Slide 1

NEUROPATHIC PAINCandy LauwrenzDefinisi 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. 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)Pain: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) Classification: PAIN CLINICAL PAIN PHYSIOLOGIC PAIN / TRANSIENT PAIN Nociceptive Psychogenic Neuropathic (inflammatory)

Somatic Visceral Peripheral CentralSuperficial SymphaticDeep

Acute : < 3-6 months, mostly nociceptive Chronic : > 3-6 months, mostly neuropathic

Dorsal HornDorsal rootganglionPeripheral sensoryNerve fibersAACLargefibersSmallfibersThere are Two Sensory Afferent Neurons

Large myelinated A fibersVery fast conduction velocityRespond to innocuous stimuli Small myelinated A & C unmyelinated fibersSlow conduction velocityRespond to noxious stimuli6

Nociceptive afferent fiberNormal Nerve Impulses Leading to PainNoxiousstimuliDescendingmodulationAscendinginputSpinal cord

Perceived pain 7Coba cari film transduksi transmisi modulasi persepsiNociception SpinothalamictractPeripheralnerveDorsal HornDorsal root ganglionPainModulation

TransductionAscendinginputDescendingmodulationPeripheralnociceptorsTraumaAdapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049. Perception

Transmission88CAUSES 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 SYNDROMESkin/subcutanMuscleTendonLigmentBoneJointVascularVisceralCancerPostoperative 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

Neuropathic Pain

11Menurut 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. 2004 dan Treede et al. 2007).

CAUSES OF NEUROPATHIC PAINCentral Causes of Neuropathic Pain Spinal Rood/Dorsal Ganglion Prolapsed discRoot 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 deficiencyHIVBrain Stem Lateral medulary syndrome Multiple sclerosis Tumour Tuberculoma Thalamus InfarctionHemorrhageTumours Surgical lesion Sub-cortical and Cortical Infarct Trauma AVM Tumour 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 AlcoholicPellagraBeri beriAmyloid Cuban neuropathy Tanzanian neuropathy Burning feet syndrome Jamaican neuropathy Drugs/Toxic IsoniazidCisplatinThaliumVincristinArsenicClioquinol Disulfiram Nitrofurantoin Infection HIV Acute Inflammatory polyneuropathy (Guillain Barre) / CIDP Hereditary Fabrys disease Dominantly inherited sensory neuropathy / HSAN MalignantMyelomaExamplesPeripheralPost-herpetic neuralgiaTrigeminal neuralgiaDiabetic peripheral neuropathyPost-surgical neuropathyPost-traumatic neuropathyCentralPost-stroke painCommon descriptors2BurningTinglingHypersensitivity to touch or coldExamples Pain due to inflammationLimb pain after a fractureJoint pain in osteoarthritisPost-operative visceral pain Common descriptors2AchingSharpThrobbingExamples Low back pain with radiculopathyCervical radiculopathyCancer painCarpal tunnel syndromeMixed PainPain with neuropathic and nociceptive componentsNeuropathic 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)2Presentation Across Pain States Varies1. 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.;11-5716This 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. 1999.;11-57

Additional key words: descriptorPathophysiology of Neuropathic Pain

NeP

Central mechanismsPeripheral mechanisms

Peripheral NeuronhyperexcitabilityLoss ofinhibitory controlsCentral Neuron hyperexcitability (central sensitization)AbnormalDischarges17 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

Peripheral Mechanism (Ectopic Discharges)Nerve lesion induces hyperactivity due to changes in ion channel functionEctopic dischargesNerve lesionSpinal cordNociceptive afferent fiberDescendingmodulationAscendinginput

Perceived pain 19Central Mechanism (Loss of Inhibitory Controls)Loss of descending modulation causes exaggerated pain due to an imbalance between ascending and descending signals

Nociceptive afferent fiberNoxiousstimuliAscendinginputSpinal cord

Loss ofdescendingmodulationExaggerated painperception20

Intact tactile fiber

Central Mechanism (Central Sensitization)After nerve injury, increased input to the dorsal horn can induce central sensitizationPerceived pain

AscendinginputDescendingmodulationNerve lesionNociceptive afferent fiberTactilestimuliPerceived pain(allodynia)Ascendinginput

Descendingmodulation

Abnormal discharges induce central sensitization 21Beberapa 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 22Negative symptoms

Neurological deficitsSensory++MotorcognitivePositive symptomsPainful symptomsSpontaneous painAllodyniaHyperalgesiaNon-painful symptomsParesthesiadysesthesiaMAIN CLINICAL FEATURES23Gejala Nyeri NeuropatikRasa terbakar kontinyuNyeri seperti ditusuk, menyentak intermitenNyeri seperti tersetrumBeberapa parestesiaSensasi abnormal yang tidak menggangguBeberapa disestesia Sensasi abnormal yang menggangguBaron, 2000; Woolf, 1999.1. Stimulus Independent Pain ( Gejala diutarakan oleh pasien ) seperti:24HiperalgesiaReaksi yang meningkat terhadap stimulus nyeri (noksius)

Alodinia Nyeri akibat stimulus yang tidak nyeri (non-noksius/inocuous)2. Stimulus evoked pain (Nyeri dibangkitkan pada pemeriksaan)25ASESMEN DAN MESUREMENTNYERI NEUROPATIK26CLINICAL 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. KARAKTERISTIK KLINIK NYERI NEUROPATIKUmumnya menunjukkan gejala:Continuous burning painParoxysmal (electric shock-like) painAllodyniaRadiating dysesthesiasParesthesias

Tanda-tanda umumnya:Sensory lossWeaknessAutonomic changes28DIAGNOSEAnamnese penyebab nyeriPemeriksaan fisik neurologikPemeriksaan Khusus Alodinia Hiperalgesia

29PEMERIKSAAN NYERI KHUSUS PADA ALODINIAJenis 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 terbakar30PEMERIKSAAN NYERI KHUSUS PADA HIPERALGESIAJenis HiperalgesiaCara PeriksaResponMekanisme tusukanTusukan dengan jarumRasa nyeri tajam superfisialTermal dinginKontak dengan pendingin (aseton, alkohol)Rasa nyeri terbakarTermal panasKontak dengan tabung air hangat 40oCRasa nyeri terbakar31Burning, 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 touchModified by Meliala 200632Pain assessment scales NoMildModerateSevereVeryWorstpainpainpainpainseverepossiblepainpainVerbal pain intensity scaleNopain Visual analog scaleWorstpossiblepainPortenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. 1996:8-10.Wong DL. Waley and Wongs Essentials of Pediatric Nursing 5th ed. 1997:1215-1216.McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16.33The slide depicts four of the pain scales that are used to assess a patients 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 patients 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 pains 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.2

1.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 Wongs Essentials of Pediatric Nursing 5th ed. Mosby, Inc. 1997:1215-1216.3.McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16.Pain assessment scales Faces scale012345010 Numeric pain intensity scaleNo Moderate Worstpain pain possible pain0123456789 10Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. 1996:8-10.Wong DL. Waley and Wongs Essentials of Pediatric Nursing 5th ed. 1997:1215-1216.McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16.34The slide depicts four of the pain scales that are used to assess a patients 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 patients 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 pains 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.2

1.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 Wongs Essentials of Pediatric Nursing 5th ed. Mosby, Inc. 1997:1215-1216.3.McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16.PENATALAKSANAAN NYERI NEUROPATIKKonsensus Nasional Diagnostik & Penatalaksanaan NyeriNeuropatik, Pokdi Nyeri PERDOSSI, 2011Meningkatkan 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.Tujuan :

Successful Management of Neuropathic Painhas a Positive Impact for The Patient

Treatment of underlying conditions and symptoms

Diagnosis

ImprovedQuality ofSleepImproved Overall Quality of LifeImproved Physical FunctioningImproved Psychological StateReduced pain36

MECHANISTIC APPROACH TO TREATMENTBRAINPNSCentral SensitizationCa++ : Pregabalin, GBP,OXC,LTG,LVTNMDA : Ketamine, TPM Dextromethorphan MethadoneOthersCapsaicinNSAIDsCox inhibitorsLevodopaDescendingInhibitorsNE/5HTOpiate receptorsPeripheralSensitizationNa+CBZOXCPHTTCATPMLTGMexiletineLidocaineTCAsSSRIsSNRIsTramadolOpiatesBeydoun, 2002TxLesiTxTxSPINAL CORD37Referred PainReferred Pain 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).

Classification: PAIN CLINICAL PAIN PHYSIOLOGIC PAIN / TRANSIENT PAIN Nociceptive Psychogenic Neuropathic (inflammatory)

Somatic Visceral Peripheral CentralSuperficial SymphaticDeep

Acute : < 3-6 months, mostly nociceptive Chronic : > 3-6 months, mostly neuropathicNociceptive 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. 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.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 Burneys point)Mechanisms acute visceral PainVisceral 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

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.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.Common examples of referred painShoulder 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.Common examples of referred painAppendicitis 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.

SELESAI