User:Christo Muller/Workshop/Pain1

Pain - general introduction

Pain meaning

The experience of pain is universally and intuitively recognised, but its definition remains controversial. Most persons suffering pain would consider that by saying that they "have pain", and by giving some indication of where and how severe the hurt is, they are making their experience clear to the listener. The idea that such a bland subjective communication tells us what the person is experiencing presents difficulties for those who wish to study pain from either a physical scientific or a philosophical perspective. The scientist and philosopher would like to be able to define what the experience of pain is, so that it may be analysed, discussed, researched, understood, and hopefully relieved. Without such an agreed upon definition, a Tower of Babel like confusion could result.

The difficulty with pain stems from the fact that pain is an observation about an unpleasant feeling about something inside the sufferer's own body, a combination of a specific kind of nerve activity, related to in internal event, leading to an unpleasant emotional experience. This differs from external sense experiences such as vision, hearing or taste, where the stimulus is a specifically definable physical or chemical entity, correlated in a very specific way with the word which we use for our percepton of that external event (e.g. blue, G-flat, or sweet). For pain, the only observation that correlates with the experience is injury to body tissue. Even so, while an injury may be quite obvious to an observer, the feeling of pain is not. Pain may be deduced from physical observations, but can be confirmed only by the sufferer.

The International Association for the Study of Pain (IASP) recognised these unique and enigmatic qualities of the pain experience when in 1995 its committee on taxonomy formulated the IASP definition of pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. This definition clearly applies to pain in humans only, since science is not able to evaluate the emotions of animals. There are other definitions of pain, and recent advances *in imaging of the brain in pain, as well as the identification of biochemical markers of nociceptor nerve activity may allow more *specific descriptions of the phenomenon of pain. At present there is no consistent explanation for how and why persons perceive pain in different situations, and in different ways. The idea that some anaesthetists propound that the stress response, spinal metabolic changes and autonomic changes are sufficient to diagnose "pain", when the person is under general anaesthesia, indicates that some are still confused about the difference between nociception and pain.

Nociceptive pain

Pain most often has a physical cause, an injury to the body outside of the nervous system. In these cases, pain is initiated by mechanical, thermal or chemical changes in non-nervous tissues, that causes activation of specific nerves which relay to spinal centres concerned with the detection of injury, and thence to the thalamus and cortex, as well as to the reticular system. This hard-wired injury detection mode for pain is called nociception, meaning detection of harm. Common causes of nociceptive pain include traumatic injury (e.g. accidents), degenerative conditions such as osteoarthritis, inflammatory conditions such as abscesses or sunburn, and cancers causing tissue breakdown.

Neuropathic pain

A second physical origin for pain, of importance because it is extremely difficult to treat, tends to be long standing, and may not be diagnosed easily, is damage to the nociceptor nerves themselves. In these cases there is no damaged tissue, and no heat, pressure, or release of pain nerve stimulating chemicals at the site where the brain perceives the pain to be sited, i.e. there is no "actual or potential tissue damage". It is the spontaneous activity of the damaged and dysfunctional nerves which convey impulses to the spinal cord nociceptor nerve structures, and thence to the higher centres. This mode of the experience of pain is called neuropathic, implying pathology or disease of the nerves themselves. Neuropathic pain may follow injury to a nerve, occurring at the same time as a more general tissue injury, so that nociceptive and neuropathic pain may co-exist, the combination often changing to more "pure" neuropathic pain as the tissue injury heals, but the nerves remain dysfunctional. A nerve may be traumatically injured in isolation, or a more generalised nerve injury may result from metabolic diseases such as diabetes, the effects of alcohol abuse, or neurotrophic infections such as shingles (zoster). Since the brain during its development learned to associate activity of a specific set of pain nerves with injury to a spacific body part, neuropathic pain is felt in the area that would normally be innervated by the damaged nerve, i.e. the person does not perceive the nerve itself to be sore.

Central pain

The third type of pain which persons may experience is caused by damage to the central nervous system, including the spinal cord, structures at the base of the brain and the brain itself. While this may correctly be called neuropathic (pathology of nerve tissue), the clinical and prognostic implications of these pain states has lead to the term "central pain" being applied to these very stubborn pain syndromes. Examples of such syndromes include spinal cord injury pain and post stroke pain. The central nervous system itself is insensitive to pain (does not contain nociceptor nerve fibres) and the pain is felt by the sufferer to be located somewhere else in the body, as is the case with peripheral nerve injury.

Complex Regional Pain Syndrome

Complex Regional Pain Syndrome (CRPS) is a chronic condition characterized by burning pain and abnormalities in the sensory, motor and autonomic nervous systems, following a regional rather than a dermatomal or vascular distribution. The clinical picture is of severe and extensive inflammation, but motor and sensory changes differentiate it from infection. Two types are described. CRPS Type I used to be called Reflex Sympathetic Dystrophy (RSD). The syndrome typically appears after an acute injury to a joint or limb, the injury may be moderate to severe (fracture tibia, Colles fracture) or extremely small (e.g. a rose thorn in a finger) or even with no known precipitating cause. Whether the injury is proximal or distal, the distal part of the limb usually first develops symptoms and signs. In the initial stages of RSD/CRPS, pain and swelling from the injury do not subside but actually intensify, spreading from the site of the injury to other parts of the limb, to the contra lateral limb or to remote regions of the body. The skin in affected areas and particularly deep somatic tissues are painfully sensitive to touch, often red and abnormally warm due to alterations in regional blood flow. Changes in sweating patterns, hair growth, subcutaneous tissues, muscles, joints or bones and difficulty moving the joint or limb are other hallmarks of the disorder. In addition to the evidence of inflammation and abnormal autonomic nervous system function, there are changes in motor systems including tremor, weakness and dystonia, which strongly suggest a central nervous system component to the disease in a subgroup of patients. CRPS 1 can affect both genders and all ages (including children), although it is thought to be more common between the ages of 40 and 60 and may be more frequent in women. The cause of CRPS 1 is unknown, and current treatments are not effective for many patients. The only hope is that one can provide sufficient analgesia so that the patient is able to keep moving the limb until the process one day "burns out". CRPS 2, has the same clinical picture and course, but there is a demonstrable nerve injury which starts the process.

Miscellaneous pain syndromes

A fourth type of pain comprises a miscellaneous group of pain conditions which may best be described as syndromes. These are typical painful diseases where the mechanisms and interactions between mind, neuropathology and peripheral tissue abnormalities are unknown or uncertain. The typical disease of this kind is fibromyalgia syndrome, but myofascial pain syndrome (trigger point disease) is equally uncertain. What about whiplash and failed back surgery?

Psychogenic pain

There is no consensus that psychogenic (in the sense of imaginary) pain exists. If a person were to experience pain as a result of a purely psychiatric disturbance, then presumably the central pain localising and "pain as suffering" pats of the brain would be activated in the same way as they would in cases of nociceptive or neuropathic pain, making the condition subjectively indistinguishable from "real pathological" pain. On the other hand, there are psychological disturbances where persons may complain of pain, and act as if in pain, but such illusions of pain are extremely rare, and the clinical picture tends to be sufficiently inconsistent that the diagnosis would not be impossible to make. It should be noted that a person who suffers hallucinations of pain, is really experiencing pain (as hallucinations of voices are subjectively real to the person), so that the complaint would then be consistent, and would demand appropriate treatment to reduce the pain. Finally, the issue of pain complaints as malingering remains a social, medical and legal problem. In the cases where the suffering of pain would lead to real benefits for the person, be it psycho-social or financial, involved persons tend to make the diagnosis without necessarily observing the course of the condition adequately. In clinical practice, malingering for financial or personal secondary gain reveals itself if the person who complains is followed up adequately, as a pattern of inconsistent, irreconcilable, and conflicting actions and complains. The psychological diagnosis of a pain disorder usually presents as persistent and excessive complaints of pain, with no obvious benefits to the person, but frequently associated with gross, persistent and intractable complaints about painful conditions which most persons would consider minor.

Pain in animals

Finally, it is appropriate to consider the problem of pain in animals. This is important for two quite different reasons. The first is the rather utilitarian consideration that the vast majority of research that is dine in an effort to advance our understanding and treatment of pain in humans is done on experimental animals. If animals do not experience pain as humans do, then all this work becomes rather inconsequential The second is that a large proportion of humanity has come to accept that the relief of suffering is an obligation which we have not only to our own kind, but to a varying extent to the animals with which we share this world. In this regard, experimental work on pain using animals as subjects carries with it the obligation of high ethical standards. At the same time, however, that which is learned about the manifestations and treatment of pain in animals can be used to pursue the ideal of helping fellow living creatures who suffer pain - the very species of animals which are used for these experiments. It is presently accepted that all vertebrates do have the mechanisms for nociception, analogous to those of humans, and that these animals can and do suffer pain. The latter is true also for the Cephalopoda, though the pain sensing and processing systems differ from those of vertebrates.

Suggested articles on pain

ADD AS THEY OCCUR. The reader is referred to the articles listed below - and to their sub-articles - for information on the different aspects of pain touched upon in this essay.

• Definition of pain
• Philosophy of pain
• Pain physiology
• Nociceptive pain
• Neuropathic pain
• Central pain
• Pain in animals
• Pain treatment
• Acute pain
• Chronic pain
• Cancer pain
• Pain clinics
• Pain and gender
• Pain syndromes
• Diseases characterised by pain
• Pain measurement
• Pain in children (foetus?)
• Pain in the older population
• Congenital absence of pain
• Pain and religion
• Pain: culture and ethnic factors
• Psychology of pain
• Economics of pain
• Pain as the prime motive for civilization
• Pain and CAM
• Pain in metabolic disease