The Anatomy and Physiology of Pain - PowerPoint Presentation

352 views
Uploaded On 2020-04-03

The Anatomy and Physiology of Pain - PPT Presentation

COs CURE Hospital Medicine Pilot Learning Objectives Gain insight into of the anatomy and physiology of pain Recognize terminology Identify the bodys physiological response to pain Recognize the effects of pain on the different body systems ID: 774995

pain chronic https www pain chronic https www management system nerve nociceptive fibers peripheral nervous central retrieved injury transmission

Link:

Copy

Embed:

<iframe width="560" height="315" src="https://www.docslides.com/embed/774995" frameborder="0" allowfullscreen></iframe>

Download Presentation from below link

Download Presentation The PPT/PDF document " The Anatomy and Physiology of Pain" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.

Presentation Transcript

Slide1

The Anatomy and Physiology of Pain

CO’s CURE

Hospital Medicine Pilot

Slide2

Learning Objectives

Gain insight into of the anatomy and physiology of pain

Recognize terminology

Identify the body’s physiological response to pain

Recognize the effects of pain on the different body systems

Apply knowledge to assess and treat pain

Slide3

Pain

THE TEACHING: Medically - pain is a symptom of an underlying conditionTHE MISSION: Find the source of pain Holistically treat the painTHE GOAL: Return to a realistic, productive life

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage.”

Slide4

The Purpose of Pain

Prevents serious injury

A light touch to something hot forces a quick reaction before serious injury occurs

Teaches avoidance

A painful activity teaches what not to repeat or when to seek help

Prevents permanent damage

Joint pain limits activity

Surgery requires down time for healing

Slide5

The Pain Roadmap

Pain sensation involves a series of complex interactions between peripheral nerves and the central nervous system

Pain is a dynamic, bidirectional process

Multiple areas of the nervous system help process pain signals

Normal and pathologic processes underlie pain mechanisms

Slide6

The Origin of Pain

Pain

Origin

Somatic or Cutaneous Pain

Arises from nociceptive receptors in the skin and mucous membranes

Superficial pain

Feels like sharp, burning, pricking and is constant

Fast or slow onset

Deep Somatic Pain

Stems from tendons, muscles, joints, periosteum and blood vessels

Visceral Pain

Originates from internal organs: pelvis, abdomen, chest and intestines

Activates nociceptors of the viscera (internal organs in main cavities of the body)

Poorly localized and is an achy and dull sensation

Visceral structures are highly sensitive to stretching, ischemia and inflammation but insensitive to other stimuli that normally provoke pain

Psychogenic Pain

Individuals “feel” pain but cause is emotional rather than physical

Slide7

The Process of Pain Physiology

Pain sensation is modulated by two types of neurotransmitters or neurochemicals:

Neurochemicals that excite pain or try to initiate pain

Neurochemicals that inhibit or try to stop the pain

Pain sensation is composed of four basic processes:

Transduction

Transmission

Modulation

Perception

Slide8

The Process of Pain Physiology

Process

Action

Transduction

Processes by which tissue-damaging stimuli activate nerve endings

Three types of stimuli can activate pain receptors in peripheral tissues: mechanical, heat, chemical

Pain stimuli is converted to energy

Electrical energy is known as “transduction”

Stimulus sends an impulse across the peripheral nerve fibers known as the nociceptor never fibers

Transmission

Nociceptive message is transmitted to the central nervous system (CNS)

A delta fibers send sharp, localized and distinct sensations

C fibers relay impulses that are poorly localized, burning and persistent

This is the route by which the CNS is informed of impending or actual tissue damage

Modulation

Natural inhibition or modulation of pain by the body

Inhibitory neurotransmitters like endogenous opioids (enkephalins, dynorphin and endorphins) that work to hinder pain transmission

Perception

Person is aware of the pain

Somatosensory cortex identifies the location and intensity of the pain

Person unfolds a complex reaction – physiological and behavioral

Slide9

The Transmission of Pain: Afferent Axons

Slide10

The Transmission of Pain: Timing

The thickness of a nerve fiber correlates directly to the speed with which information travels The thicker the nerve fiber, the faster information travels A-alpha, A-beta and A-delta nerve fibers are insulated with a protective covering called the myelin sheath, which helps with nerve conductivity C nerve fibers are unmyelinated A-delta and C fibers are the main fibers responsible for the transmission of pain, however new studies suggest A-beta fibers may have an important role to play in the diagnosis and treatment of pain

Fast Pain

Slow Pain

Transmitted by the A-delta nerve fibers at a velocity of 6-30 m/second

Felt about 0.1 seconds after a pain stimulus is applied

Pin prick, cutting or burning of skin

Caused by mechanical or thermal stimuli

Fast, sharp pain is not felt in most deeper tissues

Neurotransmitter released – glutamate

Transmission route: Neo-spinothalamic tract

Transmitted by the C-nerve fibers at a velocity of 0.5-2 m/second

Begins after 1 second or more and may range from seconds to minutes

Slow, burning, aching, throbbing, nauseous pain and chronic pain

Associated with tissue destruction

Caused mainly by chemical stimuli Neurotransmitter released – Substance P

Transmission route: Paleo-spinothalamic tract

Slide11

Transmission of Pain: Pull it Together

Peripheral Sensory Nerve

Spinal Cord

Thalamus

Cortex

Pain!

PAG

Periaqueductal Gray Matter

A-delta

Afferent neurons

Modulation

ain Signals

Transduction

Perception

ain Signals

Serotonin

Endorphins

Enkephalins

Dynorphin

Neurochemical

Pain Inhibitors

Descending Inhibition

Epinephrine

Cortisol

ACTH

Neurochemical

Pain Initiators

Glutamate – Central

Substance P – Central

Bradykinin - Peripheral

Prostaglandins - Peripheral

Transmission

Descending Pathway

Ascending Pathway

Slide12

Breakout of Pain

CO’s CURE Module Five

Slide13

Acute Pain Occurs in response to injury or illness Responds well to interventions Resolves well as healing proceeds Short-livedLess than three months Often accompanied by sympathetic nervous system arousal Adaptive pain responseHelpful pain response, which produces a behavior that promotes healing

Chronic Pain Multiple underlying mechanisms Requires multi-modal and interdisciplinary treatment approaches Pain that persists beyond the “normal” time expected to healLonger than three months Changes in both peripheral and central nervous system processing If acute pain is not managed well will move into the chronic phase

Acute Pain vs. Chronic Pain

Slide14

Acute Pain vs. Chronic Pain

Nociceptive PainACUTE

Neuropathic PainCHRONIC

Nociplastic

Pain

TYPICAL

CHRONIC

Slide15

TypeExamplesNociceptiveNoxious PeripheralStimuliStrains and sprainsBone fracturesPostoperativeInflammatoryInflammationOsteoarthritisRheumatoid arthritisTendonitisNeuropathicMultiple MechanismsPeripheral Nerve DamageDiabetic peripheral neuropathyPost-herpetic neuralgiaHIV-related polyneuropathyNoninflammatory/Nonneuropathic Abnormal Central ProcessingNo Known Tissue or Nerve DamageFibromyalgiaIrritable bowel syndromePatients may experience multiple pain states simultaneously

Pain: Types of Pain

Slide16

Nociceptive PainNeuropathic PainSubtypesSomatic – sharp, stabbing pain usually well localized to the area of injury: musculoskeletal: joint pain, myofascial painVisceral – dull, heavy, aching pain that may occur over a wide area: hollow organs, smooth musclesSensory abnormalities cause varying degrees of pain sensations from numbness to hypersensitivity (hyperalgesia) to different types of paresthesia such as tingling; pain often described as burning, stinging, prickingDurationLess than three monthsMore than three monthsCausesStimulation of nociceptors in response to inflammation or damage – i.e. surgery or broken boneDue to an injury or disease of the peripheral or central nervous system – i.e. diabetic neuropathy or phantom leg painManagementConsult the SHM ALTO Pathways for appropriate analgesic considerationsOpioids as a rescue drugPoor response to opioids Consult the SHM ALTO Pathways for appropriate analgesic considerations

Pain: Nociceptive and Neuropathic

Slide17

Acute Pain: Nociceptive

What is nociceptive pain?

Normal response to an injury of tissues

Most common type of pain

What are nociceptors?

Nerves that

detect or find

noxious stimuli

What is nociception?

Process whereby signals are sent to the brain by nociceptor receptors

What is the cause of nociceptive pain?

Injury to body tissue to the skin, muscle and bones

Examples:

Postoperative pain, bruises, burns, fractures, overused joints

Patients will present with dull, heavy, aching pain that spreads over a wide area

Slide18

Chronic Pain: Neuropathic

What is neuropathic pain?

Chronic pain lasts more than six-months

What is the cause of neuropathic pain?

Pain caused by a primary lesion or disease in the somatosensory nervous system causing varying degrees of pain sensations

What is some the cause of neuropathic pain?

Nerve damage due to some type of a viral infection or a disease involving the central or peripheral nervous system (neuralgias)

Examples:

Arthritis, migraines, shingles, multiple sclerosis, shingles

Patients will present with a variety of symptoms from numbness to burning to stinging, pins and needles and pricking sensations

Slide19

Chronic Pain: Nociplastic

What is nociplastic pain?

Nonnociceptive and nonneuropathic pain

Inflammatory response

How does nociplastic pain work?

Activation and sensitization of nociceptive pain pathway by a variety of mediators released at a site of tissue

What causes nociplastic pain?

Abnormal processing in the central nervous system, however the reason for this abnormality is generally unknown

Examples:

Fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome

Patients will present with a variety of symptoms seen in both acute and chronic pain patients

Slide20

Mixed Pain

What is mixed pain?

Mixed pain share common clinical characteristics of all three types of pain

nociceptive, neuropathic and nociplastic

Potential Examples:

Sciatica, cancer pain, lumbar spinal stenosis

Slide21

Other Types of Pain

Type of Pain

Elements of the Pain

Breakthrough Pain

Pain is intermittent, transitory and an increase in pain occurs at a greater intensity

Usually lasts from minutes to hours and can interfere with functioning and quality of life (e.g., neuropathic pain and lower back pain)

Complex Regional Pain Syndrome (CRPS)

Pain condition that most often affects one limb (arm, leg, hand or foot) usually after an injury

CRPS is believed to be caused by damage to, or malfunction of, the peripheral and central nervous system

Phantom Limb Pain

Pain in the absence of a limb

Referred Pain

Pain sensation produced in some part of the body is felt in other structures away from the point of origin

Deep pain and some visceral pain are referred to other areas

Superficial pain is not referred

Most common areas of referred pain include: heart, esophagus, kidneys, stomach, colon, appendix, gallbladder, stomach, ureters (e.g., pain from a myocardial infarction has referred pain to the left arm, neck and chest)

Chronic Pain Syndrome

(CPS)

Different than chronic pain

Combination of the original pain and the secondary

complications that are making the pain worse

Slide22

Chronic Pain Syndrome: CPS

“A chronic pain syndrome is the combination of chronic pain and the secondary complications that are making the original pain worse”

Institute for Chronic Pain

Slide23

Interaction of Complex Pain

Nociceptive PainACUTE

Neuropathic PainCHRONIC

Nociplastic PainTYPICALLYCHRONIC

MIXED PAIN

Slide24

Functional Effects of Pain

Body System

Anticipated Change

Brain

Anxiety and fear

Depression

Poor concentration

Inhibition or promotion of pain

Cardiovascular

Increased heart rate and blood pressure

Increased need for oxygen

Water retention

Potential fluid overload

Endocrine

Increased blood glucose

Increased cortisol production

Gastrointestinal

Reduced gastric emptying and intestinal motility

Nausea and vomiting

Constipation

Slide25

Functional Effects of Pain

Body System

Anticipated Change

Immune

Increased susceptibility to infection

Increased or decreased sensitivity to pain

Activation of hypothalamic-pituitary-adrenal axis (HPA)

HPA is the central stress response system in the brain

Musculoskeletal

Tense muscles local to injury

Shaking or shivering

Pilo-erection or goose bumps

Nervous

Changes in pain processing

Respiratory

Increased respiratory rate

Shallow breathing

Increased risk for infection

Urinary

Urge to urinate/incontinence

Slide26

Psychological Effects of Pain

Anticipated Change

Physical

Sleep disturbances

Chronic fatigue

Inability to keep up with daily activities

Adverse Rx effects

Psychological

Rapid escalation or changes in mood

Crying, anger, anxiety, irritability

Low emotional distress tolerance

Irrational thinking or behavior

Fear

Helplessness

Social

Work-related challenges

Relationship challenges

Intimacy challenges

Social isolation

Loss of role/identity

Spiritual

Hopelessness

Questioning faith

Guilt

Self-pity

Slide27

Sustained

currents

Peripheral

Nociceptive

Fibers

Transient Activation

ACUTE

PAIN

Surgery

orinjurycausesinflammation

Impact

of Pain: Acute to Chronic Path

Sustained

Activation

PeripheralNociceptiveFibers

Sensitization

CHRONIC PAIN

CNS

NeuroplasticityHyperactivity

Structural Remodeling

Slide28

Infants and children Elderly Racial and ethnic groups Women People with current or past history of substance abuse/addiction Cognitively impaired, non-verbal people

Groups at High Risk for Pain Management

Slide29

Take Home Points

The body’s reaction to pains to is complex and multifaceted

Pain is transmitted from the site of injury to the brain by electrical signals

Physiological changes triggered by pain are helpful in the beginning but become harmful if they continue

Understanding the anatomy and physiology of pain helps health professionals to find better ways to treat pain

Key interventions to prevent and treat pain begin with holistic pain assessments

Check the

Society of Hospital Medicine Pain Pathways

for treatment guidelines.

Slide30

References

https://www.ncbi.nlm.nih.gov/books/NBK412/

https://www.researchgate.net/publication/323539036_Epigenetics_as_a_mechanism_linking_developmental_exposures_to_long-term_toxicity/link/5c3b335d458515a4c7226428/download

https://www.nursingtimes.net/clinical-archive/pain-management/anatomy-and-physiology-of-pain-18-09-2008/

https://www.nursingtimes.net/clinical-archive/pain-management/understanding-the-effect-of-pain-and-how-the-human-body-responds-26-02-2018/

https://www.ncbi.nlm.nih.gov/books/NBK219252/

Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives

https://advances.sciencemag.org/content/5/7/eaaw1297

https://www.pnas.org/content/102/36/12950

The subjective experience of pain: Where expectations become reality

Tetsuo Koyama, John G. McHaffie, Paul J.

Laurienti

, Robert C. Coghill

Proceedings of the National Academy of Sciences Sep 2005, 102 (36) 12950-12955; DOI: 10.1073/pnas.0408576102;

Slide31

References

National Pharmaceutical Council, INC, Joint Commission on Accreditation of Healthcare Organizations. (2001, December).

Barriers to the Appropriate Assessment and Management of Pain.

Pain: Current Understanding of Assessment, Management, and Treatments.

(15-16). Retrieved from:

https://www.npcnow.org/system/files/research/download/Pain-Current-Understanding-of-Assessment-Management-and-Treatments.pdf

Niculescu, A. B., Le-Niculescu, H., Levey, D. F., Roseberry, K.,

Soe

K. C., Rogers, J., Khan, F., … White, F. A., (2019, February 12). Towards precision medicine for pain:

diagnositic

biomarkers and repurposed drugs.

Molecular Psychiatry

24:(501–522). Retrieved from:

https://www.nature.com/articles/s41380-018-0345-5

Otis, J.A.,

Macone

, A., (2019, April). When to Use Opioids: What I Didn’t Learn in Medical School.

Practical Pain Management.

Retrieved from:

https://www.practicalpainmanagement.com/resource-centers/opioid-prescribing-monitoring/when-use-opioids-what-didnt-learn-medical-school

Riberio-Pinho

, F. A.,

Verri

Jr., W. A., Chiu, I. M., (2017, January). Nociceptor Sensory Neuron-Immune Interactions in Pain and Inflammation. Trends

Immunol.

38(1) 5-19. Retrieved from:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5205568/pdf/nihms821842.pdf

University of Wisconsin School of Medicine and Public Health: Pain Management (2010). Retrieved from:

http://projects.hsl.wisc.edu/GME/PainManagement/index.html

Waller C. (2018). Colorado Hospital Association Opioid Safety Summit: The Addiction Treatment Ecosystem.

Wilensky, B.

Adapted from Woolf CJ.

Ann Intern Med.

2004;140:441-451.

https://annals.org/aim/article-abstract/717288/pain-moving-from-symptom-control-toward-mechanism-specific-pharmacologic-management?volume=140&issue=6&page=441

Chong MS,

Bajwa

ZH.

J Pain Symptom Manage.

2003;25:S4-S11.

Younger J, Aron A, Parke S, Chatterjee N, Mackey S (2010) PLOS ǀ ONE “Viewing Pictures of a Romantic Partner Reduces Experimental Pain: Involvement of Neural Reward Systems. Retrieved from:

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0013309

Slide32

References

BBC Horizon (2011). I Cut off My Arm to Save My Life. The Secret World of Pain – BBC Two. Retrieved from:

https://www.youtube.com/watch?v=r9YFk7-Dsgw

Cox S (2010)

Nursing Standard. Basic Principles of Pain Management: assessment and intervention.

(Vol 25, Issue 1). Retrieved from:

https://pdfs.semanticscholar.org/e7e6/423e73ce5696e2a2f1e2596258736fb2f486.pdf

Dmitry, A.M., Fleming, A., (2019, April). Pain Assessment: Review of Current Tools.

Practical Pain Management.

Retrieved from: