Mechanisms of pain

Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for
individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is
the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the
Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these
materials, or for any errors or omissions. Last updated on January 12, 2015
Objectives for this module

• Discuss the ways pain can be characterised

– Duration
– Mechanism
– Origin
– Situation

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Characterisations of pain

Pain can be described by its:

• Duration – acute or chronic
• Mechanism – nociceptive or neuropathic
• Origin – somatic or visceral
• Situation – incidental pain, breakthrough pain, procedural
pain

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Different mechanisms of pain

Why are they important?

• Pathophysiology is different
• Presentation is different
• Management is different

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Duration: acute vs. chronic pain

Acute pain
• Presentation: characterized by help-seeking behavior such as
crying and moving about in a very obvious manner
• Cause: definite injury or illness
• Signs/symptoms:
– Definite onset with limited and predictable duration
– Clinical signs of sympathetic over-activity: tachycardia,
pallor, hypertension, sweating, grimacing, crying, anxious,
pupillary dilation
• Example: trauma, surgery, or inflammation

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Duration: acute vs. chronic pain

Chronic pain
• Presentation: Patients may not show signs of distress seen in
acute pain
• Cause: chronic pathological process
– Under-treatment of acute pain can lead to changes in the
central nervous system that result in chronic pain
• Signs/symptoms:
– Gradual or vague onset
– Continues and may become progressively more severe
– Patient may appear depressed and withdrawn
– Usually no signs of sympathetic over-activity

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Mechanism: nociceptive pain

Nociceptive pain: caused when nerve receptors called

nociceptors are irritated. Nociceptors exist both internally
(visceral) and externally (somatic)
• Indicates that nerve pathways are intact

Beating Pain, 2nd Ed. APCA (2012); Introductory Palliative Care Course for Health Care Professionals (Uganda); PCAU/MOH (2013).7
Nociceptive pain: somatic pain

Somatic pain: stimulation of nociceptors in the skin, soft tissues,

muscle, or bone
• Pain usually is in a particular location
• Aching, throbbing, or persistent pain
• Causes: bone or soft tissue infiltration

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Nociceptive pain: visceral pain

Visceral pain: stimulation of nociceptors in internal organs and

hollow viscera organs
• Pain is often not in a single location
• Described as pressure, cramping, or squeezing pain
• Causes: blockage, swelling, stretching, or inflammation of the
organs from any cause

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Mechanism: neuropathic pain

Neuropathic pain: caused by damage to nerve pathways

• Described as burning, prickling, stinging, pins and needles,
insects crawling under skin, numbness, hypersensitivity,
shooting, or electric shock
• Causes: infiltration by cancer, HIV infection, or herpes zoster,
drug-related peripheral neuropathy, central nervous system
injury, or surgery

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Situation

• Incident pain – occurs only in certain circumstances (e.g. after

a particular movement)
• Breakthrough pain – a sudden, temporary flare of severe pain
that occurs on a background of otherwise controlled pain
• Procedural pain – related to procedures or interventions

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Assessment

Jane has come to your clinic with pain she’s describing as

constant shooting pain in her feet for the past four days. How
would you classify her pain?
A. Procedural pain
B. Chronic, visceral pain
C. Acute, neuropathic pain
D. Acute, incident pain

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Take home message

• Knowing the differences in the mechanisms of pain is

important to adequately and appropriately treat the pain

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References

• African Palliative Care Association. Beating Pain: a pocketguide for pain management in
Africa, 2nd Ed. [Internet]. 2012. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf
• African Palliative Care Association. Using opioids to manage pain: a pocket guide for
health professionals in Africa [Internet]. 2010. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/using_opiods.pdf
• Amery J, editor. Children’s Palliative Care in Africa [Internet]. 2009. Available from:
http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-in-Africa-
Full-Text.pdf
• Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet].
2010. Available from: http://www.iasp-
pain.org/files/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_Manag
ement_in_Low-Resource_Settings.pdf
• The Palliative Care Association of Uganda and the Uganda Ministry of Health.
Introductory Palliative Care Course for Healthcare Professionals. 2013.

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