Andi Husni TANRA

Professor of AnesthesiologyDepartment of Anesthesiology, IC and Pain ManagementFaculty of Medicine Hasanuddin UniversityMakassar

Introduction to Pain

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

*What is pain?

How do we feel pain?In normal situation!Noxious stimulus NociceptorsTransductionConductionModulationTransmissionPain PerceptionStimulate

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 meaningpunishment.

congenital insensitivity to pain ( chennelopathy)

CHRONIC PAIN vs ACUTE PAINChronic pain is misleading or over simplistic. The key distinction between acute & chronic is not the DURATION of pain, but chronic pain is pain thatPERSIST BEYOND HEALINGBEYOND NOCICEPTIONBEYOND EXPECTIONDIFFICULT 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 syndromeStump painPhantom painThe incidence of phantom pain varies from 50% - 85%About 40% of amputees having severe phantom pain

AllodyniaHyperalgesia

ACUTE PAINAcute pain is pain thatAssociated 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 PainALLODYNIAHYPERALGESIAPATHOPHYSIOLOGICAL PAIN(CLINICAL PAIN)

So pain, between acute & chronic pain is absolutely different ;

Different in etiologyDifferent in pathophysiologyDifferent in diagnosisDifferent in 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 DAMAGENyeri 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 definitionPain is unpleasant sensory and unpleasant emotional experience. Kata tidak menyenangkan harus ada nyeriPain usually associated with actual tissue damage Nociceptive pain or acute pain PAIN WITH NOCICEPTIONPain may occur with potential tissue damage (noxious stimulus) PHYSIOLOGICAL PAIN withdrawal- reflex.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 nosiseptor1. NOCICEPTORS

What is a nociceptor? reseptor nyeriNociceptors are peripheral sensory neurons that respond selectively to noxious stimuli (Stimulus kuat).Or A number of receptors/channels that sense damageVR1 - vanilloid receptor familyASICs - respond to low pHP2X receptors - respond to ATPTRPs receptors respond temp.Chemical sensors - prostaglandins,Diciptakan Tuhan guna melindungi diri kita dari bahaya.

2. 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).Sensory Nerve Afferent

Anatomy of peripheral sensory nerve fibers

Two distinct responses to a noxious stimulus FIRST PAIN and SECOUND PAINFirst pain: sharp and pricking, well-localised and brief. Responded by mechanoreceptors , conveyed by Ad fiber.Second pain: dull and diffuse and prolonged . Responded by polimodal nociceptors , conveyed by C fiber C Fiber A FiberFirst PainSecound PainModified by AHT

Although in normal condition A fiber does not response to noxious stimuli, but it plays a big role in NORMAL SENSATION.The Role of A fiberWithout A fiber, any noxious stimuli will perceive as BURNING PAIN (TN, HZ)

1.TRANSDUCTION2. CONDUCTION Role of nociceptors and primary afferent neurons are:

Process whereby noxious stimuli are translated into electrical activity at the sensory endings of nerveHeatChemicalTRANSDUCTION TRANSDUCTIONPressure

3. MODULATION in DHN

Lehmann, K. A.: From the first stimulus to pain memory. UN. Cologne, 2000Dorsal Horn neurons of SCPlays a big role in pain perceptionIs the first gate to control pain.Nociception (Pain) is born in DHN*

Peranan Modulasi dalam kehidupanPeran 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 experiencesensory discriminativeIdentifies the intensity, type and location of painAffective motivational Assessing the injury the meaning of injuryEmotional behavioral componentAttention, mood and behavioral due to pain

BeecherProf. HyodoThe Meaning of injury

1. MODULATION 2. TRANSMISSION Thus, the role of DHN, is the place where interaction between afferent ascendern input and descedern input.

Modulation in Dorsal Horn NeuronsDone by Descending neurons & Interneurons*Modulation at DH

4. ASCENDING PATHWAYS

5. DESCENDING MODULATING PATHWAYS

Descending pathwaysAscending pathwaysBrain is a hugePharmacetucal Factory.

Begitu kuatnya proses Desendern sehingga orang ini seperti tidak punya Otak.Perception is on the brain, so No brain no pain.

PainPerceptionBrainNoxious perception?A number of theories: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)How pain perception is processed, still obscured, and Where pain perceptions in the brain still unclear.

Pain was faithfully transmittedfrom periphery to brain1. Specificity theoryDescartes (17th Century)Modified by AHT

NO BRAIN, NO PAIN

2.GATE CONTROL THEORY by MELZACK and WallDorsal Horn GateThe 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 NYERIALLODYNIA: RANGSANG LEMAH YANG NORMAL TIDAK TERASA NYERI KINI TERASA NYERI

After tissue damage it occurs peripheral and central sensitizationIncreasing Stimulus IntensityStimulus response alteration observed with hyperalgesiaNo PainHyperalgesiaNormal ResponseWorst Pain

Tissue InjuryArachidonic AcidProstaglandinePainCycloOxyganase EnzymAspirinIbuprophenKetoprophenKetorolacEtc.Nonsteroidal Anti Inflammatory Drugs (NSAID)- Paracetamol not NSAIDAnti

Primary hyperalgesiaSecondary hyperalgesia(allodynia)

So, there are three possibilities how do we feel pain.

1. Nociception with PainPainNociception exp. normal situation Noxious stimulus with Pain Inhibition

ExcitationModulation

PainNociception Noxious stimulus without Pain

Inhibition

ExcitationExample: Stress Induced AnalgesiaXModulation2. Nociception without pain

3. Pain without nociception

New concepts of ACUTE PAIN TREATMENT

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