The gate theory of pain

Gate Control Theory

The gate control theory (GCT) was proposed in 1965 to explain the relationship between pain and emotion. Melzack and Wall (1982) concluded that pain is not just a physiologic response but that psychological variables (i.e., behavioral and emotional responses) influence the perception of pain. According to the GCT, a gating mechanism occurs in the spinal cord. Pain impulses are transmitted from the periphery of the body by nerve fibers (A, delta, and C fibers). The impulses travel to the dorsal horns of the spinal cord, specifically to the area of the cord called the substantia gelatinosa. The cells of the substantia gelatinosa can inhibit or facilitate pain impulses that are conducted by the transmission cells. If the activity of the transmission cells is inhibited, the gate is closed and impulses are less likely to be conducted to the brain. When the gate is opened, pain impulses ascend to the brain. Similar gating mechanisms exist in the descending nerve fibers from the thalamus and cerebral cortex. A person’s thoughts and emotions can influence whether pain impulses reach the level of conscious awareness (Helms & Barone, 2008; Litwack, 2009).

The gate control model ( Figure 15-5 ) differentiates the excitatory (white circle) and inhibitory (black circle) links from the substantia gelatinosa to the transmission cells as well as descending inhibitory control from brain stem systems. The round knob at the end of the inhibitor link implies that its action may be presynaptic, postsynaptic, or both. All connections are excitatory, except the inhibitory link from substantia gelatinosa to the transmission cell (Melzack & Wall, 1982).

As mentioned in the case study, it is believed that pain medication has an effect on the gating mechanism. If pain medication is administered before the onset of pain (i.e., before the gate is opened), it will help keep the gate closed longer and fewer pain impulses will be allowed to pass through. The greater the degree of pain, the greater the number of pain impulses passing through the gate. If fewer pain impulses are allowed through the gate, the person will experience less pain. If the gate is allowed to open completely, a higher dosage of pain medication is required to close the gate. Therefore, in theory, prevention and management of pain are linked to keeping the gate closed.

Application to Nursing

The GCT has also been the model for several reports related to pain management. Lane and Latham (2009), for example, presented aspects of the GCT in use of heat and cold therapy as nonpharmacologic interventions to reduce pain in hospitalized children. Tansky and Lindberg (2010) performed a comprehensive literature review on the use of breastfeeding as a intervention to reduce pain caused by immunization using the GCT as a framework. They found that there is considerable evidence that it is an effective pain management technique.

In nursing research, one study (Ngamkham, Holdern, & Wilkie, 2011) used the GCT to examine pain pattern responses in location, intensity, and quality among outpatients with cancer. Friesner, Curry, and Moddeman (2006) used GCT as the framework in a research study to compare two strategies for removal of chest tubes. They determined that encouraging slow, deep-breathing relaxation helps manage pain during chest tube removal. Finally, another experimental study, Hatfield (2008) showed that administration of an oral sucrose solution prior to immunization is effective in helping relieve pain in infants receiving routine vaccinations.

Summary

Nurses continually use concepts and principles from multiple biomedical theories in practice and in research. Indeed, these concepts, principles, and theories are so integral to nursing that they are difficult to differentiate and set aside for detailed inspection.

The biomedical theories used by nurses include theories of disease and disease causation, as well as theories related to physiology and physical functioning. Nurses, particularly advanced practice nurses such as Maria from the case study, should study these theories. They should understand their relevance to nursing practice and recognize how they are used and supported in nursing research.

Because of length constraints, only a few concepts and theories were described in this chapter. But it is hoped that these discussions will lead the reader to recognize the importance of understanding theory and to apply theory to guide practice and research. Ultimately, this will improve the care of clients.

Key Points

· Theories from the biomedical sciences have greatly influenced nursing since Nightingale’s time.

· Biomedical science theories used by nurses include theories from biology, medicine, public health, physiology, and pharmacology.

· Theories and models of disease causation commonly used by nurses include the “germ theory” (principles of infection) and public health theories, such as the epidemiologic triangle and the web of causation.

· The Natural History of Disease model outlines the concepts of health promotion as well as primary, secondary, and tertiary prevention; these principles are used by nurses in all areas of practice and research.

· Theories and principles of physiology and physical functioning include homeostasis and theories of stress and adaptation; both are commonly used by nurses in practice and research.

· Theories and principles related to immunity and immune function are widely used in nursing practice and are increasingly being studied in nursing research.

· Nursing knowledge regarding genetics, genetic principles, and genetic counseling is growing, and nurses are recognizing the importance of genetic factors on health.

· Cancer theories, particularly related to prevention and early detection, are very important to nurses and a source for study for nursing research and review for nursing practice.

· Pain management is a vital part of nursing practice; nurses are continually researching how to improve pain management.

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