Pain

• “Pain is an unpleasant sensory and emotional

experience associated with actual or potential
damage or described in terms of such
damage” –
(international association for the study of pain,
1979)
 TYPES OF PAIN
• According to duration,
– Acute pain
– Chronic pain
• Acute pain: pain starts suddenly due to
specific injury and is short-term from second
to 6 months
• Chronic pain: lasts for a longer period of time
more than month.
• According to origin:
– Cutaneous pain
– Deep somatic pain
– Visceral pain
• Cutaneous pain : pain arising from skin and
superficial tissues
• Deep somatic pain : originated from deeper
structures of the body, such as joints, tendons, and
muscles
• Visceral pain: Pain arising from visceral organ
(e.g., _ heart, lungs, liver kidney, etc.).
• According to where it is experienced in the
body,
– Radiating pain
– Referred pain
– Intractable pain
– Neuropathic pain
– Phantom pain
• Radiating Pain refers to pain that travels from
one body part to another.
• Referred pain: pain perceived at a location
other than the site of the painful stimulus/
origin
• Intractable pain: a permanent severe pain
condition mostly unaffected by drug
administration.
• Neuropathic pain : occurs when a health
condition affects the nerves that carry
sensations to your brain.
• Phantom pain is when there is pain in a part
of the body that has been removed.
 Based on Response
• Inflammatory pain: Due to tissue injury —>
release prostaglandin and bradykinin —> local
vasodilatation and capillary permeability
receptor noxious stimuli
• Non-inflammatory: Psychotic pain, e.g., lack
of support, fear
 Types of Pain Receptors (Nociceptors)
• Polymodal pain receptors— respond to a
combination of mechanical, thermal and chemical
noxious stimuli.
• Mechanical pain receptors—respond to strong
mechanical forces, such as cutting, crushing, pricking
or even firm pressure on tissues.
• Thermal pain receptors—respond to excessive
changes in temperature, such as >45°C and< 10°C
• Chemical pain receptors - respond to noxious
chemical stimuli
 Pain syndrome
• Describing excess and prolonged pain and
inflammation that can occur following an
injury or other medical event such as surgery,
trauma, stroke, or heart attack
 Common pain syndrome
• Peripheral pain syndrome
• Post herpetic neuralgia: An episode of herpes has
two phases: a vesicular eruption and neuralgic pain
that often encircles the body. The pain ranges from
mild to severe. Severe pain in the area may persist
for months or years
• Phantom limb pain: can occur in anyone who has a
body part amputated. The pain varies and may be
burning, severe, crushing, or a cramping sensation
• Central pain syndrome
• Trigeminal neuralgia: This is an intense stab
like pain that is distributed by one or more
branches of the trigeminal nerve (fifth cranial).
• The pain is usually experienced on parts of the
face and head. It is so severe that it produces
facial muscle spasms.
• Pain with underlying pathology syndromes
• Headache: This commonly occurring painful
condition can be caused by either intracranial
or extracranial problems, serious or benign
conditions. Three most common headaches are
migraine, tension type, and cluster.
• Cancer pain syndrome
• Myofacial pain syndrome: This pain occurs in
the muscles and facia.
Effect of pain in sympathetic responses
• Pallor
• Increased blood pressure
• Increased pulse
• Increased respiratory rate
• Skeletal muscle tension
• Diaphoresis
Effect of pain in parasympathetic response

• Pallor
• Decreased blood pressure
• Decreased pulse
• Nausea and vomiting
• Loss of consciousness
• Weakness
 Factors influencing pain
• Physiological
– Location
– Onset
– Duration
– Etiology
• Sensory
– Intensity
– Quality
– Pattern
• Affective
– Mood state
– Anxiety
– Depression
– Wellbeing
• Cognitive
– Meaning of pain
– View of self
– Coping skill and strategies
– Previous treatment
– Attitude and beliefs
– Factors influencing pain
• Behavioural
– Communication
– Interpersonal interaction
– Physical activity
– Medication
– Intervention
– Sleep
• Sociocultural-ethnocultural
– Family and social life
– Work and home
– Responsibilities
– Reaction and leisure
– Environmental factors
– Attitude
– Beliefs
– Social influence
 Physiology of pain
• Transduction—initial pain stimulus triggers potential
such conversion of stimulus into electrical energy.
• Transmission—action potential travels from the site
of damage to spinal cord and brain such sending of
impulse across a sensory pain nerve fiber
(nociceptor). A-delta fibers are (myelinated) send
sharp, localized and distinct sensations. C-fibers
(unmyelinated) relay impulses that are poorly
localized, burning and persistent pain. Pain stimuli
travel spinothalamic tracts.
• Perception—person experience of pain.
Somatosensory cortex identifies the location
and intensity of pain. Person unfolds a
complex reaction, physiological and behavioral
response is perceived.
• Modulation—inhabitation of pain impulse by
release of inhibitory neurotransmitters, such
as endogenous opioids work to hinder the
pain transmission.
 Gate Control Theory
• According to Melzack and Wall’s gate control
theory (1965), smalldiameter (A-delta or C)
peripheral nerve fibres carry signals of noxious
(painful) stimuli to the dorsal horn, where
these signals are modified when they are
exposed to the substantia gelatinosa (the
milieu in the CNS), which may be imbalanced
in an excitatory or inhibitory direction.
 Assessment of pain
• Pain Pattern
• Assessing pain onset (when the pain started)
• Establish the duration of the pain (how long it
has lasted).
• This helps to identify whether pain is acute or
chronic and aid in decision regarding pain
management
• Location
• Location of pain assists in identifying possible causes
and treatment.
• The location of the pain may also be referred from
its origin to another site
• Pain may also radiate from its origin to another site.
• Ask the patient to
– Describe the pain
– Point to painful area of the body
– Mark painful areas on a pain map
• Intensity
• Helps to determine the type of treatment and
its
• Can use Pain scale to identify intensity
(numerical scale,Wong-Baker FACES pain tool,
verbal descriptive scale)
• Helps to Safer analgesic administration
• Quality
• The pain quality refers to the nature or
characteristics of the pain.
• For example,
• Patient describe
• Neuropathic pain as : burning, numbing. shooting,
stabbing, electric shock-like, or itchy.
• Nociceptive pain may be described as sharp, aching,
throbbing, dull, and cramping.
• Associated symptoms
– Anxiety
– Fatigue
– Depression may exacerbate
– Poor sleep
– Poor sleep can further increase pain perception.
– Ask about aggravating factors that increase pain
• Management Strategies
• As people experience and live with pain, they may
cope differently and try different strategies to
manage it
• Strategies include prescription and non prescription
drugs and nondrug therapies, such as hot and cold
applications, complementary and alternative
therapies (e.g.. acupuncture), and relaxation
strategies (e.g., imagery).
• Collect data regarding its effect
• Impact of Pain
• Assess the effect of the pain on the patient's

– ability to sleep
– enjoy life
– interact with others
– perform work and household duties
– engage in physical and social activities
– patient's mood
• Patient's Beliefs, Expectations, and Goals
• Patient and family beliefs, attitudes, and
expectations influence responses to pain and
pain treatment.
• Assess for attitudes and beliefs that may
hinder effective treatment (e.g., belief that
opioid use will result in addiction).
• Documentation
• Document the pain assessment
• Many health care facilities have adopted
specific tools to record an initial pain
assessment, treatment, and reassessment.
• Reassessment
• Reassess pain at appropriate intervals
• The frequency and scope of reassessment are
based on factors such as pain severity, physical
and psychosocial condition, type of
intervention and risks of adverse effects, and
institutional policy.
Management of
pain
 Principles of pain management
• Follow the principles of pain assessment
• Use a holistic approach to pain management.
• Every patient deserves adequate pain
management.
• Base the treatment plan on the patient's goals.
• Use both drug and nondrug therapies
• When appropriate, use a multimodal approach to
analgesic therapy
• Address pain using an inter professional approach
• Evaluate the effectiveness of all therapies to
ensure that they are meeting the patient's
goals.
• Prevent and/or manage medication side
effects.
• Incorporate patient and caregiver teaching
throughout assessment and treatment.
 Drug therapy
• Non opioids
• Opioids
• Adjuvant drugs
 Non opioid analgesics
• Non opioid analgesics include acetaminophen,
aspirin and other salicylates, and NSAIDs
• Characteristics:
– Their analgesic properties have an analgesic ceiling; that
is, increasing the dose beyond an upper limit provides no
greater analgesia
– They do not produce tolerance or physical dependence
– many are available without a prescription. To provide
safe care, monitor over-the-counter (OTC) analgesic use
to avoid serious problems related to drug interactions,
side effects, and overdose
 Non opioid analgesics
• Nonsalicylate
– Acetaminophen
• Non steroidal anti inflammatory agent
– Ibuprofen
– Naproxen ketorolac
– Diclofenac K
– Celecoxib
• Salicylates
– Aspirin
– Choline magnesium trisalicylate
 Opioids
• produce their effects by binding to receptors
in the CNS.
• This results in
– inhibition of the transmission of nociceptive input
from the periphery to the spinal cord
– altered limbic system activity
– activation of the descending inhibitory pathways
that modulate transmission in the spinal cord..
• Pure opioid agonists are morphine, oxycodone,
hydrocodone, codeine, methadone,
hydromorphone, oxymorphone, and
levorphanol
• These are effective for moderate to severe pain
• No analgesic ceiling effect
• For moderate ain opioids can be combined with
non opioid analgesics
• Mu Agonists
– Morphine
– Hydromorphone
– Methadone
– Levorphanol fentanyl
– Oxymorphone
– Oxycodon
– Hydrocodon
• Mixed Agonist—Antagonists
– Pentazocine
– Pentazocine plus naloxone
– Butorphanol
• Partial agonists
– Buprenorphine
– Buprenorphine plus naloxone sublingual
Opioids to Avoid.
• Some opioids should be avoided for pain relief
because of limited efficacy and/or toxicities.
• Meperidine or pethidine is associated with
neurotoxicity (E.g., seizures) caused by
accumulation of its metabolite, normeperidine.
• Its use is limited for very short-term (i.e., less
than 48h) treatment of acute pain when other
opioid agonists are contraindicated.
• Side Effects of Opioids
• Constipation
• Nausea and vomiting
• Sedation
• Respiratory depression
• Pruritus.
• Less common side effects include urinary
retention, myoclonus, dizziness, confusion, and
hallucinations.
• Risk of respiratory depression is higher in opioid-
naive, hospitalized patients who are treated for
acute pain.
• Clinical Patients most at risk for respiratory
depression include those who are age 65 or older,
have a history of snoring or witnessed apneic
episodes, report excessive daytime sleepiness,
have underlying cardiac or lung disease, are obese,
have a history of smoking, or are receiving other
CNS depressants
 Adjuvant Analgesic Therapy
• Analgesic adjuvants are drugs that can be used
alone or in conjunction with opioid and non
opioid analgesics
• Corticosteroids
• Corticosteroids include dexamethasone,
prednisone, and methylprednisolone.
• They are used for management of acute and
chronic cancer pain, pain secondary to spinal cord
compression, and inflammatory joint pai syndrome
• Because they act through the same final pathways
NSAIDs, do not give corticosteroids at the same
time as NSAIDs.
• Antidepressants
• Tricyclic antidepressants (TCAs) enhance the
descending inhibitory system by preventing
the cellular reuptake of serotonin and
norepinephrine.
• Higher levels of serotonin and norepinephrine
in the synapse inhibit the transmission of
nociceptive signals in the CNS.
• Ant seizure Drugs
• Anti seizure drugs affect peripheral nerves and
the CNS in several ways, including sodium
channel modulation, central calcium channel
modulation, and changes in excitatory amino
acids and other receptors.
• Agents such as gabapentin, lamotrigine, and
pregabalin are valuable adjuvant agents in pai
management
• GABA-Receptor Agonist
• Baclofen, an agonist at GABA receptors, can
interfere with the transmission of nociceptive
impulses and is used for muscle spasms and
neuropathic pain.
• α2- Adrenergic Agonists
• Clonidine and tizanidine
• work on the central inhibitory α2-adrenergic
receptors.
• These agents may also decrease
norepinephrine release peripherally.
• They are used for chronic headache and
neuropathic pain.
• Local Anesthetics
• For acute pain from surgery or trauma, local
anesthetics such as bupivacaine and ropivacaine can
be administered epidurally by continuous infusion but
also by intermittent or continuous infusion with
regional nerve blocks.
• Topical applications of local anesthetics are used
• Systemic lidocaine administered in the form of an IV
infusion, used for neuropathic and postoperative
visceral pain.
Non pharmacological management
• Heat application:
• Superficial heat can produce heating effects at
a depth limited to between 1 cm and 2 cm..
• It has been found to be helpful in diminishing
pain and decreasing local muscle spasm.
• Cold application:
• Cryotherapy can be achieved through the use of ice, ice
packs or continuously via adjustable cuffs attached to
cold water dispensers.
• Intramuscular temperatures can be reduced local by 3°C
and 7°C, which functions to reduce local metabolism,
inflammation and pain.
• Cryotherapy works by decreasing nerve conduction
velocity, termed cold-induced neuropraxia, along pain
fibers with a reduction of the muscle spindle activity
responsible for mediating local muscle tone.
• Cutaneous stimulation and massage therapy:
• The gate control theory of pain proposes that
stimulation of fibers that transmit non-painful
sensations can block or decrease the
transmission of pain impulses, Message, which
is generalized cutaneous stimulation of the
body promotes comfort through muscle
relaxation.
• Manipulative and mobilization treatment
• Many different types of manual treatment
exist, including
– soft tissue myofascial release
– muscle energy/contract-relax
– High-velocity low. amplitude manipulation
• Acupuncture
• Involves the insertion of extremely fine needle
into the skin at specific “acupoints” This may
relieve pain by releasing endorphins, the
body's natural; pain killing chemicals, and by
affecting the part of the brain that governs
serotonin, a brain chemical involved with
mood.
• Acupressure therapy
• Acupressure points are places on the skin that
are especially sensitive to bioelectrical
impulses in the body and conduct those
impulses readily stimulating these points with
pressure, needles or heat triggers the release
of endorphins, which are the neurochemical
that relieve pain.
• Physical therapy
• Bed rest
• Transcutaneous electrical nerve stimulation (TENS) and
percutaneous electrical nerve stimulation (PENS)
• Spinal cord stimulator (SCS)
• Aroma therapy
• Guided Imagery
• Music therapy
• Placebo therapy
• Distraction therapy
 Surgical Management
• Cordotomy
• A surgical procedure aimed at destroying the
pain-conducting tracts of the spinal cord
• Performed to interrupt the transmission of
pain.