BASIC PRINCIPLES OF PAIN.ppt

7/25/2019 BASIC PRINCIPLES OF PAIN.ppt

1/48

Curriculum Vitae

Resource Exchange Programmed For Asia (REP-ASIA), Singapore,

2010

Secrear! o"#

$ %aiona& Pain Sud! 'roup o" Perdossi

$ Indonesian Pain Socie! hie" o" #

$ Pain Sud! 'roup o" Perdossi haper og*a+ara

$ Pain Su eparmen, %euro&og! eparmen , .ni/ersias

'ad*ah ada Sa"" o" %euro&og! eparmen, Facu&! o" edicine, .ni/ersias

'ad*ah ada


2/48

PAI%

(BASIC CONCEPT OF PAIN)BASIC CONCEPT OF PAIN)

udi!ana

Pain Su-ep o" %euro&og! '.


3/48

3.%.%'A% P45I35I%I3 SARAF RSS 67 2008


4/48

e"ining o" Pain

9Pain Experience:

Pain is a personal, subjective experience tat co!prises "

Sensor#$%iscri!inative, &otivational$a''ectivean% Co(nitive$evaluative%i!ensions

Ronald Melzack, Textbook of Pain 4thedition

S

o!ati*ation

+++++

,epression

Expec

tation-

,esir

e

Anxie

t#

Catastropi*ation

9An unp&easan sensor! andemoiona& experienceassociaed ;ih acua& or

poenia& issue damage, ordescried in erms o" suchdamage:

Inernaiona& Associaion "or he Sud! o" Pain(IASP) 1


5/48

Classi'ication o' Pain

Physiologic / nociceptive:

1

Pain arising from activation of nociceptors Caused by mild and short noxious impulses which usually relieved without any

medication or mild analgesics Example: Pinched, stung by mosuito

Inflammatory:2

Pain caused by in!ury to body tissues "musculos#eletal, cutaneus or visceral$ Example: Pain due to inflammation, limb pain after fracture

Neuropathic:1

Pain arising as a direct conseuence of a lesion or disease affecting the somatosensorysystem

Example: %P&, P'&

Psychogenic (functional):3

Pain due to abnormal responsiveness or function of the nervous system withoutneurologic deficit or peripheral abnormality(

Example: )ibromyalgia, irritable bowel syndrome


6/48

'racture@

Postoperative

On(oin( or

i!pen%in( injur#

sprain

In'la!ation .

In'ection

In'iltrate% or co!presse%

/tu!ors)

stran(ulate%

/scar tissue)

&uscle Stretc

in'la!e% /in'ection )

6!pe or aegor! o" Pain

3. Psychogenic

c&ear hano somaic disorder

is presen

1. Nociceptive-

Inflamatori

aused ! aci/i!

in neura& pah;a!sin response o poenia&&!

issue-damaging simu&i

2. Neuropathic

Iniiaed or caused !

primar! &esion or

d!s"uncion

in he ner/ous s!s

!. "i#e$ type

aused ! acominaion o" oh

primar! in*ur! or

secondar! e""ecs

6he Assessmen o" he Paien ;ih Pain, Se/en Richeimer, irecor .S Pain anagemen, .S edica& ener, 5os Ange&es, A, .SA, 200

o'ascial pain


7/48

6he oninuum o" Pain6he oninuum o" Pain11


8/48


9/48

S!all$'iber sensor# 0ar(e$'iber sensor# Autono!ic

$Burnin( pain

$Allo%inia

$1#peral(esia

$1#perestesia

$Parestesia.%#sestesia

$0ancinatin( pain

$0oss o' pain - te!p2

sensation

$Foot ulceration

$0oss o' visceral pain

$0oss o' vibration

$0oss o' proprioception

$0oss o' re'lexes

$Slo3e% NC4

$1eart rate abnor!alities

$Postural #potension

$Abnor!al s3eatin(

$5astroparesis

$Neuropatic %iarrea

$I!potence

$6etro(ra%e ejaculation


10/48

Nociceptive afferent fi'er

Nor!al Nerve I!pulses 0ea%in( to PainNor!al Nerve I!pulses 0ea%in( to Pain

No#ious

stimuli

escen$ing

mo$ulation

%scen$ing

input

pinal cor$

Perceive$ pain


11/48

Nociception

pinothalamicpinothalamictracttract

PeripheralPeripheral

nervenerve

orsal *ornorsal *orn

orsal rootorsal root

ganglionganglion

PainPain

"o$ulation

+rans$uction

%scen$ing%scen$ing

inputinput

escen$ingescen$ing

mo$ulationmo$ulation

PeripheralPeripheral

nociceptorsnociceptors

+rauma+rauma

;dapted from


12/48

Activation

External

Stimuli

Heat

Mechanical

Chemical

VR1

Ca2+

mDEG

P2X3

Generator potentials

action potentials

Voltage gated sodium channels

Pain and auto-sensitization

Wool ! Mitchel" 2##1

Transduction

;6P

&a@

Modifikasi Meliala, 2003

ACTION POTENTIALACTION POTENTIAL

,%,%N 0%IN%N

IN%"%I

% "I N4

NI+I%I

%,+I%I&+. I&.

i-Na5

,4N 4%I

Pg67 8*+7 %$enosin

Pengalaman

,ognitif

6ehaviour

Psiologi

Inhi'isi

$esen$en4+%,

P%IN 9 N4 P%IN

-N


13/48

An(er

Fear

Anxiet#

epression

Noxious Sti!uli

PS

1(74

54

'I(

A5

%4IEP6I?E

A

B

&E0IA0A 7889


14/48

:at is In'la!!ator# Pain+:at is In'la!!ator# Pain+ 4"en c&assed a&ong ;ih acue pain as nocicepi/e, re"ers o he4"en c&assed a&ong ;ih acue pain as nocicepi/e, re"ers o he

sponaneous pain and enderness "e&sponaneous pain and enderness "e&;hen issue is in"&amed;hen issue is in"&amed

Pain caused !Pain caused ! in*ur! o od! issuesin*ur! o od! issues(muscu&os+e&ea&, cuaneous or(muscu&os+e&ea&, cuaneous or

/iscera&)/iscera&)

Pain"u& region is !pica&&! &oca&iCed a he sie o" in*ur!$ o"en descried as

hroing, aching or si""ness

.sua&&! ime-&imied and reso&/es;hen damaged issue hea&s (eg one

"racures, urns and ruises)

an a&so e chronic(eg oseoarhriis, rheumaoid arhriis)

.sua&&!.sua&&! responsi/eresponsi/eo %SAIso %SAIs


15/48

%4IEP6I?E PAI%


16/48


17/48

Prosta(lan%ins pro%uce%

in response to tissueinjur#; increase sensitivit#o' nociceptor /pain)

Nociceptor ten releasessubstance P, 3ic %ilates

bloo% vessels an% increases

release o' in'la!!ator#

!e%iators, suc as Bra%#


18/48

Dha is %europahic painDha is %europahic pain

%efinition:

Pain arising as a direct conseuence of a lesionor disease affecting

the somatosensory &EAVE system

CharacteriBed by:

Pain often described as shooting, electric shoc#.li#e or burning(

6he painful region may not necessarily be the same asthe site of

in!ury(

;lmost always a chroniccondition "e(g( post herpetic neuralgia, post

stro#e pain$

Aesponds poorlyto conventional analgesics


19/48

IASP Classi'ications"IASP Classi'ications"Periperal Neuropatic an% Central Neuropatic PainPeriperal Neuropatic an% Central Neuropatic Pain

oeser D%, 6reede A%( 6he =yoto Protocol of +;P 2asic Pain 6erminology( Pain033541->:?>-.?>>(

Neuropathic painPain arising as a direct consequence of

a lesion or disease affecting the

somatosensory system

Peripheral neuropathic painPainarising as a direct consequence of


peripheral somatosensory system

Central neuropathic painPainarising as a direct consequence of


centralsomatosensory system


20/48

Pahoph!sio&og! o" %europahic PainPahoph!sio&og! o" %europahic Pain

NeP

&entral mechanisms

Peripheral mechanisms

Peripheral Neuron

hypere#cita'ility

oss of

inhi'itory controls

&entral Neuron

hypere#cita'ility

(central sensitiation)

%'normal

ischarges


21/48

Periphera& echanismPeriphera& echanism(Ecopic ischarges)(Ecopic ischarges)

Nerve lesion in$uces hyperactivity $ue to changes in ion channel function

Ectopic dischargesEctopic discharges

Nerve lesion

pinal cor$


escen$ing

mo$ulation

%scen$ing

input

Perceive$ pain


22/48

enra& echanism (5oss o" inhiior! conro&s)enra& echanism (5oss o" inhiior! conro&s)

oss of $escen$ing mo$ulation causes e#aggerate$ pain $ue to an im'alance

'et;een ascen$ing an$ $escen$ing signals


No#ious

stimuli

%scen$ing

input

pinal cor$

oss of

$escen$ing

mo$ulation

#aggerate$ pain

perception


23/48

+ntact tactile fiber

enra& echanism (enra& sensiiCaion)enra& echanism (enra& sensiiCaion)

A"er ner/e in*ur!, iA"er ner/e in*ur!, increased inpu o he dorsa& horn can induce cenra&ncreased inpu o he dorsa& horn can induce cenra&

sensiiCaionsensiiCaion Perceive$ pain

%scen$ing

input

escen$ing

mo$ulation

Nerve lesion

&ociceptive afferent fiber

+actile

stimuli

Perceive$ pain

(allo$ynia)

%scen$ing

input

escen$ing

mo$ulation

%'normal $ischarges in$uce central sensitiation


24/48

e/e&opmen o" %europahic Paine/e&opmen o" %europahic Pain

oolf and 9annion( ancet 14-F-:1F./?

Neuropathic pain

Spontaneous pain Stimulus-evoked pain

"echanisms

Metabolic Traumatic

ToxicIschemic

Hereditary

Compression

Infectious

Immune-related

yn$rome

ymptoms

Pathophysiology

tiology &erve damage due to:&erve damage due to:


25/48

Signs and S!mpoms o" %europahic PainSigns and S!mpoms o" %europahic Pain

%elayed, explosive response to any painful stimulus *yperpathia2

+ncreased pain from a stimulus that normally

provo#es pain( e(g( pinpric#, cold, heat *yperalgesia3

Pain due to a stimulus that does not normallyprovo#e pain(e(g( warmth, pressure, stro#ing

%llo$ynia3

timulus-evoe$

symptoms

;bnormal, not unpleasant sensations e(g( tingling Parasthesias2

;bnormal unpleasant sensations

e(g( shooting, lancinating, burning ysesthesias2

Persistent burning, intermittent shoc#.li#e or

lancinating pain pontaneous pain1

pontaneous symptoms

Description (exampleSi!n"S#mptom

1( 2aron( Clin D Pain( 033341/:10.03(0( 9ers#ey ' et al( "Eds$ +n: Classification of Chronic Pain: %escriptions of Chronic Pain yndromes and %efinitions of Pain 6erms( 1?:03.010(-( oeser D%, 6reede A%( 6he =yoto Protocol of +;P 2asic Pain 6erminology( Pain033541->:?>-.?>>


26/48

7!pera&gesia A&&od!nia7!pera&gesia A&&od!nia

.5?(

In


27/48

6he Iner-Re&aionship Be;een6he Iner-Re&aionship Be;een

Pain, S&eep, and Anxie! @ epressionPain, S&eep, and Anxie! @ epression

&icholson and Verma( Pain 9ed( 033?4F "suppl( 1$:.0>

Pain

leep$istur'ances

%n#iety Aepression

unctionalimpairment

Dha is he orre&aion Be een a ses sc &ar pain


28/48

Dha is he orre&aion Be;een auses, uscu&ar pain,

%euro-endocrine (7PA Axis) disorders and Ps!cho&ogica& disress

E!otional, Environ!ental an% 5enetic Pre%isposition

Cortex$0i!bic S#ste!$ 1#poca!pus

Tala!us - 1#potala!us

Pituitar#

A%renal,

T#roi%

Perception

C61, T61, 561, P6F, 5n61

ACT1, TS1, 51, Prolactine, FC1$01

Cortisone,T#roi%,

Prolactine, Estro(en, Pro(esterone

Neuro$or!onal is'unction

S#!patetic &etabolic

PAIN

&uscle Trau!aorsal 1orn


29/48

PAI% ASSESSE%6


30/48

Te =0 Approac to ia(nosisTe =0 Approac to ia(nosis

0ISTEN

0OCATE 0OO?Nervous s#ste!

lesion . %#s'unction

Sensor# abnor!alities,

pattern reco(nition

Patient verbal %escriptors,

@ - A


31/48

Pain Assessmen Sca&es

.ni-imensiona& Sca&e u&i-imensiona& Sca&e

Onl#measures pain inensi!Appropriae "or acute pain

6he mos common sca&e used inoutco!eassessmen (Ana&gesic

e""icac!)

2oth intensity (severity)and

unpleasantness (affective)

;ppropriate for chronic painesearch /pathophysiologyhoul$ 'e use$ in clinicalhoul$ 'e use$ in clinical

outcome assessmentoutcome assessment

4erbal 6atin( Scale /46S)

None, !il%, !o%erate, severe

Nu!eric 6atin( Scale /N6S)

4isual Analo( Scale /4AS)

Pictorial Scale

&c5ill Pain @uestionnaire /&P@)

Te Brie' Pain Inventor# /BPI)

Te &e!orial Pain Assess!ent Car%


32/48

.ni-imensiona& Pain Assessmen Sca&es


33/48

P t i .N i P i S l


34/48

Poto(rapic.Nu!eric Pain Scale


35/48

u&i-imensiona& Pain Assessmen Sca&es


36/48

@uic


37/48

Patient Pain %iary

"orning %fternoon vening 6e$time

Pain

)cale

1=

8

=ose ose


38/48

I PAI% # Screening oo& o he&p di""ereniae

nocicepi/e "rom neuropahic pain

%europahic pain screening Guesionnaire

A mu&icener sud!

Paiens (% H >8) ;ih non-headache chronic painA secondmu&icener sud! (% H J>=) e/a&uaed re&iai&i! and /a&idi! >)#1-8


39/48


40/48

0ocation# Patient or nurse !ar


41/48

:atcauses orincreases te pain+

E''ect o' pain# /Note %ecrease% 'unction, %ecrease% Dualit# o' li'e)

Oter co!!ents"

Plan"

Accompan!ing s!mpoms (eg nausea)

S&eep

Appeie

Ph!sica& aci/i!

Re&aion ;ih ohers (eg irriai&i!)

Emoion (eg anger, suicida&, cr!ing)

onsenraion

4her


42/48

Pas edica& 7isor!

1 edica& re&aed pro&ems

2 Pro&ems poenia&&! a""ec he choice o" pain

reamens

J Prior or curren susance ause hisor!


43/48

urren edicaions

1 osage and paern o" use

2 E""eci/eness

J rug o&erance


44/48

Ph!sica& Examinaion

6he hisor! ;i&& o"en generae a di""erenia& diagnosis 6he ph!sica& exam ;i&& o"en &ead o he se&ecion o" he primar!

diagnosis, and occasiona&&! a es ;i&& he&p o con"irm his diagnosis

1 ena& saus exam ("acia& expression)2 ?ia& signs

J Inspecion (od! posiion, gai, redness, s;e&&ing)

= Pa&paion uscu&os+e&ea& exam (aroph!, &ocaion

enderness o pressure, mass, ) %euro&ogic Examinaion (Sensor!, oor, Auonomic)


45/48

%E.R454'I EMAI%A6I4%

Possii&i! #

$ spina& cord compression,

$ ner/e roo &esions

$ periphera& ner/e &esions

Sensor! Exam#$ numness,

$ a&&odinia,

$ h!pera&gesia

ooric# "racure eep endon re"&exes

Sacra& Re"&exes


46/48

Ps!cho&ogica& E/a&uaion

1 ood disorder (0K chronic pain)

2 SomaiCaion

J Secondar! gain

= S&eep and appeie disurance

5oss o" energ! and &iido8 Impaired concenraion

Suicida& ideaion

> Impac o" he pain on he paien$

da!-o-da! aci/iies$ ;or+ "inances

$ persona& re&aionships

$ recreaiona& pursuis

4%5.SI4%S


47/48

ou are he on&! one ;ho +no;s ho; much pain !ou are "ee&ing

A&& paiens reGuire pain assessmen $

i is as essenia& as he oher /ia& signsN(Helen Geene!

If Bou onCt "easure It7 Bou &anCt Improve It(iel$ et al7 1DDE)

4%5.SI4%S


48/48

Documents

BASIC PRINCIPLES OF PAIN.ppt