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Pain.
- 1. Naresh sah 2nd pharmd kcp
- 2. Pain from Latin‘ ponea’ = penalty/punishment Pain defines it as an "unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage“ No.1 compaints Protective response Dual nature of pain Sensational & emotional
- 3. Sensation &emotion Feeling vs emotions Physiological and Psychological Most imp sense among all. Only one sensation on Which all of us agree is pain.
- 4. 1. painperception 2.pain reaction 1. pain perception is the process by which painful(noxious) stimulus cause the activation of noxiceptors(pain fibres) which transmits a signal to brain
- 5. A. transduction B.conduction C.transmisssion D.modualtion E.perception Nociceptors are cheomoreceptors.
- 6. Pain Signal Reception Likenormal sensory neurons, nociceptor neurons travel in peripheral sensory nerves. Their cell bodies lie in the dorsal root ganglia of peripheral nerves just inside the spine. Nociceptors sense pain through free nerve endings rather than specialized endings such as those in neurons that sense touch or pressure. However, while normal sensory neurons are myelinated (insulated) and conduct quickly, nociceptor neurons are lightly or non-myelinated and slower. We can divide nociceptors into three classes: A δ mechanosensitive receptors -- lightly myelinated, faster conducting neurons that respond to mechanical stimuli (pressure, touch) A δ mechanothermal receptors -- lightly myelinated, faster conducting neurons that respond to mechanical stimuli (pressure, touch) and to heat Polymodal nociceptors (C fibers) -- unmyelinated, slowly conducting neurons that respond to a variety of stimuli.
- 7. When you cutyour hand. Several factors contribute to the reception of pain: Mechanical stimulation from the sharp object Potassium released from the insides of the damaged cells Prostaglandins, histamines and bradykinin from immune cells will invade the area during inflammation Substance P from near by sensory nerve fibers. These substances cause action potentials in the nociceptor neurons. The signal for this pain is conducted rapidly by the A δ-type nociceptors. The pain is followed by a slower, prolonged, dull ache, which is conducted by the slower C-fibers. The three primary neurotransmitters that "ship" pain signals to the brain are substance P, NMDA (n-methyl-d-aspartate), and glutamate. Neuron Reactions
- 8. Pain Signal Transmission Thesignals from your cut hand travel into the spinal cord through the dorsal roots. There, they make synapses on neurons within the dorsal horn (the top half of the butterfly- shaped gray matter). Pain Signal Transmission
- 9. transmission: 2 pathway 3 neurone Sensory-descriminative pathway & motivational affective pathway Perception: Stereotype reation Pain tract Higher brain
- 10. Amount oftissue damage & pain #endorphins. @ pain is protective response?
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- 13. The secondary neuronssend their signals upward through an area of the spinal cord's white matter called the spinothalamic tract. This area is like a superhighway where traffic from all of the lower segments rides up the spinal cord. The signals of the spinothalamic tract travel up the spinal cord through the medulla (brain stem) and synapse on neurons in the thalamus, the brain's relay center. Some neurons also synapse in the medulla's reticular formation, which controls physical behaviors. Nerves from the thalamus then relay the signal to various areas of the brain's somatosensory cortex -- there is no single pain center in the brain. Pain signals travel along pathways through the body. Spinal cord Anatomy
- 14. Pain Pathway Once thepain information is in the brain, signals go to the motor cortex, then down through the spinal cord and to the motor nerves. These impulses would cause muscle contractions to move your hand out of the way of whatever is causing the pain. Pathway
- 15. These descendingpathways originate in the somatosensory cortex (which relays to the thalamus) and the hypothalamus. Thalamic neurons descend to the midbrain. There, they synapse on ascending pathways in the medulla and spinal cord and inhibit ascending nerve signals. This produces pain relief (analgesia). Some of this relief comes from the stimulation of natural pain-relieving opiate neurotransmitters called endorphins, dynorphins and enkephalins. Pain signals can set off autonomic nervous system pathways as they pass through the medulla, causing increased heart rate and blood pressure, rapid breathing and sweating. The extent of these reactions depends upon the intensity of pain, and they can be depressed by brain centers in the cortex through various descending pathways.
- 16. • As theascending pain pathways travel through the spinal cord and medulla, they can also be set off by neuropathic pain -- damage to peripheral nerves, spinal cord or the brain itself. However, the extent of the damage may limit the reaction of the brain's descending pathways. The influences of the descending pathways might also be responsible for psychogenic pain (pain perception with no obvious physical cause).
- 17. Pain Information fromthe Face Your face has its own mini spinal-cord system called the trigeminal nerve. Somatosensory neurons (and pain receptors all over the face and head) travel into the central nervous system through the trigeminal nerve. They synapse in the trigeminal nucleus (in the brain stem) in the mid-medulla and also on neurons in the lower medulla. Then these neurons send signals through the tregeminal-thalamic tract within the midbrain to the thalamus. Neurons in the thalamus relay signals to the somatosensory cortex and limbic system.
- 19. Gate ControlTheory ofPain Principle: Noxious afferent can be blocked at the spinal cord level. Touch sensation at the same time reduced c fibres transmission through dorsal horn. To explain why thoughts and emotions influence pain perception, Ronald Melzack and Patrick Wall(1965) proposed that a gating mechanism exists within the dorsal horn of the spinal cord. Small nerve fibers (pain receptors) and large nerve fibers ("normal" receptors) synapse on projection cells (P), which go up the spinothalamic tract to the brain, and inhibitory interneurons Gate ControlTheory
- 20. The interplay amongthese connections determines when painful stimuli go to the brain: When no input comes in, the inhibitory neuron prevents the projection neuron from sending signals to the brain (gate is closed). Normal somatosensory input happens when there is more large-fiber stimulation (or only large-fiber stimulation). Both the inhibitory neuron and the projection neuron are stimulated, but the inhibitory neuron prevents the projection neuron from sending signals to the brain (gate is closed).
- 21. Nociception (painreception) happens when there is more small-fiber stimulation or only small-fiber stimulation. This inactivates the inhibitory neuron, and the projection neuron sends signals to the brain informing it of pain (gate is open). Descending pathways from the brain close the gate by inhibiting the projector neurons and diminishing pain perception. rubbing,TENS,brushing,massage,hot,cold
- 22. 1.Inflammation Chemical Thermal Radiation immunological Infection Lowers the threshold of depolarization. Causes hyperalgesia. 2. o2 def & ischemia: Lactic acid + free H+ ion H+ ion stimulates noxiceptors= pain
- 23. 3.Spasm & colic Colic-painin hallow organ Eg: renal uretic colic Billuric cilic Labour pain Ischemic pain 4.Serous membrane: Pleural membrane Peritoneal membrane Parietal membrane 5.Skin,dermis: Rich in nociceptors 6.Muscles & joint capsules
- 24. combating the pain Startle reaction Withdrawal reflex Emotional response: Pain & vocalization Autonomic reflexes:sympathetic:mydriasis,crying,perspiring,tachycardia,bp,hr,rr Memory of past experiences Avoidance of behaviour:wincing,wringling of hands,tapping of feet,humming,rubbing of injured areas. The pain reaction threshold differs between people and even varies in an individual from day to day
- 26. Types ofPain based on duration: Acute pain caused by an injury or trauma. warning potential damage can develop slowly or quickly. last for a few minutes to six months goes away when the injury heals. Chronic pain 30.7% of US popn. Continous & recurrent persists long after the trauma has healed in some cases, it occurs in the absence of any trauma does not warn the body to respond, usually lasts longer than six months. Associated with chronic disease.
- 27. Nociceptive (tissue injury)pain: Aches & sprains Back pain Arthritis Cancer pain Headaches Hyperalgesia & allodynia
- 28. Neuropathic pain: Neuroneabnormality Peripherial or central symptoms oTrauma oDiabetes oCancer oNeuralgia oReflex sympathetic dystrophy syndrome.
- 30. Referred pain: Away from the origin Visceral organ Bone Skin myofascial
- 31. Myofascial pain: pressureon sensitive points in your muscles (trigger points) causes pain in seemingly unrelated parts of your body. Adhesions Commonly mistaken for: Fibroitis Myositis Myalgia Myofascitis Muscles strains
- 32. Muscular pain: Sharp Aching Soreness Eg:spasm,cramp,strain,fibromyalgia,itis
- 33. Phantom pain: Amputation(diabetes) Thalamicimages Neurons of stump Usually goes away after 3-6 months. Principle: the localization of particular sensation is always projected back to the site where that particular sensory pathway originates.
- 35. Congenital Analgesia:Congenital analgesia is a rare genetic disorder where the individual is unable to feel pain. You might think this sounds like a good thing, but it's actually a life-threatening condition. Pain serves as a warning against injury, so people who don't feel it can be severly injured hurt by things that most of us would react quickly to. For example, Ronald Melzack and Patrick Wall describe a girl who got third-degree burns on her knees by climbing on a hot radiator. There was no signal for her to stop. Researchers are trying to reproduce this condition by genetically altering mice so that they can study the genetic contributions to pain perception.
- 36. 1. Emotional state 2.Fatigue 3. Age 4. Gender 5. Activity level 6. Culture & religious back ground 7. Fear & apprehension 8. Past experiences 9. Sleep 10. Use of drugs 11. Attentional modulation 12. Body position 13. Need for other to know 14. Placebo/nocebo
- 37. 1.Visual scale 2.verbalscale a.No pain b.Mild pain c.Moderate pain d.Severe pain e.worst PAIN ASSESSMENT •Sign or symptoms??? (Mc caffery,1968: whatever the pts says it is, existing whenever & wherever they say it does!!! •Only pts can explain & we have to believe.(purely subjective)
- 38. PainAssessment INFORTMATION DESIRED QUESTIONASSESSING PAIN TYPE OR QUALITY OF PAIN ISTHE PAIN SHARP OR DULL,ACHING,BURNING,RADATION,PUSATI NG ,CRAMPING, INTENMITTANT OR STEADY? DOYOU KNOWWHAT MIGHT BE THE CAUSE OF IT? LOCATION OF PAIN WHERE DOES IT HURT? POINTTO IT OHSET OFTHE PAIN WHEN DOESTHE PAIN OCCURES?WASTHE OCCURANCE SUDDEN/GRADUAL? DURATION OF PAIN HOW LONG HAVEYOU HADTHIS PAIN? HAS IT BEEN INTERMITTENTOR CONTINIOUS? SEVERITY OF PAIN WHEN ISTHE PAINWORSE? AGGREVATING FACTORS WHAT MAKESTHE PAIN START / BECOME WORSE (HEATLCOLD) ?
- 39. •PQRST for diagonosticinformation : •P=provoking factors •Q=quality :deep,superficial,sharp,dull,burning •R=region & radiation(area) •S=severity •T=times,duration,frequency •Assess at rest & during moving(breathing,coughing) •Assess before & after analgesics. •Assess each pain separately(along with separate analgesics) •Assess autonomic signs: mostly:sympathetic:HR,RR,BP,sweating minor:vasovagal parasympathetic can dominate.(syncope) •Child pain •Recently identified: foetal pain due to rapid development of nervous system.
- 40. Pain Management 1.Remove the cause 2. analgesic 3. Decrease the stimulation of pain receptors(noxiceptors) Aspirin & acetaminophen 4. Block conduction of pain signals Local anesthetics 5. Depress pain reaction. Narcotic analgesic,accupuncture,meditation,biofeedback,hypnosis. 6. Electrical stimulation 7. Holistic approaches. 8. Increasing Physical activity. 9. Induce uncounciousness general anaesthetics & psychosedation.
- 41. Assess &remove the exact cause. The different way of reducing the pain due to thorn are Oral analgesics Iv morphine Anesthesia Nitrous oxide But why not take out that thorn?? It would be the best way of managing pain. Infection: antibiotics Inflammation:antinflammation Ischemia:o2 therapy MI,angina:GTN,PCI,thrombolytic Fracture:traction Wound:dressing properly
- 42. Where is thepain exactly? Yes, “the bane of pain is plainly in the brain”. No brain, n0 pain WE ARE MORE OFFEN FRIGHTENEDTHAN HURT ‘ ANDWE SUFFER MORE FROM IMINIZATION THAN FROM REALITY - LUCIS
- 43. In 2013,a 7 year study of almost 7 million pts was analysed. It was found that 95% of the sample were taking NSAID. One in 5 older americans takes a pain killer regularly. NSAIDS ACETAMINOPHEN OPIODS
- 44. Non steroidalanti- inflammatory drugs: Pain Inflammation Stiffness Mobility 1-2 weeks of use Take with food or milk Common side effects GI irritation/ulcers CV risk Strokes Liver/kidney damage Allergic reaction Common NSAIDS aspirin Ibuprofen Naproxen Cebrex Advil •Acetaminophen(paraminophenols) •Pain •Muscles soreness •Fever reduction •Common side effects •Allergic reaction •risk with alcohol •Common acetaminophen •Tylenol •calpol Advantage of acetaminophen(compar ed to aspirin) Disadvantages of acetaminophen(compar ed to aspirin) Little GI irritation Less anti-inflammatory action Lower incidence of hypersensitivity reaction
- 45. Adjuvant analgesics(co-analgesics) are primarily used for treating some other condition, but they also relieve pain. These compounds are useful in treating neuropathic pain (chronic pain that comes from injury to the central nervous system). They include the following: Anti-epileptic drugs reduce membrane excitability and action potential conduction in neurons of the central nervous system. Tricyclic antidepressants affect synaptic transmission of serotonin and norepinephrine neurons in the central nervous system, thereby affecting pain-modulating pathways. Anesthetics block action potential transmission by interfering with sodium and potassium channels in nerve cell membranes. Examples include lidocaine, novocaine and benzocaine.
- 46. •Opiods •Pain •Stress & anxiety •Coughsupressants •Common side effects •Addiction/withdrawal syndrome •Drowsiness •Constipation •Nausea •Vomiting •Risk with alcohol •Common opiods •Codeine •hydrocodone(vicodin) •Dilandid •oxycontin •Percocet •morphine EXEDRIN 250 mg of acetaminophen 250 mg of aspirin 65 mg of caffeine Analgesic contd..
- 47. Holistic health(holisticmedicine) is a diverse field of alternative medicine in which the “whole person” is focused on, not just the malady(illness) itself. Cognitive behavioural therapy Coping skills therapy(tolerate stress therapy) Imagery Hypnosis Relaxation Music Biofeedback distraction Accupuncture(gate control theory) Food
- 48. Exercise progressionfound to decrease the pain. Decrese in hormones that involves inflammation. Known link between chronic pain & tight,weak muscles. Increases blood & o2 flow to muscles. Reduces stress Study in 2012 of one million found Over weight (BMI 25-30) = 20% higher pain rate Obese I (BMI 30-35) = 68% higher pain rate Obese II (BMI 35-40) = 136% higher pain rate Obese III ( BMI less than 40) = 254% higher pain rate
- 49. TENS: transcutaneouselectrical stimulation is a therapy that uses low voltage electrical current for pain relief. The electrodes from the machine to the skin are often placed on the area of pain or at a pressure point,creating a circuit of electrical impulse that travels along the nerve fibres. When the current is delivered,some people experience less pain. This may be because the electricity from the electrodes stimulates the nerves in an affected area and send signals to brain which blocks or scramble normal pain. Electrical stimulation of nerves helps to produce endorphins which can blocks the perception of pain.
- 51. Surgery In extremecases, surgeons may have to sever pain pathways by altering areas of the brain associated with pain perception -- or performing a rhizotomy (which destroys portions of peripheral nerves) or a chordotomy (destroys ascending tracts in the spinal cord). These surgeries are usually a last resort. Surgical interventions can be aimed at eradicating the source of the pain. For example, many people suffer back pain from herniated disks between the vertebrae. An inflamed disc can compress a nerve and cause neuropathic pain. If the patient does not respond to medication, a surgeon might try to remove at least part of the disc and relieve pressure on the nerve.
- 52. AlternativeTherapy These approachesdo not involve drugs or surgery. Chiropracty manipulates joints to relieve compression of nerves. Massage stimulates blood flow, relieves muscle spasms and increases somatosensory information, which can relieve pain through the gate control theory (see previous page). Hot applications increase blood flow, and cold applications reduce inflammation, which contributes to pain. Stimulation of the skin with small electrodes can close the gate to pain.
- 53. Pain-management plans involvethe participation of doctors, patients, family members and other caregivers. As with any medical treatment, the source of pain, pain tolerance, and the potential benefits and risks of treatment must be considered. Ignoring pain Tissue damage Cortisol secretion Pain spread(2012) Compensation Central sensitization Treating symptoms conclusion Pain happens for a reason Pain is subjective What is hurting may not be what is broken Treat the symptoms but………. Act!!!!!!!!