This document provides an overview of the physiology of pain. It begins with definitions of pain from IASP and describes different types of pain. It then discusses nociceptors, stimuli that can activate nociceptors, and prostaglandins' role in sensitizing nociceptors. The ascending pain pathways and central projections are described. Substance P and the descending pain modulatory system involving opioid peptides are explained. The gate control theory of pain and theories of referred pain are also summarized.
This document provides an overview of the physiology of pain. It discusses the definition of pain, the dual nature of fast and slow pain, pain stimuli and receptors, nerve pathways carrying pain signals to the brain, brain areas involved in pain perception, descending pain modulatory pathways, and neurochemicals involved in pain pathways. It summarizes different types of pain such as neuropathic pain and nociceptive pain. The gate control theory of pain and modifications to this theory are also briefly described.
Physiology of pain was discussed covering several key topics:
1. Pain was defined by the IASP as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
2. Pain pathways involve nociceptors transmitting signals via Aδ and C fibers to the spinal cord and brain areas involved in perception.
3. Descending pain modulatory pathways originate in the brainstem and midbrain and can inhibit pain transmission via neurotransmitters like enkephalins.
4. The gate control theory proposes that activity in large diameter fibers can close the "gate" and inhibit pain transmission in the spinal cord. Modifications to this theory incorporate concepts like wide dynamic range neurons and endogenous opioids.
This document provides an overview of the physiology of pain. It discusses:
1. The definition of pain according to the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
2. The dual nature of pain as either fast, acute pain transmitted by thin myelinated nerve fibers or slow, chronic pain transmitted by unmyelinated nerve fibers.
3. The pathways that carry pain signals from nociceptors to the brain, including nerve fibers entering the spinal cord and traveling via the lateral spinothalamic tract to the thalamus and sensory cortex.
4. Descending pain modulatory pathways from the brainstem that can inhibit pain
This document provides an overview of the physiology of pain. It discusses the definition of pain, the dual nature of fast and slow pain pathways, pain stimuli and receptors, the nerve pathways that carry pain signals to the brain, brain areas involved in pain perception, descending pain modulatory pathways, and neurochemicals involved in pain transmission. Key topics covered include the gate control theory of pain, referred pain, capsaicin and vanilloid receptors, the endocannabinoid system, and excitatory and inhibitory neurotransmitters in pain pathways in the central nervous system.
This document discusses the physiology of pain. It covers topics such as the definition of pain, the dual nature of fast and slow pain, pain stimuli and the nerve pathways that carry pain signals to the brain. It also discusses the brain areas involved in pain perception, pain modulatory pathways, and the neurochemicals involved in pain pathways. The gate control theory of pain and theories on referred pain are also summarized.
This document provides an overview of the physiology of pain. It discusses:
1. Definitions of pain and terms used to describe pain.
2. Nociceptors, the receptors that detect potentially damaging stimuli and transduce them as pain signals.
3. The ascending pain pathway from nociceptors to the brain through the spinal cord and thalamus.
4. Descending pain modulatory systems from the brain that can inhibit pain transmission through pathways using neurotransmitters like endogenous opioids.
5. Theories of pain transmission and modulation including the gate control theory.
Pain is a complex, multidimensional experience influenced by sensory, emotional, cognitive, and social factors. It is defined by the IASP as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." The physiology of pain involves nociceptors transmitting signals through Aδ and C nerve fibers to the spinal cord. These signals are then modulated by descending pathways and transmitted to higher brain centers for processing. Effective pain management strategies target various components of the pain pathway, including prostaglandin inhibition, opioids, nerve blocks, and activation of descending inhibitory pathways. A biopsychosocial approach is often most effective for chronic pain conditions.
Physiology of pain involves nociceptors that detect actual or potential tissue damage and transmit signals along afferent nerve fibers. Nociceptive signals synapse in the dorsal horn and ascend via the spinothalamic tract. The brain perceives pain based on these signals. Pain is modulated by descending pathways that release inhibitory neurotransmitters like opioids. The gate control theory proposes that activity in large diameter fibers can inhibit pain transmission. Various methods aim to reduce pain transmission or enhance descending inhibition including NSAIDs, local anesthetics, TENS, opioids, and psychotherapy.
This document provides an overview of the physiology of pain. It discusses the definition of pain, the dual nature of fast and slow pain, pain stimuli and receptors, nerve pathways carrying pain signals to the brain, brain areas involved in pain perception, descending pain modulatory pathways, and neurochemicals involved in pain pathways. It summarizes different types of pain such as neuropathic pain and nociceptive pain. The gate control theory of pain and modifications to this theory are also briefly described.
Physiology of pain was discussed covering several key topics:
1. Pain was defined by the IASP as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
2. Pain pathways involve nociceptors transmitting signals via Aδ and C fibers to the spinal cord and brain areas involved in perception.
3. Descending pain modulatory pathways originate in the brainstem and midbrain and can inhibit pain transmission via neurotransmitters like enkephalins.
4. The gate control theory proposes that activity in large diameter fibers can close the "gate" and inhibit pain transmission in the spinal cord. Modifications to this theory incorporate concepts like wide dynamic range neurons and endogenous opioids.
This document provides an overview of the physiology of pain. It discusses:
1. The definition of pain according to the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
2. The dual nature of pain as either fast, acute pain transmitted by thin myelinated nerve fibers or slow, chronic pain transmitted by unmyelinated nerve fibers.
3. The pathways that carry pain signals from nociceptors to the brain, including nerve fibers entering the spinal cord and traveling via the lateral spinothalamic tract to the thalamus and sensory cortex.
4. Descending pain modulatory pathways from the brainstem that can inhibit pain
This document provides an overview of the physiology of pain. It discusses the definition of pain, the dual nature of fast and slow pain pathways, pain stimuli and receptors, the nerve pathways that carry pain signals to the brain, brain areas involved in pain perception, descending pain modulatory pathways, and neurochemicals involved in pain transmission. Key topics covered include the gate control theory of pain, referred pain, capsaicin and vanilloid receptors, the endocannabinoid system, and excitatory and inhibitory neurotransmitters in pain pathways in the central nervous system.
This document discusses the physiology of pain. It covers topics such as the definition of pain, the dual nature of fast and slow pain, pain stimuli and the nerve pathways that carry pain signals to the brain. It also discusses the brain areas involved in pain perception, pain modulatory pathways, and the neurochemicals involved in pain pathways. The gate control theory of pain and theories on referred pain are also summarized.
This document provides an overview of the physiology of pain. It discusses:
1. Definitions of pain and terms used to describe pain.
2. Nociceptors, the receptors that detect potentially damaging stimuli and transduce them as pain signals.
3. The ascending pain pathway from nociceptors to the brain through the spinal cord and thalamus.
4. Descending pain modulatory systems from the brain that can inhibit pain transmission through pathways using neurotransmitters like endogenous opioids.
5. Theories of pain transmission and modulation including the gate control theory.
Pain is a complex, multidimensional experience influenced by sensory, emotional, cognitive, and social factors. It is defined by the IASP as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." The physiology of pain involves nociceptors transmitting signals through Aδ and C nerve fibers to the spinal cord. These signals are then modulated by descending pathways and transmitted to higher brain centers for processing. Effective pain management strategies target various components of the pain pathway, including prostaglandin inhibition, opioids, nerve blocks, and activation of descending inhibitory pathways. A biopsychosocial approach is often most effective for chronic pain conditions.
Physiology of pain involves nociceptors that detect actual or potential tissue damage and transmit signals along afferent nerve fibers. Nociceptive signals synapse in the dorsal horn and ascend via the spinothalamic tract. The brain perceives pain based on these signals. Pain is modulated by descending pathways that release inhibitory neurotransmitters like opioids. The gate control theory proposes that activity in large diameter fibers can inhibit pain transmission. Various methods aim to reduce pain transmission or enhance descending inhibition including NSAIDs, local anesthetics, TENS, opioids, and psychotherapy.
This document provides an overview of the physiology of pain. It defines pain and discusses the dual nature of fast and slow pain. It describes the nerve pathways and brain areas involved in pain perception, as well as pain modulatory pathways and neurochemicals. The gate control theory of pain is explained, which proposes an interaction between pain and touch fibers at the spinal cord level. Factors such as referred pain and the role of capsaicin and vanilloid receptors are also summarized.
1. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is subjective and based on expectations, past experience, and emotional factors.
2. Pain is transmitted via nociceptors that detect extreme mechanical, thermal, or chemical stimuli and transmit signals along nerve fibers to the spinal cord and brain.
3. Chronic pain lasts longer than 6 months and is more complex, often involving altered anatomy and neural pathways. It is a lasting condition compared to acute pain which subsides with healing.
This document provides information on pain management. It begins with the history and theories of pain. It then discusses the neurophysiology of pain including nociception, transmission, modulation and perception. Gate control theory is explained in detail. Non-pharmacological approaches like rest, distraction, electrotherapy and exercise are covered. The WHO analgesic ladder is introduced and different classes of pharmacological pain medications like non-opioids, opioids, antidepressants and antiepileptics are summarized.
This document discusses the pathophysiology of pain. It covers topics such as the definition of pain, categories of pain (somatogenic, psychogenic, acute, chronic), the neuroanatomy and neurophysiology of pain processing, and different types of neuropathic pain. The gate control theory of pain is also explained, which proposes that stimulation of large nerve fibers can close the "gate" in the spinal cord and decrease pain transmission.
Pain Management (General concepts and primary discussions)Saeid Safari
This document provides an overview of pain medicine. It defines pain and discusses its epidemiology, economics, and physiological effects. It describes acute and chronic pain, including their presentations and pathophysiology. Neuropathic and nociceptive pain are major categories discussed. Pain pathways and the gate control theory of pain are also summarized. Psychiatric comorbidities with chronic pain are noted.
The document discusses pain and its pathways in the human body. It defines pain and describes its characteristics and theories. It discusses the neurochemistry and types of pain receptors. The main pain pathway described is the lateral spinothalamic tract, which carries pain and temperature sensations from the periphery to the thalamus and somatosensory cortex via the dorsal horn and spinal cord. It relays information via three orders of neurons and can be modulated in the substantia gelatinosa of the spinal cord.
oro-facial pain (other than neuralgias)Mammootty Ik
This document provides an overview of orofacial pain (OFP), including definitions, classifications, neural pathways, evaluation of patients, and treatment principles. OFP can be caused by diseases of the orofacial structures, musculoskeletal diseases, psychological factors, or referred pain from other sources. Evaluation of a patient with OFP involves taking a thorough history and performing a physical exam, with imaging and diagnostic nerve blocks used as needed to determine the cause. Classification systems organize OFP into physical and psychological categories to guide diagnosis and interdisciplinary treatment.
This document provides an overview of pain pathophysiology and management. It begins with objectives and introduces topics like neuroanatomy, pathophysiology, types of pain, assessment, and management. It describes how pain is a subjective experience transmitted by nociceptors and modulated by various factors. The neuroanatomy of pain transmission from the periphery to the CNS is outlined. Different types of pain like nociceptive, neuropathic, referred, acute, and chronic are defined. Common pain syndromes and their characteristics are mentioned. Non-opioid and opioid medications as well as non-pharmacological approaches for pain management are summarized.
This document defines pain and describes the physiology of pain. It states that pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is transmitted via nociceptors and travels along afferent nerve fibers to the spinal cord. The gate control theory proposes that pain transmission can be modulated by interactions between pain fibers and touch fibers at the spinal cord. Chronic pain may involve different nerve fibers and neurotransmitters than acute pain. Various brain regions are also involved in pain perception and modulation.
The document discusses the pathophysiology of pain. It defines pain and describes the three systems - sensory, motivational, and cognitive - that interact to produce the experience of pain. It categorizes pain into somatogenic, psychogenic, acute, and chronic types and discusses their characteristics. It also describes age-related differences in pain perception and the neuroanatomy of pain processing, including the roles of the afferent and efferent pathways and different areas of the central nervous system.
This document provides an overview of pain, including its definition, classification, theories, transmission and modulation pathways, assessment, and management approaches. It begins with definitions of pain from Dorland's Medical Dictionary and Monheim. It then classifies pain according to intensity, temporal relationship, qualities, onset, and localization. Theories of pain discussed include specificity, pattern, and gate control theories. It describes the dual nature of pain and the transduction, transmission, modulation, and perception of pain. It discusses referred pain and neuropathic pain. The document concludes by covering pain assessment tools and pharmacological and non-pharmacological management strategies.
1. Pain is a complex, subjective experience influenced by physiological, psychological, social, and cultural factors.
2. Accurate pain assessment is crucial for nurses and includes gathering subjective reports from patients, which are the primary source of data.
3. A nurse's key role is as a patient advocate for comprehensive pain management, including both pharmacological and non-pharmacological interventions tailored to each patient's individual experience of pain.
1. Pain is a complex, subjective experience influenced by physiological, psychological, social, and cultural factors.
2. Accurate pain assessment is crucial for nurses and includes gathering subjective data from patients.
3. A nurse's key role is advocating for patients by assisting with pain management through both nonpharmacological and pharmacological interventions.
Knowledge of pain physiology is very important in understanding of electrotherapy prescription. So, this slide may be useful in understanding the background of the pain processes.
The document discusses pain and its management. It defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is subjective and involves physiological, emotional, and cognitive components. Pain assessment methods include WHATSUP, PQRST, and OLDCART. Pain management involves pharmacological approaches like opioids and non-opioids, surgical interventions, physical therapy, and complementary therapies like massage, acupuncture, and meditation. Nurses play a key role in comprehensive pain management.
pathophysiology and therapeutics of pain .pptxSamuel Nimoh
The document defines acute and chronic pain and classifies pain types as nociceptive and neuropathic. It describes the pathophysiology of acute pain, involving transduction, transmission, perception, and modulation of pain signals in the nervous system. Chronic pain may involve central sensitization and wind-up phenomena in the spinal cord. Pain assessment involves history, examination, and investigations. Management follows the WHO analgesic ladder using non-opioids, weak opioids like codeine, and strong opioids like morphine. Non-opioid options include paracetamol and NSAIDs like ibuprofen.
I. Pain pathways involve nociceptors detecting damaging stimuli and transmitting signals along primary afferent neurons to the dorsal horn. Signals then project up the spinal cord and through ascending tracts to various brain regions for processing. Descending pathways from the brain modulate pain transmission.
II. The document outlines the history of pain theories, definitions of pain terminology, embryological development of pain pathways, types of pain, and components of the pain pathway including nociceptors, neurons, and brain regions involved in perception.
III. Key aspects of acute and chronic pain are distinguished. The gate control theory proposes that non-painful stimuli can inhibit pain transmission at the dorsal horn. Overall the document provides a comprehensive overview of
The document discusses pain pathways and mechanisms of pain control. It defines pain and describes different types of pain such as acute vs chronic, nociceptive vs neuropathic, somatic vs visceral, referred vs non-referred, and somatogenic vs psychogenic pain. It then explains the neuroanatomy of pain transmission from nociceptors to the central nervous system and perception in the brain. Finally, it discusses current analgesic options and the WHO analgesic ladder for treating mild to severe pain.
This document provides an overview of the physiology of pain. It defines pain and discusses the dual nature of fast and slow pain. It describes the nerve pathways and brain areas involved in pain perception, as well as pain modulatory pathways and neurochemicals. The gate control theory of pain is explained, which proposes an interaction between pain and touch fibers at the spinal cord level. Factors such as referred pain and the role of capsaicin and vanilloid receptors are also summarized.
1. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is subjective and based on expectations, past experience, and emotional factors.
2. Pain is transmitted via nociceptors that detect extreme mechanical, thermal, or chemical stimuli and transmit signals along nerve fibers to the spinal cord and brain.
3. Chronic pain lasts longer than 6 months and is more complex, often involving altered anatomy and neural pathways. It is a lasting condition compared to acute pain which subsides with healing.
This document provides information on pain management. It begins with the history and theories of pain. It then discusses the neurophysiology of pain including nociception, transmission, modulation and perception. Gate control theory is explained in detail. Non-pharmacological approaches like rest, distraction, electrotherapy and exercise are covered. The WHO analgesic ladder is introduced and different classes of pharmacological pain medications like non-opioids, opioids, antidepressants and antiepileptics are summarized.
This document discusses the pathophysiology of pain. It covers topics such as the definition of pain, categories of pain (somatogenic, psychogenic, acute, chronic), the neuroanatomy and neurophysiology of pain processing, and different types of neuropathic pain. The gate control theory of pain is also explained, which proposes that stimulation of large nerve fibers can close the "gate" in the spinal cord and decrease pain transmission.
Pain Management (General concepts and primary discussions)Saeid Safari
This document provides an overview of pain medicine. It defines pain and discusses its epidemiology, economics, and physiological effects. It describes acute and chronic pain, including their presentations and pathophysiology. Neuropathic and nociceptive pain are major categories discussed. Pain pathways and the gate control theory of pain are also summarized. Psychiatric comorbidities with chronic pain are noted.
The document discusses pain and its pathways in the human body. It defines pain and describes its characteristics and theories. It discusses the neurochemistry and types of pain receptors. The main pain pathway described is the lateral spinothalamic tract, which carries pain and temperature sensations from the periphery to the thalamus and somatosensory cortex via the dorsal horn and spinal cord. It relays information via three orders of neurons and can be modulated in the substantia gelatinosa of the spinal cord.
oro-facial pain (other than neuralgias)Mammootty Ik
This document provides an overview of orofacial pain (OFP), including definitions, classifications, neural pathways, evaluation of patients, and treatment principles. OFP can be caused by diseases of the orofacial structures, musculoskeletal diseases, psychological factors, or referred pain from other sources. Evaluation of a patient with OFP involves taking a thorough history and performing a physical exam, with imaging and diagnostic nerve blocks used as needed to determine the cause. Classification systems organize OFP into physical and psychological categories to guide diagnosis and interdisciplinary treatment.
This document provides an overview of pain pathophysiology and management. It begins with objectives and introduces topics like neuroanatomy, pathophysiology, types of pain, assessment, and management. It describes how pain is a subjective experience transmitted by nociceptors and modulated by various factors. The neuroanatomy of pain transmission from the periphery to the CNS is outlined. Different types of pain like nociceptive, neuropathic, referred, acute, and chronic are defined. Common pain syndromes and their characteristics are mentioned. Non-opioid and opioid medications as well as non-pharmacological approaches for pain management are summarized.
This document defines pain and describes the physiology of pain. It states that pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is transmitted via nociceptors and travels along afferent nerve fibers to the spinal cord. The gate control theory proposes that pain transmission can be modulated by interactions between pain fibers and touch fibers at the spinal cord. Chronic pain may involve different nerve fibers and neurotransmitters than acute pain. Various brain regions are also involved in pain perception and modulation.
The document discusses the pathophysiology of pain. It defines pain and describes the three systems - sensory, motivational, and cognitive - that interact to produce the experience of pain. It categorizes pain into somatogenic, psychogenic, acute, and chronic types and discusses their characteristics. It also describes age-related differences in pain perception and the neuroanatomy of pain processing, including the roles of the afferent and efferent pathways and different areas of the central nervous system.
This document provides an overview of pain, including its definition, classification, theories, transmission and modulation pathways, assessment, and management approaches. It begins with definitions of pain from Dorland's Medical Dictionary and Monheim. It then classifies pain according to intensity, temporal relationship, qualities, onset, and localization. Theories of pain discussed include specificity, pattern, and gate control theories. It describes the dual nature of pain and the transduction, transmission, modulation, and perception of pain. It discusses referred pain and neuropathic pain. The document concludes by covering pain assessment tools and pharmacological and non-pharmacological management strategies.
1. Pain is a complex, subjective experience influenced by physiological, psychological, social, and cultural factors.
2. Accurate pain assessment is crucial for nurses and includes gathering subjective reports from patients, which are the primary source of data.
3. A nurse's key role is as a patient advocate for comprehensive pain management, including both pharmacological and non-pharmacological interventions tailored to each patient's individual experience of pain.
1. Pain is a complex, subjective experience influenced by physiological, psychological, social, and cultural factors.
2. Accurate pain assessment is crucial for nurses and includes gathering subjective data from patients.
3. A nurse's key role is advocating for patients by assisting with pain management through both nonpharmacological and pharmacological interventions.
Knowledge of pain physiology is very important in understanding of electrotherapy prescription. So, this slide may be useful in understanding the background of the pain processes.
The document discusses pain and its management. It defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is subjective and involves physiological, emotional, and cognitive components. Pain assessment methods include WHATSUP, PQRST, and OLDCART. Pain management involves pharmacological approaches like opioids and non-opioids, surgical interventions, physical therapy, and complementary therapies like massage, acupuncture, and meditation. Nurses play a key role in comprehensive pain management.
pathophysiology and therapeutics of pain .pptxSamuel Nimoh
The document defines acute and chronic pain and classifies pain types as nociceptive and neuropathic. It describes the pathophysiology of acute pain, involving transduction, transmission, perception, and modulation of pain signals in the nervous system. Chronic pain may involve central sensitization and wind-up phenomena in the spinal cord. Pain assessment involves history, examination, and investigations. Management follows the WHO analgesic ladder using non-opioids, weak opioids like codeine, and strong opioids like morphine. Non-opioid options include paracetamol and NSAIDs like ibuprofen.
I. Pain pathways involve nociceptors detecting damaging stimuli and transmitting signals along primary afferent neurons to the dorsal horn. Signals then project up the spinal cord and through ascending tracts to various brain regions for processing. Descending pathways from the brain modulate pain transmission.
II. The document outlines the history of pain theories, definitions of pain terminology, embryological development of pain pathways, types of pain, and components of the pain pathway including nociceptors, neurons, and brain regions involved in perception.
III. Key aspects of acute and chronic pain are distinguished. The gate control theory proposes that non-painful stimuli can inhibit pain transmission at the dorsal horn. Overall the document provides a comprehensive overview of
The document discusses pain pathways and mechanisms of pain control. It defines pain and describes different types of pain such as acute vs chronic, nociceptive vs neuropathic, somatic vs visceral, referred vs non-referred, and somatogenic vs psychogenic pain. It then explains the neuroanatomy of pain transmission from nociceptors to the central nervous system and perception in the brain. Finally, it discusses current analgesic options and the WHO analgesic ladder for treating mild to severe pain.
This document provides an overview of neurophysiology topics including nerve conduction, membrane potential, action potentials, neuromuscular junction function, neurotransmitters, sensory and motor pathways, reflexes, control of movement by various brain regions like motor cortex, basal ganglia, cerebellum, and physiology of pain. It discusses concepts like electrophysiology, synapses, nerve fiber types, propagation of action potentials, factors contributing to resting membrane potential, sodium-potassium pump, action potential generation and propagation, different neurotransmitters, ascending pain pathways, descending pain modulation, and gate control theory of pain.
This document provides an overview of pain physiology. It defines pain, describes different types of pain, and the pathways involved in pain transmission and modulation. Key points include:
- Pain is a multidimensional experience defined by the IASP as "an unpleasant sensory and emotional experience." It can be acute or chronic.
- Nociceptors detect noxious stimuli and transmit signals through Aδ and C fibers to the spinal cord where substance P is released.
- Pain pathways ascend to the thalamus and brain for perception. Descending pathways from the brainstem release opioids and modulate pain transmission.
- The gate control theory proposes that activity in large myelinated fibers can inhibit nocice
This document provides an overview of pain physiology. It defines pain, describes different types of pain, and the pathways involved in pain transmission and modulation. Key points include:
- Pain is a multidimensional experience defined by the IASP as "an unpleasant sensory and emotional experience." It can be acute or chronic.
- Nociceptors detect noxious stimuli and transmit signals through Aδ and C fibers to the spinal cord where substance P is released.
- Pain pathways ascend to the thalamus and brain for perception. Descending pathways from the brainstem release opioids and modulate pain transmission.
- The gate control theory proposes that activity in large myelinated fibers can inhibit nocice
This document summarizes key concepts in neuromuscular physiology. It discusses the electrochemical basis of nerve conduction including resting membrane potential, action potentials, and ion channels. It describes the properties of excitable tissues like neurons and muscle. Factors contributing to resting membrane potential and the roles of ion channels and the sodium-potassium pump are explained. The generation and propagation of action potentials, as well as the structure and function of synapses, ionotropic receptors, and neurotransmitters are outlined. The document concludes by covering neuromuscular junction structure and function, including acetylcholine synthesis, receptor activation, and muscle contraction via calcium signaling.
Level 3 NCEA - NZ: A Nation In the Making 1872 - 1900 SML.pptHenry Hollis
The History of NZ 1870-1900.
Making of a Nation.
From the NZ Wars to Liberals,
Richard Seddon, George Grey,
Social Laboratory, New Zealand,
Confiscations, Kotahitanga, Kingitanga, Parliament, Suffrage, Repudiation, Economic Change, Agriculture, Gold Mining, Timber, Flax, Sheep, Dairying,
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
How Barcodes Can Be Leveraged Within Odoo 17Celine George
In this presentation, we will explore how barcodes can be leveraged within Odoo 17 to streamline our manufacturing processes. We will cover the configuration steps, how to utilize barcodes in different manufacturing scenarios, and the overall benefits of implementing this technology.
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...indexPub
The recent surge in pro-Palestine student activism has prompted significant responses from universities, ranging from negotiations and divestment commitments to increased transparency about investments in companies supporting the war on Gaza. This activism has led to the cessation of student encampments but also highlighted the substantial sacrifices made by students, including academic disruptions and personal risks. The primary drivers of these protests are poor university administration, lack of transparency, and inadequate communication between officials and students. This study examines the profound emotional, psychological, and professional impacts on students engaged in pro-Palestine protests, focusing on Generation Z's (Gen-Z) activism dynamics. This paper explores the significant sacrifices made by these students and even the professors supporting the pro-Palestine movement, with a focus on recent global movements. Through an in-depth analysis of printed and electronic media, the study examines the impacts of these sacrifices on the academic and personal lives of those involved. The paper highlights examples from various universities, demonstrating student activism's long-term and short-term effects, including disciplinary actions, social backlash, and career implications. The researchers also explore the broader implications of student sacrifices. The findings reveal that these sacrifices are driven by a profound commitment to justice and human rights, and are influenced by the increasing availability of information, peer interactions, and personal convictions. The study also discusses the broader implications of this activism, comparing it to historical precedents and assessing its potential to influence policy and public opinion. The emotional and psychological toll on student activists is significant, but their sense of purpose and community support mitigates some of these challenges. However, the researchers call for acknowledging the broader Impact of these sacrifices on the future global movement of FreePalestine.
This presentation was provided by Racquel Jemison, Ph.D., Christina MacLaughlin, Ph.D., and Paulomi Majumder. Ph.D., all of the American Chemical Society, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
Beyond Degrees - Empowering the Workforce in the Context of Skills-First.pptxEduSkills OECD
Iván Bornacelly, Policy Analyst at the OECD Centre for Skills, OECD, presents at the webinar 'Tackling job market gaps with a skills-first approach' on 12 June 2024
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
Chapter wise All Notes of First year Basic Civil Engineering.pptx
MD Surg pain 2022 final.pptx
1. Physiology of pain
Prof. Vajira Weerasinghe
Senior Professor of Physiology, Faculty of Medicine, University of Peradeniya
& Consultant Neurophysiologist, Teaching Hospital, Peradfniya
www.slideshare.net/vajira54
2. Objectives
1. Revised IASP definition of “pain” and different types of pain
2. Nociceptors
3. Stimuli that can excite nociceptors and the role of PGE
4. Ascending pathway
5. Central projections
6. Substance P
7. Descending pain modulatory system
8. Opioid peptides and their actions
9. Gate-control theory of pain
10.Other neurotransmitters
11.“Referred pain”
12.Physiological basis of different methods of pain relief
3. What is pain?
• Pain is a difficult word to define
• Patients use different words to
describe pain
• eg.
• Aching, Pins and needles, Annoying, Pricking, Biting, Hurting,
Radiating, Blunt, Intermittent, Burning, Sore, Miserable, Splitting,
Cutting, Nagging, Stabbing, Crawling, Stinging, Crushing, Tender,
Dragging, Numbness, Throbbing, Dull, Overwhelming, Tingling,
Electric-shock like, Penetrating, Tiring, Excruciating, Piercing,
Unbearable
• Different words in Sinhala or in Tamil
• Pain Questionnaires
4. What is pain?
• There is an International definition of pain
formulated by the IASP (International
Association for the study of pain)
• Pain is a multidimensional experience
requiring comprehensive and ongoing
assessment and effective management
5. Revised IASP definition of pain
• Definition of pain
•An unpleasant sensory and emotional
experience associated with, or
resembling that associated with, actual
or potential tissue damage
(2020 Revised IASP definition)
IASP (International Association for the study of pain)
• Revised IASP definition addresses a person’s ability to
describe the experience to qualify as pain
• There are 6 key notes given with the international IASP
definition
6. Key notes
1. Pain is always a personal experience that is influenced to
varying degrees by biological, psychological, and social
factors
2. Pain and nociception are different phenomena. Pain
cannot be inferred solely from activity in sensory neurons
3. Through their life experiences, individuals learn the
concept of pain
4. A person’s report of an experience as pain should be
respected
5. Although pain usually serves an adaptive role, it may
have adverse effects on function and social and
psychological well-being
6. Verbal description is only one of several behaviors to
express pain; inability to communicate does not negate
the possibility that a human or a nonhuman animal
experiences pain
7. 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
• Pain could be acute or chronic (persistent)
• Multidimensional nature of pain
8. 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
9. Dual nature of pain
• Fast pain
– acute
– pricking type
– well localised
– short duration
– Thin myelinated nerve
fibres are involved (A
delta)
– Somatic
• Slow pain
– chronic
– throbbing type
– poorly localised
– long duration
– Unmyelinated nerve fibres
are involved (c fibres)
– Visceral
10. 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
“Stress induced analgesia” (SIA)
• Pain due to a stimulus that does not
normally provoke pain
Allodynia
• Pain caused by a lesion or disease of the somatosensory
nervous system (pain pathways)
Neuropathic pain
11. Pain terminology
International Association for the Study of Pain
• Hyperaesthesia
– Increased sensitivity to stimulation, excluding the special senses
(increased cutaneous sensibility to thermal sensation without pain )
• Allodynia
– Pain due to a stimulus that does not normally provoke pain
• Hyperalgesia
– Increased pain from a stimulus that normally provokes pain
• Neuralgia
– Pain in the distribution of a nerve or nerves
• Analgesia
– Absence of pain in response to a normally painful stimulus
• Anaesthesia
– A loss of sensation resulting from pharmacologic depression of nerve
function or from neurological dysfunction
• Paraesthesia
– An abnormal sensation, whether spontaneous or evoked
12. Pain terminology
International Association for the Study of Pain
• Nociceptive pain
– Pain that arises from actual or threatened damage to non-neural tissue
and is due to the activation of nociceptors
• eg. Burns, fractures, injury
• Neuropathic Pain
– Pain caused by a lesion or disease of the somatosensory nervous
system
• eg. Sciatica, neuropathy
• Nociplastic pain
– Pain that arises from altered nociception without clear evidence of actual
or threatened tissue damage causing the activation of nociceptors or
evidence for disease or lesion of the somatosensory system causing pain
• eg. Chronic back pain, fibromyalgia, irritable bowel syndrome
13. Transduction and perception
• Transduction
– Process of converting noxious stimulus to action
potentials
• Perception
– Central processing of nociceptive impulses in order
to interpret pain
14. Stimuli
• Physical
– pressure etc
• Electrical
• Thermal
– cold, hot
• Chemical
– H+, lactic acid, K+, histamine, bradykinin, serotonin, acetylcholine,
proteolytic enzymes, cytokines, leucotrienes, capsaicin
– Prostaglandins (PGE2)
• Cannot directly stimulate nociceptors
• Increase the sensitivity of nociceptors for other stimuli (decrease the
threshold)
15. 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)
Nociceptors are free nerve endings
Free nerve endings are distributed everywhere
both somatic and visceral tissues
except brain tissue and lung parenchyma
16. 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
• Capsaicin receptor (TRPV1 receptor)
– Respond to capsaicin, heat, low pH
– Stimulation leads to painful, burning sensation
17. Nerve pathways carrying pain signals to
the brain
• Pain signals enter the spinal cord
• First synapse is present in the dorsal horn of
the spinal cord
• Cross over to the other side
• Then the second order neuron travels through
the lateral spinothalamic tracts
19. central connections
• afferent fibre enters the spinal cord
• synapses in laminae ii,iii
– substantia gelatinosa
substantia
gelatinosa
Neurotransmitter at the first synapse of the
pain pathway is substance P
• Acute pain : glutamate (NMDA receptors)
• Chronic pain: substance P (NK1 receptors)
• Pain inhibitory neurotransmitters: enkephalin, GABA
22. 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’
– Sensory cortex is necessary for the
localisation of pain
– Other areas are also important
• reticular formation, limbic areas,
hypothalamus and other subcortical
areas
23. Descending pain modulatory system
• several lines of experimental evidence show the
presence of descending pain modulatory system
– Electrical stimulus produced analgesia (Reynolds)
– stimulation of certain areas in the brain stem was known to
decrease the neuronal transmission along the
spinothalamic tract
– Chemical stimulus produced analgesia
– Discovery of morphine receptors
– they were known to be present in the brain stem areas
– discovery of endogenous opioid peptides
• eg. Endorphines, enkephalins, dynorphin
25. • descending tracts involving opioid peptides as
neurotransmitter were discovered
• these were known to modify (inhibit) pain
impulse transmission at the first synapse at the
substantia gelatinosa
26. • first tract was discovered in 1981 by Fields and
Basbaum
– it involves enkephalin secreting neurons in the
reticular formation
– starting from the PAG (periaqueductal grey area) of
the midbrain
– ending in the NRM (nucleus raphe magnus) of the
medulla
– from their ending in the substantia gelatinosa of the
dorsal horn
28. opioid peptides
• endorphin
• Enkephalins or encephalins - met & leu
• Dynorphin
• Receptors: mu, kappa, delta
• Morphine, fentanyl, pethidine, codeine are opioid
drugs
• Naloxone is opioid receptor antagonist
• Opium (derived from poppy plant) is a naturally
occurring substance
• “Heroin” contain naturally occurring opiates and are
highly addictive
29. Opioid action at the
spinal cord level
substance P
or glutamate
opioids
pain impulse
blocking of
pain impulse
30. Opioid actions
• Act presynaptically or postsynaptically
– Blocks Ca2+ channels and inhibits Ca2+ influx and thereby prevent pain
neurotransmitter release (glutamate, substance P) from presynaptic membrane
– Open up K+ channels and causes K+ efflux and resulting in hyperpolarisation of
the membrane and prevents pain neurotransmitter activity
– Inhibits cAMP activity and alters pain neurotransmitter activity
• Act at the spinal cord level or brainstem reticular formation level
• Activates descending pathways
• Opioid and non-opioid mechanisms are activated
• Non-opioid mechanisms use noradrenergic or serotoninergic
pathways
• Also inhibit GABA mediated inhibition of descending pathway
activity
31. Opioid actions
• Basis of respiratory depression when morphine is given is due
to inhibition of pre- Botzinger complex (BOTC) (which is the
respiratory rhythm pattern generator present in the medulla
which controls inspiratory centre) by opioids through mu
receptor
• Activate chemoreceptor trigger zone and may cause vomiting
• Opioid system is involved in pain modulation, stress, appetite
regulation, learning, memory, motor activity, immune function
• Opioids/opiates addiction (eg. due to heroin) is due to their
action through mesolimbic reward pathway (involving VTA and
nucleus accumbens) and increasing dopamine levels in the
brain which causes feeling of pleasure and euphoria
• Subsequent increased compulsion leads to tolerance and
dependence
32.
33. • since then various other descending tracts were
discovered
• all of them share following common features
– involved in brain stem reticular areas
– enkephalins act as neurotransmitters at least in some
synapses
– most of these tracts are inhibitory
– midbrain nuclei are receiving inputs from various areas in
the cortex, subcortical areas, limbic system, hypothalamus
etc
– the ascending tract gives feedback input to the descending
tracts
– recently even non-opioid peptides (serotonin and
noradrenaline) are involved
34. C fibre
Final pain perception
depends on activity
of the
Ascending
pain impulse
transmitting
tracts
Descending
pain modulatory
(inhibitory) tracts
35. Theories
of pain
There is a single pathway for touch
and pain
Less intensity produces touch
Increased intensity produces pain
There are two
different
pathways for
touch and pain
Specificity theory
touch pain
Intensity theory
touch
pain
36. Gate control theory
• This explains how pain can be relieved very quickly by
a neural mechanism
• First described by P.D. Wall & Melzack (1965)
• “There is an interaction between pain fibres and touch
fibre input at the spinal cord level in the form of a
‘gating mechanism’
37. Gate control theory
When pain fibre is stimulated, gate will be opened & pain is felt
pain
pain is felt
+
gate is
opened
38. Gate control theory
When pain and touch fibres are stimulated together, gate will be
closed & pain is not felt
pain is
not felt
touch
pain
+ -
gate is
closed
Animation
39.
40. Gate control theory
• This theory provided basis for
various methods of pain relief
– Massaging a painful area
– Applying irritable substances to a
painful area (counter-irritation)
– Transcutaneous Electrical Nerve
Stimulation (TENS)
– Acupuncture ?
41. Gate control theory
• But the anatomcal basis for all the connections
of Wall’s original diagram is lacking
?
?
42. WDR (wide dynamic range cells)
• It is known that some of the second order neurons of the pain
pathway behave as wide dynamic range neurons
• They are responsive to several somatosensory modalities
(thermal, chemical and mechanical)
• They can be stimulated by pain but inhibited by touch stimuli
• They have been found in the spinal cord, trigeminal nucleus,
brain stem, thalamus, cortex
43. WDR (wide dynamic range cells)
C fibre A fibre
pain &
mech mech
inhibitory
excitatory
WDR cell
44. Modifications to the gate control theory
• this could be modified in the
light of enkephalin activity
and WDR cells
• inhibitory interneuron may be
substantia gelatinosa cell
• descending control is more
important
• WDR cells may represent
neurons having pain as well
as touch input
45. Pain arising from abdominal
viscera
• Mediated by C fibres
• Mainly due to the sensations of distention, muscular contraction, inflammation, hypoxia but not
to cutting, tearing, local irritation, burning
• Typically vague, dull, and nauseating
• These structures are innervated by autonomic nerve fibers
• It is poorly localized and tends to be referred to areas corresponding to the embryonic origin of
the affected structure
– stomach, duodenum, liver and pancreas referred to upper abdomen
– small intestines, proximal colon and appendix referred to periumbilical pain
– distal colon and GU tract referred to lower abdominal pain
• Peritonitis causes somatic pain
• Diffuse localization of true visceral pain is probably due to the low density of visceral sensory
innervation and extensive divergence of the visceral input within the central nervous system
46. • hypoxia / pressure / inflating a BP cuff
– first affect large A fibres (touch & pressure sense)
– then affect A fibres (temperature sense & pricking
pain)
– lastly C fibres (burning pain)
• local anaesthetics
– first relieve burning pain ( C fibres)
– then temperature sense & pricking pain (A fibres)
– lastly touch& pressure sensation (large A fibres)
47. 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
– this paradoxical situation is due to an apparent error
in localisation
48. referred pain - theories
• convergence theory
– somatic & visceral structures
converge on the same
dermatome
– generally impulses through
visceral pathway is rare
– centrally brain is programmed
to receive impulses through
somatic tract only
– therefore even if the visceral
structure is stimulated brain
misinterpret as if impulses are
coming from the somatic
structure
visceral
somatic
second
order
neuron
++
+
+
+
+
+
49. referred pain - theories
• facilitatory theory
– somatic & visceral structures
converge on the same
dermatome
– stimulation of visceral
structure facilitates
transmission through somatic
tract
visceral
somatic
second
order
neuron
++
+
+
+
+
+
50. Capsaicin and vanniloid receptors
• Active compound in chilies is capsaicin
• Capsaicin chemically is one of the vanilloids
• Capsaicin receptor is called TRPV1
– (Transient receptor potential vanilloid type 1)
• This receptor is also stimulated by
– heat greater than 43°C
– low pH
• This receptor is sensitised by prostaglandins and bradykinins
• Upon prolonged exposure to capsaicin TRPV1 activity decreases
– this phenomenon is called desensitization
– Extracellular calcium ions are required for this phenomenon
– This causes the paradoxical analgesic effect of capsaicin
51. Different TRP Channels
Capsasin, the active
ingredient in chili
pepper, is used in
patches for relief of
pain.
Menthol and
peppermint gels are
used to relieve
muscle pain.
52. Cannabinoid receptor
• Cannabis (marijuvana or ganja) causes pain relief
• Cannabis act on cannabinoid receptors CB1 found in pain pathway
(presynaptic receptors)
• There are endocannabinoids as well (2-arachidonoyl glycerol (2-AG) and
anandamide)
• Secreted from the postsynaptic terminal, act on the presynaptic terminal,
receptors present on the pre-synaptic terminal
• This is a form of retrograde signalling
• Via G protein coupled activity blocks Ca++ entry or increase K efflux
• Inhibit pain neurotransmitter release
• Cannabinoid receptor-related processes are involved in cognition, memory,
anxiety, control of appetite, emesis, motor behavior, sensory, autonomic and
neuroendocrine responses, immune responses and inflammatory effects
apart from modulating pain
53. • A condition when normally
non-painful stimuli cause
pain, e.g., touch, light
pressure, cold.
• Involves changes in the
synaptic sensitivity of the
nociceptive neurons in the
spinal cord (central
sensitization).
• Drugs such as ketamine,
block NMDA receptors and
so reduce transmisison of
the nociceptive stimuli.
Allodynia
Nociceptive signals from
the periphery to
spinal cord
NMDA (a receptor for
glutamate) response
increases in the spinal
cord
Nociceptive nerve cells
in the spinal cord now
become responsive to
non-painful stimuli
A mechanism for
allodynia
55. c-fos gene and FOS protein
• Discovery of gene c-fos (a viral oncogene) & its
cellular product, the protein called Fos seem
crucial to the profound central nervous system
changes that occur when an animal (or man)
feels pain
• CNS c-fos expression correlates extremely well
with painful stimulation
• We now have a molecular marker for pain!
56. Pain memory
• 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
• Clinical interventions to blunt both the experience and persistence of pain or to
lessen its memory are now applied
• Preemptive analgesia
– Pre-emptive analgesia is a treatment that is initiated before the surgical procedure in order
to reduce sensitization
– Many studies have demonstrated that analgesic intervention before a noxious stimulus or
injury is more effective at averting central sensitization than the same analgesic
intervention given after the stimulus
57. Different methods of pain relief
• Prostaglandin inhibition (Aspirin, NSAIDS)
• Local anaesthetics (Voltage gated Na channel blocking)
• Gate control theory (Blocking first synapse)
• TENS (Gate control theory)
• Opioids (Spinal cord and central descending pathway action)
• Drugs which increase noradrenalin and serotonin (activation of non-opioid
descending pathway)
• Central acting drugs (complex mechanism)
• Psychotherapy (complex mechanism)
• Nerve blocks (Blocking nerve transmission)
• Nerve decompression (Blocking nerve transmission)
• Inhibition of gultamate release by blocking Ca channels (Gabapentin)
• Multidisciplinary management
58. Summary
• Pain is a multidimensional experience requiring
comprehensive and ongoing assessment and effective
management
• Health workers involved in pain management play an
essential role in the prevention, diagnosis and management
of acute and persistent pain
• Pain management options should be modified appropriately
for individual patients according to medical condition,
medicine availability, risk-benefit balance, cost-
effectiveness, culture, mental status, and evidence of
efficacy