The document defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It describes the causes of acute and chronic pain, including surgery, fractures, burns, and various diseases. It outlines different types of pain based on pathophysiology (nociceptive and neuropathic) and duration (acute vs chronic). Acute pain serves a protective function and resolves when the injury heals, while chronic pain has no biological function and involves dysfunctional central nervous system involvement. Treatment approaches include non-pharmacological methods like physiotherapy, psychological approaches, and traditional/complementary medicine, as well as pharmacological methods using an analgesic ladder or antineuropathic agents.

1. PAIN

2. Definition
An unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage.

3. Causes
Acute pain Chronic pain
• Surgery
• Fracture
• Burns or cuts
• Labour and childbirth
• Myocardial infarction
• Inflammation e.g. abscess, appendicitis
• Headache
• Low back pain
• Cancer
• Arthritis pain
• Chronic pancreatitis
• Chronic abdominal pain from ‘adhesion
colic’
• Neuropathic pain such as post herpetic
neuralgia, diabetic peripheral neuropathy,
post spinal cord injury pain and central
poststroke pain

4. Types (based on pathophysiological)
Nociceptive pain (physiological
pain)
Neuropathic pain (pathological
pain)
Cause Obvious tissue injury associated
with an identifiable somatic/
visceral lesion.
Nerve injury or
Central/peripheral nervous
system abnormality
Function Protective function No discernable biological
function
Description of pain Sharp
Dull
Throbbing
Well localised
Burning
Pricking
Electric-like
Shooting
Stabbing, lancinating
Poorly localised
Aggravating/
relieving factors
Aggravated by movement
Relieved by rest
Spontaneous pain
Other symptoms None or related to underlying
pathology
Numbness
Pins and needles
Allodynia
Dysaesthesias

5. Types (based on duration of pain)
Acute pain Chronic pain
General A symptom of underlying damage or disease. No
central nervous system involvement.
A chronic disease of nervous system. Central nervous
system may be dysfunctional.
Onset and
timing
Sudden onset usually due to an injury, short duration.
Resolves or disappears when tissues heal.
Onset may be insidious. Pain persists despite tissue
healing
Duration Less than 3 months, resolves when the injury heals
and/or when the underlying cause of pain has been
treated.
Usually more than 3 months.
Signal A warning sign of actual or potential tissue damage Not a warning signal of damage: a false alarm
Severity Severity correlates with amount of damage Severity may be out of proportion of damage.
The nature of the disease is that the pain level in
patients may be worse on some days and better on
others termed as ‘bad days’ and ‘good days’
CNS
involvement
CNS intact
Acute pain is a symptom
CNS may be dysfunctional
Chronic pain is a disease
Psychological
effects
Less but unrelieved pain can cause anxiety and sleep
deprivation (which improve after pain is relieved).
Often may cause depression/ anxiety, anger, fear, sleep
disturbances and social withdrawal.

6. Pain scoring
1. The Numeric Rating Scale (NRS) Ministry
of Health Malaysia pain scale which is
used in children more than > 7 years old
and above.
2. Visual Analog Scale (VAS) Ministry of
Health Malaysia pain scale which is used
in children age > 3 to 7 years
3. The Numeric Rating Scale (NRS) Ministry
of Health Malaysia pain scale which is
used in children more than > 7 years old
and above.

7. Treatment of pain

8. Non pharmacological
Physiotherapy approaches Rest, Immobilisations, Cold compression, Elevation (RICE)
TENS
Heat/Cold pack
Stretching exercise
Strengthening exercise
Psychological approaches Explanation and reassurance
Address anxiety
Breathing relaxation
Counseling
Traditional / complementary
medicine
Acupuncture
Massage/ Aromatherapy
Music
Occupational therapy Modification of activities of daily living, play, leisure and work

9. Pharmacological
Nociceptive pain (use
analgesic ladder)
i. Mild - Paracetamol (± NSAIDs)
ii. Moderate - Paracetamol (± NSAIDs) + weak opioid (Tramadol or DF118).
iii. Severe - Paracetamol (± NSAIDs) + strong opioid (Morphine)
Neuropathic pain i. Traditional analgesic medications may not be useful
ii. Use other drugs (antineuropathic agents or adjuvants) - Amitriptyline,
Carbamazepine, Gabapentin
iii. Do not forget non-pharmacological treatments