Dasar-dasar Nyeri Akut, Neuropatik dan Kronik

Andi Husni TanraKetua Program Studi Sp2 Ilmu Anestesi

Fakultas Kedokteran Universitas Hasanuddin

Makassar

Dibawakan pada kuliah perdana peserta fellow IPM ke-2, 7 Nov 2017 di Makassar

Menurut IASP 1979 “ Pain is define as: an unpleasant sensory

and emotional experience associated with actual or potential

tissue damage or describe in term of such damage. (Harold

Merskey )

Definisi Nyeri

Makna dari definisi ini adalah:

Key word of pain is unpleasant sensory and emotional

experience (rasa yg tdk menyenangkan sensorik dan emotional).

Associated with actual tissue damage (Acute Pain =Nociceptive

pain)

Due to potential tissue damage (Nociceptive pain = Physiological pain =

withdrawal Reflex)

Described in term of such damage (digambarkan seperti adanya

kerusakan jaringan .(tapi tidak) chronic pain .

• Nyeri nosiseptif adalah nyeriyang terjadi akibat adanyasuatu stimulus kuat(Mekanik, termal ataukimiawi) pada jaringan yang intact (utuh).

• Jadi ada Potential tissue damage yang menghasilkanwithdrawal reflex.

• Belum ada kerusakanjaringan.

• Gunaya sebagai alat proteksitubuh dari berbagaikerusakan.

1. Nociceptive Pain

WITHDRAWAL REFLEX

Nociceptive pain Minimal tissue damage

1. Acute Pain

• With actual tissue damage (ada kerusakan jaringan).

• Noxious stimulus Nociceptive painAcute Pain.

Nociceptive Pain

Sebenarnya pembedahan dimulai dgn nyeri nosiseptif nyeri akutnyeri inflamasi sembuh nyeri hilang, kalau sembuh tapi nyerinya menetap nyeri kronik.

Acute pain is the normal, predicted physiologic response to an adverse chemical, thermal, or

mechanical stimulus… associated with surgery, trauma, or acute illness.

Nyeri Akut adalah; respon fisiologik normal yang dapat diramalkan terhadap stimulus perusak

kimiawi, termal atau mekanik …. berkaitan denganpembedahan, trauma, atau penyakit akut

Definition of Acute pain

` (Federation of State Medical Board of the United Stated 1999.)

Mechanical

Thermal

Chemical

Transduction

Conduction

Modulation

Transmission

Persepsion

Neuron I

Neuron II

Neuron III

Modified by AHT

Transmission

Action potential

Diantara simulus noksius dan persepsi ada 5 proses yg tersendiri yaitu; Nosisepsi (respons saraf terhadap stimulus noksius)

1. Transduksi2. Konduksi3. Modulasi4. Transmisi5. Persepsi

Mekanisme Nyeri Nosiseptif atau Nyeri Akut

Ciri chas nyeri nosiseptif

• Nyeri yang di tandai dengan

Adanya jaringan rusak atau inflamasi

Nyeri kalau diraba, ditekan ataudigerakkan.

• Gejala nyerinya

Aching (sakit) atau

Throbbing (berdenyut)

Alur nyeri dimulai dari aktivasi nosiseptor.

AbnormalCentral processing

Maladaptive, low-threshold painDisease state of nervous system

PeripheralNerve damage

Neural lesionPositive and negativesymptoms

Neuropathic pain

Spontaneous painPain hypersensitivity

Injury

Stroke

Modified by AHT

. Neuropathic PainAccording to IASP.Pain as ‘initiated or caused by a primary lesion or

dysfunction in the nervous system. Depending on

where the lesion or dysfunction occurs within the

nervous system, neuropathic pain can be peripheral

or central in origin

2. Neuropathic Pain

Neuropathic Pain: Positive and Negative Sensory Symptoms

Positive symptoms

(due to increased activity)

Dysesthesia (dys = sulit)

Sensory abnormalities and pain often co-exist

Paresthesia (Par = tdk biasa)

Spontaneous pain

Hyperalgesia

Allodynia Anaesthesia

Negative symptoms(due to deficit of function)

Nervous system damage

Hypoesthesia

Hypoalgesia

Analgesia

1. Jensen TS et al. Eur J Pharmacol 2001;429:1–11; 2. Gilron I et al. Can Med Assoc J 2006;175:265–75; 3. Baron R. et al. Lancet Neurol. 2010

Gejala Nyeri Neuropatik

• Umumnya pasien menyatakannya nyerinyasebagai nyeri yang lain dari biasanya.

• Paling sering dirasakan sebagai nyeri yang terbakar, (burning) atau seperti dikontaklistrik (tingling) atau seperti kesemutan .

• Ciri khas suatu neuropatik adalah jikaditemukan 2 gejala yakni gejala positip dannegatip. (misl. hiperalgesia dan hipestesia)

Sural nerve lesion

Peroneal nerve lesion(amputation of dig. 4)

Median nerve lesion

Post cut. lumbar nerve lesion

Peripheral nerve lesions : Allodynia and hyperalgesia

Burning, feeling like the feet are on fire

Stabbing, like sharp knives Lancinating, like electric shocks

Freezing, like the feet are on ice,

although they feel warm to touch

Modified by Meliala 2006

Inflammatory Pain Neuropathic Pain Dysfunctional Pain

(Idiopathic Pain)

Inflammatory, Neuropathic and Chronic Pain.

3. Chronic pain

Chronic pain is a pain that persists beyond normal tissue healing time, which is assumed to be three – six months.

The International Association for study of pain (IASP)

Pain that continues when it should not.

WHAT HAPPENS

LONG TERM…

“Pain is unpleasant sensory and emotional experience,

or….. ..described in terms of such damage”

• beyond the healing period

• no more tissue damage

• Longer than 3-6 months

Post herpetic Neuralgia LBP

Chronic Pain(persistent pain)

Low Back Pain

This terminology is misleading as the key

distinction between acute and chronic pain is not

the duration of pain, but for chronic pain its:

“Acute and chronic pain have nothing in common but

the four-

Persistence beyond nociception

(Pain without nociception)

Beyond expectation

Difficultes to treat

Produce suffering and reduced QoL

Chronic Pain

Characteristic of Chronic Pain?

• Subjective personal experience

• Cannot be seen, except by behavior

• Difficult to diagnose.

• Difficult to treat, and costly.

• Produce suffering and reduced QoL.

• It has no biologic value as a symptom

• Life permanently disrupted.

Duration

Tissue injury

Nerve conduction

Autonomic NS

Biological value

Social effects

Associated problems

Treatment

Prognosis

Chronic PainMonths to years

Commonly none

Slow

Generally no activation

Low or absent

Depression, anxiety, suicide

Profound

Multimodal:

• Behavioral

• Drugs have a moderate role:

Adjuvan: Antidepressants

Anticonvulsants

• Unpredictable

• Treatment aim of decreasing pain and

• suffering and improving functioning.

• Coping with pain, increase QoL

Acute PainHours to days

Present

Fast

Activated

High

Uncommon

Few

Analgesics

Predictable

Aim: cure

Adapted from Ashburn and Straats, 1999

Acute vs Chronic pain

Pain as a Continuum

http://www.slideshare.net/Painspecialist/understanding-pain-short

All chronic pain was once acute,

but not all acute pain becomes chronic.

Shipton EA Anaesth Intensive Care. 2011;39(5):824-36.

Chronic Pain

… is not prolonged acute pain

… must be considered and treated as a disease.

Central sensitization

Tachykinin (Substance P, Neurokinin A)

Glutamate

Presynaptic neurons

Ca2+

Ca2+

Na+ Na+/Ca2+

Na+

Ca2+

Depolarisasi

Protein Kinase C

Mg2+

NK1 NK2 AMPA NMDA

Postsynaptic neurons

G G

Secondary Hyperalgesia /Allodynia

Central Sensitization

neurons hiperexitable Modified by I.Yusuf 2000

PERIPHERAL ACTIVITY

CENTRAL SENSITIZATION

Lowered threshold to peripheral

stimuli

Increased spontaneous

activityExpansion ofreceptive

field

HyperalgesiaAllodynia

Tissue damage

Nerve damage

Spontaneous pain

Increase in the excitability of neurons within CNS, so that normal Inputs begin to produce abnormal response.

Central Sensitization

WHAT HAPPENS

LONG TERM…

Examples

Peripheral

• Phantom Limp pain

• Postherpetic neuralgia

• Trigeminal neuralgia

• Diabetic peripheral neuropathy

• Postsurgical neuropathy

Central

• Poststroke pain

Common descriptors2

• Burning

• Tingling

• Hypersensitivity to touch or cold

Examples

• Pain due to inflammation

• Limb pain after a fracture

• Joint pain in osteoarthritis

• Postoperative visceral pain

Common descriptors2

• Aching

• Sharp

• Throbbing

Examples

• Low back pain with

radiculopathy

• Cervical radiculopathy

• Cancer pain

• Carpal tunnel

syndrome

Mixed Pain

Pain with

neuropathic and

nociceptive

components

Neuropathic Pain

Pain initiated or caused by a

primary lesion or dysfunction

in the nervous system

(either peripheral or

central nervous system)1

Nociceptive Pain

Pain caused by injury to

body tissues

(musculoskeletal,

cutaneous or visceral)2

Possible causes of chronic pain

1. International Association for the Study of Pain. IASP Pain Terminology.

2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57

Central sensitization

• Sentral Sensitizatio is situation where second order neuron in spinal cord become Hyperexitabe(mudah terpicu), means normal nociceitive input will produce abnormal response.

• Central sensitization was primarily created by NMDA r, glutamat ligan to NMDA, Ca inflow, activated PKC Protein phosphorylation to many channels as well as receptors in turn make neurons hyperexitable.

Types of Pain: mechanism-based

1. Adapted from Julius D et al. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier; 2006, p. 35. 2. Jensen TS, et al. Pain 2011;152(10):2204-2205. 3. Treede RD, et al. Neurology 2008;70(18):1630-1635.

Nociceptive painPain caused byan inflammatory or

non-inflammatory

response to an overt or potentially tissue-damaging

stimulus1,3

Neuropathic painPain arising as a direct

consequence of a

lesion or disease

affecting the somatosensory system2-3

Centralized pain/

Idiopathic pain (Chronic pain)

Pain without identifiable nerve

or tissue damage; hypothesized to be a result persistent neuronal dysregulation or dysfunction

MIXED

Chronic pain is biopsychosocialphenomenon

Chronic pain is a biopsychosocialphenomenon,

but the ‘bio’ component is usually not classical nociception, but the result of a neurologic disease ( Central Sensitization)

Chronic pain is Biopsychosocial Phenomenon

Chronic Pain is aBiopsychosocial Phenomenon

Cognitive Behavior therapies

Functional restoration

Adjuvan drugs

Neural-augmentation

Ablative Surgery

Pain Behaviors

Suffering

Pain Perception

Nociception

Antidepressants/

psychotropics

Opioids

Relaxation

Spiritual

Local blocks

NSAIDS

Opioids

Physical

Modalities

Loeser JD.Cousins MJ.Med J Aust. 1990;153;208-212,216

XXXXXXXXCentral

Sensitization (wind-up)

Why chronic pain, is so danger ?

Because Chronic pain is • Biopsychosocial phenomenon,

Produce suffering Difficult to treat High cost Reduce quality of Life

Acute Pain is • Biomedical problem

Alarm protection A symptom of injury or disease

Biomedical vs. Biopsychosocial

Management Pain

Chronic pain

• goal of treatment is to improve function in occupational, social and emotional domains; pain relief is de-emphasised

Acute pain

• goal of treatment is to obtain pain relief

1

2

Biomedical vs. BiopsychosocialManagement of Pain

Acute pain• patient is ill, and

therefore should be free from normal responsibilities

Chronic pain

• patient is not ill, and should maintain normal activity levels as far as possible

3Biomedical vs. Biopsychosocial

Management of Pain

Acute pain primary

responsibility for improvement lies with the doctor; patient’s role is passive.

Chronic pain

primary responsibility for improvement lies with the patient -patient’s role is active.

Two great obstacles

• In treating chronic pain

1. Fear avoidance behavior

(Kinesiophobia = takut bergerak)

2. Passive treatment

(menginginkan pembedahan or massage) Mudah jadi korban pengobatan

Cancer pain

Pain

Chronic painAcute pain

Nociceptive pain

Neuropathic pain

Dysfunctional pain

Non-Cancer pain

For all the happiness mankind can gain, is not in pleasure,

but rest from pain.

John Dryden (1631-1700)

Thank you very muchFor your attention

Take home message

• Acute pain is a symptom, tell us that there is

something wrong in our body.

• Chronic pain is a disease entity and that must be

treated differently to acute pain.

• Since chronic pain is biopsychosocial phenomenon

it must be treated by multidisciplinary team with

multidisiplinary approach.