What is pain and its

classification

Setelah kuliah ini mahasiswa/ peserta

mampu menjelaskan.

Apa itu nyeri, definisi nyeri.

Konsekwensi dari nyeri yang tidak
diobati.
Pembagian dari nyeri
Nyeri Nosisepsi
Nyeri Inflamasi
Nyeri Patologis
Apa itu pain behavior (prilaku nyeri)
Perbedaan ke tiga nyeri tsb diatas.

Before Eva was created from

Adams rib, he was put into sl

Anesthesia was the first

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.

IMAGES OF PAIN

Pain is a POISONS to our body

Poisons
mechanical thermal chemical
electrical

Tissue damage
Release of mediators
H , K , ATP, Prostaglandin,
Bradikinin, Serotonin, Substance P,
Histamine. Cytocaines

Stimulation of nociceptors

Transmission to CNS
ACUTE PAIN
via afferent pathways

Consequences of Pain
Poor diagnosis and impending death
Particularly when pain worsens
Decreased autonomy
Impaired physical and social
function
Decreased enjoyment and quality of life
Challenges of dignity
Threat of increased physical suffering

Relationship Between Pain, Sleep, and

Anxiety / Depression

Pain

Anxiety &
Depressio
n

Functional
impairment

icholson and Verma. Pain Med. 2004;5 (suppl. 1):S9-S27

Sleep
disturbances

Unrelieved Pain can Lead

to...

Insomn
ia

Anorex

Anxiet
y

Depressio
n

Immobilit

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 DAMAGE
Nyeri adalah perasaan sensorik dan emosional yang tidak
menyenangkan akibat kerusakan jaringan yang nyata atau
yang berpotensi rusak atau tergambarkan seperti adanya
kerusakan tersebut.

The problem lies in the word unpleasant.

Pain is more than unpleasant.

Definition
P
ain
Unpleasant sensory
and emotional
experience

- Associated with actual

or potential tissue
damage

- or described in terms of
such damage. (IASP1979)

Two key points:

1.Unpleasant sensory. (physical)

2.Emotional experience. (psychological)

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 what ever the pat eint says
(Margo Mc Caffery, 1999)

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

From neurobiological perspective

pain can be divided into 3 types

PAIN
Nocicepti
ve Pain

Inflammat
ory Pain

Pathologi
cal Pain
Neurophatic
Neurophatic

Pain
Dysfunctional
Pain
Woolf CJ. What is this thing called pain? J Clin Invest 2010;
120(11): 3742-3744

Pain is unpleasant sensory and

emotional experience associated
with.
Potential tissue damage or
Actual tissue damage or
Described in term of such damage.

Pain due to potential tissue damage .

Nociceptiv
eDue
to noxious stimulus, to protect further
Pain
damage.
E.g. touching something too hot, cold or
sharp
Adaptive and protective pain.

WITHDRAWAL REFLEX

Pain is unpleasant sensory and

emotional experience associated
with
Potential tissue damage or
Actual tissue damage or
Described in term of such damage.

Associated with actual tissue damage and

infiltration of
immune cells.
Inflammatory
To promote repaireng by pain
Pain
hypersensitivity until healing occurs.
Adaptive and protective pain
Pain is one of the cardinal features of
inflammatory.

INFLAMMATION PAIN
Pain may occur
without
noxious stimuli

Clinical Signs:
Calor (heat)
Dolor (pain)
Rubor (redness)
Tumor (swelling)
Functio laesa (loss of function)

Bimolecular changes
in inflammation

Inflammatory Pain peripheral

and central sensitiztion
Central
sensitization

CNS

Spinal windup

Inflammatory
mediators
Histamine,
Histamine,
Leukotrienes,
Leukotrienes,
Norepinephrine,
Norepinephrine,
Cytokines,
Cytokines, Bradykinin,
Bradykinin,
Prostaglandins,
Prostaglandins,
Neuropeptides,
Neuropeptides, 5-HT,
5-HT,
Purines,
Purines, H+/K+ions
H+/K+ions

Secondary
hyperalgesia

Peripheral
sensitization

Primary
hyperalgesia

After the injury the NS will changed neuro-plasticity

ATP
capsaicin

Tissue damage and pain in the periphery

Mechanical?

heat

COX1/2
H+
PGs

TRPVs ASICs

EPs

cold
warm

TRPs

DRG

ATP

P2X

Na+, K+,
Ca2+
channels

sensitize, activate

C-fibre

Sensitization
10

Pain Intensity

Inflammation
pain

Hyperalgesia

6
4

Injury
Allodynia

Normal
Pain
Response
(Nociceptive pain)e
Hyperalgesia
heightened sense of
pain to noxious stimuli

Allodyniapain
resulting from

0
Stimulus Intensity

normally painless stimuli

Gottschalk A et al. Am Fam Physician. 2001;63:1979-84.

Allodynia means;
stimulus which
normally does not
produce pain, now
produce pain.
Take a shower
normally does not
produce pain, but
after having sunburn. now produce
pain,

Pain
Autonomic response
Withdrawal reflex
Nociceptor
Sensory neuron

Nociceptive pain
A

Noxious stimuli
Heat
Cold
Intense mechanical force
Chemical irritants

Inflammatory pain
B
Inflammation
Peripheral
Inflammation
Positive
symptoms

Macrophage
Mast cell
Neutrophil
Granulocyte

Tissue damage

Adaptive, high-threshold pain

Early warning system
(protective)

Spinal cord
Spontaneous pain
Pain hypersensitivity

Adaptive, low-threshold pain

Tenderness promotes repair
(protective)

Pain is unpleasant sensory and

emotional experience associated
with
Potential tissue damage or
Actual tissue damage or
Describe in term of such damage.

Maladaptive pain and non

protective pain
This is not a symptom or Pathologi
protective pain but a disease
calstate.
Pain
Due to damage of nervus
system
Neuropathic Pain

Panthom pain
Herpetic neuralgia
Trigemenial
neuralgia

No damage of the
NS
Dysfunctional Pain

Fibromyalgia
IBS
Tension Headache

PHANTOM PAIN

Phantom Pain

phanto
m pain

Post Herpetic Neuralgia

Trigeminal Neuralgia

Pathological pain
C

Spontaneous pain
Pain hypersensitivity
Peripheral
Nerve damage

Neuropathic pain
Neural lesion
Positive and negative
symptoms

Injury
Stroke

Abnormal
Maladaptive, low-threshold pain
Central processing Disease state of nervous system
Spontaneous pain
Pain hypersensitivity
Normal peripheral
Tissue and nerves

Dysfunctional Pain
No neural lesion
No inflammation
Positive symptoms
Abnormal
Central processing

By Analogy
If pain were a fire alarm, the
nociceptive type would be activated
appropriately only by the presence
of intense heat, inflammatory pain
would be activated by warm
temperatures, and pathological
pain would be a false alarm caused
by malfunction of the system it self.

NYERI
NOSISEPTIF
Api

NYERI
INFLAMASI

Air Hangat

Tanpa

NYERI
PATOLOGIS

NOCICEPTIVE PAIN

Congenital insensitivity to pain

Penderita
tidak
dapat merasakan
nyeri
walaupun
mengalami
kerusakan
jaringan.
Dapat dilihat disini
penderita
mengalami
amputasi jari-jari,
Penderita masih bisa tersenyum,
walau
memiliki banyak luka.
luka-luka
pada
lutut dan mulut

Either Nociceptive
pain or
Inflammatory pain
the
same
has
Pain that
started
by activation of nociceptors
Nociceptive pain normal nociceptors
mechanism
Inflammatory pain nociceptors are more
sensitive.
*Spontan pain may
occur

Pain
Autonomic response
Withdrawal reflex
Nociceptor
Sensory neuron

Nociceptive pain
A

Noxious stimuli
Heat
Cold
Intense mechanical force
Chemical irritants

Inflammatory pain
B
Inflammation
Peripheral
Inflammation
Positive
symptoms

Macrophage
Mast cell
Neutrophil
Granulocyte

Tissue damage

Adaptive, high-threshold pain

Early warning system
(protective)

Spinal cord
Spontaneous pain
Pain hypersensitivity

Adaptive, low-threshold pain

Tenderness promotes repair
(protective)

Mechanism of Nociceptive
pain
Nociceptive Pain is pain
that

generated from nociceptors .

Pain started by activation of
nociceptors nociception

A nociception consist of at least 5 components

1. TRANSDUCTION
2. CONDUCTION
3. TRANSMISSION
4. MODULATION
5. PERCEPTION

Mechanism of
nociceptive pain

Neuron III

Persepsi

Transduk
si
Fisi
k

Suhu

Transmi
si
Conduct
ion

Neuron I
Kimia
wi

Modulas
i

Neuron II

Perception

Role of Modulation

Pain

Descending
Decending
Dorsal Horn
modulation
Ascending
input

inhibitory

Spinothalamic
tract

transmission

Modulation
Dorsal root
ganglion

Conduction

Transduction
Peripheral
nerve

Peripheral
nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

Trauma

The role of
modulation
Pain modulation can be
triggered by the meaning
of injury

Injury for
merit

Injury for
honor

Motivation to win

Motivation to win

Apapun yg dilakukan
shg
endorfin dpt
dilepaskan
menghilangkan
nyeri.
Seolah olah tanpa
otak

Pada saat
dilakukan
rangsang
noxious,
banyak areaarea
di hemisfer
yang
teraktivasi,
bukan hanya
di
somatosensor
y cortex
(SSC).
Hal ini menujukkan
utamanya
Bawah nyeri memilik
hemisfer
Peran penting dalam
kontralateral
Kehidupan, sehingga
Seluruh bagian tubuh
Harus diinformasikan

Pain has multidimensional

experience
1. sensory discriminative
Identifies the intensity, type and
location of pain

2. Affective motivational
Assessing the meaning of injury

3. Emotional behavioral component

Attention, mood and behavioral due to
pain

J. Loeser
(1980)

PAIN BEHAVIOR
SUFFERING

PAIN

NOCICEPTION

oncept of nociception, pain, suffering and pain behav

Behavioral characteristics
Facial expressions- grimace(meringis)
clenched teeth, wrinkled forehead,
crying
Body movements -restlessness,
immobilization, muscle tension,
protective movement of body parts
Social interaction- avoidance of
conversation & contacts

Pain behavior

INFLAMMATORY PAIN

INFLAMMATION PAIN
Pain may occur
without
noxious stimuli

Clinical Signs:
Calor (heat)
Dolor (pain)
Rubor (redness)
Tumor (swelling)
Functio laesa (loss of function)

Bimolecular changes
in inflammation

HEAT REDNESS SWELLING

Five
Cardinal
Signs of
Inflammat
ion
PAIN LOSS OF
FUNCTION

After tissue injured or inflamed

a number of substances may be released
peripherally
Painful stimulus

1 Prostaglandins

produced in response to
tissue injury; increase
sensitivity of nociceptor
(pain) Dolor

Pain-sensitive tissue

Prostaglandin

Mast cell

Substance P

Histamine
Bradykinin
Substance P

3
Nociceptor

Peripheral sensitization

Blood
vessel

2 Nociceptor then releases

substance P, which dilates

blood vessels and increases
release of inflammatory
mediators, such as
Bradykinin (redness & heat)
Rubor & Calor

3 Substance P also promotes

degranulation of mast cells,

which release Histamine
(swelling) Tumor

Cell Membrane Phospholipids

Phospholipase
Arachidonic
Acid
COX-1
Prostaglandins
Gastric Protection
Kidney protection
Platelet Hemostasis

COX-2
Prostaglandins
Acute Pain
Inflammatio
Fever
n

COX-2 and peripheral

sensitization
Tissue injury
Neuron
firing threshold
decreases

COX-2 expressed
PGE2
Increased
neuronal
membrane
excitability

EP
receptor

PKA
PKC
P

NaV1.8
TTx-resistant
sodium channel

Peripheral and Central

Sensitization in Inflammatory Pain
Central
sensitization

CNS

Spinal windup

Inflammatory
mediators
Histamine,
Histamine,
Leukotrienes,
Leukotrienes,
Norepinephrine,
Norepinephrine,
Cytokines,
Cytokines, Bradykinin,
Bradykinin,
Prostaglandins,
Prostaglandins,
Neuropeptides,
Neuropeptides, 5-HT,
5-HT,
Purines,
Purines, H+/K+ions
H+/K+ions

Secondary
hyperalgesia

Peripheral
sensitization

Primary
hyperalgesia

After the injury the NS will changed neuro-plasticity

Normal Situation
Low intensity
Stimulation

High
threshold A
and c fiber
nociceptors

A
fiber
PNS

CNS
Dorsal
Horn Cell

High intensity
Stimulation

Innocuous
Sensation

Brief Pain

After Tissue Damage

Low threshold
mechanorecept
or A

Low intensity
stimulation
Sensitized
nociceptor A
and C fibers

PNS
CNS

Hyperexcitable
dorsal horn
neuron

Pain

Inflammation Pain

HYPERALGE
SIA

ALLODYN
IA

TOOTHACHE (Sakitnya
Berdenyut)

denyut nadi p.d. kecilpun

dapat menimbulkan rasa nyeri

PATHOLOGICAL PAIN

 PATHOLOGICAL PAIN
MALADAPTIVE PAIN, can be;
Neurophatic pain
Dysfunctional pain
Is a disease of nervous
system
suffering, reduce QoL.

CRPS (Complex Regional Pain Syndrome)

DYSFUNCTIONAL PAIN
FIBROMYALGIA

Pathological pain
C

Spontaneous pain
Pain hypersensitivity
Peripheral
Nerve damage

Neuropathic pain
Neural lesion
Positive and negative
symptoms

Injury
Stroke

Abnormal
Maladaptive, low-threshold pain
Central processing Disease state of nervous system
Spontaneous pain
Pain hypersensitivity
Normal peripheral
Tissue and nerves

Dysfunctional Pain
No neural lesion
No inflammation
Positive symptoms
Abnormal
Central processing

Modify by
AHT

Nociceptive
pain

Pain

Perbandingan nyeri nosiseptif, nyeri

inflamasi dan nyeri patologis

No stimulus

Response
duration

Pain

Inflammatory
pain

Neuropathic
pain

No stimulus

Modified by AHT

Response
duration

Pain

No stimulus

Response
duration

Thank you
very much