BASIC CONCEPT OF PAIN

Dedi Susila
Pain and Regional Anasthesia division,
SMF / Lab Anastesi & Reanimasi FK UNAIR-RSUD Dr Soetomo
 Tujuan Pembelajaran
• Mengetahui sejarah tentang nyeri
• Memahami definisi nyeri
• Mampu menjelaskan konsep dasar nyeri
• Memahami fisiologi nyeri
• Memahami klasifikasi nyeri
• Memahami pengaruh nyeri terhadap organ
tubuh
 PENDAHULUAN
• Dahulu nyeri dikaitkan dengan hukuman, pengaruh
setan atau kekuatan magis
• PAIN = PEONE (Yunani) artinya hukuman
• Zaman renaissance (1400-1500 M) tonggak awal teori
tentang persepsi nyeri yang dikendalikan otak ( Da
vinci)
• Al-zahrawi (936 M) sebenernya telah lebih dulu
menjelaskan tentang nyeri secara utuh (dokter bedah
pertama di dunia)  pain pathways berada di tulang
belakang (korda spinalis)
 History of Pain

11th Century
4 Century BC
th
Ibnu zuhr &
Aristotle
Al zahrawi
Pain = Emotion Sensation: tactile,
Pain ≠ Sensation thermal, pain, itch

2nd Century 17th Century

Galen Descartes
Brain  Feeling Cartesian model
Pain = Sensation Cause  effect
Sensation??? Pain = injury

(Perl, 2007)
The Meaning of
“Pain”
Derived from greek (poine)
and latin (poena) signify “ a
penalty or punishment”
Pain is a sensation that;
 hurt
 discomfort
 distress
 agony

Nyeri adalah suatu perasaan

sensorik (inderawi) yang tidak
menyenangkan.
( International Association for Study of Pain )
 DEFINITION OF PAIN

• Scientific Pain is unpleasant sensory and

emotional experience
• ascociated with actual tissue damage or
• Potential tissue damage or
• described in term of such damage.
(Merskey ,accepted by IASP 1979)

• Clinical Pain is whatever the experiencing

person says. (Mc Caffery 1997)
“Pain is whatever the pateint says”
(Margo Mc Caffery, 1999)
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.
 The Meaning of injury
Beecher

Prof. Hyodo
 PAIN PERCEPTION
How pain perception is processed, still obscured, and
Where pain perceptions in the brain still unclear.

Noxious perception?
Pain A number of theories:
Perception Brain
SS
1. Specificity theory by Descartes
SS Limbic Cortex
(16 century)
Sensory Cortex
Thalamus 3. Gate control theory by Melzack
and Wall (i965)
4. Sensitization theory by Woolf et
al (1990 an)

Modified by AHT
1. Specificity theory
Descartes
(17th Century)

Pain was
faithfully
transmitted
from
periphery to
brain
Modified by AHT
2.GATE CONTROL THEORY by MELZACK and Wall

Central Descending
Control Modulation

Large
fibers
−
+ −
+ − Ascending Action
SG T
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
Gate Control Theory
Proposed by Melzack and Wall in the 1960's
Sensitization theory by Woolf et
Is the net process starting from:
– Nociceptor activation
– Neural conduction
– Spinal transmission
– Noxious modulation
– Limbic & frontal – cortical perception
– Spinal & supra spinal response.
After the injury is occurred sensitization in
the periphery and centrally. (Hyperalgesia
and allodynia)
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

Modified by AHT
 Peripheral and central Sensitization

• HYPERALGESIA

• ALLODYNIA
 Noxious stimulus with Pain
Pain

Inhibition
CNS Modulation
Excitation

Nociception exp. normal situation

Nociception with Pain
Noxious stimulus without Pain
Pain
X Inhibition
CNS Modulation
Excitation

Example:
Nociception Stress Induced Analgesia

Nociception without pain

Pain without noxious stimulus
Pain

Inhibition
CNS Modulation
Excitation

X Example:
Nociception Post Herpetic Neuralgia

Pain without nociception

Post Herpetic Neuralgia
Pain Pathway
 Nyeri Fisiologis

 Mekanisme
Proteksi Tubuh
 Self-Limiting
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

o Based on Pathophysiology :
- Nociceptive pain
- Inflammatory pain
- Pathological pain
Neuropathic pain
Dysfunctional pain
 Acute vs Chronic
 This terminology is misleading as the key distinction
between acute and chronic pain is not the duration of
pain, but for chronic pain its:
− Persistence beyond nociception  No Nociception
− Beyond expectation
− Difficultes to treat & Reduced Quality of Life
“Acute and chronic pain have nothing in common but the
four-letter word “pain””
(John Loeser)
Chronic Pain
… is not prolonged acute pain
… must be considered and treated
as a disease.

Since chronic pain is a disease, It must be

treated by a specialist, that is specialist
pain management

WRAMC Feb1, 2005

 Contoh Kasus Nyeri Kronik
• Post herpetic Neuralgia
• Polineurophati diabetikum
• Fibromialgia
• Complex Regional Pain Syndrome
• Fail Back Surgery Syndrome
• Nyeri Kanker
• dll
 Relationship Between Pain, Sleep, and
Anxiety / Depression

Pain

Anxiety &
Functional Sleep
Depression impairment disturbances
Unrelieved Pain can Lead to...

Insomnia Anxiety Depression

Anorexia Immobility
 The Impact of Inadequate
Pain Treatment

INADEQUATE PAIN TREATMENT

PHYSIOLOGIC, PSYCHOLOGIC AND

SOCIAL CONSEQUENCES

MORBIDITAS AND MORTALITAS

 Response Cortical
- anxiety
- fear
- apprehension

Response Suprasegmental
- neurohumoral response
- catecholamines
- cortisol
- dll.

Response Segmental
- muclespasm
- vasospasm
- bronchospasm
- decreased gastrointestinal
motility

Response Local
-release pain substances
-inflammation
RESPONSES TO NOXIOUS STIMULI INDUCED BY AN ABDOMINAL SURGERY
 Hemodinamik Psikologi

Pernafasan Akibat nyeri

Metabolik
Nyeri
Kronis
TERIMAKASIH