Tapping Into Relief: A Distraction Technique to Reduce Pain During Dermatologic Procedures.

The past 60 years has witnessed major changes in the way that pain is conceptualized and treated. In the 1950s, pain was generally conceptualized using a sensory model that maintained that pain is a simple sensory event that warned of tissue damage. Treatments for pain were biomedical and consisted mainly of attempts to identify underlying tissue damage and treat it medically or surgically. In the 1960s, clinicians and researchers expressed growing dissatisfaction with the sensory model of pain. In particular, it became increasingly clear that the sensory model failed to explain phenomena often seen in patients experiencing chronic pain: pain persisting despite multiple medical and surgical treatments aimed at correcting underlying tissue damage, reports of pain showing poor correlation with underlying evidence of tissue damage, pain being modified by psychosocial factors such as anxiety, social support, or expectations. Melzack and Wall’s gate control theory was one of the first to maintain that pain was complex in that it not only had a sensory component but also affective, ­cognitive, and behavioral components (Science 150(699):971–979, 1965). A key tenet of the gate control theory was that the brain could play a major role in modulating nociceptive signals at the spinal cord, through descending pathways from brain areas thought to be involved in affect, cognition, and behavior. The gate control theory also led to renewed interest in expanding pain treatments beyond traditional medical and surgical approaches to a wide array of ­interventions that could alter pain by modifying sensation (e.g., ­transcutaneous nerve stimulation, massage), or affective (e.g., antianxiety and antidepressant medications), cognitive (e.g., cognitive therapy, distraction techniques), and behavioral processes (e.g., exercise, graded activation).

In colchicine-resistant patients with familial Mediterranean fever (FMF), alternative therapies, which are administered parenterally, become necessary. Effective pain management is essential for FMF treatment. Buzzy® (Pain Care Labs, Atlanta, GA) is specifically designed to alleviate pain during needle procedures. This innovative tool integrates a cold pack with a vibration motor, thereby enabling the simultaneous application of cold therapy, tactile stimulation, and distraction techniques. By harnessing the combined effects of cold and vibration on the skin, Buzzy® significantly reduces pain perception. This study aimed to evaluate the effectiveness of Buzzy® in mitigating pain during subcutaneous administration of canakinumab in patients with FMF who are resistant to colchicine. This study included patients with colchicine resistance who were receiving canakinumab. Pain scores were evaluated before and after applying Buzzy® using the Visual Analog Scale (VAS), Wong-Baker FACES Pain Rating Scale (FPS-R), and Children's Fear Scale (CFS). A total of 15 patients were included in the study. Nine patients (60%) were female, and six (40%) were male. The median age of the patients was nine years (five to 18 years). The median VAS, FPS-R, and CFS scores before Buzzy® were four (0 to eight), four (0 to eight), and one (0 to four), respectively. After Buzzy® application, the median VAS, FPS-R, and CFS scores were two (0 to six), two (0 to six), and 0 (0 to three), respectively. The VAS and FPS-R scores showed a significant reduction (p=0.04 and p=0.008, respectively), indicating a notable decrease in pain. Although the CFS scores also decreased following the use of Buzzy®, this reduction was not statistically significant (p=0.526). According to the gate control theory of pain, methods like Buzzy® temporarily block pain signals from reaching the central nervous system by "closing the gates." In patients requiring continuous injections, such applications may reduce the pain and anxiety they experience.

November 2015 marks the 50th anniversary of the 1965 Science publication “Pain Mechanisms: A New Theory” by Ronald Melzack and Patrick D Wall (1), in which the authors introduced the gate control theory of pain that has since revolutionized our understanding of pain mechanisms and management. The brilliance, creativity and critical thought that went into the formulation and explication of the gate control theory of pain can best be appreciated by reading the original article. Fifty years later, having become part of our scientific history and accepted as common knowledge, the essence of the theory is often conveyed by the familiar diagram in Figure 1. In 1982, the article was recognized as a Citation Classic in Eugene Garfield’s weekly publication Current

Vibration-assisted anesthesia, grounded in the gate control theory, offers a nonpharmacologic alternative to reduce pain; however, real-world dermatologic data remain sparse. To evaluate the efficacy of a novel wearable vibrating kinetic anesthesia (VKA) device in reducing pain during dermatologic procedures, using a split-lesion, intrapatient-controlled design. In this prospective observational study, 629 patients underwent dermatologic procedures. Each patient received the same procedure on 2 comparable sites, one with and one without VKA. Pain was assessed using the Visual Analog Scale (VAS), Numeric Rating Scale (NRS), and Modified Verbal Rating Scale (MVRS). Composite clinical success was defined as a ≥2-point reduction in both VAS and NRS along with a stated preference for VKA. Use of VKA resulted in significant pain reduction: mean ΔVAS = 2.61 (95% CI: 2.46-2.76, p < .001), ΔNRS = 2.44 (95% CI: 2.30-2.58, p < .001). Effect sizes were large (Cohen's d > 1.0), and composite success was achieved in 81.5% of procedures. Patients preferred VKA in 94.6% of cases. Verbal descriptors shifted from "stabbing" and "burning" to "dull" and "prickling." Procedure type and baseline VAS score were significant predictors of response. Vibration-assisted anesthesia significantly reduces procedural pain and improves patient experience in dermatology.

The gate control theory of pain--revisited.

The focus of my research is on contemporary biomedical construction of pain as an object, i.e. the different ways in which pain has been conceptualized and approached as a specific site of investigation in biomedicine. A significant shift in the scientific conception of pain occured in the second half of XXth century. In 1965, Ronald Melzack and Patrick D. Wall propose the Gate Control theory of pain mechanism. This theory denies a fixed and direct relationship between stimulus and pain perception, and emphazises the role played by psychological factors in pain. The IASP utilizes this perspective on the phenomenon, describing pain as “an unpleasant sensory and emotional experience associated to an actual or potential tissue damage or described in the terms of such a damage.” The relationship between pain and damage is pivotal in the definition of pain as a pathological entity. In particular, the biomedical approach to pain appears to be strongly characterized by a dualistic view of its aetiology. Disease conceptions such as “psychogenic pain” and chronic pain are deeply influenced by the ways in which psychological factors have been interpreted as components, or as causes of pain. In the second part of my dissertation, I focus on fibromyalgia, which is emblematic of the problematic acknowledgment of chronic pain as a disease. Even if fibromyalgia is actually treated in Rheumatology, its status as a disease is blurred, mainly because of its complex symptomatology including both physiological manifestations and psychological ones. In the conclusion, I present a scenario of the different ways in which this disease is dealt with in biomedical knowledge, through medical literature, clinical practice, and patients’ accounts. The findings of an ethnographic enquiry in the Rheumatology Division of a local clinic and a visual research on patients’ experiences are analyzed and discussed.

Ion Channel Modulation in Spinal/Trigeminal Synaptic Plasticity

The gate control theory of pain postulates that the sensation of pain can be reduced or blocked by closing a "gate" at the earliest synaptic level in the spinal cord, where nociceptive (pain) afferents excite the ascending interneurons that transmit the signal to the brain. Furthermore, the gate can be induced to close by stimulating touch afferents with receptive fields in the same general area as the trauma that is generating the pain (the "rub it to make it better" effect). A considerable volume of research has substantiated the theory and shown that a key mechanism mediating the gate is pre-synaptic inhibition, and that this inhibition is generated by depolarizing IPSPs in the nociceptor central terminals (primary afferent depolarization; PAD). Both pre-synaptic inhibition and depolarizing IPSPs are topics that students often regard as matters of secondary importance (if they are aware of them at all), and yet they are crucial to a matter of primary importance to us all - pain control. This report describes some simple computer simulations that illustrate pre-synaptic inhibition and explore the importance of the depolarizing aspect of the IPSPs. These concepts are then built into a model of the gate control of pain itself. Finally, the simulations show how a small change in chloride homeostasis can generate the dorsal root reflex, in which nociceptor afferents generate antidromic spikes which may increase neurogenic inflammation and actually exacerbate pain. The hope is that the simulations will increase awareness and understanding of a topic that is important in both basic neuroscience and medical neurology.

The study investigated the effect of music (musical preferences of subjects) on the pain of selected post-operative patients during the first 48 hours. The subjects were 24 female gynaecologic and/or obstetric patients who made the control and experimental sample, paired accordingly by age, type of surgery, educational background and previous operative experience(s). The measurement of the experimental variable was done using an Overt Pain Reaction Rating Scale (OPRRS) devised by the writer. Analgesics received, arterial blood pressures, pulse rates, and respiratory rates were also used to test the hypothesis. Significant differences were found between the groups of post-operative patients in their musculo-skeletal, and verbal pain reactions during the first 58 hours at the 0.05 level. The blood pressures showed significance only at the 0.07 level. The pulse rate during the second 24-hour period was significant at the 0.01 level; however, no significance was shown during the first 24-hour period. The respiratory rate was insignificant during the first 48-hour post-operative period. The raw data on pain-relieving medications received by the sample indicated a difference, but this was not statistically significant. The conceptual framework of the study was based on the concept of distraction following the 'Gate Control Theory' of pain by Melzack & Wall (1965). The recommendation arrived at is to use music as a nursing measure for post-operative patients.

Spinal cord stimulation is a spin-off of the well-known ‘Gate Control Theory of Pain’ presented by Melzack and Wall in 1965. SCS has been used predominantly in chronic intractable pain conditions. Careful evaluation has revealed that a significant number of patients reported pain relief accompanied by a feeling of warmth in the lower limbs during SCS. This observation has led to the use of SCS in the treatment of patients with severe ischemic rest pain. Several studies have evaluated the effects of SCS on relief of ischemic pain, microcirculatory blood flow and limb salvage. However, up to now very little is known about the physiological mechanisms behind the beneficial effects on ischemic pain. The ‘Gate Control Theory of Pain’ comprehends a model in which the nociceptive unmyelated afferents are inhibited by stimulation of non-nociceptive myelinated afferents. Although the concept of this theory is not longer tenable in all its aspects, the idea remain unchanged. At present, several hypotheses for the relief of ischemic pain under spinal cord stimulation are discussed. These mechanisms seem most dependent on activation of the lumbal segments of the spinal cord. However, supraspinal effects may also be involved. Inhibition of afferent activity in the spinothalamic tracts, suppression of sympathetic activity, antidromic effects on peripheral reflex circuits may take part in the relief of ischemic pain. Stimulation may also induce antidromically mediated release of vasoactive substances with vasodilatory effects. Besides pain relieving effects SCS has also a beneficial effect on the ischemic condition per se. Further experimental and clinical research is necessary to increase understanding of the neurophysiological and neurochemical changes activated by spinal cord stimulation. summary

As Gligorov (2018) notes, the gate control theory of pain was an important advance over previous accounts of pain. Prior to the gate control theory of pain, prominent theories of pain were committe...

It is increasingly accepted among medical and mental health care providers that cognitions and emotions play a significant role in the perception of chronic pain and resulting disability. Though this seems an obvious point, it is a major leap considering that, as recently as 40 years ago, the primary thought was that all pain perception is directly related to the severity of injury (i.e., the worse it looks the worse it must be), as pain was believed to exist only in the presence of identifiable, causal, pathophysiology. This archaic, dualistic Cartesian style of thinking has since evolved considerably (Turk, 1996). In the 1950s, both (Bonica, 1953) and Engel (1959) described psychological factors as important contributors to the pain experience. Melzack, a leader in the exploration of the etiology behind the perception and experience of pain, made an important early contribution to its understanding. In 1965, Melzack and Wall (1965) proposed the gate control theory of pain, which solidified the involvement of the central nervous system (CNS) as an essential component in the perception and processing of pain. The gate control theory of pain served to provide a scientific understanding of how brain-generated experiences, such as emotion, affected pain perception. This theory effectively narrowed the gap between the mental and physical health fields by tying together nociception and emotional experience. Following this, a proliferation of research arose aimed at identification of specific psychological and social factors believed to play a key role in the development, maintenance and perception of pain. Specifically, Gatchel and Epker (1999) and Turk (1996) discussed at length the various contributions of behavioral, affective, and cognitive factors, as well as psychosocial risk factors for pain. In sum, their research has served to further refute the previous dualistic view of pain—that pain patients were either legitimate medical patients with “real” physical etiology or that they were psychiatric patients whose pain experience was “all in their head.” Despite the incorrect assumption that chronic pain is an inherently psychological problem, chronic pain patients do have a higher prevalence of psychiatric disorders, such as depression and personality disorders, relative to the general population (Gatchel, Polatin, Mayer, & Garcy, 1994; Kinney, Gatchel, Polatin, Fogarty, & Mayer, 1993; Polatin, Kinney, Gatchel, Lillo, & Mayer, 1993). Specifically, Kinney et al. (1993) found that, among 200 chronic low back pain patients who were assessed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-III-Revised, 70% met lifetime diagnostic criteria for Axis I disorders and 51% met criteria for Axis II diagnoses. In addition to significant psychiatric distress, patients with chronic pain often have a number of additional risk factors for increased difficulty in obtaining maximal treatment gains. Specific factors identified in the literature include: a patient’s reliance on passive coping strategies (e.g., catastrophizing, hoping and praying, M. J. L. Sullivan et al., 2001)

Physiology and Treatment of Pain

Spinal processing before gate control

Decreasing the pain of dermatologic procedures in children