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Anatomy and

Physiology of Pain
Dr. Gautam Das MD, FIPP
Chairman, Indian chapter of
World Institute of Pain

Pain management:
What is new?
Newer developments in understanding the
pathophysiology of pain.
Newer concepts of analgesic therapy.
Newer drugs to manage pain.
Interventional Pain Management to diagnose &
treat pain.

Definition of PAIN
Pain is "an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage"
( IASP : 1979).

Many people report pain in the


absence of tissue damage or any
likely patho-physiological
cause. If they regard their
experience as painit should
be accepted as pain. (IASP)

Example of Phantom limb pain


They have pain in the limb which is not there.
If the pain is always associated with actual or
potential tissue damage then they should not feel
pain on the limb where there is no tissue at all !
So till 1960s they were send to psychiatrist
thinking they must be mad because they are
complaining pain on limb which is not there!
Now it is a well established phenomenon with
clear pathophysiological explanation.

So in Phantom Limb Pain &


other Chronic Pain, problems
lies in the nerves not in the
damaged tissue.

Types of Pain

Types of Pain
Acute Pain

Chronic Pain

/Physiological Pain
Nociceptive
Symptom of a disease
Treatment of diseases
cures pain & it is selflimiting.

/Pathological Pain
Neuropathic
A disease itself, a
disease of nervous
system.
Difficult to treat &
sustaining.

Types of Pain
Acute Pain
/Physiological Pain
Simple relationship
between pain and
tissue damage
Proportionate to the
clinical finding
Biological function &
our friend

Chronic Pain
/Pathological Pain
Dissociated
relationship between
pain and tissue
damage
Disproportionate to
the clinical finding
No Biological
function

PAIN: an alarm?
True for Acute Pain which is our friend.
Chronic Pain is a false alarm, it is a
disease itself.

What is Chronic Pain?


American chronic pain association defines
it as Pain that continues a month or more
beyond the usual recovery period.
Some has described chronic pain as pain
persisting more than 3 month as by three
months pain itself becomes a disease.
All pain is acute pain till it becomes chronic
pain.

Chronic Pain
With ongoing
tissue damage

Without ongoing
tissue damage

Central Sensitization is a
constant feature

Pain
Acute Pain
Chronic Pain with tissue damage
Chronic Pain without tissue damage

Pathogenesis of
Chronic PAIN

Sensitization

Sensitization is a phenomenon of
inappropriate or disproportionate response
to normal stimulus
Peripheral Sensitization

Central Sensitization

Peripheral sensitization

Peripheral sensitization
Sensitization of primary afferent terminals.
Active nociceptors become sensitized and

sleeping nociceptors awaken.


Damaged axons sprout, forms collaterals.
Ectopic discharges along nerve axon, terminals
& at DRG.
SNS fibers invade DRG.
Phenotypic switch in expression of
neuropeptides like Sub P, CGRP.

Central
Sensitization

Dorsal horn transmission


Signals onco-genes: c-fos & c-jun neuropeptides and nerve growth factors alters
patterns of nerve connections.

Opioids, LA, NMDA antagonist like ketamine &


alfa-2 agonist clonidine suppress c-fos expression.

Central Sensitization

Central Reorganisation.
Wind up (summation of signals)
Up-regulation of NMDA receptor
Ectopic activity
Depression inhibitory synapses
Activation of WDR cells.

Central re-organization

Long continued stimulation Central


Reorganisation.

1. Ab fibres develops connections in lamina


2Allodynia.
2. Area of pain increases along other nerve
distribution.
3. Loss descending inhibitory pathways

NMDA receptor

Acute Pain AMPA receptors


dislodges Mg from NMDA receptors
activation of NMDA receptors.
Activation of NMDA receptors.
1. Increased signal transmission
2. Release of NO, sub-P & PGs

Results of Central Sensitization


1.
2.
3.
4.
5.
6.

Increased intensity of pain.


Increased area of pain.
Increased duration of pain.
Decreased tolerability to pain.
Development of psychological problems.
Pain become non-responsive to
conventional analgesics.

Symptoms of chronic pain

Pain in the area of neuro-deficit.


Allodynia, Hyperalgesia
Character of pain: Burning, shooting, electric
shock-like, stabbing pain.
Associated symptoms: Numbness, tingling,
pruritis, feeling of pin & needles.
SMP: redness, edema, painful joint movements,
decreased skin temperature, fall of hairs.

Problems of Chronic Pain


Central Sensitization: altered anatomy and
physiology of Pain processing pathway.
Decreased pain threshold.
Associated depression (due to decreased
serotonin level).
Existence of different Pain Cycles which are very
difficult to break.

Treatment of Pain:
MUTIMODAL APPROACH
Interventional Pain Management
Combination analgesics
Adjuvant therapy
Physical medicine
Psychological intervention

Treatment of Acute Pain

NSAIDs for very short period


Paracetamol in adequate doses
Tramadol + Paracetamol in adequate doses
Regional analgesia

Treatment of Chronic Pain


with tissue damage
Stopping nociceptive inputs
Correcting neuropathy/ central sensitization

Treatment of Chronic Pain


without tissue damage
Correcting neuropathy/ central sensitization

Treatment of Chronic Pain


without tissue damage

Treatment for peripheral sensitization


Na-Channel blocker, Ca-Channel blocker
Treatment for central sensitization
NMDA antagonist, Ca-Channel blocker,
opioids, drugs inhibiting Sub P, drugs enhances
inhibitory synapses.
Restoration of descending inhibitory pathways
tramadol, tricyclics

Interventional Pain Management

Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/nonNon- opioids +/opioids adjuvant
Non-pharmacological
methods

Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/nonNon- opioids
opioids
World of Misery
Non-pharmacological
methods

Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/nonNon- opioids
opioids
Non-pharmacological
methods

Interventional Pain Management are some


minimally invasive procedures which gives
permanent/long term pain relief by stopping
nociceptive inputs or correcting neuropathy.
It fills the gap between pharmacologic
management of pain & more invasive operative
procedure.

FAQs:
What are the types of Pain?
Acute Pain/ Nociceptive Pain
Chronic Pain/ Neuropathic Pain
Mixed type/ Combination of Nociceptive &
Neuropathic Pain

FAQs:
What is principle of treatment?
Acute Pain: Treat disease/ Regional analgesia/
Paracetamol +opioid/ NSAIDs
Chronic Pain: Correct Neuropathy
Tramadol+opioid/ TCA/ Anticonvulsant/
Clonidine/ IPM
Mixed Pain: Stop Nociceptive input/
opioid+Paracetamol/ TCA/ Anticonvulsant/
Clonidine

FAQs:
Why Ultracet is a very good
analgesic for chronic pain?
Can be used for years together even in renal
failure and cardiac patients.
Unlike NSAIDs, it has multidoal action which
is very useful in chronic pain.
Add TCA in burning pain/ Anticonvulsant in
shooting pain/ Clonidine in cramping pain.
It is the first line drug in all chronic pain.

Summary
Multimodal approach is necessary for chronic pain.
Interventional Pain Management works in most situations
where all other options has failed.
Combination analgesic therapy specially Tramadol +
Paracetamol is very useful & ideal combination in treating
moderate to severe chronic pain.
Adjuvant therapy is necessary in most cases.
Physiotherapy & Rehabilitation is essential too.