Pain Pain

PAIN
Overview of
pain
Pain is the most common reason people visit
their doctor. Pain may be sharp or dull,
intermittent or constant, or throbbing or steady.
Sometimes pain is very difficult to describe.

Pain may be felt at a single site or over a large
area.
The intensity of pain can vary from mild to
intolerable.
Acute Versus Chronic

Pain
Pain may be acute or chronic. Acute pain begins
suddenly and usually does not last long. Chronic pain
lasts for weeks or months
Usually, pain is considered chronic if it does one of the

following:
Recurs off and on for months or years

Lasts for more than 1 month longer than
expected based on the illness or injury
Is associated with a chronic disorder (such
as cancer, arthritis, diabetes, or
fibromyalgia) or an injury that does not heal
Acute versus Chronic

Pain
When severe, acute
pain
may
cause
anxiety, a rapid heart
rate,
an
increased
breathing
rate,
elevated
blood
pressure,
sweating,
and dilated pupils.
Usually, chronic pain

does not have these
effects, but it may
result
in
other
problems,
such
as
depression, disturbed
sleep,
decreased
energy,
a
poor
appetite, weight loss,
decreased sex drive,
and loss of interest in
activities.
Neurophat
ic pain
Types
of Pain
Psychoge
nic pain
Nocicepti
ve pain
Neurophatic Pain
Neuropathic pain is caused by damage to or
dysfunction of the nerves, spinal cord, or brain.
Neuropathic pain may be felt as burning or
tingling or as hypersensitivity to touch or cold.
Causes include compression of a nerve (for
example, by a tumor, by a ruptured
intervertebral disk, or as occurs in carpal
tunnel
syndrome),
nerve
damage
(for
example, as occurs in a metabolic disorder
such as diabetes mellitus), and abnormal or
disrupted processing of pain signals by the
Nociceptive Pain
Nociceptive pain is caused by an injury to body
tissues.
The injury may be a cut, bruise, bone fracture,
crush injury, burn, or anything that damages
tissues. This type of pain is typically aching,
sharp, or throbbing. Most pain is nociceptive
pain. Pain receptors for tissue injury (nociceptors)
are located mostly in the skin or in internal
organs.
Nociceptive Pain
The pain almost universally experienced after surgery is
nociceptive pain. The pain may be constant or
intermittent, often worsening when a person moves,
coughs, laughs, or breathes deeply or when the
dressings over the surgical wound are changed.
Most of the pain due to cancer is nociceptive. When a
tumor invades bones and organs, it may cause mild
discomfort or severe, unrelenting pain. Some cancer
treatments, such as surgery and radiation therapy,
can also cause nociceptive pain. Pain relievers
(analgesics), including opioids, are usually effective.
Psychogenic Pain
Psychogenic pain is pain that is mostly related
to psychologic factors.
When people have persistent pain with
evidence of psychologic disturbances and
without evidence of a disorder that could
account for the pain or its severity, the pain
may be described as psychogenic.
However, psychophysiologic pain is a more
accurate term because the pain results from
interaction of physical and psychologic
factors. Psychogenic pain is far less common
than nociceptive or neuropathic pain.
Neuropathic pain
IASP Definitions:
Peripheral Neuropathic and Central
Neuropathic Pain
Neuropathic pain
Pain initiated or caused by a primary
lesion or dysfunction in the nervous system
Peripheral neuropathic pain

Central neuropathic pain
lesion or dysfunction in the
lesion or dysfunction in the
peripheral nervous system
central nervous system
Merskey H et al. (Eds) In: Classification of Chronic Pain:
Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 1994:209-212.
12
The pain may be spontaneous, stimulusevoked, or a combination of both.

Its characteristics are often different from
those of other types of pain, such as the
nociceptive pain experienced after an
injury.
In neuropathic pain the central neurons are

sensitised, so that they fire spontaneously,
or abnormally.
If this sensitisation persists the pain
becomes chronic and is often difficult to
treat.
The Inter-Relationship Between Pain, Sleep, and

Anxiety / Depression
Pain
Functional
impairment
Anxiety &
Depression
Nicholson and Verma. Pain Med. 2004;5 (suppl. 1):S9-S27
Sleep
disturbances
15
There are considerable overlaps in the

pain descriptors between nociceptive and
neuropathic pain.
Some patients may have nociceptive and
neuropathic pain.
Clues to a neuropathic origin :

continuous nature (as opposed
movementinduced pain)
burning
shooting qualities.
to
There are also associated symptoms

(derived from irritation to non-noxious
afferent neurons) :
The most confusing element is the

extension of areas of stimulus-evoked pain
beyond the anatomical boundary of the area
receiving the stimulus. This occurs because
central sensitisation does not respect these
boundaries.
CLINICAL PAIN SYNDROME
Neuropathic Pain
Pain initiated or caused by a
primary lesion or dysfunction
in the nervous system
(either peripheral or
central nervous system)1
Mixed Pain
Pain with
neuropathic and
nociceptive
components
Examples
Examples
Peripheral
Postherpetic neuralgia
Trigeminal neuralgia
Diabetic peripheral neuropathy
Postsurgical neuropathy
Posttraumatic neuropathy
Central
Poststroke pain
Common descriptors2
Burning
Tingling
Hypersensitivity to touch or cold
Low back pain with

radiculopathy
Cervical
radiculopathy
Cancer pain
Carpal tunnel
syndrome
Nociceptive Pain
Pain caused by injury to
body tissues
(musculoskeletal,
cutaneous or visceral)2
Examples
Pain due to inflammation

Limb pain after a fracture
Joint pain in osteoarthritis
Postoperative visceral pain
Common descriptors2
Aching
Sharp
Throbbing
1. International Association for the Study of Pain. IASP Pain Terminology.

2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57
The investigations of neuropathic pain vary

according to the suspected cause of each
syndrome.
A cause should be sought in each case, and
treatment of that cause may contribute to
alleviation of symptoms and retard progression
of the condition.
For example, irritation caused by a
prosthesis may be contributing to a patient's
pain following amputation.
Successful Management of Neuropathic Pain

has a Positive Impact for The Patient
Diagnosis
Treatment of underlying conditions and symptoms
Improved
Quality of
Sleep
Improved
Physical
Functioning
Reduced pain
Improved
Psychological
State
Improved
Overall Quality
of Life22
Neuropathic Pain
Treatment
Non-drug treatments can help to control
the patient's pain. A multidisciplinary approach
may be required.
Current drug treatments are focused on
dampening the neuronal input to consciousness
by suppressing axonal function (for example
sodium channel blockade) or interfering with
neurotransmission (blockade of excitatory and
inhibitory neurotransmitters and modulators).
The drugs used to treat neuropathic pain

can be conveniently divided into two types:
medications used to treat other conditions
but found to be useful in reducing pain from
nervous system damage,
analgesics.
Antidepressants
Amitriptyline :
The starting dose is low ( 1012.5 mg at
bedtime) and is increased slowly at intervals
of a few days to a week.
The maximum effective dose is usually 75
mg at night
Anticonvulsants
There is a long tradition of
antiepileptic drugs in neuropathic pain.
Phenytoin
Carbamazepine
Valproate
Lamotrigine
Topiramate
using
Anticonvulsants
Newer drugs :
Gabapentin and Pregabalin
Adverse effect :
Drowsiness
Dizziness
Ataxia
Dry mouth
Edema
Weight gain
Analgesics
Simple analgesics are often ineffective in
neuropathic pain, but frequently there is a
nociceptor component to the patient's pain.
Opioids
Oxycodone
Morphine
Non Opioid:
Tramadol
NSAID
There is no indication for the use of nonsteroidal anti-inflammatory drugs in patients
with neuropathic pain unless there is clear
clinical evidence that a nociceptor pain source
is contributing to the patient's pain.

Pain Pain

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PAIN

Sometimes pain is very difficult to describe.

Acute Versus Chronic

Usually, pain is considered chronic if it does one of the

Recurs off and on for months or years

Acute versus Chronic

Usually, chronic pain

Peripheral neuropathic pain

The pain may be spontaneous, stimulusevoked, or a combination of both.

In neuropathic pain the central neurons are

The Inter-Relationship Between Pain, Sleep, and

There are considerable overlaps in the

Clues to a neuropathic origin :

There are also associated symptoms

The most confusing element is the

CLINICAL PAIN SYNDROME

Low back pain with

Pain due to inflammation

1. International Association for the Study of Pain. IASP Pain Terminology.

The investigations of neuropathic pain vary

Successful Management of Neuropathic Pain

Treatment of underlying conditions and symptoms

The drugs used to treat neuropathic pain

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