The Pain Pathway;

Pain is a response to noxious and potentially damaging stimuli. It can occur in

response to excessive stimulation of other kinds or receptors ( eg. touch, temperature
etc. ) or d/t stimulation of specific pain receptors known as nociceptors. These are not
very specialized structures - really just branched free nerve endings that respond to a
variety of stimuli but this includes a response to bradykinin and prostaglandins the
chemical mediators of inflammation. Once a nociceptor is stimulated and an impulse is
stimulated the impulse can travel along either A delta fibres which are myelinated and
transfer impulses fairly rapidly ( they are used for acute pain) or C-fibres which are
unmyelinated and so are slower impulse conductors used for chronic pain.
Pain impulses enter the spinal cord via the dorsal root and then synapse with
interneurons in the grey matter of the cord. THe interneurons then direct impulses
toward the brain via the lateral spinothalmic ascending tracts ( neospinothalmic for
acute pain and paleospinothalmic for chronic pain) . Pain impulses crossover
( decussate ) at some point before the medulla and then when they reach the medulla
or hindbrain they pass through the reticular formation. Here the RAS or reticular
activating system which regulates the level of cerebral cortex activity will send impulses
to generally stimulate a higher level of cortex activity or awareness in response to the
pain. After the reticular formation the pain impulses travel to the thalamus which directs
impulses to several locations including;
- the Somatosensory cortex responsible for the area affected by the pain so that
the pain can be localized
- the Limbic system which generates an emotional response. This can be very
useful in reinforcing our response to pain that can cause serious tissue injury.
- the Hypothalamus which, in turn, stimulates an SNS ( sympathetic nervous
system) response. Recall that this is the short term stress response also known as the
fight-or-flight response which prepares the body to deal with serious challenges. The
SNS is a bundled set of responses including;
- pupil dilation
- bronchodilation
- increased heart rate and peripheral vasoconstriction which together lead to
increased BP
- diaphoresis
- increased ventilation rate
This set of responses can usually be seen as a clear indicator that the individual is in
acute pain.
Chronic Pain differs from acute pain in several distinct ways including;
- it uses C -fibres instead of A-delta and so the impulses are slower
- it usually is much less obvious - usually it does not provoke and SNS response
- the pain is perceived as dull, nagging and generalized or poorly localized as
opposed to the bright, sharp and clearly localized acute pain
- it typically provokes a change in behaviour or personality. Depression and
irritability are common outcomes.
- It is often poorly understood and poorly treated by health care professionals and
it is less effectively treated by typical pain control measures.
Variations in the pain response;

Visceral pain emerges from pain stimuli occurring in the organs. The organs are poorly
innervated with receptors and so there are few pain impulses produced and these
impulses are bundled with impulses originating from the skin region close to the organ
( a dermatome). For this reason when we feel organ pain we often feel it as poorly
localized and as if it originated at those dermatomes. For example- heart pain is often
felt as originating in the chest, left arm and shoulder and often the left neck and face.
This is called referred pain and it makes it more difficult to pinpoint or localize the
source of pain.
Phantom limb pain. Pain that is felt as it originates from a limb that is no longer there.
Imagine a scenario in which an arm is removed ( perhaps d/t an irreparable injury of
gangrene etc.) just below the shoulder. This would mean that pain receptors in the hand
are gone and so is most of the axon but the sensory nerve cell body is located in the
dorsal root ganglion near the spinal cord and is still intact. Over time the nerve may
regrow some axon back out along the nerve tract to the limb stump where it branches
out near the surface. If the limb stump is irritated and impulse will be generated which
then travels to the spinal cord and up to the somatosensory cortex where it will excite
the neurons that were responsible for the hands of that arm and so pain will be
perceived as if it originated in that hand ( which is no longer present). This can be a very
disturbing sensation though over time is may dissipate as the brain adapts in light of
visual and other evidence that the arm does not exist.

Pain threshhold; this is the amount of stimulus required to initiate a pain impulse.
Everybody has about the same level of pain threshold.

Pain tolerance; This is the amount of pain required for a person to take action or
respond seriously to the pain. People vary widely as to their pain tolerance. Many
factors can affect this including – personal previously history of pain, emotional state,
stress, knowledge about pain, cultural factors about how pain is viewed, state of health
etc, etc.