Transcript P A I N
PAIN focus on LBP and HEADACHE Department Of Neurology dr. Hasan Sadikin Hospital Padjadjaran University Definition of PAIN Pain is unpleasent sensory and emotional experience associated with actual or potential tissue damage, or discribed in term of such damage ( IASP, 1986 ) Types of pain : Nociceptive pain, inflamatory pain Neuropathic pain Combination Pain Clinical Diagnosis • History taking • Physical examination, Neurological exam. • Laboratory examination : Lab. Neurophysiology exam. Neuroimaging Visual Analog Scales Excruciating pain No pain 0 10 Complete pain relief No pain relief 0 McQuay, 1998. Note: Lines must be exactly 100 mm long FACES SCALES 10 THE DERMATOMES Bagaimana Gejala Nyeri Neuropatik ? HAS/Neuro/RSHS-FKUP Nyeri Spontan Nyeri dibangkitkan stimulus Syndrome of lumbal-radiculopathy Syndromes of Epiconus, Conus and Cauda Equina LOW BACK PAIN (NYERI PUNGGUNG BAWAH) • Nyeri di antara sudut iga terbawah dan lipat bokong bawah yaitu di daerah lumbal atau lumbo-sakral dan sering disertai dengan penjalaran nyeri kearah tungkaikaki Pain sensitive L-S structures • • • • • • • Skin, subcutaneous, adipose tissue Muscles Facet joints, sacroiliaca joints Post/ant.longitudinal lig. Periosteum vertebra (fascia,tendon,aponeurosis) Nerve roots Blood vessels (spinal joint,sacroiliaca joint, verteb, L-S muscles) Estimated Prevalence of NeP Indonesia : 40% population, men>women hospital based : 3-17% HAS/Neuro/RSHS-FKUP Low Back Pain Triage diagnostik LPB LBP nonspesifik Sindroma radikuler Kelainan patologik serius “ Red Flags “ HAS/Neuro/2005 (Agency for Health Care Policy and Research, Bigos 1994) Low Back pain • Seriuos pathology: neoplasm infection fracture cauda equina syndrome • Ischialgia, radicular syndrome • Nonspecific LBP Syndrome of lumbal-radiculopathy Syndromes of Epiconus, Conus and Cauda Equina Low Back Pain • Diagnostic triage • History taking and physical examination to exclude red flags • Neurological examination (including Lassegue test) • Consider psychosocial factors if there is no improvement • X-rays, MRI ?? Red Flags of LBP • • • • Cancer Infection Vertebral fractur Cauda equina syndrome or Severe neurological deficit Acute subacute chronic Yellow Flags • Recognition of psychosocial factors as predictors of chronicity and obstacles to recovery Risk Factors of LBP • Physical : 35 – 55 y past history of LBP • Occupational : vibration bending, twisting heavy lifting low job satisfaction • Psychosocial : attitudes cognition fear-avoidance beliefs depression anxiety distress and related emotion Management of acute LBP • • • • Diagnostic classification, D/ triage Reassurance Early and progressive activation Analgetics ?: acetaminophen NSAID consider muscle relaxants • Recognition yellow flags HAS/P3D Management of Chronic LBP • Behavioral therapy • Education • Intensive exercise therapy Multidisciplinary HEADACHE HAS/P3D HEADACHE DEFINITION : ALL ACHES AND PAINS LOCATED IN THE HEAD ORBITA OCCIPUT HAS/P3D The International Classification of Headache Disorders ICHD 2 ( IHS 2004 ) The Primary Headaches Migraine Tension-type headache (TTH) Cluster headache Other primary headaches The Secondary Headaches Headache attributed to head and/or neck trauma Headache attributed to cranial or cervical vascular disorders Headache attributed to non-vascular intracranial disorders Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disorder of homoeostasis Headache or facial pain attributed disorder of cranial, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures Headache attributed to psychiatric disorders Cranial Neuralgias, central & primary facial pain & other headaches Cranial neuralgias & central causes of facial pain Others headache, cranial neuralgias & central or primary facial pain The International Classification of Headache Disorders ICHD 2 ( IHS 2004 ) The Primary Headaches Migraine Tension-type headache (TTH) Cluster headache Other primary headaches The Secondary Headaches Headache attributed to head and/or neck trauma Headache attributed to cranial or cervical vascular disorders Headache attributed to non-vascular intracranial disorders Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disorder of homoeostasis Headache or facial pain attributed disorder of cranial, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures Headache attributed to psychiatric disorders Cranial Neuralgias, central & primary facial pain & other headaches Cranial neuralgias & central causes of facial pain Others headache, cranial neuralgias & central or primary facial pain PAIN SENSITIVE CRANIAL STRUCTURES • • • • • • • • Skin,subcutan., muscle Extracranial arteries Skull periosteum Eye,ear, nasal cavities, sinuses Intracran.venous sinuses, large vein, pericavernous structures Basis dura, meningeal arteries, prox.ant/middle cerebral A, IC int.carotis A Superf.temporal A Cranial nerves:II.III,V,IX,X,C1-3 THE ROLE OF NEUROTRANSMITTER : SEROTONIN (5 HT) THE ENDOGENOUS PAIN CONTROL MECHANISM -> OPIOID GABA MECHANISMS OF CRANIAL PAIN : TRACTION ON OR DILATATION OF THE INTRACRANIAL ARTERIES DISTENTION OF EXTRACRANIAL ARTERIES TRACTION ON OR DISPLACEMENT OF THE LARGE INTRACRANIAL VEINS OR DURAL ENVELOPE COMPRESSION, TRACTION OR INFLAMATION OF THE CRANIAL AND SPINAL NERVES SPASM, INFLAMATION & TRAUMA TO CRANIAL & CERVICAL MUSCLE MECHANISM OF CRANIAL PAIN (con’d) DISEASE OF THE TISSUES OF THE SCALP, FACE, EYE, NOSE, EAR AND NECK MENINGEAL IRRITATION INTRACRANIAL MASS LESION RAISED INTRACRANIAL PRESSURE LOWERED INTRACRANIAL PRESSURE : LP HEADACHE HISTORY taking: ATTACK ONSET QUALITY SEVERITY LOCATION MODE OF ONSET TIME, INTENSITY, CURVE, DURATION CONDITION WHICH EXACERBATE / RELIEVE THE PAIN ASSOCIATED FEATURES SOCIAL HISTORY, FAMILY HISTORY PAST HEADACHE HISTORY HEADACHE IMPACT HAS/NEURO Faktor pencetus Nyeri Kepala Stres Kurang/kebanyakan tidur Tidak/telat makan Bau menyengat : parfum,rokok Lingkungan: cahaya silau/berkedip,gaduh ketinggian,panas,lembab ruang berasap Makanan/minuman HAS/Neuro/Bdg/04 RED FLAGS of HEADACHE Secondary Headache Red Flags “SSNOOP” • Systemic symtoms (fever, weight loss) or • Secondary risk factors : underlying diseases (HIV,systemic cancer) • Neurologic symtoms or abnormal signs (confusion, impaired alertness,or consciousness) • Onset: sudden,abrupt, or split-second (first,worst) • Older: new onset and progressive headache, especially in middle age>50 (giant cell arteritis) • Previous headache history or headache progression: pattern change, first headache or different (change in attack frequency, severity, or clinical pictures) HAS/P3D HAS/P3D CLUSTER HEADACHE YOUNG ADULT MEN ( M : F = 5 : 1 ) UNILATERAL PAIN HAS/NEURO Tension Type Headache • • • • • Psychologic factors Muscle contraction and myofacial tenderness Vascular factorsn : NO Humoral factors : 5HT Central factors : central pain control system HAS/P3D PHYSICAL EXAMINATION NEUROLOGICAL EXAMINATION Trigeminal neuralgia HAS/P3D HEADACHE TREATMENT • PRIMARY HEADACHE TREATMENT Abortive Preventive • SECONDARY HEADACHE TREATMENT Causal Symtomatic : Analgesic PRIMARY HEADACHE TREATMENT TTH Abortive : Simple analg : acetaminophen/ ASA/NSAID Preventive : Amitriptylin Nonpharmacologic therapy MIGRAINE Abortive : Simple analg : acetaminophen/ ASA/ NSAID Specific analg : ergot alkaloids ( ergotamine/ DHE )/ triptan Antiemetics : metoclopramide/ domperidone Preventive : Anticonvulsants / Adrenoceptor blockers (propranolol)/ Antidepressants/ Ca-channel blockers Nonpharmacologic therapy CLUSTER HA abortive : – o2 inhalation – ergot alkaloids, – triptans preventive : – verapamil – ergot alkaloid Cranial Neuralgias,Central Pain (Neuropathic Pain) Treatment • Antidepressants • Anticonvulsants • Antiarrhitmic • Local anesthetic Penanganan tanpa obat Edukasi Mengenal & menghindari faktor pencetus Modifikasi perilaku Latihan Relaksasi Biofeedback Terapi perilaku kognisi Terapi fisik TENS (transcutaneus electric nerves stimulation) HAS/Neuro/Bdg/04 (PERDOSSI,2001 HAS/Neuro/2004 Antikonvulsants (Rowbotham MC, Petersen KL, 2001) HAS/Neuro/RSHS-FKUP (PERDOSSI,2001) Mononeuropahies (I.C.H.E.)