Definition n classification •Pathophysiologyof pain. •Physiological Effects of pain. •Pharmacological & non-pharmacological methods of analgesia. •Principles of pain management.METHODS OF CONTROLLING METHODS OF CONTROLLING
Non-pharmacological Preoperative counseling TENS Acupuncture
Pharmacological Opioids •Im •IV infusion •IV PCA Local anaesthetics: •Local Infiltration •Nerve Blocks •Epidural Blocks NSAIDS •IM •IV infusion •IV PCA
NON-PHARMACOLOGICAL METHODS PRE-OP COUNSELLING: Well informed patients about: •Nature of operation •Nature of post operative pain •Methods of analgesia available
Cope better with Post –op Pain
NON-PHARMACOLOGICAL METHODS TENS (Trans Cutaneous electric nerve stimulation)
Stimulates afferent myelinated (A-beta) nerve fibers at 70hz
Inhibitory circuits within sp cord activated
Nerve impulse transmission reduced
Maximum benefit in neurogenic pain
PHARMACOLOGICAL METHODS OPIODS •Activate opiodreceptors within the CNS •Reduce transmission of nerve impulses by modulation in the dorsal horn
PHARMACOLOGICAL METHODS
LOCAL ANAESTHETICS –Blocks the conduction of nerve impulses –Can be given with adrenaline because •Decreases absorption of L.A allowing larger doses •Also acts on alpha 2 receptors which potentiates analgesic effect
PHARMACOLOGICAL METHODS
NASIDS –Blocks synthesis of PG’s –Only suitable for miledto moderate pain
PRINCIPLE OF MANAGEMENT OF PAIN •Pre-emptive analgesia •Balanced or combination analgesia •Analgesia ladder
PHARMACOLOGICAL METHODS
Balanced Analgesia –NASID are used in conjunction with opioids. –Reduces amount of opioids –Reduces side affect of opioids,ASSESMENT OF PAIN •Observe the behaviour of the patient •Monitor analgesic requirement of the patient –Visual Analogue Score( VAS )
–Verbal Rating Score ( VRS ) •None •Mild •Moderate •severe
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. pain perception
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
Like normal 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 cut your 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
The signals 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
13. The secondary neurons send 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 the pain 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 descending pathways 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 the ascending 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 from the 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.
18.
19. Gate ControlTheory of Pain
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 among these 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 (pain reception) 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-pain in 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
25.
26. Types of Pain
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.
28. Neuropathic pain:
Neurone abnormality
Peripherial or central
symptoms
oTrauma
oDiabetes
oCancer
oNeuralgia
oReflex sympathetic dystrophy syndrome.
29.
30. Referred pain:
Away from the origin
Visceral organ
Bone
Skin
myofascial
31. Myofascial pain:
pressure on 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
33. Phantom pain:
Amputation(diabetes)
Thalamic images
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.
34.
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.verbal scale
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 QUESTION ASSESSING 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 diagonostic information :
•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 the pain 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 steroidal anti-
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
•Cough supressants
•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(holistic medicine) 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 progression found 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: transcutaneous electrical 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.
50.
51. Surgery
In extreme cases, 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 approaches do 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 involve the 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!!!!!!!!