 By fatigue, anger, boredom,

MODULE 1.5 - PAIN apprehension;

 Sleep deprivation
Pain
a. Definition Pain Tolerance is INCREASED:
 Pain is the sensory experience evoked by  By alcohol consumption;
stimuli that injure or threaten to destroy  Medication, hypnosis;
tissue, defined introspectively by every  Warmth, distracting activities;
man as that which hurts;  Strong beliefs or faith
 An unpleasant sensory and emotional
experience associated with actual or Pain Expression
potential tissue damage, or described in • the actual feeling that a particular client
terms of such damage; shows in pain and the view of the health
care professional, also governed by
 Is a privately, experienced, unpleasant
cultural values.
sensation usually associated with disease
or injury; It has also an emotional
c. Misconceptions and Myths about Pain
component referred to as “suffering.”
1. The nurse or physician is the best judge of
a patient’s pain;
b. Terminologies
Fact: Only the patient can judge the level
and distress of the pain; pain management
Pain Perceptions
should be a team approach.
• the conscious experience of discomfort.
2. Pain is part of aging;
• Children and elderly perceived pain
Fact: Pain does not accompany aging
differently than adults;
unless a disease process or ailments is
• Infants 1-2 days old are less sensitive to
present.
pain. A full behavioral response to pain is
3. If a person is asleep, they are not in pain;
apparent at 8 – 12 months of age.
Fact: People in pain become exhausted
and may truly be asleep or merely trying
Pain Threshold
to sleep. Some people use sleep as an
• the lowest intensity of a painful stimulus
escape mechanisms.
that is perceived by a person as pain.
4. Pain is a result, not a cause;
• the amount or degree of noxious stimuli
Fact: Unrelieved pain can create other
that leads a person to first interpret a
problems such as anger, anxiety,
sensation as painful.
immobility and delay in healing.
• Older children, between 15-18 years old,
5. Real pain has an identifiable cause;
tend to have a lower pain threshold than
Fact: There is always a cause of pain, but
do adults.
it may be very obscure and must be
• Tends to increase with aging. This change
assessed carefully.
is probably caused by peripheral
6. Very young or very old people do not
neuropathies and changes in the thickness
have as much pain;
of the skin.
Fact: Age is not a determinant of pain,
but it may influence expression of pain.
Pain Tolerance
7. Nurse should rely on their own definition
• the maximum intensity or duration of pain
of pain and cultural beliefs about pain;
that a person is willing to endure once the
Fact: It is a mistake to impose one’s own
threshold has been reached.
definition, cultural beliefs and values to
• varies greatly among people and in the
another person’s pain. Let the patient tell
same person over time;
you what pain means.
• a decrease in pain tolerance is evident in
the ELDERLY.
d. Barriers to Pain
• WOMEN appear to be more tolerant to
 Reluctant to report pain due to low
pain than MEN.
expectation of obtaining relief;
 Lack of insurance and high cost of
Pain Tolerance is DECREASED:
medications;
 With repeated exposure to pain;
 Pain is a sign of weakness;
  Afraid of side effects from medications; ex. arthritis
 Poor clinician-patient communication.
 Visceral pain - refers to pain that
e. Characteristics of Pain originates from ongoing injury to the
• Pain is subjective and personal; internal organs or the tissues that support
• Physiologic pain may sometimes broaden them. When the injured tissue is a hollow
to encompass emotional hurt; structure, like the intestine or the gall
• Pain is a symptom not a disease entity; bladder, the pain often is poorly localized
• Pain is uniquely experienced by each and cramping. When the injured structure
individual and cannot be adequately is not a hollow organ, the pain may be
define, identify or measure by an pressure-like, deep, and stabbing. It is
observer; usually accompanied by ANS symptoms
• Pain is a valuable diagnostic indicator, it such as nausea & vomiting, pallor,
usually indicates tissue damage or hypotension, & sweating.
pathology;
• Pain is usually reported as a severe
discomfort or uncomfortable sensation; b. Neuropathic Pain - pain that is processed
abnormally by the nervous system and
f. Components of Pain usually results from damage to either the
1. Stimuli pain pathways in peripheral nerves or pain
2. Perception processing centers in the brain.
3. Response
4. Intensity c. Psychogenic pain – is a simple label for
5. Threshold all kinds of pain that can be best explained
6. Tolerance by psychological problems. Sometimes
occur in the absence of any identifiable
g. Types of Pain disease in the body. More often, there is a
1. According to Source physical problem but the psychological
a. Nociceptive Pain - is the noxious stimuli cause for the pain is believed to be the
that are transmitted in an orderly fashion major cause for the pain.
from the point of cellular injury over
peripheral sensory nerves to pathways 2. According to Characteristics (Onset, intensity
between the spinal cord and thalamus, and & Duration)
eventually from the thalamus to the a. Acute Pain – usually of short duration
cerebral cortex of the brain. (less than 6 months) and often described in sensory
 Somatic pain (Superficial & Deep) - term such as sharp, stabbing and shooting and
caused by injury to skin, muscles, bone, accompanied by observable physical responses.
joint, and connective tissues. Somatic pain  Recent onset
often involved inflammation of injured  Symptomatic of primary injury or disease
tissue. Although inflammation is a normal  Specific and localized
response of the body to injury, and is  Severity is associated with acuity of the
essential for healing, inflammation that injury or disease process
does not disappear with time & can result  Responds favorable to drug therapy and
in a chronically painful disease. The joint requires gradual decrease in drug therapy.
pain caused by rheumatoid arthritis may  Diminishes with healing
be considered an example of this type of  Suffering decreases as pain decreases.
somatic nociceptive pain.
Psychological & Behavioral Response to Acute
Superficial somatic pain or Cutaneous pain – Pain:
perceived as sharp or burning discomfort or Fear
pricking quality. General sense of unpleasantness or unease
ex. Insect bite , paper cut Anxiety
Deep somatic pain – produce localized sensations
that are sharp, throbbing and intense. Physical Response to Acute Pain:
- usually described as dull or aching, Increased HR, RR & BP
diffuse discomfort and localized in one area. Pallor or flushing , dilated pupils
 Diaphoresis
Increased blood sugar 2. Sclerotomic & Dermatomic Pain – deep
Decreased gastric motility & gastric pain; may originate from sclerotomic,
secretion myotomic, or dermatomic nerve
Decreased blood flow to the viscera, irritation/injury.
kidneys and skin
Nausea
h. Transmission of Pain
b. Chronic Pain – is a major health 1. TRANSDUCTION – begins a response
concern. Divided into three (3) types: to a noxious stimulus (painful stimulus)
 Chronic Nonmalignant pain – low back that results in tissue injury, can be
pain to rheumatoid arthritis mechanical, thermal or chemical. ‘’ IT
 Chronic Intermittent pain – migraine, TRIGGERS THE RELEASE OF
headache NOXIOUS STIMULI’’.
 Chronic Malignant pain – cancer a. is the conversion of chemical
 Remote onset information in the cellular
 Uncharacteristic of primary injury or environment to electrical
disease impulses that move toward the
 Nonspecific and generalized spinal cord. The chemicals that
 Severity is out of proportion to the stage are released by the damaged cells
of the injury or disease stimulate specialized pain
 Responds poorly to drug therapy receptors located in the free
 Requires increase in drug therapy nerve endings of peripheral
 Persists beyond healing stage sensory nerves called
 Suffering intensifies NOCICEPTORS.

Characteristics of Patients Experiencing 2. TRANSMISSION – the phase during

Chronic Pain: which the peripheral nerve fibers form
Depression synapses w/ neurons in the spinal cord,
Increased or decreased appetite and the pain impulses move from the spinal
weight cord sequentially levels in the brain, the
Poor physical tone impulses ascend to the reticular activating
Social withdrawal and life role changes system, the limbic system and the
Decrease concentration thalamus and finally the cerebral cortex.
Poor sleep
Preoccupation with physical manifestation 3. PERCEPTION – refers to the phase of
impulse transmission during w/c the brain
Intermittent Pain experiences pain @ a conscious level
 produces a physiologic response similar to (awareness of pain).
acute pain.
4. MODULATION – the last phase of pain
Persistent Pain impulse transmission during which the
 allows for adaptation (functions of the brain interacts with the spinal nerves in a
body are normal but the pain is not downward fashion to alter the pain
relieved) experience.

Referred Pain i. Structure and Functions of the Pain System

 used to describe discomfort that is PERIPHERAL NERVOUS SYSTEM – carries
perceived in a general area of the body, pain impulses to and from the CNS
but not in the exact site where an organ is 1. Afferent nerve fibers - carry impulses to
anatomically located. the CNS)
2. CNS
1. Myofascial Pain – trigger points, small 3. Efferent nerve fibers – carry impulses
hyperirritable areas within a m. in which from the CNS
n. impulses bombard CNS & are
expressed at referred pain. The afferent portion is composed of:
 1. Nociceptors – naked nerve endings  Describe four types of cutaneous
(thermal, chemical and mechanical) sensation: touch, warmth, cold and pain. It
a. A – Delta fibers – rapid rate, focuses on the direct relationship between
transmit ACUTE SHARP PAIN the pain stimulus and perception but does
b. C – Fibers – slower rate and not account for adaptation to pain and the
produce chronic type of pain psychosocial factors that modulate the
2. Afferent nerve fibers stimulus.
3. Spinal Cord network
GATE CONTROL THEORY (Melzack & Wall
1965) -
AUTONOMIC NERVOUS SYSTEM • Nerve fibers carry touch and pain
 regulates involuntary functions impulses from receptors on the skin to the
1. SYMPATHETIC NERVOUS SYSTEM – spinal cord
‘’ a fight or flight response to stress’’ • Nerve cells in the SG of the spinal cord
2. PARASYMPATHETIC – ‘’exhaustion or receive these touch and pain impulses
shock’’ response • Impulses then proceed through
3. NEUROTRANSMITTERS transmission cells to the brain
• Fibers from the brain send inhibiting
The CNS comprises the spinal cord and the brain information to the Substantia Gelatinosa
1. The SPINAL CORD – transmits painful (SG) in dorsal horn of spinal cord w/c
stimuli to the brain and motor responses serves as a gate for control of pain
and pain perception to the periphery.  Gate - located in the dorsal horn of the
2. The BRAIN – processes and interprets spinal cord
transmitted pain impulses  Smaller, slower n. carry pain impulses
 Larger, faster n. fibers carry other
The efferent nerve fibers- carry impulses from sensations
the CNS  Impulses from faster fibers arriving @
 Carrying signals from the brain to the gate 1st inhibit pain impulses
peripheral nervous system in order to (acupuncture/pressure, cold, heat, chem.
initiate an action skin irritation
 Ex: they are the neurons that tell your
body to perform an action, such as Three (3) Factors Involved in Opening and
removing your hand from a hot pan Closing the Gate:
1. The amount of activity in the pain fibers.
j. Factors Affecting Response to Pain 2. The amount of activity in other peripheral
1. Physiologic Factors – age, genetics, fibers.
quality 3. Messages that descend from the brain.
2. Affective factors – mood, fear,
depression, anxiety Conditions that Open the Gate:
3. Psychosocial factors – family, personal 1. Physical Conditions
spiritual, cultural beliefs, occupation a. Extent of injury
4. Cognitive – past experience, knowledge, b. Inappropriate activity level
values, expectations 2. Emotional Conditions
a. Anxiety or worry
k. Pain Control Theories b. Tension
INTENSITY THEORY c. Depression
 State that pain is the result of excessive 3. Mental Conditions
stimulation of sensory receptors. a. Focusing on pain
b. Boredom
PATTERN THEORY
 Describes that painful and non-painful Conditions that Closes the Gate:
sensation s are transmitted by nonspecific 1. Physical conditions
receptors through a common pathway to a. Medications
higher centers of the brain. b. Counter stimulation (e.g., heat,
message)
SPECIFICITY THEORY
 2. Emotional conditions during, after activity, all the time.
a. Positive emotions
b. Relaxation, Rest 2. Medical History and Physical Examination
3. Mental conditions (H & P)
a. Intense concentration or  helps the nurse to understand the unique
distraction pain experience of the client and to
b. Involvement and interest in life formulate a plan to resolve the pain.
activities  provides baseline data to allow
assessment of the patient’s progression
Pain Assessment through a pain experience.
 Effective pain management begins with a
comprehensive assessment which allows 3. Pain Assessment Tools
the health care provider to characterize the a. McGill Melzack Pain
pain, clarify its impact and evaluate other Questionnaire – a
medical and psychosocial problems. The multidimensional assessment
assessment determines whether additional tool composed of 20 words
evaluation is needed to understand the descriptors grouped into 4
pain. namely:

Goals of Comprehensive Pain Assessment

 Obtain a full description of the pain;  Sensory (1-10)
 Determine whether the description fits a  Affective (11-15)
well-known pain syndrome;  Evaluative (16)
 Determine whether there is structural  Miscellaneous (17-20)
disease of the body that may help the b. Simple Descriptive Pain
pain; Intensity Scale –from No pain to
 Try to understand the mechanisms (tissue, Worst possible pain
nerve injury, psychological processes) c. 0 – 10 Numeric Pain Intensity
that maintain the pain; Scale
 Describe the negative effects on physical d. Visual Analog Scale (VAS) /
and psychosocial functioning caused by Linear Scale
the pain; e. Wong – Baker FACES Pain
 Understand the medical and psychiatric Rating Scale
problems that co-exist with the pain and
might need treatment at the same time

Pain Management
1. Pain Assessment – Health History  refers to the techniques
 Pattern : onset & duration used to prevent, reduce
 Area : location or relieve pain.
 Intensity. : level  Effective pain
 Nature : description management is a
collaborative work,
PQRST Format involving good
Provocation – How the injury occurred & what communication among
activities ¯ the pain the patient, family and
Quality - characteristics of pain the health practitioners.
Aching (impingement), Burning (nerve A sense of partnership
irritation), Sharp (acute injury), Radiating within in trying to find the best
dermatome (pressure on nerve) therapeutic approach
Referral/Radiation – promotes the most
Referred – site distant to damaged tissue that does creative, and ultimately
not follow the course of a peripheral n. the most effective,
Radiating – follows peripheral n.; diffuse approaches. Patient-
Severity – How bad is it? Pain scale practitioner partnership
Timing – When does it occur? p.m., a.m., before, can maximize the
 patient’s involvement For all modes of PCA the basic variables are
and sense of control in  Initial loading dose to titrate up to
the healing process. minimum effective analgesic
Family communication concentration (MEAC)
helps promote positive  Demand dose (on activation of demand
patterns within the dose)
family and may reduce  Lockout interval (to prevent overdose)
the stress caused by  Background infusion (constant rate of
prolonged pain and infusion)
impaired function.  1 h and 4 h limits (to program the device
to limit the patient)
Goals in Managing Pain:
1. Reduce pain 1. Pharmacological or Drug Interventions
2. Control acute pain
3. Protect the patient from further injury Examples of NSAIDs
while encouraging progressive exercises.  Oxicams like piroxicam
 Naphthlyalkanones like nabumetone
5 General Techniques for Achieving Pain Mgt:
 Fenamates like mefenamic acid,
1. Blocking brain perception.
meclofenamic acid
2. Interrupting pain transmitting chemicals at
 Pyrazoles like phenlybutazone
the site of injury.
3. Combining analgesics with adjuvant
* Adjuvant Drug Therapy
drugs.
4. Using gate-closing mechanisms.  The so-called adjuvant analgesics
5. Altering pain transmission at the level of are defined as drugs that are on the
the spinal cord. market for indications other than
pain but may be analgesic in
Drug Interventions for Pain selected circumstances. They
1. Patient Controlled Anesthesia include a very large number of
-interactive method of pain management drugs in numerous drug classes
that allows patients to treat their pain by (Thiessen, 2003).
self-administering doses of analgesic
agents Examples of Adjuvant Analgesics
 Antidepressants (Amitriptyline or Elavil,
Pain Management Methods Clomipramine, Desipramine)
 Anticonvulsants (Pregabalin, Gabapentin,
 About half of hospitalized patients who Carbamazepine, Phenytoin, Topiramate)
have pain are under-medicated.  Local Anesthetic Agents (Mexiletine,
 Children are at particular risk of poor pain Tocainide, Flecainide)
control methods.  GABA Agonists (Baclofen)
 Medications are given as:  N-methyl-D-aspartate (NMDA)
PRN – “as needed” Antagonists - (Dextromethorphan,
As a prescribed schedule Ketamine, Amantadine, Memantine)
 Corticosteroids (prednisone,
ROUTES Dexamethasone, Methylprednisolone)
 Intravenous – first line
 Rectal – alternative when oral/iv are not
* Non opioid Analgesics
an option
 Includes acetaminophen or
 Topical- eg. Patch, gel formulation
paracetamol, dipyrone and
(EMLA)
nonsteroidal anti-inflammatory
 Intraspinal (neuraxial)/ epidural drugs or NSAIDs). The NSAIDs
(perineural) are nonspecific analgesics and can
 Oral potentially be used for any type of
acute or chronic pain.
Basics of a PCA
  Because they are both analgesic a. Heat and Cold Therapy
and anti-inflammatory, NSAIDs Heat helps soothe stiff joints and relax muscles.
are particularly useful for pain Cold helps numb sharp pain and reduce
related to joint problems and other inflammation. Use temperature therapy to
musculoskeletal disorders. complement meds and self-care. It's simple,
affordable, soothing -- and you have to sit down to
Examples of NSAIDs use either one.
* Salicylates like Aspirin,
Diflunisal,Trisalicylate &
Salsalate As a general rule of thumb, use ice for acute
* Proprionic acids like ibuprofen, injuries or pain, along with inflammation and
naproxen, ketoprofen, swelling. Use heat for muscle pain or stiffness.
fenoprofen, oxaprozin
* Acetic acids like indomethacin, * Heat Therapy
diclofenac, ketorolac, tolmetin,  Heat therapy works by improving
sulindac, etodolac circulation and blood flow to a particular
* Oxicams like piroxicam area due to increased temperature.
* Naphthlyalkanones like Increasing the temperature of the afflicted
nabumetone area even slightly can soothe discomfort
* Fenamates like mefenamic acid, and increase muscle flexibility. Heat
meclofenamic acid therapy can relax and soothe muscles and
* Pyrazoles like phenylbutazone heal damage.

* Opioid Analgesics Types of Heat Therapy

 The most effective analgesics  Dry heat (or “conducted heat therapy”)
(Ellison, 1998). This includes all includes sources like heating pads, dry
drugs that interact with opioid heating packs, and even saunas. This heat
receptors in the nervous system. is easy to apply.
These receptors are the sites of  Moist heat (or “convection heat”)
action for the endorphins, includes sources like steamed
compounds that already exist in the towels, moist heating packs, or hot baths.
body and are chemically related to Moist heat may be slightly more effective
the opioid drugs that are prescribed as well as require less application time for
for pain. the same resultsTrusted Source.

a.
Opioid antagonists – have no When NOT TO USE Heat Therapy
analgesic effect and are used to  There are certain cases where heat therapy
block the effects of opioid drugs. should not be used. If the area in question
Ex. Naloxone, Naltrexone, is either bruised or swollen (or both), it
Nalmafene may be better to use cold therapy.
b. Opioid Agonist-antagonist -  Heat therapy also shouldn’t be applied to
have analgesic effect. an area with an open wound.
Ex. Buprenorphine, Butorphanol,  People with certain pre-existing
Nalbuphine, Dezocine conditions should not use heat therapy due
to higher risk of burns or complications
Side Effects associated with Opioid Drugs due to heat application. These conditions
 Constipation include:
 Nausea o diabetes
 Itch o dermatitis
 Urinary retention o vascular
 Dry mouth diseases
 Sexual Dysfunction o deep vein
 Sleepiness, fatigue, dizziness and mental thrombosis
clouding o multiple
sclerosis (MS)
2. Non drug Interventions
 use of cold therapy;
Risk of Heat Therapy  If cold therapy hasn’t helped an injury or
 Utilize only warm water not “hot” water swelling within 48 hours, inform your
because of possibility of burn. doctor.
 Heat applied directly to a local area, like
heating packs, should not be used for b. Transcutaneous Electrical Stimulation (TENS)
more than 20 minutes at a time.  TENS has been used successfully to help
 If swelling increased, stop the treatment control chronic pain in various conditions,
immediately. including chronic neuropathy, arthritis,
 If pain doesn’t lessen after a week or the postoperative pain, post-fracture recovery,
pain increases within a few days, consult low back pain, postherpetic neuralgia,
the doctor. myofascial pain, and advanced painful
malignancies (Thorsteinsson, 1987).
* Cold Therapy  The device is an electrical unit that
 is also known as cryotherapy. It works by delivers different frequencies and
reducing blood flow to a particular area, intensities of stimulation to the skin
which can significantly reduce through electrodes. To increase the chance
inflammation and swelling that causes that TENS can help, the patient is given a
pain, especially around a joint or a tendon. TENS device and then instructed to apply
It can temporarily reduce nerve activity, a variety of different types of stimulation
which can also relieve pain. during a trial period. Patients vary a great
deal in the type of TENS that works.
Ways to Apply Cold Therapy
a. ice packs or frozen gel packs c. Acupuncture
b. coolant sprays - not sure how it works. Could include:
c. ice massage  Counter-irritation – may close
d. ice baths the spinal gating mechanism in
e. cryostretching, which uses cold pain perception.
to reduce muscle spasms during  Expectancy
stretching  Reduced anxiety from belief that
f. cryokinetics, which combines it will work.
cold treatment and active  Distraction
exercise and can useful for  Trigger release of endorphins
ligament sprains
g. whole-body cold therapy d. Acupressure
chambers  is a method of sending a signal to the
body via needles or other means, to turn
When NOT TO USE Cold Therapy on its own self-healing or regulatory
 People with sensory disorders that prevent mechanisms.
them from feeling certain sensations  used for thousands of years in China and
should not use cold therapy at home the principles is the same with the
because they may not be able to feel if acupuncture, i.e. promote relaxation and
damage is being done. This includes wellness and to treat disease.
diabetes, which can result in nerve
damage and lessened sensitivity.
 You should not use cold therapy on stiff e. Percutaneous Electrical Nerve Stimulation
muscles or joints. (PENS)
 Cold therapy should not be used if you  combines electro-acupuncture and TENS
have poor circulation. which uses acupuncture like needle
probes as electrodes placed at
Risk of Cold Therapy dermatomal levels corresponding to local
 If applied too long or too directly, can pathology.
result in skin, tissue or nerve damage;  The main advantage of PENS over TENS
 If patient has cardiovascular or heart is that it bypasses local skin resistance
disease, consult the doctor first prior to and delivers electrical stimuli at the
 precisely desired level in close proximity various forms of meditation, progressive
to the nerve endings located in soft muscle relaxation, deep breathing, and
tissue, muscle, or periosteum. paced respiration. The goal of these
therapeutic approaches is overall
f. Non invasive Techniques / Psychological Pain relaxation and stress reduction. Practice
Control Therapy can produce a set of physiologic changes
that result in slowed respiration, lowered
* Mind / Body Therapy pulse and blood pressure, and reduction in
 Pain and stress are intimately related. the body's inflammatory response
There may be a vicious cycle in which mechanism (Lutgendorf, 2000). This can
pain causes stress, and stress, in turn, have a positive impact on health and
causes more pain. improve symptoms in many acute and
 Mind/body therapy address these issues chronic illnesses and conditions,
and provide a variety of benefits, including pain.
including a greater sense of control,
improved coping skills, decreased pain
intensity and distress, changes in the way 
pain is perceived and understood, and * Biofeedback
increased sense of well being and  provides biophysiological feedback to
relaxation. These approaches may be very patient about some bodily process the
valuable for adults and children with pain patient is unaware of (e.g., forehead
(Rusy, 2000). muscle tension).
 use of electronic monitoring instruments
* Cognitive – Behavioral Therapy to provide patients with immediate
 addresses psychological component of feedback on heart rate, blood pressure,
pain including attitudes, feelings, coping muscle tension, or brain wave activity.
skills and a sense of control over one’s This allows the patient to learn how to
condition; influence these bodily responses through
 effective in reducing pain and disability conscious control and regulation.
when used as part of a therapeutic
treatment for chronic pain. * Hypnosis
 provides educational information and  relaxation + suggestion + distraction +
diffuse feelings of fear and helplessness; altering the meaning of pain.
 helps patient to find a more realistic and  during hypnosis, changes like those found
balanced view of the pain problem; in meditation can occur, such as a
 includes teaching of life skills and coping slowing of the pulse and respiration, and
skills that can assist the patient in an increase in alpha brain waves.
productive problem solving and the  Medical hypnosis has been shown to be
prevention or minimization of future pain helpful in reducing both acute & chronic
episodes. pain.

* Imagery * Prayer
 is the use of imagined pictures, sounds, or  not usually considered a mind-body or a
sensations for generalized relaxation or psychological approach, but it is
for specific therapeutic goals, such as the worthwhile considering it in this context
reduction of pain. These images can be of mind/body treatments. Changes in the
initiated by the patient or guided by a concept of health and illness, a
practitioner. The sessions in which broadening view of healing and curing,
imagery is used can be individual or and interest in other cultural systems of
group. medicine have created a growing
openness to the spiritual dimensions of
* Relaxation health
 systematic relaxation of the large muscle
groups. *Physical Therapy
 Relaxation therapies include a range of  are useful in teaching patients to control
techniques such as autogenic training,
 pain, to move in safe and structurally
correct ways, to improve range of motion,
and to increase flexibility, strength and
endurance. " Active" and "passive"
modalities can both be used, but active
modalities, such as therapeutic exercise,
are particularly important when the goal is
to improve both comfort and function.

* Exercises
 have a variety of benefits that produce
better stamina and function. Exercise may
reduce the risk of secondary pain
problems like muscle strains, and may
also lead to improved confidence and
sense of well-being.