1. Dasar-dasar Nyeri Akut,
Neuropatik dan Kronik
Andi Husni Tanra
Ketua Program Studi Sp2 Ilmu Anestesi
Fakultas Kedokteran Universitas Hasanuddin
Makassar
Dibawakan pada kuliah perdana peserta fellow IPM ke-2, 7 Nov 2017 di Makassar

2.  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 .

3. • Nyeri nosiseptif adalah nyeri
yang terjadi akibat adanya
suatu stimulus kuat
(Mekanik, termal atau
kimiawi) pada jaringan yang
intact (utuh).
• Jadi ada Potential tissue
damage yang menghasilkan
withdrawal reflex.
• Belum ada kerusakan
jaringan.
• Gunaya sebagai alat proteksi
tubuh dari berbagai
kerusakan.
1. Nociceptive Pain

4. WITHDRAWAL REFLEX

6. Nociceptive pain
Minimal tissue damage

7. 1. Acute Pain
• With actual tissue damage
(ada kerusakan jaringan).
• Noxious stimulus 
Nociceptive pain  Acute
Pain.
Nociceptive Pain

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

9. 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 dengan
pembedahan, trauma, atau penyakit akut
Definition of Acute pain
` (Federation of State Medical Board of the United Stated 1999.)

10. 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. Transduksi
2. Konduksi
3. Modulasi
4. Transmisi
5. Persepsi
Mekanisme Nyeri Nosiseptif atau Nyeri Akut

11. Ciri chas nyeri nosiseptif
• Nyeri yang di tandai dengan
 Adanya jaringan rusak atau inflamasi
 Nyeri kalau diraba, ditekan atau
digerakkan.
• Gejala nyerinya
 Aching (sakit) atau
 Throbbing (berdenyut)
 Alur nyeri dimulai dari aktivasi nosiseptor.

12. Abnormal
Central processing
Maladaptive, low-threshold pain
Disease state of nervous system
Peripheral
Nerve damage
Neural lesion
Positive and negative
symptoms
Neuropathic pain
Spontaneous pain
Pain hypersensitivity
Injury
Stroke
Modified by AHT
. Neuropathic Pain
According 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

13. 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

14. Gejala Nyeri Neuropatik
• Umumnya pasien menyatakannya nyerinya
sebagai nyeri yang lain dari biasanya.
• Paling sering dirasakan sebagai nyeri yang
terbakar, (burning) atau seperti dikontak
listrik (tingling) atau seperti kesemutan .
• Ciri khas suatu neuropatik adalah jika
ditemukan 2 gejala yakni gejala positip dan
negatip. (misl. hiperalgesia dan hipestesia)

15. Sural nerve lesion
Peroneal nerve lesion
(amputation of dig. 4)
Median nerve lesion
Post cut. lumbar nerve lesion
Peripheral nerve lesions : Allodynia and hyperalgesia

16. 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

17. Inflammatory Pain Neuropathic Pain Dysfunctional Pain
(Idiopathic Pain)
Inflammatory, Neuropathic and Chronic Pain.

18. 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.

19. WHAT HAPPENS
LONG TERM…

20. “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

21.  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

22. 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.

23. Duration
Tissue injury
Nerve conduction
Autonomic NS
Biological value
Social effects
Associated problems
Treatment
Prognosis
Chronic Pain
Months 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 Pain
Hours to days
Present
Fast
Activated
High
Uncommon
Few
Analgesics
Predictable
Aim: cure
Adapted from Ashburn and Straats, 1999
Acute vs Chronic pain

24. Pain as a Continuum
http://www.slideshare.net/Painspecialist/understanding-pain-short

25. All chronic pain was once acute,
but not all acute pain becomes
chronic.
Shipton EA Anaesth Intensive Care. 2011;39(5):824-36.

26. Chronic Pain
… is not prolonged acute pain
… must be considered and treated
as a disease.

27. Central sensitization

28. 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

29. PERIPHERAL
ACTIVITY
CENTRAL
SENSITIZATION
Lowered
threshold to
peripheral
stimuli
Increased
spontaneous
activityExpansion of
receptive
field
Hyperalgesia
Allodynia
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

30. WHAT HAPPENS
LONG TERM…

31. 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

32. 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.

33. 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 pain
Pain caused by
an inflammatory or
non-inflammatory
response to an overt or
potentially tissue-damaging
stimulus1,3
Neuropathic pain
Pain 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

35. Chronic pain is biopsychosocial
phenomenon
Chronic pain is a biopsychosocial
phenomenon,
but the ‘bio’ component is usually
not classical nociception, but the
result of a neurologic disease
( Central Sensitization)

36. Chronic pain is Biopsychosocial Phenomenon

37. Chronic Pain is a
Biopsychosocial 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
XXXXXXXX
Central
Sensitization
(wind-up)

38. 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

39. 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

40. 2
Biomedical vs. Biopsychosocial
Management 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

41. 3
Biomedical 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.

42. 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

43. Cancer pain
Pain
Chronic painAcute pain
Nociceptive
pain
Neuropathic
pain
Dysfunctional
pain
Non-Cancer pain

44. For all the happiness mankind
can gain, is not in pleasure,
but rest from pain.
John Dryden (1631-1700)

45. Thank you very much
For your attention

46. 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.