P A I Nfocus 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 painNeuropathic pain Combination
Pain Clinical DiagnosisHistory takingPhysical examination, Neurological exam.Laboratory examination : Lab. Neurophysiology exam. Neuroimaging
Visual Analog Scales010No painExcruciating pain010Complete pain reliefNo pain reliefMcQuay, 1998.Note: Lines must be exactly 100 mm longFACES SCALES
THE DERMATOMES
Bagaimana Gejala Nyeri Neuropatik ?
HAS/Neuro/RSHS-FKUP
Nyeri SpontanNyeri dibangkitkan stimulus
Syndromes of Epiconus, Conus and Cauda Equina
Syndrome of lumbal-radiculopathy
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 tungkai-kaki
Pain sensitive L-S structuresSkin, subcutaneous, adipose tissueMusclesFacet joints, sacroiliaca jointsPost/ant.longitudinal lig.Periosteum vertebra (fascia,tendon,aponeurosis)Nerve rootsBlood vessels (spinal joint,sacroiliaca joint, verteb, L-S muscles)
Estimated Prevalence of NePHAS/Neuro/RSHS-FKUP
Indonesia : 40% population, men>women hospital based : 3-17%
Low Back PainTriage diagnostik LPBLBP nonspesifikSindroma radikulerKelainan patologik serius Red Flags (Agency for Health Care Policy and Research, Bigos 1994)HAS/Neuro/2005
Low Back pain
Seriuos pathology: neoplasm infection fracture cauda equina syndromeIschialgia, radicular syndromeNonspecific LBP
Syndromes of Epiconus, Conus and Cauda Equina
Syndrome of lumbal-radiculopathy
Low Back PainDiagnostic triageHistory taking and physical examination to exclude red flagsNeurological examination (including Lassegue test)Consider psychosocial factors if there is no improvementX-rays, MRI ??
Red Flags of LBPCancer InfectionVertebral fracturCauda equina syndrome or Severe neurological deficit
Yellow FlagsRecognition of psychosocial factors as predictors of chronicity and obstacles to recoveryAcute subacute chronic
Risk Factors of LBPPhysical : 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 LBPDiagnostic classification, D/ triageReassuranceEarly and progressive activationAnalgetics ?: acetaminophen NSAID consider muscle relaxantsRecognition yellow flags
HAS/P3D
Management of Chronic LBPBehavioral therapyEducationIntensive exercise therapy Multidisciplinary
HEADACHEHAS/P3D
ALL ACHES AND PAINS LOCATED IN THE HEAD
ORBITA OCCIPUTHEADACHE DEFINITION :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 STRUCTURESSkin,subcutan., muscleExtracranial arteriesSkull periosteumEye,ear, nasal cavities, sinusesIntracran.venous sinuses, large vein, pericavernous structuresBasis dura, meningeal arteries, prox.ant/middle cerebral A, IC int.carotis ASuperf.temporal ACranial 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 ARTERIESDISTENTION OF EXTRACRANIAL ARTERIESTRACTION ON OR DISPLACEMENT OF THE LARGE INTRACRANIAL VEINS OR DURAL ENVELOPE COMPRESSION, TRACTION OR INFLAMATION OF THE CRANIAL AND SPINAL NERVESSPASM, INFLAMATION & TRAUMA TO CRANIAL & CERVICAL MUSCLE
MECHANISM OF CRANIAL PAIN (cond)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
ATTACK ONSETQUALITYSEVERITYLOCATIONMODE OF ONSETTIME, INTENSITY, CURVE, DURATIONCONDITION WHICH EXACERBATE / RELIEVE THE PAINASSOCIATED FEATURESSOCIAL HISTORY, FAMILY HISTORYPAST HEADACHE HISTORYHEADACHE IMPACT
HISTORY taking:
HAS/NEURO
Faktor pencetus Nyeri Kepala
StresKurang/kebanyakan tidurTidak/telat makanBau menyengat : parfum,rokokLingkungan: cahaya silau/berkedip,gaduh ketinggian,panas,lembab ruang berasapMakanan/minumanHAS/Neuro/Bdg/04
RED FLAGS of HEADACHE
Secondary Headache Red Flags SSNOOPSystemic symtoms (fever, weight loss) orSecondary 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 HeadachePsychologic factorsMuscle contraction and myofacial tendernessVascular factorsn : NOHumoral factors : 5HTCentral factors : central pain control system
HAS/P3D
PHYSICAL EXAMINATION
NEUROLOGICAL EXAMINATION
HAS/P3DTrigeminal neuralgia
HEADACHE TREATMENTPRIMARY HEADACHE TREATMENT Abortive Preventive
SECONDARY HEADACHE TREATMENT Causal Symtomatic : Analgesic
PRIMARY HEADACHE TREATMENT TTHAbortive :Simple analg : acetaminophen/ ASA/NSAID
Preventive : Amitriptylin
Nonpharmacologic therapyMIGRAINEAbortive :Simple analg : acetaminophen/ ASA/ NSAIDSpecific analg : ergot alkaloids ( ergotamine/ DHE )/ triptanAntiemetics : metoclopramide/ domperidone
Preventive : Anticonvulsants / Adrenoceptor blockers (propranolol)/ Antidepressants/ Ca-channel blockers
Nonpharmacologic therapy
CLUSTER HAabortive : o2 inhalationergot alkaloids, triptans
preventive : verapamilergot alkaloid
Cranial Neuralgias,Central Pain(Neuropathic Pain) Treatment AntidepressantsAnticonvulsantsAntiarrhitmicLocal anesthetic
Penanganan tanpa obat
EdukasiMengenal & menghindari faktor pencetus
Modifikasi perilakuLatihanRelaksasiBiofeedbackTerapi perilaku kognisiTerapi fisikTENS (transcutaneus electric nerves stimulation)HAS/Neuro/Bdg/04
(PERDOSSI,2001)
HAS/Neuro/2004
(Rowbotham MC, Petersen KL, 2001)Antikonvulsants
(PERDOSSI,2001)HAS/Neuro/RSHS-FKUP
(I.C.H.E.)MononeuropahiesMononeuropahies
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