NEUROPATHIC PAIN Candy Lauwrenz - PowerPoint Presentation

Slide1

NEUROPATHIC PAIN

Candy LauwrenzSlide2

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

”.

Slide3

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)Slide4

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) Slide5

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 neuropathicSlide6

Dorsal Horn

Dorsal root

ganglion

Peripheral sensory

Nerve fibers

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 stimuliSlide7

Nociceptive afferent fiber

Normal Nerve Impulses Leading to Pain

Noxious

stimuli

Descending

modulation

Ascending

input

Spinal cord

Perceived pain Slide8

Nociception

Spinothalamic

tract

Peripheral

nerve

Dorsal Horn

Dorsal root ganglion

Pain

Modulation

Transduction

Ascending

input

Descending

modulation

Peripheral

nociceptors

Trauma

Adapted from Gottschalk A et al.

Am Fam Physician

. 2001;63:1981, and Kehlet H et al.

Anesth Analg

. 1993;77:1049.

Perception

TransmissionSlide9

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

Vascular

Visceral

Cancer

PostoperativeSlide10

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

sationSlide11

Neuropathic PainSlide12

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. 2004 dan Treede et al. 2007). Slide13

CAUSES OF NEUROPATHIC PAINSlide14

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

Slide15

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

MyelomaSlide16

Examples

Peripheral

Post-herpetic neuralgia

Trigeminal neuralgia

Diabetic peripheral neuropathy

Post-surgical neuropathy

Post-traumatic neuropathy

Central

Post-stroke pain

Common descriptors2BurningTinglingHypersensitivity to touch or coldExamples Pain due to inflammationLimb pain after a fractureJoint pain in osteoarthritisPost-operative visceral pain Common descriptors2AchingSharp

Throbbing

Examples

Low back pain with radiculopathyCervical 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

. 1999.;11-57Slide17

Pathophysiology

of Neuropathic Pain

NeP

Central mechanisms

Peripheral mechanisms

Peripheral Neuron

hyperexcitability

Loss of

inhibitory controls

Central Neuron

hyperexcitability

(central sensitization)

Abnormal

DischargesSlide18

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 Slide19

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 Slide20

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

perceptionSlide21

Intact tactile fiber

Central Mechanism (Central Sensitization)

After nerve injury, i

ncreased 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 Slide22

Beberapa sindroma NP

yang banyak

ditemukan

A.

Mononeuropati

Sindroma

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 Slide23

Negative

symptoms

Neurological deficits

Sensory++

Motor

cognitive

Positive symptoms

Painful symptoms

Spontaneous pain

AllodyniaHyperalgesiaNon-painful symptomsParesthesiadysesthesiaMAIN CLINICAL FEATURESSlide24

Gejala

Nyeri

Neuropatik

Rasa

terbakar

kontinyu

Nyeri seperti ditusuk, menyentak intermitenNyeri seperti tersetrumBeberapa parestesiaSensasi abnormal yang tidak menggangguBeberapa disestesia

Sensasi abnormal yang mengganggu

Baron, 2000; Woolf, 1999.

1.

Stimulus – Independent Pain

(

Gejala

diutarakan

oleh

pasien )

seperti

:Slide25

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)Slide26

ASESMEN DAN MESUREMEN

T

NYERI NEUROPATIKSlide27

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. Slide28

KARAKTERISTIK KLINIK

NYERI NEUROPATIK

Umumnya

menunjukkan

gejala

:

Continuous burning pain

Paroxysmal (electric shock-like) painAllodyniaRadiating dysesthesiasParesthesiasTanda-tanda umumnya:Sensory lossWeaknessAutonomic changesSlide29

DIAGNOSE

Anamnese

penyebab

nyeri

Pemeriksaan

fisik

neurologikPemeriksaan Khusus Alodinia HiperalgesiaSlide30

PEMERIKSAAN NYERI KHUSUS PADA ALODINIA

Jenis

Alodinia

Cara Periksa

Respon

Mekanis

statis

(

serabut C)

Tekanan

ringan

dengan

benda

t

umpul

Rasa nyeri tumpul (dull pain)

Mekanis pungtat

Beberapa 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 panas

Tabung air hangat 40

o

C

Rasa seperti terbakar

Termal dingin

Tabung air dingin 20

o

C

Rasa

nyeri

terbakarSlide31

PEMERIKSAAN NYERI KHUSUS PADA HIPERALGESIA

Jenis Hiperalgesia

Cara Periksa

Respon

Mekanisme tusukan

Tusukan dengan jarum

Rasa nyeri tajam superfisial

Termal dingin

Kontak dengan pendingin (aseton, alkohol)

Rasa nyeri terbakar

Termal panas

Kontak dengan tabung air hangat 40

o

C

Rasa

nyeri

terbakarSlide32

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 2006Slide33

Pain assessment scales

No Mild Moderate Severe Very Worst

pain pain pain pain severe possible

pain pain

Verbal pain intensity scale

No

pain

Visual analog scale

Worst

possible

pain

Portenoy

RK,

Kanner

RM, eds.

Pain Management: Theory and Practice.

1996:8-10.

Wong DL.

Waley

and Wong’s Essentials of Pediatric Nursing 5th ed.

1997:1215-1216.

McCaffery

M,

Pasero

C.

Pain: Clinical Manual. Mosby, Inc. 1999:16.Slide34

Pain assessment scales

“Faces” scale

0 1 2 3 4 5

0–10 Numeric pain intensity scale

No Moderate Worst

pain pain possible pain

0 1 2 3 4 5 6 7 8 9 10

Portenoy

RK,

Kanner

RM, eds.

Pain Management: Theory and Practice.

1996:8-10.

Wong DL.

Waley

and Wong’s Essentials of Pediatric Nursing 5th ed.

1997:1215-1216.

McCaffery

M,

Pasero

C.

Pain: Clinical Manual.

Mosby, Inc. 1999:16.Slide35

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.

Tujuan

:Slide36

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 FunctioningImproved Psychological State

Reduced painSlide37

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

Tx

SPINAL CORDSlide38

Referred PainSlide39

Referred 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).Slide40
Slide41

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 neuropathicSlide42

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. Slide43

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.Slide44

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)Slide45

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 nociceptorsSlide46
Slide47
Slide48
Slide49
Slide50
Slide51

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.Slide52

‘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

ColonUrinary bladder : in normal state could not be activated. But that became responsive to bladder distension and contraction following to inflammation.Slide53

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.Slide54

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.Slide55

SELESAI