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What is pain?
Pain is a difficult word to define
Patients use different words to
describe pain
eg.
What is pain?
There is an International definition of pain
formulated by the IASP (International
Association for the study of pain)
Pain is an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage
IASP International Association for the Study
of Pain 2011
What is pain?
Pain is
subjective
protective
and it is modified by developmental, behavioural,
personality and cultural factors
It is a symptom
Associated signs are crying, sweating,
increased heart rate, blood pressure,
behavioural changes etc
Measurement of pain
It is difficult to describe pain although we know
what it is
It is difficult to measure pain
visual analogue scale (VAS) is used
acute
pricking type
well localised
short duration
Slow pain
chronic
throbbing type
poorly localised
long duration
Different situations
No stimuli, but pain is felt
phantom limb pain
eg. in amputated limb
Stimuli present, but no pain felt
eg. soldier in battle field,
sportsman in arena
Pain due to a stimulus that
does not normally provoke pain
Allodynia
Pain caused by a lesion or disease of the
somatosensory nervous system
Neuropathic pain
Pain terminology
International Association for the Study of Pain 2011
Hyperalgesia
Increased pain from a stimulus that normally provokes pain
Hyperaesthesia
Increased sensitivity to stimulation, excluding the special senses (increased
cutaneous sensibility to thermal sensation without pain )
Paraesthesia
An abnormal sensation, whether spontaneous or evoked
Anaesthesia
A loss of sensation resulting from pharmacologic depression of nerve function or
from neurological dysfunction
Neuralgia
Pain in the distribution of a nerve or nerves
Analgesia
Absence of pain in response to a normally painful stimulus
Allodynia
Pain due to a stimulus that does not normally provoke pain
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Pain terminology
Pain
Pain as a sensation
physiologically (nociception)
Nociceptive pain
Perception
Central processing of nociceptive impulses in order
to interpret pain
Stimuli
Physical
pressure etc
Electrical
Thermal
cold, hot
Chemical
H+, lactic acid, K+, histamine, bradykinin, serotonin, leucotrines,
acetylcholine, proteolytic enzymes, capsiacin
Prostaglandins (PGE2)
Cannot directly stimulate nociceptors
Increase the sensitivity of nociceptors for other stimuli (decrease the
threshold)
Receptors
There are no specialised receptors
Pain receptors are called nociceptors
A sensory receptor that is capable of transducing and
encoding noxious stimuli (actually or potentially tissue
damaging stimuli)
Receptors
Nociceptors are very slowly adapting type
Different types of nociceptors
Some respond to one stimulus
Some respond to many stimuli (polymodal)
Some may not respond to the standard stimuli (silent
nociceptors)
they respond only when inflammatory substances are present
afferent fibres
two types
A (thin myelinated)
C (unmyelinated)
central connections
afferent fibre enters the spinal cord
synapses in laminae ii,iii
substantia gelatinosa
substantia
gelatinosa
ascending pathway
crosses the midline
ascends up as the lateral spinothalamic
tract
Pain
C fibre
substantia
gelatinosa
lateral
spinothalamic
tract
n
se
r
so
x
te
or
yc
thalamo
cortical
tracts
thalamus
lateral
spinothalamic
tract
C fibre
Pain perception
This occurs at different levels
thalamus is an important centre of
pain perception
lesions of thalamus produces severe
type of pain known as thalamic pain
Pathophysiology of pain
Pain sensations could arise due to
Inflammation of the nerves (neuritis)
Injury to the nerves and nerve endings with scar
formation (disk prolapse)
Injury to the structures in the spinal cord, thalamus
or cortical areas that process pain information
(spinal trauma)
Abnormal activity in the nerve circuits that is
perceived as pain (phantom limb pain)
Nerve invasion, for example by cancer (brachial
plexopathy)
periaqueductal
grey nucleus
midbrain
pons
nucleus raphe
magnus
medulla
spinal cord
substantia gelatinosa
opioid peptides
short peptides originally known to be secreted
in CNS and later found to be present in GIT etc
opioid peptides
endorphin
Earliest to discover, present in pituitary
dynorphin
Endomorphine 1 & 2
Pronociceptins
substantia
gelatinosa
c fibre input
substantia
gelatinosa cell
Presynaptic inhibition
enkephalin
substance P
Presynaptic inhibition
enkephalin
substance P
blocking of
pain impulse
pain impulse
yc
or
ns
se
x
te
or
C fibre
Ascending
pain impulse
transmitting
tracts
Descending
pain modulatory
(inhibitory) tracts
Theories
of pain
Intensity theory
touch
pain
Specificity theory
touch pain
pain
+
gate is
opened
When pain fibre is stimulated, gate will be opened & pain is felt
touch
+
pain
gate is
closed
When pain and touch fibres are stimulated together, gate will be
closed & pain is not felt
?
?
C fibre
mech
A fibre
excitatory
WDR cell
inhibitory
WDR cells
have been found in
Spinal cord
Trigeminal nucleus
Brain stem
Thalamus
Cortex
referred pain
sometimes pain arising from viscera are not felt
at the site of origin but referred to a distant site.
eg.
cardiac pain referred to the left arm
diaphargmatic pain referred to the shoulder
somatic
+ ++
++ +
second
order
neuron
visceral
somatic
+ ++
++ +
second
order
neuron
visceral
Pain memory
Memory of pain often overshadows its primary experience in its
impact upon pathophysiology and human suffering
The memory of pain can be more damaging than its initial experience
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
Peripheral sensitization
Increased responsiveness and reduced threshold of nociceptive neurons in the
periphery to the stimulation of their receptive fields
Summary
Pain is not just a sensation but is a more complex
phenomenon
Pain can be blocked at many places
Chemicals play an important role in causing pain as
well as in reducing pain
Neural mechanisms also play a role in pain interaction
This complex nature of pain perception makes it a
very difficult entity to control