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What is pain and its classification

Setelah kuliah ini mahasiswa/ peserta mampu menjelaskan.


Apa itu nyeri, definisi nyeri. Konsekwensi dari nyeri yang tidak diobati. Pembagian dari nyeri Nyeri Nosisepsi Nyeri Inflamasi Nyeri Patologis Apa itu pain behavior (prilaku nyeri) Perbedaan ke tiga nyeri tsb diatas.

Before Eva was created from Adams rib, he was put into sleep

Anesthesia was the first applied science in the world

The Meaning of Pain


Derived from greek (poine) and latin (poena) signify a penalty or punishment
Pain is a sensation that; hurt discomfort distress agony Nyeri adalah suatu perasaan sensorik (inderawi) yang tidak menyenangkan.

Pain is a POISONS to our body


Poisons
mechanical thermal chemical electrical

Tissue damage Release of mediators


H , K , ATP, Prostaglandin, Bradikinin, Serotonin, Substance P, Histamine. Cytocaines

Stimulation of nociceptors

Transmission to CNS ACUTE PAIN


via afferent pathways
5

Consequences of Pain
Poor diagnosis and impending death Particularly when pain worsens Decreased autonomy Impaired physical and social function Decreased enjoyment and quality of life Challenges of dignity Threat of increased physical suffering

Relationship Between Pain, Sleep, and Anxiety / Depression


Pain

Anxiety & Depression

Functional impairment

Sleep disturbances

Nicholson and Verma. Pain Med. 2004;5 (suppl. 1):S9-S27

Unrelieved Pain can Lead to...

Insomnia

Anxiety

Depression

Anorexia

Immobility

HAROLD MERSKEY (psychiatrics) proposed definition of pain, which was accepted by IASP
(International Association for Study of Pain 1979)

PAIN IS AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE, OR DESCRIBED IN TERM OF SUCH DAMAGE Nyeri adalah perasaan sensorik dan emosional yang tidak menyenangkan akibat kerusakan jaringan yang nyata atau yang berpotensi rusak atau tergambarkan seperti adanya kerusakan tersebut.

The problem lies in the word unpleasant. Pain is more than unpleasant.

Definition Pain
Unpleasant sensory and emotional experience

- Associated with actual or


potential tissue damage

- or described in terms of such


damage. (IASP1979)

Two key points:

1.Unpleasant sensory. (physical)

2.Emotional experience. (psychological)

Scientific

Pain is unpleasant sensory and emotional experience

ascociated with actual tissue damage or Potential tissue damage or described in term of such damage.
(Merskey ,accepted by IASP 1979)

Clinical

Pain is whatever the experiencing person says. (Mc Caffery 1997) Pain is what ever the pat eint says
(Margo Mc Caffery, 1999)

Classification of Pain
Based on Duration: Acute and Chronic. Based on Clinical Context: Postsurgical Malignancy related Neuropathic Degenerative . Based on Organ Headache Pelvic pain Lowback pain
o Based on Pathophysiology :

- Nociceptive pain - Inflammatory pain - Pathological pain Neuropathic pain Dysfunctional pain

From neurobiological perspective pain can be divided into 3 types

PAIN
Nociceptive Pain Inflammatory Pain Pathological Pain
Neurophatic Pain Dysfunctional Pain
Woolf CJ. What is this thing called pain? J Clin Invest 2010; 120(11): 3742-3744

Pain is unpleasant sensory and emotional experience associated with.


Potential tissue damage or Actual tissue damage or Described in term of such damage.

Pain due to potential tissue damage . Nociceptive Due to noxious stimulus, to protect further damage. Pain E.g. touching something too hot, cold or sharp Adaptive and protective pain. Also called physiological pain withdrawal reflex.

WITHDRAWAL REFLEX

Pain is unpleasant sensory and emotional experience associated with


Potential tissue damage or Actual tissue damage or Described in term of such damage.

Associated with actual tissue damage and infiltration of immune cells. Inflammatory Pain To promote repaireng by pain hypersensitivity until healing occurs. Adaptive and protective pain Pain is one of the cardinal features of inflammatory.

INFLAMMATION PAIN
Pain may occur without noxious stimuli

Clinical Signs:

Calor (heat) Dolor (pain) Rubor (redness) Tumor (swelling) Functio laesa (loss of function)

Bimolecular changes in inflammation

Inflammatory Pain peripheral and central sensitiztion


Central sensitization

Spinal wind-up
Histamine, Leukotrienes, Norepinephrine, Cytokines, Bradykinin, Prostaglandins, Neuropeptides, 5-HT, Purines, H+/K+ions

Secondary hyperalgesia

Peripheral sensitization

Primary hyperalgesia

After the injury the NS will changed neuro-plasticity

ATP capsaicin heat

Tissue damage and pain in the periphery

Mechanical?

COX1/2
H+ PGs cold warm ATP

DRG

TRPVs
Na+, K+, Ca2+ channels

ASICs

EPs

TRPs

P2X

C-fibre

Sensitization
10 8 Pain Intensity 6 Allodynia 4 2 0 Stimulus Intensity normally painless stimuli

Inflammation pain
Hyperalgesia Normal Pain Response (Nociceptive pain)e Hyperalgesia heightened sense of pain to noxious stimuli Allodyniapain resulting from

Injury

Gottschalk A et al. Am Fam Physician. 2001;63:1979-84.

Allodynia means; stimulus which normally does not produce pain, now produce pain.
Take a shower normally does not produce pain, but after having sunburn. now produce pain,

A Nociceptive pain
Nociceptor Sensory neuron

Pain Autonomic response Withdrawal reflex

Noxious stimuli
Heat Cold Intense mechanical force Chemical irritants

Adaptive, high-threshold pain Early warning system (protective)

Spinal cord
Spontaneous pain Pain hypersensitivity

B Inflammatory pain
Inflammation
Peripheral Inflammation Positive symptoms Macrophage Mast cell Neutrophil Granulocyte

Adaptive, low-threshold pain Tenderness promotes repair (protective)

Tissue damage

Pain is unpleasant sensory and emotional experience associated with


Potential tissue damage or Actual tissue damage or Describe in term of such damage.

Maladaptive pain and non protective pain This is not a symptom or protective pain but a disease state. Pathological Pain
Due to damage of nervus system
Neuropathic Pain

No damage of the NS
Dysfunctional Pain

Panthom pain Herpetic neuralgia Trigemenial neuralgia

Fibromyalgia IBS Tension Headache

PHANTOM PAIN

Phantom Pain

phantom pain

Post Herpetic Neuralgia

Trigeminal Neuralgia

C Pathological pain
Peripheral Nerve damage

Spontaneous pain Pain hypersensitivity

Neuropathic pain
Neural lesion Positive and negative symptoms

Injury
Stroke Abnormal Central processing Spontaneous pain Pain hypersensitivity Maladaptive, low-threshold pain Disease state of nervous system

Normal peripheral Tissue and nerves

Dysfunctional Pain
No neural lesion No inflammation Positive symptoms Abnormal Central processing

By Analogy
If pain were a fire alarm, the nociceptive type would be activated appropriately only by the presence of intense heat, inflammatory pain would be activated by warm temperatures, and pathological pain would be a false alarm caused by malfunction of the system it self.

NYERI NOSISEPTIF

Api
NYERI INFLAMASI

Air Hangat

Tanpa rangsangan

NYERI PATOLOGIS

NOCICEPTIVE PAIN

Congenital insensitivity to pain


Penderita tidak dapat merasakan nyeri walaupun mengalami kerusakan jaringan. Dapat dilihat disini penderita mengalami amputasi jari-jari, lukaluka pada lutut dan mulut dan patah tulang
Penderita masih bisa tersenyum, walau memiliki banyak luka.

Either Nociceptive pain or Inflammatory pain has the same mechanism

Pain that started by activation of nociceptors

Nociceptive pain normal nociceptors Inflammatory pain nociceptors are more sensitive. *Spontan pain may occur

A Nociceptive pain
Nociceptor Sensory neuron

Pain Autonomic response Withdrawal reflex

Noxious stimuli
Heat Cold Intense mechanical force Chemical irritants

Adaptive, high-threshold pain Early warning system (protective)

Spinal cord
Spontaneous pain Pain hypersensitivity

B Inflammatory pain
Inflammation
Peripheral Inflammation Positive symptoms Macrophage Mast cell Neutrophil Granulocyte

Adaptive, low-threshold pain Tenderness promotes repair (protective)

Tissue damage

Mechanism of Nociceptive pain


generated from nociceptors . Pain started by activation of nociceptors nociception
A nociception consist of at least 5 components

Nociceptive Pain is pain that

1. TRANSDUCTION 2. CONDUCTION 3. TRANSMISSION 4. MODULATION 5. PERCEPTION

Mechanism of nociceptive pain

Neuron III

Persepsi

Transduksi Fisik

Transmisi
Conduction Suhu Modulasi

Neuron II

Neuron I
Kimiawi

Perception

Role of Modulation

Pain

Modulation
Descending Decending modulation Dorsal Horn Dorsal root ganglion

inhibitory
Ascending input

Conduction

Transduction
Spinothalamic tract
Peripheral nerve

transmission

Trauma
Peripheral nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

The role of modulation


Pain modulation can be triggered by the meaning of injury

Injury for merit

Injury for honor

Motivation to win

Motivation to win

Apapun yg dilakukan shg endorfin dpt dilepasakan menghilangkan nyeri. Seolah olah tanpa otak

Pada saat dilakukan rangsang noxious, banyak area-area di hemisfer yang teraktivasi, bukan hanya di somatosensory cortex (SSC). utamanya hemisfer kontralateral

Hal ini menujukkan Bawah nyeri memiliki Peran penting dalam Kehidupan, sehingga Seluruh bagian tubuh Harus diinformasikan

Pain has multidimensional experience


1. sensory discriminative
Identifies the intensity, type and location of pain

2. Affective motivational
Assessing the injury the meaning of injury

3. Emotional behavioral component


Attention, mood and behavioral due to pain

J. Loeser (1980)

PAIN

NOCICEPTION

Concept of nociception, pain, suffering and pain behavior

Behavioral characteristics
Facial expressions- grimace(meringis) clenched teeth, wrinkled forehead, crying Body movements -restlessness, immobilization, muscle tension, protective movement of body parts Social interaction- avoidance of conversation & contacts

Pain behavior

INFLAMMATORY PAIN

INFLAMMATION PAIN
Pain may occur without noxious stimuli

Clinical Signs:

Calor (heat) Dolor (pain) Rubor (redness) Tumor (swelling) Functio laesa (loss of function)

Bimolecular changes in inflammation

Five Cardinal Signs of Inflammation

HEAT REDNESS SWELLING

PAIN

LOSS OF FUNCTION

After tissue injured or inflamed a number of substances may be released peripherally

Painful stimulus

1 Prostaglandins
produced in response to tissue injury; increase sensitivity of nociceptor (pain) Dolor

Pain-sensitive tissue

Prostaglandin Mast cell Histamine Bradykinin Substance P

Substance P

Blood vessel

2 Nociceptor then releases

substance P, which dilates blood vessels and increases release of inflammatory mediators, such as Bradykinin (redness & heat) Rubor & Calor

3
Nociceptor

3 Substance P also promotes

degranulation of mast cells, which release Histamine (swelling) Tomor

Peripheral sensitization

Cell Membrane Phospholipids Phospholipase

Arachidonic Acid
COX-1 Prostaglandins Gastric Protection Kidney protection Platelet Hemostasis COX-2 Prostaglandins Acute Pain Inflammation Fever

COX-2 and peripheral sensitization


Tissue injury Neuron firing threshold decreases EP receptor PKA PKC

COX-2 expressed PGE2 Increased neuronal membrane excitability

NaV1.8 TTx-resistant sodium channel

Peripheral and Central Sensitization in Inflammatory Pain


Central sensitization

Spinal wind-up
Histamine, Leukotrienes, Norepinephrine, Cytokines, Bradykinin, Prostaglandins, Neuropeptides, 5-HT, Purines, H+/K+ions

Secondary hyperalgesia

Peripheral sensitization

Primary hyperalgesia

After the injury the NS will changed neuro-plasticity

Normal Situation
Low intensity Stimulation High intensity Stimulation

A fiber

High threshold A and c fiber nociceptors

Innocuous Sensation

Brief Pain

After Tissue Damage


Low threshold mechanorecept or A

Low intensity stimulation


Sensitized nociceptor A and C fibers

Hyperexcitable dorsal horn neuron

Pain

Inflammation Pain

HYPERALGESIA

ALLODYNIA

TOOTHACHE (Sakitnya Berdenyut)

denyut nadi p.d. kecilpun dapat menimbulkan rasa nyeri yg normall tidak

PATHOLOGICAL PAIN

PATHOLOGICAL PAIN MALADAPTIVE PAIN, can be; Neurophatic pain


Dysfunctional pain Is a disease of nervous system suffering, reduce QoL.

CRPS (Complex Regional Pain Syndrome)

DYSFUNCTIONAL PAIN
FIBROMYALGIA

C Pathological pain
Peripheral Nerve damage

Spontaneous pain Pain hypersensitivity

Neuropathic pain
Neural lesion Positive and negative symptoms

Injury
Stroke Abnormal Central processing Spontaneous pain Pain hypersensitivity Maladaptive, low-threshold pain Disease state of nervous system

Normal peripheral Tissue and nerves

Dysfunctional Pain
No neural lesion No inflammation Positive symptoms Abnormal Central processing
Modify by AHT

Perbandingan nyeri nosiseptif, nyeri inflamasi dan nyeri patologis


Pain

Nociceptive pain

No stimulus

Response duration

Pain
No stimulus

Inflammatory pain

Response duration

Pain
No stimulus

Neuropathic pain

Response duration

Modified by AHT