Indian J. Anaesth.

RAJAGOPAL 2006;
: PAIN 50 (5)CONSIDERATIONS
- BASIC : 331 - 334 331

PAIN - BASIC CONSIDERATIONS

Dr. Rajagopal M. R.

Keywords : Pain intractable; pain pathophysiology.

Introduction that the suffering is less important. A simple no-nonsense

Pain is a sensory and emotional experience. The definition of pain is “Pain is what the patient says, hurts.2”
emotional component is variable from person to person and The emphasis is on the patient’s experience.
in the same person from time to time. Management of pain Let us take the practical experience of a patient
has to take this fact into consideration. The patient must waiting for surgery. If he has not been given adequate
be believed about the pain. It is the physician’s duty to explanations about what to expect; but has been rudely
relieve suffering. In addition, unrelieved pain can cause snatched away from the relatives and wheeled into a
physical damage too. For one thing, it would worsen the strange frightening environment with bright lights,
pain experience by muscle spasm, peripheral and central gleaming frightening contraptions and weird masked
sensitization and recruitment and by muscle spasm. creatures, he will be anxious and apprehensive. An
Unrelieved acute pain can cause chronic pain, and long attempted spinal anaesthesia will cause severe pain in this
standing pain can cause anatomical and even genetic changes person because he will be unable to position himself properly
in the nervous system. and because his muscle tone is high. Thus the electrical
Pain can be classified in several ways, but the most impulse generated by the stimulation of the nociceptors will
relevant in terms of therapeutic application is into be more in this person than in a calm person. In addition,
nociceptive and neuropathic. In addition to such identification for any given amount of neural stimulation, his emotional
of the type of pain, it is also necessary to quantitate pain. experience of pain will be exaggerated too. Fear, anxiety
Several scoring systems are available like the numerical and sleeplessness are all factors which worsen the pain
scale, but it needs to be remembered that the patient is the experience. A few words of reassurance to the patient
only person who can quantitate his pain. (“I am going to stay with you all through the operation
and look after you; I shall make sure that you are pain-
The objective of this paper is to enable the reader free”) can easily reduce the pain experience. In the
to understand some basic facts about pain that have context of long-standing pain, the emotional component
importance in actual management of people with pain. becomes even more important.
It is not a comprehensive review of pain mechanisms.
Much of the known basic science on the subject, which Box 1 : Points of clinical application
may have future implications on management, is not 1. Emotional reasons can worsen the pain experience;
included here. and that is not the patient’s fault. It is only a reason
for exploring for the emotional problem and for
What is pain?
providing adequate analgesia.
The International Association for Study of Pain
(IASP) defines pain as “an unpleasant sensory and 2. Only the patient (and no one else) can assess his
emotional experience associated with actual or potential pain properly. A dictum that arises out of the latter
tissue damage or described in terms of such damage.1” definition is, “believe the patient about the pain”.

It is to be noted that pain is not just a physical 3. Any one attempting to take up pain medicine needs to
sensation. It is also an emotional experience. It varies learn the fundamentals of psychosocial support and
from person to person and in the same person from time to principles of communication.
time. There may be a strong emotional component
What is Chronic Pain?
contributing to the pain experience; but that does not mean
Chronic pain is defined as pain which persists
M.D. MNAMS, Medical Director a month beyond the usual course of an acute disease
Trivandrum Institute of Palliative Sciences
or a reasonable time for an injury to heal, or is associated
TC 4/436, Rose Nagar, Ambalammukku,
Trivandrum 695005, Kerala, India. with a chronic pathological process which causes
E-mail : mrraj47@gmail.com continuous pain, or pain which recurs at intervals for months
or years.3
332 PG ISSUE : PAIN INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2006

Mechanism of pain sensation stimuli normally; but are activated in the inflamed
tissues. Once they are recruited, the same degree of
peripheral stimulus generates more number of
electrical impulses, thereby resulting in worsening of
pain (fig 2).

Fig. 1 : Diagrammatic representation of the pain pathway

from the nociceptor to the dorsal horn of the spinal cord
(N= Nociceptor. DRG= Dorsal root ganglion.
DH= Dorsal horn of the spinal cord).

Fig. 1 shows an oversimplified pain pathway from

the periphery upto the dorsal horn of spinal cord. The
peripheral bare nerve ending subserving pain is called the Fig. 2 : Recruitment: peripheral and central.
nociceptor. Mechanical, thermal, electrical or chemical
stimulation of the nociceptor causes an electrical impulse
b. Central recruitment: With persisting pain, adjacent
to be generated and transmitted up the peripheral nerve
spinal segments (or adjacent supraspinal areas) get
through A-delta and C fibres to the dorsal horn of the spinal
recruited, so that pain gradually spreads to larger
cord. In the dorsal horn cells, the impulses get modified
areas5 (fig. 2). This could be the reason for the
before onward transmission to the thalamus and the cerebral
occasional patient with cancer pain or some chronic
cortex where the pain is appreciated.
pain to complain of pain from “head to foot”.
Pain must be treated. Why? c. Sensitisation of nociceptors : The nociceptors get
1. Relieving suffering: First and foremost, pain is sensitized with time so that response threshold is
suffering and it is our duty to relieve suffering. This lowered. Chemicals involved in the inflammatory
applies whether pain is acute or chronic, but process mediate this peripheral sensitization. Other
understandably, the longer the suffering the more the agents implicated are purines, cytomines, leukotrienes,
necessity. nerve growth factor and various neuro-peptides.
Prostaglandins are believed to have a major role in
2. Muscle spasm: Pain causes reflex muscle spasm. This
this process of sensitization and this accounts for the
has two negative implications:
reduction in pain obtained with the use of Non-steroidal
a. It can cause respiratory embarrassment. Pain in anti-inflammatory agents (NSAIDs).6
upper abdominal surgery is a classical case in point.
d. Central sensitization (‘wind-up” phenomenon”):
Muscle spasm can cause regional hypoventilation
The dorsal horn cells get sensitized. This is compared
and contribute to post-operative respiratory problems.
to a wound-up spring, hence the common term,
In a multiple rib fracture, pain relief may be the
“wind-up” phenomenon.7 When the painful stimulus
single factor that can avoid the need for artificial
persists, the same peripheral input produces
ventilation.
progressively increasing electrical response from the
b. The muscle spasm itself can be a major cause of dorsal horn cell. It manifests as:
pain. Even short term muscle spasm can cause
e. An increase in the receptive field for sensitised dorsal
severe pain – for example, backache – but when
horn neurons.
long-lasting, it may result in development of myofascial
trigger points. These areas of sustained contraction f. An increase in the duration of response.
then act as new foci of pain. g. A reduction in response threshold.
3. Untreated pain will keep getting worse4. This is true N-Methyl D Aspartate (NMDA) is believed to
for surgical trauma too, but understandably, is even be the most important neurotransmitter involved in
more relevant in chronic pain. There are several the “wind-up” mechanism.8
neurophysiological reasons for this: 4. Neuroanatomical re-organisation : This seems to
a. Recruitment of nociceptors: Silent’ or ‘sleepy’ accompany central sensitization often. In the face of
nociceptors are those that do not respond to noxious continued barrage of pain impulses, the integrity of
the dorsal horn of the spinal cord gets disturbed so
RAJAGOPAL : PAIN - BASIC CONSIDERATIONS 333

that neurons subserving input from A-beta fibres form Neural injury pain can be said to involve anatomical
functional connections with neurons in lamina-2 abnormality in peripheral nerves, in pain receptors or in
subserving input from A-delta and C fibres. Thus, the central pain pathway. The following three features help
stimulation of A-beta fibres, which normally causes to diagnosis a neuropathic pain.
sensations only of touch and pressure, in this case
1. The nature of the pain may be shooting, stabbing,
causes pain.8 This is called allodynia. (Such abnormal
pricking, aching or burning.
sensations can occur also in peripheral nerve lesions.)
2. It has a neural or dermatomal distribution.
5. Anatomical and genetic changes: It has been clearly
proved now that persistent unrelieved pain can cause 3. It is often associated with abnormal sensation in the
anatomical changes in the nervous system, as well as area of pain. This can take the form of hypoaesthesia
genetic changes in the dorsal horn cell.9 or hyperesthesia. Unfortunately it often takes the form
of dysaesthesia, that is, an unpleasant abnormal
Box 2 sensation whether spontaneous or evoked. Allodynia
1. Pain must be treated early. Unrelieved pain causes and hyperalgesia are examples. Allodynia has already
worsens pain both in extent and severity. been described. Hyperalgesia is increased response to
2. In long-standing pain associated with central a stimulus, particularly a repetitive stimulus, as well
sensitization, NMDA antagonism with ketamine would as an increased threshold (an exaggerated response
have a role to play. with an increase in pain threshold).
3. Once anatomical changes in the nervous system have Nerve compression pain occurs when there is
occurred in chronic pain, total relief may be unlikely. extrinsic pain on the neural structure, as for example with
a nerve root compression in prolapsed inter-vertebral disc
Classification of Pain
or with collapsed vertebrae from metastatic lesions.
The peripheral nerve ending (nociceptor) transmits
the pain impulse to the dorsal horn of the spinal cord, Neuropathic pain can also be sub-classified into
where it gets modified before onward transmission to the peripheral and central, depending on site of origin of abnormal
brain. Any pain caused primarily by stimulation of the impulse. The relevance is that central pains often behave
nociceptor can be said to be nociceptive pain. If pain is not differently from peripheral neuropathic pains, particularly
caused by a stimulus applied to the nociceptor, but is caused in their response to drugs. Central neuropathic pains are
by impulse generation within the pathway proximal to the commonest in injury to the CNS – for e.g. Spinal cord
nociceptor (this could be in the nerve, the spinal cord or injuries, stroke etc.10 It must be remembered that pain
the brain), it is called neuropathic pain (fig. 3). originally of peripheral nerve origin, can become centrally
established – by somehow altering the CNS. Once this has
This does not mean that all nociceptive pains are happened, a peripheral nerve block or neurolysis may not
similar in presentation or management. For example pain successfully remove the pain.
arising out of smooth muscle spasm can be very different
from the pain of skeletal muscle spasm. Box 3: Points of clinical application
1. Depending on site of origin of pain, different types of
pain may warrant different modalities of management.
It is necessary to understand the type of pain, to
decide on management.
2. Neuropathic pain is often burning, aching, stabbing or
pricking, is of neural or dermatomal distribution and
is usually associated with abnormal sensation in the
area of pain.
Fig. 3 : Basic classification of pain Evaluation of pain : A proper evaluation of pain is
essential for proper treatment. Patients often have more
Nociceptive pain can be subdivided to somatic and than one type of pain. Some of them may be unrelated to,
visceral pain, depending on site of origin. or only indirectly related to the basic disease. The different
pains, for e.g. muscular, neuropathic etc. would need
Neuropathic pain can be of three sub-types :
different modalities of treatment.
i) Neural injury pain ii) Nerve compression pain
iii) Complex Regional Pain Syndrome (CRPS).
334 PG ISSUE : PAIN INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2006

only visible to the person who makes a record of the

patient’s evaluation.
d) McGill Pain Questionnaire (MPQ): MPQ attempts to
assess the quality of pain too; on sensory, affective,
cognitive and miscellaneous domains.
e) A child or an illiterate person could use a set of faces
(happy or sad) to indicate the severity of his pain.
Evaluation of outcome in chronic pain
Most patients with chronic pain get some degree of
response to any new modality of treatment that is introduced.
This could be partly due to placebo effect and partly
due to reduction of the emotional element of pain. So it is
to be remembered that success of a treatment regime can
Fig. 4 : The body chart. Each pain is marked on the chart along be decided on only if the positive response lasts long
with the pain score. enough – at least for three weeks. And the evaluation is
best made in terms of quality of life too, not just with a
The following points are worth remembering pain score.
i) Pain being a somato-psychic experience, the patient
is the only person who can assess the intensity of his pain. Acknowledgment
ii) Muscular pains often can be more severe than the original I gratefully acknowledge the help from Mr Sunilkumar
pain. iii) Treatment itself may cause new pains – e.g.opioids S, Department of Radiation Physics, Regional Cancer
inducing constipation. Centre, Trivandrum in preparation of the fig. 1, 2 and 3.

The body chart References

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