Pain Management

Pain is usually considered as a subjective experience that can accompany Nociception although pain can arise without a stimulus and may include an emotional reaction. Nociception is a neurophysiologic term denoting activity in nerve pathways, which transmit unpleasant signals, and pain is usually associated with tissue damage and inflammation. Pain is an important aspect of the defense system of the body and pain signals instruct motor neurons of the central nervous system to minimize harm or injury to the body. Pain is explained by the gate control theory which concerns cognitive and emotional factors influencing painful sensations and is determined by different pain states at the brain rather than pain at a particular injured area of the body.

Nociception is the perception of physiological pain although the term pain itself is a broader term and involve psychological pain as well. When nociceptors are stimulated, signals are transmitted through sensory neurons in the spinal cord and are ultimately relayed to the thalamus in the brain and perception of pain takes place. As the brain is itself devoid of nociceptors it cannot experience pain by itself and pain is usually referred to as tissue damage by some harmful stimulus. Pain can thus be both physiologic and emotional or either one of them, Nociception describes physiologic pain or pain related to physical injury to body tissues and pain picked up and transmitted as signals via receptors. Pain in general can however also be emotional or psychological and may be associated with neural factors not entirely known.

The main characteristic of pain is its unpleasantness and usually an organism uses all means to separate itself from any unpleasant stimuli that may be the cause of the pain. Pain can be due to an injury or may even indicate that an injury is imminent but it can also serve as a protective and defensive physiologic function as organisms tend to protect injured regions in the body from further damage due to the unpleasantness of pain sensations. Thus pain is an important part of human existence and is a strong defense of the body helping in organism's survival. It is because we perceive pain as unpleasant that we tend to avoid harm and injury to the body. The study, treatment and management of pain include pharmacology, psychology and neurobiology and the subjective psychological aspect of pain is an important part of study for the search for neural correlates of consciousness.

Pain receptors are usually free nerve endings and are receptors to chemical, mechanical and thermal pain sensation usually found in the skin, internal and joint surfaces. Tissue damage in deeper part of the skin produces an aching dull pain spread across wider areas as pain receptors are fewer and spread around in deeper levels of the skin, so pain can also not be localized in these cases. In certain cases with prolong pain stimulation, excitation of pain fibers increases leading to a condition known as hyperalgesia.

Pain can be classified into several types including acute pain, which is a short-term pain from an identifiable cause and is related to tissue damage or a disease. It is sharp sensation followed by aching and is usually centralized to one area usually following an injury, trauma or fall. This sort of pain is usually treated with medications. Medically a chronic pain lasts six months or longer and this sort of pain does not help the body to prevent any further injury by being constantly present and is even more difficult to treat than acute pain. Medical advice is however sought for these cases and drug tolerance, chemical dependency and psychological addiction to drugs may also occur especially in case of opiates. The experience of physiological pain can be cutaneous, somatic, visceral or neuropathy. Coetaneous pain is referred to pain that happens due to injury to the skin or the superficial tissues of the body as coetaneous nociceptors terminate just below the skin and produce localized defined pain for short duration and include pain due to cuts and burns. Somatic pain is pain of ligaments, muscles, bones, tendons and blood vessels and may be dull and continue for longer duration than cutaneous pain. Sprained ankles, fractures and torn ligaments are examples of this sort of pain. Visceral pain involve pain originating in body organs and this sort of pain is located in internal cavities and organs producing an aching , poorly localized sensation that may be of much longer duration than somatic pain and the dull pain can spread to many areas. Neuropathy pain or neuralgia refers to pain in the nerve tissue due to injury or disease and can disrupt the ability of the nerves to transmit correct signals to the thalamus, so the brain may interpret pain although there may be no obvious physiologic causes of pain.

There are two different and distinct pathways for transmission of pain in the CNS. These are transmitted either through the neospinothalamic tract for fast pain or paleospinothalamic tract for slow pain. For transmission for fast pain Alpha-delta fibers terminate on lamina marginalis of the dorsal horns. Neospinothalalmic tract neurons branch off as long fibers and transmit signals upwards in the contralateral anterolateral columns. These fibers finally terminate on the ventrobasal complex of the thalamus. Fast pain is easily localized when A and delta fibers are stimulated with tactile receptors. Slow pain is however transmitted by the slower C fibers to lamina II and III or dorsal horns also known as substantia gelatinosa and neurons take off and join fast pain pathways and move upwards along the anterolateral pathway. These slow pain neurons terminate in the brain stem with a tenth of fibers stopping at the thalamus and also at the medulla, pons and mesencephalon although localization for slow pain is poor.




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