CHAPTER 13
Pain Management
DENNIS C. TURK AND AKIKO OKIFUJI
293UNIDIMENSIONAL CONCEPTUALIZATIONS OF
CHRONIC PAIN 294
Biomedical Model of Chronic Pain 294
Psychogenic Model of Chronic Pain 294
Secondary-Gain Model of Chronic Pain 295
Behavioral Conceptualizations 295
INTEGRATIVE, MULTIDIMENSIONAL MODEL„GA TE
CONTROL THEORY 298
PSYCHOLOGY OF PAIN 299
Affective Factors 299
Cognitive Factors 300
AN INTEGRATED, MULTIDIMENSIONAL MODEL 303
ASSESSMENT 303
Quantifying the Pain Severity 303
Physical and Laboratory Factors 304
Psychosocial Contributions 304
Assessment of Functional Activities 306
Assessment of Coping and Psychosocial Adaptation
to Pain 307
Assessment of Overt Expressions of Pain 307
COGNITIVE-BEHAVIORAL MODEL FOR THE TREATMENT
OF CHRONIC PAIN 308
PATIENT-UNIFORMITY MYTH 310
MULTIDISCIPLINARY PAIN REHABILITATION
PROGRAMS (MPRP) 312
CONCLUDING COMMENTS 313
REFERENCES 313People are capable of perceiving pain at least from the time of
birth. From our earliest experiences, we all become familiar
with the pain of a cut, sunburn, or a bruised knee. In these in-
stances, the pain is acute.That is, it is self-limiting and will
remit on its own or with use of over-the-counter analgesic
medication in a reasonably short period of time (usually
hours, days, or a few weeks). Rarely are there any long-term
consequences following acute pain episodes.
In acute pain, nociception(activation of sensory conduc-
tion in nerve “bers that transmit information about tissue
damage from the affected peripheral area to brain via the
spinal cord) has a de“nite purpose. It acts as a warning signal
directing concentration and demanding immediate attention
to prevent further damage and to expedite the healing
process. For example, when we place a hand on a hot stove,
we quickly remove it to avoid being burned. Pain also signals
that an injury or disease state is present as in the case of a
broken leg or in”amed appendix. In these instances, pain
serves an important, protective function informing us that we
should take steps to prevent additional problems and, if nec-
essary, seek medical attention.
There is another type of pain problem that does not “t
nicely or adhere to the characteristics of acute pain. There are
a number of pain diagnoses and syndromes (e.g., migraine,
rheumatoid arthritis, tic doloureux) in which intense pain
episodes recur over time, often in an unpredictable fashion.
Although each episode tends to last for a relatively brief
duration, pain may start any time often without an identi“able
provocation. For example, a migraine is a particularly severe
form of headache that may last for several hours and then
remit without any treatment. The migraine sufferer may be
headache-free for days or weeks and then have another
migraine episode. After the headache has run its course, the
person is headache free until stricken by yet another episode.
Thus, the person with migraines has repeated bouts of acute
pain. Migraine and conditions with similar episodic character-
istics may be viewed as recurrent acute paincharacterized by
pain-free periods punctuated by pain episodes. In the case of
recurrent acute pain, the role of pain is unclear because there
is no protective action that can be taken, nor is there neces-
sarily any identi“able tissue damage that might cause theSupport for the preparation of this manuscript was provided in part
by grants from the National Institute of Arthritis and Musculoskele-
tal and Skin Diseases (AR44724, AR47298) and the National
Institute of Child Health and Human Development (HD33989)
awarded to the “rst author and National Institutes of Health/Shannon
Director•s Award (R55 AR44230) awarded to the second author.