Lecture - 12 2013

PHYSIOLOGY OF PAIN
Department of physiology
Definitions of pain
the International Association for the Study
of Pain (IASP) introduced the definition of
pain.
It is an unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.
Some key points:

Pain is one of the bodys defensive
mechanisms that signalizes about the danger to
the organism;
The sensation of pain is basic to all people;
It is a personal experience that all humans
endure;
Acute pain is a primary reason why people
seek medical help;
Pain is a complex phenomenon that involves
sensory, behavioural, emotional and cultural
components.
The experience of pain

Three systems interact usually to produce pain:
1. Sensory - discriminative
2. Motivational - affective
3. Cognitive - evaluative
1. Sensory - discriminative system processes information ab

the strength, intensity, quality and temporal and spatial
aspects of pain
2. Motivational - affective system determines the individual

approach-avoidance behaviours (depression, anxiety)
3. Cognitive - evaluative system thoughts concerning the ca

and significance of pain
Classical description of pain

includes
4 processes:
1. Transduction
2. Transmission
3. Perception
4. Modulation
Transduction
It is a process of the conversion of the energy
from a noxious thermal, mechanical, or
chemical stimulus into electrical energy (nerve
impulses) by sensory receptors called
nociceptors.
Receptors for pain are called nociceptors.
Stimulus that causes pain is called noxious
stimulus.
Nociceptive (pain) and anti-nociceptive (anti-
Transduction
Nociceptors:
Endings of small unmyelinated and lightly

myelinated afferent neurons
Stimulators: Chemical, mechanical and thermal noxious

stimuli
sensation
transmitted
Location:
Mild stimulation positive, pleasurable

(e.g. tickling)
Strong stimulation pain
These differences are a result of the frequency
and amplitude of the afferent signal
from the nerve endings to the CNS
In muscles, tendons, epidermis, subcutanous
Transduction
Injury to tissue causes cells to break down and release
various tissue by products and mediators of
inflammation:
prostaglandins
substance P
bradykinin
histamine
serotonin
cytokines
All these cause the activation

of nociceptors!
Transmission
Signals from nociceptors are transmitted
via:
A(alfa)- B(beta)-D(delta) fibers (small
myelinated fibers) rapidly conducting
(acute pain);
C-fibers (unmyelinated)
slowly conducting (prolonged dull
pain)
Afferent pathways from nociceptors

terminate in the dorsal horn (DH) of
the spinal cord
from DH neurons the information

is further transmitted via
spinothalamic tract to thalamus
and than to:

reticular formation of brainstem;
hypothalamus;
somasonesory cortex;
limbic system..
Perception
It is an uncomfortable awareness of some part of the body,
characterized by a distinctly unpleasant sensation and
negative emotion, best described as threat.
Upon perception affective changes take place having:
emotional aspect
behavioral aspect
social (environmental) aspect
memorizing aspect
Modulation
It is a process of modification of pain.
Descending pain inhibitory pathways from brain to DH
( dorsal horn) neurons exist.
Following mediators are released from them:
endogenous opioids (endorphins, encephalins)
Serotonin, noradrenalin
GABA
All of them inhibit the transmission of pain stimuli in DH

neurons (the anti-nociceptive system).
Modulation
Theory of pain production and

modulation
Most rational explanation of pain production and modulation
is based on gate control theory (created by Melzack and Wall).
According to this theory neurons of DH function as a gate,
regulating transmission of impulses to CNS!
I inhibitory neuron
P projection neuron
No stimulation at all small/large fibers are quiet I neuron is active / P

neuron is not active gate is closed no pain
Non painful stimulation large fibers are active both I neuron and P
neurons are active gate is closed no pain
Painful stimulation small fibers are active I neuron is blocked and P
neuron is excited gate is opened pain reaches the brain
Pain classification
1. Somatogenic pain is pain with cause (usually known)
localized in the body tissue
a/ nociceptive pain (activation of nociceptors)
superficial somatic originating from skin and superficial tissu

(sharp, well-defined, localized);
deep somatic originating from joints, tendons, bones, muscle

(dull, aching, poorly-localized with longer duration);
visceral originating from visceral organs (can be different);
b/ neuropathic pain pain is caused by the damage with

the peripheral or central nervous systems
2. Psychogenic pain is pain for which there is no known
physical cause, but processing of sensitive information
in CNS is disturbed
Pain Classification
According to duration:
Acute pain is a protective mechanism that alerts the
individual
to
condition
or
experience
that
is
immediately
harmful to the body
Onset - usually sudden
Relief - after removal of the chemical mediators
from nociceptors
This type of pain mobilises the individual to prompt action
to relief it
Stimulation of autonomic nervous system can be observed
during this type of pain (mydriasis, tachycardia, tachypnoe,
sweating, vasoconstriction)
Pain classification
Chronic pain is persistent or intermittent usually defined
as lasting at least 6 months or more
The cause of it is often unknown, very often it is
associated with a sense of hopelessness and
helplessness. Depression often results.
Chronic pain produces
significant
behavioural and
psychological changes
The main changes are:
- depression
- sleeping disorders
- preoccupation with the pain
- tendency to deny pain
Pain threshold and pain tolerance
The pain threshold is the point at which a stimulus is perceiv

as pain.
It does not vary significantly among healthy people or in the
person over time.
The pain tolerance is expressed as duration of time or
the
intensity of pain that an individual will endure before
initiation
overt pain responses.
It is influenced by - persons cultural prescriptions
- expectations
- role behaviours
Pain tolerance is generally decreased:

- with repeated exposure to pain
- by fatigue, anger, apprehension
- sleep deprivation
Tolerance to pain may be increased:
- by alcohol consumption
- medication, hypnosis
- warmth, distracting activities
- strong beliefs or faith
Pain tolerance varies greatly among people and in
the same person over time
A decrease in pain tolerance is also evident in the elderly,

and women appear to be more tolerant to pain than
Pain characteristics that should be

found out in order to establish
correct diagnosis:
Quality
Intensity
Localization
Radiation
Frequency and duration
Onset and offset
Exacerbating factors
Relief factors
Some disorders of pain

perception include:
hyperalgesia increased response to a
stimulus which is normally painful;
hypoalgesia decreased response to a
stimulus which is normally painful;
analgesia no response to painful stimulus;
allodynia phenomenon characterised by
painful sensations provoked by non-noxious
stimuli, (e.g. touch)
Physiological basis of pain relief

Methods of pain relief :
1) Physical methods- temperature,
tactile stimulation, electrical ....
2) Pharmacological methodsuse of drugs analgesic action.
a) local anesthesia,
b) conduction anesthesia, c)central
anesthesia(narcosis). 3) Surgical
methods-section of the nerve fibers or
destruction centers of pain.
4)
Psychotherapeutic methods-principles
of meditation, yoga, hypnosis .
Give..
..Hope!

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PHYSIOLOGY OF PAIN

Some key points:

The experience of pain

1. Sensory - discriminative system processes information ab

2. Motivational - affective system determines the individual

3. Cognitive - evaluative system thoughts concerning the ca

Classical description of pain

Endings of small unmyelinated and lightly

Stimulators: Chemical, mechanical and thermal noxious

Mild stimulation positive, pleasurable

All these cause the activation

Afferent pathways from nociceptors

from DH neurons the information

and than to:

social (environmental) aspect

endogenous opioids (endorphins, encephalins)

All of them inhibit the transmission of pain stimuli in DH

Theory of pain production and

No stimulation at all small/large fibers are quiet I neuron is active / P

superficial somatic originating from skin and superficial tissu

deep somatic originating from joints, tendons, bones, muscle

b/ neuropathic pain pain is caused by the damage with

Pain threshold and pain tolerance

The pain threshold is the point at which a stimulus is perceiv

Pain tolerance is generally decreased:

A decrease in pain tolerance is also evident in the elderly,

Pain characteristics that should be

Some disorders of pain

Physiological basis of pain relief

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