as well as what to do about it is essential for practitioners who are seeking to adequately and fully treat a variety of pain conditions that are experienced differently from individual to individual. Definition. The word pain is derived from the Latin word poena, which means a fine, or penalty. The International Association for the Study of Pain defines pain as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. [5]. Pain is an unpleasant sensation that ranges from mild, localized discomfort to extreme agony. There are physical as well as emotional components to pain. The physical component is the result of nerve stimulation [6]. Emotions have the ability to affect the way a person perceives pain. While all human beings have the same anatomical structures that convey nociception to the central nervous system, there are quite a few factors that alter the intensity of the pain perception [7]. It is important that practitioners consider both physical and emotional factors when treating patients, as these both influence a patient’s recovery [8]. Some people indicate that they tolerate pain well, whereas other individuals indicate that they are highly sensitive to pain [9]. Magnitude of pain. Magnitude of pain is a difficult thing to measure, primarily because different people experience pain in different ways [10]. However, there are some instruments designed to measure pain that apply universal standards to pain sensation and can be used across the board for all individuals. One such instrument is the visual analog scale. This scale is utilized to measure pain characteristics in a way that ranges across a scale of numerical values, with the number 1 being no pain and the number 10 being the worst pain imaginable. This pain scale is ideal for use with those individuals who possess a strong ability to define their pain. Another scale that is commonly utilized is the faces pain scale. This scale is frequently utilized with children or with those who are better able to provide a description of what their pain feels like according to the expression depicted on a face. This scale ranges from a smiley face that represents no pain to a face with a frown and tears on it to describe the worst pain imaginable. There are special descriptive scales to measure pain in infants. Since infants are unable to talk to describe their pain as well as being not cognitively developed enough to identify a face representative of their pain, practitioners rely on descriptions of the infant’s behaviour to determine the magnitude of pain. The use of these scales has its advantages as well as disadvantages. An advantage of utilizing scales such as these is that there is a universal standard by which practitioners may assess pain and in turn determine an initial idea of the severity of injury. However, since these pain scales are universal, people who are more or less sensitive to pain don’t necessarily fit into the pain “norm”, which can make an initial determination of how severe a condition or injury is difficult to make. This can mean that some patients are not receiving adequate care for their pain. One scale that may help correct pain discrepancies is the magnitude matching scale. Applying this scale to pain, for instance, would be particularly useful in hospital settings; for example, it can be argued that a woman undergoing childbirth is in more pain than any pain a man could experience. Therefore, even if a pregnant woman rates her pain as a 4 on a scale of 10, it is probable that they are in more pain than a man who provides the same rating. Characteristics Pain is a particular feeling that protects the body from noxious stimuli. Pain alerts the brain that a particular stimuli is unsafe, prompting the brain and the body to respond. However, pain is not just one feeling. It is instead a grouping of distinct feelings, all of which differ in clinical characteristics. What this means, for example, is that pain in the skin is a different type of feeling than is pain in the muscles. In order for practitioners to effectively treat injuries and pain conditions, it is essential that practitioners listen to the patient describe his or her pain in order to correctly determine all pertinent information – such as pain location, pain sensation, pain modality, and pain radiation – and to in turn present a treatment plan that will address all aspects of the pain [11]. It is also particularly important to determine the site of injury, although often the patient is not sure where their pain is originating. In order to determine effective treatment, it is therefore essential that practitioners understand the clinical nature of pain. Pain Severity: Many things influence the level of severity of pain. Things such as the patient’s personality, surrounding influences, and general sensitivity to pain make a difference. It is important to note that the severity of pain does not predict enough about the injury to allow a practitioner to draw reliable conclusions for diagnosis or prescribing. A more useful predictor is the relative sensitivity of the tissues involved. For example, the cornea, when injured, may only be injured slightly; however, the pain effect may be very serious. This is because the cornea is more sensitive than are certain other tissues in the body. It would pose a very large inconvenience if all of the tissues in the body were equally sensitive. Sometimes injury occurs in body tissue that is relatively minor and does not reach the consciousness; other times injury can be extensive and prompt extreme reaction. Further, if a particular stimulus – even a mild one – continues for too long a time period or if the affected tissue is still weakened following a previous injury, further damage to the tissues may be dangerous and the threshold for pain in that tissue is lowered. What this means is that sensitivity of tissues is not constant, but rather variable; sensitivity changes in response to circumstances surrounding previous injury. Pain site: The ability to locate the injury site simply by analyzing the pain that is perceived often depends on the tissue that has been injured. Pain Quality: Quality refers to the distinctive character of a pain sensation. It can best be described by comparing it to a pain or sensation that is familiar. For instance, comparison is utilized with familiar pain that is related to areas in the body; one example of this is describing pain in the area of the stomach as feeling like a tummyache. Pain may also be compared to function; one example of this is when an individual describes their pain as throbbing. Further, pain can also be described in comparison with another pain that is prompted by a stimulus that is familiar; one example of this is describing pain as burning because this sort of pain is prompted by the physical experience of sustaining a burn. Somatic Pain: There are at least 3 types of discernable pain: Surface pain, which comes from the cutaneous surface as well as the mucosal surface. Sub-surface pain; this type of pain is also called intermediate pain, which comes from subcutaneous tissues as well as from the submucosae. This type of pain also comes from adjacent tissue structures when subcutaneous tissue is thinner. Deep pain, which comes from the muscles as well as other deep tissue that is generally considered more sensitive. Surface Pain: Surface pain can feel different depending on the duration of the stimulus affecting it. For example, if the duration of the experience is very short, generally the resulting sensation is a pricking. However, if the duration of the experience is prolonged, the resulting sensation is generally a burning. This highlights differences only in pain duration, not in pain quality. While burning is a sensation that is commonly associated with excessive heat, it is not the response of the organ systems of the body to heat; rather, it is the response of the surface to the prolonged painful stimuli. Burning can be produced by extreme cold as well as by heat. The two sensations of pricking and burning on the surface are only present if cutaneous pain organs are not functional as a result of destruction or extreme damage. Itching: Sometimes injury to the skin also prompts an itchy sensation; however for itching to be present the pain stimulus must be acting on skin that is hyperalgesic. There will be no itching on skin that has remained normal. An example of this is seen in skin that has been injured by a condition such as dermatitis. This skin is not in a normal state and there is a risk of provocation even if the added injury to the skin is very slight, such as scratching, applying ointments to the affected area, and temperature changes. Itching is a variety of surface pain that is entirely free of other sensations and occurs only in skin that is hyperalgesic from previous injury. Other notable characteristics of surface pain: The main function of surface pain is to provide information about the painful stimulus so that the individual may make effective defensive reactions. Surface pain is very accurate: the pain is located in a precise spot and localized. The protective reflexes that the injury provokes are entirely directed with extreme precision toward eliminating the painful stimulus or toward withdrawing the injured part of the body from danger. Pain from Mucosae: Not all mucosae are sensitive. For example those mucosae that are distant from the site of injury are not sensitive at all. However, when a mucosa is sensitive the pain sensation felt is either pricking or burning. Itching may also be present. Regardless of the stimulus, the quality of the pain is always the same. For example, burning in the mouth may occur as a result of eating overly heated food or as a result of another irritant, such as chemicals, ulcers, or catarrhal inflammation. The mucosa in the esophagus is not normally sensitive to thing such as gastric juice, which is frequently regurgitated even in normal digestion. However, when the mucosa is injured from another cause, it becomes sensitive to another injury and exhibits burning pain. Therefore, if the mucosa is injured by overly heated food, it will react more sensitively to gastric juice. The mucosa of the cervix does not burn in response to pain; however when underlying tissues are affected it prompts pain in this mucosa. This lends to the idea that this particular mucosa is insensitive, as it does not respond to such painful stimuli as a pin prick. Likewise, pain in the nasal mucosa is due mostly to the periostium underlying the mucosa. Nasal sinuses as well as the middle ear are generally described as possessing sensitive mucosa, but it is a likely conclusion that the mucosa itself is not sensitive and the perceived pain is periosteal. Sub-surface/Intermediate pain: Pain in the subcutaneous surface has some differing qualities from deep pain, particularly if subcutaneous tissues are thinner, as is the case in the tissue over the forearm, tibia or knuckles. However, if the subcutaneous tissue is thicker – as is the case in the mammary region on females – pain in the inner strata is not described as being much different in quality from deep pain. Pain of the subcutaneous surface is somewhat diffuse, but the diffusion is limited to a small zone surrounding the injury. Deep Pain: Pain in the deep tissues possesses an aching quality. This type of pain is commonly found in the muscles or in other deep tissues that generally are more highly sensitive. Deep pain is non-discriminative and does not have the ability to offer information about the stimulus or the source of the pain perception. This type of pain starts well after the injury and is generally persistent. Additionally, this type of pain is very diffuse. Pain in deep tissues is impossible to be felt only at the injury site. This is a type of radiating pain, and the radiation is frequently quite extensive. However, there are several factors that determine whether pain remains local or exhibits extensive radiation. For example, the severity of the injury sustained is very important, as is the depth of injured tissues. The deeper the tissue the more likely it is that pain will radiate out extensively. Additionally, if the injured tissues are close to areas of the body that are vitally important, there is a greater likelihood of radiation. . Deep pain is accompanied by reflexes. However, these reflexes do not provoke brisk and defensive movements, as is the case with surface pain. They are more focused on resting the part of the body that is injured and serve to protect that part of the body from further injury. They are not as focused on removing the injurious stimuli. The pain may then be felt as a spasm that radiates outward. Additionally, the way an individual reacts when experiencing deep pain tends to inhibit further activity in order to protect the injured area. Visceral Pain: The viscera is generally lying so deeply that it is well protected and does not respond to stimuli that normally provokes pain in somatic tissue. In fact, many viscera are entirely insensitive and the pain that may be associated with them is prompted by the extension of the lesion to adjacent tissues. However, some other viscera are sensitive. Types Duration-acute, chronic and malignant pain Acute pain is a type of pain that begins suddenly and is generally sharp in quality. Acute pain warns that there is a threat of some kind to the body, either an injury or a disease [12]. However, acute pain can be caused by a number of events, which include: Surgery Dental work Labor and childbirth Broken bones Burns or cuts Acute pain may present as mild and momentary, but it can also be severe pain that lasts for weeks or months. Generally however, acute pain does not last beyond six months. Additionally, acute pain disappears when whatever is causing the pain is healed or treated. When acute pain is not relieved it can lead to chronic pain. Chronic pain is pain that persists even after an injury has been healed or treated. This type of pain is a result of pain signals remaining active in the nervous system over an extended period of time and can last for years. It can also be affected by physical impairments, such as tense muscles or limited mobility, or a lack of energy. Emotions such as depression, anxiety, anger, and fear of aggravating an existing injury can also affect the sensation of chronic pain. Emotions in particular can hinder an individual’s ability to return to normal activity at work or play. Some of the common complaints associated with chronic pain are: Headache Cancer pain Neurogenic pain Low back pain Arthritis pain Psychogenic pain Chronic pain frequently originates with some initial trauma or injury. However, it is possible that there could be an ongoing cause of chronic pain. It is important to note though that there are those individuals who suffer from chronic pain without the presence of a past injury or trauma. It is important to understand that the pain these individuals feel is no less real than that pain caused by an ongoing disease or injury. In an effort to better understand chronic pain, some studies [13, 14] have indicated that chronic pain ranges from 10.1% to 55.2% of the population. One theory of chronic pain is that prolonged exposure to acute pain may prompt long-standing changes to the central nervous system, which creates chronic pain [15, 16]. Under normal conditions, the painful stimuli diminishes as the healing process moves forward, leading to lessened pain sensations until there is minimal to no pain detectable [17]. However, persistent pain may activate secondary mechanisms in the central nervous system that cause hyperalgesia, hyperpathis, and allodynia, which can diminish normal function. One way to better understand pain comes from the idea of neuroplasticity. Neuroplasticity occurs a short while after acute pain sets in. The remodelling of the neuronal cytoarchitecture that occurs leads to a transition from acute pain to chronic pain [18, 19]. To best understand chronic pain, practitioners must understand that even small amounts of residual pain may affect physical and social function in a negative way. Practitioners must understand that chronic pain is a common and serious problem that can greatly alter the lives of individuals who suffer it [20-23]. Location-pelvic, head ache Pelvic pain is defined as being pain that exists in the lower portion of the abdomen and pelvic [24]. Generally, pelvic pain is utilized in reference to symptoms that women suffer that arise from the reproductive or urinary system. Pelvic pain can range from dull to sharp sensations, be either constant or intermittent, and may be anywhere from mild to very severe. Pelvic pain is frequently felt in the lower back as well, as pain from the pelvis can radiate up into the lower back. Chronic pelvic pain indicates any pain in the pelvic region that has been present for more than a few months. The pain can be either constant or intermittent; what makes pelvic pain chronic is time duration. Pelvic pain may only be noticeable at certain times. Examples of this would be pain during urination, menstruation, or sexual activity. Additionally, conditions and diseases of various body systems can contribute to pelvic pain. For example, pelvic pain may originate in the intestinal tract, reproductive system, or urinary system. Pain in this area may also originate in the muscle tissues of the pelvic floor. Less frequently, pelvic pain can be caused by nerve irritation in the pelvis. Reproductive pain is the most common in the pelvic region. This kind of pain can arise from a variety of causes, including: adenomyosis, ectopic pregnancy, endometriosis, cramping during the menstrual cycle, miscarriage, ovarian cysts or cancer, or pelvic inflammatory disease. Other causes of pelvic pain that exist in both men and women include: Adhesions, appendicitis, colon cancer, constipation, Crohn’s disease, Fibromyalgia, a herniated disk, interstitial cystitis, irritable bowel syndrome, kidney stones, a urinary tract infection, physical or sexual abuse, muscle spasms of the pelvic floor, or sciatica. If an individual suddenly develops pelvic pain that is severe, this can indicate a medical emergency, and prompt medical attention is necessary. Pelvic pain should be examined by a practitioner in particular if it is a new sensation, is disrupting the patient’s daily life, or if it has been getting worse as time passes. Headache may take a variety of forms where pain is concerned. Headache pain can feel like a vise is being tightened around the top of the head, throbbing pain at the base of the skull or in the temples, or occur in combination with nausea and an increased sensitivity to such stimuli as light and sound, to offer a few examples. Headache can occur on its own or along with another disease or condition. Headache is nearly universally experienced across age groups. Both children and adults experience headache, and nearly 2/3 of children experience headache by the time they turn 15 years of age [25]. Therefore, headache is considered the most common form of pain and often leads to missed days at school or work. Some individuals experience headache only once or twice a year; others experience headache for more than 15 days per month. Headache episodes may ease and disappear for some time and then re-emerge later in life, recur, or last for weeks at a stretch. Additionally, it is also possible to have more than one type of headache at one time. Headache can range from mild to severe to the point it interferes with daily activities. This makes it essential that headache is treated promptly and effectively. Types of headaches: Primary headaches. This type of headache occurs independent of any other medical condition [26]. Researchers currently do not know exactly what mechanism sets a primary headache into motion. However, events that affect the blood vessels and nerves inside and outside the head cascade to cause pain signals that are then sent to the brain. The brain’s neurotransmitters as well as changes in the activity of nerve cells – an occurrence called cortical spreading depression – create the head pain. Primary headaches are divided into four main groupings: migraines, tension headaches, trigeminal autonomic cephalgias, and miscellaneous. Primary headache types include: Migraine. Approximately 12% of people in the United States experience migraine, which is a form of vascular headache [27]. Vascular headache is characterized by pulsating, throbbing pain that is the result of the activation of nerve fibers and reside in the brain blood vessels. The blood vessels temporarily narrow, which serves to decrease the flow of blood – and therefore oxygen – to the brain. This narrowing makes other blood vessels open wider in an attempt to increase the blood flow to the brain. Migraines often strike one side of the head. Symptoms include a throbbing, pulsing pain, sensitivity to light or sound as well as odors, and nausea or vomiting. If left untreated, migraine generally lasts between 4 and 72 hours. Even the most routine movements – such as sneezing of coughing – can worsen the pain of a migraine. The most common occurrence of migraine is in the morning hours, particularly upon waking. However, migraine can occur at any time in the day. Some individuals experience migraines at predictable times – for example, before menstruation or on the weekend after a stressful work week. Most people who experience migraine are symptom-free following a migraine. There are two main types of migraine [27]. These are: Migraine with aura. This is commonly considered the classic migraine. This type of migraine often includes neurologic symptoms that present from 10 to 60 minutes before onset of headache. These neurologic symptoms generally do not last more than one hour. Visual disturbances are a hallmark of the migraine with aura. Individuals may experience partial or complete vision loss while having this kind of migraine. This can occur even without the presence of a headache. Individuals also frequently have trouble speaking, experience numbing or muscle weakness, and tingling in the face or hands. Migraine without aura. This type of migraine is commonly considered a common migraine, as it occurs more frequently than does classic migraine. Individuals frequently have sudden headache pain occurring on one side of the head that comes on with no warning. Additional symptoms include nausea, blurry vision, mood changes and confusion, and increased sensitivity to light, noise or sound. Migraines consist of four phases. Each phase or some combination of the four may be present. These phases are: Prodromal phase, which can occur up to 24 hours prior to migraine development. Premonitory symptoms include unexplained food cravings and mood changes, fluid retention, uncontrollable yawning, and increased urination. Aura phase. In this phase some people see bright or flashing lights or an “aura” of light. This occurs immediately prior to onset of a migraine or during a migraine. Headache phase. This is the phase in which the migraine starts. The migraine may build in intensity in the headache phase. Some people experience migraine with no headache. Postdromal phase. This is the phase following the migraine attack. Individuals are frequently very tired or confused post migraine. This phase can last up to one day. There are a number of factors that increase the risk of migraine. These factors vary from individual to individual; however, these factors include sudden changes to environment or weather, too much or not enough sleep, exposure to strong fumes or odors, strong emotions, such as stress reactions, sudden noises, low blood sugar, and bright or flashing lights. In addition, medication that is overused or missed may cause sudden migraine headache. Also, certain foods or food ingredients can trigger migraine in up to 50% of those who suffer from migraine [25]. These foods include aspartame, wine, chocolate, certain cheeses, MSG, yeast, and caffeine (or withdrawal from caffeine). Individuals can help determine which foods trigger their own migraines by keeping a detailed food journal that includes indicating the onset of migraine. Tension headache. This type of headache, also commonly known as a muscle contraction headache, is the most common of the headache types. Stress, as well as mental and emotional conflicts trigger pain that originates from muscle contractions that take place in the scalp, neck, jaw, or face. This type of headache may in addition be caused by the clenching of the jaw, depression or anxiety, intense and stressful work, or lack of sleep. Sleep apnea is also a known cause of tension headaches, particularly upon waking. Tension headache pain is frequently felt on both sides of the head and the pain often resembles the feel of a vise around the head. Tension headaches often disappear once the period of stress that caused the headache has ended. Further, depression can bring on a tension headache as can certain postures that strain the muscles of the head and neck. There are two types of tension headaches: Episodic headaches, which present between 10 to 15 days a month, with each episode lasting from 30 minutes to several days in length. Chronic headaches, which generally occur more than 15 days a month over 3 months. The pain from chronic tension headache can be constant over this time and cause soreness in the scalp. Trigeminal Autonomic Cephalgia. This type of headache presents as severe pain that resides in or around the eye socket, generally on one side of the face and involuntary reaction of the same side of the face, for example, red or teary eyes, droopy eyelids, or runny nose. This type of headache is considered a pain disorder that comes in both episodic and chronic forms [28]. Episodic cephalgia may occur on a daily basis for weeks or even months per year with remissions that are pain free. Chronic cephalgia may occur on a daily basis for a year or even longer, with brief or no remission period. Cluster Headache. A cluster headache is considered the most severe form of primary headache. This type of headache consists of sudden and extreme headaches that occur in “clusters”, generally around the same time of day or night for weeks at a time. Cluster headaches affect one side of the head and present either around or behind one eye. This type of headache may start with a migraine-type aura and nausea. The nose and the eye on the side of the face that is affected may become red, teary, or swollen. Cluster headache frequently wakes people from sleep. Cluster headache generally is of shorter duration and frequency than is migraine headache. This type of headache most frequently begins between ages 20 and 50, but they can present at any age. Cluster headache is more frequent in men than in women. Alcohol and smoking in particular may prompt the onset of cluster headache. Paroxysmal Hemicrania. This type of primary headache is rare and generally begins in adulthood. Pain and other symptoms are similar to those that present in cluster headache, but the pain and symptoms are usually shorter in duration. Pain from paroxysmal hemicrania can occur between 5 and 40 times per day, with each headache attack between 2 and 45 minutes in duration. Pain is felt as a severe throbbing or piercing pain on one side of the face, with pain located in, around, or behind the eye and sometimes extending to the back of the neck. Additional symptoms may include watery or red eyes, swollen or drooping eyelid, or nasal congestion. Some individuals also experience pain and soreness between headache attacks and may be sensitive to light. There are two forms of paroxysmal hemicrania [29]: Chronic paroxysmal hemicrania. Patients experience headache attacks on a daily basis, lasting a year or longer. Episodic paroxysmal hemicrania. Patients experience headache attacks intermittently and may go months or years before experiencing a recurrence of headache pain. Paroxysmal hemicrania occurs more frequently in women than it does in men. SUNCT (Short lasting, Unilateral Neuralgiform headache with Conjunctival injection and Tearing). This type of primary headache is very rare and presents with small bursts of moderate or severe piercing or throbbing pain felt in the forehead, temple, or eye. Location is usually confined to one side of the head. Other symptoms include bloodshot or reddened eyes, watering of the eyes, nasal congestion, sweating on the face, puffiness in the eyes, and increased blood pressure. Pain may peak within a few seconds of headache onset and generally follows a pattern of increasing and decreasing intensity. Headache attacks usually occur during the day and can last between 5 seconds and 4 minutes [30]. Those who experience these attacks generally experience five or six attacks per hour and do not usually have pain between attacks. SUNCT is more common in men than it is in women. Onset is usually after 50 years of age. SUNCT also has chronic and episodic forms. Primary headaches may also be: Chronic episodes that occur daily for at least 15 days per month over a 3 month period, characterized by constant yet moderate pain throughout the day that is confined to the top or sides of the head. Stabbing, in which individuals feel intense and piercing pain that comes on without warning and lasts between 1 and 10 seconds. Stabbing headache is usually a spontaneous attack, but moving suddenly or looking into bright light can prompt stabbing headache. Exertional, in which physical exertion such as coughing or sneezing or exercise prompts headache, characterized by pain that lasts between a few minutes and 2 days, and may include nausea or vomiting. Hypnic, which is a type of headache that wakes people primarily during the night. This type of headache typically presents after 50 years of age, and can occur 15 or more times each month and last between 15 minutes and 3 hours after the individual has woken up. Pain is dispersed to both sides of the head. There is no known trigger of hypnic headache; however, researchers believe that these attacks may be a disorder that occurs during REM sleep. “Ice cream headache”. This type of headache occurs when the individual has inhaled or eaten something cold very fast. These attacks last for approximately 5 minutes and stop when the body adapts to the abrupt temperature change. “Ice cream headaches” are more common in those individuals who experience migraine. Secondary headache. Secondary headaches occur as a symptom of some other medical condition [31]. Secondary headaches may occur as a result of conditions such as infection, high blood pressure, fever, medication overuse, stress or conflict, tumors, stroke, head trauma, or mental disorders. Some of these causes are more serious than others. Serious causes of secondary headache include: Brain tumor. Tumors in the brain can press against the nerves and blood vessel walls, which in turn disrupts communication and limits the supply of blood to the brain. Headache is intermittent and can develop or worsen, come or go, and become more frequent or infrequent at irregular periods. Headache pain generally worsens when performing certain exertional activities, such as coughing, or when changing physical position very suddenly. Brain tumors are rare among those who experience headache. Stroke. Headache can cause a stroke or be the result of a stroke, where blood vessel activity is altered. There are two types of stroke: Hemorrhagic stroke. This form of stroke occurs when an artery bursts in the brain. Hemorrhagic stroke is generally associated with brain function that is disturbed and a sudden and extremely painful headache that worsens with such events as coughing or physical activity. Ischemic stroke, in which an artery in the brain becomes blocked, which decreases or stops the flow of blood to the brain, leading to cell death. Headache commonly occurs in those individuals who have clotting in the brain’s veins, with pain occurring on the side of the head where the clot is blocking blood flow. Pain frequently radiates out to the eyes or on the side of the head. Exposure to or withdrawal from certain substances. Headache can occur as a response to a toxic state, for example, drinking alcohol, being exposed to large doses of carbon monoxide, or from exposure to toxic chemicals found in cleaning products or pesticide. Headache response to a toxic state typically includes a pulsing and throbbing pain that increases with intensity the longer the individual is exposed to the substance. If left untreated, toxic exposure can cause permanent neurological damage as well as damage to organ systems within the body. Additionally, experiencing withdrawal from certain medications or from caffeine after heavy use can prompt headache. Head injury. Headache frequently occurs post-trauma and can be a symptom of concussion or other types of head injury. Pain is generally felt close to the site of injury, with pain radiating out through the head. The cause of headache that results from a trauma is frequently unknown; however, causes may include hematoma. An increase in intracranial pressure. Pressure changes in the brain may be caused by infections, hydrocephalus, or brain tumors that are increasing in size. These pressure changes frequently lead to headache with pain that is felt at the site of blood vessel compression or displacement, and radiates throughout the head. Inflammation occurring as a result of meningitis or encephalitis. Inflammation from these types of infections may harm and destroy nerve cells. The result is headache pain that can range from dull to very severe. Other results include brain damage or stroke. These conditions require immediate medical attention. Additionally, headache can occur as a result of other infections, such as the flu or a bacterial infection. Inflammation of the sinuses in conditions such as the flu results in facial pain that becomes worse if the individual strains or makes certain movements of the head. Seizure. Pain that is comparable to migraine can occur during or after seizure. The pain presents as moderate to severe, and lasts for a few hours. Pain can become worse if the individual moves their head suddenly or during physical exertion such as coughing. Symptoms also include nausea or vomiting, fatigue, and vision problems that can include sensitivity to light. Leaking of spinal fluid. Individuals who undergo lumbar puncture may experience headache that results from leakage of the cerebrospinal fluid post-procedure. Headache pain only occurs when the individual is standing; therefore, it is necessary for the individual to lie down and let the headache run its course. Headache resulting from a spinal fluid leak can last from a few hours to a few days. Abnormalities to the structure of the head, neck, or spine. Abnormalities of structure to the head, neck, or spine can cause headache. This frequently results from such abnormalities as a restriction of blood flow through the neck or irritation of nerves along the spinal pathway. This type of headache can also be the result of holding the head in a stressful or awkward position. Additionally, this headache can be the result of conditions such as chiari malformation or syringomyelia. Trigeminal neuralgia. Headache pain is caused in this condition by pressure placed on the trigeminal nerve, which sends sensations to the brain from certain portions of the face and mouth [32]. This type of headache presents as shocking or stabbing pain that occurs suddenly and is typically only present on one side of the jaw. Muscle spasms of the face may also occur. Headache may occur spontaneously or be triggered when the cheek is touched through routine activities, such as washing the face. Additionally, pain can be triggered through activity of the mouth, such as that activity that occurs with eating, talking, or brushing teeth. Individuals should see a doctor for headache under certain circumstances, as some types of headache can indicate the existence of serious medical conditions. Individuals should see a doctor immediately if they experience any of the following symptoms: Headache with sudden and severe onset that is accompanied by stiffness in the neck. Headache that includes nausea or vomiting or fever that can not be attributed to another illness. First occurrence of headache that is accompanied by weakness or confusion, or lack of consciousness. Headache that continually worsens as days or weeks passed, or headache that changes in pattern. Headache that recurs in children. Headache that occurs following injury to the head. Headache that is accompanied by weakness or loss of sensation in the body. This can indicate stroke. Headache that includes convulsions. Headache that includes shortness of breath. Headache that occurs two or more times per week. Sudden and persistent headache in an individual who was previously without headaches, particularly if the individual is more than 50 years of age. New headache in those individuals who have a history of HIV/AIDS or cancer. C. Etiology- Burn pain and postherpetic neuralgia Burn injuries can be extremely painful and disfiguring since they affect the largest organ in the body, the skin. These injuries, when major, can be disabling [33]. Approximately 45% of burn injury affects children and requires hospital admission [34]. Early pain management can significantly influence how the individual experiences pain resulting from burn injury later on. Pain in burn injury is affected by how large and deep the injury goes. Additionally, pain may be exacerbated by conditions resulting from the injury, such as infections. Burn pain is frequently difficult to manage, and as a result may be undertreated. When an individual feels the immediate pain following a burn injury, it is the result of stimulation of skin nociceptors whose job it is to respond to heat as well as both exogenous and endogenous stimuli. If the nerve endings are entirely destroyed by the injury they will not transmit pain signals, but undamaged nerve endings or others exposed to the injury will transmit pain over the course of treatment for the injury. Additionally, complications arise through the emergence of primary hyperalgesia and secondary hyperalgesia [35]: Primary hyperalgesia. A burn initiates a very powerful inflammatory response, and inflammatory mediators are released, which sensitizes the nociceptors at the injury site. This makes the area of injury as well as the skin immediately adjacent to the injury become sensitive to certain mechanical stimuli, including touching or rubbing as well as to certain chemical stimuli, including the application of antiseptics or topical ointments. Secondary hyperalgesia. Continuous peripheral stimulation of nociceptors causes greater sensitivity to areas surrounding the area of injury. This sensitivity is exacerbated by certain mechanical stimulation, such as that which occurs from changing wound dressing frequently. Burns differ in size and degree, which results in differing pain dependent on these factors. Conventionally, burns are classified by the total area of the body surface that was burned as well as depth of the burn. Simple observation may indicate that the larger or deeper the burn is, the more pain the person will feel. Realistically however, even deep burns consist of a combination of depth where the nerve endings were damaged as well as more shallow areas where some of the nerve endings are undamaged. Therefore, all burns elicit a pain response, and it is important that each instance be treated well and thoroughly. Additionally, psychological factors – such as anxiety over the new appearance of the area that was burned – also play an important role in how much pain the individual experiences. There is also more than one type of pain seen in the burn recovery process: Initial acute pain. Energy from the source of the burn leads to cell damage and the release of mediators. Individuals also experience reflex activity as a result of a burn, in which they attempt to remove the area that has been affected from the source to avoid further injury. However, this action is not always a possibility, and the individual ends up with a more severe injury. Additionally, sometimes the patient experiences stress-induced analgesia, in which the release of endorphins in the spinal cord results in there being either little or no pain immediately following the injury. Pain following hospitalization. A patient may experience various pain classifications following a burn injury. One is procedural pain that is of short to medium duration. This pain can feel highly intense during or immediately following the cleaning of the affected area or when procedures such as skin grafting take place. A patient may also have resting pain, which presents as a dull pain that is of long duration. This type of pain frequently exists when the patient is between procedures. Finally, the patient may experience breakthrough pain. This type of pain is usually of short duration and is linked with resting pain. Further, there is risk that the changes in damaged nerve fibers and surrounding tissues may lead to the development of chronic pain. In chronic pain syndromes, the sensation of pain continues for much longer than its expected duration. Chronic pain following burn injury can lead to other problems, such as difficulty sleeping, depression, and impairment of rehabilitation. The individual may experience hyperalgesia or allodynia. These issues may start very early in the post-injury course of recovery and can persist for a number of years following the initial injury. Chronic burn pain is extremely difficult to treat utilizing most analgesics unless there is inflammation or damage to tissues that is ongoing. Therefore, treatment of chronic burn pain frequently involves antidepressants, anticonvulsants, nerve blocks, or cognitive behavioural therapy. Postherpetic neuralgia occurs as a complication of shingles, which is caused by the same virus that causes chicken pox. Once an individual has had chicken pox, the virus that caused the disease remains inside the body for the rest of the individual’s life [36]. However, as the individual ages, the virus may reactivate. A number of things can cause this reactivation, including physical stress, such as that which occurs when the body is battling an infection or if the individual is taking medication that suppresses the immune system. The resulting infection is shingles. The shingles rash occurs in the areas of skin that contain the nerve where the virus was reactivated. Shingles generally clears up within several weeks. However, if there is pain lasting long after shingles has disappeared, it is termed postherpetic neuralgia. Postherpetic neuralgia affects the skin and the nerve fibers, and occurs if nerve fibers are damaged during a shingles outbreak. The damaged fibers are unable to send messages from the skin to the brain in a normal way, and instead sends confusing or exaggerated messages, which causes chronic – and frequently excruciating – pain that can last for months or years. Pain presents as a burning sensation and can be so severe that it interferes with functions such as sleep and appetite. Those who are 60 years of age and older have the greatest risk of developing postherpetic neuralgia. Those who have shingles on the face are also at greater risk of developing postherpetic neuralgia as opposed to those who experience shingles on other parts of the body. There is currently no cure for the condition, but treatment options exist that can ease pain symptoms. For many, the condition improves as time passes. VI. Negative consequence of pain Effect of acute pain Acute pain is one of the leading health conditions that today’s society experiences [37]. One source indicates that of Americans, pain is the most common ailment over hypertension, diabetes and cancer combined. Acute pain experience comes on quickly and can range from mild to severe pain; however, acute pain usually lasts shorter periods of time, for example, a few weeks, or until the injury has healed. This is in comparison with chronic pain, which lasts for a much longer duration, usually anywhere from weeks to over the course of an individual’s entire life time. Acute pain is generally the result of such events as muscle strains, headaches, broken bones, cramps, dental work, or child birth. Acute pain events are generally not life threatening; however, if acute pain is left untreated, the patient may experience a decrease in function and an increase in healthcare bills as a result. Not only are there physiological effects that come with acute pain, there is also a psychological component. Individuals who are unable to deal with their pain event or receive effective treatment may exhibit anger and irritability. Additionally, acute pain generally transitions to chronic pain if the acute pain has been prolonged, altering the individual’s way of life. Effect of chronic pain Chronic pain is a pain condition commonly thought to occur after prolonged exposure to acute pain. Chronic pain conditions can last for years. The biggest effect chronic pain has on individuals is an alteration of lifestyle; many individuals who experience chronic pain are unable to complete daily tasks in the same way they had previously been able to complete them. Chronic pain can also lead to a syndrome known as disuse, which means that people in chronic pain sometimes limit their activities in an effort to avoid pain. This in turn leads to weakness, which prompts the patient to limit activity even further, creating a vicious cycle. Additionally, there may be psychological complications that arise as a result of chronic pain. Individuals who are in chronic pain frequently experience depression, with some patients experiencing depression so bad that they express suicidal thoughts or behaviors. However, the individual’s psychological state at the time they experience the pain plays a huge role as well. If an individual was already depressed, pain may be perceived as a worse sensation. Additional to diseases such as depression, those living with chronic pain may become easily angered or irritated, or have trouble concentrating. All of these things can lead to further problems in the individual’s daily life. Since the effects of chronic pain can be so life altering, it is important to address the individual’s ongoing need to cope with pain effectively through medication, alternative treatment, and appropriate activity to offer the individual the best quality of life possible. VII. Pathophysiology of pain Past views on pain indicated that sensory input such as pricking one’s finger with a pin would then in turn cause a pain signal to make its way to the brain via one nerve. While pain isn’t entirely understood today, science has revealed that pain is much more complex; therefore, theories on pain continue to evolve. There are four concepts that are essential to understanding the physiology of pain [38].  These are: Transduction. This is a process in which afferent nerve endings take part in translating the noxious stimuli into nociceptive impulses. Transmission. This is the process in which impulses progress to the dorsal horn and then travel along sensory tracts and make their way to the brain. Modulation. This process includes the dampening or amplifying of neural signals related to pain. This process occurs primarily in the dorsal horn, but it can also occur elsewhere, with inputs from both ascending and descending paths. Perception. This last concept refers to how pain is experienced by the individual. Pain is highly subjective and perception is a result of the interaction of the previous three concepts as well as certain psychological and environmental aspects. Researchers believe that pain can manifest and affect men and women in different ways [1]. Sex hormones such as estrogen and testosterone play a part in this; however other factors such as age, psychology and culture may also play a part in the difference between how men and women respond to pain. For instance, young children may learn ways of responding to pain that are based on how they are treated when pain occurs. Therefore, if a child is encouraged to tough out the pain, or their pain is dismissed, the child learns not to highlight their discomfort. Many researchers believe that women tend to recover more quickly than do men from pain, partly because estrogen helps women recognize pain more easily. Women also seek help more readily and quickly for pain. Women are also not as likely to let pain define or control their lives. This is likely because women keep more resources at the ready for when they experience discomfort – women are more likely to speak readily about their pain, seek support, or utilize coping skills such as taking medication or using alternative therapies to deal with pain. However, women have a lower tolerance for pain than do men, which may be part of the reason why women have more coping skills at the ready than do men. Pain is also different in younger and older people. For older people, pain is the number one issue and complaint. One in 5 older Americans take painkillers regularly. The American Geriatrics Society [39] has issued guidelines to help with managing pain in older adults. These guidelines include incorporating non-drug approaches into the treatment regimen, such as exercise. They also recommend that older adults avoid utilizing NSAIDs because these drugs come with undesirable side effects that can manifest more prominently in older adults, such as gastrointestinal bleeding. Pain in younger individuals also mandates special attention. This is particularly the case since younger individuals cannot always describe the magnitude of the pain they are in. Treating children poses a challenge to both practitioners and parents; however, there should be care taken to ensure that the pain of a child is never inadvertently undertreated. Utilizing scales that rate such clues such as crying or responsiveness are important tools to help accurately diagnose pain in children. VIII. Theories of pain Theories of pain have changed throughout history, particularly as scientists have gained more insight into how the body operates. Before neurons were discovered and their part in pain was determined, there were various theories attributing the phenomenon of pain to different body parts. Greek theory is perhaps the earliest, and there were a number of competing theories to explain pain. For example, Aristotle thought that pain was the result of evil spirits entering the body; Hippocrates thought that pain was the result of an imbalance of the body’s vital fluids [40]. As time progressed, so did theories of pain. For example, Avicenna posited in the 11th century that there were different feeling senses, which included titillation, touch and pain [41]. However, all of these theories were a bit misguided, as before the scientific Renaissance that took place in Europe many had a poor understanding of pain. The predominant thought was that pain started outside the body, perhaps being a punishment from God [42]. Descartes posited a more plausible explanation of pain by stating that pain was a kind of disturbance that travelled down along the nerve fibers, with the disturbance eventually reaching the brain, and therefore awareness [40, 43]. Descartes’ theory changed the perception of pain from being that of mystery or spirit into a physical sensation. Descartes theory was an early indication of specificity, which was developed in the 19th century [44]. Another theory that was popular in the 19th century was intensive theory, the theory that thought of pain as an emotional state that was the result of unusually strong stimulus, including temperature, intense light, or pressure [45]. In the 20th century, peripheral pattern theory was developed by Sinclair and Weddell; this theory posited that the endings of skin fibers were all identical and that pain is the result of intensely stimulating these fibers [44]. Another theory that was popular in the 20th century was the theory of gate control, which indicated that both thin and large nerve fibers carried information from the injury site to a couple of destinations located in the dorsal horn [43]. Both of these theories have since been replaced with more modern pain theories. In the mid-20th century, Melzack and Casey offered a theory of pain that focused on three dimensions: cognitive-evaluative, sensory-discriminative and affective-motivational [46]. The idea was that the intensity and unpleasantness are not just determined by pain magnitude, but that cognitive activity can affect perceptions of certain aspects of pain. This theory led to new treatment recommendations: “Pain can be treated not only by trying to cut down the sensory input by anesthetic block, surgical intervention and the like, but also by influencing the motivational-affective and cognitive factors as well” [47, 48]. This theory is still influential today. Today’s theories focus on how and which sensory fibers differentiate between mild and extreme stimuli. It has been determined that some sensory fibers do not differentiate, while others, such as nociceptors, only respond to highly intense stimuli. Craig and Denton believe that pain is in a certain class of feelings, known as homeostatic emotions, which are feelings that are reflexive feelings. These feelings also include thirst or hunger, or fatigue. These feeling stem from the internal state of the body and are communicated by interoceptors to the central nervous system. Behavior is then prompted in an attempt to maintain the internal balance of the body. These emotions are different from classic emotions in that classic emotions are prompted by environmental stimuli, whereas homeostatic emotions are prompted by physical stimuli [49, 50]. IX. Factors affecting pain Different factors may affect pain perception; there are in fact a number of factors that affect the perception of pain. These include [2]: Location and severity. Pain varies in intensity and quality. It may be mild, moderate, or severe. In terms of quality, it may vary from a dull ache to sharp, piercing, burning, pulsating, tingling, or throbbing sensations; for example, the pain from jabbing one's finger on a needle feels different from the pain of touching a hot iron, even though both injuries involve the same part of the body. If the pain is severe, the nerve cells in the dorsal horn transmit the pain message rapidly; if the pain is relatively mild, the pain signals are transmitted along a different set of nerve fibers at a slower rate. The location of the pain often affects a person's emotional and cognitive response, in that pain related to the head or other vital organs is usually more disturbing than pain of equal severity in a toe or finger. Gender. Recent research has shown that sex hormones in mammals affect the level of tolerance for pain. The male sex hormone, testosterone, appears to raise the pain threshold in experimental animals, while the female hormone, estrogen, appears to increase the animal's recognition of pain. Humans, however, are influenced by their personal histories and cultures as well as by body chemistry. Studies of adult volunteers indicate that women tend to recover from pain more quickly than men, cope more effectively with it, and are less likely to allow pain to control their lives. One explanation of this difference comes from research with a group of analgesics known as kappa-opioids, which work better in women than in men. Some researchers think that female sex hormones may increase the effectiveness of some analgesic medications, while male sex hormones may make them less effective. In addition, women appear to be less sensitive to pain when their estrogen and progesterone levels are high, as happens during pregnancy and certain phases of the menstrual cycle. It has been noted, for example, that women with irritable bowel syndrome (IBS) often experience greater pain from the disorder during their periods. Family. Another factor that influences pain perception in humans is family upbringing. Some parents comfort children who are hurting, while others ignore or even punish them for crying or expressing pain. Some families allow female members to express pain but expect males to "keep a stiff upper lip." Additionally, birth order can play a part in how the individual is treated when in pain; sometimes oldest children are expected to take charge and keep their pain responses to themselves, while the “baby” of the family is allowed to freely express his or her pain responses. People who suffer from chronic pain as adults may be helped by recalling their family's spoken and unspoken messages about pain, and working to consciously change those messages. Culture and ethnicity. In addition to the nuclear family, a person's cultural or ethnic background can shape his or her perception of pain. People who have been exposed through their education to Western explanations of and treatments for pain may seek mainstream medical treatment more readily than those who have been taught to regard hospitals as places to die. On the other hand, Western medicine has been slower than Eastern and Native American systems of healing to recognize the importance of emotions and spirituality in treating pain. The recent upsurge of interest in alternative medicine in the United States is one reflection of dissatisfaction with a one-dimensional conventional approach to pain. There are also differences among various ethnic groups within Western societies regarding ways of coping with pain. One study of African American, Irish, Italian, Jewish, and Puerto Rican patients being treated for chronic facial pain found differences among the groups in the intensity of emotional reactions to the pain and the extent to which the pain was allowed to interfere with daily functioning. However, much more work on larger patient samples is needed to understand the many ways in which culture and society affect people's perception of and responses to pain. X. Instrument for assessing the pain perception Visual analogue scale The visual analogue scale is useful for people who have a strong ability to define what they are feeling as pain [51]. This scale utilizes a numerical rating system to allow practitioners to determine the severity of pain.  Obtained from: http://www.ttuhsc.edu/provost/clinic/forms/ACForm3.02.A.pdf [52] Faces pain scale The faces pain scale is particularly useful when assessing children, as children aren’t always able to adequately describe pain [51]. Oftentimes, children do not even understand that what they are feeling is pain – the faces pain scale allows for description of physical discomfort in ways that children can understand.  Obtained from: http://www.ttuhsc.edu/provost/clinic/forms/ACForm3.02.A.pdf [53] How to interpret pain in infants: It is more difficult to determine magnitude of pain in infants since they are unable to talk or describe their pain. However, there is a scale that may be utilized to assess pain in infants:  Obtained from: http://www.ttuhsc.edu/provost/clinic/forms/ACForm3.02.A.pdf [54] XI. Pain management strategies Pharmacological management Pharmacological pain management refers to the use of medication to manage pain. There are a number of pharmacological options available for pain management. These range from mild sedation to oral medication to general anesthesia that is utilized in the operating room. Pain medication may be administered in a number of ways, including [55]: Orally, through swallowing of a liquid or pill Intravenously, by way of a needle inserted into a vein Via a skin patch or cream Premedication assessment Premedication is the administration of drugs before anaesthesia [56]. Premedication can prove quite useful, and there are three main useful effects that are seen with the use of premedication. These are: Anxiolysis. This can be achieved with phenothiazines or benzodiazepenes if needed. Reduction in bronchial secretions. Reduction of secretions is not as much a major issue as it used to be. However, if needed, secretions may be reduced with hyoscine. Analgesia. The use of strong opiates is recommended. b. Balanced anesthesia Balanced anesthesia allows practitioners to minimize the risk to patients as well as maximize the comfort and safety for the patient [57]. There are several main objectives of balanced anesthesia, which include: calming the patient, minimizing pain, and reducing the likelihood of adverse effects that are associated with analgesics. It is essential to calm the patient because it allows for easy handling as well as decreases stress on the patient’s body. Easing stress is very important because it can cause other medical conditions such as tachycardia and hypertension. These conditions can all prove detrimental to the individual, as stress and anxiety play a part in the nociceptive pain process. Frequently, medications such as acepromazine, diazepam, or medetomidine are utilized to help the patient remain calm. Minimizing pain is also essential, as pain has been shown to decrease appetite, delay healing, and contribute to mortality. This is particularly the case in pediatric patients. Therefore, the best way to minimize pain is to stop the pain before it starts. There is always the risk of potential adverse reactions. Some of the more marked negative effects occur with inhalant anesthetics. These drugs are generally safe and prove extremely useful; however, it is important to consider that dosage of anesthesia can often be reduced through utilizing calming agents or analgesics properly. The best approach to balanced anesthesia also includes an individual assessment of both the patient and the procedure to properly plan anesthesia. In keeping the objectives of balanced anesthesia in mind, anesthesia may be utilized more effectively. Pro re nata (PRN) Pro re nata comes from the Latin meaning “as the circumstance arises’ [58]. This generally refers to the dosage that is unscheduled for prescribed medication; administration is left to the discretion of the practitioner, or if the patient chooses to take an unscheduled dose [59]. However, pro re nata is not an endorsement for exceeding the daily dosage of a prescribed medication [60]. Patients should take care not to exceed the dose recommended by their doctor. Pro re nata is also utilized for blood tests, wherein the practitioner will order a pro re nata for bloodwork that the patient can then use as the bloodwork is needed. Preventive approach. The best way to manage pain is to stop the pain before it starts. This can be attained by properly utilizing analgesics [57]. Some analgesics that are good for the management of pain are opioids such as morphine, butorphenol, fentanyl, and buprenorphine. Also NSAIDS such as carprofen, ketoprofen, and meloxicam are useful for preventing pain. Preventative approaches are sometimes called “pre-emptive pain control”, meaning that pain management measures are taken prior to the occurrence of pain or prior to the procedure. Often this is accomplished through utilizing a combination of medications. Practitioners will then often engage in a multi-modal approach to pain, which involves utilizing a combination of medications and techniques that help address the various ways in which an individual’s body is reacting to pain. These techniques may include some approaches that are non-pharmacological or alternative, such as distraction, hypnosis, or guided imagery. Individualized dosage. The goal of individual dosing is to provide a customized recommendation for dosage that provides the optimal efficacy with no adverse reactions [61-63]. Individualized dosing is primarily determined by characteristics about the patient, such as age, weight, gender, renal and liver function, and other diseases to ensure that patients receive the medication dose that is right for them [64]. An individualized dosage approach may be taken with even over the counter medications. The approach is worthwhile because it allows practitioners to prescribe a combination of medications in dosages that are just right for each individual’s pain experience. Patient-controlled analgesia Patient controlled analgesia (PCA) [65] is a process in which the person who is in pain is permitted to administer their own pain medication. Practitioners can program the infusion pump, which is the intravenous method of medication delivery. Morphine is frequently delivered this way. Programming the pump helps the patient to control their pain without resulting in an overdose [66]. Dosage is also controlled when the patient reaches a point in their pain relief where they are too sedated to administer more. This also keeps an overdose from occurring. However, patient controlled analgesia may be delivered by a route other than an infusion pump. For instance, the most common way patient-controlled analgesia is delivered is through the patient self administering oral medication. An example of this would be a medication that a patient may take more of if the initial dose did not effectively alleviate their pain. Patient-controlled analgesia may also be delivered through inhalation, or through intranasal analgesia, which allows for pain relief to be delivered via a nasal spray that has a built-in feature designed to control how many doses may be sprayed within a certain time period. This control feature helps prevent overdose of the medication. Finally, patient-controlled analgesia may be delivered transcutaneously. Opioids such as fentanyl are frequently delivered this way. Additionally, local anesthetics – lidocaine, for example – may be delivered transcutaneously. There are some distinct advantages and disadvantages to patient-controlled analgesia. Advantages would include the fact that the patient can self-deliver their medication, pain is alleviated more quickly because the patient has the control to address the pain immediately, and dosing levels may be monitored by medical staffs very easily through precautionary controls. It has been indicated that patients who utilize patient-controlled analgesia use less medication than do patients who are not on patient-controlled analgesia [67]; this is because patient-controlled analgesia allows the individual to spend less time in pain, which then leads to fewer overall doses being used. Disadvantages include the likelihood for abuse of medication (in particular narcotics), as well as the problems that result – such as under or overdosing on the medication – when the delivery system is not properly programmed. Also, it is important to note that patient-controlled analgesia is not appropriate for all individuals. For example, those who are easily confused or mentally disabled may not understand how to properly self-administer. Also, patients who have problems with dexterity may be physically unable to work the device. Patient-controlled analgesia is not generally appropriate for use in children. Local anaesthetic agent Local anesthesia is accomplished through the injection of a drug into the immediate area where surgery will take place. It is widely used and accepted in a variety of clinical settings [68]. Surgery in the office is highly dependent on local anesthesia. While this is convenient it is also associated with pain during administration of anesthesia. This pain can be attributed to factors involving the patient as well as the drug and technique. However, it is important to note that some patients are so adverse to this pain experience that they will either postpone or completely decline the surgery. Factors involving the patient: The first step any practitioner should take is to carefully explain to the patient exactly what will happen. This will help alleviate anxiety and better prepare the patient psychologically. It is also useful to utilize medications such as diazepam to help relieve anxiety in those patients who are very anxious. Additionally, practitioners can utilize other methods to better help the patient cope with local anesthesia, such as using distraction methods to make the patient more comfortable. Also, rubbing the skin on the injection site reduces that pain of the prick of the needle by stimulating A-fibers and inhibiting C-fibers, a process also known as the gate control mechanism. Another way that pain at the injection site can be reduced is by utilizing a topical anesthetic prior to injection. Yet another way of reducing this pain is by precooling the skin’s surface with ice packs [69]. Factors involving the drugs utilized for local anesthesia: Lignocaine and Sensoricaine are considered to be the most commonly used drugs for local anesthesia. These drugs have an acidic nature, which is what is responsible for the pain response. Technical factors: Twenty-seven to 30 gauge needles are preferred for the initial injection; this is because finer needles cause less pain [70]. When the initial infiltration is made, expanding tissues cause pain; therefore, if the drug is delivered at a slower rate there will be less pain [71, 72]. Additionally, the volume of the medication delivered at the infiltration site is proportional to the amount of pain experienced; this means that whenever possible a smaller volume of medication should be used. What is most important about local anesthesia is reassuring and counselling the patient so that they are prepared for the experience. If this is done in a confident, encouraging, and unhurried way it will allow for better results overall. Opioid analgesics Opioid analgesics have been used for the treatment of both acute and chronic pain for thousands of years [73]. The ancient Greeks were the first to identify and use opioids – which were originally derived from opium [74, 75]. From these humble roots, opioid analgesics became one of the main medical therapies utilized for pain each year [76]. Although there have been a number of drugs developed to treat different kinds of pain, there is no other single class of medication that has reached the same level of effectiveness for treating moderate to severe pain [77]. Opioids are frequently the first course of treatment for a number of painful conditions. Additionally, they may possess certain advantages over NSAID pain relievers. For instance, opioid analgesics do not have a real “ceiling” dosage; they also do not cause direct organ damage. There are, however, possible side effects that come with opioid analgesics. These include constipation, nausea or vomiting, decrease in sex drive, drowsiness, and depression of the respiratory system. Most patients do develop a tolerance to many of the side effects of opioid analgesics [77]. There is some debate over the use of opioid analgesics. It should be noted that some practitioners express concern over the use of opioids for pain conditions. However, opioids are frequently the only suitable course of treatment to control pain that is severe. This is particularly the case post-operatively [75]. Morphine is most commonly used in the post-operative period; however, some practitioners feel that other treatment action, such as the use of hydromorphone, is more suitable and better tolerated. Even given this, some recent studies indicate that there is no evidence to support the use of hydromorphone as opposed to morphine, and state that there are risks to using both drugs [78]. There is also debate over utilizing opioid analgesics to treat neuropathic pain. This is an area of study that remains a bit controversial. Recently, however, the Cochrane Review discovered that the results of utilizing opioids for neuropathic pain are mixed – shorter term trials produced contradictory results while intermediate trials indicated the efficacy of opioid analgesia for spontaneous neuropathic pain. Across all trials, the side effects that were most commonly seen were constipation, drowsiness, dizziness, and nausea [79]. It is also important to note that some individuals experience adverse reactions to opioid analgesics. This sometimes limits the effective use of opioids in certain patients. One long-term study of patients who took opioid analgesics for an extended period of time indicated that 80% of patients reported suffering at least one adverse consequence; 24% of patients stopped taking the medication as a result of experiencing one of more adverse consequences [80]. Of those who discontinued the medication as a result of an adverse consequence, 41% did so because they experienced constipation, 32% did so because they experienced nausea, 29% did so because they experienced somnolence, and 15% did so because they experienced vomiting [80]. Discontinuation of opioid analgesic treatment may result in pain being treated inadequately. This is not just an inconvenience; there are consequences to inadequate pain control that may be more far reaching. For example, patients who experience significant pain will experience an increase in autonomic and sympathetic activity [81]. In particular, older patients have a chance of developing delirium or other cognitive dysfunction [82]. Using opioid analgesics excessively may also lead to problems. There have been some reports that using opioids excessively can lead into a state of hyperalgesia [74]; this prompts some practitioners to express concern over utilizing opioid analgesics to control pain. However, the lack of effective pain control can on its own lead to a hyperalgesic state that presents as persistent pain [81]. In addition to medical issues that are tied to opioid use, there are some nonmedical issues that sometimes affect the prescribing of these drugs as well as the patient usage of the drugs. Some physicians express concern over prescribing opioids because potential legal issues may arise [83, 84]. Additionally, addiction is a concern, particularly among patients [85]. Clinical opinion polls on the subject indicate that true addiction to opioids occurs in a small percentage of the patient population who receive opioids for chronic pain [86]. Appropriate dosing and use can help ensure that addiction does not become a problem. NSAIDs NSAIDs is an abbreviation for nonsteroidal anti-inflammatory drugs. These are a class of drugs that provide relief for pain and fever, and in higher doses have anti-inflammatory effects. The name is meant to distinguish this class of drugs from steroids, which have a similar anti-inflammatory action. NSAID are unusual because they are non-narcotic. The most well-known members of this class of drugs are: aspirin, naproxen and ibuprofen. All of these drugs are available for purchase over the counter in most areas of the world. NSAIDs are generally indicated to treat acute or chronic pain conditions, particularly those where inflammation is present. Research is currently being done to examine the potential of NSAIDs in treating or preventing other conditions, such as some cancers. NSAIDs are usually indicated for relieving symptoms for a number of conditions, including [87]: Rheumatoid arthritis and osteoarthritis Inflammatory arthropathies Gout Mestatic bone pain Pain post-procedure Pain due to Parkinson’s disease Fever Renal colic Menstrual pain Headache, including migraine Pain from inflammation and tissue injury Though commonly thought of as an NSAID, acetaminophen is in fact not in this class of medications. This is because acetaminophen has little anti-inflammatory properties. Acetaminophen works to relieve pain by blocking COX-2, primarily in the central nervous system [88]. NSAIDs are advantageous, but they are also not without risk. The two most prominent adverse reactions seen with NSAIDs are gastrointestinal and renal problems. Side effects, however, are dose dependent. In some cases they are so severe that they present as a risk of ulcer perforation or gastrointestinal bleeding, or death. This limits the usage of NSAIDs. It is important to remember that NSAIDs are drugs that have the possibility of interacting with other medications. For instance, using NSAIDs and quinolones together can raid the risk of effects in the central nervous system, including seizure [89, 90]. Additionally, people who are on a daily aspirin regimen should be wary of taking other NSAIDs at the same time, as this may affect the cardioprotective aspects of aspirin. There are still many unexplained aspects of the mechanism of action for NSAIDs. One hypothesis is that there are further COX pathways to explore [88]. Muscle relaxant Pain management is a high priority for those individuals who suffer from pain. The usage of muscle relaxants to manage pain is gaining ground. These drugs include medications that reduce muscle spasms, such as diazepam, lorazepam, metaxalone, or alprazolamor some combination of drugs, such as orphenadrine and paracetamol [91]. Additionally, these drugs include medications that prevent increased muscle tone, such as baclofen and dantrolene. Antispasmodic and antispasticity medications have gained clinical acceptance as well. However, research for antispasmodic and antispasticity medications indicate that there are doubts as to the effectiveness of these medications. In one review [91] conducted to determine the safety and efficacy of muscle relaxants for managing pain in patients with rheumatoid arthritis, researchers discovered that across six trials – and with a total of 126 participants – there was no indication of any beneficial effects of muscle relaxants over a placebo for treatment of pain, and that in trials that lasted longer than 24 hours, participants experienced a marked increase in the likelihood for adverse effects. These effects were primarily side effects in the central nervous system, including such effects as dizziness and drowsiness. Anti seizure drug Anti-seizure drugs were originally designed and intended for use in epileptics. However, these drugs work to calm the nerves, which in turn can aid in quieting stabbing, burning, or shooting pain, primarily that found in nerve damage. Many things can damage the nerves, including injury, disease, surgery, or exposure to toxins [92]. After damage, these nerves are activated in an inappropriate way and relay pain signals that do not serve any useful purpose. Pain from nerve damage is frequently one of the most difficult to control and can be debilitating. Nerve damage, also called neuropathy, may be caused by a number of conditions, which includes: Diabetes. It is not uncommon to experience nerve damage as a result of high blood sugar levels, which are common in diabetes. Usually the first symptom of neuropathy in diabetics is numbness or pain in the hands and feet. Shingles. Shingles is caused by the same virus that causes chicken pox and presents as a rash that includes blisters that are extremely painful and itchy. Postherpetic neuralgia is the condition that occurs if the pain from shingles continues after the rash has disappeared. The risk of shingles increases an individuals age, so it is a good precautionary measure for anyone over 60 to make sure they receive the zoster vaccine, which can assist in preventing this condition. Chemotherapy. Sometimes chemotherapy drugs may damage nerves, which in turn causes pain and numbness that is usually first experienced as a tingling in the fingers and toes. Herniated disk. Damage to the nerves may occur as a consequence of a herniated disk when the disk squeezes a nerve passing through the vertebrae too tightly. Inherited neuropathies. Some types of neuropathy is passed on genetically. These neuropathies may affect different nerves; this is all dependent on the type of disorder. The most common of these neuropathies is Chacot-Marie-Tooth disease, which works by affecting the individual’s motor nerves and sensory nerves. It is not fully understood how anti-seizure medications help with pain management, but these medications seem to interfere with the overactive relay of pain signals that are sent from damaged nerves. Anti-seizure medications, while helpful, do have their disadvantages. One such disadvantage – which is one of the warnings the Food and Drug Administration [93] has indicated as a danger of anti-seizure medications – is that all of these medications are linked to an increase in suicidal thoughts or behaviour. Patients and practitioners must maintain effective communication through the prescribing period to ensure that these types of thoughts and behaviour are promptly caught and managed. Tricyclic antidepressants. Antidepressants are usually seen as a mainstay for treating pain conditions, in particular those that are chronic. This is often the case even when depression is not a factor. While these are not approved by the FDA to treat chronic pain conditions, they are widely utilized. Antidepressants are utilized to treat a number of pain conditions, including those caused by: Arthritis Postherpetic neuralgia Migraine Tension headache Fibromyalgia Pelvic pain Diabetic neuropathy Low back pain How these drugs work is not entirely understood. One theory is that antidepressants may increase the neurotransmitters in the spinal cord that in turn reduce pain signals. However, it is important to note that antidepressants do not provide immediate pain relief. Pain relief with antidepressants may occur in the first week following starting an antidepressant regimen, but maximum pain relief can take several weeks. Pain relief that comes from an antidepressant regimen is usually moderate. One of the most effective groupings of antidepressant drugs for pain are tricyclic antidepressants [94]. These include: Amitrityline Clomipramine Desipramine Imipramine Nortriptyline While useful, tricyclic antidepressants are not without their disadvantages. These disadvantages mostly come in the form of uncomfortable side effects, including blurred vision, dry mouth, weight gain, changes in blood pressure, drowsiness, constipation, and difficulty urinating. To help prevent side effects, practitioners should start patients at a lower dose and slowly work to increase the dose. The doses that are usually used for pain management are usually lower than the doses utilized to treat depression. Alpha adrenergic agonist. Alpha adrenergic agonists are commonly utilized for ailments such as bradycardia [95]. However, they have their uses for pain management as well. Alpha adrenergic agonists are a kind of sympathomimetic agent that works by simulating alpha adrenergic receptors. There are two classes associated with the alpha adrenergic receptor: ą1 and ą2. Two drugs in particular have been shown to provide very effective pain relief. Both are alpha-2 adrenergic agonists [96]. The first is tizanidine, which works very effectively at managing pain that results from tension headache as well as back, neuropathic, and myofacial pain. The second is clonidine, which works well at treating neuropathic pain that hasn’t responded well to other treatments. Treatment of migraine headache. Migraine treatment is unique in that pain can often be anticipated with migraines, which means that the goal of treatment is focused on both prevention and relieving symptoms [27]. There are several pharmacological treatments that specifically treat migraines, although some treatments that work on other types of pain – such as the application of ice to the forehead – are also useful in treating migraine headache. Drug use for migraines is divided into two categories – acute, which involves medication that is taken at occurrence in an attempt to ease or abort migraine symptoms; and preventative, which means the individual takes a medication every day to prevent occurrence of migraine headache. Acute treatments include: Triptan drugs to help increase the levels of serotonin in the brain. This causes blood vessels to constrict, which lowers the pain threshold. These drugs are the preferred treatment method for migraine, and they ease moderate to severe pain. Triptans are available as injections, tablets, or nasal sprays. Ergot derivative drugs work by binding to serotonin receptors, which in turn decreases the transmission of messages of pain along the nerve fibers. These drugs are more effective if the individual is still in the early stages of a migraine. Ergot derivative drugs are available as nasal sprays or injections. Nonprescription analgesics are also good choices for treating migraine. These include ibuprofen, acetaminophen, or aspirin. Some brands – such as Excedrin – are specifically formulated to treat less severe migraines. These brands are usually considered combination analgesics, as they frequently combine a non-prescription analgesic with another pain relieving agent, such as caffeine. Non-steroidal anti-inflammatory medication can help by reducing inflammation and alleviating pain. Taking a combination that includes a nausea relief drug can help by easing queasiness that is frequently seen with migraine headache. Sometimes narcotics are the way to go in treating migraine. Narcotics should be used for severe pain. They should also only be used for brief periods – if the individual experiences chronic headaches narcotics are not a good option. Prevention treatment should be seriously considered if the individual experiences migraine one or more times per week, or if their migraines are disabling. Preventative treatments include: Anticonvulsants, which are often helpful for people who experience other kinds of headache in addition to experiencing migraine. Anticonvulsants were originally developed to treat epilepsy; however, they are also useful for dampening pain impulses. Beta blockers are frequently effective in treating migraine. Calcium channel blockers work to stabilize the walls of blood vessels and work by preventing the blood vessels from widening or constricting. This helps alleviate the occurrence of headache. Additionally, there are several natural treatments available to help prevent migraine. These include vitamin B2, coenzyme Q10, magnesium, and butterbur. Non Pharmacological management The non-pharmacological management of pain refers to pain management without medication. Generally, non-pharmacological pain management uses ways to alter thoughts or focus to help decrease pain [55]. Cutaneous stimulation and massage Massage therapy has ancient origins and can be highly varied [97]. Massage therapy helps alleviate pain by releasing neurochemicals, including oxytocin, a neuropeptide. Massage has been linked to reduced blood pressure and heart rate and can also lower muscle or myofascial tension. The benefits of massage can become ongoing and give long term pain relief when the massage therapy is regular and consistent. Massage is particularly good for treating back pain or for treating certain types of headache, such as migraine. In one study of individuals with low back pain, those who received regular massage therapy had less intense pain as well as a decrease in the quality of pain. At a one-month follow-up, 63% of patients who received massage therapy reported having no pain [98]. Likewise, in a study of 26 migraine sufferers, those who received regular massage therapy sessions (defined as two 30-minute massages per week for 5 weeks) experienced less pain and sleep disturbances as well as more days free of headache [99]. Ice and heat therapies Ice and heat therapy is simple, yet effective, at managing certain types of pain, particularly pain in the lower back, muscle strains, or pain from arthritis [100]. It is essential, however, to understand how to properly use these therapies to maximize pain relief. Utilizing ice packs for the relief of back pain [101]: An ice or cold pack should be applied to the affected area for not more than 20 minutes at one time; application can take place several times per day. There are different types of ice or cold packs that may be used to help relieve pain in the lower back. Patients may select whichever option works best, or whichever option they prefer. These options include: Reusable cold packs or ice packs. There are a number of different kinds of reusable packs available for purchase at drug stores. These packs are often filled with gel and can be refrozen after each use. Individuals may also opt to make their own reusable gel ice packs. This is done by filling a small sealable bag with liquid dishwasher detergent and freezing it. Other homemade, reusable options include: placing ice in a plastic bag and holding on the affected area; freezing a damp towel and then placing it on the affected area; freezing a wet sponge, and once it is frozen placing it in a bag that is then wrapped in a towel or sock before applying to the affected area; filling a sock with rice and freezing it before placing it on the affected area; utilizing a frozen bag of peas for a quick ice pack. Disposable/Instant ice packs. Some packs are for single use only. These are generally available at most drug stores. However, a distinct advantage that many single use packs have is that they have the ability to become cold almost immediately. They also generally stay colder for a longer amount of time, even when used in warmer temperatures. There are disadvantages to single use packs, one being that they can only be utilized once, which can make them more expensive than reusable or homemade ice packs. Ice massage therapy may also be used for pain in the back. This can be done by using regular ice cubes, or by freezing water in a paper cup and then peeling part of the cup away to reveal the block of ice. Ice massages may be done by the patient themselves or by someone else. Patients can give themselves ice massages by lying to the side and reaching around the back to apply ice to the affected area. There are five steps to a successful ice therapy massage: The ice should be applied gently and massaged on the skin in a circular motion. The focus of the massage should be kept to an area of six inches around where the pain is felt. It is important not to apply the ice directly to the bony portion of the spinal column. Ice therapy massage should be done in 5 minute increments to avoid ice burn. Massage may be repeated 2 to 5 times per day. Patients should usually not apply the ice directly to skin without barrier in order to avoid burning the skin. In ice massage therapy, however, it is okay to apply ice directly to skin because the ice does not stay stationary. The aim of ice massage therapy is to make the area numb without burning the skin. After the numbness occurs, the individual can perform gentle movement that applies minimal stress to the affected area. Once the numbness wears off, ice massage therapy can be conducted once more for another cycle. Ice massage is most helpful in the 48 hours first following an injury. After this time period, heat therapy is generally more beneficial to healing. There are some precautions individuals should take to avoid getting ice burns. These include: Being certain to keep ice moving in a slow and circular motion without staying in one place for too long. Limiting ice massage to five minute massage periods. Making certain not to fall asleep with ice resting directly on skin. Avoiding ice application of all kinds if the individual has certain health conditions, such as those who have rheumatoid arthritis, cold allergic conditions, areas of impaired sensation or paralysis, or Raynaud’s Syndrome. Beyond being comforting, heat serves as an effective therapy for pain relief. Heat therapy has the ability to provide pain relief as well as healing benefits, particularly for those with lower back pain [102]. Heat therapy works to prevent pain, particularly in the lower back, through a number of mechanisms, including: Dilation of the blood vessels in the muscles surrounding the spine. This increases oxygen flow as well as the flow of nutrients to the muscles, which helps to heal damaged tissue. Stimulation of the skin’s sensory receptors; this means that applying heat therapy serves to decrease the transmission of pain signals to the brain and relieve discomfort. Facilitate the stretching of soft tissues around the spine. This means that there will be a decrease not only in injury but also in stiffness. This serves to increase flexibility as well as provide a more universal feeling of comfort. Heat therapy has the advantage of being inexpensive and easy as well as very beneficial. Heat therapy is much less expensive in general than many other forms of therapy – it is often even free, such as when the individual takes a hot bath. It is also easy – heat therapy can take place at home or even by utilizing on the go portable heat wraps. Finally, heat therapy is appealing in that it is non-invasive and non-pharmaceutical. Lower back pain from injury is not the only kind of pain that heat therapy can alleviate. Heat therapy also has the ability to reduce pain or soreness post-exercising [103]. One recent [104] study of more than 60 participants that tested the effects of low level heat therapy to delay the onset of muscle soreness concluded that it is possible to prevent delayed-onset muscle soreness by wearing heat wraps on the lumbar region prior to exercise [105]. This is a particularly important find because it is imperative to back health to remain active, as the back and spine benefits from activities that increase blood flow. Exercise also helps maintain flexibility, which is important to back health as well. However, muscle pain that results from exercising proves to be a deterrent to maintaining regular exercise activity. Therefore, research indicates that since heat wrap therapy can help minimize or eliminate the muscular discomfort that results from exercise, more individuals who are concerned about pain now have hope of staying on track with an exercise program if they apply heat therapy before exercising [106]. Low-level heat therapy wraps are available over the counter at most drug stores, or at medical supply outlets. Transcutaneous electrical nerve stimulation TENS is a type of stimulation that utilizes small electrical pulses that are delivered to nerve fibers through the skin. These pulses cause the muscles to change in certain ways, such as becoming numb or contracting, which results in temporary pain relief [107]. Additionally, there is evidence that TENS may activate certain subsets of nerve fibers that may block the transmission of pain at the spinal level. Distraction Distraction is a useful tool to help alleviate pain, particularly for children [55]. In children, using colourful objects, singing, telling stories, or reading books and viewing videos is particularly useful for distraction. Older individuals can engage in distraction techniques such as watching television or listening to music. Distraction in the form of video or board games can sometimes prove effective. Distraction eases pain by taking the individual’s attention away from the sensation of the pain. Distraction need not be tangible. Mentally distracting oneself can work just as well as physically distracting oneself. Picturing a pleasant place or experience from the past can help the individual work through the pain sensation. Guided imagery Guided imagery offers patients the opportunity to form images of their pain and in turn conduct a dialogue with the pain [55]. Guided imagery provides patients with an environment that is primarily established by a trained therapist asking questions, where the patient can create their own images that they will then use to understand their pain and communicate with it. Pain is an excellent arena for the use of guided imagery, although the technique is used for a range of issues. Since many people who have pain worry about it and imagine that it may never end, they end up seeing themselves in a state of helplessness. The aim of guided imagery is to use images to change that perception of helplessness by allowing the patient to converse with the pain and therefore have some power to change the situation. In one study [97] of 177 individuals who had chronic back pain, 76% treated with guided imagery were living normal lives with little or no pain, 8% had experienced improvement in their pain, and 16% experienced no change. That the majority of people in this study experienced immense improvement indicates that guided imagery is a viable treatment option for pain. Biofeedback is often used along with guided imagery to allow practitioners to observe how the individual is making changes to their bodily functions. Biofeedback is accomplished through hand held machinery that offers the practitioner an audio and visual look at how heart rate and muscle tension changes as the individual moves through guided imagery. Hypnosis Hypnosis was first approved to be used in a medical environment by the AMA in 1958. Hypnosis is an increasingly popular treatment, particularly when used in conjunction with medication. In hypnosis, a mental health professional or physician guides the individual into a state of altered consciousness that permits the individual to focus their attention in such a way that pain is then reduced [55]. Hypnosis is generally utilized to control a physical response, such as the amount of pain a person can withstand. Hypnosis likely results in pain relief by acting on certain chemicals within the nervous system, in turn slowing impulses [108]. While in a hypnotic state, the individual temporarily tunes out the conscious aspect of the brain; this leads to a reduction in distracting thoughts. Other physical changes occur, such as the slowing of respiration and pulse rate. Additionally, individuals become more open to suggestion, which makes hypnosis perfect for making suggestions to reduce pain. Following hypnosis, the practitioner can then reinforce the suggestions made to help the individual continue with the new, healthier behaviour. Hypnosis is generally conducted by an experienced practitioner in increments of half an hour to one hour to start, followed by 10 to 15 minute follow-up appointments. Some practitioners are able to give the individual post-hypnotic suggestions to allow the individual to induce hypnosis on themselves after the course of treatment is complete. Relaxation techniques Relaxation techniques involve things such as deep breathing or stretching to reduce pain. Deep breathing allows for greater focus and mindfulness, which may lead to pain reduction by acting on chemicals in the nervous system [55]. Additionally, greater delivery of oxygen to the brain can help alleviate pain in certain pain conditions, such as in some types of headache. Stretching is commonly recommended to help reduce pain, with one of the most recommended stretching activities being yoga. Not only does stretching help with flexibility, and therefore pain, but activities such as yoga refocus attention, which helps alleviate pain. Another relaxation technique is performing muscle relaxation exercises. This involves the individual moving through a series of movements in which they at turns tense and relax certain groups of muscles in a certain order. Often this technique begins at the feet and moves upward to the head area. Still another relaxation technique is meditation. Meditation involves clearning the mind by entering a state of mental and physical quiet to reduce anxiety. This practice leads to lowered blood pressure and slowed metabolism, as well as an increased threshold for pain. Even though the mind and body remain relaxed the individual is still awake and alert. Relaxation training is often useful in those who suffer from migraine headache. Utilizing this kind of training allows the individual to control the development of their pain as well as monitor the body’s response to stressors. Neurologic and neurosurgical approaches to pain management Stimulation procedures Electrical stimulation, which includes transcutaneous electrical stimulation (TENS), deep brain and spinal cord stimulation, or implanted electric nerve stimulation, is an extension of age old pain management practices where the nerves are subjected to a variety of stimuli. This includes cold or heat therapy, or massage. However, electrical stimulation requires a major surgical procedure and is not the right choice for everyone. Additionally, electrical stimulation is not 100% effective. The techniques utilized in electrical stimulation require special equipment as well as personnel that are trained in the exact procedure being used [107]. TENS utilizes small electrical pulses that are delivered to nerve fibers through the skin. These pulses cause the muscles to change in certain ways, such as becoming numb or contracting, which results in temporary pain relief. Additionally, there is evidence that TENS may activate certain subsets of nerve fibers that may block the transmission of pain at the spinal level. Deep brain and intracerebral stimulation is a more extreme treatment that requires that certain areas of the brain, particularly the thalamus, be surgically stimulated. This type of stimulation is generally only used for certain conditions, such as severe pain, cancer pain, central pain syndrome, and phantom limb pain. Stimulation of the spinal cord utilizes electrodes that are surgically inserted into the epidural space in the spinal cord. Individuals are then able to deliver a small electrical charge to the spinal card by using a small transmitter. Peripheral nerve stimulation utilizes electrodes that are placed on certain areas of the body. Individuals are then able to deliver a small electrical charge to the area that is affected by using a small transmitter. Administration of intraspinal opioid. Pain is extremely common, and is especially so in the low back. This type of pain can be devastating and disabling. While it is true that analgesics can provide relief in a fair number of patients, intraspinal opioids are a good option for those who are unable to tolerate oral medication [109]. Intraspinal opioids are delivered via an implanted pump. While intraspinal opioids can be advantageous, they come with similar side effects as do other opioid treatments. It is essential that practitioners work to identify those best suited for this type of therapy. Interruption of tract conducting the pain Nerve blocks for management of pain are utilized both for diagnosis and for therapeutic purposes. Some common diagnostic and therapeutic blocks are; Epidural steroid injections. These are used in particular if there is sharp, shooting pain in the spinal nerve and is performed if the pain is bilateral and includes multiple level nerve roots. Selective nerve root blocks. This type of block is done if there are only one or two nerve roots involved in radicular pain. This block is sometimes utilized for diagnosis. Peripheral nerve blocks. This type of block is done if the pain is in the distribution of peripheral nerves. Autonomic ganglion blocks. These types of blocks are utilized both for diagnostic and therapeutic purposes. There are a number of pain conditions for which these are used. XII. Alternative therapies A variety of factors affect how pain is perceived and dealt with. One factor is the extent and type of injury. Another is emotion and state of mind. Altering an individual’s mood or state of mind can be very effective when treating pain conditions [4]. Regardless of the alternative therapy chosen, relief of pain is the number one reason why Americans consult alternative therapies [110]. In an effort to locate alternative therapies that are effective at relieving pain and with few side effects, American spend billion each year on alternative treatments [111]. The National Center for Complementary and Alternative Medicine studied 31,044 adults and discovered that of these adults 36% had utilized some form of alternative medicine therapy in the preceding 12 months [112]. The researchers suggested that alternative therapies may be seen as viable choices if other therapies proved to be ineffective or had too many side effects. It is therefore essential that practitioners be aware of the alternative therapies – and adequately educated in their usage – that may be utilized to treat pain and answer patient questions effectively to ensure that there are no interactions with drug therapies, if they are being used. One study conducted by Eisenberg et al. [113] indicated that many physicians do not adequately address the use of alternative therapies because they are not knowledgeable enough about them. Another study indicated that patients were likely to begin these therapies without speaking to a doctor because of a perceived disapproval of the therapy. Therefore, it is essential that practitioners gain the necessary knowledge and remain open-minded to the use of alternative therapies in order to ensure that patients have the proper care [114]. Music therapy Music therapy is a practice in which musical intervention is utilized to manage an individual’s pain. Music therapy is typically performed by a credentialed professional who has completed a course of education in a music therapy program. Music – along with the development of a therapeutic relationship – is utilized to address physical, cognitive, or psychological needs in individuals of all levels of functioning. Music therapy is a noninvasive therapy. Music therapy outcomes are mediated through the patient’s responsiveness to the music and the music therapy relationship. Emerging finds in the area of neuroscience indicate that some individuals respond better to music therapy than do others [115]. The reason for this is not yet known. Herbal therapy Utilizing herbal therapies to treat pain is becoming increasingly popular [116]. Herbal therapies may be used alone or as a way to complement traditional approaches. However, it is important to note that research in this area that examines the efficacy of such therapy is quite limited. There are still a number of questions that remain about the underlying mechanisms in herbal therapy to provide analgesia [117]. In spite of the fact that they are utilized extensively, there is a lack of scrutiny or regulation on herbal supplements. A great number of those who utilize herbal therapies have chronic conditions. One study by Boon et al. [118] indicated that some individuals who have breast cancer utilize alternative therapies – including herbal therapy – for a variety of reasons, including boosting the immune system, increasing the quality of life, providing a feeling of control in their lives, to aid other medical treatment or to treat the cancer itself. There are many problems that lead individuals to utilize herbal therapies, but the most common are anxiety, chronic pain, back problems, and urinary tract problems [119].According to several studies, [120] those most likely to seek alternative treatment are women and older adults. Most individuals believe that herbal treatments have fewer side affects than do conventional medical treatments [113]. However, those who use herbal therapies do face the potential of adverse effects, including drug and herb interaction, as most alternative therapies are utilized in conjunction with conventional medical approaches [113]. In fact, one survey [113] indicated that 79% of survey respondents believe that the combination of alternative therapies and conventional therapies is more effective than is either approach on its own. It is important to consider the possible risks associated with herbal therapies. For example, interactions between herbs or between herbs and standard medical treatment can produce undesirable side effects [117]. One such interaction is the interaction between St. Johns Wart and certain antidepressants such as sertraline; side effects of this combination include nausea or vomiting, or anxiety [121]. Additionally, herbal remedies remain unstandardized, a fact that can prove difficult for practitioners to determine exactly what is causing an interaction. A study conducted by Abbott et al. [122] indicated that 8% of those participants who tried herbal medicine had some sort of adverse reaction. Some researchers [123] indicate that herbal remedies are simply dilutions of naturally occurring drugs, which may contain many different chemicals that are not well regulated or well documented. Further, labels on herbal therapies are not always a reliable source of information, not often listing details such as effectiveness or potential side effects [124]. The lack of information is opposed to what the general public believes must be included on labelling on herbal remedies. For example in one study [125] 68% of study participants indicated that they thought the government required makers of herbal remedies to provide labelling that detailed the remedy’s possible side effects and dangers. Reflexology Reflexology involves applying appropriate pressure to certain areas of the feet, hands, or ears, which in turn alleviates pain or improves an individual’s general health. Reflexology is performed by qualified reflexology therapists. Reflexology should not be used to diagnose or cure medical problems; however, millions use it as a complement to other medical treatments. It is in particular used to address conditions such as anxiety, cancer, diabetes, asthma, cardiovascular problems, headaches, and PMS. Reflexology is growing in popularity in particular in Europe and Asia and is used in these regions as a complement to other medical treatments as well as a preventative measure. The power of reflexology can be seen through the results obtained by corporations in Denmark who have employed reflexologists starting in the 1990s [126]. Studies indicate that utilizing reflexology has resulted in a lowered amount of sick leave or absenteeism for corporations that have employed reflexologists. Employees also have reported experiencing greater satisfaction with their jobs after having 6 reflexology sessions. There are a number of reflexology points in several areas on the body. Reflexology theory indicates that there are reflexology points on the feet, hands, and ears. These correspond to certain organs, bones, or body systems. Applying pressure to certain organs can affect organs or body systems. Most reflexologists use maps to see what areas correspond with different areas of the body:  Reflexology points on the feet and their corresponding systems. Obtained from: UMN Center for Spirituality & Healing [126] Each foot on the map represents one half of the body, divided vertically. For example, the left foot corresponds to all organs and systems on the left side of the body; conversely the right food corresponds to all organs and systems on the right side of the body. Reflexologists pay perform a general session in which multiple organ systems are addressed, or he or she may choose to focus on one specific problem area. For instance, if there is limited time and the person needs to relax quickly, the reflexologists may choose to work only on the ears. Regardless of the chosen approach, reflexology works to release stress in the nervous system and provide energy balance for the body. Researchers from the University of Portsmouth [127] who have studied the effects of reflexology have discovered that people perceived around 40% less pain as well as were able to withstand pain sensations for approximately 45% longer when reflexology was utilized as a mode of pain relief. Participants in the study conducted at the university were told to submerge their hand in a bucket of ice water. All participants participated in both a session where they received reflexology prior to submersion as well as a session in which they believed they were receiving a TENS treatment, although the machine was not actually turned on. Researchers discovered that when participants received reflexology prior to submersion had the ability to keep their hand submerged longer as well as a greater ability to tolerate the pain from the ice for a longer time period. Dr. Carol Samuel, who was a researcher on the study indicated that the study is one of the first to scientifically examine reflexology as a pain relief treatment. Samuel indicated that the results of the study suggest that reflexology may be effective when utilized as a complement to conventional drug therapy in certain conditions, such as cancer, osteoarthritis and backache. She went on to state, "As we predicted, reflexology decreased pain sensations. It is likely that reflexology works in a similar manner to acupuncture by causing the brain to release chemicals that lessen pain signals" [127]. Reflexology is commonly criticized for not being studied appropriately and under carefully controlled enough conditions. However, in this study the TENS ruse was utilized as the control against which reflexology was studied, and therefore has a greater scientific basis. Dr. Samuel has gone on to add, “This is an early study and more work will need to be done to find out about the way reflexology works…however, it looks like it may be used to complement conventional drug therapy treatment of conditions that are associated with pain…” [127]. Magnetic therapy Magnets have not been shown to work effectively for any purpose related to health; however, static magnets are widely marketed as a device to help alleviate pain [128]. Since scientific research does not support magnet usage as a viable technique to alleviate pain, it is not recommended that magnets be used in replacement for conventional treatments. Additionally, individuals should not utilize magnets in lieu of seeking help from a licensed health professional. It is important to note that magnets are not a safe treatment method for all individuals, particularly those who use insulin pumps or pacemakers, as magnets can interfere with these devices [129]. Generally, however, it is safe to use magnets; practitioners should simply be aware if an individual is trying magnet therapy and know the risks so he or she can pass these on to the patient. There have rarely been side effects or complications resulting from magnet therapy. Magnets produce a force that is measurable; this is called a magnetic field. Magnets that are static – the kind of magnet used in magnet therapy – have fields that do not change in measureable force. Magnets are generally made from certain metals or alloys, such as iron or some other mix of metals. Magnets come in different strengths that are measured in gauss units. The type of magnet generally marketed for relief of pain have a strength of 300 – 5,000 gauss [130]. To put this into perspective, this strength is many times greater than the magnetic field of the earth, but much less strong than the magnets utilized in MRI machines, which are about 15,000 gauss or higher. Magnets are frequently marketed for a number of different kinds of pain, including pain in the back or pain that results from conditions such as fibromyalgia. Magnet therapy is also available in a number of different forms, including insoles for foot pain, bracelets or other types of jewelry, in mattress pads for back pain, and in bandages to prevent localized pain relief. While there is no scientific evidence supporting utilizing magnet therapy for pain, a study sponsored by the National Institutes of Health [129] that examined back pain in a small pool of participants has indicated that participants generally benefited from utilizing magnets. However, this study is not conclusive, as it was small; most more rigorous trials have indicated that magnets do not have any affect on pain. Electrotherapy Electrotherapy is a treatment that is commonly utilized to help reduce both acute and chronic pain [131]. It is considered most helpful to utilize this treatment immediately following the injury. Electrotherapy works by stimulating the nerve fibers with small currents of electricity. This stimulation then in turn promotes the release of endorphins which alleviates the pain. Electrotherapy treatment is conducted by a qualified health professional. Electrotherapy may be used in addition to other therapies such as heat and cold therapy or conventional medical treatments. There are several types of this non-painful therapy, which differ in frequency, effect, and waveform. Some of the commonly utilized forms of electrotherapy are transcutaneous electrical stimulation (TENS) and percutaneous electrical stimulation (PENS), inferential current (IFC), and galvanic stimulation (GS): TENS utilizes small electrical pulses that are delivered to nerve fibers through the skin. These pulses cause the muscles to change in certain ways, such as becoming numb or contracting, which results in temporary pain relief. TENS machines may be utilized in a clinical setting, or individuals will be instructed in how to utilize one of these units at home. TENS is a therapy that can be tolerated for hours, but pain relief lasts for a shorter period. PENS is an electrotherapy treatment that is similar to TENS, only PENS utilizes thin, acupuncture-type needles. This electrotherapy treatment is generally tolerated for a shorter amount of time than is TENS, but pain relief also usually lasts longer. IFC is a deep form of TENS and works by delivering a high-frequency waveform that penetrates skin very deeply. This is a good therapy to target those deeper causes of pain sensation. GS is an electrotherapy that issues a direct current over the area treated. This current affects blood flow. This type of electrotherapy is most commonly utilized for acute injuries that result from major trauma and that are combined with bleeding or swelling. GS is also effective at treating lower back pain or muscle spasms. Polarity therapy Polarity therapy is a therapy that believes that the balance and flow of energy within the human body is a foundation of good health. In this therapy, optimal health is attained when the energy systems within the body function naturally and the energy within the body flows smoothly with no blockages or fixations. Polarity therapy asserts that when energy within the body is not correctly balanced, or is blocked or fixed due to certain factors (such as stress), pain and disease are the result [132]. In the typical polarity therapy session, a trained practitioner assesses the energetic attributes present by utilizing such techniques as palpitations, interview, and observation. The polarity therapist works with clients through “energetic touch”, which means: “verbal interaction is energetic communication which has to do with reading the energy in people’s words and staying neutral vs. engaging in the emotions of the patient and verbal interaction” [132]. Energetic contact can be light, medium, or firm. Generally the effects the patient feels during a session are feelings of warmth and tingling. The goal of polarity therapy is to increase the individual’s awareness of the energy flow in the body. While there is no scientific evidence to support the claims that polarity therapy effectively rebalances the body, many individuals like the therapy and utilize it in conjunction with other alternative therapies or with conventional medical treatments. Acupressure Acupressure is a “reflex therapy” [133] that is similar to reflexology. Acupressure works with different points on the body to affect problem areas or even entire body systems. However, there are differences between acupressure and reflexology, the most prominent being that while reflexology focuses on the hands, feet, and ears, acupressure practices according to meridians, which are thin energy lines that travel the entire length of the body. Acupressure manipulates the more than 800 points on these meridians in an effort to provide pain relief. Some individuals confuse practices such as acupressure with massage therapy. However, massage therapy seeks to “work from the outside in” [133] by manipulating certain muscle groups to relieve pain and stress. Conversely, acupressurists view their work as “working from the inside out” [133] by applying pressure to certain points that in turn stimulates the nervous system and releases pain and stress. Acupressure points are also called “potent points” [134]. These points on the meridians are believed to be places on the skin that are particularly sensitive to bioelectric impulses. When the points are stimulated, endorphins are released and pain is in turn blocked and relieved [135]. Additionally, the flow of oxygen and blood to the target area increases, which allows the muscles to relax. In addition to pain relief, acupressure may help deliver new balance to the body by relieving the tension and stress that is causing it to function irregularly.  Acupressure points along meridians. Obtained from: www.medicinas-alternativas.net [136] Emu oil therapy Emu oil is an oil that contains elevated levels of Omega 3, 6, and 9. Emu oil is also a natural anti-inflammatory and is effective at easing the pain that comes from arthritis, back pain, and sports injuries as well as swelling [137]. Emu devotees utilize emu oil as a rub to relieve pain. Emu oil is considered safe for all ages – from babies to senior citizens – and there are no known side effects of the treatment. There are also no scientifically proven benefits to emu oil treatment either, although emu oil is claimed to relieve a variety of ailments, including: headaches, cough, certain skin or hair conditions, burns, a variety of wounds, muscle problems, joint problems, pain from shingles, itching from insect bites, and arthritis. Given the lack of scientific data on this treatment, emu oil is best utilized in addition to conventional therapies. Pectin therapy Pectin therapy, while increasing in popularity, is not a proven remedy for pain management. However, it is popular among athletes in particular to use for aches and pains, particularly the types of aches and pains that accompany arthritis. In fact, in a profile of Bill Weinacht, and 84 year old champion sprinter, Weinacht detailed how he utilized the combination of Certo and grape juice to help him return to competition [138]. However, it is important to note that Weinacht admitted that he does not rely only on this remedy, but also take supplements such as glucosamine and chondroitin. The source of pectin therapy is unknown, but this therapy has been around since the 1940s. Joe Graeden, who writes The People’s Pharmacy, has indicated that there are a couple recipes that are effective for managing osteoarthritis. The first recipe is a combination of Certo and grape juice, taken three times daily. The second recipe is also a combination of Certo and grape juice; however, it only needs to be taken once daily. Certo is a soluble fiber that is derived from the cell walls of certain fruit, including apples, bananas, grapefruit, and pears. While there are no scientific studies that show that the combination of Certo and grape juice ease pain, some studies, such as a study done out of the University of Florida [138] have indicated that grapefruit pectin does lower cholesterol levels. Additionally, researchers are interested in pectin as a possible cancer inhibitor, although studies are still in the early stages and have only been done on mice. Graedon has indicated that the proof for pectin therapy is mostly found through individual experience, and that this remedy does not work for everyone. If it does, pain relief is not immediate; pectin therapy can take up to 2 months to show results. Aromatherapy Aromatherapy involves the use of certain sensory experiences to alleviate pain and stress. A variety of scents may be utilized in aromatherapy. There have been some studies done on the effectiveness of aromatherapy. One study [139] conducted on 40 arthritic patients utilized aromas from essential oils lavender, eucalyptus, peppermint, marjoram, and rosemary mixed with carrier oils that where 45% almond oil, 45% apricot oil, and 10% jojoba oil. The study indicated that aromatherapy decreased pain in participants a significant amount as well as had an effect on decreasing symptoms of stress and depression. Researchers concluded that aromatherapy works well at decreasing levels of pain and depression and may be useful for pain intervention. Aromatherapy is increasingly becoming a complementary treatment for certain pain sensations, including chronic pain sensaitons. This is primarily because even if aromatherapy does not contain ingredients that are known to be pharmacologically active, it does promote relaxation. Relaxation is key to pain relief. Relaxation leads to a lower heart rate, reduced blood pressure, and greater pain threshold. Relaxation also offers the individual a focus other than their pain, which has the potential to lead to pain relief. Therefore, there is merit to the idea of utilizing aromatherapy in conjunction with other, more conventional, treatments. Homeopathy Homeopathy is a system of medicine that is based in three main principles [140]: Like cures like. One example of this principle is if you have a cold and the symptoms are similar to mercury poisoning, then you would use mercury as the homeopathic remedy. Minimal dosing. It is important to remember that homeopathic remedies are taken in a very diluted form. Single Remedy. Only one remedy is given regardless of the number of symptoms being experienced, but the remedy will be targeted at alleviating all of those symptoms. Homeopathy ranks second as the most widely utilized system of medicine across the globe. It has gained in popularity in the U.S. at a rate of 25 – 50% over the last decade. This rise in popularity is influenced by certain factors, including: Homeopathy is considered very effective. Homeopaths believe that when the correct remedy has been administered, improvement will be seen rapidly. Homeopathy is considered safe, with treatment available even to babies or pregnant women. Homeopathy is not considered to interact with conventional medications. Homeopathic remedies are natural and usually based on the use of natural ingredients. Homeopathy is intended to work in harmony with the immune system. This is compared against conventional medication, some of which may suppress the immune system. Homeopathy offers remedies that are not addictive. Further, use of the remedy is only taken until the individual feels relief. If the remedy has not provided relief then the individual is likely taking the incorrect remedy. Homeopathy addresses the root cause of the ailment and treats the cause as opposed to the symptoms. However, even though homeopathy has its advantages, there are also disadvantages, primarily on the side of the practitioner. Selecting the correct remedy often takes more time than it does when utilizing conventional medication. There are no standard correct remedies or doses, so the practitioner must be precise. Also, there is a huge range of homeopathic remedies, which presents problems for most pharmacies. This makes homeopathic remedies at times difficult to obtain. Macrobiotic dieting The term macrobiotics is derived from the Greek, with “macro” meaning great and “bios” meaning life. Macrobiotic dieting is considered a tool that helps individuals live within what is considered the “natural order” [141] of life and effectively adapt to the constantly changing nature of life. Macrobiotics is not generally considered a “diet”; more, it is considered a lifestyle by those who adopt this way of eating and working at their health. The macrobiotic diet emphasizes eating whole grains and fresh vegetables. It mandates that individuals should generally avoid eating meat, processed foods, or dairy. The goal of macrobiotic dieting is to provide body systems with needed nutrients without loading in toxins that need to be eliminated or stored as fat. There are frequent changes within the body as it adjusts to environmental changes and the aging process, so needs also change as time passes; therefore, the idea of the macrobiotic diet is that it aims to balance the effects of the food eaten with other external or internal influences on the body. In doing this, the body adjusts to changes in a way that is peaceful and controlled. Those who practice eating macrobiotically believe that all things are made up of yin and yang energy, with yin being energy that moves outward and yang being energy that moves inward. The belief is that though everyone has both types of energy in their body, there is often an excess of one type of energy and a deficit of the other. Macrobiotics therefore believes that in balancing out these energies, the body will run more efficiently and with fewer problems. Further, macrobiotics devotees believe that in balancing the body’s energies, the individual is able to gain some sense of control over what happens in their body as well as freedom from fear over what happens in their body, and can take comfort in the balance. Devotees of this diet believe that macrobiotics allows the body to effectively heal itself according to the natural order of life. The macrobiotic approach is opposite of the conventional approach. The conventional approach to nutrition mandates that every individual requires certain amounts of protein, carbohydrates, fats, and vitamins and minerals each day. This approach determines these amounts by utilizing statistical averages to apply a blanket recommendation across many people. Conversely, macrobiotics approaches nutrition with the idea that the same thing may not work for every person as well as the thought that personal needs can change from day to day. This therefore means that when using macrobiotics the individual is tasked with determining the type of food that is best suited to them at that current time. Macrobiotics devotees believe that the macrobiotic approach “leads to real freedom” [141] since it requires a shift in thought from a static view of nutrition to a more dynamic, flexible one. There are several stages to becoming a macrobiotic eater, as most people find it difficult to shift from a diet that emphasizes meat and sugar (the typical American diet) to one that emphasizes grains and vegetables. These stages are: Beginning/Basic stage. This stage is focused on cleaning the body of toxins and easing into the dietary changes. The idea is that in doing this, old excesses and pain are removed from the body. The mind is also clarified, allowing the individual to better use their natural good judgment in what they choose to eat. It is wise for the patient to consult someone well-versed in macrobiotic dieting as they start the regimen, as this type of plan has to be tailored to each individual and their unique circumstances. Intermediate stage. In this stage, individuals learn about the principles of macrobiotics: that there is a “natural order” to all life and that what the individual eats in large part determines who they are and how they feel. Therefore, if an individual lives and eats in such a way that the natural order is maintained then that individual will experience good health and happiness. Conversely, if the individual lives and eats in such a way that is disharmonious, that individual will experience illness that eventually becomes serious illness and imbalance. Individuals in this stage of macrobiotics are urged to study yin and yang and to come to an understanding of what this means for their life and health. The idea is that the more an individual’s understanding of yin and yang is, the more that individual will enjoy life and experience an improvement in overall health on all levels. This increases confidence and leads to a greater positive outlook where life is concerned. Advanced stage. Individuals in the advanced stage will have reached the dietary goals of macrobiotics, which is to eat what they desire without fear. The advanced stage is much different than the beginning stage. In the beginning stage the individual is guided by the rules of macrobiotics as they learn how to eliminate toxins from their diet. The advanced stage is considered a stage of complete freedom wherein the individual has developed such good judgment when it comes to a healthy balance that they don’t have to stop to review the rules or the principles of macrobiotics. Individuals in this stage also search for more tools with which to improve their lives. Devotees of this diet believe that people in the advanced stage are easily recognized by the way they emit happiness, honesty, and a state of complete health. Macrobiotics claims to have wide-reaching benefits, although these benefits are not hard claims and rather vary from individual to individual. These benefits include: Little to no fatigue Overall better health and relief from ailments and pain, particularly things such as the flu, colds, or cancer. Overall better appetite and an ability to consume food with joy. Better sex drive and satisfaction with sex. Deep sleep on a nightly basis that is free of disturbing dreams as well as an ability to fall into a restful sleep within minutes of getting into bed. Improvement in memory, which in turn leads to an improvement in personal relationships. Also, an improvement in thought process and reasoning. Freedom to live without fear, anger, or suffering. A new ability to view difficult times as positive experiences. The ability to act I ways that are more generous. Greater honesty and a heightened understanding of Oneness (God) A number of these benefits are generally linked to good health. However, there is not much scientific evidence supporting the idea that a change in eating patterns such as macrobiotics leads to much better health or relief from illnesses and pains. Macrobiotics may, however, be somewhat effective because it focuses on low fat and high fiber food choices, contributing to decreases in blood pressure and cholesterol levels, which may in turn calm individuals and lead to feelings of a more centered, controlled life. Consultation with a medical professional is essential before beginning a macrobiotics regimen. Those who have serious illnesses are often not suited to this type of diet, although there are those who may benefit. Determining whether an individual will benefit from a macrobiotic diet should be made after a thorough physical examination. 13. Future Therapies The primary goal of researchers with regards to pain is to develop better treatments to help alleviate or prevent pain more effectively. One important goal as pain medications are developed is to block or interrupt pain signals, particularly when there is no trauma to the tissues. While there is currently no ideal pain medication, researchers are examining the body’s “pain switching center” [1] in an effort to formulate new drugs that will keep pain signals from becoming amplified or even will stop them before they start. There are quite a few areas where research has and is being conducted in efforts to come up with new and more effective pain treatments, including: Imaging advancements. There are now imaging techniques such as positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) that provide a vivid picture of what is occurring in the brain as pain is processed. Researchers have discovered that pain activates a minimum of 3 or 4 key areas in the cortex of the brain. Further, researchers have discovered that when patients are hypnotized in order to keep from feeling pain sensations, activity in many of the brain areas is severely reduced. This is one indication that pain involves more than the sensory experience of pain, and that there is an emotional component to pain as well. Channels. These are gate-like passages that are found along cell membranes that allow for electrically charged ions to pass in to cells. The study of channels leads researchers to explore the development of new classes of pain medication – including medication cocktails – that would work at the site of channel activity to alleviate pain. Trophic factors. Trophic factors are natural chemical substances that are found within the body that affect the function and survival of cells. These also promote cell death, but there is little that is known about how trophic factors can go from being beneficial to being harmful. Researchers have discovered that the over-accumulation of some trophic factors within the nerve cells in animals result in heightened sensitivity to pain as well as the fact that certain receptors found on cells react and interact to trophic factors. These receptors offer new area of study and a target for a new class of “restorer” [1] drugs. Plasticity. After an injury, the nervous system experiences a large-scale reorganization, which is referred to as plasticity. Researchers are now able to identify and examine the changes that occur in the body as pain is being processed. One example of this is the use of a technique known as polymerase chain reaction, wherein scientists can research the genes that are induced by an injury or persistent pain. Evidence has been found that proteins that are synthesized by the genes may be good targets for new therapies. Scientists assert that the changes that occur when a person is injured or experiences persistent pain should be thought of as a nervous system disorder, not simply a symptom of the injury. Therefore, scientists have the hope that new therapies that are focused on preventing long-term changes in the nervous system will allow prevention of development of chronic pain. Neurotransmitters. Researchers believe that gene mutation may have an impact on the number of neurotransmitters that are involved in controlling pain. Researchers are now able to utilize certain imaging techniques to see what is occurring chemically when a person is injured. This is important work because it may offer the opportunity to develop new therapies that would reduce or destroy severe and chronic pain. Future research on headache relief: Studies being done or sponsored by the National Institute of Neurological Disorders and Stroke are examining the ways headaches progress and searching for new treatments to relieve the pain of headache or block the headache altogether [25]. A number of factors affect headache and are being researched in an attempt to develop new treatments. These include: A molecular basis for migraine. While researchers currently do not entirely understand migraine headache and aura. There are several studies being done to determine how migraine and migraine with aura affects metabolism and neurophysical function. Researchers are also examining whether or not certain regions in the visual cortex are more susceptible to the events leading up to headache with aura [25]. Results from this research could provide a larger-scale understanding of migraine and help with the development of new migraine treatments. The mast cells that are involved in the inflammation response in headache. Researchers are studying the relationship the cells’ antianalgesic components and the proximity to nociceptors. It has been posited that mast cells may release certain substances that activate nociceptors. Discerning the link mast cells have to the resultant headache pain may help determine drug targets that could in turn lead to the development of new analgesics. Cortical spreading depression, which is the process that occurs in migraine with aura were there is a period of increased activity in the brain followed by a period of decreased activity. There are currently some drugs being tested in clinical trials that inhibit cortical spreading depression to determine the effectiveness of such drugs in treating migraine. Research into these drugs may lead to a greater understanding of how migraine begins and offer an opportunity for the development of new treatment options that would interrupt the process and in turn prevent migraine. The examination of why cutaneous allodynia is present in the head or face in those who suffer from cluster headaches. In researching cutaneous allodynia, researchers are looking to gain a greater understanding of the kinds of neurological changes that occur with cluster headaches. This research may offer a greater understanding of how and why the nervous system changes and experiences heightened sensitivity post-repeated stimulation (which leads to chronic pain) and offer the opportunity for the development of new medications to effectively treat headache pain before it becomes a chronic issue. Certain other social and genetic factors that may make a difference in who gets a migraine and how they experience the pain. Such factors include race, psychiatric conditions, quality of life, ability and willingness to follow a treatment protocol, and response to treatment. These factors are currently being examined in those who suffer migraine, tension headache, headache resulting from substance abuse, and cluster headache. Genetics in particular has been found to predispose individuals for migraine. In general, those who suffer migraine have at least one family member who also experiences migraine. Determining whether or not there is a certain gene responsible for migraine is currently being researched. In one study [25] conducted using 1,675 participants who either suffer from migraine or are close relatives of those who suffer from migraine, findings indicated that there is a link between a gene variant on certain chromosomes and the susceptibility to developing migraine. Another study [25] replicated these findings and indicated that there was in particular a link in females who suffered from migraine. Other factors, such as sleep patterns, were also determined to play a role in migraine development. Researchers found that those older adults who experience migraine are often triggered by changes in sleep patterns. Therefore, it is essential that individuals who are susceptible to migraine maintain a regular sleep pattern. 14. Educating patients The prevalence of pain is high, and as a result exacts quite a large toll on society. Unfortunately though, both public and professional knowledge regarding pain falls short, particularly because, although pain should be a public health issue, it is remarkably underaddressed. States Brown, “If pain was formally recognized as part of our national public health policy, public awareness campaigns would highlight pain prevention and cover risk factors for the development of the disease” [142]. However, since pain is not a public health priority, the burden remains on practitioners, patients, and caregivers to educate themselves and to advocate for better pain management techniques. Education strategies and tools for patient and caregivers should be presented in a variety of mediums that enhance wider learning. These include pain-specific brochures being displayed in-office; newsletters; videos; audio content; posters; the use of pain notebooks to track pain progression; referrals to credible web sites; structured education, and; web-based tools to educate and manage pain. There are several key objectives that practitioners should keep in mind as they work to educate patients and caregivers. These objectives are: Increase understanding of pain; Address disparities and cultural differences with care; Discuss the goals of treatment; Address more than just the physical aspects of pain; psychosocial and spiritual aspects should be addressed as well; Empower individuals to advocate for themselves by providing tools, handouts, or other tips; Teach how to use pain treatment options appropriately; Create an environment in which people can discuss pain openly and ask questions; provider-patient communication is essential. Educating patients is a central tool in improving the management of pain. Therefore, practitioners should be prepared to offer educational tools to patients that present pain in a way that the individual will understand. Additionally, it is essential that practitioners work to dispel myths and misperceptions about pain to provide a better educational experience. This can be done through dispelling the six most common myths about pain. These are [143]: Pain is “all in your head” [142]. It is true to an extent that pain resides in the head, as the individual’s brain is responsible for processing the pain perception. However, this does not indicate that pain is an imaginary occurrence, even if the source of the pain is not understood that well. The pain is real to the person experiencing it; therefore, it must be adequately addressed. Pain is an occurrence that one simply must live with. Traditionally views on pain state that pain is the inevitable consequence of a disease or condition. However, the fact is that most pain can be avoided or relieved through careful pain prevention or management. Pain is just a natural part of growing older. It is true that pain becomes more common as people age, mostly because the conditions that cause pain, such as arthritis, shingles, or osteoporosis, are more common in older adults. However, regardless of age, pain is not something that anyone should have to endure untreated. The practitioner is the best judge of pain. There is not much of a relationship between what the practitioner judges the pain to be and the actual patient experience. This means that the patient must have the final word on pain existence and severity. The most reliable pain indicator is self-report. Seeking medical care for pain means that the patient is weak. Seeking medical care for pain often has a stigma attached because patients don’t want practitioners to view them as whiners, or bad patients. For this reason, patients don’t always mention pain and how it affects their life. Using strong pain medications leads to addiction. It is important to remember that drugs such as opioids are not universally addictive. There are risks associated with their use, but risks may be managed through properly prescribing and monitoring the use of the medication (i.e. taking the medication as it is prescribed). There are several things that patients who experience pain want to know about their pain. It is therefore important to keep these things in mind when educating the patient or caregiver. These include: How to understand the pain, most specifically, how to understand the cause of the pain; What to expect in terms of when the pain may be experienced and what it will feel like; Treatment options, which include options involving medication, surgical treatments, and nonpharmacological approaches; The best way to cope with pain; How pain can negatively impact the individual’s life in a variety of ways, including physical, psychological, and social impacts; How to connect with other people experiencing the same kind of pain to gain understanding of their pain through peer experience; Where to find specialists to help manage pain, as well as who should be consulted; How to effectively describe pain [144]. How to enhance pain communication: Utilize pain questions that are kept handy for each appointment. These questions include: Where is the pain located? How is the pain characterized? When and how did the pain start? Is the pain intermittent or continuous? What makes the pain feel better or worse – factors would include medication, activity, rest, stress, or the application of hot or cold to the affected area. Has the patient experienced any sleep disturbances as a result of their pain? Does the patient have any ongoing medical concerns that could have caused or could be exacerbating pain? How is the individual functioning at school or work? Does the pain affect certain quality of life activities, such as sex or recreation? What does the patient expect from pain treatments? Instruct the individual to keep a pain diary and to utilize pain intensity scales to measure pain. Pain diaries not only help patients keep track of and measure their pain experiences and the effects of the pain on a variety of functions; they also offer practitioners the opportunity to educate the patient about their pain. Encourage the individual to reach out for support. Support groups, whether they are in person or online, offer patients the opportunity to connect with others who are suffering in the same way as well as provide an opportunity for education through peer information exchange. 15. Conclusion Pain is considered a “universal disorder” [1] that comes in many forms. Up to 80% of visits to physicians are for treatment of pain. Regardless of the form that pain is seen in, everyone experiences pain, with the perception of pain occurring differently in each individual. At its simplest, pain serves to warn the individual that something is not quite right. Pain can, however, be so severe that it disrupts productivity, well-being, and indeed, the entire life of the individual experiencing the pain. At its core, pain is complex and differs greatly among individuals, including those who seem to have identical injuries or illnesses. Pain today is a costly and very serious public health issue. It is also a challenge for friends and family as well as health care practitioners to offer support to the individual suffering from the pain. In order to offer this support, both practitioners and friends and family must be willing to try a variety of pain management methods, or even a combination of methods. Further, both practitioners and friends and family must listen carefully as symptoms are described in order to ensure that the pain is treated effectively. Finally, it is also important to address the education of both the individual as well as their friends and family in order to ensure effective pain management. 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