Vital Signs: Pain

Video 6.1: The Anatomy & Physiology of Pain, Part 1

- Introduction to pain
o the symptom most likely to inspire people to seek medical care
o defined as a sensory & emotional experience that is unpleasant and has the
role of alerting us to potential damage to the body or body tissues
o there are different qualities and experiences of pain

- Sensory experience of pain

o the nervous system has 2 arms
 sensory –which consists of receptors and nerve fibers (carried in nerves) that
conduct impulses/information toward the spinal cord & brain

 motor –consists of nerve fibers (carried in nerves) that conduct impulses to

effectors (effectors are either muscles or glands)

o sensory arm begins with specialized sensory receptors called nociceptors
 respond to potential harmful stimuli
 3 types of stimuli activate nociceptors:
 mechanical:

 thermal:

 chemical:

 inflammatory chemicals make nociceptors more sensitive -> signal that a

damaging stimulus is occurring

o the role of sensory receptors is to convert stimulus energy to electrical energy, which
can be conducted down the axons (nerve fibers) of neurons –we call these conducting
impulses action potentials

- Sensory pathways generally consist of 3 neurons in a chain:

o first order sensory neuron –carries action potentials from the sensory receptor to the
central nervous system (to either the spinal cord or brain)

 impulse arrives in the dorsal horn of the spinal cord, which is where
communication between the first-order & second-order sensory neuron
occurs
 o second order sensory neuron
 cell body of second-order sensory neurons are located inside the dorsal horn
of the spinal cord

 receives information from first-order sensory neuron –the communication

occurs at a specialized junction, called a synapse

 signal can be inhibited (not passed on) or passed onto the second order
neuron at this point

 nerve fibers of the second-order sensory neurons cross over from one side of
the spinal cord to the other
 this cross-over is called decussation
 as a result of decussation, signals that originate on one side of the
body get carried to the alternate side of the brain

 fibers of second order sensory neurons carry impulses up spinal cord, through
the brainstem to the thalamus:

o third order sensory neuron

 cell body of third-order sensory neurons are located in the thalamus (in the
brain)

 second-order neuron passes its signal across a synapse to third-order sensory

neuron in the thalamus

 fibers of third-order sensory neurons pass upward through the cerebrum to

the primary somatosensory cortex

Video 6.2: The Anatomy & Physiology of Pain, Part 2

Two pathways related to our perceptions of pain

- one pathway involves nociceptor passing signal via a type A delta nerve fiber

o characteristics of these fibers

 large diameter nerve fibers
 fibers are myelinated
 fastest speed of signal transduction

o carry stimulus information related to thermal and mechanical stimuli

o the signals carried by these fibers are perceived as rapid, sharp sensations of pain
 o impulse is conducted up through the spinal cord & brainstem in the spinothalamic
tract:

- The other pathway involves nociceptor passing signal via type C nerve fibers

o characteristics of these fibers

 smallest diameter nerve fibers
 fibers are unmyelinated
 slow speed of signal transduction

o carry stimulus information related to all 3 types of stimuli (thermal, mechanical,

chemical)

o the signals carried by these fibers are perceived as dull, burning, throbbing pain

o impulses are conducted up the spinal cord to the brainstem via the spinoreticular
tract

 passes up spinal cord to the brainstem, and then on to multiple sites in brain
 adds emotional overtones to perceptions of pain

Video 6.3: The Anatomy & Physiology of Pain, Part 3

Three general mechanisms of pain modulation

- one type of modulation occurs at the level of communication between the first-order and
second-order sensory neurons (in dorsal horn)

o other fibers, called type A beta fibers, are also conducting information to this
synapse
 the type A beta fibers are carried in the same nerves that are carrying type A
delta fibers & type C fibers
 type A beta fibers (like the type A delta fibers) are large diameter, myelinated
fibers (fastest conduction speed)
 type A beta neurons also synapse with second-order sensory neurons –and
the impulse/information carried by the second-order neuron is conducted via
the spinothalamic tract –and is subsequently carried to the primary
somatosensory cortex by third-order sensory neurons

o type A beta fibers carry information related to touch sensation

 - some modulation can also occur because of descending inhibitory pathways
o these pathways originate in brainstem but receive input from other parts of brain
 when activated, an inhibiting signal is passed to dorsal horn
 the signal inhibits transfer of information at the synapse between the first-
order and second-order sensory neurons
o thus, there is an inhibition of pain-related input flowing up the spinothalamic and
reticulospinal tracts

- the third mechanism of pain modulation is associated with the endogenous opiod system
o the endogenous opiods: enkephalins, endorphins, dynorphin

o opiods are analgesics –i.e., they decrease the perception of pain

o in high concentrations in the braintem –there are receptors for the endorphins in the
brainstem & spinal cord

Video 6.4: Types of Pain

Three types of pain:

- somatic pain

o can be localized and can often be replicated

o subcategories:
 superficial somatic pain
 typical experienced in response to mechanical or thermal stimuli

 sharp, rapid onset

 deep somatic pain

 typically experience in muscles and joints
 usually perceived as aching, throbbing, burning pain

- visceral pain
o this types of pain is associated with internal organs, which have nociceptors in their
walls
o deep throbbing pain
o impulses related to this type of pain are carried by type C nerve fibers
 o through unconscious neural reflexes, this kind of pain can trigger nausea, vomiting
and other symptoms
o this type of pain is difficult to localize –is often experienced as referred pain –i.e.,
brain interprets the pain as occurring at the body surface

- neuropathic pain
o unlike somatic pain & visceral pain, neuropathic pain occurs when nerves themselves
are damaged (rather than when nociceptors are activated)

o there are varied reasons for this type of pain:

 diabetic neuropathy

 phantom limb pain

 carpal tunnel syndrome

 nerves compression or trauma

Video 6.5: Assessing Pain Demonstration

- pain is a subjective experience, so it can be difficult to assess

- comprehensive pain assessment in a health care setting involves a number of question areas
o intensity
 assessed via pain scales
 verbal scales:

 picture scales-

 Veteran and Defense Pain Scale

 Wong-Baker FACES Scale

o onset

o duration

o frequency

o location

o quality
  examples -burning, aching, sharp, etc.

o associated symptoms

 examples- nausea, shortness of breath

o precipitating factors

o alleviating factors

o impact

 examples- ability to walk, sleep normally, etc.

Video 6.6: Social, Cultural & Psychological Influences on Pain

- the history of our understanding of pain-

o until the 19th century: pain was dichotomized as either a somatogenic experience or
a psychogenic experience-

 pain was thought of as a linear sensory experience

o in the 20th century- Melzack and Wall developed the gate control theory of pain-

 pain was is both a sensory and emotional experience

- influence of social factors on pain-

o examples of social factors-

 eduation
 type of work
 income-
 less access to healthcare, less continuity of care, more manual labor

o Dr. Rash Portnoi’s study-

- pain and culture-

 o culture:

o very misunderstood area in terms of pain influence -- vast heterogeneity within

cultures

o social factors often shape cultural belief structures

- effect of treatment on subsequent pain experiences-

o acute pain is adaptive (i.e., it serves a purpose)

o untreated acute pain may become pathological - chronic pain

 chronic pain is not considered to be adaptive

 puts a strain on psychological reserves and social resources

o certain groups are less likely to receive treatment

Video 6.7: The Treatment of Pain

- treating pain is important for several reasons-

o physicians and nurses make an ethical and professional commitment to decrease

suffering and promote comfort
o provides comfort
o short term and long term consequences of untreated pain-

 physiologic consequences-

 functional consequences-

 psychosocial consequences-

o nociceptive signal –is ultimately integrated in multiple areas of the brain

 manifestations are apparent with physiologic monitoring and behavioral

changes
 examples- increased blood pressure, decreased movement, grimacing
  best way to assess the pain experience is through the patient’s self-report

 sometimes a disconnect with actual pain experience and what is

reported –always explore further
o may use a different term for pain-

o may worry about consequences-

o barriers to reporting pain-

- Treating pain-

o goal of therapy is individualized-i.e., patient-focused:

o evaluate risks and benefits of different therapies-