Physiology

of pain

M. Andy Prihartono
 Pain – the 5th vital sign
Pain is "an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage“ ~
IASP 1
Pain should be considered the “fifth vital sign” 2

1. Classification of Chronic Pain, Second Edition (Revised). IASP. 2011. Available from: http://www.iasp-pain.org/files/Content/ContentFolders/Publications2/ClassificationofChronicPain/Part_III-PainTerms.pdf
2. J Intraven Nurs. 2001 Mar-Apr;24(2):85-94.
3. The Joint Commission. Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition. Illinois; 2010. Available from: http://www.jointcommissioninternational.org/approaches-to-pain-management-an-essential-guide-for-clinical-leaders-
second-edition/approaches-to-pain-management-an-essential-guide-for-clinical-leaders-second-edition-pdf-book-/ [accessed October 13th 2016]
4. Joint Commission International. Joint Commission International Accreditation Standards for Hospitals, Fifth Edition. 2013. Available from: http://www.jointcommissioninternational.org/assets/3/7/Hospital-5E-Standards-Only-Mar2014.pdf [accessed October 13th
2016]
 Definitions
• Agology – the science and study of pain
• Allodynia – pain caused by a stimulus that is not normally
painful
• Analgesia – the absence, or decrease, of pain in the presence

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of a stimulus that would normally be painful
Hyperalgesia – an increased sensitivity to a stimulus that is
normally painful
• Nociception – the reception, conduction, and central nervous
processing of nerve signals resulting in the perception of
pain
• Somatic pain – pain originating from skin, joints, muscles,
and other deep tissues
• Visceral pain – pain originating from the internal organs
 Definitions
• Noxious stimulus – a stimulus which is actually or
potentially damaging to body tissues
• Pain threshold – the point at which an individual just begins
to feel pain; is relatively consistent among normal
individuals
• Pain tolerance – the greatest amount of pain that a subject
will tolerate; varies greatly among individuals
• Radiculalgia – pain along the distribution of one or more
sensory nerve roots
• Radiculitis – an inflammation of one or more nerve roots
• Wind-up – a cascade of events resulting from ongoing
stimulation of nociceptors and activation of NMDA
receptors; causes hyperalgesia and opioid tolerance
 Types of Pain
Physiological Pain
• Is a protective
mechanism
• Causes avoidance Loading…
•
• Little to no tissue injury
• Pain stops once the
stimulus is removed
Pathological Pain
• Results from tissue injury
• Inflammation occurs in the
area
Nerve damage
• Release of
neurotransmitters with
ongoing stimulation of
nociceptors
• Can lead to hyperalgesia
• Persists after the stimulus is
removed
 Types of Pain
Acute Pain Chronic Pain
• Occurs immediately after a • Persists well past initial
stimulus is received stimulus (3-6 months)
• Severity can vary • Severity can vary
• May or may not respond
• Responds well to treatment well to treatment; may
• Subsides once stimulus is require a “multi-modal”
removed approach
• Can result in allodynia,
hyperalgesia, and opioid
tolerance
 Nociceptive Pain

Clinically, pain can be

labeled “nociceptive” if it
is inferred that the pain is
due to ongoing
activation of the
nociceptive system by
tissue injury.
 Nociceptive Pain
Although neuroplastic changes (such as
those underlying tissue sensitization) are
clearly involved, nociceptive pain is
presumed to occur as a result of the
normal activation of the sensory system
by noxious stimuli, a process that involves
4 basic processes
transduction
transmission
perception of pain
modulation of pain
 Perception
Pain Perception
Pain

Descending
Modulation
modulation Dorsal Horn

Ascending Dorsal root

input ganglion Transmission

Transduction
Spinothalamic
Periphera
tract
l
nerve

Trauma
• Pain Pathway Peripheral
nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049. 0
 Nociceptors
Tissue injury activates primary afferent neurons
called nociceptors, which are small diameter
afferent neurons (with A-delta and C-fibers)
 Nociceptors

• Nociceptors respond to
noxious stimuli
• Nociceptors are found in
●
●
skin
muscle
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● joints
● and some visceral
tissues.
 Nociceptors
• nociceptors free nerve endings has
capacity to distinguish between noxious
and innocuous stimuli when exposed to
● mechanical (incision or tumor
growth)
● thermal (burn, ice)
● chemical (toxic substance) stimuli
● tissue damage occurs
● substances are released by the damaged tissue which
facilitates the movement of pain impulse to the spinal
cord
 Pathophysiology of visceral pain
Visceral pain:
Types - angina pectoris, myocardial infarction, acute
pancreatitis, cephalic pain, prostatic pain,
nephro-lytiase pain.

●Receptors: unmyelinated C – fibres

● For human pathophysiology the kinds of stimuli apt to
induce pain in the viscera are important.
It is well-known that the stimuli likely to induce cutaneous
pain are not algogenic in the viscera. This explains why in
the past the viscera were considered to be insensitive to
pain.
 Pathophysiology of visceral pain

Visceral pain stimuli:

•abnormal distention and contraction of the hollow viscera

muscle walls
•rapid stretching of the capsule of such solid visceral organs as

are the liver, spleen, pancreas.

•abrupt anoxemia of visceral muscles
•formation and accumulation noxious substances
•direct action of chemical stimuli (oesophagus, stomach),
•traction or compression of ligaments and vessels
•inflammatory processes
•necrosis of some structures (myocardium, pancreas)
 Deep tissue nociceptor
• Unlike cutaneus pain, deep pain is diffuse and
difficult to localized, with no discernable fast (first
pain) and slow (second pain) components. In many
cases deep tissue pain is associated with autonoic
reflexes (eg sweating, hypertension and tachypnea)
• Units that do not respond to mechanical stimuli have
been termed silent nociceptros. Silent nociceptor
are also present within the viscer. Silent visceral
afferents fail to respond to innocuous or noxious
stimuli, but become responsive under inflammatory
conditions.
• Visceral afferents are mostly polymodal C- and A-
fibres.
 Pathophysiology of visceral pain

Mechanisms involved in referred pain:

●convergence of impulses from viscera and from the

skin in the CNS:
- sensory impulses from the viscera create an
irritable focus in the segment at which they enter
the spinal cord.
- afferent impulses from the skin entering the same
segment are thereby facilitated, giving rise to true
cutaneous pain.

●senzitization of neurons in dorsal horn

 Pathophysiology of visceral pain
● Painful visceral afferent impulses activate anterior
horn motor cells to produce rigidity of the muscle
(visceromotor reflexes)
● A similar activation of anterolateral autonomic cells
induces pyloerection, vasoconstriction, and
other sympathetic phenomena

● These mechanisms, which in modern terms can be

defined as positive sympathetic and motor feedback
loops, are fundamental in refered pain
● It is clear that painful stimulation of visceral
structures evokes a visceromuscular reflex, so
that some muscles contract and become a new
Referred visceral pain
 Neuropathic pain
• Pain of the nervous system
• Neuralgias
• Anesthesia dolorosa
• Root pain
• Stroke pain
 Neuropathic Pain - Difficulties
• No Consensus on Definition
• Pain Perception is subjective
• Rarely One Diagnostic Test
• Lack Of Specificity in Diagnosis
• Signs & Symptoms Change Over Time
• Patients not believed

5
 Components of Neuropathic Pain
• Pain
• Lancinating/burning/pricking/stabbing
• No ongoing tissue damage
• Delay in onset after nerve injury
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Spontaneous paroxysmal electric shock sensation

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Cancer Pain

Just as Cancer is not 1 disease

Cancer Pain is not 1 entity
 PHYSICAL DISTRESSS

SPIRITUAL EMOTIONAL
DISTRESS DISTRESS

(Biopsychosociospiritual Disease)
THANK YOU !