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NEUROPATHIC PAIN Candy Lauwrenz. Definisi nyeri : International Association for the Study of Pain (IASP) : “Nyeri adalah pengalaman sensorik dan emosional.

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Presentasi berjudul: "NEUROPATHIC PAIN Candy Lauwrenz. Definisi nyeri : International Association for the Study of Pain (IASP) : “Nyeri adalah pengalaman sensorik dan emosional."— Transcript presentasi:

1 NEUROPATHIC PAIN Candy Lauwrenz

2 Definisi nyeri : International Association for the Study of Pain (IASP) : “Nyeri adalah pengalaman sensorik dan emosional yang tidak menyenangkan akibat kerusakan jaringan, baik aktual maupun potensial atau yang digambarkan dalam bentuk kerusakan tersebut”.

3 Nyeri adalah suatu pengalaman sensorik yang multi dimensional. Fenomena ini dapat berbeda dalam – intensitas (ringan, sedang, berat), – kualitas (tumpul, seperti terbakar, tajam), – durasi (transien, intermiten, persisten), dan – penyebaran (superfisial vs dalam, terlokalisir vs difus)

4 Pain: the Joint Commission on Accreditation of Healthcare Organizations menyebutkan nyeri sebagai “The Fifth Vital Sign“ yg harus di monitor pada perawatan pasien, bersama dng suhu, nadi, respirasi, dan tekanan darah. (Campagnolo. 2005)

5 Classification: PAIN CLINICAL PAIN PHYSIOLOGIC PAIN / TRANSIENT PAIN Nociceptive Psychogenic Neuropathic (inflammatory) Somatic Visceral Peripheral Central Superficial Symphatic Deep Acute : < 3-6 months, mostly nociceptive Chronic : > 3-6 months, mostly neuropathic

6 Dorsal Horn Dorsal root ganglion Peripheral sensory Nerve fibers AA AA C Large fibers Small fibers There are Two Sensory Afferent Neurons Large myelinated A  fibers Very fast conduction velocity Respond to innocuous stimuli Small myelinated A  & C unmyelinated fibers Slow conduction velocity Respond to noxious stimuli

7 Nociceptive afferent fiber Normal Nerve Impulses Leading to Pain Noxious stimuli Descending modulation Ascending input Spinal cord Perceived pain

8 Nociception Spinothalamictract Peripheralnerve Dorsal Horn Dorsal root ganglion Pain Modulation Transduction Ascendinginput Descendingmodulation Peripheralnociceptors Trauma Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049. Perception Transmission

9 CAUSES OF NOCICEPTIVE PAIN strain tendinitis sprain Abscess,bruise ischemic avulsion fracture superficial pain d e e p p a i n PAD angina visceral pain ACUTE PAIN SYNDROME Skin/subcutan Muscle Tendon Ligment Bone Joint VascularVisceral Cancer Postoperative

10 NEUROPATHIC PAIN vs NOCICEPTIVE PAIN Characteristic Nociceptive Neuropathic Cause Often identifiable Rarely unidentifiable Duration Mostly acute Mostly chronic ( 3 months) Sensation = stimulus ≠ stimulus 1 cause  1 sen- 1 cause  > 1 sen- sation sation

11 Neuropathic Pain

12 Menurut IASP (International Association for the Study of Pain); Nyeri neuropatik adalah nyeri yang diawali atau disebabkan lesi primer atau disfungsi atau gangguan yang menetap pada sistem saraf perifer ataupun saraf sentral (Planjar et al dan Treede et al. 2007).

13 CAUSES OF NEUROPATHIC PAIN

14 Central Causes of Neuropathic Pain Spinal Rood/Dorsal Ganglion Prolapsed disc Root avulsion Post herpetic neuralgia Surgical rhizotomy Trigeminal neuralgia Arachnoiditis Tumour Spinal Cord. Trauma including compression Syringomyelia and intrinsic tumour Vascular: Infarction, hemorrhagic and AVM Syphilis Anterolateral cordotomy Multiple sclresosis Spinal dysraphisme Vitamin B12 deficiency HIV Brain Stem Lateral medulary syndrome Multiple sclerosis Tumour Tuberculoma Thalamus Infarction Hemorrhage Tumours Surgical lesion Sub-cortical and Cortical Infarct Trauma AVM Tumour

15 Peripheral Causes of Neuropathic Pain Mononeuropathies and multiple mononeuropathies Trauma: compression, transaction, post thoracothomy, painful scars Diabetic: mononeurpathy and amyothropy Neuralgic amyothrophy. Connection tissue diseases. Malignant and radiation plexopathy,Trench foot,Borreliosis. Polyneuropathies Metabolic Nuritional Diabetic Alcoholic Pellagra Beri beri Amyloid Cuban neuropathy Tanzanian neuropathy Burning feet syndrome Jamaican neuropathy Drugs/Toxic Isoniazid Cisplatin Thalium Vincristin Arsenic Clioquinol Disulfiram Nitrofurantoin Infection HIV Acute Inflammatory polyneuropathy (Guillain Barre) / CIDP Hereditary Fabry’s disease Dominantly inherited sensory neuropathy / HSAN Malignant Myeloma

16 Examples Peripheral Post-herpetic neuralgia Trigeminal neuralgia Diabetic peripheral neuropathy Post-surgical neuropathy Post-traumatic neuropathy Central Post-stroke pain Common descriptors 2 Burning Tingling Hypersensitivity to touch or cold Examples Pain due to inflammation Limb pain after a fracture Joint pain in osteoarthritis Post-operative visceral pain Common descriptors 2 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 Presentation Across Pain States Varies 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 ;11-57

17 Pathophysiology of Neuropathic Pain NeP Central mechanisms Peripheral mechanisms Peripheral Neuron hyperexcitability Loss of inhibitory controls Central Neuron hyperexcitability (central sensitization) Abnormal Discharges

18 MECHANISM OF NEUROPATHIC PAIN I. PERIPHERAL MECHANISM 1. Ectopic discharge 2. Peripheral sensitization 3. Sensitization to catecholamine II CENTRAL MECHANISM 1. Central sensitization 2. loss of descending inhibition 3. Structural reorganization at posterior horn

19 Peripheral Mechanism (Ectopic Discharges) Nerve lesion induces hyperactivity due to changes in ion channel function Ectopic discharges Nerve lesion Spinal cord Nociceptive afferent fiber Descending modulation Ascending input Perceived pain

20 Central Mechanism ( Loss of Inhibitory Controls ) Loss of descending modulation causes exaggerated pain due to an imbalance between ascending and descending signals Nociceptive afferent fiber Noxious stimuli Ascending input Spinal cord Loss of descending modulation Exaggerated pain perception

21 Intact tactile fiber Central Mechanism (Central Sensitization) After nerve injury, increased input to the dorsal horn can induce central sensitization Perceived pain Ascending input Descending modulation Nerve lesion Nociceptive afferent fiber Tactile stimuli Perceived pain (allodynia) Ascending input Descending modulation Abnormal discharges induce central sensitization

22 Beberapa sindroma NP yang banyak ditemukan A. Mononeuropati  Sindroma yangn disebabkan kompresi saraf perifer atau radiks, seperti; radikulopati lumbar dan servikal  Sindroma yang berhubungan dengan inflamasi saraf perifer; acute herpetic neuralgia  Sindroma yang berhubungan dengan ischaemic/infark pada saraf perifer; neuropatik diabetika  Painful mononeuropathy di daerah orofasial; trigeminal neuralgia  Sindroma sehubungan dengan formasi neuroma; stump pain (nyeri puntung), nyeri paska mastektomi  Causalgia (CRPS tipe II) B. Polyneuropati; misalnya dengan gejala burning feet. Berbagai keadaan seperti: defisiensi vitamin, DM, Chemoteraphy

23 Negative symptoms Neurological deficits Sensory++ Motor cognitive Positive symptoms Painful symptoms Spontaneous pain Allodynia Hyperalgesia Non-painful symptoms Paresthesia dysesthesia MAIN CLINICAL FEATURES

24 Gejala Nyeri Neuropatik Rasa terbakar kontinyu Nyeri seperti ditusuk, menyentak intermiten Nyeri seperti tersetrum Beberapa parestesia –Sensasi abnormal yang tidak mengganggu Beberapa disestesia –Sensasi abnormal yang mengganggu Baron, 2000; Woolf, Stimulus – Independent Pain ( Gejala diutarakan oleh pasien ) seperti:

25 Hiperalgesia Reaksi yang meningkat terhadap stimulus nyeri (noksius) Alodinia Nyeri akibat stimulus yang tidak nyeri (non- noksius/inocuous) 2. Stimulus evoked pain (Nyeri dibangkitkan pada pemeriksaan) (Nyeri dibangkitkan pada pemeriksaan)

26 ASESMEN DAN MESUREMENT NYERI NEUROPATIK

27 CLINICAL FEATURES OF NOCICEPTIVE PAIN ▪ Sudden onset. ▪ Quality: sharp, stabbing, pricking ▪ Localized. ▪ Self-limiting. ▪ Autonomic response: Palpitation, elevated blood pressure, sweating etc. ▪ Usually the cause is identifiable.

28 KARAKTERISTIK KLINIK NYERI NEUROPATIK Umumnya menunjukkan gejala: – Continuous burning pain – Paroxysmal (electric shock-like) pain – Allodynia – Radiating dysesthesias – Paresthesias Tanda-tanda umumnya: – Sensory loss – Weakness – Autonomic changes

29 DIAGNOSE Anamnese penyebab nyeri Pemeriksaan fisik neurologik Pemeriksaan Khusus » Alodinia » Hiperalgesia

30 PEMERIKSAAN NYERI KHUSUS PADA ALODINIA Jenis AlodiniaCara PeriksaRespon Mekanis statis (serabut C)Tekanan ringan dengan benda tumpul Rasa nyeri tumpul (dull pain) Mekanis pungtatBeberapa tusukan ringan dengan jarum Rasa nyeri tajam superfisial Mekanisme dinamis (A  ) Usapan ringan dengan kapas Rasa nyeri tajam terbakar, superfisial Mekanisme somatik dalam Tekanan ringan pada sendi Rasa nyeri yang dalam Termal panasTabung air hangat 40 o CRasa seperti terbakar Termal dinginTabung air dingin 20 o CRasa nyeri terbakar

31 PEMERIKSAAN NYERI KHUSUS PADA HIPERALGESIA Jenis HiperalgesiaCara PeriksaRespon Mekanisme tusukanTusukan dengan jarum Rasa nyeri tajam superfisial Termal dinginKontak dengan pendingin (aseton, alkohol) Rasa nyeri terbakar Termal panasKontak dengan tabung air hangat 40 o C Rasa nyeri terbakar

32 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

33 Pain assessment scales NoMildModerateSevereVeryWorst painpainpainpainseverepossible painpain Verbal pain intensity scale No pain Visual analog scale Worst possible pain 1.Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. 1996: Wong DL. Waley and Wong’s Essentials of Pediatric Nursing 5th ed. 1997: McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16.

34 Pain assessment scales “Faces” scale –10 Numeric pain intensity scale No Moderate Worst pain pain possible pain Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. 1996: Wong DL. Waley and Wong’s Essentials of Pediatric Nursing 5th ed. 1997: McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16.

35 PENATALAKSANAAN NYERI NEUROPATIK Konsensus Nasional Diagnostik & Penatalaksanaan Nyeri Neuropatik, Pokdi Nyeri PERDOSSI, 2011 Meningkatkan kualitas hidup pasien dengan melakukan pendekatan secara holistik, berupa pengobatan terhadap pain triad, yaitu nyeri, gangguan tidur dan gangguan mood ( ansietas, depresi dan obsesi konvulsi ) yang dilakukan oleh tim multidisiplin.

36 Successful Management of Neuropathic Pain has a Positive Impact for The Patient Treatment of underlying conditions and symptoms Diagnosis Improved Quality of Sleep Improved Overall Quality of Life Improved Physical Functioning Improved Psychological State Reduced pain

37 MECHANISTIC APPROACH TO TREATMENT BRAIN PNS Central Sensitization Ca++ : Pregabalin, GBP,OXC,LTG,LVT NMDA : Ketamine, TPM Dextromethorphan Methadone Others Capsaicin NSAIDs Cox inhibitors Levodopa Descending Inhibitors NE/5HT Opiate receptors Peripheral Sensitization Na+ CBZ OXC PHT TCA TPM LTG Mexiletine Lidocaine TCAs SSRIs SNRIs Tramadol Opiates Beydoun, 2002 Tx Lesi Tx SPINAL CORD

38 Referred Pain

39 Reflective pain : nyeri yang dirasakan pada lokasi yang berada jauh dari sumber nyerinya. Penyebab timbulnya referred pain ini sering disebabkan oleh adanya rangsangan pada organ organ visceral (organ dalam).

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41 Classification: PAIN CLINICAL PAIN PHYSIOLOGIC PAIN / TRANSIENT PAIN Nociceptive Psychogenic Neuropathic (inflammatory) Somatic Visceral Peripheral Central Superficial Symphatic Deep Acute : < 3-6 months, mostly nociceptive Chronic : > 3-6 months, mostly neuropathic

42 Nociceptive Pain : – Somatic Pain is the variety of nociceptive pain mediated by somatosensory afferent fibers. It is usually easly localizable and of sharp, aching or throbbing quality. Post operative, traumatic and local inflammatory pain are often of this variety. – Visceral Pain is harder to localize, (e.q headache in meningitis, biliary colic, gastritis, mesenteric infarction) may be dull, cramplike, piercing or waxing and waning. It is mediated peripherally by C fibers, and centrally by spinal cord pathways terminating mainly in the limbic system.

43 – Visceral pain is not felt in its site origin (internal organ where it originates )or but is rather referred to a cutaneus zone (of head) specific to that organ. This phenomenon is explained by the arrival of sensory impulses from both the internal organ and its related zone of head at the posterior horn at the same level of the spinal cord. The brain thus (mis)interprets the visceral pain as originating in the related cutaneous zone.

44 The pain may be describes as burning, pulling, pressure or soreness and there may be cutaneous hyperesthesia to light touch. In addition to the zones of head, referred pain may also be felt in muscles and connective tissue (pressure point, or mc Burney’s point)

45 Mechanisms acute visceral Pain Visceral sensory reseptors : – Receptors responsible for the sensations of visceral pain are the same population of visceral receptors responding to innocuous stimuli and responsible for visceral reflex actions. This receptors would respond to noxious stimuli with higher frequencies of firing – Receptors responsible for the sensations of visceral pain are a different population of visceral receptors which respond to the same stimuli that evoke visceral reflex actions but with different thresholds or by different mechanisms. This view postulates the existence of specific visceral nociceptors. Visceral nociceptors

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51 One possible trigger for the sensation of visceral pain could be the sensitization of visceral nociceptors. According to this interpretation visceral nociceptors, which normally have a relatively high threshold and respond only to intense forms of stimulation, become abnormally sensitive by decreasing their threshold for activation thus responding to mild form stimulation.

52 ‘Silent’ nociceptors : normally unresponsive to physiological forms of stimulation but being able to respon to mild stimuli when the tissue suffers persistent damage Existence of silent nociceptors : – Joints – Colon – Urinary bladder : in normal state could not be activated. But that became responsive to bladder distension and contraction following to inflammation.

53 Common examples of referred pain Shoulder Pain : this can caused by a disorders in the liver, gastric ulcer, gallstone, pericarditis, pneumonia or rupture of the spleen. Ice Cream Headache : also known as ‘brain freeze’ this is cuased by the vagus nerve being cooled when the throat is cooled by eating something cold, such as ice cream.

54 Common examples of referred pain Appendicitis pain : sometimes people with acute appendicitis feel the pain in the right shoulder and not in the abdomen Pain in a Phantom Limb : a pain sensation felt from a limb that is no longer there or from which no physical signals are sent. This type is very common in people with amputated limbs and quadriplegics.

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