Introduction To Pain: Makassar
Introduction To Pain: Makassar
Introduction To Pain: Makassar
Professor of Anesthesiology
Department of Anesthesiology, IC and Pain Management
Faculty of Medicine Hasanuddin University
Makassar
What is pain?
Poisons
Tissue damage
Release of mediators
Stimulation of nociceptors
Transmission to CNS
2
How do we feel pain?
In normal situation!
Pain
Transmission
Perception
Modulation
Conduction
Noxious
stimulus
Transduction
Stimulate
Nociceptors
Regarding to the function of pain.
TWO KINDS OF PAIN
*Good Pain, is an alarm symptom, tell us that something
wrong in our body Acute Pain, pain with nociception
(nociceptive pain). alarm protection.
Disini nyeri seperti bel rumah bunyi kl ada tamu
ALLODYNIA
HYPERALGESIA
Modulation
Conduction
Noxious
stimulus Transduction
Stimulate
Nociceptors
Nociceptive Pain is pain that generated
from nociceptors. Nyeri yang dibangkitkan
dimulai dari nosiseptor
1. NOCICEPTORS
What is a nociceptor? reseptor nyeri
Nociceptors are peripheral sensory
neurons that respond selectively to
noxious stimuli (Stimulus kuat).
Or A number of receptors/channels that
sense damage
VR1 - vanilloid receptor family
ASICs - respond to low pH
P2X receptors - respond to ATP
TRPs receptors – respond temp.
Chemical sensors - prostaglandins,
Diciptakan Tuhan guna melindungi diri kita
dari bahaya.
Tissue damage and pain in the periphery
ATP
capsaicin Mechanical?
heat DRG
COX1/2
H+
cold
PGs warm ATP
C-fibre
TRPVs ASICs EPs TRPs P2X
Na+, K+,
Ca2+
channels
2. SENSORY NERVE
AFFERENT
Sensory Nerve
Afferent
A
C A
Two sensory afferent neurons
1. Large myelinated A fibers, very fast conduction velocity. Respond to
innocuous stimuli
2. Small myelinated A & C unmyelinated fibers, have slow conduction
velocity. Respond to noxious stimuli
Large
fibers A
Dorsal root
ganglion Dorsal Horn
A
Small
fibers
C Peripheral sensory
Nerve fibers
Modified by AHT
Afferent Synaptic in DHN
Substantia
Marginal layer
gelatinosa
A Medial
A
C
Lateral
Nucleus
proprius
Characteristic of A and C-fiber
A Fiber
Rapid Conduction
MechanoThermal Glu
Nociceptors
First Pain
C-Fiber
Slow Conduction Glu
Polimodal
Nociceptors sP
Secound
Pain
Two distinct responses to a noxious stimulus
FIRST PAIN and SECOUND PAIN
Modified by AHT
The Role of A fiber
Although in normal condition A fiber does not response to
noxious stimuli, but it plays a big role in NORMAL
SENSATION.
A
1. TRANSDUCTION
2. CONDUCTION
TRANSDUCTION
TRANSDUCTION
Process whereby noxious
Pressure
stimuli are translated
into electrical activity at
the sensory endings of
nerve Heat
Chemical
“Noxious Soup”
1. TRANSDUCTION PROCESS
(NOCICEPTORS ACTIVATION and CONDUCTION)
Local &
Vescular
Mediators- Action Potential
Ca++
Bradykinin,
Cytokines Peptides- TRP Na+
Histamine, sP, CCK,
5HT. CGRP
Traumatic
Tissue Mediators-
Injury K+, H+,
ATP,PGE
In Creased Neural
Synthesis Mediators- TRP Ca++
Pro Epine,
Inflammatory Norepine
Generator
Cytocaines
Potential
-(IL) 1
-IL-6
TRP (Transient Receptor Potential) Ion
Channel is a Transducer molecules. Modified by AHT
R. Sinatra 2007
Transduction and Conduction Process
Ca2+
K+
K+
Na+
Transduction
Mechanical Conduction
Transmission
Modulation
Neuron II
Thermal
Neuron I
Chemical
Modified by AHT
3. MODULATION in DHN
Dorsal Horn neurons of SC
Plays a big role in pain perception
Is the first gate to control pain.
Nociception (Pain) is born in DHN
Lehmann, K. A.: From the first stimulus to pain memory. UN. Cologne, 2000 36
Modulation in Dorsal Horn Neurons
Done by Descending neurons & Interneurons
Modulation at DH 37
SITES OF ENKEPHALIN BINDING IN SPINAL CORD.
PLAYED BY DESCENDING INHIBITORY AND INTRNEURON INHIBITORY FIBER
Enkephalinergic
Interneuron
(Inhibitory)
Primary
Nociceptive
Presynaptic Opioid
Fiber
Receptors
(-)
ENK ENK
Postsynaptic
Opioid Glutamate
Receptors Receptors ENK
(-)
Descending
(+)
Enkephalinergic
Fiber (Inhibitory)
ENK
Spinal Sensory
Neuron
Modified by AHT
Modulation
Peranan Modulasi dalam kehidupan
1. MODULATION
2. TRANSMISSION
4. ASCENDING PATHWAYS
Pain
Medulation
Descending
modulation Dorsal Horn
Transduction
Spinothalamic Peripheral
tract nerve
Trauma
Peripheral
nociceptors
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
Modified by AHT
5. DESCENDING MODULATING
PATHWAYS
Brain is a huge
Pharmacetucal
Ascending Descending
pathways pathways
Factory.
Descending Modulatory
Cortex
Systems
PAG
Opioids
NRM LC
Opioids
Dorsal homs
Modified by AHT
Begitu kuatnya proses
Desendern sehingga orang ini
seperti tidak punya Otak.
Perception is on the brain, so
No brain no pain.
How pain perception is processed, still obscured, and
Where pain perceptions in the brain still unclear.
Noxious perception?
Pain A number of theories:
Perception Brain
SS
1. Specificity theory by Descartes
SS Limbic Cortex
(16 century)
Sensory Cortex
Thalamus 2. Gate control theory by Melzack
and Wall (i965)
3. Sensitization theory by Woolf et
al (1990 an)
1. Specificity theory
Descartes
(17th Century)
Pain was
faithfully
transmitted
from
periphery to
brain
Modified by AHT
NO BRAIN, NO PAIN
2.GATE CONTROL THEORY by MELZACK and Wall
Central Descending
Control Modulation
Large
fibers
Ascending Action
System
Small
fibers Dorsal Horn “Gate”
The Gate control theory of pain processing. T = Second-order transmission cell; SG = substantia
gelatinosa cell.
Modified by AHT
Prof. Hyodo
Prof. Hyodo
3.Sensitization theory ,
by Woolf et in 1990
:After the tissue injury, sensitization in the
periphery and centrally ns is occurred.
HYPERALGESIA : RANGSANG KUATYANG NORMAL
DIRASAKAN NYERI KINI LEBIH NYERI
ALLODYNIA: RANGSANG LEMAHYANG NORMAL TIDAK
TERASA NYERI KINI TERASA NYERI
After tissue damage it occurs peripheral
and central sensitization
Worst Pain
“Hyperalgesia” Normal
Response
No Pain
Allodynia
Primary hyperalgesia
So, there are three
possibilities how do
we feel pain.
1. Nociception with Pain
Pain
Inhibition
CNS Modulation
Excitation
Example:
Stress Induced Analgesia
Nociception
Noxious stimulus without Pain
3. Pain without nociception
Pain
Inhibition
CNS Modulation
Excitation
Perception
Modulation Transduction
Transduction
Transmission
Modulation
Modify by AHT
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