PAIN (ASSESMENT &

MODULATIN)
Presented by : Sakshi Nerle
Guide : Dr. Sanket Mungikar
Moderator : Dr. Kapil
 Introduction

Pain may be defined as a state of sensory and/or emotional

experience, which may result from Actual or potential tissue-
damaging tissue damage.

Pain experiences cover physiological, behavioral,

sociocultural & emotional aspects, etc.
Pain Receptors

NOCIOCEPTORS

TRANSDUCTION

AFFERENT
NERVE

SPINAL CORD
• Nociceptors can be activated by intense thermal, mechanical, or chemical stimuli
from exogenous or endogenous sources.

• When nociceptors are activated, they release a variety of neuropeptides from their
peripheral terminals, including substance P and a number of breakdown products of
arachidonic acid such as prostaglandins and leukotrienes.

• Nociceptors also convert the initial stimulus into electrical activity. in the form of
action potentials. by a process known as transduction.

• The action potentials resulting from the process of transduction propagate from the
nociceptors along afferent nerve pathways toward the spinal cord.
Figure: Pain transduction
 Types of pain
(According to the duration)
Acute Chronic

Reffered

Acute Pain: With acute pain, the body is responding to a noxious stimulus, which has
caused damage, therefore the body's protective mechanism is activated and the symptoms
reflect the underlying pathology. 
Chronic Pain: It is defined as, the pain that persists for at least 3 to 6 months beyond the
initial cause and after healing is presumed to have happened (Dworkin, 2002). With
chronic pain, typically the original pathology is healed, so the symptom-pathology
relationship is not as straightforward as before.
Reffered Pain: Reffered pain is felt at a location distant from its source. Pain may be
reffered from one joint to another, from a peripheral nerve to a distal area of innervation,
or from an internal organ to an area of musculoskeletal tissue.
Assessment of pain
 Pain Assessment

Subjective Objective
Subjective:

1. VAS (Visual analogue scale)

2. Numerical rating scale (NRS)
3. MC gill pain questionnaire (MPQ)
4. Pain rating scale (PRS)
5. The LANSS pain scale
6. NIPS (Neonatal infant pain scale)

Objective:

1. Pressure algometer
VAS (Visual analogue scale)

The pain VAS is a one-dimensional measurement of pain severity, most commonly

consisting of a 100-mm horizontal line that is anchored at either end with pain
descriptors, such as ‘‘no pain’’ and ‘‘worst pain imaginable.’’

Respondents are required to place a mark along the line at a location that they feel
reflects their pain intensity.
Numerical rating scale (NRS)

The numerical rating scale (NRS) involves asking patients to rate their pain intensity
by selecting a number on a scale from 0-10 (11-point scale), 0-20 (21-point scale), or
0-100 by filling in a questionnaire or stating verbally a numerical level (please indicate
on the line below the number between 0 and 10 that best describes your pain. A 0
would mean no pain and a 10 would mean worst pain imaginable).
MCgill pain questionnaire (MPQ)

The McGill Pain Questionnaire can be used to evaluate a person experiencing

significant pain. It can be used to monitor the pain over time and to determine the
effectiveness of any intervention. It was developed at by Dr. Melzack at McGill
University in Montreal Canada and has been translated into several languages.
Pain rating scale (PRS)

This pain scale is most

commonly used. A person
rates their pain on a scale of 0
to 10 or 0 to 5. Zero means
“no pain,” and 5 or 10 means
“the worst possible pain.”
These pain intensity levels
may be assessed upon initial
treatment, or periodically
after treatment.
LANSS pain scale

The Leeds assessment of neuropathic symptoms and signs (LANSS) Pain Scale
is based on analysis of the sensory description and bedside examination of sensory
dysfunction and provides immediate information in clinical settings. It was
developed in two populations of chronic pain patients.
NIPS (Neonatal infant pain scale)

This scale uses body language to help us to figure out if a child is in pain. A child is
given a score of 0 or 1 in each category based on their behavior. A total score is
calculated. Most of the time a score greater than 3 tells us a child is likely having
pain or discomfort.
Pressure algometer

Algometers are devices that can be used to identify the pressure and/or force
eliciting a pressure-pain threshold. It has been noted in pressure-pain threshold
studies that the rate at which manual force is applied should be consistent to
provide the greatest reliability.
 Pain modulation
Level of pain modulation:
Peripheral Level:

The intervention involves a reduction in the amount of those chemicals released in

response to tissue damage which is responsible for nociceptor activation.

Spiral Segment Level:

Intervention at this stage involves inhibition of activity in the small-diameter group III
(AS) and group IV © fibers before the incoming information ascends further in the
neural axis.

Supraspinal Level:

The ascending pathways make important synaptic connections with several brainstem
structures involved with descending pain modulations system as explained by Melzack
and Wall.
Cortical Level:

the intervention involves modification of individual perception and interpretation of

pain. Behavior modification and cognitive strategies are examples of psychological
approaches which operate at this level.
 Plain modulation

The descending pain

The gate control theory
suppression system

The gate control theory:

The gate control theory of pain was suggested by Melzack and Wall in 1965 and has
been expanded and modified since then. This theory has its major essence that pain
perception is regulated by a "gate" which may be opened or closed by means of other
inputs from the peripheral nerves or from the CNS, thus increasing or decreasing the
pain perception. The theory is that a physiological gating mechanism exists in the
dorsal horn, which may allow or inhibit the nociceptive traffic (pain) to proceed
centrally. The interneurons present in the SG-cells (cells of substantia gelatinosa
rolandi) of the posterior horn of the spinal cord have an inhibitory influence on the "T"
(Transmission cells) cells.
The SG cells receiving inputs from nociceptors (A8 and C fibers) and
mechanoreceptors (AB fibers), integrates and modulate the pain fiber activity and
prevent transmission of nociceptive information to higher centers, by inhibitory
influence on the T-cells, resulting in the closure of the gate to pain transmission
The descending pain suppression system:
Activation of the descending pain suppression system is also recognized as a
mechanism of pain modulation. This system is a three-tiered anatomical system
having the following principal components:
• Periaqueductal gray matter (PAG), an area reach in opioid receptors.
• The rostral ventral medulla (the nucleus raphe Magnus and adjacent reticular
nuclei)
• The spinal dorsal horn.
This descending input comes principally from the periaqueductal gray matter that
surrounds the cerebral aqueduct located in the midbrain and the nucleus raphe
Magnus located in the medulla.
stimulating the nucleus raphe Magnus and adjacent reticular nuclei
inhibitory interneurons of the substantia gelatinosa in the dorsal horn of the spinal
cord and produces a reduction of pain transmission at the level of the spinal cord.
 the descending pathways may also activate spinal cord interneurons, which release
opioids such as enkephalin, which subsequently inhibit the T-cells reducing pain
transmission at the spinal cord level.
Encephalin secretion at the substantia gelatinosa rolandi (lamina-II), leads to inhibition
of transmission of C fiber signals to the CNS, producing analgesic effect. It is believed
that opioids bind to presynaptic receptor sites on substance-P containing nociceptive
afferents and thus inhibit the release of substance Pras substance is a neurotransmitter
necessary for nociceptive transmission, this leads to inhibition of the pain at the spinal
cord level.