What is Pain??

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VSPACE="0">        <IMG SRC="2dd20200.gif" border=0 width="32" height="32" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <div> (pän)  a feeling of distress, suffering, or agony, caused by </div> <div> stimulation of specialized nerve endings. Its purpose is chiefly </div> <div> protective; it acts as a warning that tissues are being damaged and </div> <div> induces the sufferer to remove or withdraw from the source.</div> <div>   PAIN RECEPTORS AND STIMULI. All receptors for pain stimuli are free </div> <div> nerve endings of groups of myelinated or unmyelinated neural fibers </div> <div> abundantly distributed in the superficial layers of the skin and in </div> <div> certain deeper tissues such as the periosteum, surfaces of the </div> <div> joints, arterial walls, and the falx and tentorium of the cranial </div> <div> cavity. The distribution of pain receptors in the gastrointestinal </div> <div> mucosa apparently is similar to that in the skin; thus, the mucosa is </div> <div> quite sensitive to irritation and other painful stimuli. Although the </div> <div> parenchyma of the liver and the alveoli of the lungs are almost </div> <div> entirely insensitive to pain, the liver and bile ducts are extremely </div> <div> sensitive, as are the bronchi and parietal pleura.</div> <div>   Some pain receptors are selective in their response to stimuli, but </div> <div> most are sensitive to more than one of the following types of </div> <div> excitation: (1) mechanical stress of trauma; (2) extremes of heat and </div> <div> cold; and (3) chemical substances, such as histamine, potassium ions, </div> <div> acids, prostaglandins, bradykinin, and acetylcholine.</div> <div>   Pain receptors, unlike other sensory receptors in the body, do not </div> <div> adapt or become less sensitive to repeated stimulation. Under certain </div> <div> conditions the receptors become more sensitive over a period of time. </div> <div> This accounts for the fact that as long as a traumatic stimulus </div> <div> persists the person will continue to be aware that damage to the </div> <div> tissues is occurring.</div> <div>   The body is able to recognize tissue damage because when cells are </div> <div> destroyed they release the chemical substances previously mentioned. </div> <div> These substances can stimulate pain receptors or cause direct damage </div> <div> to the nerve endings themselves. A lack of oxygen supply to the </div> <div> tissues can also produce pain by causing the release of chemicals </div> <div> from ischemic tissue. Muscle spasm is another cause of pain, probably </div> <div> because it has the indirect effect of causing ischemia and </div> <div> stimulation of chemosensitive pain receptors.</div> <div>   TRANSMISSION AND RECOGNITION OF PAIN. When superficial pain </div> <div> receptors are excited the impulses are transmitted from these surface </div> <div> receptors to synapses in the gray matter (substantia gelatinosa) of </div> <div> the dorsal horns of the spinal cord. They then travel upward along </div> <div> the sensory pathways to the thalamus, which is the main sensory relay </div> <div> station of the brain. The dorsomedial nucleus of the thalamus </div> <div> projects to the prefrontal cortex of the brain. The conscious </div> <div> perception of pain probably takes place in the thalamus and lower </div> <div> centers; interpretation of the quality of pain is probably the role </div> <div> of the cerebral cortex.</div> <div>   The perception of pain by an individual is highly complex and </div> <div> individualized, and is subject to a variety of external and internal </div> <div> influences. The cerebral cortex is concerned with the appreciation of </div> <div> pain, its quality, location, type, and intensity; thus, an intact </div> <div> sensory cortex is essential to the perception of pain. In addition to </div> <div> neural influences that transmit and modulate sensory input, the </div> <div> perception of pain is affected by psychological and cultural </div> <div> responses to pain-related stimuli. A person can be unaware of pain at </div> <div> the time of an acute injury or other very stressful situation, when </div> <div> in a state of depression, or when experiencing an emotional crisis. </div> <div> Cultural influences also precondition the perception of and response </div> <div> to painful stimuli. The reaction to similar circumstances can range </div> <div> from complete stoicism to histrionic behavior.</div> <div>   PAIN CONTROL. There are several theories related to the physiologic </div> <div> control of pain but none has been completely verified. One of the </div> <div> best known is that of Mellzak and Wall, the "gate control" theory, </div> <div> which proposes that pain impulses are mediated in the substantia </div> <div> gelatinosa of the spinal cord. Essentially, the dorsal horns were </div> <div> thought to act as "gates" that control the entry of pain signals into </div> <div> the central pain pathways. Additionally, pain signals compete with </div> <div> tactile signals and the two are constantly balanced against one </div> <div> another. Since the gate theory was first proposed researchers have </div> <div> shown that the neuronal circuitry on which the theory was based is </div> <div> not precisely the same as Mellzak and Wall had thought. Nevertheless, </div> <div> there are some internal systems that are now known to occur naturally </div> <div> in the body in order to control and mediate pain.</div> <div>   One such system, the opioid system, involves the production of </div> <div> morphine-like substances called "enkephalins" ENKEPHALINS </div> <div> and "endorphins" ENDORPHINS. Both of these groups of naturally </div> <div> occurring analgesics are found in various parts of the brain and </div> <div> spinal cord that are concerned with pain perception and the </div> <div> transmission of pain signals. Signals arising from stimulation of </div> <div> neurons in the gray matter of the brain stem travel downward to the </div> <div> dorsal horns of the spinal cord where incoming pain impulses from the </div> <div> periphery terminate. The descending signals block or significantly </div> <div> reduce the transmission of pain signals upward along the spinal cord </div> <div> to the brain where pain is perceived by releasing these substances.</div> <div>   In addition to the brain's opioid system for controlling the </div> <div> transmission of pain impulses along the spinal cord, there is another </div> <div> mechanism for the control of pain. The stimulation of large sensory </div> <div> fibers extending from the tactile receptors in the skin can suppress </div> <div> the transmission of pain signals from thinner nerve fibers. It is as </div> <div> if the nerve pathways to the brain can accommodate only one type of </div> <div> signal at a time, and when two kinds of impulses simultaneously </div> <div> arrive at the dorsal horns, the tactile sensation takes precedence </div> <div> over the sensation of pain.</div> <div>   The discovery of endorphins and the inhibition of pain transmission </div> <div> by tactile signals has provided a scientific explanation for the </div> <div> effectiveness of such techniques as relaxation, massage, application </div> <div> of liniments, and acupuncture in the control of pain and discomfort.</div> <div>   ASSESSMENT OF PAIN. Pain is a subjective phenomenon that is present </div> <div> when the person who is experiencing it says it is. The person </div> <div> reporting personal discomfort or pain is the most reliable source of </div> <div> information about its location, quality, intensity, onset, </div> <div> precipitating or aggravating factors, and measures that bring relief.</div> <div>   Objective signs of pain can help verify what a patient says about </div> <div> pain, but such data are not used to prove or disprove whether it is </div> <div> present. Physiologic signs of moderate and superficial pain are </div> <div> responses of the sympathetic nervous system. They include rapid, </div> <div> shallow, or guarded respiratory movements, pallor, diaphoresis, </div> <div> increased pulse rate, elevated blood pressure, dilated pupils, and </div> <div> tenseness of the skeletal muscles. Pain that is severe or located </div> <div> deep in body cavities acts as a stimulant to parasympathetic neurons </div> <div> and is evidenced by a drop in blood pressure, slowing of pulse, </div> <div> pallor, nausea and vomiting, weakness, and sometimes a loss of </div> <div> consciousness.</div> <div>   Behavioral signs of pain include crying, moaning, tossing about in </div> <div> bed, pacing the floor, lying quietly but tensely in one position, </div> <div> drawing the knees upward toward the abdomen, rubbing the painful </div> <div> part, and a pinched facial expression or grimacing. The person in </div> <div> pain also may have difficulty concentrating and remembering and may </div> <div> be totally self-centered and preoccupied with the pain.</div> <div>   Psychosocial aspects of tolerance for pain and reactions to it are </div> <div> less easily identifiable and more complex than physiologic responses. </div> <div> An individual's reaction to pain is subject to a variety of </div> <div> psychologic and cultural influences. These include previous </div> <div> experience with pain, training in regard to how one should respond to </div> <div> pain and discomfort, state of health, and the presence of fatigue or </div> <div> physical weakness. One's degree of attention to and distraction from </div> <div> painful stimuli can also affect one's perception of the intensity of </div> <div> pain. A thorough assessment of pain takes into consideration all of </div> <div> these psychosocial factors.</div> <div>   MANAGEMENT OF PAIN. Among the measures employed to provide relief </div> <div> from pain, administration of analgesic drugs is probably the one that </div> <div> is most often misunderstood and abused. When an analgesic drug has </div> <div> been ordered "as needed" the patient should know that the drug is </div> <div> truly available when needed and that it will be given promptly when </div> <div> asked for. If the patient is forced to wait until someone else </div> <div> decides when an analgesic is needed, the patient may become angry, </div> <div> resentful, and tense, thus diminishing or completely negating the </div> <div> desired effect of the drug. Studies have shown that when analgesics </div> <div> are left at the bedside of terminally ill cancer patients to be taken </div> <div> at their discretion, fewer doses are taken than when they must rely </div> <div> on someone else to make the drug available. Habituation and addiction </div> <div> to analgesics probably result as much from the failure to use other </div> <div> measures along with analgesics for the control of pain as from giving </div> <div> prescribed analgesics when they are ordered. Patient </div> <div> controlled "analgesia" ANALGESIA has been used safely and effectively </div> <div> to control acute pain.</div> <div>   When analgesics are not appropriate or sufficient or when there is </div> <div> a real danger of addiction, there are several noninvasive techniques </div> <div> that can be used as alternatives or adjuncts to analgesic therapy. </div> <div> The selection of a particular technique for the management of pain </div> <div> depends on the cause of the pain, its intensity and duration, whether </div> <div> it is acute or chronic, and whether the patient perceives the </div> <div> technique as effective.</div> <div>   Distraction techniques provide a kind of sensory shielding to make </div> <div> the person less aware of discomfort. Distraction can be effective in </div> <div> the relief of brief periods of acute pain, such as that associated </div> <div> with minor surgical procedures under local anesthesia, wound </div> <div> débridement, and venipuncture.</div> <div>   Massage and gentle pressure activate the thick-fiber impulses and </div> <div> produce a preponderance of tactile signals to compete with pain </div> <div> signals. It is interesting that stimulation of the large sensory </div> <div> fibers leading from superficial sensory receptors in the skin can </div> <div> relieve pain at a site distant from the area being rubbed or </div> <div> otherwise stimulated. Since ischemia and muscle spasm can both </div> <div> produce discomfort, massage to improve circulation and frequent </div> <div> repositioning of the body and limbs to avoid circulatory stasis and </div> <div> promote muscle relaxation can be effective in the prevention and </div> <div> management of pain. TENS units enhance the production of endorphins </div> <div> and enkephalins and can also relieve pain.</div> <div>   Specific relaxation techniques can help relieve physical and mental </div> <div> tension and stress and reduce pain. They have been especially </div> <div> effective in mitigating discomfort during labor and delivery but can </div> <div> be used in a variety of situations. Learning proper relaxation </div> <div> techniques is not easy for some people, but once these techniques </div> <div> have been mastered they can be of great benefit in the management of </div> <div> chronic ongoing pain.</div> <div>   The intensity of pain also can be reduced by stimulating the skin </div> <div> through applications of either heat or cold, menthol ointments, and </div> <div> liniments. Contralateral stimulation involves stimulating the skin in </div> <div> an area on the side opposite a painful region. Stimulation can be </div> <div> done by rubbing, massaging, or applying heat or cold.</div> <div>   Since pain is a symptom and therefore of value in diagnosis, it is </div> <div> important to keep accurate records of the observations of the patient </div> <div> having pain. These observations should include the following: the </div> <div> nature of the pain, that is, whether it is described by the patient </div> <div> as being sharp, dull, burning, aching, etc.; the location of the </div> <div> pain, if the patient is able to determine this; the time of onset and </div> <div> the duration, and whether or not certain nursing measures and drugs </div> <div> are successful in obtaining relief; and the relation to other </div> <div> circumstances, such as the position of the patient, occurrence before </div> <div> or after eating, and stimuli in the environment such as heat or cold </div> <div> that may trigger the onset of pain.  </div> <bR> <div> <B>   </B></div> </td> </tr></table></body>