Physiology of Pain

Definition
pain is an, unpleasant sensory and emotional
experience associated with actual or potential
tissue damage (IASP)
According to Katz and Melzack, pain is a
personal and subjective experience that can
only be felt by the sufferer.
According to McCaffery pain is whatever the
experiencing person says it is and exists
whenever they say it does.

PAIN PHYSIOLOGY
Process of pain physiology
nociceptor
TRANSDUCTION
TRANSMISSION
PERCEPTION
MODULATION

Pain physiology contd..

Transduction (receptor activation)
Pain stimuli (thermal, mechanical or chemical) is
converted to electrical energy. This stimulus sends an
impulse across a peripheral nerve fiber (nociceptor).
The exact mechanism is not known, but a number of
mechanical & chemical interactions are known to
influence activity in primary afferent nociceptors at the
free nerve endings of the primary afferent fiber. These
nociceptors can be divided into A-delta and C-fiber

Pain physiology contd..

A-Delta
Myelinated, Large;
Receptive fields consist of cluster of small
spots;
May be sensitized;
Resistant to local anesthetics but susceptible to
pressure;
Inactivated with higher temp;
Responsible for I pain (early, sharp, brief pain).

Pain physiology contd..

C-Fiber
Non-Myelinated, small;
Responds to any noxious stimuli;
Receptive field is a single area rather than
clusters;
May be sensitized;
Susceptible to local anesthetics;
Inactivated at temp 55C;
Responsible for II pain (dull, prolonged pain)

Pain physiology contd..

Transmission:
Neural impulses thus produced are carried
along the peripheral nerves, nerve roots,
spinal cord, brainstem, thalamus and the
cortex (spinothalamic tracts) that
ultimately leads to an awareness of pain.

The Spino Thalamic Tract divides into

1. lateral division which terminates in
posterior nuclear group and ventrobasal
nuclei (VPM & VPC). The major projection is
from I & V laminae with receptive field
restricted to one side of the body usually
part of a limb;

2. medial division is called paleo

spinothalamic tract and terminate in the
central lateral nucleus. The major
projection is from entire body surface;
3. Spino reticular projection appear to involve
V,VI VII & VIII laminae and have complex
receptive fields from both sides similar to
paleo spino thalamic tract.

Gate Control Hypothesis suggests interaction

between myelinated and nonmyelinated
neurons occurs at inhibitory interneurons in
substantia gelatinosa and at dorsal horn.
The myelinated afferents said to excite
inhibitory interneurons and inhibit pain. The
nonmyelinated nociceptors inhibit the
inhibitory interneurons. The perceived
intensity is the net effect.

Although current evidence suggest that it is

incorrect, transcutaneous electrical-neuron
stimulator (TENS) is developed on this.
The major spinal pathways for pain travels in
the anterolateral spinal quadrant to the
thalamus (spinothalamic tract) and crosses
over to the other side 2 or 3 segments above.
Certain proportion of pain impulses can be
carried in ipsilateral pathway

Pain physiology contd..

Perception:
Person is aware of pain somatosensory
cortex identifies the location and intensity
of pain
Person unfolds a complex reactionphysiological and behavioral responses is
perceived.

Physiology contd..
Modulation:
Inhibitory neurotransmitters like
endogenous opioids work to hinder the
pain transmission.
This inhibition of the pain impulse is
known as modulation

Neurophysiology of pain
(excitatory)
Bradykinin- most potent pain producing
chemical
Prostaglandins- increase sensitivity to
pain experience . Is a potent vasodilator
and increase the production of bradykinin
resulting edema

Neurophysiology contd..
Substance P- transmits pain impulses to
brain centers and causes vasodilatation
and edema
Serotonin- causes pain by altering sodium
flowneuron to fire
Histamine,Leukotrienes and nerve growth
factor are released

Neuromodulators
(inhibitory)
Endorphins& dynorphins-morphine like
substances.
Located in the brain, spinalcord&GIT
Produce analgesia when attached with
opiate receptors in the brain

Neurotransmitter

Where found

Pain-associated function

NMDA

Spinal cord

Sustain and magnifies pain

transmission

Adenosine

Cord ang brain

Reduce pain severity

NK (neurokinins)

Spinal cord
andbrain

Involved in neuropathic pain

BK (bradikinins)

Peripheral tissue
after injury

Provoe inflamation and pain

Acetylcholine

Brain and nervous

system

Many, including synaptic

transmission and movement
control

GABA

Brain

Involved in neuropathic pain

Enkephalins

Brain

Natural analgesic

Glycine (GlyT-2)

Spinal cord

Pain responses

Serotonin (5-HT)

Brain and
peripheral tissues

Can both inhibit and enhance

pain in different
circumsstances

Effects of pain
Sympathetic responses
Pallor
Increased blood pressure
Increased pulse
Increased respiration
Skeletal muscle tension
Diaphoresis

Effects of pain
Parasympathetic responses
Decreased blood pressure
Decreased pulse
Nausea & vomiting
Weakness
Pallor
Loss of consciousness

Behavioral characteristics
Facial expressions- grimace, clenched
teeth, wrinkled forehead, crying
Body movements -restlessness,
immobilization, muscle tension, protective
movement of body parts
Social interaction- avoidance of
conversation & contacts

TYPES OF PAIN
ACUTE PAIN
CHRONIC PAIN
CUTANEOUS PAIN
DEEP SOMATIC
PAIN
VISCERAL PAIN
REFERRED PAIN
NEUROPATHIC PAIN
PHANTOM PAIN

Nociceptors (specialised sensory receptors that

respond to pain) can cause chronic pain if they are
damaged.

(A) In the normal state, if a nociceptor is

activated by a noxious stimulus, the nerve cell
transmits the information via the sensory system
to create a painful sensation in the brain.

(B) If the nociceptor is damaged, it can start firing

randomly and activate other nerves that
eventually cause phantom pain.

(C) If the nociceptor was an inhibitory

nerve, its inactivation through damage
could activate other nerves in the sensory
network that eventually cause phantom
pain.

FACTORS INFLUENCING PAIN

PHYSIOLOGICAL
SOCIAL
SPIRITUAL
PSYCHOLOGICAL
CULTURAL

PAIN ASSESSMENT
PAIN RATING SCALES- NRS,
VAS,VAT,FACES RATING SCALE,
PAIN-0-METER
McGill PAIN QUESTIONNAIRE
BODY MAP