Chapter 004

Chapter 4
Pain
Copyright © 2019 by Elsevier Inc. All rights reserved.

Pain
 Unpleasant sensation
 Discomfort caused by stimulation of pain receptors
 Body defense mechanism
 Warning of a problem
 Complex mechanisms
 Many not totally understood
 Subjective scales
 Developed to compare pain levels over time
2
Causes of Pain
 Inflammation
 Infection
 Ischemia and tissue necrosis
 Stretching of tissue
 Stretching of tendons, ligaments, joint capsule
 Chemicals
 Burns
 Muscle spasm
3
Somatic Versus Visceral Pain
 Somatic pain
 From skin (cutaneous)
 Bone muscle
 Conducted by sensory fibers
 Visceral pain
 Originates in organs
 Conducted by sympathetic fibers
 May be acute or chronic
4
Pain Pathways
 Nociceptors (pain receptors) are free sensory
nerve endings.
 May be stimulated by:
 Temperature
• Extremes of temperature
 Chemicals
• Examples: acids, bradykinin, histamine, prostaglandin
 Physical means
• Example: pressure
5
Pain
 Pain threshold
 Level of stimulation required to elicit a pain response
 Usually does not vary among individuals
 Pain tolerance
 Ability to cope with pain
 Culturally related
 Varies among individuals
6
Pain Pathways
 Nociceptors
 Stimulated by
• Thermal means: extreme temperatures
• Chemical: For example, acids or chemicals produced by
body (e.g., bradykinin, histamine, prostaglandin)
• Physical: pressure
7
Pain Fibers
 Afferent fibers
 Myelinated A delta fibers
 Transmit impulses very rapidly
 Acute pain
• Sudden, sharp, localized
 Unmyelinated C fibers
 Transmit impulses slowly
 Chronic pain
• Diffuse, dull, burning, or aching sensation
8
Pain Pathways
 Dermatome
 Area of skin innervated by a specific spinal nerve
 Somatosensory cortex → “mapped”
• Corresponds to source of pain stimuli
 Reflex response (efferent response)
 Involuntary muscle contraction away from pain source
 Involuntary muscle contraction to guard against
movement
9
Pain Pathways (Cont.)
 Spinothalamic bundle in the spinal cord
 Neospinothalamic tract → fast impulses; acute pain
 Paleospinothalamic tract → slow impulses; chronic,
dull pain
 Spinothalamic tracts connect with reticular formation
of brain
10
 Somatic sensory area in the cerebral cortex
located in the parietal lobe
 Perception and localization of sensation
 Hypothalamus and limbic system
 Emotional factors
 Communication with other regions of the brain to
integrate responses
 Reticular activating system (RAS)
 Reticular formation in the pons and medulla
 Awareness of incoming brain stimuli
11
12
Physiology of Pain and Pain Control
 Gate control theory

 Control systems, “gates” built into normal pain
pathways
 Can modify pain stimuli conduction and transmission
in the spinal cord and brain.
 Gates open
• Pain impulses transmitted from periphery to brain
 Gates closed
• Reduces or modifies the passage of pain impulses
13
Pain Control―Gate Open
14
Pain Control―Gate Closed
15
Pain Control
 Application of ice
 Impulses from temperature receptors close gates.
 Transcutaneous electrical nerve stimulation
(TENS)
 Increases sensory stimulation at site, blocking pain
transmission.
 Opiate-like chemicals (opioids)
 Secreted by interneurons of the CNS (endogenous).
 Block conduction of pain impulses to the CNS
 Resemble morphine
• Enkephalins, dynorphins, beta-lipoproteins
16
Signs, Symptoms, and Diagnosis of
Pain
 Location of pain
 Descriptive terms
 Aching, burning, sharp, throbbing, widespread,
cramping, constant, periodic, unbearable,
moderate
 Timing of pain
 Association with an activity
 Physical evidence of pain
 Pallor and sweating
 High blood pressure, tachycardia
17
Pain (Cont.)
 Nausea and vomiting
 May occur with acute pain.
 Fainting and dizziness
 May occur with acute pain.
 Anxiety and fear
 Frequently evident in people with chest pain or
trauma
18
Pain (Cont.)
 Clenched fists or rigid faces
 Restlessness or constant motion
 Guarding area to prevent stimulation of
receptors
19
Young Children and Pain
 Infants respond physiologically
 Examples: tachycardia, increased blood pressure,
facial expressions
 Great variations in different developmental
stages:
 Different coping mechanisms
 Range of behavior
 Often have difficulty describing the pain
 Withdrawal and lack of communication in older
children
20
Referred Pain
 Source may be difficult to determine.
 Pain may be perceived at site distant from
source.
 Characteristic of visceral damage in the abdominal
organs
 Heart attack or ischemia in the heart
21
Location of Referred Pain
22
Phantom Pain
 Usually in adults
 More common if chronic pain has occurred.
 Can follow an amputation
 Pain, itching, tingling
 Usually does not respond to common pain
therapies.
 May resolve within weeks to months.
 Phenomenon not fully understood
23
Pain Perception and Response
 Pain tolerance
 Degree of pain, intensity, or duration
 May be increased by endorphin release.
 May be reduced because of fatigue or stress.
 Varies among people in different situations.
 Pain perception
 Subjective but can be compared from day to day in
same person.
 Response to pain
 Influenced by personality, emotions, and cultural
norms.
24
Acute Pain
 Usually sudden and severe, short term
 Indicates tissue damage.
 May be localized or generalized.
 Initiates physiologic stress response.
 Increase blood pressure and heart rate; cool, pale,
moist skin; increase respiratory rate; increase skeletal
muscle tension
 Vomiting may occur.
 Strong emotional response may occur.
25
Chronic Pain
 Occurs over extended time; may be recurrent.
 Usually more difficult to treat than acute pain
 Often perceived to be generalized.
 Individual may be fatigued, irritable, depressed.
 Sleep disturbances common
 Specific cause may be less apparent.
 Appetite may be affected.
 Can lead to weight gain or loss.
26
Chronic Pain (Cont.)
 Frequently affects daily activities.
 Accommodation and pacing of activities may be
required.
 Periods of acute pain may accompany chronic
pain conditions.
 Usually reduces tolerance to additional pain.
27
Comparison of Acute
and Chronic Pain
28
Headache: Types and Causes
 Congested sinuses, nasal congestion, eye strain
 Muscle spasm and tension
 From emotional stress
 In temporal area
 Temporomandibular joint syndrome
 Migraine
 Abnormal blood flow and metabolism in the brain
 Intracranial headaches
 Increased pressure inside the skull
29
Headache: Types and Causes (Cont.)
 Central pain
 Caused by dysfunction or damage to the brain or spinal
cord
 Neuropathic pain
 Caused by trauma or disease involving the peripheral
nerves
 Ischemic pain
 Results from a profound, sudden loss of blood flow to an
organ or tissue
 Cancer-related pain
 Caused by advance of the disease; pain associated with
treatment; result of coexisting disease
30
Methods of Managing Pain
 Remove cause of pain as soon as possible
 Use of analgesic medications
 Orally
 Parenterally (injection)
 Transdermal patch
 Classified by ability to relieve
• Mild pain
• Moderate pain
• Severe pain
31
Analgesic Drugs
32
Methods of Managing Pain (Cont.)
 Sedatives and antianxiety drugs

 Adjuncts to analgesic therapy
 Promote rest and relaxation
 May reduce dosage requirements for analgesic
 Chronic and increasing pain
 May occur in cancer.
 Stepwise fashion to reduce pain
 Tolerance to narcotics develops over time.
• Increase dose requirements.
• New drug may be required.
33
Methods of Managing Pain (Cont.)
 Severe pain
 Patients administer medication, as needed.
 Patient-controlled analgesia (PCA)
 Lessens overall consumption of narcotics
 Intractable pain
 Cannot be controlled with medication.
 Surgical intervention is a choice.
• Rhizotomy
• Cordotomy
• Injections
34
Anesthesia
 Local anesthesia
 Injected or applied to skin or mucous membranes
 Spinal or regional anesthesia
 Blocks pain from legs or abdomen.
 General anesthesia
 Causes loss of consciousness (gas or injection).
 Neuroleptanesthesia
 Patient can respond to commands.
 Relatively unaware of procedure, no discomfort
35
Anesthetics
36

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Chapter 4

Copyright © 2019 by Elsevier Inc. All rights reserved.

 Gate control theory

 Sedatives and antianxiety drugs

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