Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is a major unmet medical need, with chronic pain reducing quality of life similar to depression. Pain signals are transmitted through nociceptors and neurons from the peripheral to central nervous system. There are two main types of pain - fast pain conducted along thin myelinated fibers for sharp pain, and slow pain conducted along unmyelinated C fibers for dull pain. Acute pain serves a protective purpose while chronic pain persists independently of tissue damage. A variety of pharmacological and non-pharmacological options are used for pain relief.

1. PAIN & PAIN MANAGEMENT
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2. PATHOPHYSIOLOGY
OF
PAIN
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3. PAIN
An unpleasant sensory and
emotional experience
associated with actual
or potential tissue damage,
or described in terms of
such damage
(International Association for study of Pain)
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4. PAIN
Pain is an Unmet Medical Need
 1 in 8 of you will experience poorly relieved persistent
pain at some point in your life
 Only 50% of patients with post-operative pain are satisfied
with the pain therapy received
 Chronic unrelieved pain produces a disease state with
progressive physical & social dysfunction
Reduction in Quality of Life similar to depression
Heavy Socio-economic burden.
Poor choices of effective & safe analgesic drugs
 The two main classes of analgesics (opiates and anti-
inflammatories) were discovered two centuries ago
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5. HISTORY OF PAIN RELIEF
 Hippocrates(Gk.); disbalance b/w blood, phlegm,
yellow/black bile
 Aristotle; Increased sensitivity to touch
originating in the heart
 Celsus(Rome); rubor, calor, tumor, dolor &
functional loss
 Leonardo da Vinci; spinal transmission of pain to
thalamus
 1803; morphine isolated from opium
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6. ..contd...
 Latin poena; punishment
 Chinese; Yin vs Yang /Chi, 14 grid imbalance
 Egyptians; spirits, treatment; vomiting,urinating,
sneezing
 Buddhists; frustration of desires
 Hindus; heart seat of all pain
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7. 400 years ago Reneé Descartes described pain transmission:
The flame that burns the hand is transmitted along the nervous system to
the brain as a stimulus, where it torments man as a small flame
MECHANISMS IN NOCICEPTION
 Noxious Stimulus
 Activates Nociceptors
 Transmit to Brain
 Perception of Pain
 Pain behavior
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8. THE PURPOSE OF PAIN
Protective mechanism;
 A signal of a disease
 Occurs whenever any tissue is being damaged
 Helps in detection, localisation and identification
of tissue damage
 Causes the individual to react to remove the
pain stimulus
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9. CROSS ROADS FOR TRANSMISSION OF
PAIN & ITS RESPONSE BY THE BODY
 Receptors - free nerve endings
 Electro-chemical transmission
 Synapse in the spinal cord - convergence
 Ascent in the spinal cord to pain
receiving areas in the brain
 Facilitatory/Inhibitory neurons
 Motor response

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11. TWO PARTS OF NERVOUS SYSTEM
 The pain response signal is transmitted by the
neuron in the peripheral nervous system (PNS)
to the central nervous system (CNS)
 Here the signals are integrated and acted upon
 The CNS is composed of the spinal cord and
brain
 The PNS is composed of all other elements of
the nervous system
 Neurons carry all afferent impulses between the
peripheral sensory receptors and the neurons
of the CNS
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12. INITIATION OF THE PAIN RESPONSE
 Algesic ( pain producing ) Substances:
 BK - Bradykinin
 5-HT - Serotonin
 H+ Acidic substance
 PgE - Prostaglandins
 SP - Substance P
 Pain Fibres:
 C fibres
 A - Delta fibres
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13. INITIATION OF THE PAIN RESPONSE
 Fast Pain
 Sharp, pricking, or pinching pain
 Arise from activation of mechanical
nociceptors via small-diameter, thinly
myelinated fibers
 Conducting at ~5 – 30 m/sec.
 The spinothalamic tract conveys fast pain.
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14. INITIATION OF THE PAIN RESPONSE
 Slow Pain
 Burning, itching, aching quality
 Arise from activation of polymodal
nociceptors that are activated by high-
intensity stimuli
 Information is sent to spinal cord via small-
diameter, unmyelinated C fibers.
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15. TYPES OF PAIN
Fast Pain;
 sharp/ prick/acute
/electric Pain
 within milisec
 not felt in the
deeper tissues of
the body
Slow Pain;
 burning/ aching/
throbbing/ nauseating
 can be excruciating
 can occur in both skin &
deep tissues
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16. CLASSIFICATION OF PAIN
 Depending on location:
deep, somatic / visceral
superficial , skin etc
 Depending on duration:
acute - more sharp
chronic - usually dull
 Depending on severity:
mild
moderate
severe
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17. THE DICHOTOMY WITH PAIN
ACUTE PAIN
( TISSUE INJURY )
 Surgical Procedures
 Trauma
 Child birth
CHRONIC PAIN
( NOT NECESSARILY TISSUE
INJURY )
 Chronic Disease
 Neuropathic Pain
 Pain syndromes of
unknown cause
 Cancer Pain
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18. IMPACT OF ACUTE PAIN ON
BODY SYSTEMS
 Respiratory; increase in RR
 Cardiovascular; increase in HR & BP
 Skeletal Muscle; contraction, rigidity
 Gastrointestinal;nausea, vomiting
 Haemostasis;
 Endocrine; increase in cortisol
 Emotions
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19. EMOTIONAL RESPONSE
 Agitation
 Anxiety
 Urge to escape or terminate pain
 Disorientation
 Sleep deprivation
 Helplessness
 Fear
 Depression
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20. METHODS OF PAIN RELIEF
Ideal - remove the cause
 Cognitive behavioural interventions
e.g. relaxation / distraction
 Physical agents e.g. massage, heat / cold
 Electroanalgesia (TENS)
 Systemic / local administration
 Patient controlled analgesia (PCA)
 Intermittent local neuronal block
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21. PHARMACOLOGICAL OPTIONS
Analgesic medications - first line treatment
 Non-Narcotics or NSAIDs oral / local
 Narcotics (IM, IV, SC, PCA
intrathecal, epidural)
 Local anaesthetics
 Combination of local anaesthetic
& narcotics

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