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Pain Flashcards

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1
Q

Pain

A

An unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage

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2
Q

Purpose of immediate pain

A

Warns of imminent tissue damage —>withdraw from the source of injury

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3
Q

Purpose of persisting pain

A

Encourages us to immobilise the injured area, giving damaged tissue the best chance to heal

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4
Q

Nociception

A

Describes the neural processes involved in producing the sensation of pain

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5
Q

Nociceptive pathways

A

Transduction in the periphery, through transmission to the dorsal horn of the spinal cord, then on to the brain

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6
Q

Acute pain

A

Pain <12 weeks duration

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7
Q

Chronic pain

A

Continuous pain lasting >12 weeks
Pain that persists beyond Tissue healing time

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8
Q

2 types of chronic pain

A

Non-cancer
Cancer

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9
Q

Nociceptive pain

A

Pain that arises from actual or threatened damage to non-neural tissue and is due to activation of nociceptors

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10
Q

Neuropathic pain

A

Pain caused by a lesion or diseases of the somatosensory nervous system

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11
Q

Nociplastic pain

A

Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors, or evidence for disease or lesion of the somatosensory system causing pain

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12
Q

Examples of neuropathic pain

A

Trigeminal Neuralgia
Glossopharyngeal Neuralgia
Post Herpetic Neuralgia
Painful Diabetic Neuropathy
Complex Regional Pain Syndrome
Phantom limb pain
Pain due to spinal cord damage / stroke / brachial plexus avulsions

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13
Q

Allodynia

A

Pain due to a stimulus that does not normally provoke pain

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14
Q

Dyesthesia

A

An unpleasant abnormal sensation, whether spontaneous or evoked

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15
Q

Hyperalgesia

A

Increased pain from a stimulus that normally provokes pain

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16
Q

Hypoalgesia

A

Dismissed pain in response to a normally painful stimulus

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17
Q

Pain pathways

A

Peripheral receptor
1st order neurons
2nd order neuron
3rd order neuron

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18
Q

1st order neuron

A

From the periphery to ipsilateral spinal cord

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19
Q

2nd order neuron

A

Crosses to the contralateral cord and ascends to the thalamus, the system’s integrative ‘relay section’

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20
Q

3rd order neuron

A

From thalamus to midbrain and higher cortical centres

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21
Q

Nociceptors

A

Transduction
Physical stimulus —> Action potential
Most are poly-modal (thermal/chemical/mechanical)

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22
Q

Primary Afferent neurones

A

Nociceptors are the free nerve endings of primary afferent neurons
AΔ fibres
C fibres
found in any area of the body that can sense pain either externally or internally

External: skin / cornea / mucosa
Internal: viscera / joints / muscles / connective tissue

The cell bodies of these neurons reside in either
Dorsal root ganglion (body)
Trigeminal ganglion (face / head / neck)

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23
Q

Cell bodies of primary Afferent neurones are found in either

A

Dorsal root ganglion (body)
Trigeminal ganglion (face/head/neck)

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24
Q

Dorsal root ganglion

A

Present on the dorsal root (sensory)
Composed of cell bodies of nerve fibres that are sensory (afferent)
First order neurons
Pseudo-unipolar neurons
Can be the source of pain pathology
Trigeminal ganglion is the equivalent for the face / head

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25
A-Alpha nerve fibre carries what kind of information
Proprioception
26
A-beta nerve fibre carries what kind of information
Touch
27
A-delta nerve fibre carries what kind of information
Pain (mechanical and thermal)
28
C nerve fibre carries what kind of information
Pain (mechanical, thermal and chemical)
29
Which nerve fibres are myelinated
A-Alpha A-beta A-delta
30
Which nerve fibre is unmyelinated
C
31
A-Alpha nerve fibre diameter
13-20 um
32
A-beta nerve fibre diameter
6-12 um
33
A-delta nerve fibre diameter
1-5 um
34
C nerve fibre diameter
0.2-1.5 um
35
A-Alpha nerve conduction speed m/s
80-120
36
A-beta nerve conduction speed m/s
35-90
37
A-delta nerve conduction speed m/s
5-40
38
C nerve conduction speed m/s
0.5-2
39
Dorsal horn
On the posterior aspect of the SC the grey matter forms two horns called the dorsal horns. (the ones at the front are called the ventral horns) Contains distal nerve endings from primary afferents, cell bodies of second order neurones as well as a complex network of other nerves such as excitatory and inhibitory interneurons (and projection neurones) that transmit somatosensory info from the SC to the brain
40
2 dimensions of pain experience
1. Sensory/discriminative - allowing us to locate tissue damage 2. Affective/aversive - ‘unpleasant’ and ‘emotional’ in the IASP definition his is reflected in the anatomy of the different components of the pain pathway: The affective component travels centrally along ancient spinal cord pathways to ‘old brain’ centres in the midbrain The discriminative part of the sensation is carried along newer tracts to the evolutionary modern sensory cortex
41
Polymodal nociceptors
A-delta and C - respond to a variety of stimuli, mechanical, thermal and chemical.
42
A-delta nociceptors
thought to mediate the initial, ‘fast’ pain on injury, e.g. on touching a red-hot surface. This ‘fast pain’ initiates the protective withdrawal reflex.
43
C nociceptors
responsible for the dull, throbbing pain that accompanies inflammation following injury. This ‘slow pain’ promotes immobilization of the injured body part, which can encourage healing
44
Visceral nociceptors
similar to Aδ and C nociceptors found in the periphery. The main difference being that they respond to distension and ischaemia rather than cutting and thermal damage. Visceral pain signals are carried by Aδ and C fibres, which travel with autonomic efferents
45
Activation thresholds
Activation thresholds for mechanical and thermal stimulation are high compared to mechanoreceptors and thermoreceptors. In other words, it is extremes of pressure and temperature that activate nociceptors.
46
How do A-delta afferents synapse
Aδ primary afferents synapse directly with secondary afferents that will eventually carry the pain signal to the thalamus.
47
How do C fibre afferents synapse
C fibres do not synapse directly with secondary afferents, but connect instead with interneurons that carry the signal on to secondary afferents in laminae I or V. These interneurons are important in modulation of the pain signal
48
Visceral input
differs in that fewer primary afferents activate a larger number of second order neurons, resulting in poorer localisation of pain. Visceral afferents also converge with somatic inputs, which may account for the phenomenon of referred pain
49
Spinothalamic tract
Sensory pathway that carries pain, temperature and crude touch information from the body 2nd order neurons Originate in the spinal cord (substantia gelatinosa and nucleus proprius) Axons decussate at / few levels above the site of entry / spinal segment Cross the midline in the anterior commissure Then form the anterolateral tract lateral STT (pain & temperature) and anterior STT (crude touch) Terminate in the thalamus (ventral posterior lateral nucleus) Some axons terminate in the reticular formation and midbrain
50
Where does the Spinothalamic tract originate
Spinal cord- Substantia gelatinosa and nucleus proprius
51
Where do fibres of the Spinothalamic tract terminate
Thalamus (ventral posterior lateral nucleus)
52
Lateral Spinothalamic tract
Pain and temperature
53
Anterior Spinothalamic tract
Crude touch
54
Where do axons of the Spinothalamic tract decussate
at / few levels above the site of entry / spinal segment
55
Ventral Spinothalamic tract
Light touch
56
Dorsal columns
Fine touch Proprioception Vibration
57
Medial Spinothalamic tract
ascends deeper in the cord, sending collaterals to the reticular activating system, periaqueductal grey and hypothalamus, before terminating in the medial nucleus. It serves the general arousal and aversive component of the pain experience.
58
Lateral Spinothalamic tract
originates from secondary afferents in laminae I and V of the dorsal horn, and runs superficially in the anterolateral white matter cord, ascending directly to the lateral thalamus. As the name suggests, it is the newer of the two spinothalamic tracts and carries the sensory, discriminative part of the pain signal
59
Thalamus
Midline, paired symmetrical structure in the brain Approx 6 X 3 cms long All sensations (except olfactory) relay / pass through Multiple nuclei VPL Medial group Reciprocal connections to all parts of the cortex
60
Thalamic nuclei
The main thalamic nuclei involved in pain processing are: Lateral ventral posterolateral (VPL) nuclei Medial midline group of nuclei The thalamic nuclei contain cell bodies of third order neurons, the projections of which make up the final part of the nociceptive pathway.
61
Lateral Thalamic nuclei
Sensory component
62
Medial Thalamic nuclei
Emotional component
63
Sensory cortex
Broadmann area 3, 1, 2 Every area on the body is represented in a spatial fashion Sensory homonculus
64
Insula
where the degree of pain (experienced or imagined) is judged Contributes to the subjective aspect of pain perception Plays a role in perception, motor control, self awareness and interpersonal experience May also play a part in addiction
65
Amygdala
plays a key role in learned emotional responses (fear, anxiety, depression) important brain center for the emotional-affective dimension of pain and for pain modulation hyperactivity in the central nucleus of the amygdala accounts for pain-related emotional responses and anxiety-like behavior
66
Cingulate cortex
Located on the medial aspect of the cerebral hemispheres Intricately linked with the limbic system which is associated with emotion formation and processing, learning and memory Maintains reciprocal connections with other pain processing areas Has recently been shown to be one of the areas activated by acupuncture
67
Where is the peri-aqueductal gray
In brainstem
68
Peri-aqueductal gray
Grey matter located around the cerebral aqueduct Receives input from cortical and sub-cortical areas Projects onto neurons in the dorsal horn Modulate afferent noxious transmission Neurons bear opioid receptors Pathways also include noradrenergic and serotonergic neurones Stimulus of the PAG can result in profound analgesia
69
Pain treatment
Stimulate descending inhibitory pathway Gate control Pharmacotherapy
70
Gate control theory
concept that onwards transmission of a nociceptive signal depends on the balance between inhibitory and excitatory inputs at points of integration along the path from transduction to perception.
71
Pain management
MDT approach Biological target Physio therapy / occupational therapy Psychology
72
Drugs commonly used in pain medicine
NSAID’S Paracetamol Opioids LA’s ⍺2 agonists NMDA receptor antagonists TCA’s gabapentinoids SNRI’s
73
Opioids use
Treat acute pain
74
Problems with long term use of opioids
Tolerance (challenge in acute pain settings) Immunosuppression Deranged HPAxis Opioid Induced Hyperalgesia (OIH)
75
Causes of cancer pain
1. Pain associated with direct tumor (tumor infiltration, bone metastases) 2. Pain associated with cancer therapy (chemo, surgery or radiation) 3. Pain unrelated to cancer (RA, OA, headache or herpes zoster)
76
Anterior cingulate cortex
number of functions, including attention and response selection. Activation studies suggest the ACC plays an important role in processing information related to the unpleasantness of pain
77
Rexed divisions
1952 Rexed subdivided the grey matter of the spinal cord into 10 laminae. Lamina 1–> 5/6 correspond to the dorsal horn Some of these rexed laminae have special names e.g. lamina II (2) is called substantia gelatinosa
78
Total pain
Bio-psych-social model +spirtual Used for palliative care
79
Overview of first order neurons
Enters the spinal cord through a spinal nerve or the brainstem through the trigeminal nerve Enters ipsilateral to the peripheral receptor Remains ipsilateral and synapses with a second order neuron
80
Overview of second order neuron
Cell body located in the spinal cord/brainstem It decussates and ascends to the thalamus
81
Overview of third order neurons
Cell body located within thalamus Axons project to the somatosensory cortex
82
What reduces the Nociceptive action potential threshold- hyperalgesia
Bradykinin Prostaglandin E2
83
What do the terminals of alpha-delta fibres release
Glutamate
84
What do the terminals of C fibres release
Glutamate Substance P
85
Substance P
Peptide neurotransmitter and vasodilator Remains bound to receptors for a longer time- causing long-lasting pain
86
Which channels respond to hot stimuli
TRP channel
87
Which channels respond to cold stimuli
TRPM8 channels
88
Mechanical UMN
Respond to excess pressure or mechanical deformation Respond to incisions that break the skin Have polymodal characteristics
89
Chemical UMN
Respond to noxious chemicals TRP channels modulate the response Eg capsaicin —> taste spicy foods
90
Sleeping UMN
Silent type Only activate if injury has occurred Response comes with onset of inflammation to the surrounding tissue
91
Polymodal UMN
Respond to thermal, mechanical and chemical stimuli Majority found in skin
92
Analgesia
Selective suppression of pain without effects on consciousness
93
Anaesthesia
Uniform suppression of pain - no pain felt at all, can cause loss of consciousness
94
Melzack-Wall pain gate
States that non-painful inputs closes the ‘gate’ to painful inputs, thereby preventing pain sensation from being perceived and felt
95
A 21 year old student volunteers to take part in a research study investigating the neuropsychology of pain. Awareness of pain is associated with activity in which region of the brain?
Prefrontal cortex

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