pain

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Pain, especially in its acute form, is usually a reflection of a tissue-damaging or potentially tissue-damaging stimulus. There is a transmission system that conveys this information to the central nervous system. This phenomenon is called nociception. Pain is more complex than other sensory systems such as vision or hearing because it not only involves the transfer of sensory information to the nervous system, but produces suffering which then leads to aversive corrective behavior. In certain disease states, defects in the transmission system can of themselves generate false information to the nervous system, as though tissue damage were occurring in the periphery. An example of this is phantom limb pain, in which the individual often has a crushing type of pain in a foot that has been amputated.

Acute pain such as occurs with broken bones and other significant injuries is almost inevitably accounted for by the phenomenon of nociception and is probably a purely neurophysio-logical event. However, the more pain becomes a chronic phenomenon, the more such influences as psychological factors and behavior become part of the expression of pain.

Acute pain is a useful warning system. There are specific nerve paths for conducting this sensation (see illustration). Pain receptors in the skin and other tissues are nerve terminals which lack any special characteristics, and they are probably triggered by a chemical stimulus when potential tissue damage occurs. There appear to be two types of terminals: one responds to many types of painful stimuli, whereas the other specifically responds to either mechanical or thermal energy. When the terminals are stimulated, the pain (that is, nociception message) is carried along specific small sensory fibers called A-delta and C fibers. The A-delta fibers are larger and transmit the “first pain” or “fast pain” The smaller C fibers transmit a secondary dull continuous pain. These nerve fibers were traditionally believed to enter the spinal cord through the dorsal root, but it now seems that many also enter through the ventral root into the spinal cord.

Neurophysiology of incoming pain. Sensation from peripheral receptors travels along specific pain nerves, and is modulated throughout the spinal cord and brain.

Having entered the spinal cord, these fibers relay in the dorsal horn of the spinal gray matter, an area of considerable regulation and modulation of the incoming pain stimulus which is influenced by other incoming sensory stimuli; that is, touch or pressure sensations can suppress the transmission of signals in the small pain fibers. This helps to explain why when a person is hurting, the pain can be reduced by rubbing the affected part, and this phenomenon forms the basis of some of the treatment strategies of stimulation-produced analgesia. In addition, the incoming pain signal in the spinal cord is also modulated by descending signals from the brain. At times of anxiety, these pain signals may be augmented. From these relay stations in the dorsal horn, the pain signal is carried by two nerve paths up to the brain. The classical pathway is the spinothalamic tract, on the side of the spinal cord opposite to the incoming stimulus, and this leads to the posterior part of the thalamus in the brainstem, and from there nerve paths radiate the pain sensation to many parts of the cerebral cortex, where the pain is appreciated. In addition to this direct path, there is also a diffuse ascending path known as the spinoreticular tract which relays to many of the basal ganglia in the brain, and from there to areas of the brain connected with motivational and affective behavior such as the hippocampus and the cingulate gyrus. It is possible that narcotic analgesics exert some of their action on this ascending spinoreticular tract because these drugs tend to reduce the suffering aspects of pain, but still preserve many of the discriminative qualities so that individuals can still feel the pain, but it does not bother them so much. See also Analgesic; Narcotic.

Certain parts of the brainstem around the central canal appear to exert a strong inhibitory effect on incoming pain signals. Stimulation of these areas probably releases endorphins, which are morphinelike substances produced by the body and liberated at various sites on the incoming pain path to suppress these signals. See also Endorphins.

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Scientists do not know exactly how we feel pain, but it involves the stimulation of specialized nerve-endings. Individuals vary in their sensitivity according to their pain threshold (minimum intensity of stimulation which can evoke pain) and pain tolerance (ability to put up with feelings of pain). Some chemical substances released in the body increase sensitivity. These include bradykinins, histamine, potassium, and serotonin, all of which may be released at sites of tissue damage.

Many sedentary people believe that all exercisers have to experience pain if they are to become fitter: this belief is encouraged by the well known training motto: ‘No pain, no gain’. Sensible people interpret this as meaning that it takes effort, dedication, and commitment to improve fitness; it does not mean that exercise has to be a masochistic ordeal. On the contrary, if real pain is experienced, an exerciser should stop. Of course, an athlete who is training for top-class competition must be able to tolerate greater discomfort than a recreational athlete, but even an elite athlete must learn to distinguish between real pain and discomfort. Real pain acts as an important warning signal that something is wrong. If the signal is ignored, serious injury may result.

Pain can be relieved by a variety of means including cold therapy (e.g. application of ice), acupuncture, transcutaneous nerve stimulation, and analgesic drugs. Used correctly, these can provide relief and accelerate recovery. However, used incorrectly they can make a bad condition even worse. Many injured athletes unwisely take painkillers to enable them to continue training or competing. This often leads to further damage and the need for stronger painkillers; a vicious cycle ensues which can only be broken by rest. See also muscle soreness.

[PAN] 1. French for "bread" or "loaf of bread". Various types of bread in France include: pain aux noix (nut bread), pain complet (whole wheat bread), pain d'épices (spiced or gingerbread), pain grillé (toasted bread), pain de mie (sliced, packaged white bread), pain ordinaire (peasant bread), pain perdu (french toast) and pain petit (roll). 2. The word pain is also used in France to describe a baked, molded loaf of forcemeat bound with a panade. Such a meat, poultry, fish or vegetable pain can be served hot, cold or at room temperature.

The International Association for The Study of Pain has provided the following definition of pain, which is used world-wide amongst scientists and clinicians interested in pain.

Pain is ‘an unpleasant sensory and emotional experience associated with actual or potential damage, or described in terms of such damage. Pain is always subjective. Each individual learns the application of the word through experiences relating to injury in early life’.

Noxious stimulation of a part of the body gives rise to electrical activity in the nervous system, extending from the periphery to the brain. Receptors and pathways dedicated to the nerve impulses giving rise to pain are described as components of somatic sensation and of visceral sensation. That activity is modulated within the central nervous system, both within the dorsal horns of the grey matter of the spinal cord and at higher levels. In this manner the input to the brain generated by noxious stimulation peripherally may be enhanced, diminished, or even, under certain circumstances, abolished — for example, in the heat of battle or a game of football. Thus, although noxious stimulation occurs, pain may not be felt at the time; such a mechanism clearly has value for survival of the individual in certain cases.

Our understanding of the physiology of pain control owes a great deal to the work of Melzack and Wall of some thirty-five years ago. Respectively a psychologist/physiologist and neurophysiologist, they proposed the gate-control theory of pain, which brought together previous work on the role of the nervous system in the generation of pain. They stated that within the dorsal horn of the spinal cord there are transmission cells (‘Trans cell’ in the figure) and that, as a result of tissue damage and stimulation, nerve impulses pass to those cells, which project further nerve impulses to the brain, where pain is experienced. The level of activity of the transmission cells is controlled by small adjacent cells which either excite or inhibit them. In turn the level of activity of the smaller cells is determined by the extent to which they are stimulated by nerve impulses from the body or the brain. Large diameter nerve fibres (beta fibres), which are stimulated by touch, excite the small inhibitory cells (white circles in the figure) adjacent to the transmission cells. In contrast, tissue injury excites other (A delta and C) nerve fibres. The former are large diameter fibres which conduct rapidly and the latter are small diameter fibres which conduct slowly. Both stimulate the transmission cell and small excitatory cells (black circles in the figure). Therefore in an acute injury, for example when the thumb is struck by a hammer, the A delta and C fibre activity exceeds the activity in beta fibres and pain is felt. When the injured part is rubbed vigorously the pain lessens and it does so because rubbing the skin stimulates beta fibres to the point where their level of stimulation of the small inhibitory cells exceeds that of the stimulation by the A delta and C fibres of the small excitatory cells. As a result, the activity of the transmission cell is reduced or ceases. This mechanism is involved when clinicians use transcutaneous electrical nerve stimulation (TENS) to relieve pain. Neurons descending from the brain may also excite or inhibit activity of the transmission cells within the spinal cord by influencing the small adjacent excitatory and inhibitory cells. For example, in states of emotional calmness, inhibition of transmission cell activity occurs, and less pain is experienced than in states of anxiety, when the activity of the transmission cells is increased by stimulation of the small excitatory cells.

Gate-control theory of pain: the nerve pathways involved (see text)


In some situations pain may be felt when part of the body is missing, for example after the amputation of a limb or breast. Such ‘phantom pains’ are located in the absent part at a site where pain may have been felt before the part was lost. How then can pain, which is at times chronic and excruciating, be experienced in a limb that does not exist as a physical reality? The answer lies in the way the brain functions. Activity in areas of the brain concerned with sensory activity in the missing limb continues despite the absence of the limb, and gives rise to a phantom. If in addition central pain processes are active, phantom pain is experienced in the phantom limb. Such pain may be eliminated by stimulation of the sensory cerebral cortex but not by the division of nerves or the spinal cord. This supports the view that, although most people believe that pain actually exists at a site in the body that hurts, it is in fact a part of consciousness and the result of brain activity.

Until recently it was thought that the sensory and emotional elements of pain experience were linked solely to specific areas of the brain, namely the sensory and the emotional cortex, respectively. However, recent work using non-invasive brain imaging techniques — for example positron emission scanning — has revealed this model to be too simple. It is true that within the brain there is a degree of functional specialization for pain, but this is only part of the story. For example, damage to one half of the cerebral cortex does not necessarily abolish pain sensations from the opposite side of the body, and damage to areas of the brain associated with emotion does not necessarily remove the emotional component of pain. The reason for these apparent anomalies seems to lie in the fact that pain is generated within a widely distributed system or neuronal network. In this way, the brain detects tissue injury even when there is considerable damage to the nervous system. The brain functions as an active system, which filters, selects, and integrates sensory input against the background of lifelong experiences, both physical and emotional, which are preserved in the systems devoted to memory. One brain output from this process is pain.

Pain therefore occurs only in the conscious individual, and it is essential for survival. A small but unfortunate number of people are born without the capacity to feel pain. As a result they suffer horrific injuries in childhood and die young as a result of accidents or undiagnosed disorders, which in normal people give rise to pain.

In everyday life pain is recognized in two forms, namely acute pain and chronic pain. The former has a protective function. It alerts us to damage to the body, it increases our level of arousal, it directs our attention to the cause of the pain, and generates behaviour that leads to an escape from it. The chief emotion associated with acute pain is anxiety, and this subsides when pain is relieved and the cause is understood. In contrast, chronic pain does not appear to the sufferer to have any purpose and indeed has negative qualities. It gives rise to feelings of anxiety and at times of depression. The behaviours generated include withdrawal from social activities and a search for relief. The latter may well lead the sufferer to move from one doctor to another and to non-medical practitioners in the hope of pain relief. At times that process itself may generate more physical suffering through unnecessary investigation and the end result is pain, despair, and depression.

Both acute and chronic forms of pain are familiar, but in addition pain occurs in two other, quite different situations. It may occur as a symptom in a depressive illness. In other words it is not, as is commonly thought in such situations, that depression has developed because pain is being experienced but, in fact, the pain is part of a primary depressive illness. Up to half of those who develop depressive illnesses experience physical symptoms unrelated to any obvious underlying pathology, and of those symptoms pain is the most common. The failure of doctors to appreciate this fact does occasionally lead to a prolonged search for a physical cause for pain because its presence overshadows other features of a depressive illness.

Pain occurs in individual's experiencing anxiety, or emotional tension. For example, tension headaches are very common. The presence of anxiety in a pain sufferer tends both to increase the severity of pain experienced and to reduce the individual's tolerance or ability to cope with it.

Pain may occur in the absence of an obvious physical cause and where the features of a mental illness are not detectable. Individuals with this type of pain may have had a trivial injury but the level of pain and disability with which they present is out of all proportion to the severity of that injury. In addition, the behaviour shown by the sufferer reveals considerable dependence upon others, loss of willingness to take responsibility for themselves, their home, and their work, and a preoccupation with a search for a ‘cure’ for the pain, which they regard firmly as physical in origin.

Consideration of pain problems in which an underlying physical cause is either minimal or absent highlights the fact that when trying to understand pain it is necessary not only to consider its sensory aspects, but also its emotional ones. Indeed it has been said that to ignore the emotional aspects of pain is to look at only one part of the problem, and probably not the most important part at that. The definition of pain given earlier reinforces this point.

As a consequence of the need to encompass the physical, psychological, and social aspects of pain experience, clinicians and pain researchers have developed what is known as the biopsychosocial model of pain. It is based upon what we know about the generation and control of pain within the nervous system, and also its psychological aspects and the social factors that influence the thinking of individuals about pain and their behaviour. This approach to pain has lead to the development of powerful psychological tools for pain management, which come under the broad heading of cognitive-behavioural theory and practice.

Consideration of socio-cultural and learning factors reveals that learning about pain takes place within a definite social context, and the way each of us behaves when in pain reflects that fact. At a national level it is customary in general for those who are from Northern European countries to regard complaints about pain, especially amongst men, as a weakness of character. In contrast, in Southern European countries to complain about pain is regarded as beneficial to the sufferer. These are very broad generalizations but do have some basis in fact. An important psychological mechanism by which we learn the behaviours we exhibit when in pain is defined as operant learning. It is a process by which overt behavioural responses to a stimulus are significantly influenced by their consequences, including the responses of others to them.

Operant learning is well illustrated by the effects of a simple injection upon a child. The sight of the needle and the pain experienced is an ‘unconditioned stimulus’ and as a response to it the child cries. On the next occasion the child cries at the sight of the syringe and needle, which have become ‘the conditioned stimulus’. If crying leads to the abandonment of the injection the child has developed a ‘conditioned escape response’. Seeing another child crying before an injection which is then not given leads to another type of learning — ‘an observational learning model’.

In some individuals such mechanisms lead to the development of pain behaviours that have a negative effect upon their lives — for example, the excessive use of rest to relieve pain, or the abuse of powerful narcotic-related drugs may actually lead to increasing chronicity of pain and disability. To counter such developments psychologists have developed techniques based upon operant conditioning, which are designed to reverse maladaptive pain behaviours and to replace them by adaptive behaviours. In other words, their techniques involve the use of learning of behaviour designed to lead to coping with pain and everyday life rather than withdrawing from them. Put in simple terms, ‘good behaviour is rewarded and bad behaviour is punished’.

Operant conditioning has been criticized on the grounds that it does not take sufficient account of mental activity. In other words, individuals have thoughts about pain and attitudes towards it. They draw on memories of past experience when in pain, and this leads to thinking and behaviour, which is the result of those experiences. Such thoughts and attitudes, or cognitions, as they are called, cannot be ignored when a clinician is evaluating a person in pain and planning their treatment. For this reason, a purely behavioural approach has been replaced by a cognitive-behavioural approach to pain analysis and management. The main cognitive elements that have been identified include beliefs about pain and its causes, beliefs about the extent to which the individual feels he or she has control over pain, and the extent to which individuals believe that they are able to function despite pain. Therefore, self-efficiency is a significant factor in determining ability to cope.

People in pain often develop what are described by psychologists as ‘cognitive errors’. For example, they may indulge in what is known as ‘catastrophizing’. In other words they develop an unnecessarily negative view of their condition and its likely outcome. In such a state they tend to focus to a extent upon the negative features of their disorder. It has been demonstrated that negative qualities of thought, and catastrophizing in particular, are consistently linked to the development of depression in chronic pain disorders. The manipulation of coping mechanisms is of great significance when considering the management of pain and especially of chronic pain. We are all familiar with coping strategies, some of which are regarded as active — for example, indulging in active and distracting behaviour, whereas others are passive — for example, taking rest or medicines. If the strategy used maximizes function in the presence of pain and reduces anxiety, then it is said to be adaptive. On the other hand, if the strategies used involve too much rest, too great a dependence on medication or on others, or conversely too much activity which provokes excessive pain, they are maladaptive. Cognitive therapies involve changing thoughts and attitudes about pain with a view to changing self-management in the direction of adaptive behaviour: a change which often leads to a lessening of pain.

— Michael R. Bond

Bibliography

• Gatchell, R. J. and Turk, D. C. (ed.) (1996). Psychological approaches to pain management. The Guilford Press, New York and London.
• Main, J. C. and Spanswick, C. C. (2000) Pain management: an interdisciplinary approach. Churchill Livingstone, Edinburgh & London.
• Wall, P. (1999). Pain; the science of suffering. Weidenfeld and Nicolson, London

See also analgesia; central nervous system; endorphins; opiates and opioid drugs; somatic sensation; visceral sensation.

noun

1. A sensation of physical discomfort occurring as the result of disease or injury: ache, pang, prick, prickle, smart, soreness, stab, sting, stitch, throe, twinge. Informal misery. See pain/pleasure.
2. A state of physical or mental suffering: affliction, agony, anguish, distress, hurt, misery, torment, torture, woe, wound, wretchedness. See happy/unhappy.
3. Attentiveness to detail. care, carefulness, fastidiousness, meticulousness, painstaking, punctiliousness, scrupulousness, thoroughness. See careful/careless.
4. The use of energy to do something. effort, endeavor, exertion, strain¹, striving, struggle, trouble, while. Informal elbow grease. See work/play.
5. One that makes another totally miserable by causing sharp pain and irritation: thorn, trial. Idioms: pain in the neck, thorn in thefleshside. See pain/pleasure.

verb

1. To cause suffering or painful sorrow to: aggrieve, distress, grieve, hurt, injure, wound. See happy/unhappy.
2. To have or cause a feeling of physical pain or discomfort: ache, hurt, pang, twinge. See pain/pleasure.

Idioms beginning with pain:
pain in the neck
paint black
paint oneself into a corner
paint the town red

See also at pains; feel no pain; for one's pains; growing pains; no pain, no gain; on pain of.

n

Definition: big problem
Antonyms: irritation

n

Definition: mental suffering
Antonyms: cheer, happiness, joy, pleasure, well-being

n

Definition: physical suffering
Antonyms: comfort, good health, health, well-being

v

Definition: bother, trouble
Antonyms: aid, assist, assuage, help, please

Definition

Pain is an unpleasant feeling that is conveyed to the brain by nerves in the body.

Description

Pain arises from any number of situations. Injury is a major cause, but pain may also arise from an illness. It may accompany a psychological condition, such as depression, or may even occur in the absence of a recognizable trigger. The discomfort signals actual or potential injury to the body. However, pain is more than a sensation or the physical awareness of pain; it also includes perception, the subjective interpretation of the discomfort. Perception gives information on the pain's location, intensity, and something about its nature. The various conscious and unconscious responses to both sensation and perception, including the emotional response, add further definition to the overall concept of pain.

Acute Pain

Acute pain often results from tissue damage, such as a skin burn or broken bone. Acute pain can also be associated with headaches or muscle cramps. This type of pain usually goes away as the injury heals or the cause of the pain (stimulus) is removed. To understand acute pain, it is necessary to understand the nerves that support it. Nerve cells, or neurons, perform many functions in the body. Although their general purpose, providing an interface between the brain and the body, remains constant, their capabilities vary widely. Certain types of neurons are capable of transmitting a pain signal to the brain. As a group, these pain-sensing neurons are called nociceptors, and virtually every surface and organ of the body is wired with them. The central part of these cells is located in the spine, and they send threadlike projections to every part of the body. Nociceptors are classified according to the stimulus that prompts them to transmit a pain signal. Thermoreceptive nociceptors are stimulated by temperatures that are potentially tissue damaging. Mechanoreceptive nociceptors respond to a pressure stimulus that may cause injury. Polymodal nociceptors are the most sensitive and can respond to temperature and pressure. Polymodal nociceptors also respond to chemicals released by the cells in the area from which the pain originates.

Nerve cell endings, or receptors, are responsible for pain sensation. A stimulus at this part of the nociceptor unleashes a cascade of neurotransmitters (chemicals that transmit information within the nervous system) in the spine. Each neurotransmitter has a purpose. For example, substance P relays the pain message to nerves leading to the spinal cord and brain. These neurotransmitters may also stimulate nerves leading back to the site of the injury. This response prompts cells in the injured area to release chemicals that not only trigger an immune response but also influence the intensity and duration of the pain.

Chronic and Abnormal Pain

Chronic pain refers to pain that persists after an injury heals, cancer pain, pain related to a persistent or degenerative disease, and long-term pain from an unidentifiable cause. It is estimated that one in three people in the United States experiences chronic pain at some point in their lives. Of these people, approximately 50 million are either partially or completely disabled. Chronic pain may be caused by the body's response to acute pain. In the presence of continued stimulation of nociceptors, changes occur within the nervous system. Changes at the molecular level are dramatic and may include alterations in genetic transcription of neurotransmitters and receptors. These changes may also occur in the absence of an identifiable cause; one of the frustrating aspects of chronic pain is that the stimulus may be unknown. For example, the stimulus cannot be medically identified in as many as 85 percent of individuals suffering from lower back pain.

Other types of abnormal pain include allodynia, hyperalgesia, and phantom limb pain. These types of pain often arise from some damage to the nervous system (neuropathic). Allodynia refers to a feeling of pain in response to a normally harmless stimulus. For example, some individuals who have suffered nerve damage as a result of viral infection experience unbearable pain from just the light weight of their clothing. Hyperalgesia is somewhat related to allodynia in that the response to a painful stimulus is extreme. In this case, a mild pain stimulus, such as a pinprick, causes a maximum pain response. Phantom limb pain occurs after a limb is amputated; although an individual may be missing the limb, the nervous system continues to perceive pain originating from the area.

Demographics

Pain is experienced by all age groups, both sexes, and all races and ethnic groups.

Causes and Symptoms

Pain is the most common symptom of injury and disease, and descriptions can range in intensity from a mere ache to unbearable agony. Nociceptors have the ability to convey information to the brain that indicates the location, nature, and intensity of the pain. For example, stepping on a nail sends an information-packed message to the brain: the foot has experienced a puncture wound that hurts a lot. Pain perception also varies depending on the location of the pain. The kinds of stimuli that cause a pain response on the skin include pricking, cutting, crushing, burning, and freezing. These same stimuli would not generate much of a response in the intestine. Intestinal pain arises from stimuli such as swelling, inflammation, and distension.

When to Call the Doctor

Parents should notify their physician or pediatrician if any of the following occurs:

• The child is in severe pain.
• The child has pain that lasts for more than three days.
• Parents have questions or concerns about their child's treatment or condition.
• The child is in the hospital and the parent thinks he or she is in pain. The sooner the pain is treated, the easier it is to control.

Diagnosis

Pain is considered in view of other symptoms and individual experiences. An observable injury, such as a broken bone, may be a clear indicator of the type of pain a person is suffering. Determining the specific cause of internal pain is more difficult. Other symptoms, such as fever or nausea, help narrow the possibilities. In some cases, such as lower back pain, a specific physiological cause may not be identified. Diagnosis of the disease causing a specific pain is further complicated by the fact that pain can be referred to (felt at) a skin site that does not seem to be connected to the site of the pain's origin. For example, pain arising from fluid accumulating at the base of the lung may be referred to the shoulder.

Since pain is a subjective experience, it may be very difficult to communicate its exact quality and intensity to other people. There are no diagnostic tests that can determine the quality or intensity of an individual's pain. Therefore, a medical examination includes a lot of questions about where the pain is located, its intensity, and its nature. Questions are also directed at what kinds of things increase or relieve the pain, how long it has lasted, and whether there are any variations in it. An individual may be asked to use a pain scale to describe the pain. One such scale assigns a number to the pain intensity; for example, 0 may indicate no pain, and 10 may indicate the worst pain the person has ever experienced. Scales are modified for infants and children to accommodate their level of comprehension.

A subsequent method of evaluating pain in children up to age four years was as of 2004 set to be implemented in 60 hospitals in the Netherlands. The Pain Observation Scale for Young Children, called POCIS, measures pain levels according to children's behavior in seven categories: facial expressions, crying, breathing, torso movements, movements in the arms and fingers and in the legs and toes, and restlessness. Physicians and nurses observe the intensity of these behaviors and calculate a pain severity score ranging from 0 to 7. Researchers from the University of Amsterdam who developed the scale said that existing behavioral pain measures were created for premature neonates or infants and may not be appropriate for older children. Some of those measures are upsetting for children because they require restraint or physical contact by a healthcare professional.

Alternative Treatment

Both physical and psychological aspects of pain can be dealt with through alternative treatment. Some of the most popular treatment options include acupressure and acupuncture, massage, chiropractic, and relaxation techniques, such as yoga, hypnosis, and meditation. Herbal therapies are increasingly recognized as viable options; for example, capsaicin, the component that makes cayenne peppers spicy, is used in ointments to relieve the joint pain associated with arthritis. Contrast hydrotherapy can also be very beneficial for pain relief. Lifestyles can be changed to incorporate a healthier diet and regular exercise. Regular exercise, aside from relieving stress, has been shown to increase endorphins, painkillers naturally produced in the body.

Prognosis

Successful pain treatment is highly dependent on successful resolution of the pain's cause. Acute pain will stop when an injury heals or when an underlying problem is treated successfully. Chronic pain and abnormal pain are more difficult to treat, and it may take longer to find a successful resolution. Some pain is intractable and requires extreme measures for relief.

Prevention

Pain is generally preventable only to the degree that the cause of the pain is preventable; diseases and injuries are often unavoidable. However, increased pain, pain from surgery and other medical procedures, and continuing pain are preventable through drug treatments and alternative therapies.

Parental Concerns

If a child has a lot of pain, it is likely that more can be done to help. The first step is for parents to tell the child's doctor or nurse what their concerns are. They can ask what more can be done for the child to control pain. If parents are still concerned about their child's pain control, they can request a meeting with the doctor. Parents should list their concerns as clearly as possible. They should take a constructive approach and seek to form a partnership with the healthcare team in managing the child's pain. For parents who are still not satisfied with what is being done, some type of formal complaint to the hospital may be unavoidable. Pain management is the right of every child. Parents working with health providers are the best advocates for this right. The U.S. Department of Health and Human Services Agency for Health Care Policy and Research has developed guidelines for pain management. These guidelines establish a standard of care that should be followed. Parents can get a copy from the hospital library or directly from the government.

Resources

Books

Lehman, Thomas J. It's Not Just Growing Pains: A Guide to Childhood Muscle, Bone, and Joint Pain, Rheumatic Diseases, and the Latest Treatments. Oxford, UK: Oxford University Press, 2004.

McGrath, Patrick J., and Allen G. Finley. Pediatric Pain: Biological and Social Context. Seattle, WA: IASP Press, 2003.

Schechter, Neil L., et al. Pain in Infants, Children, and Adolescents, 2nd ed. New York: Lippincott Williams & Wilkins, 2002.

Periodicals

Leung, Alexander K. C., and David L. Sigalet. "Acute Abdominal Pain in Children." American Family Physician (June 1, 2003): 2321.

O'Rourke, Deborah. "The Measurement of Pain in Infants, Children, and Adolescents: From Policy to Practice." Physical Therapy (June 2004): 560–70.

Springen, Karen. "Small Patients, Big Pain: Ten Million American Children Suffer Chronic or Recurrent Pain. Treating Them Poses Special Challenges. Now Doctors and Researchers are Learning How to Help." Newsweek (May 19, 2003): 54.

Tanne, Janice Hopkins. "Children Are Often Undertreated for Pain." British Medical Journal (November 22, 2003): 1185.

Williams, Mathew E. "Trouble Underfoot: Heel Pain in Children: Practitioners Must Have a High Index of Suspicion and Conduct a Thorough Workup to Determine the True Cause of a Child's Symptoms." Biomechanics (July 1, 2004): 26.

Organizations

American Chronic Pain Association. PO Box 850, Rocklin, CA 95677. Web site: www.theacpa.org.

American Pain Society. 4700 W. Lake Ave., Glenview, IL 60025. Web site: www.ampainsoc.org.

Web Sites

Rutherford, Kim. "The Truth about Pain." KidsHealth, August 2001. Available online at www.kidshealth.org/parent/general/aches/pain.html (accessed November 22, 2004).

Suresh, Santhanam. "Chronic Pain Management in Children and Adolescents." The Child's Doctor, 2004. Available online at www.childsdoc.org/spring2002/chronicpain.asp (accessed November 22, 2004).

Other

Carr, Daniel B., and Ada Jacox. "Acute Pain Management: Operative or Medical Procedures and Trauma; Clinical Practice Guideline." Available free by writing to AHCPR Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907. Available online at www.ahrq.gov/clinic/medtep/acute.htm (accessed November 22, 2004).

[Article by: Julia Barrett
Ken R. Wells]

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A favourite example of an experience that seems to resist reduction in terms of behaviour. Although pain obviously has behavioural consequences, being unpleasant, disruptive, and sometimes overwhelming, there is also something more than behaviour, something ‘that it is like’ to be in pain, and there is all the difference in the world between pain behaviour accompanied by pain and the same behaviour without pain. Theories identifying pain with neural events subserving it have been attacked (e.g. by Kripke) on the grounds that whilst a genuine metaphysical identity should be necessarily true, the association between pain and any such event would be contingent. See also mind-body problem, qualia.

A feeling of distress, suffering, or agony usually caused by the stimulation of specialized nerve endings. Pain has a protective function, acting as a warning sign and preventing further injury. However, even mild pain can have a detrimental effect on performance and severe pain will limit movement. Pain can be classified functionally into five levels: at level 1, pain occurs only after a specific activity; at level 2, pain occurs during and after specific activities, but it does not affect performance; at level 3, pain occurs during and after specific activity, and affects the performance of the activity; at level 4, pain occurs with activities of daily living; at level 5, pain occurs at rest. This classification enables an athlete to describe their pain to a physician. Also, during rehabilitation from a sports injury, the functional level of pain can be used as a guide to how recovery is progressing. Pain can be relieved by acupuncture, ice treatment, heat treatment, anaesthetics, anti-inflammatory medicines, analgesics NSAIDs, opiates, and transcutaneous nerve stimulation therapy. Substances that increase sensitivity to pain include bradykinins, free radicals, histamine, potassium, and serotonin. Some of these substances evoke pain by affecting nerves directly, others cause an inflammatory reaction. See also adaptive pain, maladaptive pain.

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The term "pain" refers to a physical sensation or a distress linked to instinctual tension, which the psychic apparatus then seeks to discharge by work according to the principle of pleasure/unpleasure.

Jean-Bertrand Pontalis (1981) noted that the outline for an original theory of pain can be found in Freud's work from "A Project for a Scientific Psychology" (1950c [1895]) onward. Taken up again in Inhibitions, Symptoms, and Anxiety (1926d [1925]), this theory covers the basic reference points of analytic theory: the theory of narcissism, the question of trauma, the definition of primary masochism, and the presentation of the death instinct. Finally, with the concept of negative therapeutic reaction in place, Freud, in The Ego and the Id (1923b), described how pain drives resistance to analysis, indeed, how pain is the final refuge from renouncing the lost object, as the resistance implies.

By 1895 Freud had postulated bipolarity as the principle of psychic functioning, and, anticipating his later theory of instinctual dualism, he opposed the experience of pain to the experience of satisfaction. In qualitative terms, pain is different from unpleasure in that pain is situated outside the economic apparatus of pleasure/unpleasure. In dynamic terms, "[p]ain is . . . characterized as an irruption of excessively large Qs [quantities] into N [neurones that don't retain quantities of energy] and R [neurones that do retain energy and are capable of retaining memory" (1950c, p. 307). Then the body discharges the accumulated excitation. Pain can cause the subject to break out of preestablished paths only because there are boundaries (bodily boundaries, ego boundaries); however, its internal discharge has an implosive effect. Like a physical or psychic hole (to be distinguished from a possible lacuna or a lack), the excess of excitation caused by pain obstructs all binding activity. Pontalis (1981) has stressed that this theory of pain breaching is a departure from the economic apparatus where the theory of anxiety is more generally situated.

In 1926, in addendum C to Inhibitions, Symptoms and Anxiety, Freud again tried to differentiate pain from anxiety, though not without difficulty or contradiction. Pain is primarily a reaction to the loss of the object, whereas anxiety is a reaction to the danger that loss entails. Pain is the consequence of a breaching of the protective shield, and by acting as a constant instinctual excitation (some authors have proposed the idea of a pseudo-instinct here), it prevents the subject from escaping from it. Nonetheless, pain has a locus: it emanates from the periphery of the body or the organs. If anxiety has already led the subject to regard the loss of the object metaphorically, the unmediated reality of pain ensures that the subject can survive without the loss of the object or the nostalgia of that loss. In a third stage of his exposition in addendum C, Freud returns to the difference between mental pain and physical pain, arguing that the former is much more closely related to the mechanism of anxiety. "The transition from physical pain to mental pain corresponds to a change from narcissistic cathexis to object-cathexis. An object-presentation which is highly cathected by instinctual need plays the same role as a part of the body which is cathected by an increase of stimulus" (1926d, pp. 171-172).

Freud thus uses the same model to describe both physical pain and psychic pain. As Pontalis has made clear, pain is not a case of metaphor but rather a case of analogy—a direct exchange between one level and another, as if with pain the body mutates into psyche and the psyche into body. But while anxiety can be communicated, pain cannot. Despite a scream of pain, the cry does nothing to ease it. The experience of pain takes place within a bodily ego. Both physical pain and mental pain partake of the content-container relationship (Enriquez, 1980; McDougall, 1978). The subject in pain finds it impossible to recover the object by means of representation: "Where there is pain, it is the lost, absent object that is present; the real, present object that is absent." The distinctive feature of pain is its blurring of boundaries. Thus, for example, certain types of physical suffering serve to alleviate mental pain. Recent clinical work on somatization and borderline states is often faced with this inchoate nature of pain: absolute, naked pain.

Bibliography

Enriquez, Micheline. (1980). Du corps de souffrance au corps en souffrance. Topique, 26, 5-27.

Freud, Sigmund. (1923b). The ego and the id. SE, 19: 1-66.

——. (1926d [1925]). Inhibitions, symptoms, and anxiety. SE, 20: 75-172.

——. (1950c [1895]). A project for a scientific psychology. SE, 1: 281-387.

McDougall, Joyce. (1978). Plaidoyer pour une certaine anormalité. Paris: Gallimard.

Pontalis, Jean-Bertrand. (1981). Frontiers in psychoanalysis: Between the dream and psychic pain (Catherine Cullen and Philip Cullen, Trans.). London: Hogarth Press and the Institute of Psycho-Analysis. (Original work published 1977)

—DRINA CANDILIS-HUISMAN

Pain research and therapy have long been dominated by specificity theory which proposes that pain is a specific sensation subserved by a straight-through transmission system, and that the intensity of pain is proportional to the extent of tissue damage. Recent evidence, however, shows that pain is not simply a function of the amount of bodily damage alone, but is influenced by attention, anxiety, suggestion, prior experience, and other psychological variables (Melzack and Wall 1982). Moreover, the natural outcome of the specificity concept of pain has been the development of neurosurgical techniques to cut the so-called pain pathway, and the results of such operations have been disappointing, particularly for chronic pain syndromes. Not only does the pain tend to return in a substantial proportion of patients, but new pains may appear. The psychological and neurological data, then, forces us to reject the concept of a single straight-through sensory transmission system.

In recent years the evidence on pain has moved in the direction of recognizing the plasticity and modifiability of events in the central nervous system. Pain is a complex perceptual and affective experience determined by the unique past history of the individual, by the meaning to him of the injurious agent or situation, and by his 'state of mind' at the moment, as well as by the sensory nerve patterns evoked by physical stimulation.

In the light of this understanding of pain processes, Melzack and Wall (1965) proposed the gate control theory of pain. Basically, the theory states that neural mechanisms in the dorsal horn of the spinal cord act like a gate which can increase or decrease the flow of nerve impulses from peripheral fibres to the spinal cord cells that project to the brain. Somatic input is therefore subjected to the modulating influence of the gate before it evokes pain perception and response. The theory suggests that large-fibre inputs (such as gentle rubbing) tend to close the gate while small-fibre inputs (such as pinching) generally open it, and that the gate is also profoundly influenced by descending influences from the brain. It further proposes that the sensory input is modulated at successive synapses throughout its projection from the spinal cord to the brain areas responsible for pain experience and response. Pain occurs when the number of nerve impulses that arrive at these areas exceeds a critical level.

Melzack and Wall (1982) have recently assessed the present-day status of the gate control theory in the light of new physiological research. It is apparent that the theory is alive and well despite considerable controversy and conflicting evidence. Although some of the physiological details may need revision, the evidence supporting the concept of gating (or input modulation) is stronger than ever.

The subjective experience of pain clearly has sensory qualities, such as are described by the words throbbing, burning, or sharp. In addition, it has distinctly unpleasant, affective qualities which are described by words such as exhausting, wretched, and punishing. Pain becomes overwhelming, demands immediate attention, and disrupts ongoing behaviour and thought. It motivates or drives the organism into activity aimed at stopping the pain as quickly as possible. On the basis of these considerations, Melzack and Casey (1968) have proposed that there are three major psychological dimensions of pain experience: sensory–discriminative, motivational–affective, and cognitive–evaluative. Psychophysiological evidence suggests that each is subserved by specialized systems in the brain which interact to produce the multidimensional qualities of pain experience.

Recent recognition of the complexity of pain experience has led to the development of a paper-and-pencil questionnaire (the 'McGill Pain Questionnaire') to obtain numerical measures of the intensity and qualities of pain (Melzack 1975). The questionnaire consists of twenty sets of words that people use to describe pain. Ten sets describe sensory qualities, five describe affective qualities, and one is an evaluative group. Four sets consist of miscellaneous words. Since each word has a numerical value, patients asked to check those words that best describe their pain provide quantitative measures for each of the major dimensions of pain. The power of the questionnaire has been demonstrated in many quantitative, controlled studies of the effects of different forms of pain therapy (Melzack 1983). In addition, the questionnaire has been shown to discriminate among different types of pain. Distinctive patterns of words discriminate between migraine and tension headaches, between low-back pain of organic and that of functional origin, and between dysmenorrhoea and pain caused by an intra-uterine device.

Drugs, especially opium and its derivatives, are among the oldest methods for controlling pain. Thomas Sydenham in 1680 wrote: 'Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and efficacious as opium.' Since then, more effective derivatives of opium, notably morphine and heroin, have been discovered. The invention of the hypodermic needle and syringe not only stimulated the search for pure, injectable analgesics but also, unfortunately, increased the risk of drug dependence. The quest for preparations free from addictive properties has proved to be fruitless, but withholding such pain-relieving drugs from the terminally ill lest they become 'addicted' is as ridiculous as it is inhumane. Other drugs said to have analgesic properties include the antidepressants, but it does not appear that relief of depression is their mode of action. Possibly this may be by blocking the reuptake of serotonin and so potentiating the effect of enkephalins in the brain (see neuropeptides).

Many new methods to control pain have been developed in recent years (Melzack and Wall 1982). Sensory modulation techniques such as transcutaneous electrical nerve stimulation (TENS) and ice massage are widely used in the attempt to activate inhibitory neural mechanisms to suppress pain. These techniques have a long history but were not understood until recently. Acupuncture, for example, is an ancient Chinese medical procedure in which long needles are inserted into specific points at the skin. The traditional Chinese explanation is that the needles bring yin and yang (which flow through hypothetical tubules called meridians) into harmony with each other. It has been discovered, however, that the sites of insertion correspond to myofascial 'trigger points' which are well known in Western medicine. It has also been found that acupuncture and electrical stimulation through electrodes placed on the skin (TENS) are equally effective in relieving low-back pain and several other forms of pain, including pains due to peripheral nerve injury. The neural mechanisms which underlie the relief produced by these forms of stimulation are not entirely understood, but evidence suggests that the intense stimulation produced by acupuncture or TENS activates an area in the brain which exerts a powerful inhibitory control over pathways that transmit pain signals.

Psychological techniques that allow patients to achieve some degree of control over their pain have also been developed. These techniques include biofeedback, hypnosis, distraction, and the use of imagery and other cognitive activities to modulate the transmission of the nerve-impulse patterns that subserve pain. Psychological techniques are being used increasingly and provide relatively simple, safe approaches to pain control. They represent a significant advance over the earlier tendency to treat pain by neurosurgical operations intended to cut the 'pain pathway' and which so frequently ended in failure.

The techniques of sensory modulation and psychological control work well in conjunction with each other. A large body of research demonstrates that several of these procedures employed at the same time — 'multiple convergent therapy' — are often highly effective for the control of chronic pain states, particularly those such as low-back pain which have prominent elements of tension, depression, and anxiety.

While great strides have been made in the control of pain, there are still many pain syndromes which are beyond our comprehension and our control. Back pains, especially of the lower back, are the most common kind of pain, and literally millions of sufferers are continually seeking help. Sometimes they obtain temporary relief, but most continue to suffer. Migraine and tension headaches similarly plague millions of people. Perhaps the most terrible of all pains are those suffered by some cancer patients in the terminal phases of the disease. In recent years, specialized medical units have been developed to cope with these problems. Their major feature is that physicians and other health professionals from many different disciplines work together in the attempt to alleviate the pain of each individual patient. Pain clinics have been set up in every major Western city to cope with benign chronic pain, and hospices or palliative care units in hospitals have been developed to control pain (and other miseries) of patients who are terminally ill with cancer.

The development of pain clinics and hospices represents a breakthrough of the highest importance in the clinical control of pain. They are radical, new approaches to old problems. Chronic pain and terminal pain are major challenges to the scientist and clinician. But the giant step has been the recognition that they are special problems. The challenges ahead are clear: to conquer pain and suffering in all their forms.

(Published 1987)

See also anaesthesia.

— Ronald Melzack

Bibliography
• Dickenson, A. H. (2002). 'Gate Control Theory of pain stands the test of time'. British Journal of Anaesthesia, 88/6.
• Melzack, R. (1975). 'The McGill Pain Questionnaire: major properties and scoring methods'. Pain, 1.
• — —  (ed.) (1983). Pain Measurement and Assessment.
• — —  and Casey, K. L. (1968). 'Sensory, motivational and central control determinants of pain: a new conceptual model'. In Kenshalo, D. (ed.), The Skin Senses.
• — —  and Wall, P. D. (1965). 'Pain mechanisms: a new theory'. Science, 150.
• — —   — —  (1982). The Challenge of Pain.
• Wall, P. (1999). Pain, the Science of Suffering.

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A cynical view of the world by Ambrose Bierce

n.

An uncomfortable frame of mind that may have a physical basis in something that is being done to the body, or may be purely mental, caused by the good fortune of another.

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Quotes:

"Who, except the gods, can live time through forever without any pain?" - Aeschylus

"The injuries we do and the injuries we suffer are seldom weighed on the same scales." - Aesop

"The greatest evil is physical pain." - St. Augustine

"The moment an ill can be patiently handled, it is disarmed of its poison, though not of its pain." - Henry Ward Beecher

"And God shall wipe away all tears from their eyes; and there shall be nor more death, neither sorrow nor crying, neither shall there be any more pain. [Revelation]" - Bible

"To banish cares, scare away sorrow and soothe pain is the business of the poet and singer." - Bodenstedt

See more famous quotes about Pain

Experiencing pain in one's dream may be a reflection of real pain that exists somewhere in the dreamer's body. Alternatively, the dreamer may consider someone or something to be a "pain." The suppression of painful memories may also be an issue.

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noun
noun

pain in the arse (etc.): a person or thing particularly annoying or tiresome. Also, to give (someone) a pain in the arse. (1972 —) .
E. Mcbain Homicide cops...were pains in the ass to detectives actually...trying to solve cases (1973).

[Developed from the informal pain in the neck.]

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A feeling of distress, suffering or agony, caused by stimulation of specialized nerve endings. Its purpose is chiefly protective; it acts as a warning that tissues are being damaged and induces the sufferer to remove or withdraw from the source.
All receptors for pain stimuli are free nerve endings of groups of myelinated or unmyelinated neural fibers abundantly distributed in the superficial layers of the skin and in certain deeper tissues such as the periosteum, surfaces of the joints, arterial walls, and the falx and tentorium of the cranial cavity. The distribution of pain receptors in the gastrointestinal mucosa apparently is similar to that in the skin; thus, the mucosa is quite sensitive to irritation and other painful stimuli. Although the parenchyma of the liver and the alveoli of the lungs are almost entirely insensitive to pain, the liver as an organ and the bile ducts are extremely sensitive, as are the bronchi, ureters, parietal pleura and peritoneum.
Some pain receptors are selective in their response to stimuli, but most are sensitive to more than one of the following types of excitation: (1) mechanical stress of trauma; (2) extremes of heat and cold; and (3) chemical substances, such as histamine, potassium ions, acids, prostaglandins, bradykinin and acetylcholine.
The conscious perception of pain probably takes place in the thalamus and lower centers; interpretation of the quality of pain is probably the role of the cerebral cortex.
There are some naturally occurring internal systems in the body that are known to control pain but none of them has been completely verified. One of the best known is the gate control system in which it is thought that pain impulses are mediated in the substantia gelatinosa of the spinal cord.

• abdominal p. — pain occurring in the area between the thorax and pelvis. Manifestations vary between species. Identifiable syndromes include: (1) horse—pawing, flank watching, rolling, straddling as though to urinate, lying on the back; (2) cattle—may depress back and paddle with hindfeet but mostly arched back, grunting, immobility; (3) dogs and cats—arched back, grunting, depression, reluctance to move. Sometimes there is elevation of the hindquarters, with the chest and forelegs on the ground (the so-called ‘praying dog’ attitude).
• Beagle p. syndrome — see beagle pain syndrome.
• projected p. — pathology in one area can affect the nerve supply to a distant area in which pain is experienced.
• p. receptors — free nerve endings of tufts of fine points or buttons.
• referred p. — pain felt in an area distant from the site of pathology but not mediated through a common innervation. There is no evidence that referred pain occurs in animals but it seems likely on anatomical grounds.
• p. threshold — the lowest level at which a stimulus can be applied and cause perceptible pain.
• p. tolerance — the level of stimulation at which pain becomes intolerable.

For a list of words related to pained, see:

• Sad, Serious, Pessimistic, or Discontented

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See words rhyming with "pain."

  See crossword solutions for the clue Pain.

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Dansk (Danish)
n. - smerte
v. tr. - smerte, bedrøve
v. intr. - gøre ondt

idioms:

• be at pains to    gøre sig umage med
• feel no pain    ingen smerte føle
• for one's pains    for ens umage
• go to great pains    gøre sig meget umage
• on pain of    under straf af
• pain barrier    smertetærskel
• pain in the arse    en lort
• pain in the neck    en irriterende person
• under pain of    med straf af

Nederlands (Dutch)
pijn, lastpost, emotionele leed, verdriet doen, pijn doen

Français (French)
n. - douleur, mal, casse-pieds, sous peine de
v. tr. - faire mal, chagriner
v. intr. - faire souffrir, chagriner

idioms:

• be at pains to    prendre grand soin de (faire qch)
• feel no pain    (lit) ne ressentir aucune douleur, (US, fig) être soûl
• for one's pains    pour sa peine
• go to great pains    se donner beaucoup de mal pour
• on pain of    sous peine de
• pain barrier    seuil de la douleur
• pain in the arse    (US) (être) emmerdant
• pain in the neck    (GB) (être) casse-pieds
• under pain of    sous peine de

Deutsch (German)
n. - Schmerz, Plage, Mühe
v. - schmerzen

idioms:

• be at pains to    sich Mühe geben
• feel no pain    keinen Schmerz fühlen
• for one's pains    für jmds. Bemühungen
• go to great pains    sich sehr anstrengen
• on pain of    unter Androhung von
• pain barrier    Schmerzgrenze
• pain in the arse    einem auf den Nerv gehen
• pain in the neck    Nervensäge
• under pain of    unter Androhung von

Ελληνική (Greek)
n. - πόνος, οδύνη, (πληθ.) κόπος, στεναχώρια, βάσανα
v. - προξενώ πόνο, πονώ, λυπώ, στενοχωρώ, θλίβω

idioms:

• be at pains to    αγωνίζομαι να
• feel no pain    δεν νιώθω πόνο
• for one's pains    για τον κόπο μου
• go to great pains    αγωνίζομαι
• on pain of    με τιμωρία, επί ποινή
• pain barrier    οδυνηρή δοκιμασία (για παίκτη που παίζει παρά τον τραυματισμό του)
• pain in the arse    φόρτωμα, κακός μπελάς, σπαζαρχίδης
• pain in the neck    φόρτωμα, κακός μπελάς, σπαζαρχίδης
• under pain of    υπό ποινή

Italiano (Italian)
addolorare, dolore, pena, male, sofferenza

idioms:

• be at/take pains    fare di tutto per, darsi pena, affannarsi
• feels no pain    é insensibile, é indolore
• for one's pains    in compenso
• give a pain    dar fastidio
• go to great pains    far tutto il possibile
• on/under pain of    su pena di
• pain barrier    limite di sopportazione, soglia del dolore
• pain in the arse/backside    rompiscatole
• pain in the neck    rompiscatole
• spare no pains    mettercela tutta

Português (Portuguese)
n. - dor (f), sofrimento (m), esforço (m), castigo (m)
v. - doer

idioms:

• be at/take pains    esforçar-se
• feels no pain    meio bêbado (coloq.)
• for one's pains    por causa de alguém
• give a pain    punir
• go to great pains    esforçar-se muito
• on/under pain of    sob pena de
• pain barrier    limiar de dor
• pain in the arse/backside    desagradável, irritante
• pain in the neck    irritante, chato (coloq.)
• spare no pains    não medir esforços

Русский (Russian)
испытывать боль, причинять боль, боль

idioms:

• be at/take pains    стараться, усердствовать
• feels no pain    пьяный в стельку, мертвый
• for one's pains    в награду за труды
• give a pain    досаждать, надоедать
• go to great pains    стараться изо всех сил
• on/under pain of    под страхом
• pain barrier    болевой барьер
• pain in the arse/backside    головная боль, зануда
• pain in the neck    головная боль, зануда
• spare no pains    не жалеть сил

Español (Spanish)
n. - dolor, sufrimiento, pena
v. tr. - doler, dar lástima, apenar, afligir
v. intr. - doler, dar lástima, apenar, afligir

idioms:

• be at pains to    hacer grandes esfuerzos, darse mucho trabajo, tomarse el trabajo de
• feel no pain    borracho como una cuba, no sentir dolor
• for one's pains    lo único que logró como recompensa
• go to great pains    afanarse, empeñarse, esmerarse
• on pain of    so pena de
• pain barrier    umbral del dolor
• pain in the arse    inaguantable, fastidioso al máximo
• pain in the neck    ser un pesado, ser una lata
• under pain of    so pena de

Svenska (Swedish)
n. - smärta, värk, plåga, (pl.) besvär, omak, möda, straff, sorg, ängslan
v. - plåga, värka, svida

中文（简体）(Chinese (Simplified))
痛苦, 辛苦, 疼痛, 使烦恼, 使痛苦, 使疼痛, 引起疼痛, 感到疼痛

idioms:

• be at pains to    尽心于..., 费尽苦心于..., 努力于...
• feel no pain    不觉得痛
• for one's pains    尽管费尽力气
• go to great pains    费大力
• on pain of    违则以...处罚
• pain barrier    痛苦障限
• pain in the arse    讨厌的人或事, 麻烦的事或人, 屁股疼
• pain in the neck    讨厌的人或事, 麻烦的事或人, 脖子疼
• under pain of    违者则处以...的处罚

中文（繁體）(Chinese (Traditional))
n. - 痛苦, 辛苦, 疼痛
v. tr. - 使煩惱, 使痛苦, 使疼痛
v. intr. - 引起疼痛, 感到疼痛

idioms:

• be at pains to    盡心於..., 費盡苦心於..., 努力於...
• feel no pain    不覺得痛
• for one's pains    儘管費盡力氣
• go to great pains    費大力
• on pain of    違則以...處罰
• pain barrier    痛苦障限
• pain in the arse    討厭的人或事, 麻煩的事或人, 屁股疼
• pain in the neck    討厭的人或事, 麻煩的事或人, 脖子疼
• under pain of    違者則處以...的處罰

한국어 (Korean)
n. - 아픔, 노력
v. tr. - 괴롭히다, 비탄에 잠기게 하다
v. intr. - 아프다, 괴로워하다

idioms:

• be at pains to    애써서 ~ 하다
• go to great pains    ~하려고 매우 애쓰다
• under pain of    죽음을 당한다는 조건으로

日本語 (Japanese)
n. - 苦痛, 痛み, 骨折り, 陣痛, 苦しみ
v. - 苦痛を与える, 心痛させる, 困らせる, 痛む, 心配させる

idioms:

• be at/take pains    骨折っている
• feels no pain    酔っ払っている
• for one's pains    骨折り賃に, 骨折りがいもなく
• on/under pain of    ～の罰をもって
• pain barrier    苦痛障害
• pain in the arse/backside    泣きっ面に蜂
• pain in the neck    いやなこと
• referred pain    関連痛

العربيه (Arabic)
‏(الاسم) ألم, وجع, آلام الولادة والطلق (فعل) يؤلم, يوجع‏

עברית (Hebrew)
n. - ‮כאב, סבל, צער, צירי-לידה, מאמצים, טרחה, עונש‬
v. tr. - ‮ציער, גרם סבל, הכאיב‬
v. intr. - ‮הכאיב, סבל כאב‬