PATOFISIOLOGI NYERI

Normal nerve impulses leading to pain

Perceived pain

Noxious
stimuli
Descending
modulation

Ascending
input

Nociceptive afferent fiber

Spinal cord

The continuum of pain

Insult

Acute
pain

Chronic
pain
36 months

Serves a protective function

Usually apparent noxious insult

Serves no protective function

Degrades health and function

Understanding key types of pain

Nociceptive pain

Neuropathic pain

Pain caused by
an inflammatory or
non-inflammatory
response to a
noxious stimulus

Pain initiated or caused

by a primary lesion or
dysfunction in the
peripheral or central
nervous system

What is nociceptive pain?

A sensory experience that occurs when specific peripheral

sensory neurons (nociceptors) respond to noxious stimuli

Painful region is typically localized at the site of injury

often described as throbbing, aching or stiffness

Usually time-limited and resolves when damaged tissue

heals (e.g. bone fractures, burns and bruises)

Can also be chronic (e.g. osteoarthritis)
Responds to conventional analgesics

Example of chronic nociceptive pain:

osteoarthritis of the knee

Example of chronic nociceptive pain:

osteoarthritis of the knee
Perceived pain

Ascending
input

Tissue
damage

Descending
modulation

Spinal cord

Peripheral
nerve

Activation of
local nociceptors

What is neuropathic pain?

Pain initiated or caused by a primary lesion or dysfunction in

the peripheral or central nervous system

Pain often described as shooting, electric shock-like,

burning commonly associated with tingling or numbness

The painful region may not necessarily be the same as the

site of injury. Pain occurs in the neurological territory of the

affected structure (nerve, root, spinal cord, brain)
Almost always a chronic condition (e.g. postherpetic

neuralgia, poststroke pain)

Responds poorly to conventional analgesics

Example of neuropathic pain:

ulnar nerve lesion following bone fracture

Ulnar nerve

Example of neuropathic pain:

ulnar nerve lesion following bone fracture
Perceived pain

Trauma
leading
to nerve
lesion

Ascending
input

Descending
modulation
Impulses generated
within ulnar nerve

Spinal cord

Lesion
Peripheral
nociceptors

The co-presentation of nociceptive and

neuropathic pain

Nociceptive pain

Both types of
pain co- exist in
many conditions

Neuropathic pain

Co-existence of nociceptive and

neuropathic pain
Co-existence of pain types has been referred to as either

a mixed or combined pain state

Examples include low back pain associated with

radiculopathy, cancer pain and carpal tunnel syndrome

Effective management requires a broader therapeutic

approach to relieve both the nociceptive and neuropathic pain

components

Example of co-existing pain: herniated disc

causing low back pain and lumbar radiculopathy

Example of co-existing pain: herniated disc

causing low back pain and lumbar radiculopathy
Activation of peripheral nociceptors
cause of nociceptive pain component
Disc herniation

Lumbar
vertebra

Compression and inflammation of nerve root

cause of neuropathic pain component

Example of co-existing pain: herniated disc

causing low back pain and lumbar radiculopathy
Constant ache, throbbing
pain in the low back

Shooting, burning
pain in the foot

Patient presents
with both types
of pain

Lesion

Activation
of local
nociceptors

Ectopic discharges
from nerve
root lesion

Nociceptive and neuropathic pain may

co-exist in low back pain conditions
Nociceptive pain component

Neuropathic pain component

Differentiating remote pain:

referred or radicular?
Nociceptive pain is usually localized; however,

when injury occurs to deep structures, pain

may be referred (e.g. pain following myocardial
infarction refers to left arm)
Referred pain is a nociceptive pain described

by patients using descriptors such as dull,

throbbing or aching
In contrast, radicular pain is a neuropathic

pain described by patients as shooting,

electric shock-like or burning, often with
tingling or numbness

Normal nerve impulses leading to pain

Perceived pain

Noxious
stimuli
Descending
modulation

Ascending
input

Nociceptive afferent fiber

Spinal cord

Ectopic discharges
Nerve lesion induces hyperactivity due to changes in ion channel function

Perceived pain

Nerve lesion
Descending
modulation

Ascending
input

Nociceptive afferent fiber

Spinal cord
Ectopic discharges

Loss of inhibitory controls

Loss of descending modulation causes exaggerated pain due to an imbalance between
ascending and descending signals

Exaggerated pain
perception

Noxious
stimuli

Loss of
descending
modulation

Ascending
input

Nociceptive afferent fiber

Spinal cord

Central sensitization
After nerve injury, increased input to the dorsal horn can induce central sensitization
Perceived pain
Nerve lesion
Descending
modulation

Nociceptive afferent fiber

Abnormal discharges induce central sensitization

Ascending
input

Pathophysiology of neuropathic pain

Peripheral mechanisms
Peripheral neuron
hyperexcitability

Loss of
inhibitory controls
Central mechanisms
Central neuron
hyperexcitability
(central sensitization)

Abnormal
discharges

NeP