Pain

Physiology of the pain

Circuit of the pain

Knowledge concerning the neurological ways of the pain is currently in full change. Currently it is individualized the ascending noxious ways of the periphery of the body towards the cerebral Cortex while passing by the Spinal-cord and the ways of controls of the noxious feeling on the basis of the cerebral cortex towards the periphery. Their goal is the modulation of the perception of the pain in the direction of a reduction or aggravation of the painful feeling. These noxious ways transmit the information of the noxious stimulus thanks to electro-biochemical mechanisms utilizing many Molécule S and amino-acid.

Consequences of the pain

In addition to the feeling of Suffering, the pain can cause a Malaise vagal by stimulation of the vagi (pneumogastric nerves). The Symptôme S of this excitation vagale or left all the following signs:

a fall of the blood flow by Bradycardia and Hypotension;
a syncope;
a Myosis (reduction in the diameter of the Pupil S by contraction of the iris);
a perspiration at the ends of the members;
an excessive secretion of saliva
a Hyperchlorhydria (excess of secretion of Hydrochloric acid by the mucous membrane of the Stomach);
a Constipation or Diarrhea S;
of the Spasm S;
of the disorders of the Breathing.

The prolonged pain is inhibited by the body by secretion of Endorphine S (or endomorphines). The production of endorphin is initially made on the levels Nerf S close relations of the seat of the pain; when this production is not enough any more (prolonged pain), it is a site closer to the Cerveau which takes over in the Sécrétion. There is thus a pain which goes and which returns by waves.

When as a last resort it is the brain which produces endorphins, the pain cannot be fought any more, there is thus appearance of a cardiovascular Collapsus, reflex of protection to the fall of the blood flow, which can lead exceptionally to the Décès.

Anthropology of the pain

The question of the cultural variation in the way in which the people apprehend the pain was the subject of many anthropological investigations, in particular on behalf of Mark Zborowski and David Breton the.

2 large mechanisms of genesis of the pain

There exist two large mechanisms of genesis of the physical pain: the pain by excess of Nociception and the pain neurogene.

The pain by excess of nociception

The pains by excess of nociception are caused by the setting concerned normal of the neurophysiological ways of the pain. It is what occurs when you strike your index instead of the nail with the hammer. They result from lesions of the peripheral fabrics, which cause an excess of painful impulse transmitted by the intact nervous system.

The pain neurogene

The characteristic of the pain neurogene, still called neuropathic pain, is to be felt like electric shocks, twinges, burns and tinglings in the territory of the Nerf S reached. It is also the pain which the patients amputees and in particular the feeling perceived in a member feel who disappeared (phantom limb).

3 dimensions of the pain

Biological: physical character of the pain such as it can be represented.
Psychological: in relation to the personally felt pain.
Sociological: the interpretation of the others of its pain.

Various types of pain

The acute pain and the chronic pain

The acute pain and the chronic pain are differentiated.

The acute pain

The acute pains are particular but very frequent in Médecine. They appear when the neurological ways of the pain are reached by a disease (diabetes, Cancer, Intoxication S various…)

The chronic pain

the chronic pains are pains prolonged in time: several days, several months even several years.
the chronic pains are invalidating as much by their chronicity that by their intensity: a not very intense but permanent pain can be very invalidating.

Mechanisms of the pain

The pains occur starting from complex systems. They are summarized schematically in pains by excess of nociception, pains neurogenes, pains psychogenic, acute and chronic pains. When they are mixed, one speaks about suffering.

The pains by excess of nociception are pains located at the place of the lesions, they are treated by peripheral analgesics. The pains neurogenes do not depend on the localization of the evil and are worsened by the nervous way or SNC. They occur in a spontaneous way or for tiny movements, persistent in painful bottom accentuated by paroxysms. The psychogenic pains are dependant on the Psychisme. They are also called functional or psychosomatic pains. Nevertheless they are true pains and not another thing.

The inflammatory pain

the inflammatory pain is more important the evening and at the beginning of night (when the blood rate of natural Cortisol is with lowest).
the inflammatory pain decreases or disappears after heating and with the effort (community activity or sporting): pain of derusting.

The mechanical pain

the mechanical pain is constant, does not even decrease is accentuated with the effort.
the mechanical pain does not increase the evening and at the beginning of night.
the mechanical pain decreases when the mobilization stops.

The muscular pain

During the medical examination of the muscles, in particular in Medicine of the sport, these various times of the examination make it possible to make the distinction between various possible pathologies.

The pain (muscular) with the effort

The muscular pain is present at the effort. The stop of the physical effort or the fall of its intensity makes decrease or disappear the pain.

The pain (muscular) at rest

The muscular pain is present at rest, when the muscles are " froids".

The pain (muscular) with palpation

The palpation of the muscle concerned causes or increases the pain: painful grin on the face of the examined subject, reaction of withdrawal…

The pain (muscular) with the contraction

The voluntary contraction causes or increases the pain.

The pain (muscular) with the stretching

The stretching of the muscle causes or increases the pain.

Sit of the pain

The pains bear different names according to their seat. These names are in general in “- pain”:

Ache: muscular pain following an effort
Cephalgia: an headache (example: the Migraine)
Dorsalgie: pain of the Back
Hépatalgie: pain with the Liver
Neuralgia: pain on the way of a Nerve (example: the Neuralgia of the trigeminal nerve)
Rachialgie: pain with the rachis

Evaluation and treatment of the pain

The perception of the pain, of its intensity, is partly subjective. The same phenomenon (Traumatism, Disease) will be felt differently according to the person and the situation. The pain can go from a simple incommodation until a Malaise, even the setting in danger of the vital prognosis or psychiatric of the person. In addition, the pain will be memorized, and this memory is likely “to arise” at the time of a similar event and thus in particular “to parasitize” the diagnosis in the future; for example, a person feels an acute pain with the alarm clock of a operation, but it is in fact only the memory of the initial pain, or a person being wounded twice feels a pain “overestimated” at the time of the second traumatism because the preceding traumatism was extremely painful.

It is thus important to be able to evaluate felt by the pain during the diagnosis. It is advisable to distinguish car-evaluation and hétéro-evaluation.

Car-evaluation

The car-evaluation consists in asking for directly to the patient the level of his pain. It requires a co-operation and a good comprehension.

The simplest system and most usually used is protocol “EVA” (analogical visual scale): a graduated small rule is presented and one asks the patient to position a cursor, the position on the left being the absence of pain and the position on the right an unbearable pain. Side expert, the small rule is graduated from 0 to 10,1 being a light incommodation and 10 being an unbearable pain. An estimate higher than 5 is in general regarded as being an important pain having to be taken into account specifically (i.e. it is necessary to also treat in account the pain and not only the traumatism and the disease).

One uses also the “simple verbal scale” (EVS): one proposes to the patient a series of Adjectif S to qualify the pain (goes away > weak > moderate > intense > extremely intense > conceivable pain maximum), which is then converted into a numerical value (of 0 for absent to 5 for the maximum pain).

One also uses in certain cases the “relative verbal scale” (EVR): the principle is similar to the EVS, but one distinguishes and quantifies separately the various types of pain and their repercussions: swarmings, electric shocks, twinge, stab, irritating, exhausting pain…

Hétéro-evaluation

Installation to evaluate the pain of subjects not being able to express it (infants, defective mental), the hétéro-evaluation is made by the inspector. There are several types (to be finished).

That is particularly complicated if the person is not able to express herself:

elderly, in particular reached cognitive disorders like the Disease of Alzheimer (Doloplus Scale)
the handicapped people cérébro-engines. It is then necessary to be helped of the interrogation of the entourage which knows them with the daily newspaper and to evaluate the changes which have occurred. Two scales exist, although little used in practice, there acts of the grid OF (the Pain Child San Salvadour) and of scale NCCPC (Not Communicating Children' S Pain Checklist) or GED-DI (Grid of Evaluation of the Pain Intellectual Deficiency)
the Nourrisson S. the major sign for the small child is the cry which the mother often arrives at ditinguer of the other cries (fear, hunger…). At a higher stage of pain the infant is often prostrate.

Treatment of the pain

The treatment of the pain is called “antalgie”.

In France, the treatment of the pain was regarded a long time as secondary, for many cultural reasons:

one believed a long time that the infants did not suffer, because their nervous system is not mature (the neurons are incompletely myelinized); in addition, they do not express their pain in a specific way (other only by cries and tears, which are their usual means of communication);
the pain reveals a Affection, to remove it removes an element of diagnosis: this is valid only before the diagnosis (it is true that another pain can appear and be masked by the antalgic treatment); in addition, certain acts diagnoses are themselves generating of pain, in particular the invasive acts like a osseous Ponction;
the treatment of the acute pain calls upon Médicament S classified like Stupéfiant S, one was afraid which the patient becomes dependant: this is unimportant in the case of a patient at the end of the lifetime;
some advance the weight of the culture Judeo-Christian in which the man and the woman were intended to suffer while being driven out Paradis.

Now, the pain is regarded as a specific affection, and sometimes even like an urgency (for example Renal colic).

The treatment of the pain depends on the intensity and its origin, the final treatment being the treatment of the cause, when that is possible. It can appeal:

with a comfort, with the fact of diverting the attention, the fact of explaining what occurs (to decrease the Anxiété); that is particularly obvious with the children;
with a Position of waiting: installation of the patient in a position which minimizes the pain (the patient in general adopts instinctively this position);
with the Cold : applied locally and with moderation, it calms the pain;
with Anti-inflammatory drug S;
with Antalgic S;
with Sedative S;
in the extreme cases with the Anesthesia;
and in certain cases one has recourse to the interventionnelle Antalgie.

In the case of intense pains, one can leave to the patient the possibility of managing the antalgie when this one is managed by morphine perfusion: the patient has a pushbutton which activates the injection Morphine, the quantity injected being limited by an adjustment of the apparatus on medical regulation. This method of analgesia is called analgesia controlled by the patient (ACP) or PCA in English.

Reaction to the pain

The reaction to the pain is used to evaluate the neurological state of a patient, and in particular its state of consciousness. It belongs to the assessment of the first-aid workers as well as scale of Glasgow.

If the victim does not have spontaneous reaction, nor with the Bruit or the Toucher, one tests his reaction to the pain. It is advisable to exert a stimulation which does not cause a wound nor of aggravation of the state. Several methods can be employed.

A pinching of the skin a long time was practiced; this one must be avoided. On a conscious person, one uses only one light pinching at the ends (back of the hand or above of the foot, inner face of the arm) to check if the person feels what one does to him, but not like method of stimulation of a person without reaction.

a pressure with the fingers on the back of the lower Jaw (international nomenclature = mandible), under the ears,
a pressure supported at the know-orbital level.

The medical assumption of responsibility of the pain

Legislative framework

In France

The number of texts of Loi which treat pain proves that this one is not any more one subject forsaken by the Politique of Santé of our country. The assumption of responsibility of the pain is a right for the neat people and a duty for looking after, and revêt a legal, ethical and moral aspect that each looking after must integrate.

Decree of competence n°2004-802 of July 29th, 2004, relating to the professional acts and the exercise of the occupation of male nurse

Article 2 : “The care male nurses (…) have as an aim (…) to take part in the prevention, the evaluation and the relief of the pain and the physical and psychic distress of the people”. Article 5 : “Within the framework of his own role, the male nurse achieves the acts or exempts the following care aiming to identify the risks and to ensure the comfort and the safety of the person (…) : collection of the observations of all nature likely to contribute to the knowledge of the health condition of the person: evaluation of the pain; (…) ”

Article 7 : “The male nurse is entitled to undertake and adapt the antalgic treatments, within the framework of the protocols preestablished, writings, dated and signed by a doctor. The protocol is integrated in the file of care male nurses. ” The nurse thus has as an obligation to take into account and to help to relieve the pain of the neat people.

N°93-221 Decree of the February 16th 1993, relating to the professional rules of the male nurses and nurses

Article 2 “the male nurse or the nurse follows her occupation in the respect of the life and the human person. It respects the dignity and the intimacy of the patient and his family” This implies that we must also recognize the person and her suffering in the respect of the life.

the charter of in-patient

“During these treatments and this care, the taking into account of painful, physical and psychological dimension of the patients and the relief of the suffering must be a constant concern of all the speakers. Any establishment must obtain the means suitable to deal with the pain of the patients whom they accommodate and to integrate these means in its project of establishment. The evolution of the scientific knowledge and techniques makes it possible to bring, in almost the whole of the cases, an answer to the pains, (…) that they are felt by children, adults or people at the end of the lifetime. ”

the charter of the child hospitalized (EACH, 1998)

Article 5 : One will avoid any examination or treatment which is not essential. One will try to the minimum to reduce the emotional physical aggressions or and the pain.

These two Charte S allow the looked after people, Enfant S or Adulte S (relative S) to take note of their Droit S as regards care, and in particular with regard to the assumption of responsibility of their pain.

Circular DHOS/E2 n°2002-266 of the April 30th 2002, relating to the implementation of the national program of fight against the pain 2002-2005 in the health care institutions.

This four-year program (2002-2005) continues the axes of improvement of the preceding plan. It in addition comprises three new priorities, of which the pain of the child. These priorities are articulated around five objectives, of which reinforcement of the male nurse role in particular in the assumption of responsibility of the caused pain. ”

basic principles of the ethical codes

Principle of nonmaléfiance : (since the Hippocratic oath) not to use what one can to do of the evil. This principle includes not only the evil itself, but also the risks to make evil. ”

Principle of bénéficience : to use all our knowledge in order to make the largest possible good in such situation. ”

Looking after are thus held, to respect the moral aspect of their Profession, not to be unaware of discomfort, even the Souffrance which can generate the physical or psychological pain.

Anthropology, sociology

The pain is not considered at all nor taken into account in the same way according to the Culture S. Each people has his own design of the pain. This concept applies as well to the recipients of care as to the values of looking after. Indeed, “they are not only the patients who integrate their pain in their vision of the world, but also the doctors and the nurses who project their values, and often their prejudices, on what live the patient of which they have the load. ” (The BRETON D., 1995, p.136). The Religion S are also sources of values, and thus of interpretation of the pain of others. Let us see what it is according to their differences:

In the Bible, the pain is associated with a divine punishment at the time of nonthe respect of the laws dictated by God: “The accounts of the Bible often associate prosperity and health with the fidelity of the men to the commands of God. Misfortune, the suffering, the pain strike any infringement with the law. ” (The BRETON D., 1995, page 82). But interpretation that makes of it the Catholic religion is different: “The Christian tradition compares on the other hand the pain to the original sin, it makes of it an inescapable data of the human condition. (…) The acceptance of the pain is a possible form of devotion which brings closer to God, purifies the heart. She was considered a long time, especially in the Antiquité and with the Moyen-âge, like a particular grace. (…) The Mort of Jesus on the cross is primarily a mystery of the suffering, an account of the Rédemption by an infinite pain only suitable to absorb infinite the Péché of the Homme. A long time for the Christian the pain is participation on a minor mode in the exemplary sufferings of the Christ…” (the BRETON D., 1995, p.89-91). This design of the pain is recurring in our culture, which would explain why in our Western companies, mainly Judeo-Christians, the pain under is estimated, to see completely occulted.

In the Islamic religion: “The Moslem is confronted less than the Christian or the Jew with the paradox of the suffering Juste, because so for the latter God is love, for the first it is especially absolute power. The faithful one recovers with patience between the hands from God and testifies to his endurance in front of the test. (…) The pain is not the sanction of a fault, it is predestined, registered in the man well before his birth. (…) But if God created the pain it also gave to the man the means of fighting it by medicine and the prayer. ” (The BRETON D., 1995, p.97-98). What means that the Musulman S never refused to relieve the pain, they are even more often petitioning of care than the Juif S or the Christians because medicine is a science known since of very many Siècle S. Moreover, the religion does not block the assumption of responsibility of the pain.

As for the Spirituality S Eastern S: “The body is pain, because it is the place of the pain. ”. “Human misery is not the fact of a punishment of the gods, but of the only ignorance of the men. The release lies in the revelation thanks to which any suffering disappears. ” (The BRETON D., 1995, p.100). With regard to the religions Polytheist S, such as the Buddhism or the Hindouisme for example, the religion makes it possible to the men to be freed from the pain by spirituality.

the pain has a significance even for the individuals atheistic S: “The pain is an incisor appears of the evil. Constant recall of the moral brittleness of the man. (…) The idea of the deserved disease, of the suffering coming to punish the rejected control of an individual is still deeply enracinée in the contemporary consciences. ” (The BRETON D., 1995, p. 104-105). Even at the nonreligious individuals, the pain is regarded as the punishment of a made fault.

In addition, the cultures also are sources of values and beliefs. Here an example which illustrates very well the differences which even exist between the cultures with regard to the direction as one gives to the pain: “A Ethnologue tells that in the company that he studies, a woman knowing that he has a case of help brings him his/her child of which it says that he has light “a sore” with the foot, the mother as the newborn do not seem to consider the wound with gravity. When the ethnologist detaches binding in sheet of banana tree of the child, he discovers with amazement that one sees the bone of the child of which the foot resembles, according to the terms of the ethnologist to “a gelatinous mass”. In this same company, one calls it another time at the bedside of a little girl suffering from a Constipation. This last case, of a less gravity to the eyes of the ethnologist is regarded as very serious by the members of this company of the south-west of the Tanzania, because the constipation perhaps due to a malevolent action, for example that of a wizard. ”. To evaluate the pain, it is thus paramount to take into account the ethnic origin of the looked after people, and, in the case of hospitalized children, of the origin of their parents. They will exert a critical eye on the assumption of responsibility of the pain of their child, according to their beliefs and their ethnic origins.

Psychology

The assumption of responsibility of the pain can be explained by the fact why “(…) the daily practice of painful acts obliges looking after it to implement a certain number of mechanisms of defense aiming at protecting it, to secure it against stagnation and the contamination by the suffering of the other…” One can note an interesting aspect of the echo which can produce the pain of the child at looking after: the Refusal. “To recognize, to admit the reality of the pain of the child is a difficult exercise for many teams accommodating of the children. The more so as it not recognition of the pain is easier in the child because its means of expression are limited. ” (…) “This refusal is often the reflection of a faintness at looking after, of an incomprehension of the attitude of the child, of a dysfunction within a service. ”. One hears still unfortunately in the services: “It is not pain, it is fear or anxiety… ”, or: “It is pain but he will forget… ”, or even: “It is in the head, it is psychological… ”. The disavowal is a Mechanism of defense looking after which completely denies a more or less significant part of the external Réalité. “The refusal is a psychological mechanism where the person reacts as if its thought were very powerful and that it was enough to refuse the thought of a thing so that this thing does not exist. Pathological mechanism when it east prevail and rigid but which is found in a form attenuated at each and everyone in the form: “one should not think of misfortune, death, etc”; heritage of the magic Thought in the young children. In the relation of care, this refusal seldom appears in an open way but rather in an unconscious way which can result in the persistence of harmful attitudes (the refusal supports the conduits at the risk)… ”. There exists another concept which can return in account in this refusal of looking after vis-a-vis the pain of the child: the infantile concept of Amnesia which belongs to the psychological development of the child. It is true “that we have all be of the children”. But this period of our life that we have all joint is covered “with a veil of strangeness”, little, to see any memory of this time returns to us consciously to the memory. “That it is thus difficult to include/understand what wants, which seeks, which request a child! ”: that explains this facility of looking after not to take into account the pain of the child whom it looks after, not remembering themselves what they felt and lived at this period of their life. Another interesting concept concerning lived of the pain by looking after is the transfer. Looking after adult resist the pain better in general, and thus transfer their felt and their emotions on the person whom they look after. They think that the child supports the pain in the same way that they would do it.

Bibliography

Pain and medicine, end of a lapse of memory , Isabelle Baszanger of CERMES, ED. Threshold, 1995
the assumption of responsibility of the pain , French pharmaceutical Annals, ED. Masson, 2000
the pain, the network and the general doctor , Francine Hirszowski, Francis Diez and François Boureau, ED. John Libbey Eurotext, 2001
To fight the pain , Raoul Relouzat and Jean-Pierre Thiollet, Anagram ED., 2002
History of the pain , Roselyne Rey, ED. The Discovery Pocket (social sciences), 2000

External bonds

the discovery of a natural molecule anti-pain: a video of the Educational channel at the Request of partnership with the Institute Pasteur
a life in the pain: Testimony of a badly burned person.

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