NYERI MUSKULOSKELETAL

DANPENATALAKSANAANNY

ASusatyo P. Hadi

SMF SARAF RSUD KUDUS

POKOK-POKOK BAHASAN PENDAHULUAN

BATASAN NYERI MUSKULOSKELETAL MEKANISME NYERI GEJALA KLINIK DAN SIMTOM DIAGNOSIS TATALAKSANA KESIMPULAN

POKOK-POKOK BAHASAN

PENDAHULUAN BATASAN NYERI

MUSKULOSKELETAL MEKANISME NYERI GEJALA KLINIK DAN SIMTOM DIAGNOSIS TATALAKSANA KESIMPULAN

The INTERNATIONAL ASSOCIATION for the STUDY of PAIN (IASP) : “the 2009 – 2010 GLOBAL YEAR AGAINST THE MUSCULOSKELETAL PAIN”.

NYERI MUSKULOSKELETAL MERUPAKAN MASALAH KESEHATAN BESAR YANG DIDERITA JUTAAN MANUSIA DI BUMI.

NYERI MUSKULOSKELETAL MERUPAKAN PROBLEM YANG KOMPLEK DAN MASIH KURANG DIPAHAMI DENGAN BAIK.

PENDAHULUAN

LOW BACKPAIN

JOINTPAIN

BONEPAIN

OTHERS’ CHRONIC

PAIN

LIMB PAIN

NECK PAIN

MACAM – MACAM NYERI

MUSKULOSKELETAL

PRODUKTIVITAS

MENURUN

PATOFISIOLOGI

KURANG DIPAHAMI

ETIOLOGI

TIDAK JELAS

HILANG HARI KERJA

KASUS MENINGKA

T

USIA TUA &

GEMUK

TERAPI SIMTOMATI

K

TERAPI TIDAK

ADEKWAT

CHALLENGES&

ISSUES

BIAYA MAHAL

POKOK-POKOK BAHASAN

PENDAHULUAN BATASAN NYERI

MUSKULOSKELETAL MEKANISME NYERI GEJALA KLINIK DAN SIMTOM DIAGNOSIS TATALAKSANA KESIMPULAN

BATASAN NYERI MUSKULOSKELETAL

NYERI MUSKULOSKELETAL MELIBATKAN :

MUSKULUS LIGAMENTUM TENDON TULANG

PROLONGED IMMOBILIZATION

TRAUMAPOSTURAL

STRAINREPETITIVE

MOVEMENTSOVERUSE

Gerakan kejut Kecelakaan Jatuh Fraktur Sprint Dislokasi Benturan

ETIOLOGI

POKOK-POKOK BAHASAN

PENDAHULUAN BATASAN NYERI

MUSKULOSKELETAL MEKANISME NYERI GEJALA KLINIK DAN SIMTOM DIAGNOSIS TATALAKSANA KESIMPULAN

PAIN PATHWAY/PERCEPTION

Spinothalamictract

Peripheralnerve

Dorsal Horn

Dorsal root ganglion

Pain

Modulation

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.

Transduction

Perception

Transmission

POOR SLEEP MISSING WORK NEGATIVE SELF-

TALK

MUSCLE ATROPHY & WEAKNESS WEIGHT LOSS/GAIN

LESS ACTIVE DECREASED MOTIVATION INCREASED ISOLATION

DISABILITYPAIN

DISTRESS

The PAIN CYCLE

DIFFERENCES OF PAIN CONCEPT

DISEASE PAINDISEASE

PAIN

DOCTORPATIENT

POKOK-POKOK BAHASAN

PENDAHULUAN BATASAN NYERI

MUSKULOSKELETAL MEKANISME NYERI GEJALA KLINIK DAN SIMTOM

DIAGNOSIS TATALAKSANA KESIMPULAN

GEJALA KLINIK DAN SIMTOM

FATIGUE (LELAH)

PAIN (NYERI)

GANGGUAN TIDUR

SELURUH BADAN SAKIT SEMUA

TANDA – TANDA YANG LAZIM

POKOK-POKOK BAHASAN

PENDAHULUAN BATASAN NYERI

MUSKULOSKELETAL MEKANISME NYERI GEJALA KLINIK DAN SIMTOM DIAGNOSIS TATALAKSANA KESIMPULAN

Believe Pain

Pain is always subjective

Patients’Self-report of pain is theGold standard for assessment

IASP 1999; Portenoy RK, Lesage P. lancet, 1999

GOLD-STANDARD of PAIN ASSESSMENT

TEKNIKDIAGNOS

IS

RIWAYAT PENYAKIT

PEMERIKSAAN FISIK

PENUNJANGDIAGNOSTIK

POKOK-POKOK BAHASAN

PENDAHULUAN BATASAN NYERI

MUSKULOSKELETAL MEKANISME NYERI GEJALA KLINIK DAN SIMTOM DIAGNOSIS TATALAKSANA KESIMPULAN

BEBERAPA PERTIMBANGAN DALAM PEMILIHAN TERAPI NYERI

MUSKULOSKELETAL

TENTUKAN JENIS / MACAM NYERI TENTUKAN KWANTITAS NYERI PEMILIHAN JENIS ANALGETIK

MACAM-MACAM NYERI

TIPE CAMPURAN

AKIBAT KOMBINASI TRAUMA PRIMER DAN SEKUNDER

NYERI NOSISEPTIF

AKIBAT KERUSAKAN JARINGAN/RESEPTOR

NYERI NEUROPATIK AKIBAT LESI PRIMER PADA SERABUT SARAF

PASCA OPERASI LOW BACK PAIN ARTHRITIS TRAUMA OLAHRAGA TRAUMA PANAS, DINGIN,KIMIAWI, DLL.

SAKIT KEPALA (HEADACHE) NEURALGIA POST HERPES ZOOSTER

NEURALGIA TRIGEMINAL NYERI KANKER RADICULOPHATY IN LOW BACK PAIN

POLINEUROPATI DISTAL (MIS. DM, HIV)

PEMERIKSAAN SARAF

MOTORIK : KEKUATAN OTOTREFLEK FISIOLOGIS /

PATOLOGIS

SENSORIK : NYERIRABASUHUVIBRASIPOSISI

OTONOM : MIKSI, DEFEKASI, KELJ. KERINGAT

INTENSITAS NYERI

1. VISUAL ANALOG SCALE (VAS)

2. NUMERIC PAIN RATING SCALE (NPRS)1 – 3 NYERI RINGAN

4 – 6 NYERI SEDANG

7 – 10 NYERI BERAT

3. FACES PAIN RATING SCALE (untuk anak)

1. VISUAL ANALOG SCALE (VAS)

2. NUMERIC PAIN RATING SCALE (NPRS)1 – 3 NYERI RINGAN

4 – 6 NYERI SEDANG

7 – 10 NYERI BERAT

3. FACES PAIN RATING SCALE (untuk anak)

(PENGUKURAN SKALA NYERI )

(PENGUKURAN SKALA NYERI )

   VISUAL ANALOG SCALE (VAS)   VISUAL ANALOG SCALE (VAS)

FACES PAIN RATING SCALE (untuk anak)FACES PAIN RATING SCALE (untuk anak)

NUMERIC PAIN RATING SCALE (NPRS)

NUMERIC PAIN RATING SCALE (NPRS)

Tramadol+ APAP

COX-PATHWAY

Arachidonic acid (a fatty acid)

Arachidonic acid (a fatty acid)

COX-1COX-1 COX-2COX-2

Normalconstituent

Normalconstituent

brain kidney ovary uterus

InducibleInducible

inflammation

pain

fever

CoxibsNSAIDs

(-) (-)

gastric cytoprotection renal sodium / water balance platelet aggregation

Glucocorticoids(block mRNA expression)(-)

Normalconstituent

Normalconstituent

ACR 2006 Updated Guideline for OA Management

Physical measures – patient education

Medication

Intra - articularAnalgesicsAnti- inflammatory

NSAIDs plus PGE2/PPI, COX-2 Non-acetylated

salicylate Tramadol Capsaicin Opioids

ParacetamolDepot steroids

Hyaluronate

Antispasmodics / Antidepressants / Sugars / Anthraquinone / Lipids

Surgery

Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29

Paracetamol up to 4g/day

Gastrointestinalrisk

Renal risk

Cardiovascularrisk

Avoid NSAIDs/COX-2 inhibitors

Long termFlares

• Paracetamol / tramadol weak opioid combinations*• Tramadol• Strong opioid

Moderate

Severe

COX-2 inhibitor

NSAIDs+PPI

Paracetamol /Tramadol

•Tramadol•Strong opioids

* 2nd choice

Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29

WGPM ( The Working Group on Pain Management ) Recommendation at the 2nd meeting in EULAR 2005

2006 New Guideline in Treatment Moderator- to-Severe Pain in OA patients with Risk Factors

2006 New Guideline in Treatment Moderator-to-Severe Low Back Pain

NOCICEPTIVE +/- NEUROPATHIC PAIN

YOUNG / HEALTHYELDERLY

• Weak opioid combinations eg. Paracetamol / tramadoll

•Tramadol

• Strong opioid

Moderate

Severe

• COX-2 inhibitors /NSAIDs low dose) +/or paracetamol/ tramadol (NSAIDs-sparing)

•Tramadol*

•Strong opioids IR

*Tramadol is efficacious for both nociceptive and neuropathic pain

Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29

WGPM ( The Working Group on Pain Management ) Recommendation at the 2nd meeting in EULAR 2005

LONG TERM

THERAPEUTIC CHOISE

TERAPI :• TCA, SSRI, SNRI• TRAMADOL• OPIOID

GLUTAMATE, CA++

( CENTRAL SENSITIZATION )

TERAPI :• PREGABALIN• GABAPENTIN• OXCARBAZEPINE• LAMOTRIGIN• NMDA ANTAGONIST

SPINAL CORD

DESCENDING INHIBITION (5HT, NE)

NOCICEPTOR

NA -CHANNEL( PERIPHERAL SENSITIZATION )

TERAPI :• NA CHANNEL BLOCKER• CARBAMAZEPINE• OXCARBAZEPINE• PHENYTOIN• GABAPENTIN• LIDOCAIN

BRAIN

KESIMPULAN The INTERNATIONAL ASSOCIATION for the STUDY of PAIN (IASP) : “the 2009–2010 GLOBAL YEAR AGAINST THE MUSCULOSKELETAL PAIN”.

NYERI MUSKULOSKELETAL MERUPAKAN MASALAH KESEHATAN BESAR YANG DIDERITA JUTAAN MANUSIA DI BUMI.

NYERI MUSKULOSKELETAL MERUPAKAN PROBLEM YANG KOMPLEK DAN MASIH KURANG DIPAHAMI DENGAN BAIK.

BEBERAPA PERTIMBANGAN DALAM PEMILIHAN TERAPI NYERI MUSKULOSKELETAL :

TENTUKAN JENIS/MACAM NYERI TENTUKAN KWANTITAS NYERI PEMILIHAN JENIS ANALGETIK

THANK YOU......