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 dalamintensitas (ringan, sedang, berat),kualitas (tumpul, seperti terbakar, tajam),durasi (transien, intermiten, persisten), danpenyebaran (superfisial vs dalam, terlokalisir vs difus)
4 Pain: “The Fifth Vital Sign“ the Joint Commission on Accreditation of Healthcare Organizationsmenyebutkan nyeri sebagai“The Fifth Vital Sign“yg harus di monitor pada perawatan pasien , bersama dng suhu , nadi , respirasi , dan tekanan darah . (Campagnolo. 2005)
6 There are Two Sensory Afferent Neurons Large myelinated A fibersVery fast conduction velocityRespond to innocuous stimuliSmall myelinated A & C unmyelinated fibersSlow conduction velocityRespond to noxious stimuliLargefibersADorsal rootganglionDorsal HornASmallfibersCPeripheral sensoryNerve fibers
7 Normal Nerve Impulses Leading to Pain Perceived painNoxious stimuliCoba cari film transduksi – transmisi – modulasi – persepsiDescending modulationAscending inputNociceptive afferent fiberSpinal cord
8 Nociception Perception Modulation Transmission Transduction Pain DescendingmodulationDorsal HornTransmissionAscendinginputDorsal root ganglionTransductionSpinothalamictractPeripheralnerveTraumaPeripheralnociceptorsAdapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.8
9 CAUSES OF NOCICEPTIVE PAIN ACUTE PAIN SYNDROMESkin/subcutanMuscleTendonLigmentBoneJointVascularVisceralCancerPostoperativestrain tendinitis sprainAbscess,bruise ischemic avulsion fracturesuperficial paind e e p p a i nPAD anginavisceral pain
10 NEUROPATHIC PAIN vs NOCICEPTIVE PAIN Characteristic Nociceptive Neuropathic • Cause Often identifiable Rarely unidentifiable • Duration Mostly acute Mostly chronic (<3 months) (>3 months) • Sensation = stimulus ≠ stimulus 1 cause 1 sen- 1 cause > 1 sen- sation sation
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).
14 Central Causes of Neuropathic Pain Spinal Rood/Dorsal GanglionProlapsed discRoot avulsionPost herpetic neuralgiaSurgical rhizotomyTrigeminal neuralgiaArachnoiditisTumourSpinal Cord.Trauma including compressionSyringomyelia and intrinsic tumourVascular: Infarction, hemorrhagic and AVMSyphilisAnterolateral cordotomyMultiple sclresosisSpinal dysraphismeVitamin B12 deficiencyHIVBrain StemLateral medulary syndromeMultiple sclerosisTuberculomaThalamusInfarctionHemorrhageTumoursSurgical lesionSub-cortical and CorticalInfarct TraumaAVM Tumour
15 Peripheral Causes of Neuropathic Pain Mononeuropathies and multiple mononeuropathiesTrauma: compression, transaction, post thoracothomy, painful scarsDiabetic: mononeurpathy and amyothropyNeuralgic amyothrophy. Connection tissue diseases.Malignant and radiation plexopathy,Trench foot ,Borreliosis.PolyneuropathiesMetabolicNuritionalDiabetic AlcoholicPellagraBeri beriAmyloidCuban neuropathyTanzanian neuropathyBurning feet syndromeJamaican neuropathyDrugs/ToxicIsoniazidCisplatinThaliumVincristinArsenicClioquinolDisulfiramNitrofurantoinInfectionHIVAcute Inflammatory polyneuropathy (Guillain Barre) / CIDPHereditaryFabry’s diseaseDominantly inherited sensory neuropathy / HSANMalignantMyeloma
16 Presentation Across Pain States Varies Neuropathic PainPain initiated or caused by a primary lesion or dysfunction in the nervous system (either peripheral or central nervous system)1Nociceptive PainPain caused by injury to body tissues (musculoskeletal, cutaneous or visceral)2Mixed PainPain withneuropathic andnociceptivecomponentsExamplesPeripheralPost-herpetic neuralgiaTrigeminal neuralgiaDiabetic peripheral neuropathyPost-surgical neuropathyPost-traumatic neuropathyCentralPost-stroke painCommon descriptors2BurningTinglingHypersensitivity to touch or coldExamplesLow back pain with radiculopathyCervical radiculopathyCancer painCarpal tunnel syndromeExamplesPain due to inflammationLimb pain after a fractureJoint pain in osteoarthritisPost-operative visceral painCommon descriptors2AchingSharpThrobbingThis slide illustrates three broad categories of pain: neuropathic (pathologic), nociceptive (physiologic), and mixed pain states that encompass both nociceptive and neuropathic components, with examples of common causes of each type of pain.The key talking points on this slide are as follows:Neuropathic pain has been defined by the International Association for the Study of Pain as ‘initiated or caused by a primary lesion or dysfunction in the nervous system’.1 Depending on where the lesion or dysfunction occurs within the nervous system, neuropathic pain can be peripheral or central in origin.Causes of peripheral neuropathic pain include postherpetic neuralgia (PHN) and diabetic peripheral neuropathy (DPN). Due to the prevalence and characteristics of PHN and DPN, these states may be considered representative of peripheral neuropathic pain.Nociceptive pain is an appropriate physiologic response that occurs when specific peripheral sensory neurons (nociceptors) respond to noxious stimuli. Nociceptive pain has a protective role because it elicits reflex and behavioral responses that keep tissue damage to a minimum.Acute pain, such as that seen with tissue inflammation and chronic pain, such that accompanying osteoarthritis, are examples of nociceptive pain.Although there are no specific descriptors for each type of pain, neuropathic pain is frequently described as ‘burning or tingling’ in quality, while nociceptive pain is often described as ‘aching or throbbing’.There are cases in which an individual experiences pain sensations that are a blend of pain having a nociceptive and a neuropathic origin. For example, in carpal tunnel syndrome, it is common experience to have nociceptive pain, felt around the wrist, and neuropathic pain, felt in the distribution territory of the median nerve (fingers).ReferencesInternational Association for the Study of Pain. IASP Pain Terminology.Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. Edinburgh, UK: Harcourt Publishers Limited ;11-57Additional key words: descriptor1. 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 Peripheral mechanismsPeripheral Neuron hyperexcitabilityCentral mechanismsAbnormal DischargesLoss of inhibitory controlsNePCentral Neuron hyperexcitability (central sensitization)
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 functionPerceived painNerve lesionDescending modulationAscending inputNociceptive afferent fiberSpinal cordEctopic discharges
20 Central Mechanism (Loss of Inhibitory Controls) Loss of descending modulation causes exaggerated pain due to an imbalance between ascending and descending signalsExaggerated pain perceptionNoxious stimuliLoss of descending modulationAscending inputNociceptive afferent fiberSpinal cord
21 Central Mechanism (Central Sensitization) After nerve injury, increased input to the dorsal horn can induce central sensitizationPerceived painNerve lesionDescending modulationAscending inputNociceptive afferent fiberPerceived pain (allodynia)Abnormal discharges induce central sensitizationTactile stimuliDescending modulationAscending inputIntact tactile fiber
22 Beberapa sindroma NP yang banyak ditemukan A. MononeuropatiSindroma yangn disebabkan kompresi saraf perifer atau radiks, seperti; radikulopati lumbar dan servikalSindroma yang berhubungan dengan inflamasi saraf perifer; acute herpetic neuralgiaSindroma yang berhubungan dengan ischaemic/infark pada saraf perifer; neuropatik diabetikaPainful mononeuropathy di daerah orofasial; trigeminal neuralgiaSindroma sehubungan dengan formasi neuroma; stump pain (nyeri puntung), nyeri paska mastektomiCausalgia (CRPS tipe II)B. Polyneuropati; misalnya dengan gejala burning feet.Berbagai keadaan seperti: defisiensi vitamin, DM, Chemoteraphy
24 Gejala Nyeri Neuropatik 1. Stimulus – Independent Pain ( Gejala diutarakan oleh pasien ) seperti:Rasa terbakar kontinyuNyeri seperti ditusuk, menyentak intermitenNyeri seperti tersetrumBeberapa parestesiaSensasi abnormal yang tidak menggangguBeberapa disestesiaSensasi abnormal yang menggangguBaron, 2000; Woolf, 1999.
25 (Nyeri dibangkitkan pada pemeriksaan) 2. Stimulus evoked pain(Nyeri dibangkitkan pada pemeriksaan)HiperalgesiaReaksi yang meningkat terhadap stimulus nyeri (noksius)AlodiniaNyeri akibat stimulus yang tidak nyeri (non-noksius/inocuous)
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 painParoxysmal (electric shock-like) painAllodyniaRadiating dysesthesiasParesthesiasTanda-tanda umumnya:Sensory lossWeaknessAutonomic changes
30 PEMERIKSAAN NYERI KHUSUS PADA ALODINIA Jenis AlodiniaCara PeriksaResponMekanis statis (serabut C)Tekanan ringan dengan benda tumpulRasa nyeri tumpul (dull pain)Mekanis pungtatBeberapa tusukan ringan dengan jarumRasa nyeri tajam superfisialMekanisme dinamis (A )Usapan ringan dengan kapasRasa nyeri tajam terbakar, superfisialMekanisme somatik dalamTekanan ringan pada sendiRasa nyeri yang dalamTermal panasTabung air hangat 40oCRasa seperti terbakarTermal dinginTabung air dingin 20oCRasa nyeri terbakar
31 PEMERIKSAAN NYERI KHUSUS PADA HIPERALGESIA Jenis HiperalgesiaCara PeriksaResponMekanisme tusukanTusukan dengan jarumRasa nyeri tajam superfisialTermal dinginKontak dengan pendingin (aseton, alkohol)Rasa nyeri terbakarTermal panasKontak dengan tabung air hangat 40oC
32 Freezing, like the feet are on ice, although they feel warm to touch Burning, feeling like the feet are on fireStabbing, like sharp knivesModified by Meliala 2006Lancinating, like electric shocks
33 Pain assessment scales Verbal pain intensity scaleNo Mild Moderate Severe Very Worst pain pain pain pain severe possible pain painVisual analog scaleThe slide depicts four of the pain scales that are used to assess a patient’s pain. The scales are considered simple for patients to use as well as being valid methods for measuring the severity of pain.1These scales can be used at the patient’s bedside, and patients can be asked to respond to either a spoken or written question.With some scales, especially the visual analog scale, the patient marks the line at the point that best indicates the pain’s intensity.The Wong-Baker FACES Pain Rating Scale is validated and recommended for patients aged 3 years and older. On this scale, Face 0 indicates no pain an all, Face 1 feels mild pain, Face 2 feels moderate pain, Face 3 feels severe pain, Face 4 feels very severe pain, and Face 5 feels the worst possible pain. The original appears above, and can be used as is or with the brief word descriptions under each number. In a study of 148 children aged 4 to 5 years, there were no differences in pain scores when children used the original or brief word instructions.21. Portenoy RK, Kanner RM. Definition and Assessment of Pain. In: Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. Philadelphia, Pa: FA Davis Company; 1996:8- 10.2. Wong DL. Waley and Wong’s Essentials of Pediatric Nursing 5th ed. Mosby, Inc :3. McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16.NopainWorst possible painPortenoy RK, Kanner RM, eds. Pain Management: Theory and Practice :8-10.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 0–10 Numeric pain intensity scaleNo Moderate Worst pain pain possible pain“Faces” scaleThe slide depicts four of the pain scales that are used to assess a patient’s pain. The scales are considered simple for patients to use as well as being valid methods for measuring the severity of pain.1These scales can be used at the patient’s bedside, and patients can be asked to respond to either a spoken or written question.With some scales, especially the visual analog scale, the patient marks the line at the point that best indicates the pain’s intensity.The Wong-Baker FACES Pain Rating Scale is validated and recommended for patients aged 3 years and older. On this scale, Face 0 indicates no pain an all, Face 1 feels mild pain, Face 2 feels moderate pain, Face 3 feels severe pain, Face 4 feels very severe pain, and Face 5 feels the worst possible pain. The original appears above, and can be used as is or with the brief word descriptions under each number. In a study of 148 children aged 4 to 5 years, there were no differences in pain scores when children used the original or brief word instructions.21. Portenoy RK, Kanner RM. Definition and Assessment of Pain. In: Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. Philadelphia, Pa: FA Davis Company; 1996:8- 10.2. Wong DL. Waley and Wong’s Essentials of Pediatric Nursing 5th ed. Mosby, Inc :3. McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16.Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice :8-10.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 Tujuan :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.Konsensus Nasional Diagnostik & Penatalaksanaan Nyeri Neuropatik, Pokdi Nyeri PERDOSSI, 2011
36 Successful Management of Neuropathic Pain has a Positive Impact for The Patient Treatment of underlying conditions and symptomsDiagnosisImproved Quality of SleepImproved Overall Quality of LifeImproved Physical FunctioningImproved Psychological StateReduced pain
39 Referred PainReflective 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).
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 firingReceptors 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
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 Existence of silent nociceptors : ‘Silent’ nociceptors : normally unresponsive to physiological forms of stimulation but being able to respon to mild stimuli when the tissue suffers persistent damageExistence of silent nociceptors :JointsColonUrinary 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 abdomenPain 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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