This document provides an overview of the pathophysiology of pain. It discusses the definition of pain, pain receptors and pathways in the peripheral and central nervous systems. It describes the gate control theory of pain modulation in the spinal cord and descending pain inhibitory pathways in the brain. The document also covers physiological and psychological effects of pain, classifications of pain including nociceptive and neuropathic pain, and assessments used to evaluate pain.
Pain is the common symptom in many chronic conditions such as cancers, neuropathies, and chronic disease. It is also experienced in trauma varying from mild to severe based on the location and degree of trauma. This presentation is a brief outline on types of pain, classification of pain, pain pathways and management of pain
Pain pathway gate control theory
Pain management
An unpleasant emotional experience usually initiated by noxious stimulus and transmitted over a specialized neural network to CNS where it is interpreted as such.
1. Exteroceptors: arising from receptors from skin & mucosa. sensed at conscious level
E.g. Merkel corpuscles : Tactile receptors.
Free Nerve ending :Perceive superficial pain.
2. Proprioceptors : From musculoskeletal structures.
The presence , positions & movement of body. below conscious levels.
E.g. 1) Muscle spindles : Skeletal muscle fibers. Mechanoreceptors.
2) Free nerve ending : Perceive deep somatic pain & other sensations.
3. Interoceptors : From viscera of body below conscious level.
E.g. Pacinian corpuscles : perception of touch-pressure.
Free nerve ending : Perceive visceral pain & other sensations.
Pain is defined as an “unpleasant emotional experience usually initiated by a noxious stimulus and transmitted over a specialized neural network to the central nervous system where it is interpreted as such”.
Free nerve endings – responsible for carrying noxious stimulus from both superficial as well as deep somatic and visceral pain sensations therefore reffered as nociceptors
According to type of impulses they carry second order neuron can be classified as –
LOW THRESHOLD MECHANOSENSORY( ligth touch, pressure and Proprioception)
NOCIOCEPTIVE SPECIFIC ( Noxious stimulation)
WIDE DYNAMIC RANGE ( wide range of stimulus intensities from nonnoxious to noxious.
SILENT NOCICEPTORS (It is an afferent neuron that appear to remain or silent to any mechanical stimulation .These neuron become active with tissue injury and add to the nociceptive input entering the CNS.
Pain is the common symptom in many chronic conditions such as cancers, neuropathies, and chronic disease. It is also experienced in trauma varying from mild to severe based on the location and degree of trauma. This presentation is a brief outline on types of pain, classification of pain, pain pathways and management of pain
Pain pathway gate control theory
Pain management
An unpleasant emotional experience usually initiated by noxious stimulus and transmitted over a specialized neural network to CNS where it is interpreted as such.
1. Exteroceptors: arising from receptors from skin & mucosa. sensed at conscious level
E.g. Merkel corpuscles : Tactile receptors.
Free Nerve ending :Perceive superficial pain.
2. Proprioceptors : From musculoskeletal structures.
The presence , positions & movement of body. below conscious levels.
E.g. 1) Muscle spindles : Skeletal muscle fibers. Mechanoreceptors.
2) Free nerve ending : Perceive deep somatic pain & other sensations.
3. Interoceptors : From viscera of body below conscious level.
E.g. Pacinian corpuscles : perception of touch-pressure.
Free nerve ending : Perceive visceral pain & other sensations.
Pain is defined as an “unpleasant emotional experience usually initiated by a noxious stimulus and transmitted over a specialized neural network to the central nervous system where it is interpreted as such”.
Free nerve endings – responsible for carrying noxious stimulus from both superficial as well as deep somatic and visceral pain sensations therefore reffered as nociceptors
According to type of impulses they carry second order neuron can be classified as –
LOW THRESHOLD MECHANOSENSORY( ligth touch, pressure and Proprioception)
NOCIOCEPTIVE SPECIFIC ( Noxious stimulation)
WIDE DYNAMIC RANGE ( wide range of stimulus intensities from nonnoxious to noxious.
SILENT NOCICEPTORS (It is an afferent neuron that appear to remain or silent to any mechanical stimulation .These neuron become active with tissue injury and add to the nociceptive input entering the CNS.
this presentation discusses pain pathways, definition and glossary of pain symptoms, classification of pain, pathogenesis, causes, diagnosis , types and treatment of neuropathic pain
illustrated with figures
Physiology of Pain, Characteristic of pain, Basic consideration of nervous system, Pain receptor, Mechanism of pain causation, Theories of pain, Pathways of pain, Pain Receptors
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
this presentation discusses pain pathways, definition and glossary of pain symptoms, classification of pain, pathogenesis, causes, diagnosis , types and treatment of neuropathic pain
illustrated with figures
Physiology of Pain, Characteristic of pain, Basic consideration of nervous system, Pain receptor, Mechanism of pain causation, Theories of pain, Pathways of pain, Pain Receptors
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
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
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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.
2. INTRODUCTION
PATHOPHYSIOLOGY OF PAIN
PERCEPTION
PHYSIOLOGICAL EFFECTS OF PAIN
CLASSIFICATION OF PAIN
ASSESSMENT OF PAIN
3. INTRODUCTION
Latin word ‘Poena’ - Penalty or punishment.
Definition : IASP - “An unpleasant and emotional experience
associated with actual or potential tissue damage or described in
terms of such damage”.
Sherrington – “The psychical (pertaining to mind) adjunct (joint to)
of an imperative (urgent) protective reflex”.
Subjective experience.
Awareness of harmful agent.
Reflex withdrawal response.
Pain sensation has a protective function.
4. Why pain should be treated ?
To releive suffering
Reflex muscle spasm
• Respiratory embarrassment
• Itself can be major cause of severe pain
Untreated pain will keep getting worse
Anatomical and genetic changes
5. PATHOPHYSIOLOGY OF PAIN PERCEPTION
Two major classes
Normal or nociceptive
Abnormal or pathophysiologic
Nociception : “Complex series of physiologic events that
occurs between the initiation of tissue damage and perception
of pain”
Four processes
• Transduction :
• Transmission :
• Modulation :
• Perception :
6. PAIN RECEPTORS
The receptors which mediate pain is called nociceptors
Nociceptors - Two types of nerve fibers.
a) Aδ myelinated nerve fibers
b) C unmyelinated nerve fibers
Points Aδ Fibre nociceptor C fibre nociceptor
1) Number Less More
2) Myelination Myelinated Unmyelinated
3) Diameter 2 – 5 micron 0.4 – 1.2 micron
4) Conduction
velocity
12 – 30 m/sec 0.5 – 2 m/sec
5) Neurotransmitter Glutamic acid Substance P
7) Impulse
conduction
Noxious stimulus
Fast component
Thermal & mechanical
stimulus, Slow component
9) Sensitivity to
electrical stimulus
More Less
7. Pain receptors are activated by three noxious stimuli
• Mechanical, • Thermal, • Chemical
Mechanical :
• Excessive pressure or tension on nerve
• E.g. blow on the head, pulling of hair, pain of child birth.
Thermal :
• Raising skin temperature above 450
C or exposure to cold
(00
) is painful.
Chemical :
• Endogenous – Histamine, Kinins, prostaglandin released
from damaged tissue.
• Exogenous – H2SO4, HCl, H2O2
8. Chemical mediators of pain acting on nociceptors
Potassium, ATP, ADP
Bradykinines
Leukotrines
Serotonin
Histamines
Prostaglandins
Excitatory Inhibitory
Substance P Somatostatin, acetyl choline
Calcitonine gene related peptides Enkephalins, β-endorphins
Glutamate Norepinephrine, adrenaline
Aspartate GABA
ATP Glycine
Chemical mediators of pain acting on CNS
9. NEURAL PATHWAYS FOR PAIN
Three neuron pathways
1. First order neurons :
Dorsal root ganglion
2. Second order neurons :
Spinal cord and arranged as 10 laminae of rexed.
Cross to the opposite side and form the spino thalamic tract.
Two types of nociceptive spinal projection of second order
neurons are
• Wide dynamic range – Aδ, C, Aβ fibers
Both noxious
Non noxious stimulus.
• Neuron specific - Aδ, C fibers
Noxious stimulus.
3. Third order neurons :
Thalamus somato sensory area i.e I & II.
10. PATHWAYS FOR THE FAST PAIN
In peripheral nerves :
Aδ
velocities between 6 and 30
m/sec
DRG spinal cord
In the spinal cord :
Tract of Lissauer
Lamina I.
Opposite side
Neospinothalamic tract.
In the brain stem : Reticular
formation thalamus.
In the thalamus : Ventral
posterolateral nucleus
Primary sensory cortex.
11. PATHWAYS FOR SLOW PAIN
In peripheral nerves :
Unmyelinated C fibres
Velocities ranging from 0.5 to 2
m/sec
DRG Spinal cord
In the spinal cord :
Laminae II and III
Substantia gelatinosa
Crosses the midline
Paleospinothalamic tract
In the brain stem :
Reticular formation, and also in
superior colliculus, and
periaqueductal grey region.
Intralaminar nuclei and posterior
nuclei of thalamus
Hypothalamus
Brain
12. PAIN SUPPRESSION SYSTEMS IN CNS
Two major components:
Spinal pain suppression system, and
Supraspinal pain suppression system.
Spinal pain suppression system
Gate control hypothesis
Metzak and Wall in 1965.
Dorsal grey horn
• Segmental suppression
• Supraspinal suppression
13. A. Segmental Suppression :
Myelinated (Aβ) touch fibres
Collateral
Presynaptic inhibition
Blocking calcium channels
Clinical application
Local application of warmth and cold
Rubbing or massage or pressure in the vicinity of painful area
Local application of counter irritants
Acupuncture
Transcutaneous electric nerve stimulation
14. Supraspinal pain suppression system :
Descending serotonergic and opiod inhibitory
system
Descending purinergic inhibitory system and
Descending adrenergic inhibitory system
15. Descending serotonergic and
opioid inhibitory system :
Components
Raphe Magnus Nucleus (RMN) :
Lower pons and upper
medulla.
Periaqueductal Grey (PAG)
reticular formation,
hypothalamus, and frontal
cortex.
Serotonin and substance P.
Project down the dorsolateral
column
postsynaptic inhibition.
16. Periaqueductal grey (PAG) area
in the midbrain
Raphe Magnus Nucleus
(RMN)
Opioid receptors
Four types of opioid
receptors µ,κ,δ and σ.
Stimulation
Pain suppression circuitry
Reduced pain perception.
17. Primary afferent pain
carrying fibres
Substantia gelatinosa of
dorsal horn.
Substance P as
neurotransmitter.
endorphin and enkephalin
Decrease the release of
substance P
Presynaptic inhibition.
Stimulate both i.e. PAG
as well as RMN.
OPIOID RECEPTORS
Hypothalamus and frontal cortex
Stimulate – PAG as well as RMN
18. Descending purinergic inhibitory system :
Adenosine.
Pre and postsynaptic
Excitatory amino acid release.
Descending noradrenergic inhibitory system :
Locus coeruleus and medullary reticular formation
Dorsolateral fasciculus.
Stress
Pain perception in children –
26th
week of gestation
It has larger receptor field
High concentration of receptors sites for substance P
Less developed descending inhibitory pathway.
19. PHYSIOLOGICAL AND PSYCHOLOGICAL EFFECTS OF PAIN
Respiratory system
Reduction in lung volume (TV, VC, FRC)
Regional lung collapse (atelectasis)
Decrease alveolar ventilation leads to hypoxemia and hyper
capnia.
Cough is decreased
Secretions are retained
Chances of chest infections are more
Increase O2 consumption
Increase metabolic substrate formation.
20. Cardiovascular system :
Increase in HR, BP, CO, Systemic and coronary vascular
resistance.
Increase in cardiac work and myocardial oxygen consumption
Decrease myocardial oxygen delivery
Risk of ischaemia, infarction and deep venous thrombosis
increases.
Gastrointestinal and genitourinary system :
Increases intestinal secretion
Increases smooth muscle sphincter tone
Decreases gastrointestinal motility (stasis & ileus)
Increase bladder sphincter tone – retention of urine.
21. Neuroendocrine and metabolic effects :
↑ Catabolic hormones e.g. ACTH, ADH, GH, Cortisol,
Catecholamines, renin, angiotensin II, aldosteron, glucagon.
↓ Anabolic hormones e.g. insulin and testosterone.
Ebb phase Flow phase Catabolism.
Net resulting negative nitrogen balance.
Carbohydrates metabolism :
Hyperglycemia, glucose intolerance, insulin resistance.
Protein metabolism :
Muscle protein catabolism
Fat metabolism :
Increase lypolysis and oxidation
22. Immunological :
Immune dysfunction.
Infection
Tumour recurrence
Coagulations :
Deep venous thrombosis and pulmonary embolism
PSYCHOLOGICAL RESPONSE :
Behaviour :
Self absorption and concern, withdrawal from inter personal
contact, increase sensitivity to external stimuli, grimacing,
postering, reduced activity and seeking help and attention.
Affect :
Fear and anxiety
Feeling of helplessness, loss of control, depression and
insomnia.
23. CLASSIFICATION OF PAIN
A) Physiological pain
Brief noxious stimulus
Activates receptors
Impulse modification
Normal neural processing
Allerting mechanism
Good correlation
B) Clinical pain
Prolonged noxious stimulus
Activates receptors
Peripheral and central sensitization
Two types – Nociceptive and Neuropathic
24. I) Nociceptive pain –
Stimulation of nociceptor.
Primary and secondary hyperalgesia and allodynia.
Hyperalgesia – An increased response to a stimulus which is
normally painful.
• Primary hyperalgesia – excessive sensitivity of pain
receptors itself e.g. sunburned skin.
• Secondary hyperalgesia – means facilitation of sensory
transmission.
Allodynia – Pain due to a stimulus which does not normally
provoke pain.
Protective function
Poor correlation
25. II) Neuropathic pain –
“Pain associated with injury, disease or surgical section of the
peripheral and central nervous system”
Three types :
Neural injury pain – e.g.
Nerve compression pain – e.g.
Complex regional pain syndrome
CRPS – I : Reflex symphathetic dystrophy – “Continuous
pain in a portion of extremity after trauma which may
include fracture but not involved major nerve, associated
with symphathetic over activity”
CRPS – II : Causalgia – “Burning pain, allodynia, usually in
the hand and foot after partial injury of a nerve or one of its
major branches”
No correlation between injury and pain perception
26. Acute pain Chronic pain
1) Pain of recent onset and
limited duration with identifiable
relation with injury of disease
1) Pain which persist a month beyond the
usual course of an acute disease or a
reasonable time for an injury to heal
3) Usually caused by noxious
stimulation
3) Cause is often unclear. Psychological
and environmental factors play major role
5) Disappear with t/t of cause 5) Often unresponsive to many form of
treatment
6) Opioids typically effective and
indicated
6) Poorly effective
7) Most commonly – acute
medical illness, MI, pancrititis,
renal colic
7) Commonly in chronic backache and
cancer pain.
CLASSIFICATION ACCORDING TO DURATION OF PAIN
27. Fast Pain
Aδ fibers
Sharp, well localized and pricking sensation
Within 0.1 msec
Accompanient of fast pain
• Reflex withdrawal response
• Sympathetic response i.e. increase BP, HR,
respiration.
Not radiate.
28. Slow pain :
C fibres
Poorly localised, dull, throbbing, burning sensation
After 1 sec
Accompanient
• Unpleasantness, irritation, frustration and depression.
• Nausea, vomiting, sweating, bradycardia, hypotension.
• Generalized reduction of skeletal muscle tone
29. CLINICAL TYPES OF PAIN
Somatic pain and visceral pain
Referred pain and radiating pain
Somatic pain :
Arises from the tissue of the body other than the viscera.
a) Superficial somatic pain
• Skin and subcutaneous tissue.
• Similar to the fast pain.
a) Deep somatic pain
• Muscle, joints, bones and fascia.
• Similar to slow pain.
Clinical condition
• Injuries
• Tissue ischaemia
• Inflammation of tissues
• Muscle spasm
30. Visceral pain :
Poorly localized
Unpleasant
Nausea, vomiting, decrease BP & HR profuse sweating.
GUARDING
Radiates or referred to other site
C fibres.
Common causes :
Inflammation of viscera
Over distension of hollow viscus.
Spasm of hollow viscus.
Chemical stimuli
Ischaemia
31. Referred pain :
Pain which originates due to irritation of visceral organ and
is felt not in the organ but in some another somatic
structure. (skin) supplied by same neural segment.
DERMATOMAL RULE.
e.g.
Myocardial infarction
Stone in ureter
Inflammation of diaphragm
32. THEORIES OF REFERRED PAIN
Convergence theory
Facilitation theory
Convergence theory :
First order neuron
Somatic area and a visceral organ
Second order neuron
Source of pain
Somatic pain is more common
Facilitation theory :
The visceral irritation
Facilitates pain fiber
Even minor somatic irritation
Pain
Radiating pain :
• Pain seems to spread from local area to the distant site is
called radiating pain.
• E.g. in appendicitis, pain starts in right iliac fossa and
radiates towards centre of abdomen.
33. ASSESSMENT OF PAIN
Evaluation of pain in children and adults
Verbal rating scale
0 – No pain
1 – Mild pain
2 – Moderate pain
3 – Severe pain
Verbal Numerical rating scale
0 – 10
0 – No pain
10 – Worst pain
Visual analog scale
10 cm horizontal line
No pain at one end
Worst possible pain on other end
Describe intensity not the quality
34. McGill’s pain questionnaire
20 aspects
1 – 10 – Sensory aspects
11 – 15 – Affective aspects
16 – evaluative aspects or
17 – 20 – Other miscellaneous aspect
Evaluation of pain in preschool children
Physiological and behavioural
Self report
Methods
Happy sad face scale, the oucher scale, colour analog
scale, poker chip tool, ladder scale, linear analog scale.
35. Evaluation of pain in neonate and children
Physiological and behavioural response
Physiological changes - ↑ HR, RR, BP, palmer, sweating
Behavioural changes
Eyebrow bulge, eye squeeze, nasolabial furrow, open
lips, vertical or horizontal stretching of mouth, lip purse.
Diffuse body movement
Type of cry