PAIN MANAGEMENT:

BIOPSYCHOLOGICAL ASPECT OF (CHRONIC) PAIN

Jimmy Barus
Dept. of Neurology
Faculty of Medicine, Atma Jaya Catholic University

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

DEFINISI
Nyeri adalah pengalaman sensorik dan
emosional yang tidak menyenangkan akibat
kerusakan jaringan, baik aktual maupun
potensial, atau yang digambarkan dalam
bentuk kerusakan tersebut

Meliala, et.al, 2002, Pokdi Nyeri

Perdossi
KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

JALUR NYERI
PERSEPSI
NYERI

MODULASI
TRANSMISI

TRANSDUKSI

MODULATION
The process of dampening or amplifying
pain-related neural signals
A variety of modalities can activate
descending antinociceptive pathways,
including:

Systemic or neuraxial injection of opioids

Electric stimulation
Stress
Suggestion
Pain

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

PERCEPTION
Refers to the subjective experience of pain
Results from the interaction of transduction,
transmission, modulation
Dependent on the psychological aspects of the
individual

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

PAIN MODULATION
Pain can be modulated
depending upon the balance of
activity between nociceptive
and other afferent inputs
GATE CONTROL THEORY
Melzack & Wall 1960s
Ex: Transcutaneus
electrical nerve
stimulation (TENS)

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

SUPRA SPINAL MODULATION OF PAIN

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

NOCICEPTIVE PAIN
Noxius Pheripheral Stimuli
Heat

Pain
Autonomic Response
Witdrawal Reflex

Cold

Brain

Intense
Mechanical
Force

Nociceptor sensory neuron

Heat
Cold

Spinal cord

Modifikasi Meliala, 2005

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

INFLAMMATORY PAIN
Spontaneous Pain
Pain Hypersensitivity

Inflammation

Macrophage

Reduced Threshold : Allodyna

Increased Response : Hyperalgesia

Mast Cell
Neutrophil
Granulocyte

Brain

Nociceptor sensory neuron

Tissue Damage

Spinal cord
Modifikasi Meliala, 2005
KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

NEUROPATHIC PAIN
Spontaneous Pain
Pain Hypersensitivity
Brain

Peripheral Nerve
Damage

Spinal cord Injury

Modifikasi Meliala, 2005
KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

10

FUNCTIONAL PAIN
Spontaneous Pain
Pain Hypersensitivity
Brain

Normal Peripheral
Tissue and Nerves

Abnormal Central
Processing
Modifikasi Meliala, 2005
KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

11

75% Psychologic
25 % Somatic

PERSEPSI NYERI

Marah

Cemas

Takut

Depresi
PSIKOLOGIS

SOMATIK

Stimuli Noxious
KULIAH PAIN MANAGEMENT FPSI UAJ

MELIALA 2004

7/19/16

12

ILUSTRASI KASUS

Seorang perempuan usia 25 tahun, belum menikah, mengeluh sering merasa nyeri pada
kepala, leher, bahu, punggung, pinggul, paha dan betis. Nyeri terkadang disertai rasa
kesemutan. Nyeri terkadang terasa sedemikian berat, intensitas sedang sampai berat,
bahkan sering menyebabkan pasien menjadi kejang-kejang dan pingsan. Nyeri hilang
timbul sudah dialami selama 3 tahun semakin memberat.

Wawancara Psikologis:
Pasien mengalami hal seperti ini semenjak diputuskan oleh pacarnya
Pasien kehilangan kepercayaan diri, menarik diri, tidak merawat diri, memutuskan
untuk berhenti dari pekerjaan
Nyeri akan kambuh setiap saat pasien merasa kesal

Pemeriksaan Tanda Vital dan Fisik NORMAL

Pemeriksaan MRI Kepala, EEG normal

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

13

ILUSTRASI KASUS

Case of Frank Jones

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

14

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

15

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

16

THE BURDEN OF CHRONIC PAIN IASP REPORT

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

17

THE ROLE OF PSYCHOLOGIST IN PAIN

MANAGEMENT
to reduce the frequency and severity of pain
To reduce the personal and social impact of pain with a variety
of psycho-educational methods in a good therapeutic
relationship
Help the person lead as close to normal a life as possible help
to change view of pain and suffering from overwhelming to
manageable
Work together with other professionals: Pain physician,
physiotherapist, rehabilitation specialist etc.

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

18

BEHAVIORAL TECHNIQUES
Biofeedback and relaxation techniques (including
hypnosis and self hypnosis)
Cognitive coping skills distraction, relabeling the pain,
changing negative thought pattern
Cognitive behavioral therapy to decrease
maladaptive attitude, increase activity, decrease painrelated anxiety and depression
Psychotherapy

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

19

SPECIFIC TECHNIQUE IN CBT

Problem exploration
Cognitive restructuring
Assessing environmental factors
Increase self efficacy
Stress management
Managing sleep disturbance
Distraction
Anxiety and depression management

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

20

COPING SKILL STRATEGY AMERICAN CHRONIC

PAIN ASSOCIATION

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

21

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

22

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

23

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

24

CBT VS ACTIVE CONTROL AT POST-TREATMENT

Pain (13 studies, 1258 subjects) no significant effect
Disability (12studies,1130 subjects) significant effect
(small effect size)
Mood (13 studies,1256 subjects) no significant effect
Catastrophising (6 studies, 735 subjects) - significant
effect (small effect size)

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

25

CBT VS ACTIVE CONTROL AT FOLLOW UP

Pain (11 studies,1261 subjects) no significant effect
Disability(12studies,1295 subjects) significant effect
with (small effect size)
Mood (11 studies,1261 subjects) no significant effect
Catastrophising (2 studies 282 subjects) no
significant effect

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

26

PSYCHOLOGICAL THERAPIES FOR THE MANAGEMENT OF CHRONIC

PAIN (EXCLUDING HEADACHE) IN ADULTS (REVIEW) : COCHRANE
COLLABORATION, 2012
COMPARISON IN PLAIN LANGUAGE

Small to moderate benefits, more for disability, mood and

catastrophic thinking than for pain, were found in trials which
compared CBT with no treatment.
Some of these were still positive six months later. Behavior
therapy showed few and only brief benefits.
Psychological therapies can help people with chronic pain
reduce negative mood (depression and anxiety), disability,
catastrophic thinking, and in some cases, pain.

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

27

Cases: Chronic Low Back Pain

Multidisciplinary Rehab:
Using Biopsychosocial aspect
Physical Therapy
Psychological Therapy
Social Therapy

BMJ 2015;350:h444
KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

28

Multidisciplinary rehabilitation versus

physical treatment in long term.

Steven J Kamper et al. BMJ 2015;350:bmj.h444

2015 by British Medical Journal Publishing Group

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

30

Pain is a major health problem. Although acute pain may reasonably be considered a
symptom of disease or injury, chronic and recurrent pain is a specific healthcare problem, A
DISEASE IN ITS OWN RIGHT http://www.efic.org/eap.htm)

KULIAH PAIN MANAGEMENT FPSI UAJ

7/19/16

31