CHAPTER 19

Physiology of pain
Ted Lin
NOCICEPTION 431 Descending modulatory system 446
Nociceptors 432 Neuromodulators in the pain system 446
The dorsal root ganglion 434
The dorsal horn 435 CLINICAL ASPECTS OF PAIN 447
The primary synapse 436 Phasic pain, acute pain and chronic pain 447
Ascending tracts 439 Chronic pain conditions 449
The thalamus 442 Physiological and pathological pain 449
Cortical sites of pain projection 442 Hyperalgesia 449
Neuropathic pain 450
SENSITISATION OF THE PAIN SYSTEM 443 Pain descriptors and localisation 450
Peripheral sensitisation 443 Psychology of pain 451
Central sensitisation 444 Pain management 452

MODULATION OF PAIN 445

The ‘gate control’ theory 446

Pain has been defined as ‘an unpleasant sensory and

Dimensions of the pain experience
emotional experience associated with actual or potential
tissue damage’ by the International Association for the
Study of Pain (IASP), which has become the parent
organisation for many national pain societies. This
definition has arisen because pain is a multimodal
experience.
Nociception
Nociception is the sensory modality by which noxious
stimuli are detected peripherally and transmitted centrally
to the central nervous system. Noxious stimuli may
or may not be associated with tissue damage. The pathway
by which nociception is mediated (Figure 19.1)
consists of:
r Nociceptors
r Dorsal root ganglia containing the body of the
nociceptor
r The primary synapse
r The dorsal horn of the spinal cord
r Ascending tracts
r Thalamus and higher centres
r Pain has a protective function and may or may not
be associated with tissue damage.
r Pain should not be equated to nociception.
Nociception is often a component of pain
symptoms but not necessarily so.
r Intrinsic modulatory mechanisms exist in the body
which attenuate the intensity of the pain experience.
r Sensitisation mechanisms exist which intensify
pain symptoms, resulting in the phenomenon of
hyperalgesia.
r Pain possesses a subjective and affective element
as a result of connections between the pain system,
cortical centres and the limbic system.
r Pain levels are also influenced by past
experience and anticipation due to interaction
between the pain system and the prefrontal
cortex.
r Pain can affect visceral and neuroendocrine
function as a result of interconnections
with medullary centres and the hypothalamus.

Fundamentals of Anaesthesia, 4th edition, ed. Ted Lin, Tim Smith and Colin Pinnock. Published by Cambridge University Press. © Cambridge University Press 2016.

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 432 SECTION 2: Physiology

afferents respond to different types of noxious stimuli.

Such stimuli are most commonly mechanical, thermal
cortex or chemical.

Nociceptor characteristics
r The type of stimuli they are sensitive to
r The class of nerve fibre serving the receptor
r The receptor response characteristics – slow or fast,
short or long latency
thalamus r The ion channel proteins expressed on the receptor
cell membrane

Unimodal receptors respond to mechanical distortion,

thermal receptors to heat, and polymodal receptors to
ascending tracts mechanical distortion, heat, cold or chemical stimuli.
The majority of receptors are polymodal, being sensitive
to mechano-heat (MH) stimuli. Some receptors are only
sensitive to mechanical stimuli and are referred to as
mechanically sensitive afferents (MSA) while others are
insensitive to mechanical stimuli (mechanically insensi-
dorsal horn tive afferents, MIA).
There are two main types of nociceptor fibre which
transmit nociceptor signals to the central nervous system,
C fibres and Aδ fibres.
r C nociceptors are unmyelinated, with conduction
velocities < 2 m s 1. They evoke slow-response
dorsal root ganglion burning pain and dull aching pain. They are mostly
polymodal, responding to heat, mechanical and
chemical stimuli. These nociceptors may be referred
to using the nomenclature CMH (C mechano-heat
nociceptors). Some C-fibre nociceptors are mechan-
ically insensitive afferents, and are referred to as
nociceptor
C-fibre MIAs.
r Aδ nociceptors are connected centrally by myeli-
nated fibres with conduction velocities between
15 and 55 m s 1. Aδ fibres evoke sharp fast-response
pains of a burning, stabbing, pricking and aching
nature. There are two types of Aδ nociceptor.
STIMULUS
Type I have higher conduction velocities
(> 25 m s 1) and are found in hairy and
Figure 19.1 The nociceptive pathway glabrous skin (palms of hands and soles of feet).
These Aδ nociceptors may be referred to as AMHs
(A mechano-heat nociceptors). Type II are slower,
Nociceptors with conduction velocities of around 15 m s 1,
The primary afferent neurones for pain are referred to and are distributed in hairy skin only. An outline
as ‘nociceptors’, which possess specialised nerve endings of their contrasting responses to stimuli is shown
in almost all tissues of the body. These primary in Figure 19.2.

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Figure 19.2 Responses of type I and type II Aδ nociceptors
Response Type I
Mechanical Usually sensitive (MSA)
Heat Insensitive (high threshold) initially
with increasing response to prolonged
stimulus (> 5 s)
Long latency
Chemical Sensitive
Cellular functions of nociceptors
Nociceptor functions
r Transducing and encoding noxious stimuli to
generate afferent action potentials
r Synthesising and releasing neuropeptides such as
calcitonin gene-related peptide (CGRP) and
substance P, both peripherally and centrally
r Synthesising and releasing neurotrophins such as
glial cell-line-derived neurotrophic factor (GDNF)
and nerve growth factor (NGF), which modulate
gene expression in the nociceptor
r Synthesising and releasing neurotransmitters at the
primary synapse, e.g. glutamate
r Synthesising and releasing inflammatory mediators
which sensitise the nociceptive pathway centrally
and peripherally
Nociceptor ion channels
Nociceptors possess families of ion channels in their cell
membranes which initiate their functions and have the
following properties:
r They are usually specific for sodium, potassium,
calcium or hydrogen ions (acid-sensing ion
channels, ASICs). However, non-specific ion channels
also exist.
r Transient receptor potential (TRP) channels
in the nociceptor membrane transduce noxious
physical or chemical stimuli to initiate action
potentials.
r TRP channels can be sensitised or activated by
inflammatory mediators released from damaged tissue
or by the nociceptors themselves. This results in
hyperalgesia.
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Chapter 19: Physiology of pain 433
Type II
Usually insensitive (MIA)
Sensitive (low threshold) initially
with decreasing response to prolonged
stimulus
Short latency
Sensitive
r Voltage-gated channels are opened at different
thresholds of membrane potential. Such channels can
be triggered by the transient changes in membrane
potential produced when TRP channels are activated.
TRP channels can thus initiate an action potential.
In this way a stimulus can be encoded into action
potentials with a rate which varies according to the
intensity of the stimulus.
r Up to nine different voltage-gated sodium channels
have been identified in a single nociceptor cell mem-
brane. Individual members of such families of ion
channels are identified by established nomenclature:
e.g. ion channels specific to nociceptors have been
identifed as Nav 1.8 and 1.9 (Na, sodium; v, voltage-
gated; ‘1’ gene subfamily; ‘8’ isoform).
Nociceptor functions are initiated by ion channels and
receptors in the nociceptor cell membrane. Each
nociceptor possesses different types of ion channel.
They include transient receptor potential (TRP) ion
channels, ligand-gated ion channels and voltage-gated
ion channels.
Nociception and inflammatory mediators
When a noxious stimulus is applied, chemical mediators
such as prostaglandins, hydrogen ions and kinins are
released by the nociceptor or as a result of tissue damage.
These substances not only initiate nociception, but also
produce hyperalgesia. In addition, these agents mediate the
inflammatory process by inducing the following changes:
r Increases in local blood flow and vascular permeability
r Activation and migration of immune cells
r Release of growth and trophic factors from surround-
ing tissues
 434 SECTION 2: Physiology
Na/Ca
ions
transmembranous
polypeptide (TM)
cell
membrane
cytoplasm
anchor
Figure 19.3 Transient receptor potential (TRP) channel
Transient receptor potential (TRP) channels
r TRP channels are the ‘transducer’ channels in the
plasma membranes of a wide variety of animal and
human cells (Figure 19.3).
r They are activated by different physical and
chemical stimuli (pressure, temperature, osmotic
pressure, vibration, H+, capsaicin, cannabinoids).
r When activated, the TRP channels produce a
transient drop in resting membrane potential to
trigger action potentials and thus mediate sensory
modes such as heat and pressure sensation,
vibration sense and pain.
r At least seven subfamilies of TRP channel have
been identified.
r A prominent TRP channel in hyperalgesic
conditions is the TRPV1 (vanilloid 1) channel,
which is a calcium/sodium channel. The TRPV1
channel can also be potentiated by heat and H+,
and is inhibited by glycine or intracellular
phosphatidylinositol biphosphate (PIP2).
There are different mechanisms by which inflammatory
mediators influence nociceptor function:
r Activation of membrane ion channels, e.g. lipid
metabolite activation of TRPV1 channels, proton
activation of ASICs, ATP activation of purinergic
(P2X) channels.
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filter region
6TM subunit
gate
r Activation of G-protein-coupled receptors which
increase the activities of second messengers such as
cyclic adenosine monophosphate (cAMP) or inositol
triphosphate (IP3). These in turn may lead to structural
changes in membrane ion channels or changes in the
activity of intracellular enzymes affecting membrane
excitability.
r Activation of cytokine receptors by interleukins (IL-1)
or tumour necrosis factor α (TNF-α).
r Activation of tyrosine kinase receptors TrkA, TrkB, by
specific neurotrophic factors such as NGF (which
activates TrkA), and brain-derived neurotrophic factor
(BDNF) (which activates TrkB)
Some examples of inflammatory mediators and their
origins are shown in Figure 19.4.
The dorsal root ganglion
The dorsal root ganglion (DRG) contains the cell bodies
for all primary afferents including the nociceptors. The
primary afferent fibres are classified according to conduc-
tion velocity. Aα and Aβ fibres are the fastest group with
large cell bodies, forming about 40% of the DRG cells. Aδ
and C fibres are slower with small cell bodies, and account
for about 60% of the DRG population. Nociceptors form
the majority of the small cells. They can be further classi-
fied into peptidergic if they contain peptides (CGRP,
substance P, somatostatin) or non-peptidergic. Approxi-
mately 50% of C and 20% of Aδ fibres are peptidergic.
Although nociceptors are mainly small-cell-bodied, some
 Chapter 19: Physiology of pain 435

nociceptors also exist in the faster larger-neurone groups. syndrome (CRPS), in which abnormal overgrowth of
Specific populations of DRG neurones can be identified by the DRG by fibres from the sympathetic chain is
the expression of different neurotrophin receptors on thought to be responsible for the sympathetically main-
their cell membranes. tained symptoms and trophic changes in the
The DRG is situated in the lateral foramen between affected areas.
neighbouring vertebral bodies and is in close relation-
ship to the sympathetic chain (Figure 19.5). This ana-
tomical relationship becomes significant in chronic
The dorsal horn
Nociceptors terminate almost exclusively in the dorsal
pain conditions such as complex regional pain
horn of the spinal cord. The grey matter of the spinal
cord was divided into 10 laminae (numbered I to X) by
Rexed in 1952. The dorsal horn is composed of laminae
Figure 19.4 Some inflammatory mediators and I to VI (Figure 19.6). The majority of nociceptor fibres
their origins (Aδ and C) terminate in two areas, which are laminae
I/II (marginal layer and substantia gelatinosa) and
Mediator Source/origin lamina V. It should be noted that in addition to Aδ
Bradykinin Damaged tissue and C fibres, a small fraction of Aβ afferent fibres are
nociceptive with high-threshold mechano-heat charac-
Arachidonites Arachidonic acid
teristics. The nociceptive fibres synapse with second-
Serotonin Platelet and mast order neurones or interneurones within the dorsal horn.
cells The second-order neurones in the dorsal horn may be
Histamine Mast cells excited or inhibited by different configurations of the
nociceptors and interneurones. Sensitisation of the pri-
Cytokines (TNF-α, IL-1) Immune system mary synapse by the descending modulatory system or
Intracellular molecules (ATP, Damaged tissue interneurones can also occur in hyperalgesic states
NO) (Figure 19.7). Similarly, various configurations of the des-
cending modulatory system and interneurones may occur
Neurotrophins (NGF, GDNF, Nociceptors to inhibit transmission in the primary synapse
BDNF)
(Figure 19.8).

dorsal root
ganglion
overgrowth
rami of DRG by
communicantes sympathetic
fibres
sympathetic
ganglion

vertebral body

Figure 19.5 Anatomy of a dorsal root ganglion

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 436 SECTION 2: Physiology

nociceptor (a)
fibres nociceptor dorsal horn
neurone

C I
II
Ad and C III (b)
IV nociceptor dorsal horn
V interneurone
neurone
Ad VI

VII X (c)
descending
modulatory
VIII system sensitisation
IX
nociceptor dorsal horn
neurone

Figure 19.6 Dorsal horn laminae in spinal cord

Figure 19.7 Excitatory connections in the dorsal horn

r Gating of nociceptive signals (see The ‘gate control’

Contents of the dorsal horn theory, below)
r Sensitisation of the primary synapse
The dorsal horn contains the following neuronal
r Presynaptic inhibition of primary afferents
elements which participate in nociception:
r Relaying primary afferent signals to the appropriate
r Primary afferent axons and their synapses ascending tracts
connecting with secondary neurones or
interneurones
r Secondary neurones which project afferent Interneurone function
information to the brain via ascending tracts Interneurones form at least 90% of the neurones in the
r Interneurones which form interconnection circuits
dorsal horn. They perform multiple functions
at one level, or can ascend and descend to including sensitisation and inhibition of transmission
interconnect in other segments in the primary synapse, as well as gating and relaying
r Descending axons from supraspinal centres
nociceptive signals.
modulating nociception

Interneurones The primary synapse

The great majority of neurones in the dorsal horn are
interneurones. Inhibitory and excitatory interneurones
exist. Excitatory interneurones release glutamate as the
neurotransmitter into the primary synapse. Inhibitory
neurones use γ-aminobutyric acid (GABA) and glycine
as their neurotransmitters, and may be stimulated by
primary afferents, the descending modulatory system or
non-nociceptive primary afferents such as Aβ fibres. The
interneurones form interconnection circuits which par-
ticipate in the following aspects of dorsal horn activity:
Nociceptors are the primary afferent neurones of the pain
system; they stimulate action potentials in the dorsal horn
neurone via the primary synapse. The primary synapse is
central to the mechanism by which the pain system con-
trols its sensitivity. The main excitatory neurotransmitter
in the primary synapse is glutamate (Figure 19.9).
Primary afferents can also inhibit action potentials in
dorsal horn neurones by stimulating inhibitory interneur-
ones. The main inhibitory neurotransmitters are GABA
and glycine (Figure 19.10).

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 Chapter 19: Physiology of pain 437

(a) nociceptive afferent

descending
modulatory
system

nociceptor dorsal horn

neurone
(b)
descending
modulatory
system

nociceptor interneurone dorsal horn

neurone glutamate

(c)
descending
modulatory opioid NMDA receptors AMPA/kainate
system interneurone inhibition by producing dorsal receptors producing
postsynaptic horn sensitisation fast action potentials
m receptors
Figure 19.9 Excitation at the primary synapse
nociceptor interneurone dorsal horn
neurone non-nociceptive afferent
(d)
descending
modulatory opioid
system interneurone

glutamate

nociceptor inhibition by dorsal horn

presynaptic neurone
m receptors
inhibitory
Figure 19.8 Inhibitory connections in the dorsal horn interneurone

Synaptic transmission is also influenced by a variety of

neuromodulators which act through a spectrum of pre-
and postsynaptic membrane receptors. These modulators
include endogenous opioids, which suppress transmis-
sion, but other modulators can enhance transmission.
GABA/glycine
Neuromodulators in the pain system are described
further below.
Descending control of the primary synapse is exerted
by supraspinal centres which form the descending mod- GABA/glycine
ulatory system. This system not only can inhibit synaptic receptors producing
transmission but may also facilitate it, leading to dorsal horn inhibition
sensitisation. Figure 19.10 Postsynaptic inhibition at the primary synapse

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 438 SECTION 2: Physiology

Figure 19.11 Some examples of neurotransmitters in the pain system

Neurotransmitter Location Comments

Excitatory neurotransmitters
Glutamate Widespread throughout Main excitatory transmitter in CNS. > 50% of DRG
CNS. Primary afferents neurones. The main excitatory transmitter in
nociception, acting via ionotropic receptors (AMPA,
NMDA and kainite receptors)
Substance P Primary afferents 30% of DRG neurones, mainly small sensory afferents.
Small peptide agonist for neurokinin (NK1) receptor.
Excitatory role in ‘wind up’
Calcitonin gene- Dorsal root ganglion cells 50% of DRG neurones, both small and large pain
related peptide fibres. Released by thermal and mechanical stimuli.
(CGRP) Excitatory role in ‘wind up’
Inhibitory neurotransmitters
γ-Aminobutyric Descending modulation Potent inhibition of spinal cord neurones. Act through
acid (GABA)/ system, dorsal and ventral ligand-gated channels
glycine horn
Noradrenaline Dorsal horn and Dorsal horn inhibition
descending modulation
system
Serotonin Dorsal horn and Dorsal horn inhibition
descending modulation
system
Glutamate Dorsal horn Inhibitory effects in dorsal horn exerted via
metabotropic receptors

proteins (Figure 19.12). Some receptors (ionotropic) con-

Control of transmission in the primary synapse
Control of synaptic transmission in the dorsal horn is
therefore a result of complex interactions between
afferent, descending, ascending and interneurone
fibres (Figures 19.7 and 19.8).
trol associated ion channels. Others, such as tyrosine
kinase (Trk) receptors, signal intracellular pathways,
resulting in the synthesis and release of peptides, neuro-
transmitters or neurotrophic factors. These are metabo-
tropic receptors.

Primary synapse receptors

Neurotransmitters in the pain system
Many different synapses exist in the pain pathways of the
CNS. It is recognised that each synapse operates with
multiple transmitters. Some examples of known neuro-
transmitters in the pain system are presented in
Figure 19.11.
Receptors in the primary synapse
The presynaptic and postsynaptic membranes of the
primary synapse possess different families of receptor
Primary synapse receptors may be classified into
metabotropic receptors and ionotropic receptors:
r Metabotropic receptors activate intracellular
pathways when triggered by an agonist.
r Ionotropic receptors alter the conductivity of an
associated ion channel.
The main excitatory transmitter is glutamate, which
activates three different subtypes of ionotropic receptor

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 Chapter 19: Physiology of pain 439

Figure 19.12 Examples of primary synapse receptors

Receptor Location Comments

NMDA Postsynaptic membrane Important in producing long-lasting sensitisation by allowing
calcium influx into the projecting dorsal horn neurones.
Normally suppressed by Mg 2+, may also be blocked by
ketamine
AMPA Postsynaptic membrane Produce fast excitatory postsynaptic action potentials. The
main receptor responsible for transmission between primary
afferents and dorsal horn neurones. Mainly sodium ionophores
Kainate Postsynaptic membrane Produce slow postsynaptic potentials associated with activation
of high-threshold primary afferents. Sodium and potassium
ionophores
NK1 Metabotropic receptors activated by substance P. Activate
nociceptive dorsal horn neurones and produce hyperalgesia.
Increase intracellular Ca2+
CGRP receptors Postsynaptic membrane Produce facilitation of the dorsal horn response
Opioid δ, κ, μ Postsynaptic and Inhibition of dorsal horn neurones
presynaptic membranes
GABAA, GABAB Postsynaptic membrane Inhibition of dorsal horn neurones
GABAA increases Cl conductance and stabilises postsynaptic
membrane potential
GABAB decreases Ca2+ conductance and causes postsynaptic
membrane hyperpolarisation
α2 Presynaptic membrane Selective inhibition of nociceptive primary afferents leading to
analgesia
Serotonin Postsynaptic Inhibition of dorsal horn transmission. Some serotonin
receptors membrane, NMDA receptors associated with excitatory action
receptors

on the postsynaptic membrane. These are NMDA
(N-methyl-D-aspartate), AMPA (α-amino 3-hydroxy
5-methyl 4-isoxazolepropionic acid) and kainate receptors
(Figure 19.9). The NMDA receptor has a prominent role
in chronic pain conditions, while the AMPA receptor
mediates the transmission of fast action potentials.
In addition to these ionotropic receptors there
are modulatory receptors on the postsynaptic mem-
brane which can facilitate or inhibit action potential
formation.
The main inhibitory receptors are γ-aminobutyric acid
(GABA) and glycine receptors (Figure 19.8). Other inhibi-
tory receptors include μ and κ opioid receptors and
adenosine receptors, which are G-protein coupled.
The presynaptic nociceptor membrane has a range of
receptors which include opioid (μ, δ and κ), nicotinic and
muscarinic receptors. These also function to modulate
synaptic transmission (Figure 19.13).
Ascending tracts
The signals generated by nociception ascend to the brain
by sensory-discriminative pathways and affective path-
ways. The sensory-discriminative pathways enable a noci-
ceptive stimulus to be localised and its different qualities
to be distinguished. The affective pathways relay the noci-
ceptive signals to visceral, neuroendocrine and affective
centres in the brain to produce the multidimensional
nature of the pain response.

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 440 SECTION 2: Physiology

descending pain somatosensory cortex

inhibitory system

nociceptive afferent

NAD/serotonin thalamus

opioid
receptors

opioid
interneurone
trigeminal tract
and nucleus

decreased
glutamate endogenous
release opioid

opioid medulla

receptors
spinal lemniscus
decreased dorsal horn excitation
Figure 19.13 Presynaptic inhibition at the primary synapse

Sensory discriminative pathways Ad and C

r The spinothalamic tract (STT) is formed by fibres from
dorsal horn neurones which cross the midline and
carry touch, pinprick, pain and temperature sensations
from below the neck, to the thalamus. It is monosy-
naptic and phylogenetically the most recent of the
nociceptive pathways. It is sometimes referred to as the
‘neospinothalamic’ pathway.
r The STT terminates in the ventral posterior nucleus
(VPN) of the thalamus, and is divided into an anterior
portion mainly responsible for touch sensation and a
lateral portion responsible for pain, temperature and
pinprick modes.
r The trigeminothalamic tract – this pathway is
responsible for pain, temperature, pinprick
and touch sensations in the head and neck, to
the thalamus. Fibres from the contralateral spinal
trigeminal nucleus form this tract and again terminate
in the VPN.
Both pathways tend to lie laterally in the spinal cord and
ascend to the contralateral VPN of the thalamus, from
which they are projected to the cortex (Figure 19.14).
nociceptor fibres
spinothalamic tract
spinal cord
Figure 19.14 Sensory discriminative pain pathway
Affective pathways
r These pathways are the spinoreticular tracts, which are
multisynaptic and thought to be phylogenetically the
more primitive of the ascending tracts. They are
sometimes referred to as ‘palaeospinothalamic’
projections.
r Initially they project to brainstem areas including
the reticular formation, the parabrachial nuclei,
catecholamine cell groups and the periaqueductal
grey matter.
r Spinoreticular tracts function by integrating
incoming pain signals with visceral nuclei

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 Chapter 19: Physiology of pain 441

thalamus
projection to limbic system
projection to prefrontal cortex

hypothalamus
- neuroendocrine
function periaqueductal grey matter
- descending pain modulation

visceral nuclei
in medulla
reticular for mation
- autonomic function - conscious level

multisynaptic affective multisynaptic affective

spinoreticular pathways spinoreticular pathways
50% ipsilateral 50% contralateral

A and C
nociceptor fibres

spinothalamic tract
spinoreticular tract
Figure 19.15 Affective pain pathways

(e.g. nucleus tractus solitarius), the limbic system
and the descending inhibitory system. They
therefore mediate the emotional autonomic
responses to pain.
r Spinohypothalamic pathways ultimately connect
incoming nociceptive signals through to the hypo-
thalamus, and these are also relayed to the prefrontal
cortex. These hypothalamic connections are
reflected by the disturbance of neuroendocrine
function such as ACTH and vasopressin activity,
produced by pain. The prefrontal cortex is concerned
with the highest cerebral activities such as abstract
thought, decision making and anticipation. Such
connections enable the prefrontal cortex to influence
the response to nociceptive input.
The affective pathways assume a position medial to the
spinothalamic tract in the spinal cord (Figure 19.15).

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 442 SECTION 2: Physiology

Thalamus and surrounding structures

Ascending pain pathways
somatosensory cortex
Two types of ascending pathway transmit nociceptive
signals to the brain:
lateral ventricle
r The sensory discriminative pathway is
third ventricle
monosynaptic with cortical projection, enabling
somatosensory localisation of the noxious stimulus. thalamus
internal capsule
This is phylogenetically more recent.
r The affective pathways are phylogenetically more
primitive. They are polysynaptic, projecting to
subcortical centres and mediating affective and Ventral posterior nucleus of thalamus
autonomic dimensions of the pain response. lateral
ventricle
intralaminar nulei

The thalamus thalamus

reticular nucleus
The right and left thalami are large oval masses of neur-
ones which are located deep in the brain, forming the
lateral walls of the third ventricle. Lateral to the thalamus
on each side is the internal capsule, and above the thal- third
amus is the floor of the lateral ventricle. The thalamus is a ventricle
ventral posterior nucleus with
complex collection of nuclei with multiple connections to somatotopic organisation
the cortex and other basal ganglia. Figure 19.16 Thalamus and surrounding structures

of the cortex (S2) at the foot of the postcentral gyrus

The thalamus and pain
Although no single function can be attributed to the
thalamus, because of its complexity, one of its primary
functions is the projection of somatosensory signals
from the spinothalamic tracts and the trigeminal
nuclei, which mediates the localisation and
discrimination of painful stimuli.
The afferent nociceptive signals are received by
the ventral posterior nucleus (VPN) of the thalamus,
which is somatotopically arranged. This ‘mapping’
of the sensory signals is maintained in the thalamic
projection to the cortex, and corresponds to the
‘homunculus’ representation on the postcentral gyrus
(S1 somatosensory area).
Spinoreticular projections from the brainstem are
received in the reticular, intralaminar and some medial
areas of the thalamus. These are thought to exert an
inhibitory influence on the VPN via interconnections.
Disruption of these interconnections may underlie ‘cen-
tral’ or ‘thalamic’ pain conditions. Part of the thalamic
projection also goes to the secondary somatosensory area
(Figure 19.16).
Cortical sites of pain projection
Nociception not only activates subcortical structures such
as the thalamic and brainstem nuclei, but also activates a
network of cortical centres which is sometimes referred to
as the ‘cortical pain matrix’.
Imaging studies have consistently demonstrated acti-
vation of the following cortical areas during acute and
chronic pain:
r The primary somatosensory cortex (postcentral
gyrus, SI)
r The secondary somatosensory cortex (S2)
r The insular cortex (IC)
r The anterior cingulate cortex (ACC)
Activation of the somatosensory areas, S1 and S2,
is thought to play a role in perceiving the location
and duration of pain. The ACC, which is part of
the limbic system, and the IC, which is close to the
limbic system, are thought to be important in the
emotional, affective and motivational aspects of pain
(Figure 19.17).

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(a) Lateral aspect of cerebral hemisphere
primary somatosensory cortex (S1)
x x
secondary somatosensory cortex (S2)
(b) Horizontal section of brain (xx) insula
(c) Medial aspect of cerebral hemisphere
anterior cingulate cortex
Figure 19.17 Cortical matrix for pain
The prefrontal cortex, which is responsible for higher
cortical thought processes such as anticipation, predic-
tion and modelling based on past experience, is
also activated by noxious stimuli and can exert an
enhancing or suppressive effect on the intensity of pain
experienced. It is thought to play a part in placebo
analgesia.
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Chapter 19: Physiology of pain 443
The cortical pain matrix
This is the network of cortical centres activated by
ascending nociceptive signals. It provides a cortical
dimension to the pain experience, enabling accurate
somatic localisation of noxious stimuli as well as
predictive and affective dimensions to the pain
experience. The response of the cortical matrix can be
enhanced to increase the intensity of the pain
experience, as in hyperalgesia.
Sensitisation of the pain system
One of the characteristic features of pain which distin-
guishes it from other sensory modalities is the ability of
the pain pathways to sensitise themselves. This can be
regarded as a form of positive feedback control, in con-
trast to the familiar negative feedback control of homeo-
static physiological systems. Sensitisation is recognised as
occurring both peripherally at nociceptor level and cen-
trally in the dorsal horn.
Sensitisation is a neurophysiological term used to
describe an enhanced response of nociceptors
(peripheral sensitisation) or an enhanced efficacy of
the primary synapse in the dorsal horn (central
sensitisation). It should not be confused with the
clinical term ‘hyperalgesia’, which refers to the overall
pain response experienced and may involve
supraspinal mechanisms as well as sensitisation.
Sensitisation is mediated by chemical factors
acting through various cellular mechanisms
outlined below.
Peripheral sensitisation
Nociceptors, like other sensory receptors, are character-
ised by a response–stimulus curve. These receptors are
sensitive to thermal, mechanical and chemical stimuli,
but only respond above a certain threshold of stimulus
intensity. Peripheral sensitisation usually occurs when
tissue damage takes place, producing a shift of the noci-
ceptor response curve to the left so that the nociceptor
response is enhanced at any given stimulus intensity
(Figure 19.18). It is dependent on the release of various
substances such as inflammatory mediators, prostaglandins
and cytokines.
Peripheral sensitisation can also occur in neuropathic
pain conditions, owing to peripheral sympathetic–sensory
 444 SECTION 2: Physiology

coupling. Such conditions are referred to as sympathetic-
ally maintained pain (SMP). The underlying mechanisms
in SMP are thought to be increased adrenergic sensitivity
of sensory neurones and proliferation of sympathetic
nerve endings. Proliferation of sympathetic nerve endings
around the dorsal root ganglion has also been suggested as
a site of sympathetic–sensory coupling in chronic pain
conditions such as complex regional pain syndrome.
Central sensitisation
A number of mechanisms operate to sensitise nociception
in the dorsal horn.
sensitised
nociceptor response
r Short-term homosynaptic potentiation (‘wind-up’) –
Dorsal horn cells can produce progressively increasing
outputs in response to prolonged C-fibre nociceptor
inputs. When dorsal horn neurones are repetitively
stimulated by C fibres at low frequencies, the postsy-
naptic potentials may steadily increase in amplitude
with each stimulus. This type of sensitisation only
manifests itself in the primary synapse fed by the
stimulated primary afferent (homosynaptic) and
only occurs over the duration of the nociceptive
stimulus.
r Long-term homosynaptic potentiation – This is
a prolonged increase in the efficacy of primary
synapses which have already been activated by a period
of high-intensity nociception. NMDA receptors
(Figure 19.19) play a key role in a cascade which leads
to AMPA receptor sensitisation on the postsynaptic
membrane. Other mechanisms include presynaptic

sensitisation via tyrosine kinase receptors (Trk)

which increase the release of glutamate. This type
of potentiation may outlast the noxious stimulus by
hours or longer.
normal r Heterosynaptic sensitisation – When a nociceptive
stimulus is maintained for a period of minutes,
synapses outside the directly activated path
(heterosynaptic) will also become sensitised. This
sensitisation includes non-nociceptive (low-threshold)
afferents, such as Aβ fibres serving areas neighbouring
stimulus intensity the area receiving the noxious stimulus. Heterotopic
Figure 19.18 Nociceptor response-curve shift in sensitisation contributes to secondary hyperalgesia
hyperalgesia and can also be associated with the production

glutamate Ca2+ ions glycine

receptor receptor

transmembranous 4TM subunit

polypeptide (TM)

cell
membrane
Mg++

cytoplasm Mg2+/ketamine
blocking site
Figure 19.19 NMDA channel

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 Chapter 19: Physiology of pain 445

of muscular, joint and visceral pains, and headache.

Central sensitisation involves changes in the primary
This form of sensitisation may also outlast the
synapse (synaptic plasticity) and plays a significant
nociceptive stimulus by hours.
part in the production of neuropathic pain. These
r Transcription-dependent sensitisation – Intense
changes occur at the cellular level in the expression of
prolonged nociceptive stimulation, such as that
presynaptic and postsynaptic receptors, in the
produced by inflammation or nerve injury, produces
inhibitory mechanisms modulating synaptic
increased levels of factors including substance P and
transmission, in dorsal horn architecture and in glial
BDNF. These factors activate gene transcription
cell (astrocyte and microglia) function.
centrally in dorsal horn cells and the primary afferents
themselves. This process switches on genes in dorsal
horn neurones, leading to an increase in levels of
receptors such as NK1 and TrkB (i.e. the receptors
for substance P and BDNF). The gene activation
Modulation of pain
Pain is essential for the survival of an animal. It functions
is mediated by an intracellular kinase (extracellullar
by aiding the animal to avoid harmful external influences
signal-regulated kinase, ERK) which can enter
and it ensures that an animal takes the appropriate actions
the nucleus and promote transcription. In some
to immobilise and protect injured tissue, thus promoting
chronic inflammatory conditions the promotion
recuperation and healing. Prolongation and sensitisation
of Cox-2 transcription contributes to the systemic
of the pain response beyond the immediate occurrence of
effects of muscular aches and pains, anorexia and
tissue injury or damage is required to fulfil these
headaches experienced.
functions.
r Loss of inhibition – As described above, primary
However, under certain circumstances survival may be
afferents not only activate secondary dorsal horn
advantaged by transiently suppressing the pain response.
neurones but also inhibit them via inhibitory
This might occur in order to allow escape in the face of
GABAergic interneurones. Sustained stimulation of Aδ
threat, to ensure victory in combat, or to protect offspring.
fibres or peripheral nerve injury results in long-term
Pain modulation can thus suppress the pain experience
loss of inhibitory activity. In the case of nerve
or intensify it, and it is thought to occur at cortical,
injury this loss of inhibition involves death of the
brainstem and spinal levels. A number of mechanisms
GABAergic inhibitory neurones. GABA mimetics
are discussed in further detail below.
such as gabapentin can thus compensate for this
reduction of inhibition in neuropathic pain conditions.
Long-term loss of inhibition may also involve
resorption of AMPA receptors by dorsal horn Pain modulating mechanisms
neurones. Thus long-term sensitisation occurs via r Gate control – This is one of the earliest pain
degenerative changes in the dorsal horn in neuropathic
modulation mechanisms proposed
pain conditions. r Descending modulatory system – These pathways
r Changes in synaptic architecture – Allodynia following
originate in the midbrain and medulla and descend
nerve injury is mediated by non-nociceptive Aβ fibres
to suppress nociception in the dorsal horn. They
and associated changes in dorsal horn architecture. In
are not only known to exert an antinociceptive
particular, low-threshold Aβ afferents sprout and
effect, but can also have a pronociceptive effect,
reconnect from their normal position in laminae III
enhancing nociception. Nociceptive sensitivity is
and IV to dorsal horn nociceptive neurones in lamina
therefore a resulting balance of this bidirectional
II. This abnormal reorganisation of dorsal horn archi-
control.
tecture can be prevented by treatment with neurotro- r Neuromodulators – These modify
phins (NGF, BDNF).
neurotransmission both supraspinally and in the
r Glial cell activity – There is substantial evidence that
dorsal horn. Many modulators have been
activation of glial cells (astrocytes and microglia)
identified, both enhancing and suppressing
follows tissue injury and results in facilitation of pri-
neurotransmission. They include endogenous
mary synapses in the dorsal horn, thus leading to
opioids, orphanins and cholecystokinins.
hyperalgesia.

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 446 SECTION 2: Physiology

spinothalamic tract RVM activated by:

- morphine
- endogenous opioids
- periaqueductal
non-nociceptive grey matter (PAG)
Ab fibre
_ _
nociceptive
A and C +
fibres
rostral
ventromedial + _
medulla
OFF ON
(RVM)

spinothalamic tract
Figure 19.20 Gating mechanism

The ‘gate control’ theory primary nociceptive

The ‘gate control’ theory was first proposed by Melzack afferent neurone +
and Wall in 1965. It describes how synaptic transmission _
between primary nociceptive neurones and secondary
nociceptive neurones can be modulated or ‘gated’ by dorsal horn neurone
internuncial neurones. In particular, inhibitory interneur- Figure 19.21 PAG–RVM axis in the descending pain
ones in the substantia gelatinosa can exert presynaptic modulatory system
inhibition on primary afferent neurones and postsynaptic
inhibition on secondary neurones, thus closing the ‘gate’ bidirectional control over nociceptive transmission in
and decreasing the pain response to a nociceptive stimu- the dorsal horn via ‘on’ and ‘off’ cells (Figure 19.21).
lus (Figure 19.20). These inhibitory interneurones may be
activated by alternative non-nociceptive primary afferents The descending pain modulatory system consists of:
(e.g. Aβ mechanoreceptor afferents). This enables acti-
vated pain fibres to be ‘gated’ out by other sensations, r The nucleus raphe magnus
such as rubbing or pressure, applied to the affected area. r The locus coeruleus
r The dorsolateral pontine tegmentum
r The nucleus reticularis gigantocellularis
Examples of ‘gating’ at spinal level
r ‘Rubbing a sore spot’ These components are illustrated in Figure 19.22.
r Transcutaneous electrical nerve stimulation (TENS)
r Dorsal column electrodes
Descending modulation therefore results from the
integration of multiple inputs enabling diverse cerebral
functions such as prediction, anticipation, affect and emo-
Descending modulatory system
tion, as well as the neuroendocrine axes and autonomic
Descending modulation of nociception is mediated by a
function, to modulate the intensity of pain. This concept
network of pathways. It centres around an axis between
has implications in the management of both acute and
the periaqueductal grey (PAG) region of the midbrain and
chronic pain conditions.
the rostral ventromedial medulla (RVM).
The PAG is believed to be the main descending inhibi-
tory control over nociception. It receives inputs from the Neuromodulators in the pain system
hypothalamus, thalamus, limbic system and cortex and The neurotransmitters in the pain system are outnum-
delivers its main projections to the RVM. The RVM is bered by families of neuromodulators, which suppress or
central in a network of medullary nuclei, and exerts enhance synaptic transmission in the pain system.

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 Chapter 19: Physiology of pain 447

Families of neuromodulators exist which up-regulate

or down-regulate synaptic transmission in the pain
system, forming the basis by which the intensity of
pain is endogenously controlled.
In the primary synapse, neuromodulators released
Periaqueductal
grey matter (PAG)
by the descending pain modulatory system or by
interneurones control the ascending pain signals to
supraspinal centres.
Locus coeruleus (LC)

Nucleus reticularis
gigantocellularis (NRG)
Dorsolateral pontine
tegmentum (DPT)
Rostral ventromedial
medulla (RVM)
Nucleus raphe
magnus (NRM)
Figure 19.22 Components of the descending pain
modulatory system
Endogenous opioids
Endogenous opioids are peptides which are released
supraspinally and spinally. They have a recognised inhibi-
tory effect on the pain response and exert their effects by
their selective affinities for a number of receptors. These
receptors are the classically described μ, δ, κ receptors
together with the more recently discovered ORL1
(‘opioid-receptor like’) type.
The opioid receptors are G-protein-coupled receptors
with seven transmembrane regions and six extracellular
loops (Figure 19.24). When activated, they decrease neur-
onal excitability by inhibiting voltage-dependent sodium
channels and activating potassium and calcium channels.
Some properties of endogenous opioids are summarised
in Figure 19.25.

r Excitatory and inhibitory modulators operate in the Clinical aspects of pain

primary synapses and are responsible for producing
hyperalgesic states or analgesic states at the dorsal
horn level.
r Different neuromodulators also act at the
supraspinal level and ultimately enhance or suppress
nociception in the dorsal horn via descending
connections.
r Spinal and supraspinal interaction is important in
determining the effect of some modulators.
r A modulator released supraspinally may have the
opposite effect on nociception if released at the
spinal level.
r Simultaneous excitation of spinal and supraspinal
areas may be essential to produce some analgesic
effects.
Thus the clinical effects of neuromodulators depend on
their properties and location of action. Properties of some
of the recognised neuromodulators in the pain system are
summarised in Figure 19.23.
The complex nature of pain conditions has led to the
introduction of different methods of characterising pain.
Pain has been described by its
r Temporal variation – phasic, acute or chronic
r Physiological and pathological mechanisms
r Anatomical localisation
r Qualitative descriptors
Phasic pain, acute pain and chronic pain
A number of terms are applied as clinical descriptions of
the course of pain symptoms.
Phasic pain
This term is used to describe the short-duration often
high-intensity pain when the immediate impact of trauma
or tissue injury is experienced. It is usually accompanied
by reflex verbal or non-verbal (facial) expression, with-
drawal or protective action.

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 448 SECTION 2: Physiology

Figure 19.23 Neuromodulators in the pain system

Neuromodulator Location Comments

Excitatory modulators – enhancing nociception
Cholecystokinin 8 Dorsal horn Endogenous antiopioid
Supraspinal centres – RVM
Prostaglandins Dorsal horn Reduce the inhibitory action of glycine
and cause hyperalgesia. Suggest a role
for cyclo-oxygenase inhibitors in
hyperalgesic conditions
Dynorphin 1–17 Dorsal horn May be implicated in hyperalgesic and
allodynic conditions
Orphanin FQ/ Supraspinal inhibition of opioid action Endogenous agonist for ORL1 receptor.
nociceptin Reverses opioid analgesia when released
at supraspinal sites
Inhibitory modulators – suppressing nociception
Opioids Mesencephalon – PAG Some opioids may have excitatory effects
Basal ganglia – thalamus, amygdala producing hyperalgesic conditions.
Descending inhibitory pain system – Analgesic effects may depend on
locus coeruleus (LC) synergistic concurrent action at two sites
Dorsal horn – primary synapse e.g. PAG and LC
Cannabinoids Wide distribution of cannabinoid Analgesic effects of cannabinoids
receptors (CB1 and CB2) in CNS, probably dependent on complex
including limbic system, descending interaction between supraspinal and
pain inhibitory system, thalamus and spinal sites
spinal cord
Orphanin FQ/ Dorsal horn inhibition Gives analgesia when released at spinal
nociceptin sites
Acetylcholine Dorsal horn inhibition Inhibition of nociception mediated by
muscarinic and nicotinic receptors in
laminae I–II of the dorsal horn

m, d, k selectivity Acute pain

extracellular
transmembranous This is applied to the pain provoked by tissue damage; it
polypeptide (TM) consists of a phasic component of short duration and a
cell tonic component which is of longer variable duration
membrane (hours to days). Acute pain occurs in the period initially
G protein following trauma or surgery.
intracellular

activation of Chronic pain

G protein This is pain persisting beyond the period of time normally
increased Ca2+ and K+ conductivity expected for healing and recovery from trauma or tissue
leading to hyperpolarisation and injury. A chronic pain condition may therefore exist in
inhibition of action potentials the absence of active tissue injury or damage, and can be
Figure 19.24 Opioid receptor recognised as early as 6 weeks after trauma. Such

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 Chapter 19: Physiology of pain 449

Figure 19.25 Summarising endogenous opioid receptor Pathological pain

affinities When tissue or nerve damage occurs, pain becomes
pathological. Thus pathological pain may be classified as
Opioid Number of Receptor
amino acids affinity nociceptive or neuropathic. When tissue or nerve injury
occurs, sensitisation of the pain system is mediated
Leu- 5 δ>κ>> through the various mechanisms described above. An
enkephalin μ adaptive function of sensitisation is thought to be the
Met- 5 δ>μ>> optimisation of conditions for healing. Pain sensitisation
enkephalin κ may persist and pain may be experienced long after
healing has occurred. This type of sensitisation is mal-
β-endorphin 30 δ=μ>>
adaptive. Sensitisation results in the clinical phenomena
κ
of hyperalgesia and allodynia.
Dynorphin 17 κ
Endomorphin 4 μ
Hyperalgesia
1
Hyperalgesia is an inevitable companion of injury, and
Endomorphin 4 μ can be defined as follows:
2
Hyperalgesia – a clinically used term describing the enhanced
Nociceptin 17 ORL1 pain response resulting from sensitisation. It may arise from
both peripheral and central mechanisms.

conditions, however, are usually diagnosed some months
after a precipitating injury, and are frequently associated
with depression, social and behavioural dysfunction as
well as functional impairment. They may run a progres-
sively deteriorating course over many years.
Chronic pain conditions
Some commonly recognised chronic pain conditions are
outlined in Figure 19.26.
Physiological and pathological pain
Underlying mechanisms can be used to divide pain into:
r Physiological (normal) pain – occurring within the
bounds of normal physiological function
r Pathological (abnormal) pain – pain outside the
bounds of normal physiology
Primary hyperalgesia is localised in the zone of injury
and occurs in response to both mechanical and thermal
stimuli. Secondary hyperalgesia is produced in areas
neighbouring the primary zone and only occurs in
response to mechanical stimuli. It is contributed to by
‘heterotopic sensitisation’ (see Sensitisation of the pain
system, above).
Two distinct forms of hyperalgesia are recognised,
differing in the type of mechanical stimulus employed:
r Punctate hyperalgesia occurs in response to
pressure from a fine probe (e.g. blunt pin) and is
thought to be mediated by small-diameter nocicep-
tive fibres.
r Allodynia (stroking hyperalgesia) is a hyperalgesic
response to light stroking touch, and is mediated by
low-threshold mechanoreceptors.

Physiological pain Hyperalgesia, allodynia and sensitisation

This term describes pain caused by a noxious stimulus in r Hyperalgesia describes the enhanced pain response
the absence of actual tissue or nerve damage. Physio-
resulting from sensitisation.
logical pain therefore simply warns of impending injury, r Allodynia is a hyperalgesic response to light touch.
and can be described as nociceptive, warning of potential r Sensitisation is a neurophysiological term used to
tissue damage (e.g. painful heat sensation without occur-
describe an enhanced nociceptor response
rence of burns). In physiological pain no sensitisation of
(peripheral sensitisation) or an enhanced efficacy of
the pain system occurs.
the primary synapse in the dorsal horn (central
Examples of physiological pain include muscle cramp,
sensitisation).
tourniquet pain and abdominal colic.

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 450 SECTION 2: Physiology

Figure 19.26 Common chronic pain conditions

Condition Signs/symptoms
Complex regional pain syndrome Accompanied by abnormal perfusion, localised oedema and abnormal
Type I (reflex sympathetic sweating in the affected limb or area. Trophic changes in skin, hair and
dystrophy) – no nerve injury nails also occur. Impaired limb function is accompanied by muscle
Type II (causalgia) – nerve injury wasting and loss of bone density.
Trigeminal neuralgia Unilateral severe shooting/stabbing pains in the territory of one branch
of the trigeminal nerve. Background constant burning, gnawing pain
may be present.
Phantom limb pain Phantom sensations are felt by virtually all amputees. Severe pain only
persists in 5–10%. Stump pain also develops in 5–10%. The role of pre-
emptive analgesia is uncertain.
Post herpetic neuralgia This pain syndrome follows shingles (herpes zoster infection). Peripheral
sensitisation of nociceptors and central sensitisation of the dorsal horn
occur. Hyperalgesia, allodynia and spontaneous pain result, together
with numbness and loss of temperature sensation. Symptoms may
persist for years.
Low back pain (LBP) LBP affects a significant proportion of the population, but only 5–10%
of these become chronic LBP sufferers. Serious consequences include
reduction of individual quality of life, disability and socioeconomic costs.
A specific underlying pathology can be found in only 10% of LBP patients.
Painful neuropathies The most common cause of painful neuropathy is diabetes. Other
causes include hypothyroidism, alcohol, beriberi and drug toxicity
(isoniazid, cytotoxics). Distal symmetrical peripheral neuropathy is
present, with associated numbness, paraesthesia, hyperalgesia and
burning pain. Symptoms are often most distressing at night.

Neuropathic pain Joint pain

The concept of pathological pain gives rise to the term
neuropathic pain. Neuropathic pain is defined by the
IASP as:
Pain initiated or caused by a primary lesion or dysfunction of
the nervous system
r Inflammatory changes in the synovium, periosteum
and surrounding capsule.
r Stretching and distortion of the periosteum.
r Inflammatory changes in tendons (tendinitis) and their
insertions (enthesopathies).

Neuropathic pain does not necessarily imply physical Muscular pain

damage or destruction of nerves but may be due to
reorganisation or dysfunction of the intact nervous
system. Most chronic pain conditions will have a signifi-
cant neuropathic pain component.
Pain descriptors and localisation
Somatic pain occurs in structures such as skin, muscle and
joints. Visceral pain occurs in internal organs. Consider-
ation of the underlying mechanisms of these pains can be
useful in their management.
r Deep, intense, unpleasant sensation associated with
ischaemic muscular damage.
r Localised tenderness with referred distribution of pain
characteristic of myofascial ‘trigger points’.
r Distributed diffuse tenderness and pain associated with
chronic conditions such as fibromyalgia.
Visceral pain
r Diffuse and poorly localised because of sparse innerv-
ation and spread of spinal input over several segments.

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 Chapter 19: Physiology of pain 451

r Convergence of spinal input with somatic afferents Figure 19.27 Qualitative descriptors
which leads to referred pain in somatic structures such
as skin and muscle. Type of Characteristics
r Viscerovisceral convergence may also occur, leading to pain
referred pain in neighbouring viscera and the diffuse Sharp pain Localised, sharp sensation
nature of visceral pain. transmitted by Aδ fibres. Rapid-
r Associated with autonomic symptoms because visceral response pain
afferents often traverse prevertebral and paravertebral Dull pain/ Diffuse, dull, intense sensation
autonomic plexuses, giving rise to dual afferents. aching transmitted by C fibres. Slow-onset
r Stronger emotional and autonomic associations than
pain
with somatic pain.
Burning Mediated by TRPV receptors on
pain C and Aδ fibres
Headache
r Primary neurovascular headaches caused by activation Pinprick Mediated by Aδ fibres – mechano-
heat sensitive nociceptors
of the trigeminocervical complex by changes in intra-
cranial vasculature, e.g. migraine and cluster Itching A nocifensive sensation which
headaches. provokes a characteristic scratch
r Associated with head or neck trauma, e.g. whiplash reflex. Is subject to peripheral and
involving myofascial trigger points in neck, cranial and central sensitisation, as in chronic
shoulder musculature. pain conditions.
r Headache associated with raised intracranial pressure/
intracranial infection involving mechanical or inflam-
matory meningeal irritation. of these psychological responses can not only reduce the
r Tension type headache is the most common type of
intensity of pain symptoms but also help patients to
headache. The underlying mechanism remains reduce the impact of pain on their lives.
uncertain.

Qualitative descriptors of pain
Descriptors are commonly used by pain patients and may
be suggestive of underlying mechanisms (Figure 19.27).
Psychology of pain
The supraspinal connections of the nociceptive system
project via somatosensory and affective pathways to the
cortex, limbic system and reticular formation. These pro-
jections not only affect the intensity of the pain experi-
enced but also stimulate psychological responses, which
include:
r An emotional response
r A cognitive reponse
r A behavioural response
These psychological processes are inextricably interwoven
with the physiological process of nociception. They are
important because they play a significant part in deter-
mining the intensity of pain perceived and the effect of
pain on a patient’s life, particularly in the context of
chronic pain symptoms. Clinically, good management
Emotional response
A person’s emotional response can have a significant
effect on physiological parameters as well as analgesic
requirements in the context of acute pain. In chronic pain
patients, the emotional response can often lead to long-
term depression and anxiety, which can seriously affect
their quality of life. Pain can produce the basic emotions
of anxiety, fear, depression, anger and guilt. It is com-
monly believed that depression and anxiety not only
accompany pain symptoms but also increase their inten-
sity. Such a causal relationship remains controversial, but
it is recognised that the treatment of depression and
anxiety are an important part of pain management.
Cognitive response
The cognitive response refers to the information-
processing functions of the brain and involves the inter-
action of variables such as a patient’s pain beliefs, pain
memories and degree of attention to pain symptoms.
Maladaptive cognitive responses include catastrophising
and lack of self-efficacy (low self-confidence). Use of the

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 452 SECTION 2: Physiology
patient’s cognitive responses to produce coping strategies
is a useful part of a pain management programme.
Behavioural response
This refers to the learned patterns of behaviour resulting
from the emotional and cognitive responses. Behavioural
responses can be adaptive or maladaptive, producing
either a beneficial or a detrimental effect on a patient’s
quality of life. Manipulation of behavioural responses may
be useful in managing patients with chronic pain.
Pain management
The management of pain is multidisciplinary, corres-
ponding to the multiple physiological and psychological
mechanisms which determine the intensity of pain
experienced.
In the clinical setting, pain management divides into
acute pain and chronic pain management. Acute pain
usually focuses on postoperative pain, and is increasingly
being managed outside the recovery room by an acute
pain team. Chronic pain on the other hand is managed by
the multidisciplinary team of a pain management service,
which will operate through pain clinics, day-case proced-
ure lists, specialist nurse-led clinics and a pain manage-
ment programme.
Acute (postoperative) pain management
The mechanisms underlying acute pain are mainly those
of nociception, with a limited degree of sensitisation per-
ipherally and centrally. Supraspinal effects are minimal,
with anxiety and fear contributing to the pain experienced
to a limited extent. Pain management techniques rely on
modifying the nociceptive process and involve the use of
drugs administered by the oral and parenteral routes
together with local anaesthetic techniques.
Chronic pain management
In chronic pain conditions, the effect of central sensitisa-
tion at the dorsal horn level, and of supraspinal mechan-
isms, is more pronounced. A multidisciplinary team is
essential, and pain management may involve multiple
inputs in order to achieve a satisfactory result. The
approaches used may include:
r Pharmacology
r Local anaesthetic techniques
r Physiotherapy
r Complementary therapies
r Psychological techniques
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Pharmacology
The range of drugs used in the pharmacological approach
to chronic pain management reflects the diverse physio-
logical factors that determine chronic pain levels. Many
exert their effects by multiple actions. They include those
listed in Figure 19.28.
Local anaesthetic techniques
These methods include spinoaxial blockade, peripheral
nerve blocks and sympathetic blockade. In some cases neu-
rolytic blockade may be useful, either with a chemical agent
such as phenol or using radiofrequency (RF) lesioning.
Physiotherapy
Physiotherapy remains an essential component of chronic
pain management. It reduces pain levels and improves
function. In order to reduce pain, physiotherapy employs
techniques such as massage and manipulation, injections,
acupuncture and acupressure, ultrasound and the appli-
cation of heat and ice. Active management of rehabili-
tation is crucial in minimising the impact of injury and
pain on a patient’s life, and is a major part of the physio-
therapist’s role.
Complementary techniques
These methods include:
r Osteopathy – a system of medicine based on the
principle that many disease conditions can be
improved by musculoskeletal manipulation, which
reverses dislocations and malalignments in the
body’s musculoskeletal framework, thus allowing
the body to heal itself. This is essentially a holistic
approach to the patient.
r Chiropractic – an alternative system of treatment by
musculoskeletal manipulation which focuses on
treating ‘subluxations’ and ‘malpositioning’ of verte-
bral segments in order to allow the body to heal itself.
In common with osteopathy, chiropractic is also a
holistic approach to the patient.
r Acupuncture – has been imported from traditional
Chinese medicine and is based on restoring the flow of
‘chi’ (interpreted as ‘energy’) through a system of
14 meridians in the body by dry needling. The success
of acupuncture has led to extensive research into
its mechanisms over the past 30 years or more
but the picture still remains incomplete, although
endorphin release is believed to form an integral
part of the process.
 Chapter 19: Physiology of pain 453

Figure 19.28 Some useful drugs in chronic pain management

Type of drug Example Comment

Opioids Morphine, oxycodone, Action by opioid receptors
buprenorphine
Non-steroidal Ibuprofen, diclofenac, Ibuprofen and diclofenac are non-selective COX inhibitors
analgesics celecoxib Celecoxib is a selective COX-2 inhibitor
Tricyclic Amitriptyline, Inhibit presynaptic uptake of serotonin and noradrenaline in
antidepressants imipramine descending inhibitory system
Block sodium and calcium ion channels
Block postsynaptic muscarinic and histamine receptors
Anticonvulsants Carbamazepine, Both block voltage-dependent sodium channels
phenytoin Carbamazepine also has serotonergic effects
GABA mimetics Gabapentin, pregabalin Increase GABA concentrations in some areas of the brain
Modulation of voltage-gated calcium channels
Antispasmodics Buscopan, baclofen Both relax smooth muscle spasm
Baclofen also decreases skeletal muscle tone
Anxiolytics Diazepam, temazepam Also relax skeletal muscle spasm
α2-Agonists Clonidine, tizanadine Systemic effect in reducing neuropathic pain
Local effect, reducing allodynia
NMDA Ketamine Has been used to treat chronic pain state by infusion
antagonists
Combination Tramadol Opioid action, and increases serotonin and noradrenaline
activities in the descending inhibitory system

r Reflexology – a system of treating patients by stimulat-
ing nerves on the feet, hands, and ears. Again the prac-
titioners operate on the basis of restoring balance to
the flow of ‘chi’ in the patient’s body. It is believed that
the body has a topographical representation over the
soles of the feet, as well as on the hands and the ears.
r Homeopathy – a holistic system of medicine based on
treating ‘like with like’, using medicines in which the
active ingredient has been diluted to virtually
undetectable levels. The active ingredient if given in
adequate concentrations is thought to reproduce the
original patient’s symptoms. The dilution process
producing the medicines involves vigorous shaking of
the solutions (‘succusion’) which is thought to leave
an ‘imprint’ of the solute molecules in the aqueous solu-
tion. Homeopathy is generally accepted as being a safe
form of treatment and is compatible with other forms of
therapy, but mechanisms of action remain unproven.
The underlying mechanisms of complementary thera-
pies remain uncertain, but they may succeed in cases
where other therapies fail. Although such complemen-
tary therapies are accepted by many workers in chronic
pain management, their use remains controversial due
to difficulties in evaluating their effects objectively. The
possibility of the placebo effect being the primary
underlying mechanism is questioned by the successful
application of many of these techniques in veterinary
practice.
Psychological techniques and pain management
programmes
Clinical psychologists are an integral part of the pain
management team. As seen throughout this chapter,
pain levels are influenced significantly by the activity of
cortical centres and the limbic system. Psychological tech-
niques have long been recognised as playing an important
part in helping patients to cope with chronic pain symp-
toms. This is particularly so in the context of pain man-
agement programmes, which provide a structured course
of training for patients in psychological and physical
methods.

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