Pain

I Putu Pramana Suarjaya

Pain :unpleasant sensory & emotional

experience associated with actual

or potential tissue damage or
describe in terms of such damage

Nyeri Merupakan Pengalaman

Sensorik dan Emosional yang Tidak
Menyenangkan Akibat Adanya
Kerusakan / Ancaman Kerusakan
Jaringan

Pain
Always subjective
A sensation & unpleasant
physical & non physical component

Multidimensional :
Neurophysiologic
Biochemical
Psychologic
Ethnocultural
Cognitive
affective

Pain Mechanism
Series of complex neurophysiologic process

4 distinct components
:
-transduction
-transmission
-modulation
-perception

Brain

Pain Perception
Descending control
pathway from base
of brain

Encephalin
interneuron
Dorsal Root
Ganglion

Encephalin
interneuron
Dorsal
Horn

Spinal Cord

Nociceptor

Dorsal
Horn

Brainstem

Nociceptive
transmission
via ascending
pain pathways
(spinothalamic tract)

Dorsal Root
Ganglion

Nociceptor sensitization
sensitivity to norepinephrine
heat / cold, local ion fluxes
mechanical stimulation

Adapted from Goldstein A. Hospital Practice 1978 1:32

Spinal Cord

Nociceptor

Nociceptor
evoked
discharges

Pain Neurochemistry
Transmission via
spinothalamic
tract
to brain

Dorsal
Horn

Dorsal
root
ganglion

Ion
fluxes
(H+/ K+)
Prostaglandins

Tissue injury

Bradykinin

leukotrienes

Spinal Cord

Substance P
To brain
Histamine
Substance P, aspartate,
neurotensin, glutamate

Sensitized
nociceptor

Peripheral Nerve Physiology

Nociceptor (Pain
Receptor)
Detecting noxious stimuli
Screening impuls to CNS
No adaptation (protective effect)
Transduction
Mechanical, thermal, chemical
stimulus action potential
Hyperalgesia
Decreased Pain treshold
due to local release of
mediator

Allodynia
Pain sensation in response to
normally non painful stimuli

Transmission

Fast & Slow Pain

Fast pain
Short, well localized, stabbing sensation,
match to stimulus such as pinprick
Stimulation of small, myelinated A-delta
Slow Pain
Throbbing, burning, aching, poorly
localized
Continue after stimulus

Ascending Pain
Pathways

Class I, II III
neurons become
hyperexcitable

Dorsal Root
Dorsal
Root
Ganglion

To Brain

III II I

Corticospinal
Tract
Spinothalamic
Tract

A-Delta fibers:
Sharp, shooting pain
A-Delta and C fibers

C fibers:
Dull, aching
burning pain

Prolonged activation of primary afferent

nociceptor sensitize spinal chord neurons

Modulation of Nociception
Peripheral Modulation
Liberation & elimination neurotransmitter
sP, glutamate
Bradykinin, histamine prostaglandins, serotonin,
K , H+, lactic acid

Spinal Modulation
Excitatory
substance
Glu, aspartat, neuropep, sP
Inhibitory substance
GABA, glycine, enkephalins, endorphins,
norepinephrine, dopamine, adenosine

Supraspinal
Modulation
Descending inhibitory
tract
Cognitive Modulation
Ability to relate painful
experience
Only fixed number of impulse
reach cotical center
Neuroplasticity
Central sensitisation ->, functional
change in
Spinal cord processing

CNS Physiology
Dorsal Horn & ascending Nociceptive
pathway
Thalamus & Cerebral
Cortex
Gate Cells
Central
Sensitization

Pathways of Opioid
Activity
Brain

Pain Perception
Descending
impulse
from base
of brain

Afferent Descending
impulse
Periacqueductal neuron
from
from
Raphe
gray matter
dorsal
nucleus Opioid
Root
Periaventricular
agent-receptor
Ganglion
gray matter
binding site

Nucleus Raphe
Encephalin Magnus
interneuron
Dorsal
Horn

Brain
stem

Dorsal
Root
Ganglion

Neurotransmitter
Spinal Cord
Substance P
Nociceptor

Nociceptor
evoked
discharges

Adapted from Goldstein A. Hospital Practice 1978 1:32

Nociception
inhibited

Neuroreceptor

Brain

Pain Perception
Descending control
pathway from base
of brain

Encephalin
interneuron
Dorsal Root
Ganglion

Encephalin
interneuron
Dorsal
Horn

Spinal Cord

Nociceptor

Dorsal
Horn

Brainstem

Nociceptive
transmission
via ascending
pain pathways
(spinothalamic tract)

Dorsal Root
Ganglion

Nociceptor sensitization
sensitivity to norepinephrine
heat / cold, local ion fluxes
mechanical stimulation

Adapted from Goldstein A. Hospital Practice 1978 1:32

Spinal Cord

Nociceptor

Nociceptor
evoked
discharges

Sub-optimal pain management can

have serious consequences
Inadequate pain
management

Induction of
chronic pain

Acute postoperative pain

Clinical and
psychological changes

Decreased
mobilisation

Increased risk of
deep vein thrombosis, pulmonary embolism,
myocardial infarction and coronary ischaemia
Mortality/morbidity, longer hospital stay, re-admission, decreased quality of life,
decreased patient satisfaction and increased health costs
Ballantyne et al. Anesth Analg 1998;86:598;
Wu et al. Anesth Analg 2003;97:1078;
Pavlin et al. Anesth Analg 2002;95:627;
Anesthesiology 2004;100:1573;
Perkins et al. Anesthesiology 2000;93:1123

Classification of Pain
Duration
Acute
Chronic
Pathophysiology
Nociceptive
visceral
somatic
Neuropathic

Acute Pain
Well define tissue damage
Limited duration
Nociceptors return to
normal treshold

Chronic Pain
Persistent pain
May have both nociceptive &
neuropathic element
Often has no detectable pathology

TERIMA KASIH