What we know about pain very new prof husni
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Pain is how your brain interpret the stimulus is
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What we know about pain very new prof husni
- 1. WHAT WE KNOW ABOUT PAIN Husni Tanra Hasanuddin University Faculty of Medicine Departement of Anesthesiology, IC and Pain Management. Makassar Presented in the IVth National meeting of ISAPM , Manado 16-17 October 2015.
- 3. Pain was faithfully transmitted from periphery to brain Specificity theory Descartes (17th Century) Modified by AHT
- 4. Rene Descartes One unit of pain stimulus produce one unit of pain. Pain system was a straight forward channel from the peripheral to the brain. Nervous System is just like “a church bell system” “a hard wire system” No Modulation Cartesian model Mechanistic concept
- 5. Progress in understanding pain -1965-
- 6. VIth Worid Congres on Pain in Adelaid, Australia 1990
- 7. 2. Gate Control Theory Aβ fiber C fiber (Melzack & Wall, 1965) First central transmission cell Pain Substantia gelatinosa
- 9. Gate Controle Theory Melzack & Wall The beginning of Modulation
- 10. Placebo Effect (1966) Henry Knowles Beecher Beecher Pioneering American Anesthesiologist Medical Ethicist Investigator of Placebo Effect Modulation effect
- 12. Beecher Prof. Hyodo The Meaning of injury
- 13. 1979 H. MERSKEY (psychiatric) proposed pain definition, which was accepted by IASP PAIN IS “AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE, OR DESCRIBED IN TERM OF SUCH DAMAGE”. Why unpleasant? Because pain is so important symptom that human should not ignore it.
- 14. Cortex Thalamus Midbrain Projection To PGA Brainstem Reticular formation Spinothalamic tract Spinoreticular tract Dorsal horn Of spinal cord Cell body in DRG Noxious stimulus Nociceptors C fiber A fiber Pain is unpleasant sensory and emotional experience. So, pain has two dimentions (physical and psychological). Normal Situation Limbic System
- 15. Sensitization Theory by C J. Woolf in 1990 Allodynia Hyperalgesia
- 16. Normal Situation Innocuous Sensation Low intensity Stimulation High intensity Stimulation High threshold A and c fiber nociceptors Brief Pain A fiber
- 17. After Tissue Damage Low threshold mechanoreceptor A Sensitized nociceptor A and C fibers Hyperexcitable of DHN Pain Low intensity stimulation Allodynia Hyperalgesia
- 18. So, after the surgery there is a change in NS what we called: “Neuro-Plasticity of the Nervous System” Neuroplasticty is defined as “ the capacity of neuron to change their structure, function, or chemical profile” play a key role in chronic pain disorders.
- 19. After the surgery, it occurs plasticity of the Nervous System • HYPERALGESIA • ALLODYNIA Clinical Features of Postoperative Pain Primary Hyperalgesia Secondary Hyperalgesia Inflammed area Non-Inflammed area C. Woolf 1990
- 20. Among nociceptive pain, postoperative pain is well understood. • We know what causes it • We know the mechanism • We know how to treat it • We know the best drugs for it • We know mostly self limited (Lema MJ, Department of Anesthesiology, Buffalo State University) So, no more reason to feel pain after surgey
- 21. Nature of post operative pain Four out or five patients undergoing surgery experiences postoperative pain 86% of these patient rating Moderate Severe Extreme pain > 50% of patients report inadequate pain relief 10% to 50% acute post operative pain may become chronic, depending on the surgical procedure Pain, ASHP advantage E-NEWSLETTER, March 2014
- 22. Our problem now days is not Acute Pain but Chronic Pain
- 23. Phantom Limb Pain Feeling of pain in an absent limb or locations where sensory nerve roots have been completely destroyed Pain without nociception Post-Amputation Pain Phantom Limb Pain If postoperative pain is prototype of acute pain Phantom limb pain is prototype of neuropathic pain, or chronic pain.
- 24. The Paradigm Shift Peripheral Central The brain as an active organ Accounts for pain with no physical pathology Reconceptualization of “psychogenic pain”
- 25. Phantom Limb Pain is a „Pain Memory‟! In 57% of subjects with phantom pain, this resembled preamputation pain. “… somatosensory inputs of sufficient intensity and duration can produce long- lasting changes in central neural structures” Katz&Melzack, Pain 1990;43:319
- 26. Pain in Neuromatrix in the brain (Melzack, 2001)Perception of a unified body Continuous neural pattern
- 27. Brain areas and structures that are involved in pain processing Pain Matrix (Dillworth et al., 2012) SomatoSensory Cortices (SSC1&2) Insular Cortex (IC) PreFrontal Cortex (PFC) Anterior Cingulate Cortex (ACC) Thalamus Hippocampus Amygdala
- 28. Pain is Integrating of Sensory and Emotional experiences Thalamus Pre Frontal cortex (PFC) Hippocampus Insular cortex (IC) Primary / secondary Somatosensor Cortex (S1 & S2) Anterior Cingulated Cortex (ACC) Amygdala
- 29. Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Signals from periphery and spinal cord Hippocampus Amygdala
- 30. Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Thalamus Primary relay center for transmission to somato- sensory and emotional signals Hippocampus Amygdala Signals from periphery and spinal cord
- 31. Anterior Cingulate Cortex (ACC) Affective/ emotional component (e.g. sense of suffering) Initiation and facilitation of coping behavior Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 32. Prefrontal Cortex Cognitive aspects of pain Meaning of pain, what to do about the pain Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 33. Somatosensory Cortices Primary (S1): Location of pain Secondary (S2): Severity and quality of pain Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 34. Insular Cortex Survival instinct Active with the presence of threat Lack of oxygen, pain, low blood sugar Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 35. Hippocampus Aversive input pain memory Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 36. Amygdala Excecution decision, what to do due to pain Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 37. Neuroanatomy of Pain Main brain region that activate during a painful experience, highlighted as bilaterally active but with increased activation on contra lateral hemispheres (orange) Tracey & Mantyh 2007 Begitu pentingnya nyeri dalam hidup kita, sehingga seluruh Tubuh kita harus dibertahu.
- 38. So, Where in the brain is the pain? The Philosopher, Bertrand Russell was asked by his dentist, “where does it hurt?” “In my mind of course”, Russell Replied
- 39. Pain is NOT experienced unless these brain areas are active
- 40. NO BRAIN, NO PAIN
- 41. So,… we can conclude that There is no one pain area in the brain. But there are area that lay up or correlate to pain location and intensity SENSORY DISCRIMINATIVE. Another different area that lay up or active correlated to emotional power of pain LIMBIC SYSTEM AFFECTIVE MOTIVATIONAL
- 44. So …”The bane of pain is plainly in the brain.” But where and to what extent.
- 45. It depends on : 1. Who was stimulated 2. The psychological state of the subject when he/she was stimulated. 3. How much attention is paid to the stimulus. 4. How much pain you expect to experience.
- 46. It depends on who was stimulated…
- 49. It depends on… the psychological state of the subject when he/she was stimulated…
- 51. It depends on… how much attention is paid to the stimulus…
- 56. It depends on… how much pain you expect to experience…
- 60. Take home message There is no pain area in the Brain but there are area that correlate to ..... Sensory- Discriminative: oLocation, Modality, Intensity Affective –Motivational oHow unpleasant or upsetting is the pain? oWhat will I do about the pain?
- 61. Pain has multidimensional experience 1. sensory – discriminative Identifies the intensity, type and location of pain 2. Affective – motivational Assessing the injury the meaning of injury, (Fear, anxiety or depression) 3. Emotional – behavioral component Attention, mood and behavioral due to pain.
- 62. Clinical Management of Pain Multi-disciplinary Team Approach
- 63. 16th Century 21st Century Prior experiences From symplicity to Complexity Attention Mood (Psychological state) Ecpectation The meaning of pain Pain Experience Noxious stimulus
- 64. In other word Pain is how your brain interpret the stimulus is