Cold Pressor on Chronic Pain - Research Paper Example

?Cold Pressor on Chronic pain: Review of Literature Defining Pain Pain is the least among all things that people would want to experience. Back pain,toothache, headache, chest pain, abdominal pain, and joint pain- all these terms connote the thing everyone wants to relieve if not to avoid for life. Whether pain is in every aspect, pain connotes something that is not good to experience but as human beings the possibility of experiencing pain, especially physiologic, a hundred percent accurate. Pain has been the most prevalent and talked about illness in the world, that every person has already experienced how pain feels. Researches and studies have also been done to define what pain really is. Various definition of pain has been derived by many scholastics. It has been defined literally, technically, medically or even personally by experience. The International Association for the Study of Pain (IASP) has worked to update both pain terms and the classification of pain syndromes. All terms pertaining to pain have been carefully reviewed and assessed by the committee in reference to new knowledge about both clinical and basic science aspects of pain and have recently presented the recent 2011 version of IASP pain terminology. And the committee opens to changes that the more the committee learn about pain thus the terminology needs to be updated (IASP). Thus after such studies the IASP have come up with an internationally acceptable definition of pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Meanwhile, an alternative definition is offered by McCaffrey and Beebe, "Pain is whatever the experiencing person says it is, existing whenever the experiencing person say it does.” Both of these definitions of pain therefore highlight that a painful experience is more than just a tissue damage triggering a response from the nervous system but more than that it is an emotional experience. Thus for these definitions, the management of pain involves more than simply treating the tissue injury but as well as the emotional trauma that goes with it (Pain Community Centre). From these definitions of pain one must say that the feeling of having it is something a person would not want to experience. Thus alongside with the study of pain is the hope for the relief of the condition that brings pain or most importantly the pain itself. The National Cancer Institute has cited three different types of pain. Pain definition is something the NCI is very familiar with since cancer patients experience and defines pain along the process cancer patients have to go through. The common terms used to describe the types of pain are: Acute, chronic and breakthrough pain. The least type of pain is referred to as an acute pain that ranges from mild to moderate severity and comes and lasts quickly. While chronic pain ranges from mild to severe and the pain experience either won't go away or comes back often. Lastly, breakthrough pain is an intense rise in pain that occurs suddenly or is felt for a short time and it occurs several times a day, even when a person is taking the right dose of medicine (National Cancer Institute; National Institute of Neurological Disorders and Stroke). The Arthritis Foundation have cited that although pain seems to be the most avoided feeling in the world it is studied to have a physiologic purpose that is said to be the body’s alarm system that tells a person that something is wrong. That is when a person is injured, nerves in the affected area release chemical signals to the brain recognized as pain. The pain sensation arises from the stimulation of specialized sensory neurons indicating tissue damage or the potential for damage (Fishman et al. 1144). According to the British Pain Society, millions of people experience pain everyday that has a major impact on the quality of these people’s lives that they often skip work because of the painful experience. Pain hinders people from functioning up to the optimum level as well as hindering the full economic potential. According to a survey regarding diseases that makes people experience pain, the numbers of work days are markedly decreased like in Endometriosis that showed an average loss of 55 days from work per annum for females suffering with this condition. Likewise, the National Rheumatoid Arthritis Society estimated that 9.4 million working days are lost through Rheumatoid Arthritis, also a painful condition. On the same note, British businesses reported losses amounting to an estimated 4.9 million days due to employee absenteeism because of back pain. With each affected employee taking an average of 19 days off work this is clearly a problem that needs to be addressed. These surveys show that pain, although just part of a symptom of a disease, is an enormous problem that has to be given relief to ease people from what appear to be an accurate measure of the total burden to industry of chronic pain (British Pain Society). The disability that comes from painful experiences is one of the main factors why people are against pain. With pain many people are deprived of working on their full potential that can greatly affect economic status—lessened work pay and not to mention the cost of medications people have to take for a long time due to chronic pain. This is where therapeutics comes in to lessen if not to avoid the hindering painful experience. Medications and treatments, along with pain management techniques like relaxation, pacing, and exercise, can play a big role in reducing pain and improving quality of life (American Chronic Pain Association). On this note this study is opted for the effectiveness of cold pressor as a therapeutic none pharmacologic relief of chronic pain. This study is to gather information and relevant studies that would point out on the effectiveness of cold pressor in alleviating painful experience. Cold pressor test on chronic pain The cold pressor test is a test done by immersing a limb into ice cold water for 1 to 2 minutes. It has been widely used to elicit an emotional or motivational pain experience from the immersion and to evaluate pain (Walsh et al.). Cold pressor test works on the idea of distracting nerve perceptions by inducing an intense painful sensation by submerging a limb in ice cold water. The cold pressor test is a widely used measure of acute stress with well-established methodology. The cold-pressor apparatus is a container divided into 2 compartments by a wire screen. Ice cubes are placed in the smaller part and water in the larger part. The water temperature is maintained at 1–2°C via a submerged pump that circulates the water around the ice (Ulrich et al. 216). Distraction and attention can exert a powerful influence on the perceived intensity of painful stimuli. There are studies that support the modulation of pain and unpleasantness that have documented the effect of stimuli in any form to increase pain tolerance (Anesthesia Progress Blog). The principle on the use of cold therapy, also known as cryotherapy, as a pain relief were first written about by the great Hippocrates thousands of years ago using the benefits of snow and ice. The very same principle is now modernly applied when a person applies ice over a sprained ankle to reduce the swelling. It can be applied in various ways like icepacks, coolant sprays, ice massage and whirlpools. This therapy remains to be one of the simplest and yet time-tested remedies in managing pain and swelling at home, hospitals, schools and elsewhere if access to ice is applicable. Who would have thought that the most basic home remedy that almost all mothers knew is a thousand-aged principle that is still applied in the field of medicine and healthcare (University of Rochester Medical Center). Numbers of studies have been made that have used the effectiveness of cold pressor to identify pain quality, intensity and scale for every subject. Cold pressor test has been used widely to elicit pain response for every subject since it is inexpensive, easy to perform and widely recognized experimental stress stimulus in human studies. For example, a normative study of Walsh et al. was done to develop a normative mathematical model for pain tolerance using the cold pressor test with over 600 subjects. Norms for age, sex, and ethnic group were calculated. In addition, chronic pain patients were then compared with pain free patients to determine normative differences in response if there are any for this matter. The results of the normative study indicated that Anglo-Saxon males have the longest tolerance time followed by non-Anglo-Saxon males, Anglo-Saxon females, and finally non- Anglo-Saxon females. Significantly, there is a consistent decrease in tolerance time as the male age increases and minimal change in tolerance time as the female age increases. Chronic pain patients exhibited the same type of pain response pattern as healthy volunteers when corrected for age, sex, and ethnocultural subgroup (Walsh et al.). Moreover, physical challenges like the cold pressor test challenge are included in the commonly used methods. The mechanism underlying the response involves a response temperature in the form of constriction to blood flow of both superficial and deep tissues of the hand and consequential strong perception of pain. Cold pressor is an adequate model to study psychobiological responses to stressful discomfort because cold-induced vasospasms are frequently present in syndromes of chronic pain and chronic stress. This test has been used successfully in a variety of experimental models, including elucidating characteristics of endocrine responses in patients with chronic pain (Minagar & Shapshak 146). A variety of experiments have been done using the cold pressor test. Cold pressor is said to be an effective chronic pain relief as revealed by Schmidt and Brands in a study that chronic low back pain patients have extreme sensitivity to cold pressor test reporting a higher pain levels and tolerating the ice water for a shorter period of time (Schmidt & Brands). Schmidt and Brands performed two successive studies using the cold pressor test in which both authors have found out that maximum tolerance time for cold pain was significantly lower in back pain patients than in pain free controls (Schmidt & Brands as cited in Lautenbacher & Fillingin 63). Another study bearing the similar effect of cold pressor was obtained by Johnson & Petrie stating that tolerance time was shorter in back pain patients than in pain free volunteers (Lautenbacher & Fillingin 63). Similarly, studies of Barrish et al. and Coffin et al. supports the idea of physical stimulation, such as cold pressor, and demonstrates that patients with various clinical syndromes can display heightened pain sensitivity to such controlled stimulation of tissues associated with the experienced pain syndromes (Barrish et al. &Coffin et al as cited in Fishman et al. 1444). Using the cold pressor test, three experiments were conducted to investigate the effects of water temperature and labeling on three dependent measures in college women: behavioral pain tolerance (BPT), a sensory rating of the pain experience (SR) and a parallel affective rating of the experience (AR). Temperature of the cold pressor was varied as the physical factor while discomfort or pain was varied as the psychological factor. Result of the said tests were as follows: Experiment 1 varied only water temperature; colder temperatures led to significantly lower behavioral pain tolerance scores and significantly higher sensory rating of the pain experience and affective rating of pain experience scores. Experiment 2 varied only labeling and demonstrated that behavioral pain tolerance decreased and Affective Rating of the experience increased as labels became more painful-sounding but on the contrary, the Sensory Rating was unaffected by labeling. During the 3rd experiment both the psychological and physical factors were varied simultaneously. Results indicated significantly higher behavioral pain tolerance scores as the water temperature increased and the pain label became more benign. In addition, both sensory rating of the pain experience and affective rating of the experience were sensitive to changes in temperature, whereas only affective rating of the experience was affected by changes in labeling (Hirsch & Liebert 41). These experiments show the remarkable changes in pain perception using the cold pressor test as an effective sensory distraction thus a potent pain remedy. Whiplash injury and chronic whiplash syndrome is a major health problem in most western countries and pain is the main symptom hence another study for chronic pain was made using the cold pressor test. Pain that takes longer than the usual that some does not even recover from the injury. Imagine pain everyday is excruciating to a person. In a study of Kasch et al. (561), cold pressor test was used to determine pain tolerance for whiplash patients. The study was aimed to know if tolerance to endure pain stimuli (cold pressor stimuli) may predict outcome in whiplash injury. In this one-year long prospective study, 141 acute whiplash patients exposed to car collision and 40 ankle-injured controls were followed and exposed to cold pressor test for several time frame—1 week , 3, 6 and 12 months respectively. Pain score was determined before during and after immersion of the dominant hand into cold water for 2 minutes (Kasch et al. 561). Using the McGill Pain Questionnaire, results have shown that ankle-injured controls had higher initial pain scores while whiplash-injured subjects had higher scores at 6 months. While there was no difference that was found in cold pressor pain between recovered whiplash patients and ankle-injured subjects. Non-recovery was only encountered in whiplash injury. Eleven non-recovered whiplash patients showed reduced time to peak pain from 1 week to 6 months but not later than 12 months after. There was a larger pain area observed in non-recovered whiplash-injured subjects during the entire observation period (Kasch et al. 561). In this experiment using the cold pressor test it has been studied and proved that non-recovery after whiplash is associated with initially reduced pain endurance and increased peak pain, suggesting that dysfunction of central pain modulating control systems plays a role in chronic pain after acute whiplash injury hence cold pressor test was used to here was useful in determining pain response for patients experiencing chronic pain due to whiplash injuries (Kasch et al. 561). Another study using the cold pressor test to assess chronic musculoskeletal pain was done by Carli et al. (259). In this study pain sensitivity was evaluated in patients with fibromyalgia and other types of chronic diffuse musculoskeletal pain to establish whether fibromyalgia represents the end of continuum of dysfunction in the nociceptive system using 145 patients and 22 healthy individuals as controls. Von Frey monofilaments were used to assess superficial punctate pressure pain thresholds. Heat and cold pain thresholds were determined with a thermal stimulator. Ischemic pain was assessed by the cold pressure test and the sub maximal effort tourniquet test. It was found out that the heat pain and cold pain threshold by cold pressure test were lower in the fibromyalgia and secondary-concomitant fibromyalgia groups than in healthy subjects. Moreover, the cold pressure tolerance was lower in patients with widespread pain than in healthy subjects. In summary, in each psychophysical test, patients with widespread pain and patients with multiregional pain showed similar thresholds; however, the thresholds in the multiregional pain or multiregional pain associated with at least 11 tender points. The results indicate that dysfunction in the nociceptive system is already present in patients with multiregional pain with a low tender point count; it becomes more and more severe as the positive tender point count and pain extent increase and it is maximal in fibromyalgia patients (Carli et al. 259). There are several methods to determine pain scale. One of the many pain determination scales is the McGill pain questionnaire. This questionnaire is designed to provide quantitative measures of clinical pain for statistical treatment. This study helps to detect differences among different methods to relieve pain (Melzack 277). The universality on the use of Cold pressor test was even put into a study if safe even for children. The study of Birnie et al. has looked into the ethical side regarding the therapeutic induction of pain in children and was aimed at describing the ethical challenges and acceptability of cold pressor test from the perspective of researchers, parents and even children themselves. The study has used the survey type of research to gather information from children and parents regarding the experiences obtained from undergoing the cold pressor task. Surprisingly majority of the researchers, children and parents have reported positive experiences with the cold pressor task thus have concluded that cold pressor therapy can be used ethically in pediatric research with appropriate study safeguards (Birnie et al. 1081) Another study entitled, Cold Pressor Pain Sensitivity in Twins Discordant for Chronic Fatigue Syndrome, was done to find whether pain and fatigue ratings and pain threshold and tolerance levels for cold pain differed between twins with chronic fatigue syndrome and their co-twins without the said syndrome. During the study, Twins were instructed to place the non-dominant hand and forearm in a cradle in the water compartment and to inform the research assistant when the cold sensation had become painful already and when the pain was no longer tolerable. Twins were asked to withdraw their arm at tolerance or 5 minutes, whichever comes first (Ulrich et al. 222) To note the ratings of pain and fatigue for the statistical treatment of the study a pre and post rating were done using the visual analog scale. Before beginning the cold pressor test, participants were asked to rate the pain and fatigue on a 100 mm visual analog scale (VAS), anchored at 0 as no pain/fatigue and 100 as worst pain/fatigue ever. Pain and fatigue were rated again at the threshold and tolerance points, and again 15 minutes after reaching tolerance. In addition, at the beginning of the day before starting any tests, each twin rated personal fatigue and pain levels on similar 100 mm VAS. These daily ratings were used as adjustment variables in statistical modeling (Ulrich et al. 222) In summary of the research finding, it has been found that despite similarities in threshold and tolerance levels, twins with chronic fatigue syndrome experienced greater subjective pain and fatigue in response to the cold pressor test. Chronic fatigue syndrome may be associated with a heightened perception of pain and fatigue in reaction to stressful or painful situations. The study’s findings also highlight the possible role of genetic and familial factors in the association between chronic fatigue syndrome and pain sensitivity. Though the study was a success in eliciting the differences and similarities in pain sensation for twins using the cold pressor test, the study still suggests for future studies to be made and should focus on examining the heritability of pain sensitivity and the underlying mechanisms involved in the perception of pain sensitivity (Ulrich et al. 217). Cold pressor test has also been used on clinical and experimental studies on rats to delineate the medullar and spinal pathways mediating the cardiovascular responses to cold pressor test (CPT) and to identify neurotransmitters in these pathways. This study by Nakamura et al. (H1780) used cold pressor test to rats the same way it was used in human subjects, CPT elicited an immediate increase in mean arterial pressure (MAP), heart rate (HR), and greater splanchnic nerve activity (GSNA). The study worked by recording the variables such as arterial pressure (AP), heart rate (HR), and muscle or skin sympathetic nerve activity (SNA). The usual responses to the test included an increase in AP, HR, and SNA. These responses are vital in eliciting and identifying some medical conditions because these responses have been reported to be either absent or attenuated in pathological conditions such as Guillain-Barre syndrome, Parkinson's disease, idiopathic orthostatic hypotension, and diabetes mellitus with neuropathy while they are normal in other pathological situations such as Down's syndrome, arterial hypertension, and McArdle's disease. Hence CPT was used here to identify disease conditions by using pain tolerance response (Nakamura et al. H1780). Furthermore the use of cold pressor test has also been used clinically. In one study, the use of CPT was made during echocardiography as a new intervention for mitral valve prolapse. A study was performed in 13 patients with idiopathic mitral valve prolapse and in 21 control subjects to assess the effect of the cold pressor test on systolic motion of the mitral valve. It was found out that a significant increase in blood pressure occurred in 10 patients with mitral valve prolapse and in 19 controls after immersion of one hand in ice-cold water. The echocardiographic recordings from the mitral valve were obtained in all patients before, during, and after the cold pressor test, together with simultaneous phonocardiograms in selected patients. Nine out of 10 patients showed a significant increase in the depth of mitral valve prolapse during the cold pressor test whereas in three patients no change was noted during the cold stimulation. No evidence of mitral valve prolapse was seen in any of the control subjects before, during or after the cold pressor test. In four patients with mitral valve prolapse and a hypertensive response to cold stimulation the systolic click was delayed by the cold pressor test, whereas the time of the systolic click remained constant in the three patients whose blood pressure did not increase. It is therefore concluded that the cold pressor test can be a significant tool that provides a stimulus sufficient to delay the onset and increase the depth of mitral valve prolapse, thereby enhancing the diagnostic sensitivity of echocardiography in this condition (Pitcher et al. 524). Cold pressor test have been used widely to differentiate and classify the pain sensation that a person is experiencing especially for patients who are suffering from chronic pain and chronic pain syndrome that can come from various disease process. It has been shown that the cold pressor test is an effective tool used over and over again during studies, experiment and researches about pain stimuli, pain response and pain sensation variation. The author of this paper have observed that cold pressor testing had been used clinically and experimentally to elicit pain stimuli responses from people suffering from pain as well as healthy individuals to note the differences in response. Moreover it has also been used to define responses that could be absent in some diseases as well as a testing control to note pain response and the effectiveness of pharmacologic and non pharmacologic pain remedies. The wide use of the cold pressor test can be attributed to its easy accessibility and inexpensiveness as a tool for pain study making researches regarding pain even better over the years. Work Cited Anesthesia progress blog. Pain and Unpleasantness Evoked by a Cold Pressor Test. Web. 9 March 2010 Arthritis Foundation. Defining Pain: Not all Pain is alike. 2012. Web. October 2012 Birnie K.A., Noel M., Chambers C.T. von Baeyer C.L. & Fernandez C.V. (2011) The Cold pressor task: is it ethically acceptable pain research method in children? Journal of Pediatric Psychology, 2011. 36(10):1071-81. Print Carli G., Suman A., Biasi G. & Morcolongo R. Reactivity to superficial and deep stimuli in patients with Chronic musculoskeletal pain. 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