Pain Neuroscience

7/17/2019 Pain Neuroscience

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PainPain

I Putu Pramana SuarjayaI Putu Pramana Suarjaya



Pain :Pain :““unpleasant sensory & emotionalunpleasant sensory & emotionalexperience associated with actualexperience associated with actual

or potential tissue damage oror potential tissue damage ordescribe in terms of such damage”describe in terms of such damage”

Nyeri erupa!an PengalamanNyeri erupa!an Pengalaman

Sensori! dan "mosional yang #ida!Sensori! dan "mosional yang #ida!

enyenang!an $!ibat $danyaenyenang!an $!ibat $danya

%erusa!an $ncaman %erusa!an%erusa!an $ncaman %erusa!an 'aringan 'aringan



ultidimensional :ultidimensional :

Neurophysiologic(iochemicalPsychologic"thnocultural)ogniti*e

a+ecti*e

$lways subjecti*e

$ sensation & unpleasant

physical & non physical component

Pain



Pain echanismPain echanism

Series of complex neurophysiologic processSeries of complex neurophysiologic process

,transduction,transmission

,modulation,perception

- distinct components- distinct components::



Pain PerceptionPain Perception

Adapted from Goldstein A. Hospital Practice 1978 1:32Adapted from Goldstein A. Hospital Practice 1978 1:32

Dorsal RootDorsal Root

GanglionGanglion

BrainBrain

DorsalDorsal

HornHorn

ncep!alinncep!alin

interne"roninterne"ron

Descending controlDescending control

pat!#a$ from %asepat!#a$ from %ase

of %rainof %rain

&ociceptor &ociceptor


e'o(ede'o(ed

disc!argesdisc!arges

)pinal *ord)pinal *ord

BrainstemBrainstem

&ociceptor sensiti+ation&ociceptor sensiti+ation

ncep!alinncep!alin

interne"roninterne"ronDorsal RootDorsal Root

GanglionGanglion

DorsalDorsalHornHorn

↑ sensiti'it$ to norepinep!rinesensiti'it$ to norepinep!rine

!eat , cold- local ion fl"es !eat , cold- local ion fl"es

mec!anical stim"lation mec!anical stim"lation&ociceptor &ociceptor

&ocicepti'e&ocicepti'e

transmissiontransmission

'ia ascending'ia ascendingpain pat!#a$spain pat!#a$s

/spinot!alamic tract0/spinot!alamic tract0)pinal *ord)pinal *ord



Pain NeurochemistryPain Neurochemistry

o %raino %rain

DorsalDorsal

HornHorn

)"%stance P- aspartate-)"%stance P- aspartate-

ne"rotensin- gl"tamatene"rotensin- gl"tamate


DorsalDorsal

rootroot

ganglionganglion

iss"e in"r$iss"e in"r$

Brad$(ininBrad$(inin

le"(otrienesle"(otrienes

ononfl"esfl"es

/H/H44 , 5 , 54400

ProstaglandinsProstaglandins

ransmission 'iaransmission 'iaspinot!alamicspinot!alamic

tracttract

to %rainto %rain

)"%stance P)"%stance P

HistamineHistamine

)ensiti+ed)ensiti+ed

nociceptor nociceptor



Peripheral Ner*e PhysiologyPeripheral Ner*e Physiology

Nociceptor .Pain/eceptor0

#ransduction

1etecting noxious stimuli

Screening impuls to )NS

No adaptation .protecti*e e+ect0

echanical2 thermal2 chemicalstimulus action potential

3yperalgesia

1ecreased Pain tresholddue to local release ofmediator



$llodynia

Pain sensation in response to

normally non painful stimuli

#ransmission



4ast & Slow Pain

4ast pain

Short2 well locali5ed2 stabbing sensation2

match to stimulus such as pinpric!Stimulation of small2 myelinated $,delta

Slow Pain

#hrobbing2 burning2 aching2 poorlylocali5ed

)ontinue after stimulus

,



$scending Pain$scending Pain

PathwaysPathwaysDorsal RootDorsal Root

DorsalDorsalRootRoot

GanglionGanglion

o Braino Brain

*orticospinal*orticospinalractract

)pinot!alamic)pinot!alamic

ractract

*lass - *lass -

ne"rons %ecomene"rons %ecome

!$perecita%le!$perecita%le

A6Delta fi%ers:A6Delta fi%ers:

)!arp- s!ooting pain)!arp- s!ooting pain

A6Delta and * fi%ersA6Delta and * fi%ers

* fi%ers:* fi%ers:

D"ll- ac!ingD"ll- ac!ing

%"rning pain%"rning pain

Prolonged acti'ation of primar$ afferentProlonged acti'ation of primar$ afferent

nociceptor sensiti+e spinal c!ord ne"ronsnociceptor sensiti+e spinal c!ord ne"rons



odulation of Nociceptionodulation of NociceptionPeripheral odulation

Spinal odulation

7iberation & elimination neurotransmitter

sP2 glutamate

(rady!inin2 histamine prostaglandins2 serotonin2% + 2 382 lactic acid

"xcitatory

substance

Inhibitory substance

9$($2 glycine2 en!ephalins2 endorphins2

norepinephrine2 dopamine2 adenosine

9lu2 aspartat2 neuropep2 sP



Supraspinalodulation

)ogniti*e odulation

1escending inhibitorytract

$bility to relate painfulexperience

nly 6xed number of impulsereach cotical center

Neuroplasticity

)entral sensitisation ,;2 functionalchange in

Spinal cord processing



1orsal 3orn & ascending Nocicepti*epathway

#halamus & )erebral

)ortex

9ate )ells

)entralSensiti5ation

)NS Physiology)NS Physiology

h f i idP h f i id



Pathways of pioidPathways of pioid

$cti*ity$cti*ityBrainBrain Pain PerceptionPain Perception

DorsalDorsal

HornHorn

ncep!alinncep!alin


DescendingDescending

imp"lseimp"lse

from %asefrom %ase

of %rainof %rain

&ociceptor &ociceptor &ociceptor &ociceptor

e'o(ede'o(ed



BrainBrain

stemstem

DorsalDorsal

RootRoot

GanglionGanglion

Periac"ed"ctalPeriac"ed"ctal

gra$ matter gra$ matter

Peria'entric"larPeria'entric"lar

gra$ matter gra$ matter

&"cle"s Rap!e&"cle"s Rap!e

agn"sagn"s

pioidpioid

agent6receptoragent6receptor

%inding site%inding site

DescendingDescending

imp"lseimp"lse

from Rap!efrom Rap!e

n"cle"sn"cle"s

&ociception&ociception

in!i%itedin!i%ited&e"roreceptor &e"roreceptor

&e"ro6&e"ro6

transmitter transmitter

)"%stance P)"%stance P

AfferentAfferent

ne"ronne"ronfromfrom

dorsaldorsal

RootRoot

GanglionGanglion




Pain PerceptionPain Perception



GanglionGanglion

BrainBrain

DorsalDorsal

HornHorn

ncep!alinncep!alin


Descending controlDescending control

pat!#a$ from %asepat!#a$ from %ase

of %rainof %rain



e'o(ede'o(ed



BrainstemBrainstem

&ociceptor sensiti+ation&ociceptor sensiti+ation

ncep!alinncep!alin



GanglionGanglion

DorsalDorsalHornHorn

↑ sensiti'it$ to norepinep!rinesensiti'it$ to norepinep!rine

!eat , cold- local ion fl"es !eat , cold- local ion fl"es

mec!anical stim"lation mec!anical stim"lation&ociceptor &ociceptor

&ocicepti'e&ocicepti'e

transmissiontransmission

'ia ascending'ia ascendingpain pat!#a$spain pat!#a$s

/spinot!alamic tract0/spinot!alamic tract0)pinal *ord)pinal *ord



Sub-optimal pain management canSub-optimal pain management can

have serious consequences…have serious consequences…

Decreased

mobilisation

Acute postoperative pain

Induction ofchronic pain

Increased risk of

deep vein thrombosis, pulmonary embolism,

myocardial infarction and coronary ischaemia

Mortality/morbidity, longer hospital stay, re-admission, decreased quality of life,

decreased patient satisfaction and increased health costs

Ballantyne et al . Anesth Analg 1998;86:598;

Wu et al . Anesth Analg 2003;97:1078;

Pavlin et al . Anesth Analg 2002;95:627;

Anesthesiology 2004;100:1573;

Pe!ins et al . Anesthesiology 2000;93:1123

Clinical and

psychological changes

Inadequate pain

management



)lassi6cation of Pain

1uration

Pathophysiology

$cute

)hronic

Nocicepti*e

*isceral

somatic

Neuropathic



$cute Pain

<ell de6ne tissue damage

7imited duration

Nociceptors return to

normal treshold

)hronic Pain

Persistent pain

ay ha*e both nocicepti*e &neuropathic element

ften has no detectable pathology



TERIMA KASIHTERIMA KASIH

Pain Neuroscience

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