Physiology of Pain and

Principles of Pain Relief

Dr Dushyanthi Perera MD FRCA
Senior Lecturer in Anaesthesiology
Faculty of Medicine
University of Kelaniya
Pain is one of the commonest reason
for a patient visiting a doctor.
Definition of pain
Pain pathway
Post op pain
Analgesia for post op pain
Pain in labour
Chronic Pain
Cancer pain
Non malignant
Ethical issues



DEFINITION
An unpleasant sensory and
emotional experience
associated with potential or
actual tissue damage.
EMOTIONAL
RATIONAL
PHYSICAL
Psychological
Anxiety
Prev. experiences
Insight
Motivation
Factors influencing the pain
experience
Age
Gender
Personality
Culture
Learned behaviour from past
experiences
Beliefs / Attitudes
Religious
Anxiety and fears
Pain is whatever the patient says it is,
existing whenever the patient says it
does.

The patients self reporting of pain is the
single most reliable indicator of pain.
Assessment of Pain
A detailed history
A comprehensive physical examination
An understanding of the pathophysiology
of pain
Methodical documentation
Measurement of Pain
Pain History
Site
Intensity
Duration
Elsewhere radiation

Associated factors
Relieving factors
Management to date

SIDE ARM

Pathophysiology of Pain

Types of pain
Acute ( brief pain that subsides with
healing)
Labour
Post op
Chronic Pain
Cancer
Non malignant pain
Types of pain
Nociceptive pain ( stimuli from somatic
and visceral structures)

Neuropathic (abnormal processing of
the nervous system)
Nociception
Term used to describe how pain becomes
conscious

Transduction
Transmission
Perception
Modulation


Transduction changing of the noxious
stimuli in sensory nerve endings to
impulses
Transmission movement of these
impulses to the brain
Perception recognizing, defining and
responding to the pain
Modulation activation of descending
pathways that exert inhibitory effects on
pain transmission
Peripheral Receptors (somatic
or visceral)
High threshold cutaneous receptors

Silent nociceptors

Peripheral opioid receptors ( anti
nociceptors)
Inflammatory Mediator soup
Neurogenic eg Substance P

Tissue mediated eg Bradykinin
prostoglandins, 5HT,
histamine, K and H ions

Substance P and Prostoglandins further
sensitize the nociceptors including
activating the silent type.
PHYSIOLOGY OF PAIN



TRAUMA
Nociceptors
Skin
Deep tissues
Viscera
Mechanoreceptors
Polymodel Symp and Parasymp
Ad (sharp,localized)
C (dull,poorly localized, aching)
Inflammatory mediators- SP,
Hist, Bradykinin
+
+
+
PHYSIOLOGY OF PAIN
DORSAL HORN
substance P,glutamate,ATP

SPINOTHALAMIC TRACTS

THALAMUS

CORTEX
Descending tracts
Exact location in the brain where pain is
perceived is unclear

Reticular activating system- symp
response
Somatosensory cortex localizes and
characterizes
Limbic system emotional and
behavioural response
Central Spinal Processing
Gate Control Theory

Wind Up phenomenon (AMPA and
NMDA receptors)

Descending inhibitory control
( endogenous opioids, 5HT,
Noradrenaline, GABA)
Higher Centres
T cell
SG
Large fibres
Ab
C fibres
+
-
+ +
-
-
Gate Control Theory of Melzack and Wall
Harmful Effects of Pain
CVS Increased heart rate and BP.
Hypercoagulability
RS inadequate ventilation
Stress response release of multitude
of hormones and hyperglycaemia
GIT nausea and vomiting
GUT fluid and urinary retention
Immune depressed immunity
Muscle spasm

REQUIREMENTS
CONTINUOUS ANALGESIA


ANALGESIA TITRATABLE TO PAIN

AVAILABLE ANALGESIC
TECHNIQUES
OPIODS
Morphine, Pethidine,Codeine
NSAIDS
Paracetamol, Diclofenac sodium
LOCAL ANAESTHETICS
Local infiltration, Epidural, EMLA
OTHERS
Acupuncture, Entonox,
TRAMADOL
OPIOIDS
ROUTES- im, iv, sc,continuous infusion, PCA
SIDE EFFECTS
VENTILATORY DEPRESSION
SEDATION
VASODILATATION
COUGH SUPPRESSION
NAUSEA AND VOMITING
TOLERENCE AND DEPENDENCE
CONSTIPATION
NSAID
OPIOID SPARING
CONTRA INDICATIONS
GASTRIC ULCERS
BLEEDING DIATHESIS
RENAL DYSFUNCTION
HYPOVOLAEMIC, ELDERLY, INADEQ.
RESUSC POST OP
HYPERSENSITIVITY
LOCAL ANAESTHETIC
EXPERTISE
MONITORING
Low Tech Topical
Wound infiltration
Peripheral nerve blocks
Plexus blocks
High Tech Spinal , Epidural
Advantages of epidural
Prolong the duration of analgesia by
use of the catheter
Decreases the incidence of DVT
Less sedation therefore early
mobilization and feeding
Early return of bowel function
Disadvantages
Expensive
Expertise
Monitoring
Hypotension, urinary retention
Resp depression with added opioids

If opioids are added they must not be given
by any other route.
Ideally keep on O
2
.
Balanced analgesia
Combination of appropriate analgesics.
Act on different sites in the pain
pathway
Decrease individual doses and thereby
decrease the incidence of side effects


PRE EMPTIVE ANALGESIA
Factors to consider when
choosing analgesics
Appropriateness of the intervention for
the pain
Coexisting illness
Available staff
Available equipment
Risks and side effects
Cost / Benefit ratio
MONITORING
PAIN SCORE
1 NO PAIN AT REST OR MOVEMENT
2 NO PAIN AT REST SLIGHT PAIN ON
MOVEMENT
3 PAIN AT REST. MOD. PAIN ON
MOVEMENT
4 CONTINUOUS PAIN AT REST AND
SEVERE PAIN ON MOVEMENT
Visual Analogue Score

MONITORING
SEDATION
0 NONE
1 DROWSY. EASYY TO ROUSE
2 ASLEEP .EASY TO ROUSE
3 SOMNOLENT AND DIFFCULT TO
ROUSE
MONITORING
RESPIRATORY RATE

NAUSEA AND VOMITING

CVS - HEART RATE AND BP
Steps to Successful
Management of Pain
Regular assessment and recording of pain
and side effects
Protocols for monitoring and treating pain
Protocols for monitoring and treating side
effects
Use a safe and simple balanced analgesic
regime
Appropriate backup by identified personnel
Continuing in service training and education.