Rangsang Nyeri

PSIK Block 1.3 Year 2009 Andreanyta Meliala, Dr.,Ph.D Dept. of Physiology (Med.F-GMU)

Nyeri.
Terjadi oleh karena gangguan keseimbangan eksitasi dan inhibisi

Eksitasi

Inhibisi

Low intensity stimulus

High intensity stimulus

High threshold A delta and C nociceptor

Low threshold A beta fibre

PNS CNS

Cortex

Non-painful sensation

PAIN
Stubhaug, 2002 Modifikasi Meliala, 2003

PEGEL PERIH PANAS BRAIN

PRESSURE

HEAT

CHEMICAL

Modifikasi Meliala, 2003

TRANSDUCTION
Activation
Heat
VR1 Ca2+ mDEG P2X3

External

Pain and auto-sensitization

Na+ PAIN PAIN Voltage gated sodium channels

Mechanical

Stimuli

ATP Chemical

action potentials Generator potentials

Woolf & Mitchel, 2001 Modifikasi Meliala, 2003

Pemeriksaan
Neuromuskuloskeletal (5 menit)
Frozen shoulder Tennis Elbow De Quervain Sindrom servikal

Low back pain

Ischialgia Tendinitis Fasciitis plantaris

OA, RA, Trigger finger OA lutut

Anger

Anxiety

Fear

Depression
A

NOCICEPTIVE

Noxious Stimuli

MELIALA 2004

HIPERSENSITIFITAS : Sensitisasi Perifer (Modulasi)

Activation: AMPA/KAI receptor fast EPSPs
C-fiber terminal Glu Inhibitory interneuron

GABA B adenosine
Glu

Ca2+

Gly/GABA NK1 mGluR

AMPA KAI NMDA

GABA B Adenosine

TrkB

K K++

Nociceptive Dorsal horn neuron

VGCC

NSC

GABA-A

GLY

K K++

Woolf & Mitchel, 2001 Modifikasi Meliala, 2003

HIPERSENSITIFITAS: Sensitisasi sentral

Activation: Slow EPSPs, plateau potentials, summation & wind-up
C-fiber terminal Glu
Ca2+ Ca2+

GABA B adenosine
Glu SP

Inhibitory interneuron

P2X NMDA
Ca2+ Mg2+ AMPA KAI NMDA Ca2+

Gly/GABA GABA B Adenosine Ca2+

Ca2+

NK1 mGluR

TrkB

Na2+

Na2+

K K++

IP3
Ca2+

VGCC
Ca Ca2+
2+

NSC

GABA-A

GLY

K K++

Woolf & Mitchel, 2001 Modifikasi Meliala, 2003

TERAPI BERDASAR MEKANISME

BRAIN PAINT
Inhibisi Descenden

NE/SHT
Reseptor Opoid

Medula Spinalis
Sensitisasi perifer ion Na

Beydoun, 2002 Modifikasi Meliala, 2003

TERAPI BERDASAR MEKANISME

NO PAIN BRAIN PAIN PAIN
Inhibisi Descenden

NE/SHT
Reseptor Opoid

Medula Spinalis
Sensitisasi perifer ion Na
CBZ OXC PHT MEXILETIN LIDOCAIN DLL

TX

Beydoun, 2002 Modifikasi Meliala, 2003

TERAPI BERDASAR MEKANISME

NO PAIN NO PAIN BRAIN PAIN
Inhibisi Descenden

NE/SHT
Reseptor Opoid GBP OXC LTG Ketamin Dextro Metor phan DLL

Medula Spinalis
Sensitisasi perifer ion Na

Sensitisasi Sentral
(NMDA, Calcium)

TX

Beydoun, 2002 Modifikasi Meliala, 2003

TERAPI BERDASAR MEKANISME

NO PAIN BRAIN PAIN PAIN
Inhibisi Descenden TCA Tramadol Opioid DLL

NE/SHT
Reseptor Opoid

TX

Medula Spinalis
Sensitisasi perifer ion Na

Beydoun, 2002 Modifikasi Meliala, 2003

Posterior Longitudinal ligament Disc

Nucleus Annulus

Spinous process Ligamentum flavum Joint Capsule

Nerves

Spinal cord and sheath (Dura)

JARINGAN DENGAN SENSOR NYERI

Disc bulging

Osteophytes (trapping nerve) Joint Capsule

TITIK TEKAN DISEKITAR ARTIKULASIO SPINALIS

Longissimus capitis

Iliocostalis cervicis
Intertransversarii Multifidus

Longissimus cervicis Spinalis cervicis

Iliocostalis thoracis Iliocostalis lumborum

Spinalis thoracis Longissimus

GAMBAR OTOT PUNGGUNG

Keterangan : Otot pendek berfungsi sebagai stabilisator dan otot panjang untuk pergerakan

Kekuatan/Stabilitas/Fungsi

Keterangan : Penurunan fungsi oleh usia

Waktu

Epesode akut dengan pengobatan yang baik

Pengobatan tidak adekuat menyebabkan NPB kronik Pengobatan Nyeri yang baik memungkinkan rehabilitasi

Sel Mast

BRAIN DRG

1. Histamin

2. 3. 4. 5.

Lesi

1.

Medula spinalis

Pembuluh darah

Meliala, 2005

Mekanisme Proteksi Nyeri

C

spasme otot
Joint receptor (nociceptor)

Descending influences

Spinothalamic tract

II-IV
B Joint dysfunction or pain

III-IV I
-Motoaxon -Motoaxon

Ia

Nociceptor A Muscle pain

NO PAIN PAIN
Muscle spindle

Eperison

Diabetic foot ulcer in typical location

Medscape

http://www.medscape.com

Medscape

http://www.medscape.com

Semmes-Weinstein monofilament being used to

test sensation in a diabetic patient

Medscape

http://www.medscape.com

Measuring temperature sensation thresholds using the CASE IV quantitative sensory testing device.

Medscape
Medscape

http://www.medscape.com
http://www.medscape.com

Measuring vibratory sensation thresholds using the

CASE IV quantitative sensory testing device

Axonal polyneuropathy Demyelinating Neuropathy Neuronopathy (Ganglionopathy) Polyneuropathy is caused by the degeneration of axon terminals and results in symmetric distal sensory loss with shading to normal sensation. A compression neuropathy often results in demyelination with the axon left relatively intact. Sensory loss follows a radicular pattern. When the neuronal cell body dies the condition is called "neuronopathy." If the cell body is in the sensory ganglion the condition is often referred to as "ganglionopathy." The pattern is usually random

TYPES OF ACUTE PAIN

Pain in a patient with no pre-existing chronic painful condition Pain in patient with a chronic painful condition, not related to the pre-existing problem. Pain due to an exacerbation of a chronic painful condition.

CLASSIFICATION OF PAIN
PAIN TYPE Nociceptive Somatic Peripheral nociceptive and somatic sensory efferent nerves Visceral nociceptive and efferent nerves Undamaged Ussualy well localized PAIN RECEPTORS INVOLVED STATUS OF NERVOUS SYSTEM SYMPTOMS

Visceral

Undamaged

Poorly localized, deep aching, cramping

Neuropathic

None

Damaged due to injury or disease

Burning sensation

PAIN MANAGMENT
Noninvasive
Physical Physical therapy Occupational therapy Activity modification Brancing Cognitive-behavioural Relaxation therapy Psychological/psychiatric management Pharmacological

Invasive
Blocks Diagnostic Therapeutic Implanted devices Medication pumps Spinal-cord stimulators Surgery

ANALGESIC MEDICATIONS
PRIMARY ANALGESICS Acetminophen Prostaglandin synthesis inhibitors Salicylates Traditonal NSAIDs COX-2-selective NSAIDs (coxibs) Tramadol Opioids Traditional Mixed ADJUVANT MEDICATIONS Antidepressants Anticonvulsants Local anesthetics Miscellaneous agents

PAIN SERIES OF EVENTS

PERCEPTION PAIN

MODULATION TRANSMISSION

TRANSDUCTION

V. PRINCIPLES OF PAIN MANAGEMENT WITH ANALGESICS

See text

Andreanyta Meliala, Dewanto Husodo, Benaia Decitta Husodo, Jedidia Suksmatatya Husodo Picture taken: May, 2007