perdosri- terapi nyeri muskuloskeletal
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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......
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