Nyeri adalah pengalaman sensorik dan emosional yang tidak menyenangkan akibat kerusakan jaringan,

baik aktual maupun potensial, atau yang digambarkan dalam bentuk kerusakan tersebut.
Dari definisi nyeri, tersurat selain pengalaman sensoris terdapat pula pengalaman emosional. Kedua hal tersebut perlu
diperhatikan dalam penanganan.
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1:222
2:3

Acute and chronic pain are serious problems for a large portion of
1:222
the population. Pain is the most common symptom for which people
seek medical attention.1 Acute pain affects between 15% and 20%
2:3 of the US population annually, and between 25% and 30% of the
US population experiences chronic pain.2 In 1996, musculoskeletal
problems accounted for approximately 90 million physician visits, 1:222-3
129 million visits were for the treatment of acute injury, and nearly
25 million visits were for surgical procedures performed in outpatient
and inpatient settings.1
However, despite the high prevalence of pain, it is underdiagnosed 3:121
and undertreated. In a recent multispecialty survey, only about half
(51%) of physicians queried thought that they managed patients’
pain well (good or very good).3
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Commentary

Pain is detected by nociceptive receptors located in the periphery, deep

tissues, and viscera. There are two types of nociceptive fibersAd
and C fibersthat project to the dorsal horn of the spinal cord.
From the spinal cord, pain information is relayed to the thalamus,
and thence to the cerebral cortex.
At each point in the pathway, the signal may be modulated by intrinsic
neurons or by descending input from higher centers. Descending
pathways into the spinal cord originate in the somatosensory and
limbic cortices, project to the periaquaductal gray area, and thence
to the dorsal horn of the spinal cord.
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2:1981
3:55

Activation of peripheral pain receptors, also called nociceptors, by

noxious stimuli generates signals that travel to the dorsal horn of the
spinal cord via the dorsal root ganglion. From the dorsal horn, the
signals are carried along the ascending pain pathway or the
spinothalamic tract to the thalamus and the cortex. Pain can be 2:1979
controlled by pain-inhibiting and pain-facilitating neurons. Descending 3:55
signals originating in supraspinal centers can modulate activity in the
dorsal horn by controlling spinal pain transmission.1,2

Gottschalk A, Smith DS. New concepts in acute pain therapy:

preemptive analgesia. Am Fam Physician. 2001;63:1979-1984.
Fields HL, Martin JB. Pain: pathophysiology and management. In:
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Pain is often categorized as either acute or chronic, with duration 4:17

being used to make the distinction between acute and chronic
pain.1
Another way to make a distinction between acute and chronic pain
is to categorize it according to time and physical pathology. Acute
pain is temporary or relatively brief in duration, results from an
injury, and diminishes as healing occurs. Examples include
postsurgical pain and trauma. Chronic pain persists for a long time 4:17,20

and usually occurs as a result of injury. However, in chronic pain,

the underlying pathology is not as apparent as the pathology seen
5:778 in acute pain. Consequently, the presence or degree of pain, or
both, are poorly explained by the underlying pathology. Examples
include rheumatoid arthritis (RA), osteoarthritis (OA), and lower
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Note to speaker: this slide contains an animated build. The first bullet appears
automatically, then click on the slide to bring up the remaining 4 bullets
sequentially.

• The painful region is typically localized at the site of injury in nociceptive

pain. This contrasts with neuropathic pain where the painful region may
not necessarily be the same as the site of injury and occurs in the neurol
ogical territory of the affected structure (nerve, root, spinal cord, brain). T
his is outlined on slide 15.

• Nociceptive pain usually responds well to conventional analgesics such

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This slide shows the differences between a joint affected by osteoarthritis and
a normal joint.

• Osteoarthritis, a degenerative condition of the joint, is an example of a

condition that causes chronic nociceptive pain.
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Note to speaker: this slide contains an animated build to represent the

involvement of the nervous system in chronic nociceptive pain (osteoarthritis
of the knee). Clicking on this slide will cause subsequent components of this
build to appear automatically.

• In osteoarthritis, chronic pain is caused by activation of local nociceptors

by inflammation in the affected joint.
• These activated nociceptors send impulses along the peripheral
(afferent) nerves to the dorsal roots where they enter the spinal cord to
reach the dorsal horn.
• Signals ascend from the sensory nerves via various pathways to the
brain where they give rise to the experience of pain. Pathways include
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Note to speaker: this slide contains an animated build. The first bullet appears
automatically, then click on the slide to bring up the remaining 4 bullets
sequentially.

The painful region may not necessarily be the same as the site of injury. Pain
occurs in the neurological territory of the affected structure (nerve, root, spinal
cord, brain).
• In peripheral neuropathic pain, it is in the territory of the affected nerve or
nerve root.
• In central neuropathic pain, it is related to the site of the lesion in the spi
nal cord or brain.
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MEKANISME NYERI NEUROPATIK meliputi mekanisme perifer dan

sentral.
I. Mekanisme Perifer
1. Aktivitas ektopik
2. Sensitisasi nosiseptor
3. Interaksi abnormal antar serabut saraf
4. Sensitisasi terhadap katekolamin
II. Mekanisme Sentral
1. Sensitisasi sentral
2. Disinhibisi
3. Reorganisasi struktural
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Peripherally, after nerve injury, the sensitivity of nociceptors of C and A

fibers is increased by chemical mediators released from inflammatory
cells.

Impulses are propagated along nociceptor C fibers toward the spinal

cord. Subsequently, inflammatory cells release their contents
peripherally, and increase the sensitivity of these nociceptors through
chemical mediators such as substance P, bradykinin, serotonin, and
histamine.
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Finally, pain fibers within the spinal cord may reorganize such that
sections of the spinal cord that normally receive only noxious input from
the periphery via C fibers begin to receive information regarding non-
noxious stimuli from A fiber terminals that sprout into the superficial
dorsal horn. Thus, even light touch may be perceived as painful.

References:
Attal N, Bouhassira D. Mechanisms of pain in peripheral neuropathy.
Acta Neurol Scand. 1999;100(Suppl):12-24.
Woolf CJ, Doubell TP. The pathophysiology of chronic pain—increased
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Excitatory as well as inhibitory input determines what information is

transferred from the periphery to the brain.

Inhibitory influences may arise from inhibitory interneurons at the level

of the spinal cord, mediated by neurotransmitters such as 
aminobutyric acid (GABA) and glycine.

Also, inhibitory influences may arise from descending pathways from the
brain, mediated by endogenous opioids or neurotransmitters like
serotonin and noradrenaline.
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Note to speaker: this slide contains an animation illustrating the flow of activity
along a nociceptive afferent fiber following noxious stimulation. Clicking on this
slide will cause subsequent components of this animation to run automatically.

• Under normal circumstances, impulses are generated in nociceptor

terminals only in response to noxious stimuli. The impulses are
transmitted to the brain and are perceived as pain.
• The ascending input is modulated by the descending control
mechanisms.
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Note to speaker: this slide contains an animation illustrating the

consequences of ectopic discharges from a damaged or diseased nociceptive
afferent fiber. Clicking on this slide will cause subsequent components of this
animation to run automatically.

• The equilibrium between ion channels (e.g. sodium and potassium) in the
axonal membrane of damaged or diseased neurons becomes altered.
• This may result in hyperexcitability causing impulse ‘over-firing’ – also
known as ectopic discharges.
• Such ectopic discharges may occur spontaneously or may be evoked by
mechanical stimuli
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Note to speaker: this slide contains an animation to illustrate the

consequences of the loss of inhibitory controls following impulses in a
nociceptive afferent fiber. Clicking on this slide will cause subsequent
components of this animation to run automatically.

• Under normal circumstances, the information transferred from the periph

ery to the brain depends on the balance of ascending (excitatory) and de
scending (inhibitory) modulation acting on dorsal horn neurons.

• Under pathological circumstances, inhibitory controls may be lost or impa

ired, causing
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Note to speaker: this slide contains an animated build to show that central
sensitization involves changes at the level of the dorsal horn neurons. Clicking
on this slide will cause subsequent components of the build to appear
automatically.

Under normal conditions:

• Activation of tactile fibers is unable to stimulate dorsal horn nociceptive n
eurons, therefore tactile stimuli are perceived as non-painful.

Under pathological conditions:

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This slide illustrates the course of neuropathic pain development.

Note to speaker: this slide contains an animated build, split into 4 sections.
The first section appears automatically, then the other 3 sections appear
sequentially.

• There are many possible causes of neuropathic pain. Neuropathic pain i

s commonly classified according to the etiological nature of the damage t
o the nervous system or the anatomical distribution of the pain, although
the relationship between etiology, mechanisms and symptoms/signs is c
omplex.