Dr. Moch. Bahrudin, SpS

Fakultas Kedokteran Universitas Muhammadiyah Malang

TOPICS Pain fisiologi dan patofisiologiMusculoskeletal pain The causes of musculoskeletal painSign and symptomThe different types of musculoskeletal painDiagnosedTreated

Pain

PROTECTION

DefinitionsPain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Physiology of Pain PerceptionTransductionTransmissionModulationPerceptionInterpretationBehaviorInjuryDescending PathwayPeripheral NerveDorsal Root GanglionC-FiberA-beta FiberA-delta FiberAscending PathwaysDorsal HornBrainSpinal CordAdapted with permission from WebMD Scientific American Medicine.*

Peripheral Mechanisme of Pain

Mixed TypeCaused by a combination of both primary injury and secondary effectsNociceptive vs Neuropathic PainNociceptivePainCaused by activity in neural pathways in response to potentially tissue-damaging stimuliNeuropathic PainInitiated or caused by primary lesion or dysfunction in the nervous systemPostoperative painMechanical low back painSickle cell crisisArthritisPostherpetic neuralgia Neuropathic low back painCRPS*Sports/exercise injuriesCentral post- stroke painTrigeminal neuralgiaDistal polyneuropathy (eg, diabetic, HIV)

What is musculoskeletal pain?

Musculoskeletal pain affects :the bones, muscles, ligaments, tendons, and nerves. It can be acute or chronic (long-lasting). Musculoskeletal pain can be localized in one area, or widespread.Lower back pain >>>Other common types include tendonitis, myalgia (muscle pain), and stress fractures.

What are the causes of musculoskeletal pain?

an injury to the bones, joints, muscles, tendons, ligaments, or nerves. >>>

Musculoskeletal pain can also be caused by overuse. Pain from overuse affects 33% of adults. ( Lower back pain)

Poor posture or prolonged immobilization

What are the symptoms of musculoskeletal pain?

Clinical manifestation include:PainParesthesia or hypesthesiaStiffnessWeaknesEdemaThe limitation of range of motion

What are the different types of musculoskeletal pain?

Musculoskeletal pain has varying symptoms and causes.

Bone pain: This is usually deep, penetrating, or dull. It most commonly results from injury.

Muscle pain (myofasial pain) : This is often less intense than bone pain, Anita HoldcroftAnita Holdcroft, CORE TOPICS IN PAIN, Cambridge University Press 2005

Anita HoldcroftAnita Holdcroft, CORE TOPICS IN PAIN, Cambridge University Press 2005

Tendon and ligament pain: Pains in the tendons or ligaments are often caused by injuries, including include sprains. This type of musculoskeletal pain often becomes worse when the affected area is stretched or moved.

Fibromyalgia Syndrome (FMS) : This is a condition that may cause pain in the muscles, tendons, or ligaments. The pain is usually in multiple locations and can be difficult to describe. Fibromyalgia is usually accompanied by other symptoms.

Common symptoms in FMS patients are: Sleep disturbance. Fatigue. Morning stiffness. Anxiety. Depression. Co-morbidity with rheumatic and endocrinedisorders.

Joint pain: Joint injuries and diseases usually produce a stiff, aching, "arthritic" pain. The pain may range from mild to severe and worsens when moving the joint. The joints may also swell. Joint inflammation (arthritis) is a common cause of pain.

"Tunnel" syndromes: This refers to musculoskeletal disorders that cause pain due to nerve compression. The disorders include carpal tunnel syndrome, cubital tunnel syndrome, and tarsal tunnel syndrome. The pain tends to spread along the path supplied by the nerve and may feel like burning. These disorders are often caused by overuse.

How is musculoskeletal pain diagnosed?

Medical history. Examination looking for the source of the pain.

These may include:Blood tests to confirm a diagnosis, such as rheumatoid arthritis X-rays to take images of the bones CT scans to get an even more detailed look at the bones MRIs to look at soft tissues such as muscles, cartilage, ligaments, and tendons Based on the findings from your examination and the results of these tests,

How is musculoskeletal pain treated?

Musculoskeletal pain is best treated by treating its cause.

1. Physical or occupational therapy Using a splint to immobilize the affected joint and allow healing Using heat or cold Reducing workload and increasing rest Reducing stress through relaxation and biofeedback techniques Acupuncture or acupressure Strengthening and conditioning exercises Stretching exercises Chiropractic care Therapeutic massage

CON'T2. Midications Injections with anesthetic or anti-inflammatory medications in or around the painful sites For patients with fibromyalgia, medications to increase the body's levels of serotonin and norepinephrine (neurotransmitters that modulate sleep, pain, and immune system function) are often prescribed in low doses. Analgesics such as acetaminophen, NSAIDS, or, if pain is severe, opioids.

3. Operative

Musculoskeletal pain affects : the bones, muscles, ligaments, tendons, and nerves.Clinical manifestation include: Pain, Paresthesia or hypesthesia,Stiffness,Weaknes,edema,The limitation of range of motion Diagnosed : Medical history, Examination looking for the source of the pain and Laboratory.Treatments include: Physical or occupational therapy , medication and operative

Pain that manifests in diverse diseases may operate through common mechanisms. No pain mechanism is an inevitable consequence of a particular disease process. A given pain mechanism could be responsible for many different symptoms. More than one mechanism can operate in a single patient, and these may change over time.The main neurotransmitter in primary afferents is the excitatory amino acid glutamate. Activation of nociceptors causes the release of glutamate from central terminals; this release acts on the ionotropic glutamate receptor amino-3-hydroxy-5-methylisoxazole-4-proprionic acid postsynaptically to cause a rapid depolarization of dorsal horn neurones and, if threshold is reached, action potential discharge.Transduction: noxious stimuli cause ion channels in the membranes of thermal, mechanical, and chemical receptors located in the skin and tissue to open. Ions enter the receptor and depolarize it. Transmission: a wave of depolarization, or action potential, travels toward the spinal cord via A-beta (thinly myelinated) fibers and C (unmyelinated) fibers and up the ascending pathway. A-beta (light touch) fibers may become sensitized by CNS mechanisms to produce allodynia.Modulation/Perception: the ascending pain pathway carries impulses from the nociceptor to the sensory cortex; thus the sensation of pain is perceived.Interpretation: impulses are carried by 1st, 2nd, and 3rd order neurons. 1st order neurons carry impulses from the nociceptor to the dorsal horn of the spinal cord. 2nd order neurons carry impulses from the spinal cord to the thalamus, while 3rd order neurons carry the impulse from the thalamus to the primary sensory cortex.

Crossman AR, Neary D. Neuroanatomy, 2nd ed. Churchill Livingstone, 2000.Galer B, Gammaitoni A, Alvarez N. 6. Immunology [XIV. Pain]. In: Dale DC, Federman DD, eds. WebMD Scientific American Medicine. New York, NY:WebMD Corporation; 2003.Guyton AC, Hall J. Textbook of Medical Physiology, 10th Ed. Saunders, 2000.Woolf CJ, Mannion RJ. Neuropathic pain: aetiology, symptoms, mechanisms, and management. Lancet. 1999;353:1959-1964.Nociceptive, or inflammatory, pain is pain resulting from activity in neural pathways caused by potentially tissue-damaging stimuli.1 Examples include postoperative pain, arthritis, mechanical low back pain, sickle cell crisis, and sports or exercise injuries.Neuropathic pain is pain caused by a primary lesion or dysfunction in the peripheral and/or central nervous systems.2 Examples of peripheral neuropathic pain syndromes include HIV sensory neuropathy, postherpetic neuralgia (PHN), and diabetic neuropathy. Examples of central neuropathic pain include central poststroke pain, spinal cord injury pain, trigeminal neuralgia, and multiple sclerosis pain. As indicated by the mixed type area on the slide, chronic pain can be of mixed etiology with both nociceptive and neuropathic characteristics. Two types of neuropathic painPHN and diabetic neuropathywill be emphasized within this module. These types of pain are being stressed because the great majority of randomized controlled trials of treatments for neuropathic pain have examined these two disorders, and because our understanding of the mechanisms of neuropathic pain is largely derived from those studies.

1.Portenoy RK, Kanner RM. Definition and Assessment of Pain. In: Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. Philadelphia, Pa: FA Davis Company; 1996:4.2.Galer BS, Dworkin RH. A Clinical Guide to Neuropathic Pain. Minneapolis, Minn: The McGraw-Hill Companies Inc; 2000:8-9.*