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Mekanisme dan Penatalaksanaan NYERI dr. TW. Yuliati Sp.S, M.Kes Kamis, 26 Februari 2009

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  • Mekanisme dan Penatalaksanaan NYERI

    dr. TW. Yuliati Sp.S, M.KesKamis, 26 Februari 2009

    Past, Current, and Future of FM

  • DEFINISI NYERI

    (International Association for the Study of Pain / IASP) :

    Pain is an unpleasant sensory & emotional experience associated with actual or potential tissue damage or described in terms of such damage.Merskey, Qual Life Res 1994;3(suppl 1):569-76

    Pengalaman sensorik dan emosional yg tidak menyenangkan sehubungan dengan kerusakan jaringan, baik aktual mau pun potensial, atau dalam penggambarannya. (Mersky, 1994)

    Pain is the fifth vital signThe American pain Society was underscore the importance of monitoring and managing the pain in patients

    Past, Current, and Future of FM

  • Klasifikasi Nyeri (berdasarkan patofisiologi)

    Nyeri nosiseptif (stimulus dari struktur somatik dan viseral) danNyeri neuropatik (stimulus diproses sist. saraf scr abnormal)

    Past, Current, and Future of FM

  • Nociceptive pain

    means pain caused by an injury or disease outside the nervous system. It is often an on-going dull ache or pressure, rather than the sharper, trauma-like pain morecharacteristic of neuropathic pain.Examples of chronic nociceptive pain include pain from cancer or arthritis.

    Past, Current, and Future of FM

  • Neuropathic pain is

    pain that is caused by damage to nerve tissue. It is often felt as a burning orstabbing pain. One example of a neuropathic pain is a "pinched nerve."

    Past, Current, and Future of FM

  • TISSUE INJURYNOCICEPTORTNF-IL-6IL-1IL-8SYMPATHETICNERVEPGINFLAMMATIONPGPGPG

    Past, Current, and Future of FM

  • Senyawa kimia sebagai respon jaringan yang rusakAsam amino eksitatori, glutamat, dan aspartatGABAAsetilkolin AdenosinATPSerotoninProtonNeuropeptida bradikinin dan substansi-PNorepinefrinEikosanoids (prostasiklin,prostaglandin E2) Growth factor (misal NGF) dan sitokins (enterleukin-I, tumor necrosis factor

    Past, Current, and Future of FM

  • SISTEM SARAFSistem saraf pusat - otak - medulla spinalisSistem saraf tepi anatomis: - nervi craniales - nervi spinales fungsional: - somatik - viseral - enterik

    Past, Current, and Future of FM

  • Peripheral Nerves Consist of : Axon bundles Schwann cellsConnective tissue Endoneurium Perineurium Epineurium

    Past, Current, and Future of FM

  • Mekanisme Patofisiologi NyeriNurmikko et al., 19991. Pada Sistem Saraf Perifera. sensitisasi nosiseptorb. tunas kolateralc. naiknya aktivitas akson yang rusak dan tunas-tunasnyad. hantaran impuls abnormal dari sel ganglion radiks dorsalise. invasi ganglionik radiks dorsalis oleh serabut pasca ganglionik simpatisf. pergantian fenotipe

    Past, Current, and Future of FM

  • 2. Pada Sistem Saraf Pusata. hipereksitabilitas dari neuron sentral (sensitisasi sentral)b. reorganisasi hubungan sinaptik dalam medula spinalis dan dimana saja dalam sistem saraf pusatc. kerusakan inhibisiCont..

    Past, Current, and Future of FM

  • SENSATIONAwareness of external or internal conditions of the bodyTraditionally: 5 sensations - sight, hearing, touch, smell, tasteincluded under touch --> pain, pressure, temperature, joint position, muscle sense, and movement.THE SENSE ORGAN

    Past, Current, and Future of FM

  • FOUR STEPS FOR SENSATION TO OCCUR1. Stimulus capable of activating sensory neurons (receptor) must occur = STIMULATION2. Receptor must transduce the stimulus into nerve impulse = TRANSDUCTION3. The impulse must be conducted along a neural pathway to the brain = CONDUCTION4. Region of the brain must translate the impulse into a sensation then a perception (conscious awareness & interpretation of sensations) = TRANSLATION

    Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • MEKANISME NYERI

    Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • TERMINOLOGI

    1. Nyeri Nosiseptik : Nyeri yang disebabkan oleh cetusan spontan pada nosiseptor atau inflamasi pada kerusakan jaringan yang dikarenakan adanya stimuli langsung.

    Nyeri Neuropatik : Nyeri yang disebabkan oleh adanya lesi atau disfungsi primer pada sistem saraf. Nyeri neuropatik perifer, kerusakan sist. saraf periferNyeri neuropatik sentral, kerusakan sist. saraf sentral

    3. Paresthesia : nyeri spontan yang dirasakan seperti panas, tusuk, geli terjadi dengan atau tanpa rangsang dari luar, dimana dalam keadaan normal tidak ada.

    Past, Current, and Future of FM

  • 4. Hiperalgesia : Respons yang berlebihan terhadap stimulus yang secara normal menimbulkan nyeri. Hiperalgesia primer, peningkatan kepekaan nosiseptor - Hiperalgesia sekunder, sensitisasi/pengkaktifan pada penjalaran impuls pd serabut saraf perifer dan sentral

    5. Allodinia : nyeri yang ditimbulkan oleh stimulus yang secara normal tidak menimbulkan rasa nyeri. Hal ini terjadi karena sensitisasi sentral, reorganisasi serabut AB dan kontrol inhibisi hilang.

    6. Nyeri alih : nyeri yang dirasakan dibagian tubuh yang letaknya jauh dari jaringan yang menyebabkan rasa nyeri. Hal ini terjadi karena serabut nyeri visceral dan kulit difungsikan oleh beberapa neuron yang sama

    Past, Current, and Future of FM

  • FIGURE 1. Noxious stimuli can sensitize the nervous system response to subsequent stimuli. The normal pain response as a function of stimulus intensity is depicted by the curve at the right, where even strong stimuli are not experienced as pain. However, a traumatic injury can shift the curve to the left. Then, noxious stimuli become more painful (hyperalgesia) and typically painless stimuli are experienced as pain (allodynia).

    Past, Current, and Future of FM

  • Woolf & Mannion, 1999Nyeri pada saraf normalNyeri neuropati / ada kerusakan sarafNoxious stimulusDorsal Horn neuronNociceptorsPainsensationTo brain-adrenoceptorsPainsensationSodium channelsNo stimulusTo brain

    Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Secara klasik, nyeri dibedakan berdasarkan lama diderita :Akut < 6 bulan dan Kronik > 6 bulan. Karakteristik nyeri:

    Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Sensory dermatomes.

    Past, Current, and Future of FM

  • Tahapan diagnosis untuk nyeri (secara skematis)

    Anamnesis

    2. Pemeriksaan Fisik - Pemeriksaan fisik umum Pemeriksaan NeurologikKesadaranSaraf-saraf kranialMotorik SensorikOtonomFungsi luhur

    3. Pemeriksaan Penunjang: elektrofisiologik, Quantitative Sensory Testing (QST), neuroimaging, laboratorium

    4. Catatan harian : berguna untuk evaluasi dan pemantauan

    Past, Current, and Future of FM

  • Akurat

    Pasien Dokter Diagnosis

    Transfer informasi

    Penatalaksanaan

    PERSIAPAN PEMERIKSAAN

    Past, Current, and Future of FM

  • 0 5 10Tidak Nyeri Paling Nyeri yg terbayangkanVisual Analogue Scale

    Past, Current, and Future of FM

  • 0 1 2 3 4 5 6 7 8 9 10

    0 = Tak nyeri sama sekali 10 = Nyeri paling berat yg mungkin dirasakanNumerical Rating Scale

    Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • PENATALAKSANAAN NYERIPrinsip penatalaksanaan

    AKUT : terutama pemberian analgesik dan hilangkan penyebab

    KRONIK : (pilih sesuai gjl individual)1. Medikasi: analgesik, antidepresan, trankuiliser,antikonvulsan, steroid, anestesi lokal.2. Pembedahan: bedah spinal, operasi eksplorasi, potong saraf, lesi radiofrekuensi.3. Injeksi: anestesi lokal, steroid, dan fenol.4. Pompa obat spinal.5. Fisioterapi: fisioterapi pasif, fisioterapi aktif.6. Stimulasi: TENS, akupunctur, stimulasi kolumna dorsalis7. Tx psikologik: hipnosis, relaksasi, tx kognitif / perilaku

    Past, Current, and Future of FM

  • HipnosisMembayangkanPlaseboMusik/hiburanSystemic OpioidTricyclicsAnticonvulsanNSAIDs

    Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Step 1: NSAIDs

    Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • Past, Current, and Future of FM

  • BAHAN BACAAN

    Bradley, Daroff, Fenichel, Marsden - Neurology in Clinical Practice, 2nd Ed, Butterworth-Heinemann, Newton, MA, 1996.McCaffery, Pasero -Pain Clinical Manual, 2nd Ed., Mosby, New York.Meliala, Suryamihardja, Purba - Konsensus Nasional Penanganan Nyeri Neuropatik, Kelompok Studi Nyeri, Perhimpunan Dokter Spesialis Saraf Indonesia, 2000Mersky, Bogduk - Classification of chronic pain, 2nd Ed., Seattle, 1994, IASPPortenoy - Basic mechanisms. Dalam Portenoy RK., Kanner RM., editors: Pain management: theory and practice, pp. 83-125, Philadelphia, 1996, FA DavisRowbotham - Neuropathic Pain and Quality of Life: The State of Our Current Knowledge, dalam: Raj, P. (Ed.), Pain Practice (2nd World Congress of World Institute of Pain: Pain Management in the 21st Century, Istanbul), Blackwll Science, Inc., Massachussets, 2001.Sang - An Individualized Approach to the Management of Neuropathic Pain, dalam: Raj, P. (Ed.), Pain Practice (2nd World Congress of World Institute of Pain: Pain Management in the 21st Century, Istanbul), Blackwll Science, Inc., Massachussets, 2001.Wall, Melzack - Textbook of Pain, Churchill Livingstone, Edinburgh, 1999

    Past, Current, and Future of FM

  • Past, Current, and Future of FM

    Past.Current, and Future of FMDalam keadaan normal, stimulus noksious yang berasal dari perifer akan diteruskan ke otak melalui kornu dorsalis yang dianggap sebagai sensasi nyeriLesi atau trauma pada saraf perifer akan menyebabkan perobahan pada membran saraf yang nantinya akan bereaksi melalui perobahan molekul sehingga aktivitas SSA menjadi abnormal (mekanisme perifer) dan selanjutnya mengakibatkan gangguan nosiseptik sentral yang dikenal dengan sensasi nyeri di otakSugito Wonodirekso