PHYSIOLOGY OF PAIN

1. COMPONENTS OF PAIN Pain sensation has got two components namely: 1. Fast pain 2. Slow pain. • Whenever a pain stimulus is applied, first a bright, sharp and localized pain sensation is produced. This is called the fast pain. • The fast pain is followed by a dull, diffused and unpleasant pain. This is known as slow pain. • The receptors for both the components of pain are the free nerve endings. But, the afferent nerve fibers are different. The fast pain sensation is carried by Aδ fibers and the slow pain sensation is carried by C type of nerve fibers.

2. PATHWAYS OF PAIN SENSATION

a. PATHWAY OF PAIN SENSATION FROM SKIN AND DEEPER STRUCTURES

The receptors of both the components of pain are the free nerve endings. The free nerve endings are distributed throughout the body.

First order neurons are the cells in the posterior nerve root ganglia. These neurons receive impulses of pain sensation from the pain receptors through their dendrites and their axons reach the spinal cord.

After reaching the spinal cord, the fibers synapse with marginal cells in the posterior gray horn. The fibers transmitting impulses of slow pain belong to C type and these fibers synapse with substantia gelatinosa in the posterior gray horn (Fig. 143-4).

Second order neurons The marginal cells and the cells of substantia gelatinosa form the second order neurons. Fibers from these celis ascend in the form of the lateral spinothalamic tract:

Pacinian Corpuscle Chief

LATERAL SPINOTHALAMIC TRACT(PAIN PATHWAY)

• Fibers of marginal cells for fast pain are long. • Immediately after taking origin, the fibers cross the midline via anterior gray commissure, reach the anterolateral white column and ascend. • These fibers form the neospinothalamic tract-a part of lateral spinothalamic tract. • These nerve fibers terminate in ventral posterolateral nucleus of thalamus. Some of the fibers terminate in ascending reticular system of brainstem. • The fibers arising from substantia gelatinosa for slow pain cross the mid line and run along with fibers of fast pain as paleospinothalamic fibers in lateral spinothalamic tract. • One fifth of these fibers terminate in ventral posterolateral nucleus of thalamus. • The remaining fibers terminate in nuclei of reticular formation in brain stem or in tectum of mid brain or in the gray matter surrounding aqueduct of Sylvius. Third Order Neurons • The third order neurons of pain pathway are the neurons of thalamic nucleus, reticular formation, tectum and gray matter around aqueduct of Sylvius. • Axons from these neurons reach the sensory area of cerebral cortex. • Some fibers from reticular formation reach hypothalamus. Center for Pain Sensation The center for pain sensation is in the post central gyrus of parietal cortex. Fibers reaching hypothalamus are concerned with arousal mechanism due to pain stimulus.

PATHWAY OF PAIN SENSATION FROM VISCERA AND FACE 1. The pain sensation from thoracic and abdominal viscera is transmitted by sympathetic (thoracolumbar) spinal nerves. 2. Pain from esophagus, trachea and pharynx is carried by vagus and glossopharyngeal nerves. 3. Pain sensation from face is carried by trigeminal nerve. PATHWAY OF PAIN SENSATION FROM PELVIC REGION Pain sensation from deeper structures of pelvic region is conveyed by sacral parasympathetic nerves.

VISCERAL PAIN - Pain from viscera is unpleasant. It is poorly localized.

CAUSES OF VISCERAL PAIN 1. Ischemia: The substances released during ischemic reactions like bradykinin and proteolytic enzymes stimulate the pain receptors of viscera. 2. Chemical stimuli: The chemical substances like acidic gastric juice leaks from ruptured ulcers into peritoneal cavity and produce pain. 3. Spasm of hollow organs: Spastic contraction of muscles in gastrointestinal tract and other hollow organs of viscera cause pain by stimulating the free nerve endings. 4. Over distention of hollow organs also causes pain.

REFERRED PAIN DEFINITION • The pain sensation produced in some parts of the body is felt in other structures away from the place of development. This is called referred pain.

• The deep pain and some visceral pain are referred to other areas. But the superficial pain is not referred.

EXAMPLES OF REFERRED PAIN 1. Cardiac pain is felt at the inner part of left arm and left shoulder. 2. Pain in ovary is referred to umbilicus. 3. Pain from testis is felt in abdomen. 4. Pain in diaphragm is referred in right shoulder. 5. Pain in gallbladder is referred to epigastric region. 6. Renal pain is referred to loin. MECHANISM OF REFERRED PAIN Dermatomal rule: Pain is referred to a structure, which is developed from the same dermatome from which the pain producing structure is developed. This is called dermatomal rule. A dermatome includes all the structures or parts of the body which are innervated by afferent nerve fibers of one dorsal root. For example, the heart and inner aspect of left arm originate from the same dermatome. So, the pain in heart is referred to left arm. NEUROTRANSMITTER INVOLVED IN PAIN SENSATION • Substance P is the neurotransmitter involved in pain sensation. • It is secreted by the ending of pain nerve fibers in dorsal gray horn. CONTROL OF PAIN SENSATION The central nervous system has got its own control system. This inhibits the impulses of pain sensation. This is called analgesia system. This control system is present in both brain and spinal cord.

PAIN CONTROL SYSTEM IN BRAIN This blocks the pain impulses before entering the brain. This system is present in: 1. Gray matter surrounding aqueduct of Sylvius

2. Raphe Magnus nucleus in pons. The neurotransmitters involved in inhibition of pain by control system in brain are serotonin and opiate receptor substances namely 1. Endorphin 2. Enkephalin 3. Dynorphin.

PAIN CONTROL IN SPINAL CORD This is in posterior gray horn. The posterior gray horn is considered as the gateway for the pain impulses to reach the brain via spinothalamic tracts. Gate Theory • When pain sensation is produced in a part of body along with pain fibers, some of the other afferents particularly the touch fibers reaching the posterior column of spinal cord are also activated. • The dorsal column fibers send collaterals to the cells of substantial gelatinosa in the posterior gray horn. • Thus, some of the impulses ascending via dorsal column fibers pass through the collaterals and reach substantia gelatinosa. • Here, the impulses inhibit the release of substance P by the pain fibers ending on substantia gelantinosa so that, the pain sensation is suppressed. Thus, the gating of pain in posterior gray horn level is similar to presynaptic inhibition. APPLIED PHYSIOLOGY 1. Analgesia: Loss of pain sensation. 2. Hyperalgesia: Increased sensitivity to pain sensation 3. Paralgesia: Abnormal pain sensation.

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