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Introduction
Pain Types
Pain Mechanisms
Pain Transmission
Gate Theory
Dorsal Horn
Sensitisation
Emotions
Beliefs
Medication Types
Tips for Relief
Analgesic lo! "hart
"oping #ith Pain
Sleep
Genetics and Pain
A$out Pain Pain Mechanisms

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Pain Transmission
Ho do e feel !ain " & let's ta(e an e)ample li(e cutting
your finger !ith a sharp (nife & !hat are the pain path!ays
that allo! the pain messages to tra*el from your finger to your
$rain+ and !hat are the mechanisms of pain processing along
the !ay,
Pain receptors in the s(in are stimulated $y the in-ury+ due to
the release of *arious chemicals $y the damaged cells
including histamine+ su$stance P+ serotonin ./HT0+ $rady(inin
and prostaglandins1
Pain signals are generated $y these receptors !hich then are
transmitted *ia the sensory ner*es to the spinal cord 1 The
cell $odies of these sensory ner*es are grouped together in a
small s!elling called the dorsal root ganglion1
In the spinal cord the pain impulses are processed $y a
2computer2 called the dorsal horn1
Messages come out of the spinal cord and tra*el *ia motor
ner*es to the arm muscles+ causing the arm to !ithdra!
3uic(ly1 This is an automatic refle) that does not in*ol*e the
$rain or conscious thought1
Depending on the settings in the dorsal horn computer .see
Gate "ontrol Theory and Dorsal Horn Sensitisation $elo!0+
pain signals are also sent up!ards in the spinal cord *ia the
Spinothalamic tract .amongst others0 to an area in the $rain
stem .$ase of the $rain0 called the thalamus1
urther processing occurs in the thalamus !ith signals $eing
sent to areas controlling $lood pressure+ heart rate+ $reathing+
and emotions1 An acute pain e*ent often causes a rise in heart
rate+ $lood pressure+ and $reathing rate+ as !ell as a change in
emotions and $eha*iour e1g1 shouting 2ouch2+ contorted facial
e)pressions+ and $eha*ioural displays such as !a*ing the arm
in the air1

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Last updated: 23/04/10

Pain signals are also sent up!ards from the thalamus to the
primary sensory corte) .part of the outer surface of the $rain
dealing !ith sensory input01 It is thought that some crude
perception of pain and sensation occurs at the thalamic le*el+
!ith much finer discrimination occurring in the primary
sensory corte)1
There is initially a sharp fast onset short li*ed pain
transmitted from the in-ured area to the spinal cord dorsal horn
$y large diameter high *elocity sensory ner*es .A&delta fi$re
ner*es01 This is follo!ed $y a dull slo!er onset longer lasting
pain transmitted from the in-ured area to the spinal cord dorsal
horn $y smaller diameter lo! *elocity sensory ner*es ." fi$re
ner*es01
Pain Mechanisms is a short PoerPoint presentation .1pps0
a$out acute and chronic pain mechanisms1 Aou can either
2O!en2 it or 2#a$e2 it to your hard dri*e1 The presentation
should play automatically+ $ut if it doesn't start you may need
to do!nload the Po!erPoint 7ie!er1
The follo!ing pu$lication .PD0 is a*aila$le from the Britis%
Pain #ociety .9:0B&
o 9nderstanding and Managing PainB Information for
Patients
Gate Theory
Ru$$ing an in-ured area often helps to relie*e the pain1
Ru$$ing stimulates *i$ration receptors+ sending signals to the
dorsal horn *ia large diameter A&$eta fi$res .C in the
diagram 01
These *i$ration signals enter the dorsal horn computer at the
same time as the small diameter " fi$re pain signals from the
in-ured area .S in the diagram 01
If the *i$ration signals are of the correct magnitude+ they
pre*ent further on!ard transmission .Pro-ection neuron .P0
and Spinothalamic tract in the diagram 0 i1e1 closing the gate
on pain1
Pain relie*ing treatment modalities li(e TE>S+ Pain Gone
Pen+ acupuncture and heat produce pain control $y a similar
mechanism1 TE>S stimulates the A&$eta fi$res+ and
acupuncture stimulates the A&delta fi$res1
Dorsal Horn Sensitisation
#ithin hours of an in-ury+ changes ta(e place in the dorsal horn of the
spinal cord !hich alter the !ay that sensory impulses are processed1
#hen these changes ha*e occurred the dorsal horn is said to ha*e
$ecome sensitised1 This means that sensory and painful signals are

more li(ely to $e transmitted up the spinal cord to the $rain+ rather
than $eing $loc(ed at the dorsal horn le*el1 Sensitisation is said to $e
dependant on >&methyl&D&aspartate .>MDA0 receptor acti*ation1
>MDA receptor antagonists .$loc(ers0 li(e (etamine can help pre*ent
sensitisation occurring1
"linically dorsal horn sensitisation can $e measured as
changes in pain and sensory thresholds e1g1 for temperature
sensation the normal comforta$le range of < & D5 deg " is
reduced to ?5 & <5 deg " in the area of s(in supplied $y the
sensitised dorsal horn1
Sensory thresholds can $e altered for all the sensory
modalities including *i$ration+ heat+ cold+ light touch1
Thresholds for pain can also $e altered in t!o !aysB&
o A stimulus !hich !as not painful $efore is no!
percei*ed as painful1
o #hat !ould ha*e produced a little pain+ no! causes a
great deal of pain1
>ormally after an in-ury dorsal horn sensitisation reduces in
line !ith tissue healing1 Ho!e*er+ in some people the
sensitisation seems to go on for much longer+ and may e)plain
!hy some go on to de*elop chronic pain1 In some of these
people there is a continuing focus of pain in the periphery
!hich continues to (eep the dorsal horn sensitised+ and in
others the e)act cause is un(no!n1
There is also a connection $et!een emotions and dorsal horn
sensitisation1 In se*ere an)iety and depression states+ lac( of
descending inhi$ition is enough to maintain the dorsal horn in
its sensitised state1
"hronic pain management techni3ues can therefore $e di*ided
into three $road areasB&
o Reducing the magnitude of pain signals coming from
the periphery $y either $loc(ing the ner*es that carry
the pain or $y doing something to the tissue that is
generating the painful signal e1g1 steroid in-ections
reducing peripheral tissue inflammation1
o Reducing the degree of dorsal horn sensitisation $y
using analgesic drugs+ TE>S+ Acupuncture+ and spinal
manipulation1
o Impro*ing descending inhi$ition $y e)amining patient
$eliefs+ impro*ing education+ treating an)iety and
depression+ and $y pro*iding reassurance that there is
nothing terri$le going on1
Emotions
Emotions can also affect the gate in the dorsal horn computer1
The normal state of affairs is that there are continuous
descending signals from the $rain to all the dorsal horn
computers in the $ody1
These descending signals .descending inhi$ition0 (eep nearly
all of the gates in a closed state+ pre*enting unnecessary
sensory information reaching the $rain i1e1 pre*enting sensory
o*erload1
Emotions li(e anger and e)citement tend to increase the
degree of descending inhi$ition+ ma(ing it harder for pain
signals to gain access to the spinal cord and $rain e1g1 a
foot$aller in-ures himself on the pitch $ut doesn't notice the
in-ury until he stops playing1 Distraction therapy also !or(s
$y a similar mechanism1
Emotions li(e an)iety and depression tend to reduce
descending inhi$ition+ ma(ing it easier for pain signals to gain
access to the $rain and spinal cord e1g1 patients !ith an)iety
and depression ha*e increased pain perceptions compared to
normal people1
There aren't too many adults in this !orld that do not carry
some form of emotional $aggage around !ith them1 "arrying
this $aggage around on a daily $asis can seriously impair your
a$ility to deal !ith many things in life+ including
relationships+ !or(+ and coping !ith pain1
E)amples of $aggage areB&
o Guilt a$out things that they should or should not ha*e
done or said in relation to partners+ spouses+ children
or parents1
o Emotional turmoil caused $y $erea*ement+
separation+ di*orce+ a $ad relationship+ or e*en
marrying the !rong person1
o #ocioeconomic Distress & caused $y the effects of
sudden loss of income due to redundancy+ $attling !ith
go*ernment departments a$out income support and
disa$ility li*ing allo!ance etc1
o C%ild%ood &'use & emotional+ physical and se)ual
a$use in childhood E early teens can ha*e catastrophic
effects on the a$ility to cope !ith life in general1 Some
adults ha*e already come to terms !ith the past and no
longer re3uire any attention+ !hereas others are
desperate for help and guidance+ $ut are afraid to tal(
$ecause of feelings of guilt or shame1 Some a$used
children recei*e support after!ards from trusted family
mem$ers+ helping them to !eather the storm1 The most
pernicious situation seems to $e !here the child !as
$lamed $y an adult .usually the mother0 for leading the
perpetrator astray1 As adults this latter group seem to
ha*e the greatest disruption to their coping a$ilities+
and re3uire the most care and support1
Assessing and understanding people's emotional $aggage is
therefore *ery important !hen trying to understand their pain1
There is a *ery close lin( $et!een our emotions+ $eliefs and
our $eha*iour1 Please read the ne)t section to learn more1
Beliefs
Most of our $eha*iour in life re*ol*es around our o!n
indi*idual set of $eliefs & for e)ampleB&
o Aou $elie*e that $rushing your teeth is good for your
gums and teeth+ and therefore you do it t!ice a day
o I $elie*e that sitting in front of this computer is going
to ma(e me rich one day+ and therefore I sit here for
hours on end typing a!ay FF
#e de*elop our $eliefs from our o!n life e)periences & for
e)ampleB&
o #hat !e ha*e !itnessed !ith our o!n eyes .personal
interactions and interpretations0
o #hat !e ha*e $een told $y others .parents+ media+
education+ health professionals0
Generally spea(ing if you $elie*e something is good for you+
you (eep doing it+ and if you $elie*e something is $ad for you+
you stop doing it .a*oid it01
>o! let's ta(e an e)ample of t!o patients !ith acute lo! $ac(
pain seeing different doctors a$out their pro$lemB&
o Patient & consults Doctor A !ho says+ the pain is due
to an acute soft tissue sprain+ the $ody has tremendous
po!ers of healing+ it's a self limiting pro$lem+ no real
harm has $een done+ (eep as acti*e as you can !ithin
the pain+ and then you !ill ha*e a @56 chance of it all
settling do!n on its o!n !ithout treatment in 8 !ee(s1
o Patient B consults Doctor B !ho says+ you'*e
damaged your $ac( !hilst lifting at !or(+ the G&ray
you had yesterday sho!s early osteoarthritis+ rest if it
hurts too much+ your pain is a !arning that you'*e
o*erdone things+ it can only can !orse !ith age+ there
is no cure for spinal arthritis1
Aou can see that these t!o patients !ill come out of the
surgery !ith completely differing ideas a$out their $ac( pain1
Their doctors ha*e instilled different $eliefs into their minds1
rom no! on their $eha*iours in relation to their $ac( pain are
going to completely differentB&
o Patient & !ill ha*e a positi*e $eliefs around his $ac(
pain+ e)pecting that the pain !ill go a!ay on its o!n+
and that maintaining normal acti*ities !ill $e good for
his $ac(1 It is 3uite li(ely that this patient !ill reco*er
fully and go on to ha*e a normal lifestyle1
o Patient B !ill ha*e a negati*e set of $eliefs around his
$ac( pain+ e)pecting that he is doomed for e*er+ that it
can only get !orse+ that rest is the only cure+ and that
acti*ity !ill cause more pain and therefore more
damage1 Because he's 2$een told $y his doctor2+ he
!ill no! modify his $eha*iour+ $ecome less acti*e+
de*elop more $ac( pain $ecause of his inacti*ity+ and
slo!ly spiral do!n!ards into disa$ility+ chronic pain
and dependency1
If o*er a period of time patient B is repeatedly told $y his
doctor and other health professionals .nurses+
physiotherapists0 that his $ac( pain is due to spinal arthritis
.spondylosis0+ the message $ecomes reinforced and more
entrenched in the patient's mind1
E*ery time he modifies his $eha*iour .does less0 in response
to the pain+ he $ecomes more unfit and more prone to ha*ing
$ac( pain+ reinforcing his o!n $eliefs1 These $eliefs can also
$e inad*ertently reinforced $y lo*ed ones and colleagues at
!or( $y $eing o*er concerned a$out the pain and telling them
to do less E ta(e it easy1
#hen the pain comes on !ith e*ery mo*ement+ and the pain
in the patient's mind means that his $ac( has $een damaged
further+ se*eral things then happenB&
o The patient $ecomes frightened to do anything that
may cause the pain & this is called Pain &$oidance
Be%a$iour or fear of the pain1
o He anticipates the pain $efore he mo*es+ causing him
to hold his $reath and guard his $ac(+ !hilst tightening
his $ac( muscles & this is called Guarded Mo*ements1
Guarding only ser*es to increase the pain during
mo*ement+ as most of the pain is muscular in the first
place1
o An)iety and depression de*elop o*er time !ith a
tendency to catastrophise a$out the pain+ its cause+ and
its conse3uences .to ma(e it seem !orse than it
actually is+ to ma(e the pain into a catastophe01
An)iety and depression may also cause the patient to
misinterpret the se*erity of the pain leading to a
*icious spiral do!n!ards1
#hen patient B e*entually presents to a chronic pain clinic for
help+ he has firmly entrenched *ie!s a$out the pain+ it's cause+
and ho! he should manage it1 The clinic !ill e)amine his
$eliefs a$out the pain in order to try to help him+ $ut the
longer the a$normal $eliefs ha*e $een held+ the harder it is to
change them+ and the stronger the emotional reaction during
the process of trying to change1
The technical !ord for a $elief is a 2cognition21 Psychological
treatment to try to re&educate the patient a$out his $eliefs is
called Cogniti$e Be%a$ioural (%era!y ."BT0+ and is
administered $y someone properly trained in clinical
psychology1
Many chronic pain clinics ha*e multi&disciplinary teams .pain
doctor+ clinical psychologists and physiotherapists0 !ho !ill
try to use psychology treatments li(e "ogniti*e Beha*ioural
Therapy ."BT0 to try to modify the patient's set of $eliefs
a$out the pain+ in order for him to $egin the long road to!ards
physical and psychological reha$ilitation1 They often operate
!ithin a Pain Management Program1 If his $eliefs cannot $e
changed+ then he !ill not modify his $eha*iour .not get fit0+
and not !in the $attle against chronic pain1
Some patient can manage their pain $y com$ining "BT plus
specialised physiotherapy+ !hereas others need some form of
pain relie*ing procedure $efore em$ar(ing do!n this road1
#hate*er techni3ue is used+ the messages are the sameB&
o Aou must learn as much a$out your pain as possi$le
through education1
o Aou must stop thin(ing that pain e3uals more damage1
o Aou must learn ho! to control the fear of the pain+
and stop anticipating it $y guarding your muscles1
o Aou ha*e to stop catastrophising a$out the pain+
instead trying to minimise it in your mind .e1g1 telling
yourself it's only muscle spasm01
o Aou must $e as acti*e as you possi$ly can $e+ in order
to pre*ent the negati*e conse3uences of inacti*ity1
A *ital message to all health professionals is thereforeB&
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