supplement to Journal of the association of physicians of india Published on 1st of every month 1st february, 2015

Pathophysiology of Pain
Vikram A Londhey*

W hy so much pain and suffering

in this world? 1 What a pain
he or she is! The word pain is used in
are stimulated by mechanical, thermal
and chemical stimuli. Physiologically
pain has been classified into 2 types:
various contexts. Most often it is linked to fast pain and slow pain. Fast pain is
emotions of grief, sorrow and suffering. felt within 0.1sec. It is also described as
The word pain comes from the Latin sharp, acute, electric or pricking pain. It
word poena meaning a fine, a penalty. is commonly felt in superficial tissues,
Pain as the fifth vital sign has been seldom in deeper tissues. Fast pain
introduced by the American Pain Society pathway is stimulated by mechanical
in 1996. 2 According to the International or thermal pain stimuli and carried by
Association for the Study of Pain(IASP) A fibers at velocities between 6 and
it is defined as Pain is an unpleasant 30m/sec. Sharp pain makes the person
sensory and emotional experience arising
aware of the damaging influence and
from actual or potential tissue damage.3
react immediately to remove himself or
It is a sensation that can range from
herself from the stimulus. Slow pain is
mild, localized discomfort to agony.
also called burning, aching, throbbing,
Pain has both physical and emotional
gnawing, nauseating or chronic pain.
components. The physical part of pain
results from nerve stimulation. Pain It is present in skin as well as deep
may be contained to a discrete area, as tissues. The slow pain pathway is mainly
in an injury, or it can be more diffuse, stimulated by chemical stimuli (but also
as in disorders like fibromyalgia. Pain is by mechanical and thermal) and carried
also a term specifically used to denote by type C fibers at velocities between 0.5
a painful uterine contraction occurring and 2 m/sec. Chemicals like bradykinin,
in childbirth known as labour pains. serotonin, histamine, potassium ions,
With this background, it is necessary acids, acetylcholine and proteolytic
to have the basic understanding of the enzymes are responsible to generate
neuroanatomy and physiology of pain to pain. Prostaglandins and substance P
tackle it in a reasonable way in the era of enhance the sensitivity of the nerve
evidence- based- medicine. endings without directly exciting them.
Hence, i am sure all the readers of this The pain receptors are non-adapting
issue will recollect their 1 st MBBS days as and hence differ from other receptors
a medical student, when all of us have of sensations. They have the unique
been trained in physiology of pain. Lets property of hyperalgesia. The factors
go into flash-back and recollect a few of causing pain are heat, lactic acidosis
those aspects. resulting from tissue ischemia, tissue
contusion, bacterial infection; muscle
Types of Pain, its Receptors spasm due to stimulation of mechanical
And Stimuli4 receptors directly and indirectly by
compression of blood vessels thereby
Most of the body ailments cause pain. causing ischaemia.
The ability to diagnose different clinical
conditions depends on a clinicians Pain Pathways4
knowledge of different types of pain.
On entering the spinal cord from
Pain is a protective mechanism. It occurs
dorsal spinal roots, the pain fibers
when tissues are damaged and there is a
terminate on relay neurons in dorsal
natural reaction from the individual to
horns. Further, they are carried to the
*
Associate Professor, remove pain stimulus. The pain receptors
Department of Medicine, TNMC brain by the neospinothalamic tract or
are free nerve endings. They are present
and BYL Nair Ch Hospital, the paleospinothalamic tract.
Mumbai 400 008; Visiting
in superficial layers of skin, periosteum,
Consultant Rheumatologist, arterial walls, joint surfaces, falx cerebri
Seven Hills Hospital, Marol and the tentorium. The pain receptors
Maroshi, Mumbai
6 supplement to Journal of the association of physicians of india Published on 1st of every month 1st february, 2015

Somato Periaqueductal gray

region around Ventrolateral
Sensory aqueduct of Sylvius nuclei of thalamus
Ventro Posterior Cortex
Tectal Reticular
Basal Nuclues area of formation of medulla,
Reticular formation mesencephalon
Nuclei of pons and mesencephalon
of Thalamus
Thalamus

Antero Anterolateral
lateral columns
Columns (Ascending Tracts)
(Ascending
Tracts)

Cross over
to opp. side

Cross
over Spinal Dorsal root ganglion Substantia
Cord Gelatinosa
to opp. side
Slow
C fibers
pain

Free Nerve Endings

Dorsal root Spinal Fig. 1 : Paleospinothalamic tract

ganglion cord continue as anterolateral ascending tracts. The
Fast A paleospinothalamic tract terminates in brain stemin
Pain Fibers one of the following areas:
1. R e t i c u l a r n u c l e i o f m e d u l l a , p o n s a n d
Free Nerve Endings mesencephalon.
Fig. 1 : Neospinothalamic tract 2. Tectal area of mesencephalon deep.10-25% of the
fibers pass to the thalamus.
The Neospinothalamic tract4 3. Periaqueductal gray region surrounding the
aqueduct of Sylvius.
A fibers transmit mainly mechanical and thermal The signals are relayed into the intralaminal and
pain, terminate in the dorsal horns, cross over to the ventrolateral nuclei of thalamus, hypothalamus and
opposite side of the cord and continue upwards to the basal regions of brain. The pain carried by slow
brain as anterolateral columns. Most fibers terminate chronic pathway is poorly localised. Substance P is the
in the ventrobasal or posterior nuclei of the thalamus; neurotransmitter concerned with slow pain (Figure 2).
few fibers terminate in the reticular areas. Signals are
also sent to the somatosensory cortex. Glutamate is Higher Centres for Pain4
the neurotransmitter secreted in the spinal cord at A
fibers (Figure 1). Reticular formation, thalamus and lower brain
centres cause conscious perception of pain. But the
The Paleospinothalamic tract4 cerebral cortex is responsible for interpreting the
quality of pain. The pain signals have a strong effect
The C fibers which carry slow pain terminate in on the arousal system which explains the disturbed
the substantia gelatinosa of dorsal horns in spinal sleep or insomnia in a person experiencing pain.
cord. They also cross over to the opposite side and
supplement to Journal of the association of physicians of india Published on 1st of every month 1st february, 2015 7

Periaqueductal gray and periventricular areas of Visceral pain and Concept of Referred
mesencephalon and upper pons surrounding the Pain4
aqueduct of Sylvius and portions of 3 rd and 4 th
ventricles. The viscera in the different parts of the body also
have pain receptors. The visceral pain differs from
the surface pain. The visceral pain in the thorax and
abdominal cavity is transmitted through the C fibers.
Raphe Magnus nucleus in lower pons and Medulla The visceral pain fibers synapse in the spinal cord on
and nucleus reticularis paragigantocellularis(in same second order neurons that receive pain signals
lateral medulla) from the skin fibers. Hence pain in the remote or deep
seated organs is experienced in the skin which have
Through Dorsolateral
a common embryological dermatomal origin.This is
columns to spinal cord
called as referred pain. The stimuli for visceral pain
Pain inhibitory complex in dorsal horns of spinal also include ischaemia, smooth muscle spasm, excess
cord. distension of hollow organs, action of proteolytic
enzymes and stretching of surrounding connective
Fig. 3 : Analgesia system tissue.
Coming back to the present day from our flash-back,
Analgesia System4 this special issue of JAPI Understanding Pain-The 5 th
Vital Sign discusses elaborately the ways of assessing
The pain threshold varies from person to person
pain, managing acute and chronic pain. There are also
and the reaction to pain is highly variable. There is a
practical tips on evaluation of the back pain and the
natural inbuilt system of the brain to suppress input
various interventions necessary for pain management.
of pain signals called analgesia system. The analgesia
At times, it may be challenging to all the clinicians
system is diagrammatically represented in Figure 3.
when the pain in psychogenic in nature; hence the
The neurotransmitters released by the analgesia differential diagnosis and treatment of psychogenic
system are enkephalin and serotonin. Enkephalins pain disorder has been discussed in this special issue.
inhibit pre and post synaptic C fibers and A fibers Managing pain is a team-work and hence beyond the
when they synapse in dorsal horns, thus blocking patient and the clinician, the paramedics particularly
the pain signals at initial entry into the spinal cord. the physiotherapist has a major role to play. The issue
Activation of the analgesia system by nervous signals has been well written by a series of authors well known
entering the periaqueductal gray and periventricular in their fields for the management of pain. I am quiet
areas or inactivation of pain pathways by analgesics confident that this special issue on pain would act as a
almost totally suppress the pain signals entering Bible for all the practioners and the resident doctors
through the peripheral nerves. of various specialities in making our patients free from
The large type A sensory fibres responsible for pain i.e Aah se Aha tak!.
carrying touch sensation can depress transmission
of pain signals from the same area. Hence, when References
stimulated simultaneously, there is suppression of 1. Indeed, one of the greatest Christian theologians of the last century
pain. This is the rationale and the basis of pain relief remarked, The fact of suffering undoubtedly constitutes the single
by applying liniments, massage, acupuncture and greatest challenge to the Christian faith. John Stott, The Cross of
acupressure. Christ(Downers Grove, IL: IVP Books, 2006), 303.
2. Preeti Doshi. How to assess Pain? JAPI 2015;63;Suppl.5-11.
3. International Association for the Study of Pain: Pain Definition. Bonica
JJ. The need of a Taxonomy. Pain 1979;6:247-8.
4. John.E.Hall. Chapter 48 Somatic Sensations II. Pain, Headache &
Thermal Sensations. Guyton and Hall Textbook of Physiology Twelth
Edition. In Ed. John E. Hall Elsevier Saunders 2011;583-593.