Multidimensional Model of Pain

The Multidimensional Model of Pain - An Overview

By: Isaac Winkler Music Therapy Intern Children's Minnesota June 1st, 2021 - December 1st, 2021

About me

• Graduate student at Augsburg University
• MT Intern since June 2021
• Minneapolis and St. Paul
• Future MT-BC at Healing Rhythms in Mankato

Why a multidimensional model?

• Western medical tradition has favored a biomedical approach
• Non-physical pain is ignored or passed off
• Over-reliance on medication
• Many non-western cultures have a rich tradition of holistic medicine.

" Pain is a perception that cannot be treated as a purely physiological symptom. There are different kinds of pain."

Joanne Loewy

Multidimensional model of pain

Socio-cultural

Physical

Cognitive

Sensory

Affective

Spiritual

Behavioral

Patient's behaviors in response to pain

Impact of patient's anatomic structure on pain

Quality and severity of the pain experience for the patient

Influence of social and cultural factors on pain experience

Thoughts, beliefs, and attitudes toward pain.

How the patient feels in response to pain and about their pain

Meaning the patient attaches to pain

(Ahles, Blanchard, & Ruckdeschel 1983, McGuire, 1992, Silkman, 2008)

Physical dimension of pain

Physical dimension of pain

1. Nerve endings (nociceptors) detect mechanical, chemical, thermal stimuli (nociceptive pain) or nerve damage (neuropathic pain).
2. Nerve impulses travel to the brain, which processes the impulses and interprets them as pain.
3. The brain responds by triggering the sympathetic nervous system
1. Increased HR
2. Increased blood pressure
3. Shallow breathing
4. Tensed muscles
4. Motor responses in turn increase perception of pain (Mites, 1997).

A Train Education. (2021)

Physical dimension of pain

1. Gate theory: Melzack and Wall (1965) propose that nerve impulses can be "blocked" by neural activity in the dorsal horns of the spinal cord.
2. Alternate engagement: Using engagement with a cognitively challenging task to reduce perception of pain.
3. Iso-principle: Entrainment to music can reduce heart rate, blood pressure, and muscular tension. (Loewy, 1997), which in turn reduces pain perception.

Sensory dimension of pain

Sensory dimension of pain

1. Characteristics:
1. Location
2. Intensity
1. 0-10 pain scale
2. Face scale
3. FLACC (face, legs, activity, cry, consolability)
3. Quality (burning, stabbing, throbbing, dull, sharp, etc.)
2. Musical improvisation can be an assessment tool to help patients qualify and describe their pain.

Behavioral dimension of pain

Behavioral dimension of pain

1. Pain and anxiety activate the sympathetic nervous system, driving "fight or flight" response.
2. Patients' behavioral responses to pain can intensify their experience of it.
3. Young children draw cues from family/caregivers (Sundar, 2016).
4. Routine procedures can contribute toward anticipatory anxiety and even traumatization.

Behavioral dimension of pain

1. Music therapy can reduce anxiety before (Giordano, 2020), during (Sundar, 2016, Zengin, 2013), and after procedures (Allred, Nelson, 2017)
2. During procedural support, music therapy can give caregivers and staff a role (one voice).
3. Attention to needs of the individual child (avoidance vs. involvement)

Socio-cultural dimension of pain

Socio-cultural dimension of pain

1. Historical trauma - "Multigenerational trauma experienced by a specific cultural, racial, or ethnic group." (U.S. Department of Health & Human Services)
2. Medical abuse of racialized black individuals in U.S.
1. Tuskegee untreated syphilis study (1932)
2. "Race corrected" tools and measures
3. Epigenetics - Biological consequences of trauma can be inherited across generations. (Dias and Ressler, 2014), (Conching, 2019)

(https://www.acf.hhs.gov/)

Socio-cultural dimension of pain

1. Music therapy can incorporate patient's language and culture into medical setting.
2. Family-centered care - How do we support the tools that families are already using to cope? (vs. "expert")
3. Listen to family perspectives and do not characterize them as "uncooperative", "attention seeking", "disruptive", etc.

Cognitive dimension of pain

Cognitive dimension of pain

1. Pain appraisal - The "meaning" ascribed to pain by a patient, including whether they believe they can cope with it or not (Love-Jones, 2019).
2. Psychological "meaning" of pain can vary wildly by age.
1. Children ages 2-7 are more likely to see pain as "punishment" for transgressing rules or negative thoughts
2. Children ages 7-12 are more likely to understand the concrete physical causes of pain.
3. Children age 12 or older likely understand some of the psychological causes of pain.

Cognitive dimension of pain

1. Catastrophizing - Exaggerated negative orientation toward actual or anticipated pain experiences, associated with increased pain perception and physiological dysfunction (Love-Jones, 2019)
2. Perceived control over pain - The patient's belief that they can have control over their pain, which increases pain tolerance.
3. Identification with "sick role"
4. Post-meal anxiety for CTED patients.

Cognitive dimension of pain

1. Song discussion and songwriting can provide opportunities for patients to share and process.
2. Adaptive lessons can cognitively engage patients with anxiety.
3. Coping skill development through group programming

Affective dimension of pain

Affective dimension of pain

1. Feelings of helplessness
2. Inability to engage with usual activities
3. Isolation due to long-term hospitalization

Affective dimension of pain

1. Music therapy can offer choice and control.
2. Musical skill development can make time in hospital meaningful and encourage feelings of competence.
3. Iso-playlists can be a tool for patients to move from one affective state to another.

Spiritual/existential dimension of pain

Spiritual/existential dimension of pain

1. Patients and families grapple with spiritual and existential questions:
1. "Why did this have to happen to me?"
2. "How do I find meaning living with illness/a sick child?"
2. Grief from bereavement, loss of role, complex or ambiguous loss, etc.

Spiritual dimension of pain

1. Music therapy can incorporate music that has spiritual significance for the patient.
2. Songwriting can be used to affirm and support activities that create meaning for the patient/family.
3. Legacy work

Case example: "George"

• Older teen with Ataxia-telangiectasia and leukemia (ALL)
• Difficulty coordinating movements, slurred speech
• Said "I can't keep fighting" to mom on second admit

Goals:

• Reduce pain
• Increase coping skills
• Increase creative/emotional expression

Interventions:

• Patient-preferred live music
• Therapeutic instrumental music performance (TIMP)
• Songwriting
• Legacy project

Endorphins Fly - "George"

Verse 1: Way back in the year two thousand three a boy was born in spring yeah that's me! Small bundle of joy given to Mom and Dad they smiled with pride and shared laughter too. Chorus: Share a little gift one you don't have to buy. It helps me out in life makes my endorphins fly. Humor and laugther, well.... just make you feel good! Verse 2: I was told my baby life was good Then grew into a toddler having fun in the neighborhood Things started to change in the grade of 1. Walking became harder and getting round was not fun.

Verse 3: Third grade came ‘round ‘n they got me a ride Cool lime green it helped me walk when it was by my side Ataxia they said was the cause of my probs Dang it though my mobility gets robbed So why not… Chorus Verse 4: Sociability helps to send and receive The gift of humor from you to me Your brain gets good feelings when laughter expels it gets your body back to well. You can live and cope with what life deals you out by using your humor without a doubt. Chorus

References:

A Train Education. (2021). The physiology of pain. In Pain: healthcare’s persistent challenge. Online course. Ahles, T, Blanchard, E, and Ruckdeschel, J. (1983). The multidimensional nature of cancer-related pain. Pain, 17:277-288. Brown, C, Chen, A, and Dworkin, S. (1989). Music in the control of human pain. Music Therapy. Vol. 8, No. 1, 47-56. Conching, A., Thayer, Z. (2019). Biological pathways for historical trauma to affect health: A conceptual model focusing on epigenetic modifications, Social Science & Medicine, Volume 230, Pages 74-82, ISSN 0277-9536, https://doi.org/10.1016/j.socscimed.2019.04.001. Dias, B. G., & Ressler, K. J. (2014). Parental olfactory experience influences behavior and neural structure in subsequent generations. Nature neuroscience, 17(1), 89–96. https://doi.org/10.1038/nn.3594 Hyung Lee, J. (2016). The effects of music on pain: A meta-analysis. Journal of Music Therapy, 53(4), 430–477. doi:10.1093/jmt/thw012 Love-Jones S.J. (2019) Pain as a Subjective, Multidimensional Experience. In: Abd-Elsayed A. (eds) Pain. Springer, Cham. https://doi.org/10.1007/978-3-319-99124-5_35 McGuire, D. (1992). Comperehensive and multidimensional assessment and measurement of pain. Journal of Pain and Symptom Management. 7 (5), 312-319) Mites, E. (1997). Tune your brain. The Berkley Publishing Group, NY, USA.

Nelson, K., Adamek, M, Kleiber, C. (2017.) Relaxation training and post-operative music therapy for adolescents undergoing spinal fusion surgery. Pain Management Nursing, 18(1), 16-23. Polkki T., & Korhonen A. (2012). The effectiveness of music on pain among preterm infants in the neonatal intensive care unit: a systematic review. Joanna Briggs Institute Library of Systematic Reviews. 10 (48), 4600-4609. Scorza, P., Duarte, C.S., Hipwell, A.E., Posner, J., Ortin, A., Canino, G., Monk, C. and (2019), Research Review: Intergenerational transmission of disadvantage: epigenetics and parents' childhoods as the first exposure. J Child Psychol Psychiatr, 60: 119-132. https://doi.org/10.1111/jcpp.12877 Silkman, C. (2008). Assessing the seven dimensions of pain. American Nurse. Retrieved October 1st from https://www.myamericannurse.com/assessing-the-seven-dimensions-of-pain/ Sundar, S., Ramesh, B., & et al. (2016). Live music therapy as an active focus of attention for pain and behavioral symptoms of distress during pediatric immunization. Clinical Pediatrics, 55(8), 745-8. Zengin, S. et al. (2013). Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complementary Therapies in Medicine, 21(6), 689-96.