CHRONIC PAIN GLOSSARY
PAIN

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Note: Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain.

Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause.

ALLODYNIA

Pain due to a stimulus which does not normally provoke pain.

Note: The term allodynia was originally introduced to separate from hyperalgesia and hyperesthesia, the conditions seen in patients with lesions of the nervous system where touch, light pressure, or moderate cold or warmth evoke pain when applied to apparently normal skin. Allo means "other" in Greek and is a common prefix for medical conditions that diverge from the expected. Odynia is derived from the Greek word "odune" or "odyne," which is used in "pleurodynia" and "coccydynia" and is similar in meaning to the root from which we derive words with - algia or -algesia in them. Allodynia was suggested following discussions with Professor Paul Potter of the Department of the History of Medicine and Science at The University of Western Ontario.

The words "to normal skin" were used in the original definition but later were omitted in order to remove any suggestion that allodynia applied only to referred pain. Originally, also, the pain-provoking stimulus was described as "non-noxious." However, a stimulus may be noxious at some times and not at others, for example, with intact skin and sunburned skin, and also, the boundaries of noxious stimulation may be hard to delimit. Since the Committee aimed at providing terms for clinical use, it did not wish to define them by reference to the specific physical characteristics of the stimulation, e.g., pressure in kilopascals per square centimeter. Moreover, even in intact skin there is little evidence one way or the other that a strong painful pinch to a normal person does or does not damage tissue. Accordingly, it was considered to be preferable to define allodynia in terms of the response to clinical stimuli and to point out that the normal response to the stimulus could almost always be tested elsewhere in the body, usually in a corresponding part. Further, allodynia is taken to apply to conditions which may give rise to sensitization of the skin, e.g., sunburn, inflammation, trauma.

It is important to recognize that allodynia involves a change in the quality of a sensation, whether tactile, thermal, or of any other sort. The original modality is normally non- painful, but the response is painful. There is thus a loss of specificity of a sensory modality. By contrast, hyperalgesia (q.v.) represents an augmented response in a specific mode, viz., pain. With other cutaneous modalities, hyperesthesia is the term which corresponds to hyperalgesia, and as with hyperalgesia, the quality is not altered. In allodynia the stimulus mode and the response mode differ, unlike the situation with hyperalgesia. This distinction should not be confused by the fact that allodynia and hyperalgesia can be plotted with overlap along the same continuum of physical intensity in certain circumstances, for example, with pressure or temperature.

See also the notes on hyperalgesia and hyperpathia.

ANALGESIA

Absence of pain in response to stimulation which would normally be painful.

Note: As with allodynia (q.v.), the stimulus is defined by its usual subjective effects.

ANESTHESIA DOLORASA

Pain in an area or region which is anesthetic.

CAUSALGIA

A syndrome of sustained burning pain, allodynia, and hyperpathia after a traumatic nerve lesion, often combined with vasomotor and sudomotor dysfunction and later trophic changes.

CENTRAL PAIN

Pain initiated or caused by a primary lesion or dysfunction in the central nervous system.

DYSESTHESIA

An unpleasant abnormal sensation, whether spontaneous or evoked.

Note: Compare with pain and with paresthesia. Special cases of dysesthesia include hyperalgesia and allodynia. A dysesthesia should always be unpleasant and a paresthesia should not be unpleasant, although it is recognized that the borderline may present some difficulties when it comes to deciding as to whether a sensation is pleasant or unpleasant. It should always be specified whether the sensations are spontaneous or evoked.

HYPERALGESIA

An increased response to a stimulus which is normally painful.

Note: Hyperalgesia reflects increased pain on suprathreshold stimulation. For pain evoked by stimuli that usually are not painful, the term allodynia is preferred, while hyperalgesia is more appropriately used for cases with an increased response at a normal threshold, or at an increased threshold, e.g., in patients with neuropathy. It should also be recognized that with allodynia the stimulus and the response are in different modes, whereas with hyperalgesia they are in the same mode. Current evidence suggests that hyperalgesia is a consequence of perturbation of the nociceptive system with peripheral or central sensitization, or both, but it is important to distinguish between the clinical phenomena, which this definition emphasizes, and the interpretation, which may well change as knowledge advances.

HYPERESTHESIA

Increased sensitivity to stimulation, excluding the special senses.

Note: The stimulus and locus should be specified. Hyperesthesia may refer to various modes of cutaneous sensibility including touch and thermal sensation without pain, as well as to pain. The word is used to indicate both diminished threshold to any stimulus and an increased response to stimuli that are normally recognized.

Allodynia is suggested for pain after stimulation which is not normally painful. Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms should be used wherever they are applicable.

HYPERPATHIA

A painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive stimulus, as well as an increased threshold.

Note:It may occur with allodynia, hyperesthesia, hyperalgesia, or dysesthesia. Faulty identification and localization of the stimulus, delay, radiating sensation, and after-sensation may be present, and the pain is often explosive in character. The changes in this note are the specification of allodynia and the inclusion of hyperalgesia explicitly. Previously hyperalgesia was implied, since hyperesthesia was mentioned in the previous note and hyperalgesia is a special case of hyperesthesia.

HYPOALGESIA

Diminished pain in response to a normally painful stimulus.

Note: Hypoalgesia was formerly defined as diminished sensitivity to noxious stimulation, making it a particular case of hypoesthesia (q.v.). However, it now refers only to the occurrence of relatively less pain in response to stimulation that produces pain. Hypoesthesia covers the case of diminished sensitivity to stimulation that is normally painful.

The implications of some of the above definitions may be summarized for convenience as follows:

Allodynia: lowered threshold: stimulus and response mode differ

Hyperalgesia: increased response: stimulus and response mode are the same

Hyperpathia: raised threshold: stimulus and response mode may be the increased response: same or different

Hypoalgesia: raised threshold: stimulus and response mode are the same lowered response:

The above essentials of the definitions do not have to be symmetrical and are not symmetrical at present. Lowered threshold may occur with allodynia but is not required. Also, there is no category for lowered threshold and lowered response - if it ever occurs.

HYPOESTHESIA

Decreased sensitivity to stimulation, excluding the special senses.

Note: Stimulation and locus to be specified.

NEURALGIA

Pain in the distribution of a nerve or nerves.

Note: Common usage, especially in Europe, often implies a paroxysmal quality, but neuralgia should not be reserved for paroxysmal pains.

NEURITIS

Inflammation of a nerve or nerves.

Note: Not to be used unless inflammation is thought to be present.

NEUROGENIC PAIN

Pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the peripheral or central nervous system.

NEUROPATHIC PAIN

Pain initiated or caused by a primary lesion or dysfunction in the nervous system.

Note: See also Neurogenic Pain and Central Pain. Peripheral neuropathic pain occurs when the lesion or dysfunction affects the peripheral nervous system. Central pain may be retained as the term when the lesion or dysfunction affects the central nervous system.

NEUROPATHY

A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy.

Note: Neuritis (q.v.) is a special case of neuropathy and is now reserved for inflammatory processes affecting nerves. Neuropathy is not intended to cover cases like neurapraxia, neurotmesis, section of a nerve, or transitory impact like a blow, stretching, or an epileptic discharge. The term neurogenic applies to pain due to such temporary perturbations.

NOCIEPTOR

A receptor preferentially sensitive to a noxious stimulus or to a stimulus which would become noxious if prolonged.

Note: Avoid use of terms like pain receptor, pain pathway, etc.

NOXIOUS STIMULUS

A noxious stimulus is one which is damaging to normal tissues.

Note: Although the definition of a noxious stimulus has been retained, the term is not used in this list to define other terms.

PAIN THRESHOLD

The least experience of pain which a subject can recognize.

Note: Traditionally the threshold has often been defined, as we defined it formerly, as the least stimulus intensity at which a subject perceives pain. Properly defined, the threshold is really the experience of the patient, whereas the intensity measured is an external event. It has been common usage for most pain research workers to define the threshold in terms of the stimulus, and that should be avoided. However, the threshold stimulus can be recognized as such and measured. In psychophysics, thresholds are defined as the level at which 50% of stimuli are recognized. In that case, the pain threshold would be the level at which 50% of stimuli would be recognized as painful. The stimulus is not pain (q.v.) and cannot be a measure of pain.

PAIN TOLERANCE LEVEL

The greatest level of pain which a subject is prepared to tolerate.

Note: As with pain threshold, the pain tolerance level is the subjective experience of the individual. The stimuli which are normally measured in relation to its production are the pain tolerance level stimuli and not the level itself. Thus, the same argument applies to pain tolerance level as to pain threshold, and it is not defined in terms of the external stimulation as such.

PARESTHESIA

An abnormal sensation, whether spontaneous or evoked.

Note: Compare with dysesthesia. After much discussion, it has been agreed to recommend that paresthesia be used to describe an abnormal sensation that is not unpleasant while dysesthesia be used preferentially for an abnormal sensation that is considered to be unpleasant. The use of one term (paresthesia) to indicate spontaneous sensations and the other to refer to evoked sensations is not favored. There is a sense in which, since paresthesia refers to abnormal sensations in general, it might include dysesthesia, but the reverse is not true. Dysesthesia does not include all abnormal sensations, but only those which are unpleasant.

PERIPHERAL NEUROGENIC PAIN

Pain initiated or caused by a primary lesion or dysfunction or transitory perturbation in the peripheral nervous system.

Peripheral neuropathic pain

Pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system.