Monday, 28 January 2013

Pain management & Hypnotherapy

I recently attended a fascinating course on pain management, run by Hypnotherapist Clem Turner as part of my CPD (Continued Professional Development). This has lead me to investigate and read further on the subject.

Imagine the chain of events. You are in the street and someone sells you a charity badge, which (with clumsy fingers) they helpfully pin to your Jacket. Unfortunately as they work their clumsy fingers, they push the pin into your flesh. You experience pain.

“Bluggerax!” you shriek pushing them away.

What is pain? This sensation that has caused you to react so instantly?

In your flesh there are lots of little detectors, or nociceptors as they are known, and when stimulated by the pin they these send a signal at high speed along the neural pathway to the spinal chord. The signal is relayed up the spinal chord to a point in the thalamus, which is in the midbrain. Here the signal is processed and sent to an area at the top of the brain in the sensory cortex. This part of the brain defines the sensation as PAIN! And sends a signal to motor cortex which is conveniently close by. This part of the brain generates a signal that is sent back to the body and results in a response that is aimed at stopping that sensation. 

You push them away with sudden hand movements and shriek at them:

“Bluggerax! – Get off me you clummock!”

Further examination of the situation will show us that there are two types of nerve fibre involved. A and C Nerve fibres.

The A fibres are divided into three types , and . If the level of stimulation only activates the and you feel no pain. If, however the level of stimulation rises to a point when it activates the then Yabbles! That hurts! The stimulation of these nerves causes what we describe as sharp acute pain. If the C cell fibres are also stimulated you will experience a duller longer pain.

There are a bewildering number of ways that pain is measured. It’s difficult because of course there is an element of subjectivity about it all.

However there are a lot of ways of asking someone how much it hurts.

Maybe the most simple is the visual analogue scale:

As in please make a mark on the line that indicates the level of pain you are experiencing:
No pain------------------------------------------------------------------Worst possible pain

Or with numbers

As in please circle the number that corresponds to level of pain you are experiencing:
No pain   1  2  3  4  5   Worst possible pain.

Or circle a word that describes your pain:
None Moderate Severe Unbearable

However these methods of measuring pain don’t tell you an awful lot about the quality of the pain and are clearly subjective.

We all use words to describe pain such as “It’s a shooting pain” or It’s a “sharp” pain.
The marvelously named “Brief Pain Inventory” measures both the intensity of the pain and the way it interacts with a person’s whole life. For example how it interferes with work or mood. Originally it was developed by a group focusing on cancer pain, but now the BPI a commonly used pain assessment tool.

The multidimensional affect and pain survey (or MAPS) uses a staggering number of descriptors that describe the qualities of pain in a more nuanced way. These descriptions of pain are grouped into 30 “sub clusters” which are themselves grouped into three big groups called “super clusters”. (Someone enjoyed this form organization too much!)

The big super clusters are:
Sensory pain (includes descriptions like “burning”),

Emotional pain (Descriptions such as “depressed”),

Well being (descriptors like “calm”).

Interestingly using this tool it can be seen that people who anticipate greater pain and emotional distress before an operation actually consume more morphine postoperatively. This aspect of anticipated pain is clearly of great interest to me, as it can be acted on within hypnotherapy sessions.

As a research tool into pain some people were asked to keep a “pain diary”. How reliable are patients’ reports of past pain? In this research it has been seen that your memory of pain may not be very accurate. The memory of past pain, is in fact influenced by any present pain. However even more interestingly for me, as a Hypnotherapist, is the fact that memory of past pain is also influenced by present worry, anxiety, stress, and fear. This in turn may become a lens through which any future pain is anticipated. Thus making it terrifying to visit a dentist, or go to a doctor. 

One particular model of pain interests me a great deal: the  so called “three dimensions” of pain, described by In 1968 Ronald Melzack and Kenneth Casey. This model of pain proposes the following three aspects of pain:

“Sensory – discriminative” In other words the intensity, location and duration

“Affective – motivational” The unpleasantness – the power of the urge to get rid of the sensation.

“Cognitive – evaluative” Formed by an appraisal of the pain,  the cultural values and context surrounding the sensations.

You can see that these categories are very similar to the ones used by the MAPS as Super clusters.

What is interesting to me is that certainly the Cognitive / Evaluative aspects of pain can be influenced by hypnotherapy. 

To an extent it is also possible to lessen the Affective / Motivational dimension (the unpleasantness) of a sensation by using your mind to transform the sensation into another sensation; simply imagining that an ache is a hot sensation instead of an ache for example. 

With regard to the actual physical transmission of the sensation of pain (the sensory / discriminative) along the nerves to the brain there are many approaches within hypnotherapy that suggest that you can induce numbness; mostly well known of these approaches being so called “glove anesthesia” in which the clients hand becomes numb and may then be placed against another part of the body – a jaw for example, to lessen the sensation of tooth ache.

In 1983 Spiegel and Bloom worked with 54 women with chronic cancer pain from breast carcinoma. They put the women into two support groups. One group was taught self-hypnosis and the other was not. The group using hypnosis used suggestions such as “filtering out” pain by imagining other different sensations competing for supremacy on the sight of the pain. They  were also encouraged to use self hypnosis on their own. The study lasted 12 months. The group that had been taught to use hypnosis demonstrated significantly less pain and suffering than the control group.

In 2004 a similar piece of research was carried out. Elkins et al did a randomized study of 39 advanced-stage (Stage III or IV) cancer patients with malignant bone disease.  Again patients were randomly assigned to receive either weekly sessions of supportive attention,  or a hypnotic intervention. Patients assigned to hypnotherapeutic intervention received four sessions per week in which a hypnotic induction was followed a script. This included suggestions for relaxation, comfort, mental imagery for dissociation and pain control, and instruction in self-hypnosis.
 Thety were also given a recording and asked to listen to this outside the sessions. So it was quite an intense blast of hypnotherapy. The hypnotic group reported far less pain than the control group.

The human mind really is a huge warehouse of resources,