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7/17/2019 Pain Neuroscience
http://slidepdf.com/reader/full/pain-neuroscience 1/20
PainPain
I Putu Pramana SuarjayaI Putu Pramana Suarjaya
7/17/2019 Pain Neuroscience
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Pain :Pain :““unpleasant sensory & emotionalunpleasant sensory & emotionalexperience associated with actualexperience associated with actual
or potential tissue damage oror potential tissue damage ordescribe in terms of such damage”describe in terms of such damage”
Nyeri erupa!an PengalamanNyeri erupa!an Pengalaman
Sensori! dan "mosional yang #ida!Sensori! dan "mosional yang #ida!
enyenang!an $!ibat $danyaenyenang!an $!ibat $danya
%erusa!an $ncaman %erusa!an%erusa!an $ncaman %erusa!an 'aringan 'aringan
7/17/2019 Pain Neuroscience
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ultidimensional :ultidimensional :
Neurophysiologic(iochemicalPsychologic"thnocultural)ogniti*e
a+ecti*e
$lways subjecti*e
$ sensation & unpleasant
physical & non physical component
Pain
7/17/2019 Pain Neuroscience
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Pain echanismPain echanism
Series of complex neurophysiologic processSeries of complex neurophysiologic process
,transduction,transmission
,modulation,perception
- distinct components- distinct components::
7/17/2019 Pain Neuroscience
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Pain PerceptionPain Perception
Adapted from Goldstein A. Hospital Practice 1978 1:32Adapted from Goldstein A. Hospital Practice 1978 1:32
Dorsal RootDorsal Root
GanglionGanglion
BrainBrain
DorsalDorsal
HornHorn
ncep!alinncep!alin
interne"roninterne"ron
Descending controlDescending control
pat!#a$ from %asepat!#a$ from %ase
of %rainof %rain
&ociceptor &ociceptor
&ociceptor &ociceptor
e'o(ede'o(ed
disc!argesdisc!arges
)pinal *ord)pinal *ord
BrainstemBrainstem
&ociceptor sensiti+ation&ociceptor sensiti+ation
ncep!alinncep!alin
interne"roninterne"ronDorsal RootDorsal Root
GanglionGanglion
DorsalDorsalHornHorn
↑ sensiti'it$ to norepinep!rinesensiti'it$ to norepinep!rine
!eat , cold- local ion fl"es !eat , cold- local ion fl"es
mec!anical stim"lation mec!anical stim"lation&ociceptor &ociceptor
&ocicepti'e&ocicepti'e
transmissiontransmission
'ia ascending'ia ascendingpain pat!#a$spain pat!#a$s
/spinot!alamic tract0/spinot!alamic tract0)pinal *ord)pinal *ord
7/17/2019 Pain Neuroscience
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Pain NeurochemistryPain Neurochemistry
o %raino %rain
DorsalDorsal
HornHorn
)"%stance P- aspartate-)"%stance P- aspartate-
ne"rotensin- gl"tamatene"rotensin- gl"tamate
)pinal *ord)pinal *ord
DorsalDorsal
rootroot
ganglionganglion
iss"e in"r$iss"e in"r$
Brad$(ininBrad$(inin
le"(otrienesle"(otrienes
ononfl"esfl"es
/H/H44 , 5 , 54400
ProstaglandinsProstaglandins
ransmission 'iaransmission 'iaspinot!alamicspinot!alamic
tracttract
to %rainto %rain
)"%stance P)"%stance P
HistamineHistamine
)ensiti+ed)ensiti+ed
nociceptor nociceptor
7/17/2019 Pain Neuroscience
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Peripheral Ner*e PhysiologyPeripheral Ner*e Physiology
Nociceptor .Pain/eceptor0
#ransduction
1etecting noxious stimuli
Screening impuls to )NS
No adaptation .protecti*e e+ect0
echanical2 thermal2 chemicalstimulus action potential
3yperalgesia
1ecreased Pain tresholddue to local release ofmediator
7/17/2019 Pain Neuroscience
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$llodynia
Pain sensation in response to
normally non painful stimuli
#ransmission
7/17/2019 Pain Neuroscience
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4ast & Slow Pain
4ast pain
Short2 well locali5ed2 stabbing sensation2
match to stimulus such as pinpric!Stimulation of small2 myelinated $,delta
Slow Pain
#hrobbing2 burning2 aching2 poorlylocali5ed
)ontinue after stimulus
,
7/17/2019 Pain Neuroscience
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$scending Pain$scending Pain
PathwaysPathwaysDorsal RootDorsal Root
DorsalDorsalRootRoot
GanglionGanglion
o Braino Brain
*orticospinal*orticospinalractract
)pinot!alamic)pinot!alamic
ractract
*lass - *lass -
ne"rons %ecomene"rons %ecome
!$perecita%le!$perecita%le
A6Delta fi%ers:A6Delta fi%ers:
)!arp- s!ooting pain)!arp- s!ooting pain
A6Delta and * fi%ersA6Delta and * fi%ers
* fi%ers:* fi%ers:
D"ll- ac!ingD"ll- ac!ing
%"rning pain%"rning pain
Prolonged acti'ation of primar$ afferentProlonged acti'ation of primar$ afferent
nociceptor sensiti+e spinal c!ord ne"ronsnociceptor sensiti+e spinal c!ord ne"rons
7/17/2019 Pain Neuroscience
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odulation of Nociceptionodulation of NociceptionPeripheral odulation
Spinal odulation
7iberation & elimination neurotransmitter
sP2 glutamate
(rady!inin2 histamine prostaglandins2 serotonin2% + 2 382 lactic acid
"xcitatory
substance
Inhibitory substance
9$($2 glycine2 en!ephalins2 endorphins2
norepinephrine2 dopamine2 adenosine
9lu2 aspartat2 neuropep2 sP
7/17/2019 Pain Neuroscience
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Supraspinalodulation
)ogniti*e odulation
1escending inhibitorytract
$bility to relate painfulexperience
nly 6xed number of impulsereach cotical center
Neuroplasticity
)entral sensitisation ,;2 functionalchange in
Spinal cord processing
7/17/2019 Pain Neuroscience
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1orsal 3orn & ascending Nocicepti*epathway
#halamus & )erebral
)ortex
9ate )ells
)entralSensiti5ation
)NS Physiology)NS Physiology
h f i idP h f i id
7/17/2019 Pain Neuroscience
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Pathways of pioidPathways of pioid
$cti*ity$cti*ityBrainBrain Pain PerceptionPain Perception
DorsalDorsal
HornHorn
ncep!alinncep!alin
interne"roninterne"ron
DescendingDescending
imp"lseimp"lse
from %asefrom %ase
of %rainof %rain
&ociceptor &ociceptor &ociceptor &ociceptor
e'o(ede'o(ed
disc!argesdisc!arges
)pinal *ord)pinal *ord
BrainBrain
stemstem
DorsalDorsal
RootRoot
GanglionGanglion
Periac"ed"ctalPeriac"ed"ctal
gra$ matter gra$ matter
Peria'entric"larPeria'entric"lar
gra$ matter gra$ matter
&"cle"s Rap!e&"cle"s Rap!e
agn"sagn"s
pioidpioid
agent6receptoragent6receptor
%inding site%inding site
DescendingDescending
imp"lseimp"lse
from Rap!efrom Rap!e
n"cle"sn"cle"s
&ociception&ociception
in!i%itedin!i%ited&e"roreceptor &e"roreceptor
&e"ro6&e"ro6
transmitter transmitter
)"%stance P)"%stance P
AfferentAfferent
ne"ronne"ronfromfrom
dorsaldorsal
RootRoot
GanglionGanglion
Adapted from Goldstein A. Hospital Practice 1978 1:32Adapted from Goldstein A. Hospital Practice 1978 1:32
7/17/2019 Pain Neuroscience
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Pain PerceptionPain Perception
Adapted from Goldstein A. Hospital Practice 1978 1:32Adapted from Goldstein A. Hospital Practice 1978 1:32
Dorsal RootDorsal Root
GanglionGanglion
BrainBrain
DorsalDorsal
HornHorn
ncep!alinncep!alin
interne"roninterne"ron
Descending controlDescending control
pat!#a$ from %asepat!#a$ from %ase
of %rainof %rain
&ociceptor &ociceptor
&ociceptor &ociceptor
e'o(ede'o(ed
disc!argesdisc!arges
)pinal *ord)pinal *ord
BrainstemBrainstem
&ociceptor sensiti+ation&ociceptor sensiti+ation
ncep!alinncep!alin
interne"roninterne"ron
Dorsal RootDorsal Root
GanglionGanglion
DorsalDorsalHornHorn
↑ sensiti'it$ to norepinep!rinesensiti'it$ to norepinep!rine
!eat , cold- local ion fl"es !eat , cold- local ion fl"es
mec!anical stim"lation mec!anical stim"lation&ociceptor &ociceptor
&ocicepti'e&ocicepti'e
transmissiontransmission
'ia ascending'ia ascendingpain pat!#a$spain pat!#a$s
/spinot!alamic tract0/spinot!alamic tract0)pinal *ord)pinal *ord
7/17/2019 Pain Neuroscience
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Sub-optimal pain management canSub-optimal pain management can
have serious consequences…have serious consequences…
Decreased
mobilisation
Acute postoperative pain
Induction ofchronic pain
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;
Pe!ins et al . Anesthesiology 2000;93:1123
Clinical and
psychological changes
Inadequate pain
management
7/17/2019 Pain Neuroscience
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)lassi6cation of Pain
1uration
Pathophysiology
$cute
)hronic
Nocicepti*e
*isceral
somatic
Neuropathic
7/17/2019 Pain Neuroscience
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$cute Pain
<ell de6ne tissue damage
7imited duration
Nociceptors return to
normal treshold
)hronic Pain
Persistent pain
ay ha*e both nocicepti*e &neuropathic element
ften has no detectable pathology