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Introduction

Pain is part of the body's defense system, producing a reflexive retraction from the painful
stimulus, and tendencies to protect the affected body part while it heals, and avoid that harmful
situation in the future. It is an important part of animal life, vital to healthy survival.

Definition

Pain can be define is an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage. In medical diagnosis, pain is
regarded as a symptom of an underlying condition.

Classification of pain

Pain is most often classified by the kind of damage that causes it. The two main categories are pain
caused by tissue damage, also called nociceptive pain, and pain caused by nerve damage, also called
neuropathic pain. A third category is psychogenic pain, which is pain that is affected by
psychological factors. Psychogenic pain most often has a physical origin either in tissue damage or
nerve damage, but the pain caused by that damage is increased or prolonged by such factors as fear,
depression, stress, or anxiety. In some cases, pain originates from a psychological condition.

Nociceptive pain is caused by stimulation of sensory nerve fibers that respond to stimuli
approaching or exceeding harmful intensity (nociceptors), and may be classified according to the
mode of noxious stimulation. The most common categories are "thermal" (e.g. heat or cold),
"mechanical" (e.g. crushing, tearing, shearing, etc.) and "chemical" (e.g. iodine in a cut or
chemicals released during inflammation). Some nociceptors respond to more than one of these
modalities and are consequently designated polymodal.

Nociceptive pain may also be divided into "visceral", "deep somatic" and "superficial somatic"
pain. Visceral structures are highly sensitive to stretch, ischemia and inflammation, but relatively
insensitive to other stimuli that normally evoke pain in other structures, such as burning and
cutting. Visceral pain is diffuse, difficult to locate and often referred to a distant, usually
superficial, structure. It may be accompanied by nausea and vomiting and may be described as
sickening, deep, squeezing, and dull. Deep somatic pain is initiated by stimulation of nociceptors
in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-
localized pain. Examples include sprains and broken bones. Superficial pain is initiated by
activation of nociceptors in the skin or other superficial tissue, and is sharp, well-defined and
clearly located. Examples of injuries that produce superficial somatic pain include minor wounds
and minor (first degree) burns
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Neuropathic pain is caused by damage or disease affecting any part of the nervous system
involved in bodily feelings (the somatosensory system). Peripheral neuropathic pain is often
described as "burning", "tingling", "electrical", "stabbing", or "pins and needles".[22] Bumping the
"funny bone" elicits acute peripheral neuropathic pain .e.g phantom limb syndrome .The main
causes of neuropathic pain are alcoholism, chemotherapy and diabetic mellitus.

Psychogenic pain, also called psychalgia or somatoform pain, is pain caused, increased, or
prolonged by mental, emotional, or behavioral factors. Headache, back pain, and stomach pain
are sometimes diagnosed as psychogenic. Sufferers are often stigmatized, because both medical
professionals and the general public tend to think that pain from a psychological source is not
"real". However, specialists consider that it is no less actual or hurtful than pain from any other
source.

However, pain can also be Pain is also classified by the type of tissue that's involved or by the part
of the body that's affected. For example, pain may be referred to as muscular pain or joint pain,
chest pain.

Similarly, pain may be also further classified into Acute and Chronic pain

Acute pain is the body's normal response to damage such as a cut, an infection, or other physical
injuries. This type of pain usually comes on fast and often goes away in no more than a few
weeks or months if treated properly. Acute pain can become chronic when the cause is difficult
to treat.

Chronic pain, according to the Veterans Health Administration (VHA) "generally refers to
intractable pain that exists for three or more months and does not resolve in response to
treatment." It is viewed more as its own disease rather than as a symptom of another health
problem. It can be affected by physical (sitting or standing), environmental (weather changes),
and psychological (such as stress) factors. Chronic pain often cannot be treated or cured; it can
only be managed. Therefore, chronic pain may reduce quality of life, well-being, and ability to
function over the long term.

Theory

Before the relatively recent discovery of neurons and their role in pain, various different body
functions were proposed to account for pain. There were several competing early theories of pain
among the ancient Greeks: Hippocrates believed that it was due to an imbalance in vital fluids. In
the 11th century, Avicenna theorized that there were a number of feeling senses including touch,
pain and titillation.
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In 1968 Ronald Melzack and Kenneth Casey described pain in terms of its three dimensions:
"sensory-discriminative" (sense of the intensity, location, quality and duration of the pain),
"affective-motivational" (unpleasantness and urge to escape the unpleasantness), and "cognitive-
evaluative" (cognitions such as appraisal, cultural values, distraction and hypnotic suggestion)
They theorized that pain intensity (the sensory discriminative dimension) and unpleasantness
(the affective-motivational dimension) are not simply determined by the magnitude of the painful
stimulus, but "higher" cognitive activities can influence perceived intensity and unpleasantness.
Cognitive activities "may affect both sensory and affective experience or they may modify
primarily the affective-motivational dimension. Thus, excitement in games or war appears to
block both dimensions of pain, while suggestion and placebos may modulate the affective-
motivational dimension and leave the sensory-discriminative dimension relatively undisturbed.

Mechanisms of pain

The process of pain includes transduction, transmission, perception, and modulation. However,
the exact mechanism
Of pain is unknown, and this process does not explain all types of pain, such as phantom limb.
Also, not all nociception results in the perception of pain

Transduction begins with a response to a noxious s(painful) stimulus that results in tissue
injury. The noxious stimuli can be mechanical, thermal, or chemical. The noxious stimuli are
then converted into a nerve impulse by
sensory receptors called nociceptors.

Transmission Once the nociceptors are activated, the nerve impulse is transmitted to the spinal
cord and brain. The sensory Nerve impulses travel via afferent neurons to the dorsal horn of the
spinal cord. Primary afferent nerve fibers travel along C-fibers, unmyelinated ,slow-conducting
fibers that transmit dull, aching pain, or A-delta fibers ,myelinated, fast-conducting fibers that
transmit sharp, localized pain.C-fibers transmit slow, constant pain from mechanical, thermal,
and chemical stimuli. A-delta fibers transmit fast, intermittent pain from mainly mechanical
stimuli.

Perception is an awareness of pain and involves both the cortical and the limbic system
structures. Realize that pain threshold, the point at which a painful stimulus is perceived as
painful, is consistent from one person to the next; however, pain tolerance, the amount of pain
one is able to endure, varies greatly. Psychosocial and cultural factors and past experiences
influence pain perception, thereby accounting for such individual differences in
pain perception even with similar painful stimuli.
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Modulation

Nerve transmission from the dorsal horn is modulated by descending inhibitory input. Inhibition
can also occur at the peripheral, spinal, and supraspinal levels. Inhibition occurs by analgesia or
the gate-control theory of pain modulation. Inhibitory substances (e.g., GABA and neuropeptides
[endogenous opioids, serotonin, norepinephrine])bind to primary afferent receptors and dorsal
horn neurons to inhibit transmission of impulse. Endogenous opioids include enkephalins,
dynorphins, and beta endorphins. Endogenous opioids can also be produced through exercise,
meditation, visualization, and music therapy. The brain also sends descending inhibitory input
that modulates the transmission of nociceptive transmission in the dorsal horn.

Pain Assessment

Pain assessment includes a history and physical examination. As with any assessment, always
begin with a history.
Since pain is subjective in nature, the history component of the pain assessment is the most
important.

Health History

Self-report is the most accurate indicator of pain. Because pain is subjective, the patient’s health
history provides the best assessment of pain. The history also allows you to assess past
experiences with pain, effective pain treatments, and the effects pain has on every aspect of the
patient’s life.

Biographic data

Review your patient’s biographical data. As described previously, your patient’s age, ethnicity,
and religion may affect her or his perception and behavioral response to pain. Even the patient’s
gender may influence her or his perception of pain. Also, your patient’s occupation may be a
direct cause of the pain, such as back pain related to heavy lifting; the presence of pain may
prohibit a return to work.

Current Health Status

When your patient presents with pain, perform a symptom analysis. The mnemonic PQRST
provides a thorough description of pain. Ask for :
P stands for Precipitating/Palliative/Provocative Factors
Q stands for Quality/Quantity

R stands for Region/Radiation/Related Symptoms

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S stand for Severity.

T stands for Timing.

Pain scale

Various instruments are available to assess pain. Consider the patient’s age and developmental
status along with his or her cultural background when selecting a pain scale .Select the one that
will best meet your patient’s needs. The pain scale for adult which, is either one-dimensional or
multidimensional pain scale.

One dimensional scale these scales generally use numeric, verbal, or visual descriptors to
quantify pain. Examples include the Numeric Rating Scale, Visual Analogue Scale, and
categorical scales. While Multidimensional scales are scales assess pain characteristics and its
effects on patient’s activities of daily living and include the Initial Pain Assessment Inventory
(IPAI), Brief Pain Inventory (BPI), McGill Pain Questionnaire (MPQ), and the Neuropathic Pain
Scale.

Past Health History

The past health history can identify factors that may affect the patient’s pain, response to pain,
and treatment plan. When conducting the past health history, make sure to identify cause of pain,
past and present medical problem that may influence pain and it management, past psychiatric
illness and past and present pain management strategy.

Family History
The family history may identify genetically linked causes of pain, such as sickle cell anemia and
cancer. The family history also identifies familial history of chronic pain or illness. Ask the
patient about hereditary or familial health problems.

Psychosocial Profile
Assessing the psychosocial history identifies the effects that pain has on every aspect of the
patient’s life and evaluates quality of life.
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Pain management

Inadequate treatment of pain is widespread throughout inpatient and outpatient unit in hospitals.
In general practice, the management of all forms of pain including cancer pain, and in end of life
care should aim toward decrease the intensity of pain in an effort to reduce or prevent permanent
changes in the nervous system that may result in permanent disability such as allodynia and
hyperalgesia . Multimodal therapy which involves drug and non-drug treatments and rational
combinations of drugs that work by different mechanisms are important in providing optimal
relief of pain and reducing the probability of persistent changes that characterize chronic pain

Acute pain is usually managed with medications such as analgesics and anesthetics. Caffeine,
when added to pain medications such as ibuprofen, may provide some additional benefit.
Management of chronic pain, however, is much more difficult and may require the coordinated
efforts of a pain management team, which typically includes medical practitioners, clinical
pharmacists, clinical psychologists, physiotherapists, occupational therapists, physician
assistants, and nurse practitioners.

Psychological Therapy

Individuals with more social support experience less cancer pain, take less pain medication,
report less labor pain and are less likely to use epidural anesthesia during childbirth or suffer
from chest pain after coronary artery bypass surgery.

Exercise believe to be of helpful in management of pain comprises aerobic activities -such as

swimming, stationary cycling, and walking-to build your strength and health.. However
improvement of lifestyle such stops smoking, getting good balance diet and reduce stress.