Pain control system

Physiology III
Sec 2 Group c
Hossam Al Din Ayman Mohamed Abd elsamea Dwidar Tarek moataz Abo Elyazid
392100267 392100271 392000290

Kerolos mina yakoub Mostafa mahmoud mohamed Elashry mohammed Ahmed

392100220 392000022 392100263
• Definition
• Over view
• Pain system Content
• Level of pain
• analgesia system
• Stimulation produced analgesia (SPA)
• Stress
• Stress-Induced Analgesia (SIA)
• Stress-Induced Hyperalgesia (SIH)
• Role analgesic drugs
• Theories of pain
• Role of physical therapy
• Pain Management With TCM
What is the Pain?
 Definition
When we feel pain, such as when we touch a hot
stove, sensory receptors in our skin send a
message via nerve fibers (A-delta fibers and C
fibers) to the spinal cord and brainstem and then
onto the brain where the sensation of pain is
registered, the information is. But the truth
is, pain is constructed entirely in the brain. This
doesn't mean your pain is any less real – it's just
that your brain literally creates what your body
feels, and in cases of chronic pain, your brain
helps perpetuate it. The pain information in the
CNS is controlled by ascending and descending
inhibitory systems, using endogenous opioids, or
other substances like serotonin as inhibitory
mediators.
 transduction, transmission, modulation,
Mechanisms of pain and perception.
That classified pain mechanisms as
'nociceptive', 'peripheral neuropathic' and
'central’, and outlined both subjective and
objective clinical indicators for each

Over
v i eChemicals
w that cause pain
Types of pain
•The five most common types of pain are: Chemical substances produced by the body
Acute pain , Chronic pain , Neuropathic pain , that excite pain receptors
Nociceptive pain and Radicular pain include bradykinin, serotonin, and
histamine.
 Pain system
Nociceptive pain occurs in 5 phases: 1) Transduction, 2) Conduction, 3)
Transmission, 4) Modulation, 5) Perception.
1.Transduction begins when peripheral terminals of nociceptive C fibers and A-delta (Aδ) fibers
are depolarized by noxious mechanical, thermal, or chemical energy. The membranes of these
terminals contain proteins and voltage-gated ion channels that convert thermal, mechanical,
or chemical energy into an action potential (AP). Nociceptor terminals are spread densely
throughout the skin. They are found less on periosteum, joints, tendons, muscles, and least on
the surface of organs.
Normally, nociceptor terminals have a high activation threshold. They requiring
intense stimulation to generate an AP.
For example, thermal nociceptors are only activated by temperature extremes
(>45°C or < 5°C).
 Pain system
PAIN PROCESSING IN BRAIN
The advances in neuroimaging techniques seen within the past 2 decades have led to a virtual explosion
in the numbers of studies on the human brain’s activity under conditions of acute pain and chronic pain.
These noninvasive techniques have provided corroborative evidence that brain regions found to
contribute to pain processing and modulation by pharmacologic or electrophysiologic means in animal
studies correspond to regions of the human brain that are responsive to pain. In addition, these
investigations have also shown that pain activates a network of brain regions affecting somatosensory
and emotional aspects.

DESCENDING PAIN MODULATION

Numerous investigations over the past half-century have established that activation of midbrain and medullary
sites can exert bidirectional control over nociception. The periaqueductal gray (PAG) receives inputs from higher
brain centers and is capable of activating a powerful analgesic effect. The rostroventromedial medulla (RVM) can
both facilitate or inhibit nociceptive inputs and acts as a final relay in the control of descending pain facilitation.
These structures provide a mechanism through which cortical and subcortical sites can influence nociception.
 Pain system
Sites activated by noxious stimulation
Neuroimaging studies have led to the identification of brain regions activated by noxious
stimuli, including the primary somatosensory cortex (S1), secondary somatosensory cortex
(S2), anterior cingulate cortex (ACC), prefrontal cortex (PFC), insula, amygdala, thalamus,
cerebellum and the mesolimbic reward circuit, which includes the ventral tegmental area
(VTA) and nucleus accumbens (NAc) . The somatosensory cortices (S1 and S2) and the
insula are believed to encode the sensory features of pain, which include quality (stinging,
burning or aching), location and duration . emotional and motivational cues can alter the
experience and perception of pain through interactions with the descending pain modulatory
system.
 Level of pain
Mild Pain – Nagging, annoying, but doesn’t really interfere with daily living
activities.
1 – Pain is very mild, barely noticeable. Most of the time you don’t think about it.
2 – Minor pain. Annoying and may have occasional stronger twinges.
3 – Pain is noticeable and distracting, however, you can get used to it and adapt.
Moderate Pain – Interferes significantly with daily living activities.
4 – Moderate pain. If you are deeply involved in an activity, it can be ignored for a period of time
but is still distracting.
5 – Moderately strong pain. It can’t be ignored for more than a few minutes,
but with effort you still can manage to work or participate in some social activities.
6 – Moderately strong pain that interferes with normal daily activities.
Difficulty concentrating.
Severe Pain – Disabling; unable to perform daily living activities.
7 – Severe pain that dominates your senses and significantly limits
your ability to perform normal daily activities or maintain social relationships.
8 – Intense pain. Physical activity is severely limited. Conversing requires great effort.
9 – Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably.
10 – Unspeakable pain. Bedridden and possibly delirious.
 analgesia system
Endogenous analgesia system refers to pathways originating in the brainstem and
terminating in the spinal cord (and in trigeminal sensory nuclei) that inhibit
spinal/trigeminal nociceptive processing. Neurotransmitters released by this system include
endogenous opioids and monoamines (e.g., norepinephrine, serotonin).
types of analgesia drugs
Analgesic drugs can be classified into three
groups: nonopioid drugs, opioid drugs.
 Co-analgesic drugs, also known as adjuvants.
There are two major groups of analgesics: 
anti-inflammatory analgesics and opioids.
Anti-inflammatory drugs work by reducing
inflammation (swelling) at the site of the pain.
Examples include: Acetaminophen.

types of analgesia : Stimulation produced

analgesia (SPA) and Stress-Induced
Analgesia (SIA)
 Stimulation produced analgesia (SPA)
Stimulation produced analgesia (SPA)
Evidence for an intrinsic analgesia system was demonstrated by intracranial electrical stimulation of
certain discrete brain sites. These areas are the periaqueductal gray (PAG) and nucleus raphe magnus
(NRM), dorsal raphe (DR), caudate nucleus (CN), septal nucleus (Spt) and other nuclei. Such stimulation
inhibits pain, (i.e., producing analgesia without behavioral suppression), while the touch, pressure and
temperature sensation remain intact. SPA is more pronounced and lasts a longer time after stimulation
in humans than in experimental animals. Moreover, during SPA, the subjects still respond to nonpainful
stimuli such as touch and temperature within the circumscribed area of analgesia. The most effective
CNS sites for SPA are the PAG and the raphe nuclei (RN).
 Stimulation produced analgesia (SPA)
Electrical stimulation of PAG or NRM inhibits spinal thalamic cells, (i.e. spinal
neurons that project monosynaptically to the thalamus) in laminae I, II and V
so that the noxious information from the nociceptors are modulated at the
spinal cord level. PAG has neuronal connections to NRM.
The action of the PAG most likely occurs by activation of the descending
pathway from NRM and probably also by activation of ascending connections
acting on higher subcortical levels of the CNS. Moreover, electrical stimulation
of PAG or NRM produces behavioral analgesia.
 Stimulation produced analgesia (SPA)
If OA and SPA act through the same intrinsic system, then the
hypothesis that opiates activate a pain-suppression mechanism is
more likely. In fact, present evidence indicates that microinjections
of an opiate into the PAG activate an efferent brainstem system that
suppresses pain transmission at segmental (spinal cord) levels.
These observations indicate that analgesia elicited from the PAG
requires a descending pathway to the spinal cord
 Stress
What is Stress? Stress can be defined as any type of change that causes physical,
emotional or psychological strain. Stress is your body's response to anything that requires
attention or action. Everyone experiences stress to some degree.
what happens to the body during stress?
•Aches and pains.
•Chest pain or a feeling like your heart is racing.
•Exhaustion or trouble sleeping.
•Headaches, dizziness or shaking.
•High blood pressure.
•Muscle tension or jaw clenching.
•Stomach or digestive problems
Stress causes your muscles to tense or spasm,
which increases pain. When you feel stressed,
levels of the hormone cortisol rise. This can
cause inflammation and pain over time.
 Stress
What are symptoms of stress pain?
These effects might include:
•Difficulty breathing.
•Panic attacks.
•Blurred eyesight or sore eyes.
•Sleep problems.
•Fatigue.
•Muscle aches and headaches.
•Chest pains and high blood pressure.
 Stress-Induced Analgesia (SIA)
Stress-Induced Analgesia (SIA)
Analgesia may be produced in certain stressful situations. Exposure to a variety of painful or stressful
events produces an analgesic reaction. This phenomenon is called stress induced analgesia (SIA). SIA has
been thought to provide insight into the psychological and physiological factors that activate endogenous
pain control and opiate systems. For example, soldiers wounded in battle or athletes injured in sports
events sometimes report that they do not feel pain during the battle or game; however, they will
experience the pain later after the battle or game has ended. It has been demonstrated (in animals) that
electrical shocks cause stress-induced analgesia. Based on these experiments, it is assumed that the stress
the soldiers and the athletes experienced suppressed the pain which they would later experience.
It has been suggested that endogenous opiates are released in response to stress and inhibit pain by
activating the midbrain descending system. Moreover, some SIA exhibited cross tolerance with opiate
analgesia, which indicates that this SIA is mediated via opiate receptors. Experiments using different
parameters of electrical shock stimulation demonstrate that such stress produces analgesia and some of
these stresses that produce analgesia could be blocked by the opioid antagonist naloxone, whereas others
were not blocked by naloxone. These observations lead to the conclusion that both opiate and non-opiate
forms of SIA exist.
 Stress-Induced Hyperalgesia (SIH)
What is stress-induced hyperalgesia?
In particular, stress, fear and anxiety exert potent, but complex, modulatory
influences on pain. Stress can either suppress pain (stress-induced analgesia)
or exacerbate it (stress-induced hyperalgesia; SIH) depending on the nature,
duration and intensity of the stressor.
(SIA) refers to a reduced pain response after stress exposure, which is mediated by
descending pain-inhibitory circuits and may be an indicator of adequate centrally
mediated pain control.
Stress-induced analgesia occurs
when an injured person can
ignore the pain of an injury
because of other stressful
situations going on at the same
time. For example, if you bang
your shin while hiking, it stops
hurting if you see a mountain
lion.
 Role analgesic drugs
Pain relievers (analgesics) are the main drugs used to treat pain. Doctors choose
a pain reliever based on the type and duration of pain and on the drug's likely
benefits and risks. Most pain relievers are effective for nociceptive pain (due to
injury) but are less effective for neuropathic pain (due to damage or dysfunction
of the nerves, spinal cord, or brain). For many types of pain, especially 
chronic pain, nondrug treatments are also important.
In some cases, treating the underlying disorder eliminates or minimizes the pain.
For example, setting a broken bone in a cast or giving antibiotics for an infected
joint helps reduce pain. However, even if the underlying disorder can be treated,
pain relievers may still be needed to quickly manage the pain.
There are two major groups of analgesics: anti-inflammatory analgesics and opioids.
Anti-inflammatory drugs work by reducing inflammation (swelling)
at the site of the pain.
Examples include:
•Acetaminophen.
•Aspirin.
•COX inhibitors.
•Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen
 Theories of pain
The four most influential theories of pain perception include the Specificity (or Labeled
Line), Intensity, Pattern, and Gate Control Theories of Pain.

The Gate Control Theory of Pain is a mechanism, in the spinal cord, in which
pain signals can be sent up to the brain to be processed to accentuate the
possible perceived pain, or attenuate it at the spinal cord itself. The 'gate' is the
mechanism where pain signals can be let through or restricted.

Specificity theory is one of the first modern theories for pain. It holds
that specific pain receptors transmit signals to a "pain center" in the brain that
produces the perception of painVon Frey (1895) argued that the body has a
separate sensory system for perceiving pain—just as it does for hearing and
vision.
 Theories of pain
First, conceptualized in the fourth century BCE by Plato in his oeuvre
Timaeus (Plato 1998), the theory defines pain, not as a unique sensory
experience but rather, as an emotion that occurs when a stimulus is
stronger than usual. This theory is based on Aristotle’s concept that pain
resulted from excessive stimulation of the sense of touch. Both stimulus
intensity and central summation are critical determinants of pain. It was
implied that the summation occurred in the dorsal horn cells.

The pattern theory of pain suggests that the nerves involved in

detecting pain also detect other sensations. According to this theory,
there are no specific nerve fibers or endings used just for the
sensation of pain.
 Role of therapist
Knowledge of the descending pain modulatory system and its components can help
physiotherapists in several ways. It helps physiotherapists explain why the amount of
pain a patient is experiencing does not always relate to the amount of tissue damage
they have sustained .Physiotherapists can educate their patients about the role of the
descending pain modulatory system and how the central nervous system weighs all the
information before deciding if a pain experience is the most appropriate action for
survival. Knowledge of the anatomy involved in the descending pain modulatory system
can help physiotherapists utilize management strategies to that access and activate the
system. These could include adding distractions to exercises and performing exercises in
different emotional states and or in different environments. Manual techniques e.g.
joint mobilizations, manipulations have been proposed to activate the system and
significantly contribute to their therapeutic effects .It is important to understand the
extent to which manual therapy influences these underlying mechanisms. New studies
of manual therapy should aim to link the many immediate changes in neurophysiological
function (e.g., changes in sympathetic nervous system function and the endogenous
pain inhibitory systems, among others) more closely to the clinical complaints of our
patients.
 Pain Management With TCM
in Traditional Chinese Medicine (TCM), pain management is
customized to the individual.
Finding out the patient's body constitution type is crucial to a
TCM physician. TCM diagnostic principles are used to assemble
a patient's medical history, signs, and symptoms and make a
TCM diagnosis. Acupuncture, cupping, tui na, and/or herbal
medication is given to the patient depending on his or her
physical constitution and condition.
           
Acupuncture uses hair-thin needles and careful selection of
acupoints to clear blockages in the meridians, and to strengthen the
flow of qi to restore the yin-yang balance and relieve pain. 
Read more about acupuncture in Singapore here.
Cupping uses glass cups to painlessly create pressure, suction,
and heat along the body's meridian points to improve qi circulation.
Stationery cupping, gliding cupping, and fire cupping are different types
of cupping that can be combined depending on a patient's needs.
Circular bruise marks left after cupping will disappear within a week.
Tui na
 reference
Role drugs
https://my.clevelandclinic.org/health/drugs/21483-analgesics
Drugs
https://www.msdmanuals.com/home/brain,-spinal-cord,-and-
nerve-disorders/pain/treatment-of-pain
Pain system
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4301419/
Theories
https://www.painscale.com/article/the-pattern-theory-of-pain
https://pubmed.ncbi.nlm.nih.gov/11780656/
https://www.physio-pedia.com/Theories_of_Pain
TCM
https://www.human.com.sg/pain-management-with-traditional-
chinese-medicine
Stress
https://www.stanfordchildrens.org/en/topic/default?id=the-
stress-pain-connection-88-p11008
Analgesia System
https://link.springer.com/referenceworkentry
/10.1007/978-3-642-28753-4_200698
Types of Analgesic drugs
https://www.rnceus.com/ages/types.htm
https://my.clevelandclinic.org/health/drugs
/21483-analgesics
https://pubmed.ncbi.nlm.nih.gov/24850075/
Types of analgesia
https://nba.uth.tmc.edu/neuroscience
/m/s2/chapter08.html
https://www.ncbi.nlm.nih.gov/books/NBK219252/
Level of pain
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3454549/