Chapter 47 - Pain Flashcards
_______ cause inflammation when tissue injury occurs.
prostaglandins
What is pain threshold?
level of pain stimulation required to be percieved
What are the two major subtypes of pain?
- physiologic
- pathologic
What are the clinical manifestations of cancer-related pain?
- sympathetic nervous system activation
- behavoiural changes
What is pain expression?
way in which the pain experience is communicated to others
What are the 4 stages in the physiology of pain?
- transduction
- transmission
- perception
- modulation
_____ result from dysfunction of the brainstem areas involved with modulation of craniovascular afferent fibers
migraines
What are the clinical maifestations of headaches?
- unilateral throbbing
- nausea
- vomitting
- photophobia - fear of light
- phonophobia - fear of sound
- lacrimation - flow of tears
______ pain is percieved in an area other than side of injury
referred
What is radiculopathy?
pain due to spinal nerve injury
What are treatments for trigeminal neuralgia?
anticonvulsants, surgical nerve decompression and gamma radiosurgery
True or false: the etiology of fibromyalgia syndrome is known.
false - not known
What are emotional conditions that would open and close the gate?
open
- anxiety/worry
- tension
- depression
close
- positive emotions
- relaxation
- rest
What do substance P, glutamate, GABA, cholecystokinin, and calcitonin-gene related peptide have in common?
involved in synaptic transmission at spinal cord level
______ are useful for locating a source of neurologic pain
dermatomal maps
Clicker: A patient presenting with a severe pounding headache accompanied by nausea and photophobia is likely experiencing a ________ headache.
A) tension
B) migrane
C) sinus
D) chronic
B
What is radiculopathy?
pain located in the pattern of a dermatome that occurs with spinal nerve injury
Clicker: The _______ is the level of painful stimulation required to be percieved.
A) perception
B) tolerance
C) expression
D) threshold
D
What is the treatment for chronic pain?
pain clinic with multimodal therapies
What is pathologic pain?
pain occurs after tissue injury, but long-term changes occur in PNS and CNS via somatosensory pathways
True or false: glumate release stimulating the “wind up” phenomenon can lead to (acute/chronic) pain.
chronic
______ is associated with disordered mechanisms in the CNS.
fibromyalgia syndrome (FMS)
What are mental conditions that would open and close the gate?
open
- focusing on the pain
- boredom
close
- intense concentration or distraction
- involvement and interest in life activities
What is substantia gelatinosa?
is a collection of cells in the dorsal horns of the spinal cord that receives direct input from the dorsal (sensory) nerve roots, especially those fibers from pain and thermoreceptors
What are the risk factors of fibromyalgia?
- trauma
- sexual abuse
- stress
What does neuropathic pain result from?
- altered central processing of nociceptive input (releasing norepinephrine onto nociceptors)
What is a sensory dermatome?
a particular area of the body surface innervated by a spinal nerve with nociceptor fibers
What is accute pain?
- results from tissue injury (physiological cause)
- resolves when it heals, 3-6 months max
- causes elevated heart rate, respiratory rate, blood pressure, pallor, sweating, nausea, and anxiety
- treatment via conventional analgesia
true or false: young and old often recieve inadequate pain management
true
true or false: infants do not have pain perception
false - they do
What is the “wind up” phenomenon and what neurotransmitter stimulates it?
- glutamade binding to NMDA receptors stimulates synaptic memory in the pain pathway
- excessive or repeated stimulation of c fibers sensitizes the spinal cord neurons so that even mild stimulation may be percieved as painful
What are the 3 classifications of pain?
- duration (acute, chronic)
- source (cancer, neuropathic, ischemic)
- location and referral pattern
_____ interprets pain quality
cortex
What are the 3 factors that open or close the gate?
- activity in pain fibers - opens gate
- activity in other sensory nerves (i.e. rubbing the affected area) - closes the gate
- messages from the brain
- concentrating on the pain - opens gate
- trying not to think about it - closes gate
True or false: Adequate of cancer-related pain control is a major factor affecting quality of life
true
Describe the pathogenesis of chronic pain.
Injury leads to pain and inflammation which is healed. Although healed, pain signals continue which cause structural CNS chances to alter neural transmission. This leads to chronic pain, hyperalgesia, allodynia, and spread of pain.
What are the clinical manifestations of trigeminal neuralgia?
- sharp or shooting, electrick shock pain
- may be pain free between episodes or
- complain of a dull ache in area
True or false: men are affected by fibromyalgia syndrome more than women.
false - women affected more
What does activation of the sympathetic nervous system during acute pain do?
- increased HR, respiration, BP
- dilated pupils
- perspiration
- pallor
- increased circulating blood glucose
- decreased gastrointestinal motility
- hypomotility of bladder
How is pain modulated within the brain/spinal cord?
endogenous opioids (enkephalins, endophins)
True or false: vertebral disk disease is an example of radiculopathy
true
Fill in the blanks. Tissue injury results in the realse of ______ from the breakdown of phospholipids in cell membranes. Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the _______ enzyme and block the production of prostaglandins.
prostaglandins, cyclooxygenase
Distinguish between the 4 types of headaches?
- sinus: pain behind forehead and/or cheekbones
- cluster: pain in and around one eye
- tension: pain is like a band squeezing the head
- mirgrane: pain, nausea, and visual changes
What is transduction?
- process of converting painful stimuli to neuronal actional potentials at the sensory level
- nociceptors transduce noxious stimuli into action potentials
- chemical mediaters alter the membrane potential of the pain
What are the clinical manifestations of neuropathic pain?
- allodynia
- hyperalgesia
- atrophy of affected extremity
- coldness in affected area
- dystrophic changes
- hair loss
- shiny skin
Why is referred pain percieved in an area other than the site of injury?
pain generally referred to other structures in the same dermatome
What are the clinical manifestations of chronic pain?
- psychological
- job loss
- irritability
- depression
What is the treatment for cancer-related pain?
- multifaceted approach
- potent medications
What is trigeminal neuralgia?
- sudden, momentary, but excruciating pain along second and third divisions of trigmental nerve
True or false: carpal tunnel syndrome is an example of a peripheral neuropathy
true
What is perception?
when brain interprets pain as painful
_____ pain results from tissue injury in which the nerves become damaged or dysfunctional
neuropathic pain
Pain of myocardial infraction being felt in the jaw or left arm, shoulder pain after pelvic procedures, and diaphragmatic irritation from peritonities are all examples of what type of pain?
a) Cancer-related
b) Neuropathic
c) Referred
c
What does cancer-related pain result from?
- infiltration of organs
- compression of structures by expanding tumor
- result of cancer treatments
There are ____% of C fibers in the body.
a) 10
b) 45
c) 75
d) 90
d
True or false: trigminal neuralgia is more common in men than women
false - more common in women
What are the symptoms of neuropathic pain?
- constant aching
- intermittent sharp, shooting, burning, or shock-like pain
True or false: sharp, stinging, cutting, pinching feelings of pain are modulated by a-delta fibers.
true
What is fibromyalgia syndrome (FMS)?
- chronic widespread pain affecting all four extremeties
- hypoeralgesia
- trigger or tender points
- posterior side
- greater trochanter
- gluteal
- supraspinatus
- trapezius
- occiput
- anterior side
- knee
- lateral epicondyle
- second rib
- low cervical
- posterior side
List the fibers in order of increasing speed: a-delta fibers, c-fibers, a-beta fibers
c-fibers (unmylenated), a-delta fibers (lightly mylenated), a-beta fibers (heavily mylenated)
Describe the physiology of modulation of pain.
Descending pathways the originate from the raphe magnus in the brain go to the dorsal horn and release neurotransmitters that can inhibit synaptic transmission of pain signals
What is the enzyme responsible for the formation of prostaglandins?
cyclooxygenase
What are physical conditions that would open and close the gate?
open
- extent of injury
- inappropriate activity level
close
- medication
- counter stimulation (i.e. massage)
What are peripheral neuropathies?
they do not follow a dermatomal pattern
_____ causes conscious perception of pain
lower brian centers
Clicker: Which of the following statements about C-afferent sensory pain fibers is true.
A) These fibers transmit signals very rapidly
B) They are myelinated
C) They transmit the majority of pain signals
D) Their pain signals are highly localized in the brain
C
True or false: pain perception does not decrease with aging, but communication and expression of pain may vary
true
What is the result of referred pain?
convergence of visceral nociceptor activity with primary somatic afferents in the posterior horn of the cord
What is allodynia?
non-noxious stilmuli may cause pain
Clicker: Referred pain may be percieved at some distance from the area of tissue injury, but generally felt
A) on the same side of the body
B) within slightly less intensity
C) within the same dermatome
D) within 10-15 cm area
What is this diagram of and what does this diagram show?
primary efferent pain fibers (A-delta and C fibers) entering the dorsal horn, synapsing on interneurons, crossing to the opposite side and traveling to the brain in the anterolateral tract
What is physiologic pain?
pain where tissue injury has occured
There are ____% of A-delta fibers in the body.
a) 10
b) 45
c) 75
d) 90
a
________ is the physiologic mechanisms of pain processing
nociception
_______ pain is associated with cancer disease process
cancer-related
What is hyperalgesia?
pain can be significantly enhanced
______ is a symptom of an underlying problem.
pain
What does gate control theory state?
non-painful stimulus can block the transmission of a painful stimulus
True or false: dull, burning, aching types of pain are modiated by c fibers.
true
What can be used as treatment for headaches?
- identifying and avoiding triggers
- antiepileptics
- ergot alkaloids
- NSAIDs
- antidepressants
- beta/alpha blockers
- calcium-channel blockers
- pain medication
Clicker: A patient is using transcutaneous electrical nerve stimulation (TENS) to control pain. A neurse realizes TENS decreases pain by:
A) interrupting peripheral transmission of nocicpetions
B) modulating pain transmission at the spinal cord level
C) altering perception and integration of nociceptive impulses in the brain
D) producing relaxation as well as analgesia
B
What is the result of inadequate pain treatments in neonates and infants?
persistent behavioural changes and physical changes in CNS
How does the brain localize a pain sensation to a particular part of the body?
nociceptor pathways are kept in specific anatomic order (sensory dermatomes)
What is pain tolerance?
degree of pain an individual willing to bear before seeking relief
______ is a complex mechanism wherbey synaptic transmission of pain signals is altered
modulation
What is chronic pain?
- lasts longer than expected healing time, > 6 months
- associated with disease process
- increased peripheral transduction sensitivity
- central sensitization causes abnormal state of responsiveness or increased gain of nociceptive inputs
What are the three treatment modalities for pain mangement?
- interrupting peripheral transmission of nociception
- modulating pain transmission at the spinal cord level
- altering the perception and integration of nociceptive impulses in the brain
Explain this diagram.
- nociceptive signals trasmitted by first-order primary afferent neurons
- transduced by membrane depolarization due to activation of ion chanels
- conducted along A-delta and C fibers into dorsal root ganglion where they synapse with second-order nociceptive neurons
- which travel up the brainstem to third-order neurons in the thalamus which project to several cortical and subcortical regions that encode pain
True or false: Lamina V is the key area for referred pain
true
What does trigeminal neuralgia result from?
compression of trigeminal nerve by other structures causing demylination and irritation
Clicker: The gate control theory of pain transmission predicts that activity in touch receptors will
A) enhance perception of pain
B) decrease pain signal transmission in the spinal cord
C) activate opioid receptors in the CNS
D) increase secretion of substance P in the spinal cord
B
The _____, located in the dorsal horn of the spinal cord, modulates the afferent nerve impulses.
gate
