The following pain terminology is updated from "Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994.
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Changes in the 2011 List
The work of the Task Force on Taxonomy in the era of 1979 to 1994 has been continued by the Committee on Taxonomy that has worked to update both pain terms and the classification of pain syndromes. All of the terms have been carefully reviewed and their utility assessed in reference to new knowledge about both clinical and basic science aspects of pain. The Committee conducted its business primarily by e-mail, but face-to-face meetings were held at each of the annual Congresses of IASP. We now present the 2011 version of IASP Pain Terminology. Members of the Taxonomy Committee in this era included: David Boyd, Michael Butler, Daniel Carr, Milton Cohen, Marshall Devor, Robert Dworkin, Joel Greenspan, Troels Jensen, Steven King, Martin Koltzenburg, John Loeser, Harold Merskey, Akiko Okifuji, Judy Paice, Jordi Serra, Rolf-Detlef Treede, and Alain Woda. The Chair would like to acknowledge the continuous contributions that Harold Merskey has made to taxonomy since the founding of IASP. As stated in prior publications of the IASP taxonomy, we do not see this listing of terms as immutable. As we learn more about pain, we will need to update terminology.
John D. Loeser, M.D.
Chair, IASP Terminology Working Group
Changes in the 1994 List
There was substantial correspondence from 1986 to 1993 among members of the Task Force and other colleagues. The previous definitions all remain unchanged, except for very slight alterations in the wording of the definitions of Central Pain and Hyperpathia. Two new terms have been introduced here: Neuropathic Pain and Peripheral Neuropathic Pain.
The terms Sympathetically Maintained Pain and Sympathetically Independent Pain have also been employed; however, these terms are used in connection with syndromes 1–4 and 1–5, now called Complex Regional Pain Syndromes, Types I and II. These were formerly labeled Reflex Sympathetic Dystrophy and Causalgia, and the discussion of Sympathetically Maintained Pain and Sympathetically Independent Pain is found with those categories.
Changes have been made in the notes on Allodynia to clarify the fact that it may refer to a light stimulus on damaged skin, as well as on normal skin. Also, in the tabulation of the implications of some of the definitions, the words lowered threshold have been removed from the features of Allodynia because it does not occur regularly. Small changes have been made to better describe Hyperpathia in the definition and note. A sentence has been added to the note on Hyperalgesia to refer to current views on its physiology, although as with other definitions, that for Hyperalgesia remains tied to clinical criteria. Last, the note on neuropathy has been expanded.
Introduction to the 1986 List
A list of pain terms was first published in 1979 (Pain 1979;6:249–52). Many of the terms were already established in the literature. One, allodynia, quickly came into use in the columns of Pain and other journals. The terms have been translated into Portuguese (Rev Bras Anest 1980;30(5):349–51), into French (H. Dehen, Lexique de la douleur, La Presse Medicale
PAIN TERMS and Definitions
An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.
Six key notes and etymology:
- Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
- Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
- Through their life experiences, individuals learn the concept of pain.
- A person’s report of an experience as pain should be respected.
- Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
- Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.
Etymology: Middle English, from Anglo-French peine (pain, suffering), from Latin poena (penalty, punishment), in turn from Greek poine (payment, penalty, recompense).
A central change in the new definition, compared to the 1979 version, is replacing terminology that relied upon a person’s ability to describe the experience to qualify as pain. The old definition read: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” This wording was interpreted as excluding infants, elderly people, and others – even animals -- who could not verbally articulate their pain, said Dr. Jeffrey Mogil, Director of the Alan Edwards Center for Research on Pain, McGill University and member of the Task Force.
Pain due to a stimulus that does not normally provoke pain.
Note: The stimulus leads to an unexpectedly painful response. This is a clinical term that does not imply a mechanism. Allodynia may be seen after different types of somatosensory stimuli applied to many different tissues.
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, or 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 nonpainful, 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.
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.
Pain in an area or region which is anesthetic.
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.
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.
Increased pain from a stimulus that normally provokes pain.
Note: Hyperalgesia reflects increased pain on suprathreshold stimulation. This is a clinical term that does not imply a mechanism. 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. Hyperalgesia may be seen after different types of somatosensory stimulation applied to different tissues.
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.
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 aftersensation may be present, and the pain is often explosive in character.
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.
Decreased sensitivity to stimulation, excluding the special senses.
Note: Stimulation and locus to be specified.
Multimodal treatment provided by a multidisciplinary team collaborating in assessment and treatment using a shared biopsychosocial model and goals. For example: the prescription of an anti-depressant by a physician alongside exercise treatment from a physiotherapist, and cognitive behavioral treatment by a psychologist, all working closely together with regular team meetings (face to face or online), agreement on diagnosis, therapeutic aims and plans for treatment and review.
Multimodal treatment provided by practitioners from different disciplines. For example: the prescription of an anti-depressant by a physician alongside exercise treatment from a physiotherapist, and cognitive behavioral treatment by a psychologist, all the professions working separately with their own therapeutic aim for the patient and not necessarily communicating with each other.
The concurrent use of separate therapeutic interventions with different mechanisms of action within one discipline aimed at different pain mechanisms. For example: the use of pregabalin and opioids for pain control by a physician; the use of NSAID and orthosis for pain control by a physician.
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.
Inflammation of a nerve or nerves.
Note: Not to be used unless inflammation is thought to be present.
Pain caused by a lesion or disease of the somatosensory nervous system.
Note: Neuropathic pain is a clinical description (and not a diagnosis) which requires a demonstrable lesion or a disease that satisfies established neurological diagnostic criteria. The term lesion is commonly used when diagnostic investigations (e.g. imaging, neurophysiology, biopsies, lab tests) reveal an abnormality or when there was obvious trauma. The term disease is commonly used when the underlying cause of the lesion is known (e.g. stroke, vasculitis, diabetes mellitus, genetic abnormality).
Somatosensory refers to information about the body per se including visceral organs, rather than information about the external world (e.g., vision, hearing, or olfaction). The presence of symptoms or signs (e.g., touch-evoked pain) alone does not justify the use of the term neuropathic. Some disease entities, such as trigeminal neuralgia, are currently defined by their clinical presentation rather than by objective diagnostic testing. Other diagnoses such as postherpetic neuralgia are normally based upon the history. It is common when investigating neuropathic pain that diagnostic testing may yield inconclusive or even inconsistent data. In such instances, clinical judgment is required to reduce the totality of findings in a patient into one putative diagnosis or concise group of diagnoses.
Pain caused by a lesion or disease of the central somatosensory nervous system. See neuropathic pain note.
Pain caused by a lesion or disease of the peripheral somatosensory nervous system. See neuropathic pain note.
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.
The neural process of encoding noxious stimuli.
Note: Consequences of encoding may be autonomic (e. g. elevated blood pressure) or behavioral (motor withdrawal reflex or more complex nocifensive behavior). Pain sensation is not necessarily implied.
A central or peripheral neuron of the somatosensory nervous system that is capable of encoding noxious stimuli.
Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.
Note: This term is designed to contrast with neuropathic pain. The term is used to describe pain occurring with a normally functioning somatosensory nervous system to contrast with the abnormal function seen in neuropathic pain.
An actually or potentially tissue-damaging event transduced and encoded by nociceptors.
A high-threshold sensory receptor of the peripheral somatosensory nervous system that is capable of transducing and encoding noxious stimuli.
Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.
Note: Patients can have a combination of nociceptive and nociplastic pain
A stimulus that is damaging or threatens damage to normal tissues.
The minimum intensity of a stimulus that is perceived as painful.
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.
The maximum intensity of a pain-producing stimulus that a subject is willing to accept in a given situation.
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.
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 that are unpleasant.
Increased responsiveness of nociceptive neurons to their normal input, and/or recruitment of a response to normally subthreshold inputs.
Note: Sensitization can include a drop in threshold and an increase in suprathreshold response. Spontaneous discharges and increases in receptive field size may also occur. This is a neurophysiological term that can only be applied when both input and output of the neural system under study are known, e.g., by controlling the stimulus and measuring the neural event. Clinically, sensitization may only be inferred indirectly from phenomena such as hyperalgesia or allodynia.
Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.
Note: See note for sensitization and nociceptive neuron above. This may include increased responsiveness due to dysfunction of endogenous pain control systems. Peripheral neurons are functioning normally; changes in function occur in central neurons only.
Increased responsiveness and reduced threshold of nociceptive neurons in the periphery to the stimulation of their receptive fields.
Note: See note for sensitization above.
Single therapeutic intervention directed at a specific pain mechanism or pain diagnosis. For example: the application of exercise treatment by a physiotherapist.
Note: An asterisk (*) indicates that the term is either newly introduced or the definition or accompanying note has been revised since the 1994 publication.
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: increased response - Stimulus and response mode may be the same or different
Hypoalgesia: Raised threshold: lowered response - Stimulus and response mode are the same
Note: 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.