What is Pain and Classification of Pain_AHT_26 Februari 2013

Slide pidato purna bakti

What is pain and its classification

1Setelah kuliah ini mahasiswa/ peserta mampu menjelaskan.Apa itu nyeri, definisi nyeri.Konsekwensi dari nyeri yang tidak diobati.Pembagian dari nyeriNyeri NosisepsiNyeri InflamasiNyeri Patologis Apa itu pain behavior (prilaku nyeri) Perbedaan ke tiga nyeri tsb diatas.2

Anesthesia was the first applied science in the worldBefore Eva was created from Adams rib, he was put into sleep3

The Meaning of Pain Derived from greek (poine) and latin (poena) signify a penalty or punishmentPain is a sensation that; hurt discomfort distress agony Nyeri adalah suatu perasaan sensorik (inderawi) yang tidak menyenangkan.45Poisonsmechanical thermal chemical electricalTissue damage Release of mediatorsH , K , ATP, Prostaglandin, Bradikinin, Serotonin, Substance P, Histamine. CytocainesStimulation of nociceptors Transmission to CNS ACUTE PAIN via afferent pathways Pain is a POISONS to our body5Consequences of Pain Poor diagnosis and impending deathParticularly when pain worsensDecreased autonomyImpaired physical and social functionDecreased enjoyment and quality of lifeChallenges of dignityThreat of increased physical sufferingRelationship Between Pain, Sleep, and Anxiety / DepressionNicholson and Verma. Pain Med. 2004;5 (suppl. 1):S9-S27PainSleepdisturbancesAnxiety &DepressionFunctional impairmentUnrelieved Pain can Lead to...

InsomniaAnorexiaAnxietyDepressionImmobilityHAROLD 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 DAMAGENyeri 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 experienceAssociated 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) 1986ScientificPain is unpleasant sensory and emotional experience ascociated with actual tissue damage orPotential tissue damage ordescribed in term of such damage. (Merskey ,accepted by IASP 1979)

ClinicalPain is whatever the experiencing person says. (Mc Caffery 1997)Pain is what ever the pat eint says (Margo Mc Caffery, 1999)Definition of Pain1111

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 Based on Pathophysiology : - - Nociceptive pain - Inflammatory pain - Pathological pain Neuropathic pain Dysfunctional painFrom neurobiological perspective pain can be divided into 3 typesPAINNociceptive PainInflammatory PainPathological PainNeurophatic Pain Dysfunctional PainWoolf CJ. What is this thing called pain? J Clin Invest 2010; 120(11): 3742-3744 13Nociceptive PainPain due to potential tissue damage .Due to noxious stimulus, to protect further damage.E.g. touching something too hot, cold or sharpAdaptive and protective pain.Also called physiological pain withdrawal reflex.Pain is unpleasant sensory and emotional experience associated with. Potential tissue damage orActual tissue damage orDescribed in term of such damage. 14

WITHDRAWAL REFLEXInflammatory PainAssociated with actual tissue damage and infiltration of immune cells. To promote repaireng by pain hypersensitivity until healing occurs.Adaptive and protective painPain is one of the cardinal features of inflammatory.Pain is unpleasant sensory and emotional experience associated with Potential tissue damage orActual tissue damage orDescribed in term of such damage. 16

INFLAMMATION PAINClinical Signs:Calor (heat)Dolor (pain)Rubor (redness)Tumor (swelling)Functio laesa (loss of function)Bimolecular changes in inflammationPain may occur without noxious stimuli

Inflammatory Pain peripheral and central sensitiztionPrimary hyperalgesiaPeripheral sensitizationSecondary hyperalgesiaSpinal wind-upInflammatory mediatorsCentral sensitizationCNSHistamine, Leukotrienes, Norepinephrine, Cytokines, Bradykinin, Prostaglandins, Neuropeptides, 5-HT, Purines, H+/K+ions

After the injury the NS will changed neuro-plasticity18TRPVsASICsTRPsP2XcapsaicinH+PGsEPscoldwarmATPCOX1/2ATPheatsensitize, activateNa+, K+, Ca2+channelsDRGC-fibreTissue damage and pain in the peripheryMechanical?19SensitizationGottschalk A et al. Am Fam Physician. 2001;63:1979-84. InjuryPain Intensity10

8

6

4

2

0Stimulus IntensityNormalPainResponse(Nociceptive pain)eAllodyniaHyperalgesiaHyperalgesiaheightened sense of pain to noxious stimuliAllodyniapain resulting fromnormally painless stimuliInflammation pain20

In the normal pain response, pain intensity increases as the stimulus intensity increases.1 Sensitization following injury causes the curve to shift to the left, resulting in hyperalgesia, in which noxious stimuli cause greater and more prolonged pain, as well as allodynia, in which pain results from normally painless stimuli.1 Sensitization is the manifestation of neuronal plasticity.2

Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. Am Fam Physician. 2001;63:1979-1984.Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000;288:1765-1768.

2:19802:19804:1768

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

Spinal cordAdaptive, high-threshold painEarly warning system (protective)Adaptive, low-threshold painTenderness promotes repair (protective)PeripheralInflammationPositivesymptomsNociceptorSensory neuronHeatColdIntense mechanical forceChemical irritantsMacrophageMast cellNeutrophilGranulocyteInflammationTissue damageNoxious stimuliInflammatory painNociceptive painABPain Autonomic responseWithdrawal reflexSpontaneous painPain hypersensitivity

22Pathological PainMaladaptive pain and non protective painThis is not a symptom or protective pain but a disease state.Due to damage of nervus systemNeuropathic PainDysfunctional PainNo damage of the NSPanthom painHerpetic neuralgiaTrigemenial neuralgiaFibromyalgiaIBS Tension HeadachePain is unpleasant sensory and emotional experience associated withPotential tissue damage orActual tissue damage orDescribe in term of such damage. 23PHANTOM PAIN phantom pain

Phantom Pain

Post Herpetic Neuralgia

Trigeminal Neuralgia

AbnormalCentral processingMaladaptive, low-threshold painDisease state of nervous systemPeripheralNerve damageNeural lesionPositive and negativesymptomsNo neural lesionNo inflammationPositive symptomsDysfunctional PainNeuropathic painPathological painCSpontaneous painPain hypersensitivity

InjuryAbnormalCentral processingSpontaneous painPain hypersensitivityNormal peripheralTissue and nervesStroke 28By AnalogyIf 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.29

NYERI NOSISEPTIFNYERI INFLAMASI

NYERI PATOLOGIS?

Air HangatApiTanpa rangsangan NOCICEPTIVE PAINCongenital insensitivity to pain

Penderita tidak dapat merasakan nyeri walaupun mengalami kerusakan jaringan.Dapat dilihat disini penderita mengalami amputasi jari-jari, luka-luka pada lutut dan mulut dan patah tulangPenderita masih bisa tersenyum, walau memiliki banyak luka. Pain that started by activation of nociceptorsNociceptive pain normal nociceptorsInflammatory pain nociceptors are more sensitive. *Spontan pain may occur

Either Nociceptive pain or Inflammatory pain has the same mechanism 33

Spinal cordAdaptive, high-threshold painEarly warning system (protective)Adaptive, low-threshold painTenderness promotes repair (protective)PeripheralInflammationPositivesymptomsNociceptorSensory neuronHeatColdIntense mechanical forceChemical irritantsMacrophageMast cellNeutrophilGranulocyteInflammationTissue damageNoxious stimuliInflammatory painNociceptive painABPain Autonomic responseWithdrawal reflexSpontaneous painPain hypersensitivity

34Nociceptive Pain is pain that generated from nociceptors . Pain started by activation of nociceptors nociception A nociception consist of at least 5 components

1. TRANSDUCTION 2. CONDUCTION 3. TRANSMISSION 4. MODULATION 5. PERCEPTIONMechanism of Nociceptive pain35

FisikSuhuKimiawiTransduksiConductionModulasiTransmisiPersepsiNeuron INeuron IINeuron IIIMechanism of nociceptive pain 363636

Role of Modulation SpinothalamictractPeripheralnerveDorsal HornDorsal root ganglionPainModulation

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

transmission ConductionDecendinginhibitory38

Injury for meritThe role of modulationPain modulation can be triggered by the meaning of injury39

Injury for honor

Motivation to win42

Motivation to win

Apapun yg dilakukan shg endorfin dpt dilepasakan menghilangkan nyeri.Seolah olah tanpa otak 44

Pada saat dilakukan rangsang noxious, banyak area-area di hemisfer yang teraktivasi, bukan hanya di somatosensory cortex (SSC).utamanya hemisferkontralateralHal ini menujukkanBawah nyeri memiliki Peran penting dalam Kehidupan, sehingga Seluruh bagian tubuhHarus diinformasikan

Pain has multidimensional experiencesensory discriminativeIdentifies the intensity, type and location of painAffective motivational Assessing the injury the meaning of injuryEmotional behavioral componentAttention, mood and behavioral due to pain46J. Loeser (1980)Concept of nociception, pain, suffering and pain behavior P A I NSUFFERINGPAIN BEHAVIOR NOCICEPTIONBehavioral characteristicsFacial expressions- grimace(meringis) clenched teeth, wrinkled forehead, cryingBody movements -restlessness, immobilization, muscle tension, protective movement of body partsSocial interaction- avoidance of conversation & contactsPain behavior

INFLAMMATORY PAIN

INFLAMMATION PAINClinical Signs:Calor (heat)Dolor (pain)Rubor (redness)Tumor (swelling)Functio laesa (loss of function)Bimolecular changes in inflammationPain may occur without noxious stimuli

Five Cardinal Signs of Inflammation HEAT REDNESS SWELLING PAIN LOSS OF FUNCTION After tissue injured or inflameda number of substances may be released peripherallyProstaglandins produced in response to tissue injury; increase sensitivity of nociceptor (pain) DolorNociceptor then releases substance P, which dilates blood vessels and increases release of inflammatory mediators, such as Bradykinin (redness & heat)Rubor & CalorSubstance P also promotes degranulation of mast cells, which release Histamine (swelling) Tomor123

Pain-sensitive tissuePainful stimulusProstaglandinSubstance PHistamineMast cellBlood vesselBradykininNociceptorSubstance P231Peripheral sensitization58Cell Membrane PhospholipidsArachidonic AcidPhospholipaseProstaglandinsProstaglandins Gastric Protection Kidney protection

Platelet HemostasisAcute Pain Inflammation FeverCOX-2 COX-159Tissue trauma sets off a cascade leading to the development of algesic substances that activate and sensitive peripheral nociceptors leading to the influx of acute pain signals to the CNS.Fortunately, the cyclooxygenase pathways involved with pain both peripherally and centrally are the COX-2 and COX-3(acetaminophen). The peripheral inflammatory COX pathways are chiefly COX-2.The primary incentive for the drug industry to develop the COX-2 was to avoid the huge morbidity and mortality related to the upper GI problems associated with the chronic use of non-specific COX inhibitors. The fact that the COX-2 inhibitors are an even better solution to the anti-platelet problem is a coincidental winfall for the acute post-operative pain patient, where the market is relatively small compared to the arthritic patient population.COX-2 and peripheral sensitizationEPreceptorPKA

PKCIncreased neuronal membrane excitabilityPGE2NaV1.8TTx-resistantsodium channel

Neuronfiring thresholddecreasesTissue injuryCOX-2 expressedP60Central sensitisation?RMP = resting membrane potentialSequence of events : phosphorylation of TTX-resistant sodium channel opens channel and allows Na+ influx, increased Na+ influx leads to increased RMP, which then in turn decreases the neuron firing threshold making the neuron more sensitive to stimulations.

Peripheral and Central Sensitization in Inflammatory PainPrimary hyperalgesiaPeripheral sensitizationSecondary hyperalgesiaSpinal wind-upInflammatory mediatorsCentral sensitizationCNSHistamine, Leukotrienes, Norepinephrine, Cytokines, Bradykinin, Prostaglandins, Neuropeptides, 5-HT, Purines, H+/K+ions

After the injury the NS will changed neuro-plasticity61Normal SituationCNS Dorsal Horn CellInnocuous SensationPNSLow intensity StimulationHigh intensity StimulationHigh threshold A and c fiber nociceptorsBrief Pain AfiberAfter Tissue DamagePNSCNSLow threshold mechanoreceptor ASensitized nociceptor A and C fibersHyperexcitable dorsal horn neuronPainLow intensity stimulationHYPERALGESIA

Inflammation PainALLODYNIATOOTHACHE (Sakitnya Berdenyut)

denyut nadi p.d. kecilpun dapat menimbulkan rasa nyeri yg normall tidakPATHOLOGICAL PAINPATHOLOGICAL PAIN MALADAPTIVE PAIN, can be; Neurophatic pain Dysfunctional pain Is a disease of nervous system suffering, reduce QoL.

CRPS (Complex Regional Pain Syndrome)DYSFUNCTIONAL PAINFIBROMYALGIA

AbnormalCentral processingMaladaptive, low-threshold painDisease state of nervous systemPeripheralNerve damageNeural lesionPositive and negativesymptomsNo neural lesionNo inflammationPositive symptomsDysfunctional PainNeuropathic painPathological painCSpontaneous painPain hypersensitivity

InjuryAbnormalCentral processingSpontaneous painPain hypersensitivityNormal peripheralTissue and nervesStrokeModify by AHT70

Perbandingan nyeri nosiseptif, nyeri inflamasi dan nyeri patologisNociceptivepainInflammatorypainNeuropathicpainNo stimulusNo stimulusNo stimulusResponsedurationResponsedurationResponsedurationPainPainPainModified by AHT71Thank youvery much72