Académique Documents
Professionnel Documents
Culture Documents
Chronic Pain
Yuneldi Anwar
Department Neurology
Medical Faculty of North Sumatera
Perception
Descending
Pathway
Ascending
Pathway
Spinal
Cord
C-Fiber
- Fiber
- Fiber
Conduction
Peripheral
Nerve
Transduction
Dorsal
Horn
Dorsal
Root
Ganglion
Injury
1. Galer BS, Dworkin RH. A Clinical Guide to Neuropathic Pain. Minneapolis, MN: McGraw-Hill; 2000.
2. Irving GA, Wallace MS. Pain Management for the Practicing Physician. New York, NY: Churchill Livingstone; 1997.
3. Woolf CJ, et al. Ann Intern Med. 2004;140:441-451.
Transmission/
Modulation
NOCICEPTION
Nocious Stimuli
mechanical thermal chemical electrical
Tissue damage
Release of mediators
Hydrogen and potassium ions,
neurotransmitters, kinins, prostaglandins
Stimulation of nociceptors
Transmission to CNS
via afferent pathways
Robert W. Gereau IV, PhD, and Judith P. Golden, PhD. Peripheral Mechanisms and Persistent pain, 2014
Stage of Nociception
Perception
3.Modulation
2.Transmission
1.Transduction
Nociceptor
Free nerve ending
Least differentiated
Cell body at dorsal root
ganglia and trigeminal
ganglia
Synapse in dorsal horn
of spinal cord
On local interneuron
On projection neuron
A & C fiber
Stage of Nociception
Perception
3.Modulation
2.Transmission
1.Transduction
10
11
Stage of Nociception
Perception
3.Modulation
2.Transmission
1.Transduction
13
Descending fibre
Endorphins
in the synapse
Presynaptic
neuron
Signal from
brain to inhibit
pain signal
Opiate
receptor
Glutamate
Receptor (non-NMDA)
Postsynaptic
neuron
14
ACUTE PAIN
Tissue
injuries
Healing
Subside pain
CHRONIC
/PERSISTENT PAIN
Tissue
injuries
Healing
Does not
Subside pain
Patologic condition
General differences
between acute and chronic pain
Acute pain
Chronic pain
No reporting, protective, or
healing function
Becomes a free-standing
pain disease
Examples: post-traumatic or
post-operative pain, toothache
21
Working Group A.M.A.D.E.U.S. Basic Course in Treatment of Chronic Pain Cologne 2003
1. NociceptiveInflamatorik
Caused by activity
in neural pathways
in response to potentially
tissue-damaging stimuli
fracture /
Postoperative
Ongoing or
impending injury
4. Mixed type
Caused by a
combination of both
primary injury or
secondary effects
2. Neuropathic
Initiated or caused by
primary lesion or
dysfunction
in the nervous sys.
sprain
Inflamation /
Infection
Muscle Stretch
strangulated
(scar tissue)
Myofascial pain
inflamed (infection )
Infiltrated or compressed
(tumors)
The Assessment of the Patient with Pain, Steven Richeimer, M.D. Director USC Pain Management, USC Medical Center, Los Angeles, CA, USA, 2007
NOCICEPTIVE PAIN
Noxius Pheripheral Stimuli
Heat
Pain
Autonomic Response
Witdrawal Reflex
Cold
Brain
Intense
Mechanical
Force
Heat
Cold
Modifikasi Meliala, 2005
Spinal cord
NOCICEPTIVE PAIN
INFLAMMATORY PAIN
Inflammation
Macrophage
Spontaneous Pain
Pain Hypersensitivity
Reduced Threshold : Aliodyna
Increased Response : Hyperalgesia
Mast Cell
Neutrophil
Granulocyte
Brain
Tissue Damage
Prostaglandin
Sitokin
Bradikinin
Substansi P
Modifikasi Meliala, 2005
Spinal cord
Thermal/
SP: vascular permeability; CGRP: long-lasting vasodilation
Characterized by:
Pain often described as pinprick sensation, numbness,
Peripheral Neuron
hyperexcitability
Central mechanisms
Loss of
inhibitory controls
Central Neuron
hyperexcitability
(central sensitization)
NeP
Central sensitization
Wind- up phenomena
Genetic factor
Microglial activation
Neuroplasticity
CENTRAL SENSITIZATION
Increased spontaneous
discharge
Central Sensitization
result from low and
high nociceptive
stimulation
increased excitability
neurons at DH
Injury to PNS or
Inflammation in spinal
cotd and brain
increasing excitability
of spinal nociceptive
neurones through
removal on an
inhibitory influence, or
disinhibition ( Sherman,
SE, Loomis ,CW, 2004 )
Genetic Factor
Mutation inactivation of spesific sodium
channel unable to feel pain (Fertleman CR,
Baker MD, Parker, KA, et al. 2006 )
Other mutation ifluence modify the kinetic
of sodium channel perception of persistent
pain ( Yang Y, Wang Y, Li S, et al, 2004)
Neuroplasticity
Chronic pain disease affecting brain structure
and function (neuroplasticity) , MRI studies have
showns abnormality anatomical and functional
connectivity involving area related to the
processing of pain (Geha PY, Baliki MN, Harden
RN, et al ;2008)
CONCLUSIONS