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7/25/2019 BASIC PRINCIPLES OF PAIN.ppt
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Curriculum Vitae
Resource Exchange Programmed For Asia (REP-ASIA), Singapore,
2010
Secrear! o"#
$ %aiona& Pain Sud! 'roup o" Perdossi
$ Indonesian Pain Socie! hie" o" #
$ Pain Sud! 'roup o" Perdossi haper og*a+ara
$ Pain Su eparmen, %euro&og! eparmen , .ni/ersias
'ad*ah ada Sa"" o" %euro&og! eparmen, Facu&! o" edicine, .ni/ersias
'ad*ah ada
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PAI%
(BASIC CONCEPT OF PAIN)BASIC CONCEPT OF PAIN)
udi!ana
Pain Su-ep o" %euro&og! '.
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3.%.%'A% P45I35I%I3 SARAF RSS 67 2008
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e"ining o" Pain
9Pain Experience:
Pain is a personal, subjective experience tat co!prises "
Sensor#$%iscri!inative, &otivational$a''ectivean% Co(nitive$evaluative%i!ensions
Ronald Melzack, Textbook of Pain 4thedition
S
o!ati*ation
+++++
,epression
Expec
tation-
,esir
e
Anxie
t#
Catastropi*ation
9An unp&easan sensor! andemoiona& experienceassociaed ;ih acua& or
poenia& issue damage, ordescried in erms o" suchdamage:
Inernaiona& Associaion "or he Sud! o" Pain(IASP) 1
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Classi'ication o' Pain
Physiologic / nociceptive:
1
Pain arising from activation of nociceptors Caused by mild and short noxious impulses which usually relieved without any
medication or mild analgesics Example: Pinched, stung by mosuito
Inflammatory:2
Pain caused by in!ury to body tissues "musculos#eletal, cutaneus or visceral$ Example: Pain due to inflammation, limb pain after fracture
Neuropathic:1
Pain arising as a direct conseuence of a lesion or disease affecting the somatosensorysystem
Example: %P&, P'&
Psychogenic (functional):3
Pain due to abnormal responsiveness or function of the nervous system withoutneurologic deficit or peripheral abnormality(
Example: )ibromyalgia, irritable bowel syndrome
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'racture@
Postoperative
On(oin( or
i!pen%in( injur#
sprain
In'la!ation .
In'ection
In'iltrate% or co!presse%
/tu!ors)
stran(ulate%
/scar tissue)
&uscle Stretc
in'la!e% /in'ection )
6!pe or aegor! o" Pain
3. Psychogenic
c&ear hano somaic disorder
is presen
1. Nociceptive-
Inflamatori
aused ! aci/i!
in neura& pah;a!sin response o poenia&&!
issue-damaging simu&i
2. Neuropathic
Iniiaed or caused !
primar! &esion or
d!s"uncion
in he ner/ous s!s
!. "i#e$ type
aused ! acominaion o" oh
primar! in*ur! or
secondar! e""ecs
6he Assessmen o" he Paien ;ih Pain, Se/en Richeimer, irecor .S Pain anagemen, .S edica& ener, 5os Ange&es, A, .SA, 200
o'ascial pain
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6he oninuum o" Pain6he oninuum o" Pain11
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S!all$'iber sensor# 0ar(e$'iber sensor# Autono!ic
$Burnin( pain
$Allo%inia
$1#peral(esia
$1#perestesia
$Parestesia.%#sestesia
$0ancinatin( pain
$0oss o' pain - te!p2
sensation
$Foot ulceration
$0oss o' visceral pain
$0oss o' vibration
$0oss o' proprioception
$0oss o' re'lexes
$Slo3e% NC4
$1eart rate abnor!alities
$Postural #potension
$Abnor!al s3eatin(
$5astroparesis
$Neuropatic %iarrea
$I!potence
$6etro(ra%e ejaculation
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Nociceptive afferent fi'er
Nor!al Nerve I!pulses 0ea%in( to PainNor!al Nerve I!pulses 0ea%in( to Pain
No#ious
stimuli
escen$ing
mo$ulation
%scen$ing
input
pinal cor$
Perceive$ pain
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Nociception
pinothalamicpinothalamictracttract
PeripheralPeripheral
nervenerve
orsal *ornorsal *orn
orsal rootorsal root
ganglionganglion
PainPain
"o$ulation
+rans$uction
%scen$ing%scen$ing
inputinput
escen$ingescen$ing
mo$ulationmo$ulation
PeripheralPeripheral
nociceptorsnociceptors
+rauma+rauma
;dapted from
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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
Wool ! Mitchel" 2##1
Transduction
;6P
&a@
Modifikasi Meliala, 2003
ACTION POTENTIALACTION POTENTIAL
,%,%N 0%IN%N
IN%"%I
% "I N4
NI+I%I
%,+I%I&+. I&.
i-Na5
,4N 4%I
Pg67 8*+7 %$enosin
Pengalaman
,ognitif
6ehaviour
Psiologi
Inhi'isi
$esen$en4+%,
P%IN 9 N4 P%IN
-N
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An(er
Fear
Anxiet#
epression
Noxious Sti!uli
PS
1(74
54
'I(
A5
%4IEP6I?E
A
B
&E0IA0A 7889
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:at is In'la!!ator# Pain+:at is In'la!!ator# Pain+ 4"en c&assed a&ong ;ih acue pain as nocicepi/e, re"ers o he4"en c&assed a&ong ;ih acue pain as nocicepi/e, re"ers o he
sponaneous pain and enderness "e&sponaneous pain and enderness "e&;hen issue is in"&amed;hen issue is in"&amed
Pain caused !Pain caused ! in*ur! o od! issuesin*ur! o od! issues(muscu&os+e&ea&, cuaneous or(muscu&os+e&ea&, cuaneous or
/iscera&)/iscera&)
Pain"u& region is !pica&&! &oca&iCed a he sie o" in*ur!$ o"en descried as
hroing, aching or si""ness
.sua&&! ime-&imied and reso&/es;hen damaged issue hea&s (eg one
"racures, urns and ruises)
an a&so e chronic(eg oseoarhriis, rheumaoid arhriis)
.sua&&!.sua&&! responsi/eresponsi/eo %SAIso %SAIs
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%4IEP6I?E PAI%
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Prosta(lan%ins pro%uce%
in response to tissueinjur#; increase sensitivit#o' nociceptor /pain)
Nociceptor ten releasessubstance P, 3ic %ilates
bloo% vessels an% increases
release o' in'la!!ator#
!e%iators, suc as Bra%#
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Dha is %europahic painDha is %europahic pain
%efinition:
Pain arising as a direct conseuence of a lesionor disease affecting
the somatosensory &EAVE system
CharacteriBed by:
Pain often described as shooting, electric shoc#.li#e or burning(
6he painful region may not necessarily be the same asthe site of
in!ury(
;lmost always a chroniccondition "e(g( post herpetic neuralgia, post
stro#e pain$
Aesponds poorlyto conventional analgesics
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IASP Classi'ications"IASP Classi'ications"Periperal Neuropatic an% Central Neuropatic PainPeriperal Neuropatic an% Central Neuropatic Pain
oeser D%, 6reede A%( 6he =yoto Protocol of +;P 2asic Pain 6erminology( Pain033541->:?>-.?>>(
Neuropathic painPain arising as a direct consequence of
a lesion or disease affecting the
somatosensory system
Peripheral neuropathic painPainarising as a direct consequence of
a lesion or disease affecting the
peripheral somatosensory system
Central neuropathic painPainarising as a direct consequence of
a lesion or disease affecting the
centralsomatosensory system
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Pahoph!sio&og! o" %europahic PainPahoph!sio&og! o" %europahic Pain
NeP
&entral mechanisms
Peripheral mechanisms
Peripheral Neuron
hypere#cita'ility
oss of
inhi'itory controls
&entral Neuron
hypere#cita'ility
(central sensitiation)
%'normal
ischarges
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Periphera& echanismPeriphera& echanism(Ecopic ischarges)(Ecopic ischarges)
Nerve lesion in$uces hyperactivity $ue to changes in ion channel function
Ectopic dischargesEctopic discharges
Nerve lesion
pinal cor$
Nociceptive afferent fi'er
escen$ing
mo$ulation
%scen$ing
input
Perceive$ pain
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enra& echanism (5oss o" inhiior! conro&s)enra& echanism (5oss o" inhiior! conro&s)
oss of $escen$ing mo$ulation causes e#aggerate$ pain $ue to an im'alance
'et;een ascen$ing an$ $escen$ing signals
Nociceptive afferent fi'er
No#ious
stimuli
%scen$ing
input
pinal cor$
oss of
$escen$ing
mo$ulation
#aggerate$ pain
perception
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+ntact tactile fiber
enra& echanism (enra& sensiiCaion)enra& echanism (enra& sensiiCaion)
A"er ner/e in*ur!, iA"er ner/e in*ur!, increased inpu o he dorsa& horn can induce cenra&ncreased inpu o he dorsa& horn can induce cenra&
sensiiCaionsensiiCaion Perceive$ pain
%scen$ing
input
escen$ing
mo$ulation
Nerve lesion
&ociceptive afferent fiber
+actile
stimuli
Perceive$ pain
(allo$ynia)
%scen$ing
input
escen$ing
mo$ulation
%'normal $ischarges in$uce central sensitiation
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e/e&opmen o" %europahic Paine/e&opmen o" %europahic Pain
oolf and 9annion( ancet 14-F-:1F./?
Neuropathic pain
Spontaneous pain Stimulus-evoked pain
"echanisms
Metabolic Traumatic
ToxicIschemic
Hereditary
Compression
Infectious
Immune-related
yn$rome
ymptoms
Pathophysiology
tiology &erve damage due to:&erve damage due to:
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Signs and S!mpoms o" %europahic PainSigns and S!mpoms o" %europahic Pain
%elayed, explosive response to any painful stimulus *yperpathia2
+ncreased pain from a stimulus that normally
provo#es pain( e(g( pinpric#, cold, heat *yperalgesia3
Pain due to a stimulus that does not normallyprovo#e pain(e(g( warmth, pressure, stro#ing
%llo$ynia3
timulus-evoe$
symptoms
;bnormal, not unpleasant sensations e(g( tingling Parasthesias2
;bnormal unpleasant sensations
e(g( shooting, lancinating, burning ysesthesias2
Persistent burning, intermittent shoc#.li#e or
lancinating pain pontaneous pain1
pontaneous symptoms
Description (exampleSi!n"S#mptom
1( 2aron( Clin D Pain( 033341/:10.03(0( 9ers#ey ' et al( "Eds$ +n: Classification of Chronic Pain: %escriptions of Chronic Pain yndromes and %efinitions of Pain 6erms( 1?:03.010(-( oeser D%, 6reede A%( 6he =yoto Protocol of +;P 2asic Pain 6erminology( Pain033541->:?>-.?>>
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7!pera&gesia A&&od!nia7!pera&gesia A&&od!nia
.5?(
In
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6he Iner-Re&aionship Be;een6he Iner-Re&aionship Be;een
Pain, S&eep, and Anxie! @ epressionPain, S&eep, and Anxie! @ epression
&icholson and Verma( Pain 9ed( 033?4F "suppl( 1$:.0>
Pain
leep$istur'ances
%n#iety Aepression
unctionalimpairment
Dha is he orre&aion Be een a ses sc &ar pain
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Dha is he orre&aion Be;een auses, uscu&ar pain,
%euro-endocrine (7PA Axis) disorders and Ps!cho&ogica& disress
E!otional, Environ!ental an% 5enetic Pre%isposition
Cortex$0i!bic S#ste!$ 1#poca!pus
Tala!us - 1#potala!us
Pituitar#
A%renal,
T#roi%
Perception
C61, T61, 561, P6F, 5n61
ACT1, TS1, 51, Prolactine, FC1$01
Cortisone,T#roi%,
Prolactine, Estro(en, Pro(esterone
Neuro$or!onal is'unction
S#!patetic &etabolic
PAIN
&uscle Trau!aorsal 1orn
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PAI% ASSESSE%6
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Te =0 Approac to ia(nosisTe =0 Approac to ia(nosis
0ISTEN
0OCATE 0OO?Nervous s#ste!
lesion . %#s'unction
Sensor# abnor!alities,
pattern reco(nition
Patient verbal %escriptors,
@ - A
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Pain Assessmen Sca&es
.ni-imensiona& Sca&e u&i-imensiona& Sca&e
Onl#measures pain inensi!Appropriae "or acute pain
6he mos common sca&e used inoutco!eassessmen (Ana&gesic
e""icac!)
2oth intensity (severity)and
unpleasantness (affective)
;ppropriate for chronic painesearch /pathophysiologyhoul$ 'e use$ in clinicalhoul$ 'e use$ in clinical
outcome assessmentoutcome assessment
4erbal 6atin( Scale /46S)
None, !il%, !o%erate, severe
Nu!eric 6atin( Scale /N6S)
4isual Analo( Scale /4AS)
Pictorial Scale
&c5ill Pain @uestionnaire /&P@)
Te Brie' Pain Inventor# /BPI)
Te &e!orial Pain Assess!ent Car%
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.ni-imensiona& Pain Assessmen Sca&es
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P t i .N i P i S l
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Poto(rapic.Nu!eric Pain Scale
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u&i-imensiona& Pain Assessmen Sca&es
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@uic
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Patient Pain %iary
"orning %fternoon vening 6e$time
Pain
)cale
1=
8
=ose ose
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I PAI% # Screening oo& o he&p di""ereniae
nocicepi/e "rom neuropahic pain
%europahic pain screening Guesionnaire
A mu&icener sud!
Paiens (% H >8) ;ih non-headache chronic painA secondmu&icener sud! (% H J>=) e/a&uaed re&iai&i! and /a&idi! >)#1-8
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0ocation# Patient or nurse !ar
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:atcauses orincreases te pain+
E''ect o' pain# /Note %ecrease% 'unction, %ecrease% Dualit# o' li'e)
Oter co!!ents"
Plan"
Accompan!ing s!mpoms (eg nausea)
S&eep
Appeie
Ph!sica& aci/i!
Re&aion ;ih ohers (eg irriai&i!)
Emoion (eg anger, suicida&, cr!ing)
onsenraion
4her
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Pas edica& 7isor!
1 edica& re&aed pro&ems
2 Pro&ems poenia&&! a""ec he choice o" pain
reamens
J Prior or curren susance ause hisor!
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urren edicaions
1 osage and paern o" use
2 E""eci/eness
J rug o&erance
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Ph!sica& Examinaion
6he hisor! ;i&& o"en generae a di""erenia& diagnosis 6he ph!sica& exam ;i&& o"en &ead o he se&ecion o" he primar!
diagnosis, and occasiona&&! a es ;i&& he&p o con"irm his diagnosis
1 ena& saus exam ("acia& expression)2 ?ia& signs
J Inspecion (od! posiion, gai, redness, s;e&&ing)
= Pa&paion uscu&os+e&ea& exam (aroph!, &ocaion
enderness o pressure, mass, ) %euro&ogic Examinaion (Sensor!, oor, Auonomic)
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%E.R454'I EMAI%A6I4%
Possii&i! #
$ spina& cord compression,
$ ner/e roo &esions
$ periphera& ner/e &esions
Sensor! Exam#$ numness,
$ a&&odinia,
$ h!pera&gesia
ooric# "racure eep endon re"&exes
Sacra& Re"&exes
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Ps!cho&ogica& E/a&uaion
1 ood disorder (0K chronic pain)
2 SomaiCaion
J Secondar! gain
= S&eep and appeie disurance
5oss o" energ! and &iido8 Impaired concenraion
Suicida& ideaion
> Impac o" he pain on he paien$
da!-o-da! aci/iies$ ;or+ "inances
$ persona& re&aionships
$ recreaiona& pursuis
4%5.SI4%S
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ou are he on&! one ;ho +no;s ho; much pain !ou are "ee&ing
A&& paiens reGuire pain assessmen $
i is as essenia& as he oher /ia& signsN(Helen Geene!
If Bou onCt "easure It7 Bou &anCt Improve It(iel$ et al7 1DDE)
4%5.SI4%S
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