Pain Lecture Nociceptic and Neuropathic

8/13/2019 Pain Lecture Nociceptic and Neuropathic

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PAIN

(NOCICEPTIC AND NEUROPATHIC)

Yudiyanta

Pain Sub-Dept. of Neurology GMU


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KUNJUNGAN POLIKLINIK SARAF RSS TH 2006

4957 (44%)

2850 (25%)

1731 (15%)

626 (6%) 451 (4%)217 (2%)

498 (4%)

0

1000

2000

3000

4000

5000

6000

Nyeri Stroke Epilepsi Vertigo Parkinson Hipertensi Lain-lain

Atralgia28%

Cefalgia

20%

Neuropati

9%

Myalgia

4%LBP39%


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Defining of Pain

Pain Experience

Pain is a personal, subjective experience that comprises :

Sensory-discriminative, Motivational-affective and Cognitive-evaluative dimensions

Ronald Melzack, Textbook of Pain 4th edition

?????

Catastrophization

An unpleasant sensory andemotional experienceassociated with actual or

potential tissue damage, ordescribed in terms of suchdamage.

International Association for the Study of Pain(IASP) 1994, Kyoto Protocol IASP 2008


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Classification of Pain

Physiologic / nociceptive:1

Pain arising from activation of nociceptors

Caused by mild and short noxious impulses which usually relieved without anymedication or mild analgesics

Example: Pinched, stung by mosquito

Inflammatory:2

Pain caused by injury to body tissues (musculoskeletal, cutaneus or visceral) Example: Pain due to inflammation, limb pain after fracture

Neuropathic:1

Pain arising as a direct consequence of a lesion or disease affecting the somatosensorysystem

Example: DPN, PHN

Psychogenic (functional):3

Pain due to abnormal responsiveness or function of the nervous system withoutneurologic deficit or peripheral abnormality.

Example: Fibromyalgia, irritable bowel syndrome


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fracture /

Postoperative

Ongoing or

impending injury

sprain

Inflamation /

Infection

Infiltrated or compressed

(tumors)

strangulated

(scar tissue)

Muscle Stretch

inflamed (infection )

Type or Category of Pain

3. Psychogenic

clear thatno somatic disorder

is present

1. Nociceptive-

Inflamatorik

Caused by activity

in neural pathwaysin response to potentially

tissue-damaging stimuli

2. Neuropathic

Initiated or caused by

primary lesion or

dysfunction

in the nervous sys.

4. Mixed type

Caused by acombination of both

primary injury or

secondary effects

The Assessment of the Patient with Pain, Steven Richeimer, M.D. Director USC Pain Management, USC Medical Center, Los Angeles, CA, USA, 2007

Myofascial pain


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The Continuum of Pain1


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Dorsal Horn

Dorsal root

ganglion

Peripheral sensory

Nerve fibers

A

A

C

Large

fibers

Small

fibers

There are Two Sensory Afferent Neurons

1. Large myelinated A fibers

Very fast conduction velocity

Respond to innocuous stimuli2. Small myelinated A & C unmyelinated fibers

Slow conduction velocity

Respond to noxious stimuli


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Small-fiber sensory Large-fiber sensory Autonomic

-Burning pain

-Allodinia-Hyperalgesia

-Hyperesthesia

-Paresthesia/dysesthesia

-Lancinating pain

-Loss of pain & temp.sensation

-Foot ulceration

-Loss of visceral pain

-Loss of vibration

-Loss of proprioception-Loss of reflexes

-Slowed NCV

-Heart rate abnormalities

-Postural hypotension-Abnormal sweating

-Gastroparesis

-Neuropathic diarrhea

-Impotence

-Retrograde ejaculation


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Nociceptive afferent fiber

Normal Nerve Impulses Leading to Pain

Noxious

stimuli

Descending

modulation

Ascending

input

Spinal cord

Perceived pain


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Nociception

Spinothalamictract

Peripheral

nerve

Dorsal Horn

Dorsal root

ganglion

Pain

Modulation

Transduction

Ascending

input

Descending

modulation

Peripheral

nociceptors

Trauma

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

Perception

Transmission


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Activation

External

Stimuli

Heat

Mechanical

Chemical

VR1

Ca2+

mDEG

P2X3

Generator potentials

action potentials

Voltage gated sodium channels

Pain and auto-sensitization

Woolf & Mitchel, 2001

Transduction

ATP

Na+

Modifikasi Meliala, 2003

ACTION POTENTIALACTION POTENTIAL

KERUSAKAN JARINGAN

INFLAMASI

SSA MI NOS

SENSITISASI

AKTIFASIECT. DISC.

Si-Na+

KORNU DORSALIS

PgB, 5HT, Adenosin

Pengalaman

Kognitif

Behaviour

Psikologik

Inhibisi

desendenOTAK

PAIN NO PAIN

R-NE


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Anger

Fear

Anxiety

Depression

Noxious Stimuli

NOCICEPTIVE

A

B

MELIALA 2004


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What is Inflammatory Pain?

Often classed along with acute pain as nociceptive, refers to the

spontaneous pain and tenderness felt when tissue is inflamed.

Pain caused by injury to body tissues (musculoskeletal, cutaneous or

visceral)

Painful region is typically localized at the site of injury often described as

throbbing, aching or stiffness .

Usually time-limited and resolves when damaged tissue heals (e.g. bone

fractures, burns and bruises)

Can also be chronic (e.g. osteoarthritis, rheumatoid arthritis)

Usually responsive to NSAIDs


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NOCICEPTIVE PAIN


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Prostaglandins produced

in response to tissueinjury; increase

sensitivity of nociceptor

(pain)

Nociceptor then releasessubstance P, which dilates

blood vessels and increases

release of inflammatory

mediators, such as Bradykinin

(redness & heat)

Substance P also promotes

degranulation of mast cells,

which release histamine

(swelling)

2

3

Pain-sensitive tissue

Painful stimulus

Prostaglandin

Substance P

Histamine

Mast cell

Blood

vessel

Bradykinin

Nociceptor

Substance P

2

3

1

Inflammation Tissue

1


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What is Neuropathic pain?

Definition:

Pain arising as a direct consequence of a lesion or disease affecting

the somatosensory NERVE system

Characterized by:

Pain often described as shooting, electric shock-like or burning.

The painful region may not necessarily be the same as the site of

injury.

Almost always a chronic condition (e.g. post herpetic neuralgia, poststroke pain)

Responds poorly to conventional analgesics


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IASP Classifications:Peripheral Neuropathic and Central Neuropathic Pain

Loeser JD, Treede RD. The Kyoto Protocol of IASP Basic Pain Terminology. Pain 2008;137:473-477.

Neuropathic painPain arising as a direct consequence of

a lesion or disease affecting the

somatosensory system

Peripheral neuropathic painPain arising as a direct consequence of


peripheral somatosensory system

Central neuropathic painPain arising as a direct consequence of


centralsomatosensory system


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Pathophysiology of Neuropathic Pain

NeP

Central mechanisms

Peripheral mechanisms

Peripheral Neuron

hyperexcitability

Loss of

inhibitory controls

Central Neuron

hyperexcitability

(central sensitization)

Abnormal

Discharges


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Peripheral Mechanism (Ectopic Discharges)

Nerve lesion induces hyperactivity due to changes in ion channel function

Ectopic discharges

Nerve lesion

Spinal cord


Descending

modulation

Ascending

input

Perceived pain


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Central Mechanism (Loss of inhibitory controls)

Loss of descending modulation causes exaggerated pain due to an imbalance

between ascending and descending signals


Noxious

stimuli

Ascending

input

Spinal cord

Loss of

descending

modulation

Exaggerated pain

perception


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Intact tactile fiber

Central Mechanism (Central sensitization)

After nerve injury, increased input to the dorsal horn can induce central

sensitization Perceived pain

Ascending

input

Descending

modulation

Nerve lesion


Tactile

stimuli

Perceived pain

(allodynia)

Ascending

input

Descending

modulation

Abnormal discharges induce central sensitization


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Development of Neuropathic Pain

Woolf and Mannion. Lancet 1999;353:1959-64

Neuropathic pain

Spontaneous pa in Stimu lus -evoked pa in

Mechanisms

Metabolic Traumatic

ToxicIschemic

Hereditary

Compression

Infectious

Immune-related

Syndrome

Symptoms

Pathophysiology

Etiology Nerve damage due to:


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The Impact of Neuropathic Pain

Neuropathic pain is widely prevalent & generally affects: 6.9% of people with chronic pain1

Up to 24% of people with diabetes2

Up to 50% of people over 50 who recently had herpes

zoster2

75% of people over 70 who have had herpes zoster3

Approximately 33% of cancer patients4

Approximately 4.5% of individuals over 30 following backinjury5

1. Zussman J, Young L. Clin Interv Aging2008;3(2):241-250.

2. Gauthier A et al. Epidemiol Infect 2009;137(1):38-47.

3. Khoromi et al. Pain 2007;130(1-2):66-75.4. Davis MP, Walsh D.Am J Hosp Palliat Care 2004;21(2):137-142.

5. Meyer-Rosberg K et al. Eur J Pain 2001;5(4):379-389.


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Signs and Symptoms of Neuropathic Pain

Delayed, explosive response to any painful stimulus Hyperpathia2

Increased pain sensitivity e.g. pinprick, cold, heat Hyperalgesia3

Painful in response to a non-nociceptive stimuluse.g. warmth, pressure, stroking

Allodynia3

Stimulus-evoked

symptoms

Abnormal, not unpleasant sensations e.g. tingling Parasthesias2

Abnormal unpleasant sensations

e.g. shooting, lancinating, burning Dysesthesias2

Persistent burning, intermittent shock-like or

lancinating pain Spontaneous pain1

Spontaneous symptoms

Descr ipt ion (example)Sign/Symptom

1. Baron. Clin J Pain. 2000;16:S12-S20.2. Merskey H et al. (Eds) In: Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 1994:209-212.3. Loeser JD, Treede RD. The Kyoto Protocol of IASP Basic Pain Terminology. Pain 2008;137:473-477


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Hyperalgesia & Allodynia

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

Injury

Pain

Intensity

10

8

6

4

2

0

Stimulus Intensity

Normal

Pain

Response

Allodynia

Hyperalgesia

Hyperalgesiaheightened

sense of pain to noxious

stimuli

Allodyniapain resulting

from normally painlessstimuli


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What is the Correlation Between Causes Muscular pain


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What is the Correlation Between Causes, Muscular pain,

Neuro-endocrine (HPA Axis) disorders and Psychological distress

Emotional, Environmental and Genetic Predisposition

Cortex-Limbic System- Hypocampus

Thalamus & Hypothalamus

Pituitary

Adrenal,

Thyroid

Perception

CRH, TRH, GhRH, PRF, GnRH

ACTH, TSH, GH, Prolactine, FCH-LH

Cortisone,Thyroid,

Prolactine, Estrogen, Progesterone

Neuro-hormonal Disfunction

Sympathetic Metabolic

PAIN

Muscle TraumaDorsal Horn


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NE5-HT (K l t l 2002)


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DORSAL HORN

NE5-HT

PAF

Spinal Cord

Periphery

STT

STT

Other

Dorsal

Horn

Neurons

Anterior

Horn

Neurons

25-HT3

mu

5-HTNE

NMDA

AMPA

NK1

Glu

SP

NKA

DorsalHorn

Neuron

2 5-HT1Amu

GABA

A/B

GABA

Inter-

Neuron

5-HT

NE

(Kanzler et al., 2002)

PAF


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PAIN ASSESSMENT


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The 3L Approach to Diagnosis

LISTEN

LOCATE LOOKNervous system

lesion / dysfunction

Sensory abnormalities,

pattern recognition

Patient verbal descriptors,

Q & A


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Pain Assessment Scales

Uni-Dimensional Scale Multi-Dimensional Scale

Only measures pain intensity

Appropriate for acute pain

The most common scale used inoutcome assessment (Analgesic

efficacy)

Both intensity (severity) and

unpleasantness (affective)

Appropriate for chronic pain Research /pathophysiology

Should be used in clinical

outcome assessment

Verbal Rating Scale (VRS)

None, mild, moderate, severe

Numeric Rating Scale (NRS)

Visual Analog Scale (VAS)

Pictorial Scale

McGill Pain Questionnaire (MPQ)

The Brief Pain Inventory (BPI)

The Memorial Pain Assessment Card


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Uni-Dimensional Pain Assessment Scales


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Photographic/Numeric Pain Scale


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Photographic/Numeric Pain Scale


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Multi-Dimensional Pain Assessment Scales

Modified


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Modified

McGill Pain

Questionnaire

71,4% Baik

28,6% Lumayan dan

sedang

(Meliala, 1999)

15 Minutes

Sensorik

Afektif

Evaluatif

Macam2IRN

INS


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Quicker and easier

Well established reliabilityin cancer, arthritis, andAIDs.

Sensory, affective andfunctional status

Useful for treatment

response Takes up to 15 min

Good choice for patientswith progressive disease

Worst

Least

Average

Right Now

Treatment

Relief

General Activity

Mood

Walking ability

Normal work

Relation with other people

Sleep

Enjoyment of life


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Rapid: Sensory and affective Reliable in Cancer patients Validated Pocket


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Patient Pain Diary

Morning Afternoon Evening Bedtime

Pain

Scale

10

5

0 Dose Dose


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ID PAIN : Screening tool to help differentiate

nociceptive from neuropathic pain

Neuropathic pain screening questionnaire

A multicenter study

Patients (N = 586) with non-headache chronic painA secondmulticenter study (N = 384) evaluated reliability and validity.

89-item questionnaire 6 items

ID Pain appeared to accurately indicate the presence of aneuropathic component of pain (c 74,2%)

Portenoy R et al. Curr Med Res Opin. 2006 Aug;22(8):1555-65.


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Mark Yes to the following items that describe your pain over the past week and

No to the ones that do not.

If patients have more than one painful area, they are to consider the one area that is most

relevant to them when answering the ID Pain questions.

Scoring was from1 to 5. If you score 2 or more, you may have nerve pain. Talk to your

doctor. Higher scores are more indicative of pain with a neuropathic component


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Location: Patient or nurse marks drawing

Intensity: Patient rates the pain. Scale Used:

Quality: Use patints words, e.g. prick, ache, burn, sharp, hot etc.

Onset, duration, variations, rhythms (spontaneus or evoked):

Manner of expressing pain:

What relieves the pain?

(Pain Behaviour)

What causes or increases the pain?


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What causes orincreases the pain?

Effect of pain: (Note decreased function, decreased quality of life)

Other comments:

Plan:

Accompanying symptoms (eg nausea)

Sleep

Appetite

Physical activity

Relation with others (eg irritability)

Emotion (eg anger, suicidal, crying)

Consentration

Other


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Current Medications

1. Dosage and pattern of use

2. Effectiveness

3. Drug tolerance


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Physical Examination

The history will often generate a differential diagnosis The physical exam will often lead to the selection of the primary

diagnosis, and occasionally a test will help to confirm thisdiagnosis

1. Mental status exam (facial expression)2. Vital signs

3. Inspection (body position, gait, redness, swelling)

4. Palpation & Musculoskeletal exam (atrophy, location

tenderness to pressure, mass, )5. Neurologic Examination (Sensory, Motor, Autonomic)


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NEUROLOGIC EXAMINATION

Possibility :

spinal cord compression,

nerve root lesions

peripheral nerve lesions

Sensory Exam.: numbness,

allodinia,

hyperalgesia

Motoric: fracture? Deep tendon reflexes

Sacral Reflexes

Di ti T ti


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Diagnostic TestingEx.: Diagnostic Test For Low Back Pain

Modality Accuracy Sensitivity Specivity% Agree with

Surgery

Large of Estimates

Clinical Exam 46-76 0.80 0.82

Radiography 34 - -

Myelography 71-91 0.67-0.95 0.76-0.95

CT or MRI 70-100 0.80-0.95 0.68-0.95

Discography 30 0.83 0.63-0.78

ENMG 78 0.66-0.72 -

Bone scans

Somato-sensory evoked potential testing (SSEP)

Quantitative Sensory Testing (QST)


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Psychological Evaluation

1. Mood disorder (50% chronic pain)2. Somatization

3. Secondary gain

4. Sleep and appetite disturbance

5. Loss of energy and libido6. Impaired concentration

7. Suicidal ideation

8. Impact of the pain on the patient day-to-day activities

work & finances personal relationships

recreational pursuits

CONCLUSIONS


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You are the only one who knows how much pain you are feeling

All patients require pain assessment

it is as essential as the other vital signs!(Helen Greene)

If You Dont Measure It, You Cant Improve It(Field et al, 1997)

CONCLUSIONS


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Pain Lecture Nociceptic and Neuropathic

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