Understanding the Pain and its Management - PowerPoint Presentation

Slide1

Understanding the Pain and its Management

Dr. Mohammad Shoaib

(

Assistant Professor)

D/o Ilaj-bit-Tadbeer,

F/o Unani Medicine,

A.M.U., Aligarh.

Slide2

Introduction:Pain - Poena (fine, penalty, or punishment).

Pain

is a matter of

mind,

purely Subjective feeling

,

unpleasant experience

originating from damaged cells / tissue.

It is uniquely experienced by each individual,

it cannot be adequately defined, identified, or measured by an observer.

Slide3

Pain is purely an afferent sensory experience. Pain has two part:

1. awareness of a painful stimulus

2. emotional impact evoked by the pain. e.g. anxiety & depression

Pain occurs due to the noxious stimulation (mechanical, thermal or chemical) of pain receptors (nociceptors) leads to transmission of impulse by nerves to the brain.

Slide4

Unani concept of painAccording to Ibne sina pain occurs due to soo-e-

mizaj

mikhtalif

and

Tafarruk

-e-

itsal

while

jalinos

said it is due to only

Tafarruke itsal

.

Soo-e-

Mizaj

Mukhtalif:

Excessive heat produces takhalkhul while extreme coldness produces astringent (qabiz) action leads to

tafarruk

-e-

itsal

results pain

excessive accumulation or production of Khilt, metabolic waste, morbid materials,

alteration in

quwat

-e-

Masika

,

jaziba

wa

dafiya

Tafarruk

-e-Itsal:

alteration in homeostasis lead to cells injury and tissues damage results pain

Slide5

Components of pain: Pain

has

3

components which are given

below

1. Physiological

(

visible) - Labour Pain

2. Pathological

(

visible) - Disease

3. Psychological

(

invisible) - Stress

Slide6

Physical and Pathological components:

Cell injury - inflammatory

mediators

like

prostaglandin, Bradykinin, Leukotrienes, interleukins

etc. – sensitize

the nerve

ending, manifest as

a pain signal in the form of electrical

impulse,

travelling to the brain through synapse and

gelatinous substances of spinal cord (substantia gelatinosa)

help in transmission of pain.

On receiving the pain impulses substantia gelatinosa can either facilitate or inhibit the pain

impulse to the brain (Thalamus & Cerebral cortex).

Slide7

NEUROCHEMISTRY: Cell injury produces release of endogenous chemicals like Prostaglandins,

Bradykinin

,

Histamine

,

Serotonin

, S

ubstance P

, Leukotrienes & Potassium ion.

SUBSTANCES & EFFECTS ON NOCICEPTORS (Pain Receptor):

Substances Effects

Prostaglandins Sensitization

Bradykinin Activation & Sensitization

Substance-P Sensitization

Leukotrienes Sensitization

Potassium Activation

Serotonin Activation

Histamine Activation

Bradykinin is most potent pain produced agent,

powerful vasodilator and causes increased capillary permeability.

Prostaglandin presence is necessary for the activation of Bradykinin action.

Slide8

Slide9

S.No.

Functions of Prostagladine-1

Applications

1.

Mucous coating on gastric mucosa

Peptic Ulcer

2.

Help in Platelets aggregation(TXA2)

To avoid platelets damage & improve harvesting

3.

Vasodilators(PGI2)

To maintain patency of Ductus Arteriosus(PGI2)

Nephrons vasodilators

Peripheral vascular diseases

4.

Cervix dilator and Uterine Contractor

Abortion,

Induction / Augmentation of labour (PGE2)

\

Cervical Ripening (make soft)

Post Partum

Haemorrhage

(PPH) due to atonic Uterus

S.No.

Functions of Prostagladine-2

:

Applications

1.

Responsible for Pain & inflammation

----

Slide10

Pain Gate Theory by Melzack and Wall (1965

)

:

In

substantia gelatinosa there is a

hypothetical gate

through which impulses travel towards the brain, by closing this gate

it

can modify or block the impulse to reach the brain or to the organ from brain.

In

spinal cord two chemicals are produces like Enkephalin (endogenous morphine) and

Substance-P (neurotransmitter

) which block and open the pain gate respectively.

Thus

we say that enkephalin (endorphin) produces analgesic effect by increasing the pain threshold / blocking the pain gate while Substance-P decreases the pain threshold by opening the pain gate in the spinal cord.

Slide11

Slide12

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Psychological components:

Endorphin is an endogenous morphine produced in pituitary and hypothalamus. They increase the threshold of pain

results in

relief of pain, and

produces

morphine like

actions euphoria.

During Anxiety & Depression the production of Endorphin is decreases leads to decrease pain threshold resulting perception of more pain in stress.

Slide14

Endorphin enhancers: There are certain factors and situation responsible for increasing the production of endorphin from Pituitary and Hypothalamus in the body results in increasing pain threshold level which are given below.

1. Certain

types of food (Chilli, Chocolates)

2. Aerobic

/ Moderate Exercise (Swimming, walking, cycling)

3. Coitus

/ Vaginal stimulation / Sexual orgasm

4. Laughter

therapy

5. Acupuncture

6. Acupressure

7. Relaxation

activities

8. Music

/ Dancing

9. Religious activities

10. good night sleep

Slide15

The natural analgesic (endorphin) effect of a six mile run is roughly equivalent to 10mg morphine, so regular exercise is better option for the replacement of analgesic.

Opoid analgesics act on spinal and supra spinal level by blocking the formation of substance-P and increases the level of endorphin

Slide16

Endorphin reducers: There are certain factors and situation responsible for decreasing the production of endorphin from Pituitary and Hypothalamus in the body results in decreasing pain threshold level which are given below.

Psychological

stress

Depression

Anxiety

Insomnia

Fearful & Apprehension

Fatigue

emotionally unstable

Smoking

Pollution

Slide17

Types of Pain:Acute pain: usually sudden onset, triggered by inflammatory chemical mediators that stimulate the nociceptors

.

Response of acute pain

:

stimulation of autonomic nervous system can be observed like mydriasis, tachycardia,



B.P., Pallor or flushing, tachypnoea, sweating, vasoconstriction, Nausea,



blood sugar,



gastric acid secretion,



gastric motility,



blood flow to the viscera

, kidney

and skin .

*Psychological and behavioural response to acute pain is

f

ear, anxiety and general sense of unpleasantness.

Slide18

Chronic pain: lasting at least 6 months, often unknown cause, develops insidiously, associated with a sense of hopelessness, sleeping disorders, tendency to deny pain, an attempt to keep pain related behaviour to a minimum and depression often results.

Chronic pain may be more debilitating than the trauma itself and in many circumstances it becomes emotionally and physically devastating and leads to develops suicidal tendency.

Slide19

Pain categories:Nociceptive Pain: results from ongoing activation of mechanical, thermal, or chemical nociceptors typically NSAID & opoid responsive. Addiction is main drawback of opoid user.

Neuropathic Pain

:

Dysfunction of the nervous system, Abnormality in the processing of sensations

,

Associated with medical conditions rather than tissue damage

,

typically Antidepressant & Anticonvulsant responsive like Amitryptillin, Deuloxitine & Carbamazepine, Gabapentine.

Pain Measurement

:

Visual Analogue Scales

(

VAS

),

Numerical rating score

(intensity from 0 to 10),

Verbal rating scale

and U

sing words ‘severe’, ‘moderate’, ‘mild’, ‘none’

.

Slide20

Management of PainDrug Therapy:

Non Selective COX Inhibitors (Both COX-1&2):

It inhibits the formation of prostaglandin while increase production of Leukotrienes by providing concentration of Arachidonic acid leads to Bronchconstriction. Hence, some time COX inhibitors produces Bronchconstriction and such type of drugs is contraindicated in asthmatic patients. e.g.

Asprin

,

Diclofenac

Sodium, Ibuprofen,

Naprosyn

,

Piroxicam

.

Selective COX-2 Inhibitor

:- It only inhibits the formation of Prostaglandin-2 by blocking the enzyme Cyclooxiginase-2 which is responsible for pain and inflammation results in free from adverse effect of Non Selective COX Inhibitors like gastritis etc. e.g.

Etoricoxib

,

Celecoxib

,

Roficoxib

etc.

Slide21

Corticosteroid: It blocks both formation of Prostagladines and Leukotrienes producing relief from inflammation and allergic and autoimmune disorders. Long term used leads to osteoporosis, Hypertension & Diabetes mellitus. e.g.

Prednisolone,

Methyl

Prednisolone,

Betamethasone,

Dexamethasone etc.

Opioid Analgesic:

They are blocking the pain impulse at spinal & supra spinal level by decreasing the production of substance-P in spinal cord resulting increase the pain threshold. e.g.

Dextropropxyphene, Tramadol, Pentazocine. Most common side effect of

opoid

analgesic is addiction.

Adjuvant therapy:

Antidepressant, Anticonvulsant, Anaesthetics (Neuronal blockage), Capsaicin (Chilli), antipsychotic, antihistaminic, Benzodiazepine, Stimulants (Amphetamine, Caffeine, Cocaine),

Cannabinoids

(Bhang), Placebo, Surgical lesion &

Multidisciplinary Pain Rehabilitation.

Slide22

Drugs used in Unani system of Medicine: Munzij wa Mushil therapy: for tanqiya wa ikhraje

mawad

-e-

fasida

, taadel-e-

mizaj

& imala-e-mawad.

Systemic:

Habbe Asghand, Habbe Ghule Aakh, Habbe Shifa, Suranjan, Aujaiya, Aujai, Mafsaleen, Arthrilcure, Qurse Sadaf, Majoone Flasfa, Majoone Suranjan, Majoone Chobchini, Khamira Sadaf, Khamira Khashkash, Sufoofe Musakkin, Tab-

Rhumalya

, Tab-

Rhumalya

fort, Tab-

Bayna

etc.

Locally:

Qairooti, Rhogane Ahmar jadeed, Rhogane Surkh, Rhogane Seer, Roghane Akseer etc.

Local Fomentation:

Ghule Teesu, Nakhuna, Babuna, Poste Khashkhash, Ajwain,

Barghe

Arand

, Barghe Dhatura, Barghe Madar etc.

Slide23

Vitamin B6 (Pyridoxine) known as pain fighting vitamin. Their deficiency leads to Carpal Tunnel Syndrome (CTS).

Oestrogen hormone

reduces the level of Vitamin-B6 in the body, so females are more prone to CTS.

Tryptophan

rich diet is milk, cheese, egg and animal protein help in the formation of

Serotonin

which is antidepressant resulting pain relief by increasing pain

threshold.

Oestrogen

hormone has

uricosuric effect

(increase uric acid excretion) leads to decreases the chances of Gout in fertile life of female.

Slide24

Non Drug Therapies: They mostly work on the spinal cord to close the gate to shut pain impulse by increasing the endorphin level resulting blocks the perception of pain impulse in thalamus and Cerebral cortex (seat of pain). These are given below

:

Cupping therapy:

(increasing blood circulation, break muscular spasm diverting morbid material, removing congestion & increases healing process of damaged

tissues)

Leeching

:

(diverting & removing morbid materials, increasing blood circulation, removing congestion & injecting anti-inflammatory, anticoagulants, Vasodilators &

Anaesthetics agents)

Fasd

:

((diverting & removing morbid materials, removing congestion & normalise blood volume)

Slide25

Takmeed Har (Thermal therapy): (increasing blood circulation, break muscular spasm diverting morbid material & healing process of damaged tissues) e.g. short & long wave diathermy, infra red, ultrasound therapy

Takmeed

Barid

(Cold Therapy):

(Decreasing the blood circulation & Inflammatory mediators at the site of damaged tissues)

Acupuncture

:

((balancing energy (

Qi

) forces and releasing

endorphin)

Osteopathy

:

(manipulation or stretching of skeletal

muscles)

Chiropractic

:

(manually correct postural distortion),

Magnet

therapy:

(suppress pain perception by releasing endorphin)

Ionised

bracelet:

(discharge +

ve

ion made balance between +

ve

& -

ve

forces)

Slide26

Hypnosis: (diverting attention)Relaxation: (audio, video & physical exercise)

Psychotherapy:

(Placebo effect)

Autosuggestion:

(self hypnosis or self talk)

Transcutaneous Electric Nerve Stimulation (TENS):

(Low voltage shock)

Massage:

(break muscular spasm, increases blood circulation and decreases level of stress hormone)

Summation:

(both pharmacological and non pharmacological treatment applied at the same time)

Slide27

Conclusion: NSAID act on tissue level

or infraspinal

level

Opoid act on spinal and supraspinal (brain) level

Almost all

IBT

modalities or

non

drug therapies increases the production of

endorphin and diversion & evacuation of morbid matter.

Slide28

Thanks