Pain the most common symptom that brings patients to see a physician, nearly

always manifests a pathologic process. Any treatment plan must be directed at

the underlying process as well as at controlling pain. Pantients are generally
referred for pain management by primary care practitioners or spesialists once a
diagnosis has been made and treatment of any underlying process has been
initiated. Notable exceptions are pantients with chronic pain in which the cause
remains obscure after preliminary in investigations serious and life threatening
illnesses should, however, have been excluded.
The term pain management in a general sense aplies to the entire
discipline of anesthesiology, but its modern usage is restricted to management
of pain outside the operating room. This type of practice may be broadly divided
into acute and chronic pain management. The former primarily deals with
patiens recovering from surgery or with acute medical conditions in a hospital set
ting, while the latter includes diverse groups of patients in the outpatient setting.
Unfortunately, this distinction artifisial because considerable overlap exists, a
good example is the cancer patient who frequently requires short and long term
pain management, both in and out of the hospital.
The practice of pain management
is not just limited to anesthesiologists but other practitioners that include
physicians ( such as internists, onkologists and neurologists) and non physicians
( physichologists, chiropractors, acupuncturists and hypnotists) . Clearly the most
effectiv approach is multidisciplinary, where the patient is evaluated by one
physician ( the case manager) who conducts the initial evaluation and
formulates a trearment plan. And where the sevices and resources of other
specialists are readily available. Moreover, the case manager and the various
consultants meet regularly in formal case conferences to discuss patients. Single
specialty pain clinics tend to be either syndrome or modality oriented. The
former spesialize in chronic back pain, headache and temporomandibular joint
dysfungtion, while the latter offer nerve block, acupuncture, hypnosis and
biofeedback.
Anesthesiologists trained in pain management are in a unique position to
coordinate multi dischiplinary pain management centers because of broad
training in dealing with a wide diversity of patients from surgical, obstetric,
pediatric an medical subspecilties, as well as expertise in clinical pharmacology
an applied neuroanatomy, including the use of periphereal and central nerve
blocks.
DEFINITIONS & CLASIFICATION OF PAIN
Like other conscious sensations, normal pain perception is
dependent on specialized neurons that functions as receptors, detecthing the
stimulus and then transducing and conducting it into the central nervous system.
Sensation is often described as either protopathic ( noxious) or epicritic ( non
noxious) . epicritic sensation ( light touch, pressure, proprioception and
temperature discriminatoin) is characterized by low threshold receptors and
generally conducted by large myelinated nerve fibers ( table 18-1). In contrast
protopathic sensation ( pain) is subserved by high threshold receptors and
conducted by smaller , lightly myelinated (A*) and unmyelinated (C) nerve fibers.

What is pain?
Pain is not just a sensory modality but an experience. The
international assosiation for the study of pain defines pain as an unpleasant
sensory and emotional experience associated with actual or potential tissue
damage , or described in terms of such damage. This defenition recognizes the
interplay between the objective, emotional and psychological components. The
response to pain can be highly variable between individuals as well in the same
individual at differents times.
The term nociception, which is derives from noci ( latin for
harm or injury), is used only to describe the neural response to traumatic or
noxiuos stimuli. All nociception produces pain, but not all pain results from
nociception. Many patients experience pain in the absense of noxious stimuli. It
is therefore clinically useful to devide pain into one of two categories , (1) acute
pain, which is primarily due to nociception and (2) chronic pain, which may be
due to nociception but in which psychological and behavioral factors often play a
major role. Table 18-2 lists terms frequently used in describing pain.

TABLE 18-1. Clasification of nerve fibers

Fiber Type

Sensory
Classification

Aa

Modality
Served

Diameter

Conductions
(m/s)

Motor

12-20

70-120

Aa

Type la

Proprioception

12-20

70-120

Aa

Type lb

Proprioception

12-30

70-120

AB

Type ll

Touch
pressure
proprioception

5-12

30-70

Motor
( muscle
spindle)

3-6

15-30

Ay

A*

Type lll

Pain cold
temperature
touch

2-5

12-30

Typr lv

Pregenglion
autonomic

3-14

fiber
C dorsal root

C Sympathetic

Pain warm
and cold
temperature
touch

0,4-1,2

0,5-2

0,3-1,3

0,7-2,3

A.Acute Pain
Acute pain can be defined as that which is caused by noxious
stimulation due to injury, a disease process, or abnormal function of muscle or
visera. This type of pain is typically assosiated with a neuroendocrine stress
that is propotional to intersity. Teleologically , acute pain serves to detect,
localize and limit tissue damage, consequently, it is frequently referred to as
nociceptive pain. Its most common forms include posttraumatic, postoperative
and obstetrical pain, as well as that associated with acute medical illnesses such
as myocardial infarction, pancreatitis andrenal calculi. Most forms of acute pain
are self limited or resolve with treatment in a few day oe weeks. When the pain
fails to resolve because of either abnormal healing or inadequate treatment, the
pain becomes chronic ( below) . three types of acute pain : superfisial, deep
somatic and viseral, are differen tiated based on origin and features.
1. Superficial
This type of acute pain is due to
nociceptive input arising from skin, subcutaneous tissues and mucouse
membranes. It is characteristically well localized and described as a sharp,
pricking throbbing or burning sensation.
2.Deep somatic
Deep somatic pain arises from muscles, tendons, joints or
bones. It usually has dull, aching quality and is less well localized. An additional
feature is that both the intensity and duration of the stimulus affect the degree
of localization. For example, pain following brief minor trauma to the elbow joint
is localized to the elbow, but severe or sustained traumaoften causes pain in the
whole arm.
3. Visceral
This third form of acute painis due to a disease process or abnormal
fuction of an internal organ or its covering ( eg, parietal pleura, pericardium or
peritoneum ). Four subtypes are described: (1)true localized viseral pain, (2)
localized parietal pain (3) referred viseral pain and (4) referred parietal pain.
True viseral pain is dull, diffuse and usually midline. It is frequently assosiated
with either abnormal sympathetic or parasympathetic activity causing nause,
vomiting, sweating and changes in blood pressure and heart rate. Parietal pain is
typically sharp and often described as a stabbing sensation that is either
localized to the area around the organ or referred to adistant site ( table (18-3).
The phenomenon of visceral or parietal pain referred to cutaneous areas result
from pattern of embryologic development and migration of tissues, and the
convergence of visceral and somatic afferent input into the central nervous

system ( below) .Thus , pain assosiated with disease processes involving the
peritonium or pleura over the central diapragm is frequently referred to the neck
and shoulder, whereas disease affecting the parietal surfaces of theperipheral
diaphragm is referred to the chest or upper abdominal wall.
B.CHRONIC PAIN
Chronic pain is defined as that which persists beyond
the usual course of an acute disease or after a reasonable time for healing to
occur this period varies between 1 to 6 months in most definitions. Chronic pain
may result from periphereal nociception, or periphereal or central nervous
system sysfunction. A distinguishing feature is that psychological mechanisms
or environmental factors frequently play a major role. Patients with chronic pain
often have an attenuated or absent neuroendocrine stress response, and have
prominent sleep and affective ( mood ) disturbances.
The most
common forms of chronic pain include those associated with musculoskeletal
disorders, chronic viseral disorders, lesions of peripheral nerves, nerve roots, or
dorsal root ganglia ( including causalgia, phantom limb pain and postherpetic
neuralgia), lesions of the central nervous system ( stroke, spinal cord injury and
multipel sclerosis) and cancers invading the nervous system. Some clinicians
use the term chronic benign pain when pain does not result from cancer. This is
to be discouraged, because pain is never benign from the patients point of view,
regardless of it cause.
Chronic pain assosiated with peripheral or central
nervous system dysfunction is usually spontaneous, has a burning quality and is
associated with hyperpathia. This type of pain is frequently referred to as
neuropathic. When also assosiated with loss of sensory inpu into the central
nervous system, it is termed deafferentaton pain.
TTT
Table 18-2 Terms used in pain management
TERM

DESCRIPTIONS

Allodynia

Perception of an ordinarily nonnoxious stimulus as

pain

Analgesia

Absense of pain perception

Anesthesia

Absense of all sensation

Anesthesia dolorosa

Pain in an area that lacks sensation

Dysesthesia

Unpleasant or abnormal sensation with or wthout

a stimulus

Hypalgesia( Hypoalgesia)

Diminished response to noxioux stimulation ( eg,

pin prick )

Hyperalgesia

Increased response to noxious stimulation

Hyperesthesia

Increased response to mild stimulation

Hyperpatia

Presece of hyperestesia, allodyna and

hyperalgesia usually associated with overreaction
and persistance of the sensation after the stimulus

Hypestesia( Hypoestesia)

Reduced cutaneous sensation ( og, light touch,

pressure, or temperature)

Neuralgia

Pain in the distribution of s nerve or s group of

nerves

Paresthesia

Abnormal sensation perceived with out an

apperent stimulus

Radiculophaty

Functional abnormality of one or more nerve roots