
While taking a hot water bag to find relief for a severe spondylosis pain, I wondered why pain could not be expressed in a way different from the generally used
Visual analog scale. The patient is asked to look at a chart (shown in the figure) and told to rate his sensation, that tallies most well with his pain. If that hot bag were to be applied to a person
not having any pain, he would jump almost instantly. The fact that I tolerated it so well
(and benefited from it), only shows its countering
(counter irritant property) property, which should be somewhat proportional to the severity of one's pain. The relationship
of a counter-irritant to pain severity, whether linear, logarithmic or exponential, needs to be established and quantified.
A patient's own account of pain may be
subjectively modified according to the personality of the patient and many other factors. As such, this type of quantification is liable to be erroneous. Pain should better be measured in an
objective manner, free of bias. In this instance cited above, one could use the formula:
Q(heat)=m(mass) x s(specific heat of the substance) x t(temperature), to know the amount of heat energy transferred to the patient.
I am assuming that the pain relieving techniques will, kind of, obey Newton's Third law. Amount (intensity) of counterirritant that just suffices pain relief will be equal to the degree of pain. But it is not actually so, as we will see later.
By noting the difference in local temperatures before and after the procedure, one could get "t".
Mass or "
m" could be measured by estimating the
volume of the body tissue that was
actually heated by infrared mapping, for example; and the expected
density of that area. Specific heat for the tissue in question could be easily known and standardized using some cross-sectional studies. A suitable
nomogram may later be drawn by plotting values obtained from such observations, for quick estimates. It seems logical that pain so measured, will have its units in
British Thermal Units (btu), calories or their
work (mechanical) equivalents like
ergs, Joules,
foot-pounds etc..
In pain therapies using
mechanical energies (
Ultrasound),
electromagnetic devices (
laser, short wave diathermy, high frequency photons such as X rays) , a similar formula may be used to obtain the
pain equivalent. For example, in laser or short wave therapy, we may design a device that will measure the
amount of energy in
Watt.seconds/
Joules the given area of tissue is supposed to absorb, over a given period of time. The chemical analgesics (pharmaceuticals e.g.
Non
Steroidal
Anti
Inflammatory
Drugs or steroids;
counter irritants such as capsaicin) may be quantified using
Scoville scale or by evaluation on the degree of relief from algesia.
Calculating pain may be quite painful in itself. Pain sensation does not tally linearly with noxious stimulus. Rather, a logarithmic relationship was proposed in the Weber Fechner law, which held that the magnitude of pain (or a sensation) felt, was
proportional to the log of the intensity of a stimulus. In other words, to feel
twice as much pain, you needed to hurt
10 times! To complicate matters further, our present knowledge suggests that the magnitude of a sensation is
related by a power factor to the intensity of that sensation. R=KS^A; where R is the sensation felt, S the intensity of stimulus, K and A are constants for that particular tissue. The brighter side is, we get a preformulated relationship for pain calculation.
Pain
(musculo skeletal/ visceral, exogenous/endogenous) is generally of two types:
fast pain and
slow pain. Fast pains such as sharp pain of pricks, stabs are usually carried by A
d (A delta) nerve fibres, while slow aching pains are carried by type C nerve fibers. A
d fibres can carry impulses rapidly as these fibers are myelinated and are of large caliber. C fibers, on the other hand, are unmyelinated and narrow. A-delta fibres release
glutamate and C fibers secrete
substance-P. A way to measure these chemicals could be a step closer to quantifying pain.
The signals from these fibers travel to the
thalamus, a part of the lower brain, on their way to the cerebrum for the
localization of pain. Measuring the metabolic activity in thalamus, arising out of increased neural discharges there, by
fMRI or
PET scan may also shed some light on the intensity of pain stimuli
(the stimulus at this level is unmodified by the higher brain) that reaches thalamus. We can also measure the
blood levels of endogenous
opioids (enkephalins, endorphins) which are secreted in body's response to the pain and
adrenaline, secreted in response to increased sympathetic discharge, which is an usual accompaniment of pain. Their blood/plasma levels may correspond with pain severity. Other pain markers like bradykinin, histamine, potassium ions and proteolytic enzymes could be probed too.
True, that the patient may or may not feel as much pain as has been measured this way, because pain
perception may not be proportional to the physical/chemical parameters thus described and it is not uniform in all subjects. The brain sees pain in its own mathematical terms, and everyones' brain is different in this regard. A soldier may overlook his gushing wounds, whereas pampered girls of rich persons may feel a lot of pain from an apparently trivial injury. But, quantification of pain in this way
(by measuring the physical/chemical yardsticks) may correctly establish the severity of pain in
silent myocardial infarction of neuropathy
(pain
sensation is dulled here due to neural malfunction)
, decubitus ulcers, trophic ulcers, malingering and in similar situations. In this way we may be able to find a better and objective correlate of pain in clinical practice and develop more efficient analgesics.
P.S. In a
recent development, some objective physiological correlates of pain has been tracked. These include measurements from the nonlinear composite of heart rate, heart rate variability, amplitude of the photoplethysmogram, skin conductance, fluctuations in skin conductance, and their time derivatives. Algorithms can then convert the data into a real-time, continuous index on a bedside monitor. This has resulted in the fabrication of a wearable sensing device can be mounted on a finger.
Last modified: Nov 28, 2015
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