MONIQUE MAVRONICOLAS PAIN

The main objective of this paper is to define, analyse and understand what is meant by the term pain. The aim will be to explore different
causes and types of pain as experienced by human beings, with a view to reaching an understanding of appropriate types of management
techniques associated with the relief of pain.
Pain is difficult to quantify since humans all perceive pain differently. In effect, this complicates the efforts to reach a consensus as far as
defining pain is concerned, as one persons experience of pain and trying to express this into words, could differ vastly from someone
elses experience. In medical terms, pain can be defined as, an unpleasant feeling that is conveyed to the brain by sensory neurons. The
discomfort signals actual or potential injury to the body. (http://medical-dictionary.thefreedictionary.com/pain). Thus, at the very least
understanding, pain can be understood to be a stimulus which the body perceives to be unpleasant. In addition this stimuli signal relays a
warning to the brain that the body faces potential injury.
However, pain is more than just a physical awareness or a sensation which includes the subjective interpretation of discomfort. Ones
perception will be a translation of neurological sensory stimuli as to where the pain is situated, how strong or intense the pain is and what
kind of pain it is. The factors above, which include sensory stimuli and related emotional responses, will add to a holistic definition of the
overall definition of pain. Therefore one can define pain as the way ones brain interprets information with regards to a specific external or
internal stimulus that the body experiences. However many factors can influence the way that ones brain interprets the stimuli signals of
pain, such as age, gender, sleep, diet and illness.
Two types of pain can be differentiated; chronic pain and acute pain. Acute pain is usually pain that is short lived and intense, which
may indicate an injury and as soon as the injury heals, the pain ceases. Chronic pain on the other hand is usually a sensation that lasts
longer (typically 6 weeks or more) and can be moderate or severe in terms of intensity.
We classify pain in different classes, the main two classes are nociceptive and non-nociceptive pain. According to Walker (2002),
Nociceptive pain comes from where specific pain receptors are stimulated. These receptors could respond to heat, cold vibration, stretch

MONIQUE MAVRONICOLAS PAIN

and chemical stimuli to release from damaged cells. Whereas Non-Nociceptive pain arises from within the peripheral and central nervous
system. Specific receptors do not exist here, with pain being generated by nerve cell dysfunction.

Table 1 (http://www.painclinic.org/aboutpain-paintypes.htm) below lists the four pain sub-classifications namely somatic, visceral,
neuropathic and sympathetic, along with brief discussions and examples indicating the source, receptors activated, characteristics,
medications that could be used, features and examples.

Source

Somatic
Tissues such as skin,

Visceral
Internal organs such as

Neuropathic
Originate within the

Sympathetic
A probable over-stimulated

bones, joints, ligaments

the thorax (lungs and

nervous system a

SNS (sympathetic nervous

and muscle - often

heart), abdomen (spleen,

trapped or pinched

system), CNS (central

referred to as

bowls, liver and kidneys)

nerve. The pain originate

nervous system) and the

musculoskeletal pain

and pelvis (bladder,

from either the PNS

PNS (peripheral nervous

womb, and ovaries).

(peripheral nervous

system) mechanisms.

Visceral

system)
Neuropathic

Sympathetic

Somatic

MONIQUE MAVRONICOLAS PAIN

Receptors

Specific nociceptors for

Specific nociceptors for

There are no specific

Like nerve pain there are no

Activated

vibration, heat, stretch

inflammation, stretch and

non-nociceptive

specific non-nociceptive

within the muscles, cold,

oxygen starvation

receptors in the nervous

receptors in the nervous

inflammation like sprains

(ischaemia).

system for pain. If one

system for pain The same

and cuts which cause

injures a nerve, the

processes as mentioned to

tissue disruption and

nerve becomes

the left in Neuropathic may

ischaemic muscle cramps

electrically unsteady,

operate in Complex

which is due to oxygen

shooting off signals in a

Regional Pain Syndrome,

starvations

completely erroneous,

previously known as Reflex

arbitrary, and disordered

Sympathetic Dystrophy

Characteristics

Medication

Easily located as it is

Often difficult to pin point

fashion.
The brain interoperates

The sufferer will often not

frequently a sharp and

but in a region and feels

the signals as pain, this

use the limb as it would be

limited to a small area,

like deep ache within the

could be connected with

to painful. This could lead to

and can often be

body, sometimes

signs of the nerve

more problems after some

reproduced by touching or

cramping or colicky. This

malfunction such as

time and could cause joint

moving the area or tissue

often It often results in

tingling, hypersensitivity

contractures, muscle

involved.

referred pain to the back

(touch, hot, vibration and

wasting and osteoporosis of

(usually lower back) and

cold), numbness, and

the bones. It is possible that

pain with in the abdomen

weakness. It is often

it could be caused by

referring pain to the mid-

described as shooting,

trauma to small peripheral

Somatic
May respond to

back.
Visceral
Very responsive to weak

burning pain.
Neuropathic
Somewhat sensitive to

nerves close to the injury.

Sympathetic
Nerve pain medications

combinations of

and strong opioids

paracetamol, NSAIDs,

may be useful as allot of the

3

MONIQUE MAVRONICOLAS PAIN

Features

Paracetamol Strong or

opioids, however more

symptoms are the same.

Weak Opioids and NSAID

sensitive to Anti-

Treatment should include

convulsants, anti-

appropriate multi-modal

depressants, anti-

medications, intensive

arrhythmic and NMDA.

rehabilitation combining

Something else that may

occupational, sympathetic

be helpful would be

nerve blocks and

Antagonists and Tropical

physiotherapy

Aching, often constant

Constant or crampy,

Capsaicin
Burning, squeezing,

Extreme hypersensitivity in

But may be dull or sharp,

aching, poorly localized,

tingling, itching

the skin around the injury

gets worse with

often referred

stabbing, aching, shock-

and superficially in the limb.

like, electric shooting

Abnormal sweating and

movement, can pin point

temperature control in the

Examples

Bones, soft tissue and

CA pancreas

Diabetic neuropathy

area
Limb Fractures or soft

chest wall

Liver capsule distension

Post-herpetic neuropathy

tissue damage

Bowel obstruction

trigeminal neuralgia
may be a component of
any neuropathic pain

Depending on the cause of pain, pain management could be simple or complex. Often simple causes could be treated with medication, but
at other times a variety of skills and techniques are required to treat pain. This could include:

Medication management
4

MONIQUE MAVRONICOLAS PAIN

Physical therapy or chiropractic therapy

Interventional procedures
Alternative therapies including Acupuncture
Counselling and support
Referral to Specialists

Because pain can influence many aspects of ones everyday life, in terms of managing pain, these skills and services prove necessary.
Medication management includes several different analgesics (painkillers or pain relievers) that will provide short term pain relief. There are
several different analgesics that could be used for different types and classification of pain as well as other medications that one could use to
assist in pain treatment. Below, a detailed description of various medications and how each of them function. These consist of NSAIDs, COX-2Inhibitors, Opioid Analgesics or Narcotic Analgesics (but generically distinguished as painkillers), as well as combination analgesics.

NSAIDs (Non-Steroidal Anti-inflammatory Drugs) - These are used for reducing inflammation and pain by reducing the proinflammatory (prostaglandins) through the inhibition of COX (Cyclooxygenase). Unfortunately they have no effect on the perception
of pain examples Naproxen, Ibuprofen and Aspirin. The best way to describe NSAIDs and the way they work within the body
according to Dr. Ogbru a pharmacist, is Prostaglandins are a family of chemicals that are produced by the cells of the body and
have several important functions. They promote inflammation that is necessary for healing, but also results in pain, and fever;
support the blood clotting function of platelets; and protect the lining of the stomach from the damaging effects of acid.
Prostaglandins are produced within the body's cells by the enzyme cyclooxygenase (COX). There are two COX enzymes, COX-1
and COX-2. Both enzymes produce prostaglandins that promote inflammation, pain, and fever. However, only COX-1 produces
prostaglandins that support platelets and protect the stomach. Nonsteroidal anti-inflammatory drugs (NSAIDs) block the COX
enzymes and reduce prostaglandins throughout the body.
(http://www.medicinenet.com/nonsteroidal_antiinflammatory_drugs/article.htm)

MONIQUE MAVRONICOLAS PAIN

COX-2 Inhibitors - These drugs are a subclass of NSAIDs According to Annette (Gbemudu) Ogbru, PharmD, Unlike older
NSAIDs that block both COX-1 and COX-2, the newer COX-2 inhibitors only block the COX-2 enzyme. Since COX-2 inhibitors do
not block COX-1 (which primarily produces prostaglandins that protect the stomach and promote blood clotting) they do not cause
ulcers or increase the risk of bleeding as much as the older NSAIDs. Nevertheless, COX-2 inhibitors are as effective as the older
NSAIDs for treating inflammation, pain and fever (http://www.rxlist.com/cox-2_inhibitors/drugs-condition.htm) There is only one
current example of COX-2 on the market namely Celecoxib (Celebrex)

Opioid Analgesics or Narcotic Analgesics (Painkillers) - These drugs act directly on the Central Nervous System and are unique in
that they have the ability to block incoming nociceptive signals, but are also able to control affective components in the brain for the
relief of pain on different receptors in the brain and spinal cord. Examples of mild opioids include codeine and dihydrocodeine and
strong opioids include: diamorphine, morphine, oxycodone, and pethidine.

Combination Analgesics - They contain more than one type of painkiller in one tablet. This combination is often more effective when
they work through different analgesics mechanisms and synergistically. Examples include Co-codamol, Co-codaprin and Codydramol.

Medication management is often just a short term solution for pain, but unfortunately they do not treat the source or cause of the pain.
Medical professionals follow formal protocols to identify the cause of the pain, attempting to effectively manage acute pain to improve the
patient outcomes and reduce incidence of side effects that might lead to chronic pain. According to an article in the British Medical Journal
published in 2009, back pain effects more than 80% of adults in the UK some or other time in their life, with more than 50% of adults reporting
lower back pain that lasts typically more than 24 hours at some time in the course of a year.

MONIQUE MAVRONICOLAS PAIN

In terms of the physiology of the back, the region consists of muscles, joints, nerves, bones, as well as tissue and this anatomical region
protects some major organs. With these anatomical complexities, it often makes it extremely difficult to pin-point the exact location of pain.
Most cases of back pain is acute and often not serious. There are numerous factors which, in daily life, could potentially contribute to lower
back pain. These factors or physical stressors include lifting, carrying, slouching, twisting, over-stretching, pulling heavy objects, driving for
extended hours and overusing the back muscles. Additionally, there are certain risk factors which could increase ones chances of
contracting back pain. These include psychological stress, being overweight, smoking, depression and long-term use of certain
medications. A small number of incidents of back pain are caused by specific medical conditions such as; frozen shoulder, whiplash,
prolapsed or herniated disk (also known as slipped disk), sciatica, shoulder pain and ankylosing spondylitis.
According to the NHS website, A slipped disc occurs when the circle of connective tissue surrounding the disc breaks down. This
allows the soft, gel-like part of the disc to swell and protrude out (http://www.nhs.uk/Conditions/Slipped-disc). The cause of a herniated disk
is often the result of age but it is not clear what the causes are for the connective tissue to break down. There are certain factors that could
put additional strain on the spine that could weaken the disk tissue and cause a slipped disk, such as lifting heavy or awkward items, certain
jobs that require long distance driving or extended periods of sitting, smoking, being overweight or any distressing injuries to the back. In
some cases one could have a slipped disk for years and not be cognisant of it.
A slipped disk could be classified as an acute, nociceptive, somatic pain often referred to as muscular skeletal pain however the slipped
disk could also cause non-nociceptive neuropathic pain from compression and inflammation on the nerve root. Thus, in this case, treatment
should be both for the somatic and neuropathic pain components. Treating a slipped disk involves combination therapy, starting with
medication management often a combination of Paracetamol, Opioids (strong or weak, depending on the scale of the patients pain) and
NSAID to relieve the pain. The medication will be prescribed based on each individual patients needs and history. In addition to medication
management, one could be referred to a physiotherapist, chiropractor, or osteopath for manipulation. In these cases, exercise is often
suggested and advised.

MONIQUE MAVRONICOLAS PAIN

Lumbar spine illustration, depicted in Figure A below (http://www.nhs.uk/Conditions/Slipped-disc) - reflects the difference of a healthy disk,
slipped disk, damaged disk and the impact on the spinal cord and nerves

1. Healthy disc
2. Nerve
3. Slipped disc
4. Damaged disc
5. Spinal cord

MONIQUE MAVRONICOLAS PAIN

It could take between 4 and 6 weeks to recover from a slipped disk. Often after the inflammation has decreased and the slipped disk
has shrunk away from the nerve, the pain will ease, there are times where the pain goes away due to the brain becoming use to the pain
coming from the nerve and accepts is as the norm.
There are certain steps one could follow to prevent and assist in healthy spine management like, ensuring your use safe lifting
techniques, maintain a healthy weight, do regular exercise to strengthen your core muscles, and the muscles in the legs, back and
abdomen, refrain from sitting for long periods of time, and stretch regularly.
In severe circumstances a slipped disk can cause loss of control over the bladder and bowels, pins and needles in the saddle region, pain
in thighs and could cause paralysis in one or both legs. In most of these circumstances surgery will be an option after an MIR have established
where and how much damaged the disk has caused to the nerve.
Kidney pain (also known as flank pain) on the other hand could be either acute or chronic nociceptive visceral pain. Depending on the
cause of kidney pain is could either be an acute sudden sharp pain on the side of the back or could become a chronic dull pain with occasional
sharp pains. There are various things that could cause kidney pain. Children and women are more susceptible to urinary tract infections (UTI),
most commonly it is be due to bacteria from the anus enter through the urethra accidently into the bladder and up to the kidneys. Other causes
include, obstruction within the urinary tract like kidney stones, weakened immune system due to type 2 diabetes, a catheter, sexual intercourse,
alcohol and even being pregnant.
Treatment for kidney pain depends on the cause, kidney stone will be treated with NSAIDs whereas UTIs will be treated with paracetamol.
The analgesics are only to treat the pain associated with the cause and will not resolve the problem or cause. Most kidney related treatments
will include a strong antibiotic for 7-14 days in conjunction with hydration to assist the kidneys to flush the toxins out. In severe cases your
practitioner might refer you to an Urologist for further treatment.

MONIQUE MAVRONICOLAS PAIN

Non-nociceptive Neuropathic pain is one of the most difficult pains to access the cause of the pain due to the nature of the pain, Doctor
however, there are several known causes including; alcohol abuse, certain medications, diabetes, trauma, stroke, tumour compressing nerves
and multiple sclerosis.
Diabetics often suffer from pain, numbness and tingling sensation in their feet, this is due to the damage the diabetes have caused to the
peripheral nerves, particularly the nerves in the feet and legs.
The best way to treat diabetic peripheral neuropathy is with antidepressant medication. According to the Mayo Clinic The painkilling
mechanism of these drugs still isn't fully understood. Antidepressants may increase neurotransmitters in the spinal cord that reduce pain
signals. But they don't work immediately. You may feel some relief from an antidepressant after a week or so, but maximum relief may take
several weeks. People generally experience moderate pain relief from antidepressants (http://www.mayoclinic.org/pain-medications/art20045647)

10

MONIQUE MAVRONICOLAS PAIN

References
What is pain? What causes pain - http://www.medicalnewstoday.com/articles/145750.php accessed 27 December 2014
Introduction to pain management - available at http://www.medicinenet.com/script/main/mobileart.asp?articlekey=77988&page=1
accessed on 27 December 2014
Pain available at http://medical-dictionary.thefreedictionary.com/pain accessed on 27 December 2014
Walker, R. (2002), Pain Classification available at http://www.painclinic.org/aboutpain-paintypes.htm accessed 27 December 2014
The British Pain Society available at http://www.britishpainsociety.org/patient_faq.htm accessed on 27 December 2014
Back Pain Causes available at http://www.nhs.uk/Conditions/Back-pain/Pages/Causes.aspx accessed on 27 December 2014
Nonsteroidal Anti-inflammatory Drugs (NSAIDs) available at
http://www.medicinenet.com/nonsteroidal_antiinflammatory_drugs/article.htm accessed on 27 December 2014
COX-2 Inhibitor drug Information available at http://www.rxlist.com/cox-2_inhibitors/drugs-condition.htm accessed on 27 December
2014
Differences between Opioid and Non-opioid Analgesics available at - http://www.emedexpert.com/compare/opioids-non-opioids.shtml accessed on 27 December 2014
Kidney Infections available at http://www.nhs.uk/Conditions/Kidney-infection accessed 27 December 2014
11

MONIQUE MAVRONICOLAS PAIN

Antidepressants, another weapon against chronic pain available at - http://www.mayoclinic.org/pain-medications/art-20045647 accessed

on 27 December 2014

12