18 PPT Pain

Pain
LO 2 & 3
Gould Pathophysiology: Chapter 4

Pain
• Variable characteristic and is subjective
• Unpleasant sensory or emotional experience associated with actual or potential
tissue damage
• Body defense mechanism – warning of a problem
• Each individual ‘eel’ pain depending on their experiences to injury in early life
Types of pain
• Physical
• Emotional
• Somatic
• Visceral
Terminologies in Pain
Pain threshold:
• Amount of stimulus required to activate pain receptors
• Associated with nerve fibres
• Relatively constant over time and individual
Pain tolerance
• Ability to withstand pain or perception of its intensity
• Amount of pain person can put up with and continue normal function
Pain Pathway
Causes of pain
1. Inflammation or Infection
2. Ischaemia or necrosis
3. Stretching of tissues – ligaments, tendons, joint capsule
4. Action of chemicals
5. Burns
6. Muscle spasms
Types of pain
Somatic pain:
• From skin (cutaneous) or deeper structures – muscle, bone – conducted
by sensory nerves
• Results in withdrawal of affected part of body – to protect the region
from further damage
Visceral pain:
• Originated in organs and travel via the sympathetic nerve fibres
• Results in tonic muscular spasm – to decrease movement of affected
area
Process of Pain
(1) Transduction
• Conversion of energy from the stimuli (thermal, mechanical or
chemical) into electrical energy (nerve impulses) by sensory receptors
(nociceptors)
• A beta fibres – large diameter, myelinated fibres – fastest - for touch
• A delta fibres – smaller with less myelin
• C pain fibres – smallest, non-myelinated, slow pain
• Exact mechanism is unknown
Process of Pain
(2) Transmission
• ‘Movement’ of neural signals / nerve impulses from site of
transduction (periphery) to the spinal cord and brain
Neurotransmitters
Help conduct impulses across synapse
Example:
• Substance P, Vasoactive intestinal polypeptide (VIP), and Calcitonin
• Mediators or sensitisers of visceral pain receptors
• Prostaglandin, histamine, serotonin, bradykinin,
• Also of importance
Pathways of Pain
• Peripheral receptors (nociceptors)
• Neural pathways
• Spinal cord mechanisms and long tracts
• Brainstem, thalamus and cortex
• Descending pathways
Spinal Pathways
• About 70% of pain fibres enter in the dorsal root, but the rest double
back and enter the ventral (so called "motor" root).
• Thegrey matter of the spinal cord has ten "laminae" or layers
• Unmyelinated C fibres synapse in laminae I to V while A delta fibres
synapse in laminae I, V and X
Multiple Pathways of Nociceptor Transmission
Process of Pain
(3) Perception
• Appreciation of nerve impulses at higher functional structure as ‘pain’
Defined as
• Active process of selecting, organising and interpreting the
information brought to the brain by the senses
• Can be manipulated by cognitive, emotional, mental and
environmental factors
Factors of Pain Perception
1. Expectation – our perception of the amount of hurt we may
feel
• May be modified if we are prepared
• Placebo effect – if we believe pain has stopped, it has
2. Personality
• Stress and anxious type of personalities – often have more
pain
3. Mood
• Bad mood, anger, unhappiness, etc – often increases pain
experience
Process of Pain
(4) Modulation
• Descend of inhibitory or facilitatory from brain – influences
/modulates nociceptor transmission at the spinal cord level
Process by which the nervous system modifies nociceptor activity

Involves number of brainstem regions
• Stimulation of these sites reduces pain and inhibit nociceptor activity
Modulation
Production of endogenous opioids such as enkephalin, B-endorphin, etc –
partially responsible for analgesia - act on opioid receptors widely
distributed in the brain
Opioids work in two ways:

1. Block neurotransmitter release – inhibiting calcium influx into
presynaptic terminal
2. Hyperpolarise neurones – by opening potassium channels – effectively
knock the neuron out of action temporarily
Gate Control Theory of Pain
Control systems /’gates’ built into normal pain pathways that can modify the
entry of pain stimulus into the spinal cord and brain - Gates are at the nerve
synapses
When the ‘gates’ are open
• Allows pain impulses to pass from the peripheral nerves to the spinothalamic
tract and ascend to the brain
When the ‘gates’ are closed
• Reduces or modifies the passage of pain
.
Gate Control Theory of Pain
Gate closure can occur due to other sensory stimuli - e.g.

• Application of ice to a painful site reduces pain – you are more aware
of the cold then the pain
• Transcutaneous electrical nerve stimulation (TENS) – increases
sensory stimulation at the site – blocks pain transmission
• Brain can inhibit or modify incoming pain stimuli depends on:
• Prior conditioning, emotional state of person, distracting events,
etc
Characteristics of Pain
Subjective symptom – very variable
Helpful details in diagnosing severity and cause of pain:
1. Location
2. Descriptive terms: sharp, pricking type (more localised) or dull ache
(poorly localised)
3. Timing of pain or its association with activity – e.g. food intake, movement
or pressure applied to site
4. Physical evidence - pallor, sweating, raised blood pressure, tachycardia,
etc (differs in adults vs young children and infants)
5. Associated with nausea, vomiting, fainting, dizziness, etc.
6. Anxiety or fear may be evident in persons with chest pain – (impending
doom)
7. Clenched fist, rigid face, restlessness or lack of movement (protecting or
guarding – affected area)
Young children and Pain
Infants respond physiologically
• Tachycardia, increased blood pressure, facial expression, persistent
crying
Great variations in different developmental stages

• Differing coping mechanisms
• Range of behaviour
• Difficulty describing the pain
• Withdrawal and lack of communication – older children
Acute pain
• Sudden and severe, but short term
• Indicated tissue damage – decreases once cause has been treated /
overcome
• Localised or generalised
• May be self-limiting, lasts less than 6 weeks
Now viewed as a complex unpleasant experience with emotional and

cognitive as well as sensory features which occur in response to trauma
• Normally said to be experienced within 0.1 second following
stimulation of nociceptors
Chronic pain
Pain that extends beyond period of healing – with low levels of identified
pathology – with insufficient explanation as to its presence and extend
• Serves no adaptive purpose
• Long term pain – leads to different and often negative effects e.g. loss of
employment, interference with personal relationships, etc.
• Usually more difficult to treat effectively – prognosis less favourable
• Perceived by person as being more generalised – difficult to pin-point
location
• Specific cause may be less apparent – more difficult to deal with and more
debilitation
• Sustaining pain over a long period of time results in person being fatigue,
irritable and depressed
Chronic pain
• Sleep disturbance common, appetite affected with weight loss
• Constant pain affects daily activities
• Periods of acute pain may accompany exacerbations of chronic
disease – making it more difficult to effectively manage the pain
• Long term pain – reduces tolerance over time
Comparison of Acute and Chronic Pain
Referred pain
• Occurs when sensation of pain is identified in areas some distant from the
actual source
• Usually originates in deep organ or muscle – perceived on surface of body
This may be due to:

• Dermatome – skin innervated by nerve root
• Myotome – muscle innervated by nerve root
• Sclerotome – bone innervated by nerve root
Example:
• Pain in left neck and arm – may indicate heart attack or ischaemia
• Pain in shoulder – stretching of diaphragm
Multiple sensory fibres from different sources connect at a single level of the
spinal cord – difficult for brain to interpret the actual site of pain
Physiological Consequences of Pain
Phantom Limb
• Ability to feel pain, pressure, temperature and other types of sensations
in a limb that does not exist (amputated or born without)
• Feeling can be life-like that person may try to perform an action with the
limb
• Usually seen soon after amputation or a few years later

Explanations:
i. Remaining nerves at stump grow into a nodule (neuroma) – continue
to fire signals which follow same pathway as original limb
ii. Neurons in spinal cord although no longer receiving information from
the lost appendage – continue to send ‘information’ to the brain
iii. Brain compensates for loss or altered signals – creating impression that
limb exists and functions normally
Measurement of Pain
• Intensity of p[ain is rated by patients using a simple rating scale
• Types of rating scales include:
• Numeric (1 – 10)
• Verbal – (mild, moderate, severe)
• Visual – image
Tools used to measure pain must be appropriate for the patient’s
developmental, physical, emotional and cognitive status
Management of Pain
1. Remove the cause

2. Use of analgesics
• Orally
• Parenterally
• Transdermal patch
3. Sedative and anti-anxiety drugs – promote rest and relaxation
4. For intractable pain not relieved by medication – surgery may be
indicated
• Rhizotomy – severe nerve roots at the spinal cord
• Cordotomy – disable certain pain conduction tracts
Analgesic Drugs
Anaesthesia
A form of pain relieve. Includes:

1. Local anaesthesia – injected or applied to skin or mucous
membrane
2. Spinal or regional anaesthesia – block pain to a region e.g. leg,
abdomen, finger, etc
3. General anaesthesia – loss of consciousness
4. Neuroleptanaesthesia – patient is unaware of procedure but can
respond to commands
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Pain

Gould Pathophysiology: Chapter 4

Process by which the nervous system modifies nociceptor activity

Opioids work in two ways:

Gate closure can occur due to other sensory stimuli - e.g.

Great variations in different developmental stages

Now viewed as a complex unpleasant experience with emotional and

This may be due to:

• Usually seen soon after amputation or a few years later

1. Remove the cause

A form of pain relieve. Includes:

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