Physiology of pain, classification

and treatment
Acıbadem University, Faculty of Medicine
Department of Physical Medicine and Rehabilitation
 Learning Outcomes
•
Definition of pain
•
Get familiar with pain terminology
•
Classification of pain
•
Measurement of pain
•
Treatment options
 Pain
•
Pain is the most common reason for which
patients seek treatment by physicians.
•
Pain is a major symptom of many different
disease.
•
Pain signal represents potentially dangerous
tissue damage.
•
Pain is a complex interplay of peripheral
nerve, spinal cord and brain processess.
Role of physiatrists...

•
Most acute pain can be eliminated by
discontinuing the source of tissue damage,
resting the damaged part and using simple
analgesia.
•
Physical medicine techniques enhance
physical recovery from many painful
conditions, particularly if simple measures
have not eliminated pain or significant loss of
function has occured.
 Epidemiology of Pain
•
A major problem in modern society 20%
•
The negative effects on quality of life and productivity
have an immense social and economic impact (LBP-the
most common cause of work absence )
•
Women>men
•
With aging chronic pain becomes more prevalent due to
osteoarthritis (age > 45 years)
•
Chronic neuropathic pain affects 8.2% of the general
population (Torrance 2006).
 Definition of Pain
•
The International Association for the Study of
Pain (IASP) defines pain as “an unpleasant
sensory and emotional experience associated
with actual or potential tissue damage, or
described in terms of such damage”
•
Pain is always subjective experience.
 Pain terms
•
Allodynia: pain due to a stimulus that does not
normally provoke pain.
•
Analgesia: absence of pain in response to a stimulation
which would normally be painful.
•
Dysesthesia: an unpleasant abnormal sensation,
whether spontaneous or evoked.
•
Hyperalgesia/Hypoalgesia: increased/decreased pain
from a stimulus that normally provokes pain.
•
.......many more. Read them please!
 Acute vs Chronic Pain
Temporal
•
Acute pain (<3 months) can persist and
eventually become subacute (3-6 months),
with the passage of time chronic (> 6 months)
in nature.
•
Chronic pain is generally considered a pain
that continues to persist long after the
expected healing time.
 Aspects of Pain
•
The pain sensation has a
sensory discriminative
aspect such as location,
duration and intensity
•
Affective aspect-you
feel unpleasant
 Types of Pain

•
When a noxious stimulus is applied to normal
tissue, acute physiologic nociceptive pain is
elicited. This pain protects tissue from being further
damaged, withdrawal reflexes are elicited.
•
Pathophysiological nociceptive pain occurs when
the tissue is inflamed or injured.
 Types of Pain
Neuropathic pain results from an injury or
disease of neurons in the peripheral and central
nervous system (burning***, electrical
character, hyperalgesia, allodynia.
Central pain occurs as a result of damage to
central pain processing neurons (e.g. Thalamus)
 Measurement of Pain
•
VAS (Visual Analogue Scale) 100 mm
horizontal line

•
NRS (Numerical Rating Scale)
•
VRS (Verbal Rating Scale)
•
FPS (Faces Pain Scale)
Faces Pain Scale
 Acute Pain
•
Acute pain usually time limited (less than 3
months) and its intensity gradually decreases as
the noxious stimulus is removed. It serves as a
useful biologic purpose by warning organism,
causing to seek help and guard the affected part
of the body.
 Chronic Pain

• In general, the longer pain persists, the less

likely resolution becomes.
• Chronic pain syndrome is an abnormal
condition in which pain is no longer a
symptom of injury but in which pain and pain
behaviour become the primary disease.
 Chronic vs Acute Pain
•
Onset is ill-defined, duration unpredictable
•
Intensity is variable
•
Persists long after healing should have occured
•
Alteration of behaviour and mood
•
Limitation of activity, deconditioning, loss of strength
and flexibility
•
Not always clear relationship to pathology
•
Multiple non productive tests, surgeries, medical
treatments and therapies
Major cause of chronic pain

1-Nociceptive pain of musculoskeletal origin

(osteoarthritis, LBP, neck pain)
2-Neuropathic pain
3-Migraine, tension headache, functional GI
problems
4-Widespread soft tissue pain
 Treatment of Pain
•
Best treatment of chronic pain is prevention.
Identify contributing factors and address them
earlier.
•
In acute pain management, resting the
damaged structure is essential for recovery
(example resting splint).
•
Chronic pain patient usually needs
mobilization because of underuse of affected
areas.
 Treatment of Pain
•
Studies demonstrate that patients are usually
treated inadequately for acute pain
syndromes and overtreated for chronic pain.
•
Give medications on a scheduled dose (not
on as needed)
•
Moderate or eliminate the use of narcotics,
tranquilizers and hypnotics.
 Treatment of Pain-I
Pharmacological
•
Nonopiods: acetaminophen=paracetamol, NSAIDs
•
Adjuvants: antidepressants (TCA, SSRI, SNRI) and
anticonvulsants (gabapentin, pregabalin)
•
Opioids (codeine, tramadol…)
•
Local agents: Blocking nociceptors by local agents
(lidocaine patch, capsaicin)
 Treatment of Pain-II
Physical Therapy
•
Physical medicine modalities enhance physical
recovery in various painful conditions.
•
Exercise and mobilization-pain results in
deconditioning, loss of strength and flexibility.
Address these problems in addition to medical
treatment.
•
Arthrogenic muscle inhibition
 Treatment of Pain-II
Interventional
•
Interventional techniques and procedures are last step in treatment
•
If pain is inadequately controlled by medications or patient is not
able to tolerate medication
•
Local injections, trigger point injections, nerve blocks, plexus
blocks, epidural or intrathecal administration
•
Joint injections: steroids, hyaluronate, PRP
•
Ablative surgeries (nerve resection, DREZ, cordotomy, myelotomy
etc)
•
Stimulation techniques (brain and spinal cord)
Acetaminophen

•NSAIDs > Acetaminophen > Placebo

•Can relieve mild to moderate arthritis pain
in OA subjects

•1000mg three to four times daily

 Nonsteroidal antiinflammatory drugs
(NSAIDs)
• NSAID block the cyclooxygenase (COX)
enzymes and reduce prostaglandins
throughout the body.
• NSAIDs relieve pain and reduce inflammation
and fever.
• They are recommended for patients who do
not get adequate pain relief with simple
analgesics.
 NSAIDs side effects
Side effects :
GIS symptoms, abdominal pain, nausea , vomiting,
diarrhea, constipation,
• rash, hypersensitivity reactions
• dizziness, headache, drowsiness, edema,
• impairment of renal, hepatic, and bone marrow function,
and platelet aggregation
Serious side effects :
Liver and kidney failure, GI bleeding, gastric ulceration and
perforation.
 Opioids (Narcotic Analgesics)

Tramadol , Codeine, Oxycodone

•patients who are not candidates for surgery and who

continue to have moderate to severe pain despite being
on NSAIDs
•patients with pain of sudden, severe arthritis
exacerbations
•they are often most effective when taken together with
nonsteroidal antiinflammatory drugs (NSAIDs).
•Narcotics can also be combined with acetaminophen.
Examples of CNCP conditions for which opioids were shown
Evidence of Opioid Efficacy
to be effective in placebo-controlled trials
Tramadol only Weak or strong opioid
Fibromyalgia Diabetic neuropathy
Peripheral neuropathy
Postherpetic neuralgia
Phantom limb pain
Spinal cord injury with pain below level of
injury
Lumbar radiculopathy
Osteoarthritis
Rheumatoid arthritis
Low-back piain
Neck pain
 Stepped Approach to Opioid
Selection (Canadian Guideline for Safe and Effective use of
Opioids for CNCP-2010)
Mild-to Moderate Pain Severe Pain
First-line: Codeine or First-line: Morphine,
tramadol Oxycodone,
Hydromorphone
Second-line: Morphine, Second-line: Fentanyl
Oxycodone,
Hydromorphone
Third-line: Methadone
 Opioids may cause addiction?
•
The major risk factor for addiction is a current
or past history of addiction (Canadian
guideline for safe and effective use of Opioids
2010).
 Topical NSAIDs

• short term (one to two weeks) efficacy for

pain relief and functional improvement
• topical NSAIDs are generally inferior to oral
NSAIDs, however topical route is safer than
oral use
• side effects are rare (irritation of skin, allergic
reaction)
Capsaicin Cream

•principle ingredient of chili peppers (Substance P)

•capsaicin depletes substance P in nerve endings
and lessens the arthritis pain by about 30% in some
people.
•40% of people experience side effects including
burning, stinging, and redness of the skin and
especially of the eye.
 Joint Injections
• glucocorticoid (steroid)
• hyaluronate
• platelet-rich Plasma (PRP)
Hyaluronate Injections
(Viscosupplementation)
Indications :
•patients with osteoarthritis who cannot take
NSAIDs
• who do not achieve adequate pain relief with
oral drugs or physical therapy
• awaiting joint surgery may benefit from these
injections.
Corticosteroid Injections

• glucocorticoids can suppress inflammation and can

relieve arthritis symptoms when injected into arthritic
joints.
• indications : patients who have osteoarthritis
confined to a few joints and who still have pain despite
the use of NSAIDs and physiotherapy
• patients with osteoarthritis who cannot take NSAIDs.
Corticosteroid Injections
Warning :
•Glucocorticoids injections may damage joint
cartilage when injected frequently.

•It is recommend no more than three to four

injections per year for each particular weight-
bearing joint such as a knee.
Platelet-rich Plasma (PRP)
• PRP involves injecting the liquid
component of a patient’s own blood
into the joint to deliver a high
concentration of growth factors to
arthritic cartilage that can enhance
healing.
Summary

Pain is a major problem-prevalance 20%

Patients are usually treated inadequately for acute
pain syndromes and overtreated for chronic pain.

Give medications on a scheduled dose

Physical medicine modalities enhance physical
recovery in various painful conditions.

Interventional techniques and procedures are last
step in treatment
Thank you