Clinical Mentoring Nyeri kronik Dr Darma Imran Sp.S

Clinical Mentoring
Nyeri kronik
Dr Darma Imran Sp.S
Departememen Neurologi RSCM - FKUI
1
Kasus 1
Seorang pria 49 tahun dengan keluhan nyeri pada
kepala, leher lengan bawah dan pinggang yang telah
berlangsung berulang dalam beberapa tahun
Pemeriksaan klinis neurologi dan ortopedik : dalam
batas normal
Pada pemeriksaan laboratorium dan pemeriksaan
radiologi : dalam batas normal
Apa yang harus kita jelaskan pada pasien ini ?
2
Kasus 1
Apa yang akan kita sampaikan pada pasien ini ?
1. Keluhan nyeri ini tidak ada kelainan, ini hanya
perasaan pasien saja
2. Keluhan ini merupakan penyakit psikosomatik
3. Akan dilakukan pemeriksaan lain yg lebih canggih
untuk mencari sumber nyeri
4. Proses Central sensitization - FM
3
The Normal Pain Processing Pathway
3. A signal is sent via
the ascending tract
to the brain, and
perceived as pain
Pain
Perceived
4. The descending tract carries
modulating impulses back to
the dorsal horn
2. Impulses from afferents
depolarize dorsal horn
neurons, then, extracellular
Ca2+ diffuse into neurons
causing the release of Pain
Associated Neurotransmitters
– Glutamate and Substance P
Glutamate
1. Stimulus sensed by
the peripheral nerve
(ie, skin)
1. Staud R and Rodriguez ME. Nat Clin Pract Rheumatol. 2006;2:90-98.
2. Gottschalk A and Smith DS. Am Fam Physician. 2001;63:1979-1984.
Substance P
4
Central Sensitization: A Theory for
Neurological Pain Amplification in FM
Central sensitization is believed to be an underlying cause of the
amplified pain perception that results from dysfunction in the CNS1
– May explain hallmark features of generalized heightened pain sensitivity2
• Hyperalgesia – Amplified response to painful stimuli
• Allodynia - Pain resulting from normal stimuli
Theory of central sensitization is supported by:
– Increased levels of pain neurotransmitters3,4
• Glutamate
• Substance P
fMRI data demonstrates low intensity stimuli in patients with FM
comparable to high intensity stimuli in controls5
fMRI = functional magnetic resonance imaging
1. Staud R and Rodriguez ME. Nat Clin Pract Rheumatol. 2006;2:90-98.
2. Williams DA and Clauw DJ. J Pain. 2009;10(8):777-791.
3. Sarchielli P, et al. J Pain. 2007;8:737-745.
4. Vaerøy H, et al. Pain. 1988;32:21-26.
5. Gracely RH, et al. Arthritis Rheum. 2002;46:1333-1343.
5
Central Sensitization Produces Abnormal
Pain Signaling
Perceived pain
Ascending
input
After nerve injury, increased input to the dorsal
horn can induce central sensitization
Nerve dysfunction
Descending
modulation
Nociceptive afferent fiber
Induction of central sensitization
Perceived pain
(hyperalgesia/allodynia)
Increased release of pain neurotransmitters
glutamate and substance P
Minimal
stimuli
Pain
amplification
Increased pain perception
1. Adapted from Gottschalk A and Smith DS. Am Fam Physician. 2001;63:1979-1984.
2. Woolf CJ. Ann Intern Med. 2004;140:441-451.
6
FM: An Amplified Pain Response
Subjective pain intensity
10
Pain in FM
Normal pain
response
8
Hyperalgesia
6
(when a pinprick causes an
intense stabbing sensation)
4
Allodynia
Pain
amplification
response
(hugs that feel painful)
2
0
Stimulus intensity
Adapted from Gottschalk A and Smith DS. Am Fam Physician. 2001;63:1979-1986.
7
fMRI Study Supports the Amplification of
Normal Pain Response in Patients With FM
14
Pain intensity
12
10
8
6
4
2
0
1.5
2.5
Stimulus intensity
3.5
4.5
(kg/cm2)
Patients with FM experienced high
pain with low grade stimuli
FM (n=16)
Subjective pain control
Stimulus pressure control
fMRI = functional magnetic resonance imaging
Gracely RH, et al. Arthritis Rheum. 2002;46:1333-1343.
(n=16)
Red: Activation at low intensity stimulus in patients with FM
Green: Activated only at high intensity stimulus in controls
Yellow: Area of overlap (ie, area activated at high
intensity stimuli in control patients was activated by low
intensity stimuli in patients with FM)
8
Patients With FM Have Elevated Pain
Neurotransmitter Substance P in Their CSF
Substance P concentration
(fmoles/mL)†
In 3 separate clinical studies, substance P, a pain
neurotransmitter, was elevated in FM patients1-3
50
40
P<0.001
P<0.001
42.8
43
FM patients
Healthy control subjects
30
P<0.03
20
10
19.26
17
16.3
12.83
0
Russell 1994
*1
*2
*3
Russell 1995
Bradley
n=32
n=24
n=14
n=30
n=24
n=10
CSF = cerebrospinal fluid
sample collected via lumbar puncture in FM and healthy controls and SP levels assessed by radioimmunoassay
†fmoles/mL = femtomole/mL = 10-15 mole/mL
1. Russell IJ, et al. Arthritis Rheum. 1994;37:1593-1601.
2. Russell IJ, et al. Myopain 1995: Abstracts from the 3rd World Congress on Myofascial Pain and Fibromyalgia; July 30 - August 3, 1995; San Antonio, TX.
3. Bradley LA, et al. Arthritis Rheum. 1996;suppl 9:212. Abstract 1109.
*CSF
9
Patients With FM Have Elevated Pain
Neurotransmitter Glutamate in Their CSF
CSF level of glutamate (µg/mL)
CSF Levels of Glutamate
2.5
P<0.003
FM patient
Control
2.0
1.5
Sarchielli et al measured
CSF levels of glutamate in
20 FM patients and 20
age-matched controls
Significantly higher levels
of glutamate were found in
FM patients compared
with controls
1.0
0.5
0
FM patient
CSF = cerebrospinal fluid
Sarchielli P, et al. J Pain. 2007;8:737-745.
Control
10
FM Pathophysiology: Summary
Central sensitization is a leading theory of FM
pathophysiology1
Elevated pain neurotransmitters in CSF of patients with
FM2-4
– Several studies showed elevated levels of glutamate and
substance P
– Elevated levels suggest that this may contribute to pain
amplification
fMRI data supports FM as a disorder of central pain
amplification5
– Areas activated by high intensity stimuli in control patients were
activated by low intensity stimuli in patients with FM
CSF = cerebrospinal fluid
fMRI = functional magnetic resonance imaging
1. Staud R and Rodriguez ME. Nat Clin Pract Rheum. 2006;2:90-98.
2. Russell IJ, et al. Arthritis Rheum. 1994;37:1593-1601.
3. Bradley LA, et al. Arthritis Rheum. 1996;suppl 9:212. Abstract 1109.
4. Sarchielli P, et al. J Pain. 2007;8:737-745.
5. Gracely RH, et al. Arthritis Rheum. 2002;46:1333-1343.
11
Clinical Features of FM
Chronic Widespread Pain1,2
• CORE criteria of FM
• Pain is in all 4 quadrants of the body ≥3 months
• Patient descriptors of pain include:4
• Aching, exhausting, nagging, and hurting
Tenderness2
• Sensitivity to pressure stimuli
• Hugs, handshakes are painful
• Tender point exam given to assess tenderness
• Hallmark features of FM4
• Hyperalgesia
• Allodynia
Other Symptoms2,3,5
• Fatigue
• Pain-related conditions/symptoms
• Chronic headaches/migraines, IBC, IC, TMJ, PMS
• Subjective morning stiffness
Other
Symptoms
• Neurologic symptoms
• Nondermatomal paresthesias
• Subjective numbness, tingling in extremities
• Sleep disturbance
• Non-restorative sleep, RLS
1. Leavitt F, et al. Arthritis Rheum. 1986;29:775-781.
2. Wolfe F, et al. Arthritis Rheum. 1995;38:19-28.
3. Roizenblatt S, et al. Arthritis Rheum. 2001;44:222-230.
4. Staud R. Arthritis Res Ther. 2006;8(3):208-214.
5. Harding SM. Am J Med Sci. 1998;315:367-376.
12
Widespread Pain and Tenderness
are the Defining Features of FM
In patients with FM, pain involves more areas
than other chronic pain conditions
*
Chronic Pain Controls
FM patients
98
100
*
85
*
*
80
72
69
% of patients
79
60
51
46
40
24
20
0
Widespread pain
Thoracic pain
Lumbar pain
Cervical pain
*P<0.001
Wolfe F, et al. Arthritis Rheum. 1990;33:160-172.
13
Patients With FM Present With
a Global Pain Disorder
While the ACR classification
criteria focuses on 18 points,
patients do not usually speak
of tender points1
This is a pain drawing—a
patient colors all areas of the
body in which they feel pain2
The diagram shows that the
pain of FM is widespread1
ACR = American College of Rheumatology
1. Wolfe F, et al. Arthritis Rheum. 1990:33:160-172.
Back
Front
Adapted from pain drawing provided courtesy of L Bateman.
2. Silverman SL and Martin SA. In: Wallace DJ, Clauws DJ, eds. Fibromyalgia & Other Central Pain
Syndromes. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2005:309-319.
14
Manual Tender Point Survey* for the
Diagnosis of FM
LOW CERVICAL –
Anterior aspects of C5, C7
intertransverse spaces
TRAPEZIUS –
Upper border of trapezius,
midportion
OCCIPUT –
At nuchal muscle
insertion
FOREHEAD
SUPRASPINATUS –
SECOND RIB SPACE –
At attachment to medial
border of scapula
about 3 cm lateral to sternal
border
ELBOW –
RIGHT FOREARM
Muscle attachments to
Lateral Epicondyle
GLUTEAL –
Upper outer quadrant of
gluteal muscles
KNEE –
Medial fat pad of knee
proximal to joint line
LEFT
THUMB
Manual Tender Points Survey:
• Presence of 11 tender points on palpation to a maximum of 4 kg
of pressure (just enough to blanch examiners thumbnail)
*Based on 1990 ACR FM Criteria
1. Adapted from Chakrabarty S and Zoorob R. Am Fam Physician. 2007;76(2);247-254.
GREATER
TROCHANTER –
Muscle attachments just
posterior to GT
Control Points
Tender Points
15
Kasus 1
Seorang pria berusia 36 tahun jatuh dari
atap rumah, saat memperbaiki antena TV
Pasien mengeluhkan nyeri hebat di
pinggang bawah-bokong, disertai dengan
nyeri tekan pada bokong. Selain itu pasien
juga merasakan bokongnya terasa baal.
– Nyeri apakah yg dialami pasien ini ?
A. Nyeri akut
B. Nyeri kronik
C. Nyeri nosiseptif
D. Nyeri neuropatik
E. Nyeri campuran
Karakter nyeri : deskripsi keluhan nyeri
Nyeri tajam (sharp pain)
Nyeri ditusuk (stabbing pain)
Nyeri tumpul (dull pain)
Nyeri berdenyut (throbbing pain)
Identifikasi istilah yg digunakan oleh berbagai bahasa di
Indonesia untuk melukiskan nyeri
–
–
–
–
Cekot-cekot …?
Mules
Panas
Sakit
Pendekatan thdp
pasien dgn masalah nyeri
1.
Lokasi
2.
Onset dan durasi
3.
Karakter nyeri – intensitas nyeri
4.
Faktor yg memperberat dan meringankan, akibat nyeri pd aktifitas
pasien
5.
Tentukan gejala-tanda penyerta
6.
Tentukan sindrom nyeri dan patofisiologinya
7.
Tentukan diagnosis dan penyebab nyeri
8.
Rencanakan pemeriksaan lain untuk menunjang diagnosis sementara
9.
Atasi kegawat daruratan yang ada
10. Tentukan strategi pengobatan secara holistik
Penanganan Nyeri
Non-farmakologik
–
–
–
–
–
–
Information, Reassurance and Identification of Trigger Factors
Psychological Treatments
Relaxation Training
Electromyography Biofeedback
Cognitive–Behavioural Therapy
Physical Therapy
Terapi farmakologik
Kerja obat anti nyeri
• Bekerja pd tempat cedera dgn mengurangi
reaksi inflamasi : dengan menghambat kerja
enzim cyclo-oxygenase (COX). Contoh
:NSAID seperti aspirin, ibuprofen dan asam
mefenamat.
•
Merubah konduksi saraf : menghambat
potensial aksi dengan cara menghambat
channel natrium. Obat anastesi lokal
•
Modifikasi transmisi pd ganglion dorsalis :
golongan opioid dan agonisnya, obat
antiepileptik
•
Mempengaruhi komponen sentral dari
jaras sensorik : antidepresan, antiepileptik,
opioid, relaksan otot
Kasus 3
Seorang wanita berusia 50 thn
Mengeluh nyeri hebat pd pada rahang atas kanan yang
berlangsung sangat singkat namun sering berulang
dalam 4 bulan terakhir.
Apa yg dialami oleh pasien ini ?
–
–
–
–
Nyeri neuropatik
Nyeri nosiseptif
Nyeri neuralgia trigeminal
Nyeri neuralgia glosofaringeal
lanjut…… Kasus 3
Obat apa yg dapat diberikan utk mengurangi keluhan
pasien ini ?
a)
b)
c)
d)
Asam mefenamat
Parasetamol
Ibuprofen
Karbamazepin
Apa efek samping obat tsb ?
Kasus 4
Pria berusia 30 tahun
Nyeri hebat pada pinggang yang menjalar ke tungkai kiri
hingga ibu jari kaki sejak 3 hari yg lalu.
6 bulan yll pasien telah menjalani operasi untuk keluhan
yg sama karena saraf kejepit di pinggang.
Tentukan pilihan obat yang akan digunakan
a) Ibuprofen
b) Gabapentin
c) Morfin
d) Neurorestorasi modulasi nyeri di otak
Kasus 5
Seorang wanita 30 thn
Nyeri kepala berulang sejak 5 hr yll
– data apa lagi yg ingin anda
dapatkan ?
Lanjut ….. Kasus 5
Nyeri berulang dialami sejak 3-5 thn yll
Durasi nyeri ??
Nyeri datang beberapa jam terutama disiang hari dan berkurang
dimalam hari.
Tidak ada penglihatan ganda, namun pasien tidak kuat melihat sinar
terang dan juga suara yg bising
Pasien juga mengeluhkan mual dan tidak pergi ke kantor akibat nyeri
kepala yg terjadi
Letak nyeri tu pd kepala sisi kiri, berdenyut
Tanda vitaldalam batas normal
PF Neurologi : dalam batas normal
Lanjut …. Kasus 5
1. Apakah ada tanda sakit kepala yg berbahaya
2. Apakah termasuk sakit kepala primer ?
a)
b)
Migren ?
Tension type headache ?
Chronic pain
"Chronic pain really is a disease of the central nervous
system," . "As such, it is a disease that affects the
sensory, emotional, motivational, cognitive and
modulatory pathways.
The way we approach patients in pain may need to be
revised.“
Borsook et al 2011
Kesimpulan
Fibromyalgia sering kali ditemukan bersama dengan berbagai
kelainan kronik lainnnya yang berhubungan dengan central
sensitization
Kriteria fibromyalgia
–
Nyeri luas ≥3 bulan
– Nyeri di 4 kuadran and aksial skeleton
– tender points > 11
Perlu dibedakan apakah nyeri akut atau nyeri kronik
Masalah nyeri nosiseptif atau nyeri neuropatik atau nyeri campuran.
Tatalaksana nyeri secara non-farmakologik dan farmakologik.
Aspek Central sensitization dipertimbangkan dlm setiap kasus nyeri
29