ACUTE PAIN AND CHRONIC PAIN

Pain, in the sense of physical pain, is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm. Individuals experience pain by various daily hurts and aches, and sometimes through more serious injuries or illnesses. For scientific and clinical purposes, pain is defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage "Pain is whatever the experiencing person says it is, existing whenever he says it does". It is a major symptom in many medical conditions, significantly interfering with a person s !uality of life and general functioning. "iagnosis is based on characteri#ing pain in various ways, according to duration, intensity, type $dull, burning, throbbing or stabbing%, source, or location in body. &sually pain stops without treatment or responds to simple measures such as resting or ta'ing an analgesic, and it is then called acute pain. (ut it may also become intractable and develop into a condition called , in which pain is no longer considered a symptom but an illness by itself. )he study of pain has in recent years attracted many different fields such as pharmacology, neurobiology, nursing, dentistry, physiotherapy, and psychology.

Pain medicine is a separate subspecialty figuring under some medical specialties li'e anesthesiology, neurology, and psychiatry. Pain is part of the body s defense system, triggering a reflex reaction to retract from a painful stimulus, and helps adjust behavior to increase avoidance of that particular harmful situation in the future. +iven its significance, physical pain is also lin'ed to various cultural, religious, philosophical, or social issues.

Pain" used without a modifier usually refers to physical pain, but it may also refer to pain in the broad sense, i.e., suffering. )he latter includes physical pain and mental pain, or any unpleasant feeling, sensation, and emotion. It may be described as a private feeling of unpleasantness and aversion associated with harm or threat of harm in an individual. ,are should be ta'en to ma'e the right distinction when re!uired between the two meanings -ociception, the unconscious activity induced by a harmful stimulus in sense receptors, peripheral nerves, spinal column and brain, should not be confused with physical pain, which is a conscious experience.. .ualifiers, such as mental, emotional, psychological, and spiritual, are often used for referring to more specific types of pain or suffering. In particular, mental pain may be used along with physical pain for distinguishing between two wide categories of pain. )he term unpleasant or unpleasantness commonly means painful or painfulness in a broad sense. It is also used in $physical% pain science for referring to the affective dimension of pain, usually in contrast with the sensory dimension. For instance/ 0Pain1unpleasantness is
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often, though not always, closely lin'ed to both the intensity and uni!ue !ualities of the painful sensation.3

4uffering is sometimes used in the specific narrow sense of physical pain, but more often it refers to mental pain, or more often yet to pain in the broad sense. 4uffering is described as an individual s basic affective experience of unpleasantness and aversion associated with harm or threat of harm.

. Mechanism 4timulation of a nociceptor due to a chemical, thermal, or mechanical event that has the potential to damage body tissue, may cause nociceptive pain. "amage to the nervous system itself, due to disease or trauma, may cause neuropathic or neurogenic pain. -europathic pain may refer to peripheral neuropathic pain, which is caused by damage to nerves, or to central neuropathic pain, which is caused by damage to the brain, brainstem, or spinal cord. -ociceptive pain and neuropathic pain are the two main 'inds of pain when the primary mechanism of production is considered. 5 third 'ind may be mentioned/ see below psychogenic pain. -ociceptive pain may be classified further in three types that have distinct organic origins and felt !ualities.

*. 4uperficial somatic pain is caused by injury to the s'in or superficial tissues. ,utaneous nociceptors terminate just below the s'in, and due to the high concentration of nerve endings, produce a sharp, well1defined, locali#ed pain of short duration. 7xamples of injuries that produce cutaneous pain include minor wounds and minor $first degree% burns. 2."eep somatic pain originates from ligaments, tendons, bones, blood vessels, fasciae, and muscles. It is detected with somatic nociceptors. )he scarcity of pain receptors in these areas produces a dull, aching, poorly1 locali#ed pain of longer duration than cutaneous pain8 examples include sprains, bro'en bones, and myofascial pain.

6.9isceral pain originates from body s viscera, or organs. 9isceral nociceptors are located within body organs and internal cavities. )he even greater scarcity of nociceptors in these areas produces pain that is usually more aching or cramping and of a longer duration than somatic pain. 9isceral pain may be well1locali#ed, but often it is extremely difficult to locali#e, and several injuries to visceral tissue exhibit "referred" pain, where the sensation is locali#ed to an area completely unrelated to the site of injury. -ociception is the unconscious afferent activity produced in the peripheral and central nervous system by stimuli that have the potential to damage tissue. It is initiated by nociceptors that can detect mechanical, thermal or chemical changes above a certain threshold. 5ll nociceptors are free nerve endings of fast1conducting myelinated 5 delta fibers or slow1conducting

unmyelinated , fibers, respectively responsible for fast, locali#ed, sharp pain and slow, poorly1locali#ed, dull pain. ;nce stimulated, they transmit signals that travel along the spinal cord and within the brain. -ociception, even in the absence of pain, may trigger withdrawal reflexes and a variety of autonomic responses such as pallor, diaphoresis, bradycardia, hypotension, nausea and fainting. (rain areas that are particularly studied in relation with pain include the somatosensory cortex which mostly accounts for the sensory discriminative dimension of pain, and the limbic system, of which the thalamus and the anterior cingulate cortex are said to be especially involved in the affective dimension. )he gate control theory of pain describes how the perception of pain is not a direct result of activation of nociceptors, but instead is modulated by interaction between different neurons, both pain1transmitting and non1pain1 transmitting. In other words, the theory asserts that activation, at the spine level or even by higher cognitive brain processes, of nerves or neurons that do not transmit pain signals can interfere with signals from pain fibers and inhibit or modulate an individual s experience of pain. ,hronic pain, in which the pain becomes pathological rather than beneficial, may be an exception to the idea that pain is helpful to survival, although some specialists believe that psychogenic chronic pain exists as a protective distraction to 'eep dangerous repressed emotions such as anger or rage unconscious.

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Diagnosis and assessment )o establish an understanding of an individual s pain, health1care practitioners will typically try to establish certain characteristics of the pain/ site $locali#ation%, onset and offset, character, radiation, associated symptoms, time pattern, exacerbating and ameliorating factors, and severity 5ccording to its duration, pain may be categori#ed as acute $short term%, subacute $medium term%, or chronic $long term%. 5 complete diagnosis of pain will re!uire also to loo' at the patient s general condition, symptoms, and history of illness or surgery. )he physician may order blood tests, =1rays, scans, 7>+, etc. Pain clinics may investigate the person s psychosocial history and situation. 5mong the most fre!uent technical terms for referring to abnormal perturbations in pain experience, there are/

5llodynia pain due to a stimulus which does not normally provo'e pain, ?yperalgesia an increased response to a stimulus which is normally painful, ?ypoalgesia diminished pain in response to a normally painful stimulus.

5 'ey characteristic of pain is its !uality. )ypical descriptions of pain !uality include sharp, stabbing, tearing, s!uee#ing, cramping, burning, lancinating $electric1shoc' li'e%, or heaviness.

It may be experienced as throbbing, dull, nauseating, shooting or a combination of these. Indeed, individuals who are clearly in extreme distress such as from a myocardial infarction may not describe the sensation as pain, but instead as an extreme heaviness on the chest. 5nother individual with pain in the same region and with the same intensity may describe the pain as tearing which would lead the practitioner to consider aortic dissection. Inflammatory pain is commonly associated with some degree of itch sensation, leading to a chronic urge to rub or otherwise stimulate the affected area. Intensity Pain may range in intensity from slight through severe to agoni#ing and can appear as constant or intermittent. )he threshold of pain varies widely between individuals. >any attempts have been made to create a pain scale that can be used to !uantify pain, for instance on a numeric scale that ranges from A to *A points. In this scale, #ero would be no pain at all and ten would be the worst pain imaginable. )he purpose of these scales is to monitor an individual s pain over time, allowing care1givers to see how a patient responds to therapy for example. Localization Pains are usually called according to their subjective locali#ation in a specific area or region of the body/ headache, toothache, shoulder pain, abdominal pain, bac' pain, joint pain, myalgia, etc. Bocali#ation is not
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always accurate in defining the problematic area, although it will often help narrow the diagnostic possibilities. 4ome pain sensations may be diffuse $radiating% or referred. P5I- >5-5+7>7-) >edical management of pain has given rise to a distinction between acute pain and chronic pain. 5cute pain is normal pain, it is felt when hurting a toe, brea'ing a bone, having a toothache, or wal'ing after an extensive surgical operation. ,hronic pain is a pain illness , it is felt day after day, month after month, and seems impossible to heal. In general, physicians are more comfortable treating acute pain, which usually is caused by soft tissue damage, infection andDor inflammation among other causes. It is usually treated simultaneously with analgesics or appropriate techni!ues for removing the cause and for controlling the pain sensation. )he failure to treat acute pain properly may lead to chronic pain in some cases. 5nti1inflammatory drugs 1 5spirin $5nacinE, (ayerE%, coated or buffered aspirin $5scriptonE, (ufferinE% and aspirin with acetaminophen $7xcedrinE% may be used to reduce swelling and irritation as well as to relieve pain. )here also are non1steroidal anti1inflammatory drugs $-45I"s, commonly called "-1sayeds"% such as ibuprofen $5dvilE, >otrinE% and naproxen $5leveE%. 5nti1inflammatory drugs are used to relieve pain, inflammation and fever. )here also are steroidal drugs $li'e cortisol and

prednisone%, available only by prescription, that are used to treat more serious inflammatory conditions such as chronic arthritis. Opioid pain medications 1 >orphine1li'e drugs called opioids are prescribed to treat acute pain or cancer pain. )hey are occasionally used for certain chronic, noncancer pain as well. Anti-depressants 1 )hese drugs were originally used only to treat depression. 4tudies now show, however, that they also can relieve certain pain. 5vailable only by prescription, they often are used to help you sleep better at night. Anti-seizure medicines 1 )hese medications are used to relieve what some patients describe as "shooting" pain by decreasing abnormal painful sensations caused by damaged nerves. Other medicines 1 )he doctor may also prescribe other types of medication that will be helpful for your specific pain problems. In addition, medications that counteract the side effects of opioids or treat the anxiety and depression associated with pain may also be prescribed.

Anesthesia 5nesthesia is the condition of having the feeling of pain and other sensations bloc'ed by drugs that induces a lac' of awareness. It may be a total or a minimal lac' of awareness throughout the body $i.e., general anesthesia%, or a lac' of awareness in a part of the body $i.e., regional or local anesthesia%

Injection treatments 1 Bocal anesthetics $such as -ovocainE%, with or without cortisone1li'e medicines, can be injected around nerve roots and into muscles or joints. )hese medicines reduce swelling, irritation, muscle spasms and abnormal nerve activity that can cause pain. Nerve blocks 1 ;ften a group of nerves, called a plexus or ganglion, that causes pain to a specific organ or body region can be bloc'ed with local anesthetics. If successful, another solution that numbs the nerves can then be injected.

Analgesia 5nalgesia is an alteration of the sense of pain without loss of consciousness. )he body possesses an endogenous analgesia system, which can be supplemented with pain'illers or analgesic drugs to regulate nociception and pain. 5nalgesia may occur in the central nervous system or in peripheral nerves and nociceptors. )he endogenous central analgesia system is mediated by three major components / the peria!ueductal grey matter, the nucleus raphe magnus and the nociception1inhibitory neurons within the dorsal horns of the spinal cord, which act to inhibit nociception1transmitting neurons also located in the spinal dorsal horn. )he peripheral regulation consists of several different types of opioid receptors that are activated in response to the binding of the body s endorphins. )hese receptors, which exist in a variety of areas in the body,

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inhibit firing of neurons that would otherwise be stimulated to do so by nociceptorsH )he gate control theory of pain postulates that nociception is "gated" by non1 noxious stimuli such as vibration.. Pain is also "gated" by signals that descend from the brain to the spinal cord to suppress $and in other cases )his ancient ,hinese practice uses very thin needles at very specific points on the s'in to treat disease and pain. Practitioners of acupuncture undergo speciali#ed training in these techni!ues and may offer this treatment for certain painful conditions. 5lthough the mechanism is not fully understood, acupuncture may stimulate the release of large !uantities of endogenous opioids. Pain treatment may be sought through the use of nutritional supplements such as, glucosamine, chondroitin, bromelain and omega16 fatty acids. )here is interest in the relationship between vitamin " and pain, but the evidence is unconvincing. 4evere vitamin " deficiency causes pain due to osteomalacia , but there is no clear mechanism for its relationship to other pain. ?ypnosys as well as diverse perceptional techni!ues provo'ing altered states of consciousness have proven to be of important help in the management of all types of pain. 4ome 'inds of physical manipulation or exercise are showing interesting results as well.

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Physical and aquatic therapy 1 )he physiatrist or physical therapist may suggest an exercise program tailored for you that will increase your daily functioning and decrease your pain. ;ther treatments may include whirlpool therapy, ultrasound and deep1muscle massage. Electrical stimulation 1 )ranscutaneous electrical nerve stimulation $)7-4% is the most common form of electrical stimulation used in pain management. It is not painful and does not re!uire needles or medicine. )7-4 consists of a small, battery1operated device that can diminish pain by stimulating nerve fibers through the s'in. Psychological support 1 >any patients who are in pain feel the emotional effects of suffering along with the physical aspects of pain. )hese may include feelings of anger, sadness, hopelessness or despair. In addition, pain can alter one s personality, disrupt sleep, interfere with wor' and relationships and often have a profound effect on family members. 4upport and counseling from a psychiatrist or psychologist, combined with a comprehensive pain treatment program, may be needed to help you manage your condition. )hese trained professionals also can teach you additional self1help therapies such as relaxation training or biofeedbac' to relieve pain, lessen muscle spasms and reduce stress. Surgery 1 Ihen necessary, surgical treatment may be recommended. In rare instances when severe pain has not responded to other treatments and procedures, surgery on certain nerves can be done to give the patient some relief and allow them to resume near1normal activities. &sually all other avenues of treatment are tried before surgery is considered.

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pecial cases Phantom pain is the sensation of pain from a limb or organ that has been lost or from which a person no longer receives physical signals. Phantom limb pain is an experience almost universally reported by amputees and !uadriplegics. Phantom pain is a neuropathic pain.

Insensiti!ity to pain )he ability to experience pain is essential for protection from injury, and recognition of the presence of injury. Insensitivity to pain may occur in special circumstances, such as for an athlete in the heat of the action, or for an injured soldier happy to leave the battleground. )his phenomenon is now explained by the gate control theory. ?owever, insensitivity to pain may also be an ac!uired impairment following conditions such as spinal cord injury, diabetes mellitus, or more rarely ?ansen s "isease leprosy. 5 few people can also suffer from congenital analgesia, a rare genetic defect that puts these individuals at constant ris' from the conse!uences of unrecogni#ed injury or illness. ,hildren with this condition suffer carelessly repeated damages to their tongue, eyes, bones, s'in, muscles. )hey may attain adulthood, but they have a shortened life expectancy. Psychogenic pain is physical pain that is caused, increased, or prolonged by mental, emotional, or behavioral factors. Psychogenic pain commonly manifests as headache, bac' pain, or stomach pain. 4ufferers are often

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stigmati#ed, because both medical professionals and the general public tend to thin' that pain from a psychological source is not "real". ?owever, specialists consider that it is no less actual or hurtful than pain from other sources.

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