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Managing Pain
What is Pain?
An unpleasant sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage
The International Association for the Study of Pain
Subjective sensation Perception of actual or threatened damage Physiological response produced by activation of specific types of nerve fibers Experienced because of nociceptors being sensitive to extreme mechanical, thermal, & chemical energy. Composed of a variety of discomforts One of the bodys defense mechanism (warns the brain that tissues may be in jeopardy) Perception based on expectations, past experience, anxiety, suggestions, cognitive factors
Acute Chronic - the total person must be considered. It may be worse at night when the person is alone. They are more aware of the pain because of no external diversions.
Pain Sources
Cutaneous Pain sharp, bright, burning; can have a fast or slow onset Deep Somatic Pain stems from tendons, muscles, joints, periosteum, & b. vessels Visceral Pain originates from internal organs; diffused @ 1st & later may be localized (i.e. appendicitis) Psychogenic Pain individual feels pain but cause is emotional rather than physical
Pain Sources
Fast vs. Slow Pain
Fast localized; carried through A-delta axons in skin Slow aching, throbbing, burning; carried by C fibers Nociceptive neuron transmits pain info to spinal cord via unmyelinated C fibers & myelinated A-delta fibers.
The smaller C fibers carry impulses @ rate of 0.5 to 2.0 m/sec. The larger A-delta fibers carry impulses @ rate of 5 to 30 m/sec.
Referred Pain
Occurs away from pain site 3 types of referred pain:
Myofascial Pain trigger points, small hyperirritable areas within a m. in which n. impulses bombard CNS & are expressed at referred pain
Active hyperirritable; causes obvious complaint Latent dormant; produces no pain except loss of ROM
Sclerotomic & Dermatomic Pain deep pain; may originate from sclerotomic, myotomic, or dermatomic n. irritation/injury
Sclerotome: area of bone/fascia that is supplied by a single n. root Myotome: m. supplied by a single n. root Dermatome: area of skin supplied by a single n. root
Withdrawal Reflex
SEVERITY how bad is it? Pain scale TIMING When does it occur? At night, a.m., after activity, all the time
Terminology
Noxious harmful, injurious
Noxious stimuli stimuli that activate nociceptors (pressure, cold/heat extremes, chemicals)
Nociceptor - specialized receptor on n. that transmit pain impulses Nociception impulse giving rise to sensation of pain Accommodation phenomenon adaptation by the sensory receptors to various
stimuli over an extended period of time (e.g. superficial hot & cold agents). Less sensitive to stimuli. Hyperesthesia abnormal acuteness of sensitivity to touch, pain, or other sensory stimuli Paresthesia abnormal sensation, such as burning, pricking, tingling Inhibition depression or arrest of a function Inhibitor an agent that restrains/retards physiologic, chemical, or enzymatic action Analgesic a neurologic or pharmacologic state in which painful stimuli are so moderated that, though still perceived, they are no longer painful Pain Threshold level of noxious stimulus required to alert an individual for possible tissue damage
Sensory Receptors
A n. ending is the termination of a n. fiber in a peripheral structure. (Prentice, p. 37) N. endings may be sensory (receptor) or motor (effector). Sensory endings may be:
Capsulated free n. endings, Merkels corpuscles Encapsulated end bulbs of Krause Meissners corpuscles
Sensory Receptors
Some sensory receptors respond to phasic activity & produce an impulse when the stimulus is or , but not during sustained stimulus. They adapt to a constant stimulus. (Meissners c. & Pacinian c.) Tonic receptors produce impulses as long as the stimulus is present. (muscle spindles, free n. endings, Krauses end bulbs)
Sensory Receptors
Mechanoreceptors touch, light or deep pressure
Meissners corpuscles (light touch), Pacinian corpuscles (deep pressure), Merkels corpuscles (deep pressure, but more slowly than pacinian c.; hair follicle deflection)
Nociceptors
Sensitive to repeated or prolonged stimulation Mechanosensitive excited by stress & tissue damage Chemosensitive excited by the release of chemical mediators
Bradykinin, Histamine, Prostaglandins, Arachadonic Acid
Primary Hyperalgesia due to injury Secondary Hyperalgesia due to spreading of chemical mediators
Types of Nerves
Afferent (Ascending) transmit impulses from the periphery to the brain
First Order neuron Second Order neuron Third Order neuron
Neurotransmitters
Chemical substances that allow nerve impulses to move from one neuron to another Found in synapses
Norepinephrine Substance P - neurotransmitter thought to be responsible for the transmission of pain-producing impulses Acetylcholine Enkephalins 2 types of chemical neurotransmitters that mediate pain
Endorphins - morphine-like neurohormone; thought to pain threshold by
binding to receptor sites Serotonin - substance that causes local vasodilation & permeability of capillaries
Both are generated by noxious stimuli, which activate the inhibition of pain transmission
Types
Wide range specific
Receive impulses from A-beta, A-delta, & C
Nociceptive specific
Receive impulses from A-delta & C
Ends in thalamus
Descending Neurons
Transmit impulses from the brain (corticospinal tract in the cortex) to the spinal cord (lamina)
Periaquaductal Gray Area (PGA) release enkephalins Nucleus Raphe Magnus (NRM) release serotonin
Stimulation of the PGA in the midbrain & NRM in the pons & medulla causes analgesia. Endogenous opioid peptides - endorphins & enkephalins (substances released by the body that reduce
the perception of pain by binding to pain receptor sites)
Pain Scales
Visual Analog Scale None Severe 0 10 Locate area of pain on a picture McGill pain questionnaire
Evaluate sensory, evaluative, & affective components of pain
20 subcategories, 78 words
Pain Threshold level of noxious stim. required to alert an individual of a potential threat to tissue
Pain Tolerance amount of pain a person is willing or able to tolerate Referred Pain - Mix-up in spinal cord in the transmission of pain impulses
Pattern Theory
A single nerve responded to each type of sensation by creating a code (i.e. different telephone rings)
If A-beta neurons are stimulated SG is activated which closes the gate to A-delta & C neurons If A-delta & C neurons are stimulated SG is blocked which closes the gate to A-beta neurons
This can be overridden by Level II
Gate (T
cells/ SG)
ACTH/B-lipotropin is released from the anterior pituitary in response to pain broken down into B-endorphins and corticosteroids Mechanism of action similar to enkephalins to block ascending nerve impulses Examples: TENS (low freq. & long pulse duration)
Pain response is initiated by stimulation of nociceptors. Mechanical stress excites mechanosensitive nociceptors Chemicals bradykinin, serotonin, histamine, prostaglandins excite chemosensitive nociceptors
The initiation of the pain process always begins with chemical stimulus.