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Ovid: Oxford Handbook of Palliative Care

Editors: Watson, Max S.; Lucas, Caroline F.; Hoy, Andrew M.; Back, Ian N. Title: Oxford Handbook of Palliative Care, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Symptom Management > Chapter 6a – The management of pain > Pain classification Pain classification Pain is traditionally classified into four different modalities:

  • Physical,
  • Psychosocial,
  • Emotional, and
  • Spiritual.

It is imperative that patients’ anxieties and frequent misconceptions related to these factors are explored. Pain will not be adequately controlled unless patients feel a degree of control over their situation. To ignore such psychological aspects of care may often be the reason for seemingly intractable pain. Having prescribed analgesics, the patient’s pain should be under constant supervision and the response to treatment reviewed regularly. Having identified the cause of the pain, it is useful to classify the pain into predominantly nociceptive or neuropathic categories in order to determine the correct management. Nociceptive pain This refers to pain resulting from stimulation of peripheral nerves transmitted by an undamaged nervous system. Pain impulses enter the spinal cord through the dorsal horn, where they ascend to higher centres in the brain. Inhibitory impulses block transmission at the dorsal horn in the spinal cord, preventing further transmission of the pain impulse. It is usually opioid responsive.

Fig. 6a.2 Nocioceptive pain

Neuropathic pain Neuropathic pain refers to pain arising from damage in the peripheral or central nervous system. Clinically it may present with hyperalgesia and allodynia, with patients describing sensations such as burning or stabbing. It may be only partially opioid responsive.

Fig. 6a.3 Neuropathic pain

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Peripheral pain Peripheral neuropathic pain is caused by damage within the peripheral nervous system. There is often an associated area of altered sensation around the site of nerve injury. Central pain Central pain refers to neuropathic pain caused by damage within the central nervous system. There is usually an area of altered sensation incorporating the area of pain. A cerebrovascular accident or spinal cord damage may be associated with central pain. Sympathetically-maintained pain Sympathetically-maintained pain is due to sympathetic nerve injury. Essential features are pain (often burning) and sensory disorder related to a vascular as opposed to neural distribution. In patients with cancer such pain is more common in the lower limbs, and is usually associated with disease in the pelvis. Such pain is also associated with reduced sweating and dry shiny skin within the affected area.

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