Introduction To Pain: Makassar

Introduction to
Pain
Andi Husni TANRA
Professor of Anesthesiology
Department of Anesthesiology, IC and Pain
Management
Faculty of Medicine Hasanuddin University
Makassar
Before Eva was created from

Adams rib, he was put into sleep
Anesthesia was the

first
applied science in
What is pain?
Tissue damage
Stimulation of nociceptors
How do we feel
pain?
In normal situation!
Pain
Percepti
on
Transmissio
n
Modulation
Conduction
Noxious
stimulus
Transductio
Stimulate
n
Nociceptor
s
Regarding to the function of pain.

TWO KINDS OF PAIN
*Good Pain,
is an alarm symptom, tell us that

something wrong in our body Acute Pain, pain with
nociception (nociceptive pain). alarm protection.
Disini nyeri seperti bel rumah bunyi kl ada
tamu
*Bad pain,
is a disease entity, no nociception,

nothing wrong but patient feel severe pain
makes patient suffering Chronic Pain.
Disini nyeri seperti bel rumah yg korsleting
tidak ada tamu tapi bel rumah bunyi terus.
The word pain

derives from latin
word poena
meaningpunish
ment.
congenital insensitivity to pain ( chennelopath
CHRONIC PAIN vs ACUTE PAIN

Chronic pain
is misleading or over
simplistic. The key distinction between
acute & chronic is not the DURATION of
pain, but
chronic pain is pain that

PERSIST
BEYOND HEALING
BEYOND NOCICEPTION
BEYOND EXPECTION
DIFFICULT TO TREAT.
(symptom is disproportionate)
NO BIOLOGICAL MEANING.
IT CAUSED SUFFERING AND BEHAVIOR
CHANGES Bad Pain
Phantom Limb Pain

After limb amputation
Two type of pain syndrome
Stump pain
Phantom pain
The incidence of phantom pain
varies from 50% - 85%
About 40% of amputees having

severe phantom pain
Allodynia
Hyperalgesia
Post Herpetic
Neuralgia
ACUTE PAIN
Acute pain is pain that
Associated with tissue damage or
nociception.
Has biological meaning.
Has tendency to recover as nociception is
vanished.
Symptom is slightly proportionate.
It caused protection for further damage
Good Pain
Prototipe dari acute pain
postoperative pain
Clinical Features
of Postoperative Pain
ALLODYNIA
HYPERALGESIA
PATHOPHYSIOLOGICAL PAIN
(CLINICAL PAIN)
Vanished after
healing process
finished
So pain, between acute &

chronic pain is absolutely
different ;
Different
Different
Different
Different
in
in
in
in
etiology
pathophysiology
diagnosis
treatment
Chronic pain is not prolongation of

acute pain
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 adanya kerusakan jaringan
yang nyata atau yang berpotensi rusak atau
tergambarkan seperti kerusakan tersebut.
The problem lies in the word unpleasant.

Pain is more than unpleasant.
The great merits of this

definition
1.
Pain is unpleasant sensory and unpleasant

emotional experience. Kata tidak
menyenangkan harus ada nyeri
2.
Pain usually associated with actual tissue

damage Nociceptive pain or acute pain
PAIN WITH NOCICEPTION
3.
Pain may occur with potential tissue damage

(noxious stimulus) PHYSIOLOGICAL PAIN
withdrawal- reflex.
4.
Pain is described in term of such damage,

although nothing wrong in his/her body but
patient feel severe pain, PAIN WITHOUT
NOCICEPTION CHRONIC PAIN
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 Pathophysiological
-Mechanism : - Nociceptive
pain
- Neuropathic pain
Most Accepted
Classification:
Nociceptive Pain is pain that

generated from nociceptors.
Nyeri yang dibangkitkan oleh nosiseptor
1. NOCICEPTORS
What is a nociceptor?
reseptor nyeri
Nociceptors are peripheral sensory
neurons that respond selectively to
noxious stimuli (Stimulus kuat).
Or A number of receptors/channels that
sense damage
VR1 - vanilloid receptor family
ASICs - respond to low pH
P2X receptors - respond to ATP
TRPs receptors respond temp.
Chemical sensors - prostaglandins,
Diciptakan Tuhan guna melindungi diri kita
dari bahaya.
2. SENSORY NERVE
AFFERENT
Sensory Nerve
Afferent
Sensory afferent
n.f. connecting
receptors to the
CNS
(Centripetal)
Motor afferent
n.f. is connecting
CNS to muscle or
gland
(centrifugal).
Anatomy of peripheral sensory

nerve fibers
Two distinct responses to a noxious

stimulus FIRST PAIN and SECOUND PAIN
A
Fiber
First pain: sharp and

pricking, well-localised
and brief. Responded
by mechanoreceptors ,
conveyed by Ad fiber.
First Pain
Secound
Pain
C Fiber
Modified by AHT
Second pain: dull and

diffuse and prolonged
. Responded by
polimodal nociceptors ,
conveyed by C fiber
The Role of A fiber

Although in normal condition A fiber does not
response to noxious stimuli, but it plays a big
role in NORMAL SENSATION.
Without A fiber, any noxious stimuli will perceive

as BURNING PAIN (TN, HZ)
Role of nociceptors
and primary
afferent neurons
are:
1.TRANSDUCTION
2. CONDUCTION
TRANSDUCTION
Process whereby
noxious stimuli
are translated into
electrical activity
Heat
at the sensory
endings of nerve
TRANSDUCTION
Pressure
Chemical
3. MODULATION in DHN
Dorsal Horn neurons of SC

Plays a big role in pain perception
Is the first gate to control pain.
Nociception (Pain) is born in DHN
Lehmann, K. A.: From the first stimulus to pain memory. UN. Cologne, 2000
28
Peranan Modulasi dalam

kehidupan
Peran modulasi inilah yang membuat persepsi
nyeri menjadi sangat subyektif.

Ransangan yang sama dirasakan berbeda oleh
tiap orang. ( latar belakang yang berbeda)
Bahkan R yang sama dirasakan berbeda oleh
orang yg sama kr kondisi emasionalnya

berbeda.
Suatu Nyeri mamiliki 3 dimensi;
1. Cognitive ( dimana dan
intesitas nyeri)
2. Affective ( arti dari suatu nyeri)
3. Emotional ( atensi thp nyeri )
Pain is very
Subjective
feeling
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
Beecher
The Meaning of injury
Prof. Hyodo
Thus, the role of DHN, is

the place where
interaction between
afferent ascendern input
and descedern input.
1. MODULATION
2. TRANSMISSION
Modulation in Dorsal Horn Neurons

one by Descending neurons & Interneurons
Modulation at DH
34
4. ASCENDING
PATHWAYS
5. DESCENDING
MODULATING PATHWAYS
Ascending
pathways
Descendin
g
pathways
Brain is a huge
Pharmacetucal
Factory.
Begitu kuatnya proses

Desendern sehingga
orang ini seperti tidak
punya Otak.
Perception is on the
brain, so
No brain no pain.
How pain perception is processed, still obscured

Where pain perceptions in the brain still unclea
Noxious perception?
A number of theories:
Pain
Perception
Brain
S
S
S
S
Limbic
Cortex
Sensory
Cortex
Thalamu
s
1. Specificity theory by
Descartes (16 century)
2. Gate control theory by
Melzack and Wall (i965)
3. Sensitization theory
by Woolf et al (1990 an)
1. Specificity theory
Descartes
(17th Century)
Pain was
faithfully
transmitted
from
periphery to
brain
Modified by AHT
NO BRAIN, NO PAIN
2.GATE CONTROL THEORY by MELZACK

and Wall
Central
Control
Descending
Modulation
Large
fibers
Ascending Action
System
Small
fibers
Dorsal Horn Gate
The Gate control theory of pain processing. T = Second-order transmission cell; SG = substantia
gelatinosa cell.
Modified by AHT
Prof. Hyodo
Prof. Hyodo
3.Sensitization theory ,
by Woolf et in 1990
:After the tissue injury,
sensitization in the periphery and

centrally ns is occurred.
HYPERALGESIA : RANGSANG KUAT
YANG NORMAL DIRASAKAN NYERI KINI

LEBIH NYERI
ALLODYNIA: RANGSANG LEMAH YANG
NORMAL TIDAK TERASA NYERI KINI
TERASA NYERI
After tissue damage it occurs

peripheral and central
sensitization
Worst Pain
Hyperalgesia
Normal
Response
No Pain
Allodynia
Increasing Stimulus Intensity

Stimulus response alteration observed with hyperalgesia
Nonsteroidal Anti Inflammatory Drugs

-Aspirin
-Ibuprophen
-Ketoprophen
-Ketorolac
-Etc.
Tissue Injury
- Paracetamol not NSAID
Pain
Prostaglandine
Anti
CycloOxyganase
Enzym
Arachidonic Acid
Secondary hyperalgesia
(allodynia)
Primary hyperalgesia
So, there are
three
possibilities how
do we feel pain.
1. Nociception with Pain

Pain
CNS
Inhibition
Modulation
Excitation
Nociception
exp. normal situation
Noxious stimulus with Pain
2. Nociception without pain

Pain
CNS
Inhibition
Modulation
Excitation
Example:
Stress Induced Analgesia
Nociception
Noxious stimulus without
Pain
3. Pain without nociception

Pain
CNS
Inhibition
Modulation
Excitation
Example: Phantom Pain

Neurophatic Pain
Nociception
Pain without noxious stimulus
New concepts of
ACUTE PAIN TREATMENT
SEKIAN
Terima Kasih Banyak

Semoga Ada Manfaatnya

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Introduction to

Before Eva was created from

Anesthesia was the

Regarding to the function of pain.

is an alarm symptom, tell us that

is a disease entity, no nociception,

The word pain

congenital insensitivity to pain ( chennelopath

CHRONIC PAIN vs ACUTE PAIN

chronic pain is pain that

Phantom Limb Pain

varies from 50% - 85%

About 40% of amputees having

So pain, between acute &

Chronic pain is not prolongation of

HAROLD MERSKEY (psychiatrics)

PAIN IS AN UNPLEASANT SENSORY AND EMOTIONAL

The problem lies in the word unpleasant.

The great merits of this

Pain is unpleasant sensory and unpleasant

Pain usually associated with actual tissue

Pain may occur with potential tissue damage

Pain is described in term of such damage,

Nociceptive Pain is pain that

Anatomy of peripheral sensory

Two distinct responses to a noxious

First pain: sharp and

Second pain: dull and

The Role of A fiber

Without A fiber, any noxious stimuli will perceive

Dorsal Horn neurons of SC

Peranan Modulasi dalam

nyeri menjadi sangat subyektif.

orang yg sama kr kondisi emasionalnya

Pain has multidimensional

3. Emotional behavioral component

The Meaning of injury

Thus, the role of DHN, is

Modulation in Dorsal Horn Neurons

Begitu kuatnya proses

How pain perception is processed, still obscured

2.GATE CONTROL THEORY by MELZACK

Dorsal Horn Gate

sensitization in the periphery and

YANG NORMAL DIRASAKAN NYERI KINI

After tissue damage it occurs

Increasing Stimulus Intensity

Nonsteroidal Anti Inflammatory Drugs

- Paracetamol not NSAID

So, there are

1. Nociception with Pain

2. Nociception without pain

3. Pain without nociception

Example: Phantom Pain

Terima Kasih Banyak

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