PAIN BASIC MECHANISMS

By: Annie Yu-Soliven,Md, Dpba

Professor Department Of Anesthesiology

Transcribed by: Thea C. Marcelo Section C

!Pain is "hat the patient says hurts#
- M$%affery &'()
!Pain is perfe$t misery, the "orst of evils, and e*$essive,
overturns all patien$e+#
- ,ohn Milton
PAIN
An unpleasant sensory and emotional e*perien$e
asso$iated "ith a$tual or potential tissue damage, or
des$ribed in terms of su$h damage-
.Mers/ey, &'0', 1nternational Asso$iation for the Study of
Pain 2eady 3 4d"ards &''56
DEFINITIONS OF PAIN TEMINO!O"#
Allodynia 7 per$eption of non-no*ious stimulus as
pain
Anal$esia 7 absen$e of pain per$eption
Anesthesia 7 absen$e of all sensations
Dysesthesia - unpleasant sensation "ith or "ithout
stimulus
Hy%oal$esia 7 diminished response to no*ious
stimulus
Hy%eral$esia - in$reased response to no*ious
stimulus
Hy%eresthesia 7 in$reased response to mild stimulus
Hy%oesthesia - redu$ed $utaneous sensation
Ne&ral$ia 7 pain in the distribution of a nerve
Ne&ritis 7 inflammation of a nerve or nerves
Ne&ro%athy - disturban$e of fun$tion or pathologi$
$hange in a nerve
Pain %erce%tion 7 point "hi$h the person be$omes
a"are of pain
Pain threshold 7 least e*perien$e of pain that a
patient $an re$ogni8e
Pain tolerance 7 greatest level of pain a patient $an
tolerate
Paresthesia 7 abnormal sensation "hether
spontaneous9evo/ed
PH#SIO!O"# OF PAIN
Ma'or Mechanis(s:
Nocice%ti)e *sensory+ - inflammatory pain due to
$hemi$al, me$hani$al and thermal stimuli at the
no$i$eptors
Ne&ro%athic - initiated or $aused by a primary lesion
or dysfun$tion in the nervous system .Mers/ey &'':6;
a$utely o$$urs after trauma and surgery+
TIAD OF PAIN PECEPTION
Pain rece%tors 7 no$i$eptors; free nerve endings that
respond to intense, potentially damaging stimuli
Pain sti(&li 7 me$hani$al; thermal; $hemi$al
o Me$hani$al 7 pressure, s<uee8e, pin pri$/
o =hermal 7 heat9free8ing
o %hemi$al 7 !P# fa$tors- brady/inin, serotonin,
histamine, prostaglandin, substan$e P
Pain ,ibers
o Myelinated A-delta
small diameter
rapidly transmit .fast pain6; initial pain
sharp pain sensation
o .n(yelinated C
very small diameter
slo"er .slo" pain6; delayed pain
diffuse burning9a$hing sensation
deep throbbing pain, vis$eral, $hroni$
pain
NOCICEPTION
ability to dete$t no*ious and potentially tissue-
damaging stimuli
prote$tive me$hanism
involves multiple intera$ting peripheral 3 $entral
me$hanisms
multifa$torial influen$ed by psy$hologi$al 3
environmental fa$tors
PHASES OF NOCICEPTION
Transd&ction - translation of no*ious stimuli into
ele$tri$al energy at peripheral no$i$eptors+
Trans(ission - propagation of impulse from
no$i$eptors to the dorsal spinal $ord
Mod&lation - alteration of no$i$eptive information to
attenuate9amplify the signal
Perce%tion - sensory dis$rimination 9lo$ali8ation of
no$i$eptive information in the thalamus and $orte*
resulting into the emotional and physi$al pain
e*perien$e
"ATE CONTO! THEO#
onald Mel/ac0 1 Patric0 2all 7 peripheral
nerve fibers $arrying pain to the spinal $ord
$an have their input modified at the spinal
$ord level before transmission to the brain
%on$ept: a non-painful stimulus $an blo$/ the
transmission of a no*ious stimulus; based on
the premise that the gate lo$ated in the dorsal
horn modulates afferent nerve impulses
Small diameter nerve fibers $arry pain stimuli
through same gate
>arge diameter fibers that $arry non-pain
impulses go through same gate and inhibit
transmission of pain impulses, that is, $lose
the gate
4*ample:
o Bumping the head
o 1nitial trauma a$tivates A-delta and %
fibers
o 2ubbing traumati8ed area stimulates A-
beta fibers "hi$h a$tivate the S? to $lose
the spinal gate
o 1nhibiting transmission of painful stimulus
=he theory led to re$ognition that PA1@ $an be
redu$ed or modulated at : points:
&+ Peripheral site
5+ Spinal $ord
A+ Brainstem
:+ %erebral $orte*
4le$tri$al stimulation of s/in-s sensory nerve fibers
inhibits pain
2elease of endogenous opioids from the %@S
.en/ephalins, endorphins,dynorphins6 have
morphine-li/e a$tions
Pain gate at the substan$ia gelatinosa in the dorsal
horn of the spinal $ord $an be shut by stimulation of
tou$h-fibers .rubbing, stro/ing, massage, vibration,
liniments6
@ormal9e*$essive sensory stimuli may relieve pain
by $ompeting "ith pain stimuli .musi$, heat9$old,
imagery, video games6 $an $lose the pain gate
T#PES OF PAIN
Accordin$ to location3ori$in
o Superfi$ial $utaneous 7body surfa$e or s/in
segments
o Deep somati$- ligaments, tendons, bones, blood
vessels, nerves
o Bis$eral 7 abdominal $avity, thora*, $ranium
Accordin$ to d&ration3intensity
S&r$ical tra&(a - produ$es an initial afferent barrage
of pain signals and subse<uently generate a
se$ondary inflammatory response releasing
inflammatory mediators .sensiti8ing soup6 at the site
of inCury and surrounding uninCured tissue+
=hese signals initiate $hanges in the peripheral and
%@S that amplify and prolong pain+
Peri%heral sensiti/ation results due to redu$tion in
the threshold of no$i$eptor afferent terminals
brought by inflammation at the site of inCury+
Central sensiti/ation3s%inal 4ind-&% - a$tivity-
dependent in$rease in the e*$itability of spinal
neurons due to persistent e*posure to afferent input
from peripheral neurons+
%ombined, the pain signals and inflammation
$ontribute to the hypersensitivity state responsible
for a de$rease in pain threshold, at the site of inCury
as primary hyperalgesia and in the surrounding
uninCured tissue as se$ondary hyperalgesia; and
e*plains "hy pain may be prolonged beyond the
duration normally e*pe$ted "ith an a$ute insult li/e
surgery+
The %rolon$ed central sensiti/ation $an result to
permanent alterations in the %@S in$luding death of
inhibitory neurons, repla$ement "ith ne" afferent
e*$itatory neurons, and the establishment of
aberrant e*$itatory synapti$ $onne$tions+
=his is the reason for the intra$table post-surgi$al
pain unresponsive to many analgesi$s+
PAIN SENSITI5ATION
=he impa$t of a$ute postoperative pain $an therefore
e*tend beyond the time of surgi$al inCury and healing and
imprint indelibly on the nervous system amplifying the
response to subse<uent no*ious stimuli+
PS#CHOSOCIA! FACTOS IN PAIN
STESS
o Per$eption influen$ed by stress
o Stress leads to behaviors .teeth grinding, mus$le
tensing6
o Stress-indu$ed analgesia .in$reased toleran$e via
endogenous opioids6
!EANIN"
o Modeling
o Se$ondary gain9reinfor$ement
o %ulturally learned
CO"NITION
o Anti$ipation is "orse than pain itself
o 4*pe$tations of ability to $ope
ASSESSMENT TOO!S
Self-2eport !=he ?old Standard#
Dnidimensional Pain S$ales
o Eong-Ba/er FA%4S Pain 2ating S$ale
o Berbal 2ating S$ale .B2S6
o @umeri$al 2ating S$ale .@2S6
o Bisual Analogue S$ale .BAS6
Multidimensional Pain S$ales
o Brief Pain 1nventory
o M$?ill Pain Guestionnaire
o Memorial pain Assessment %ard
o @europathi$ Pain S$ale
o >eeds Assessment of @europathi$
Symptoms and Signs .>A@SS6
Physiologi$9Biologi$ Parameters
Behavioral Observations

SE!ECTION OF S.ITAB!E ASSESSMENT TOO!