Role of Neurotropic Vitamin
-
Upload
herlina-miranti -
Category
Documents
-
view
219 -
download
0
Transcript of Role of Neurotropic Vitamin
![Page 1: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/1.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 1/92
THE ROLE OF NEUROTROPIC
VITAMIN IN NEUROLOGIC
DISORDERS
![Page 2: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/2.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 2/92
NEUROTROPIC VITAMIN IN
NEUROLOGIC DISORDER
Sering dijumpai:
- Diabetic
polyneuropathy
- Carpal tunnel
syndrome- Lumbal-cervical
radiculopathy
- pain
Jarang dijumpai:•Wernicke ensealopati
•Subacute Combined Degeneration
![Page 3: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/3.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 3/92
Batasan Nyeri
Pengalaman sensoris dan emosionalsensoris dan emosional , tidak
menyenangkan terkait dengan jejas jaringan
yang nyata atau potensial atau yang dapatdigambarkan sebagai suatu kerusakan
jaringan.
The International Association for the Study of Pain(IASP,), adopted from Merskey.
![Page 4: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/4.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 4/92
Classifications of Pain
Acute
Chronic
Duration
Nociceptive
MixedPathophysiology
Neuropathic
![Page 5: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/5.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 5/92
TISSUE INJURY ORINFLAMMATION
•Arthritis•Trauma•Burn
NEUROPATHI PAIN
• !ia"eti# ne$ro%ath&• Trigeminal Neuralgia• Nerve root compression
( erniated disc !
ENTRAL PAIN
• Posttalamic stroke• "ultiple sclerosis• Psycologic mecanisms
#$ % TricyclicsPysical terapy andpsycoterapy
&ensory nerve
& y m p a t e t i c
n e r v e
'asomotorand tropiccanges
S&m%atheti#all&mediated %ain're(le) s&m%atheti#d&stro%h& *
#$ % Peno$ybenamine&ympatetic nerve block
#$ % N&)*+sNarcotics
#$ % Tricyclics (e.g.,amitriptyline!,carbamaepine, penytoin,capsaicin
Sites of origin of pain within the nociceptive pathway
![Page 6: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/6.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 6/92
![Page 7: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/7.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 7/92
+$rning, (eeling li-e the (eet are on (ire
Sta""ing, li-e shar% -ni.es Lan#inating, li-e ele#tri# sho#-s
Free/ing, li-e the (eet are on i#e,altho$gh the& (eel 0arm to to$#h
"odified by "eliala --
![Page 8: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/8.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 8/92
HIPERALGESIAHIPERALGESIA
#eaksi yang meningkat teradap stimulus#eaksi yang meningkat teradap stimulusnyerinyeri(noksius!(noksius!
ALODINIAALODINIA
Nyeri akibat stimulus yang tidak nyeri (non/Nyeri akibat stimulus yang tidak nyeri (non/noksius0noksius0inocuousinocuous!!
![Page 9: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/9.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 9/92
![Page 10: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/10.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 10/92
E)am%lesPeri%heral• Posterpetic neuralgia• Trigeminal neuralgia• +iabetic periperal neuropaty
•Postsurgical neuropaty
• Posttraumatic neuropatyentral• Poststroke painCommon descriptors2
• Burning• Tingling• 1ypersensitivity to touc or cold
E)am%les • Pain due to inflammation• 2imb pain after a fracture• 3oint pain in osteoartritis
• Postoperative visceral pain Common descriptors2
• )cing• &arp• Trobbing
E)am%les • Lo0 "a#- %ain 0ith
radi#$lo%ath&• er.i#al
radi#$lo%ath&• Cancer pain• Carpal tunnel
syndrome
Mi)ed PainPain 0ith
ne$ro%athi# andno#i#e%ti.e#om%onents
Ne$ro%athi# Pain
Pain initiated or #a$sed "& a%rimar& lesion or d&s($n#tion
in the ner.o$s s&stem'either %eri%heral or
#entral ner.o$s s&stem*1
No#i#e%ti.e Pain
Pain #a$sed "& inj$r& to"od& tiss$es
'm$s#$los-eletal,#$taneo$s or .is#eral*2
PRESENTATION ACROSS PAIN STATES VARIES
4. *nternational )ssociation for te &tudy of Pain. *)&P Pain Terminology.3 #aja et al. in 5all P+, "elack # (6ds!. Te$tbook of pain. 7t 6d. 4888.944/:;
![Page 11: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/11.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 11/92
SENSI IZA ION OF NOCICEP ORS IN
INFLAMMA ION
Prostaglandins %rod$#ed inres%onse to tiss$e inj$r&4in#rease sensiti.it& o(no#i#e%tor '%ain*
No#i#e%tor then releasess$"stan#e P, 0hi#h dilates"lood .essels and in#reasesrelease o( in(lammator&mediators, s$#h as
+rad&-inin 'redness 5 heat*
S$"stan#e P also %romotesdegran$lation o( mast #ells,0hi#h release histamine's0elling*
14
6<
Pain/sensitive tissue
Pain($l stim$l$s
Prostaglandin
S$"stan#e P
Histamine
Mast #ell+lood .essel
+rad&-inin
No#i#e%tor
S$"stan#e P
26
1
![Page 12: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/12.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 12/92
Fase Infamasi (1)
• )kut% Pelepasan autakoid%= 1istamin % vasodilatasi, permeabilitas
vaskular
= &erotonin % permeabilitas= Bradikinin % vasodilatasi, nyeri
= Prostaglandin % vasodilatasi, permeabilitas
kemotaksis= 2eukotrin % permeabilitas, kemotaksis
![Page 13: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/13.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 13/92
The ontin$$m o( Pain1
<1 month
Time to resolution
3-6 months
AcutePain
ChronicPain
•Usually obvious tissue damage
•Increased nervous systemactivity
•Pain resolves upon healing
•Serves a protective function
•Pain for 3-6 months ormore2
•Pain beyond expectedperiod of healing2
•Usually has no protectivefunction3
•egrades health andfunction3
!" #ole $%" &osp Physician" 2''2(3)*23-3'"
2"+ur, and ,ifu.i" $onica/s 0anagement of Pain" 2''!"3" #hapman and Stillman" Pain and +ouch" !116"
Insult
![Page 14: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/14.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 14/92
EXAMPLE OF CHRONIC NOCICEPTIVE PAIN:
OSTEOARTHRITIS OF THE NEE
Normal jointOsteoarthritis
S&no.ial
mem"rane
artilage
S&no.ial(l$id
Joint#a%s$le
In(lammationas "ones r$"
together
Thinned#artilage
![Page 15: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/15.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 15/92
Fase Infamasi (2)
• &ubakut% aktivasi respon imun
• kronik% pelepasan mediator%
= *2/4, *2/, *2/< % aktivasi limfosit, produksiprostaglandin
= TNF7 8 %rod$-si %rostaglandin
= *nterferon
= P+>? % kemotaksis @ proliferasi fibroblast
![Page 16: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/16.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 16/92
SENSITIZATION OF CENTRAL NERVOUS S!STEM
Imm$ne #ells
Ma#ro%hage
Mi#roglia
Mono#&te
Inj$r&
Imm$ne res%onse
&to-ines
hemo-ines
S$r(a#eantigens
Adenosinetri%hos%hate
anna"inoids
Ne$ro%e%tides
9l$tamate
+rad&-inin
O:72
Ind$#ed nitri#o)ides&nthase
Sensiti/ationo( #entralner.o$ss&stem
TNF ;, gro0th (a#tors, IL 1 ,IL <
=itamin
+ #om%le)
![Page 17: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/17.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 17/92
Ne$roanatomi dan Pato(isiologi N&eri
• Bagian dari sistim saraf yang bertanggung jaAabuntuk sensasi dan persepsi nyeri dapat dibagimenjadi tiga area, yaitu%
= 3aras afferent
= &&P (susunan saraf pusat!
= 3aras efferent
![Page 18: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/18.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 18/92
THE PAIN PATH"A!
Pain PerceptionBrain
Dorsal Root
Ganglion
Dorsal Horn
Nociceptor
Spinal Cord
Gottschalk A et al. Am Fam Physician. 2001;!"1#$#%&'.(ields H) et al. Harrison’s Principles of Internal Medicine. 1##&"*!%&.
![Page 19: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/19.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 19/92
Jaras Aerent Jaras Aerent
• Nociceptors (reseptor nyeri! jaras afferentberakir pada kornu dorsalis dari medulaspinalis 'ne$ron a((erent %ertama*
• Ne$ron a((erent -ed$a membentuk bagianspinal dari jaras afferent sampai talamus(traktus spinotalamikus!
• Ne$ron -etiga terbentuk mulai talamus sampaike korteks serebri
![Page 20: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/20.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 20/92
PERCEPTION
O!"#ATION
TRAN$I$$ION
TRAN$!"CTION
PI 4 S%5I%S %7%+S
PAIN
![Page 21: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/21.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 21/92
!orsal Horn
!orsal rootganglion
Peri%heral sensor&Ner.e (i"ers
A
Aδ
Large(i"ers
Small(i"ers
There are Two Sensory Afferent NeuronsThere are Two Sensory Afferent Neurons
!" Large myelinated #β ibers•$ery ast conduction velocity•%espond to innocuous stimuli
&" Small myelinated #δ ' C unmyelinated ibers•Slo( conduction velocity•%espond to no)ious stimuli
![Page 22: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/22.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 22/92
![Page 23: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/23.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 23/92
NORMAL IMPULSE
RANSMISSION
S$"stan#e P
Pres&na%ti#ne$ron
S&na%ti# #le(t
9l$tamate
Posts&na%ti#ne$ron
NM!A re#e%tor is
"lo#-ed "& Mg2>
AMPAre#e%tor
NM!Are#e%torN?71
Im%$lses rea#h terminals o( %res&na%ti# ne$ron
![Page 24: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/24.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 24/92
S$"stan#e P
Pres&na%ti#ne$ron
S&na%ti# #le(t
9l$tamate is released into s&na%ti# #le(t
9l$tamate
Posts&na%ti#ne$ron
AMPAre#e%tor
NM!Are#e%torN?71
NM!A re#e%tor
remains "lo#-ed"& Mg2>
NORMAL IMPULSE TRANSMISSION
![Page 25: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/25.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 25/92
S$"stan#e P
Pres&na%ti#ne$ron
S&na%ti# #le(t
9l$tamate "inds to AMPA re#e%tor and im%$lse is transmitted to %osts&na%ti# ne$ron
9l$tamate
Posts&na%ti#ne$ron
NM!A re#e%tor
remains "lo#-ed"& Mg2>
N?71
NORMAL IMPULSE TRANSMISSION
AMPAre#e%tor
![Page 26: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/26.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 26/92
PERIP%ERA#ACTI&IT' CENTRA#$EN$ITIATION
!ecreasethreshol to*eri*heral
stimuli
Increases*ontaneou
acti+it,E-*ansion o.
rece*ti+e
/el
%,*eral0esiaAllo,niaTissue ama0e
Ner+e ama0e
$*ontaneous*ain
![Page 27: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/27.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 27/92
DEVELOPMENT OF CENTRAL SENSITIZATION
Inj$r& or tra$ma #a$ses in#reased ner.e a#ti.it&
NM!Are#e%torN?71
S$"stan#e P
S&na%ti# #le(t
Posts&na%ti#ne$ron
Pres&na%ti#ne$ron
9l$tamate
AMPAre#e%tor
NM!A re#e%tor is"lo#-ed "& Mg2>
and =itamin
![Page 28: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/28.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 28/92
S$"stan#e P and e)#essi.e le.els o( gl$tamate are released into the s&na%ti# #le(t
NM!Are#e%torN?71
NM!A re#e%tor is
"lo#-ed "& Mg2>
and =itamin
DEVELOPMENT OF CENTRAL SENSITIZATION
S$"stan#e P
S&na%ti# #le(t
Posts&na%ti#ne$ron
Pres&na%ti#ne$ron
9l$tamate
AMPAre#e%tor
![Page 29: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/29.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 29/92
S$"stan#e P "inds to N?71 re#e%tors, #a$sing NM!A re#e%tors to release Mg2> ions
N?71NM!A
re#e%tor
DEVELOPMENT OF CENTRAL SENSITIZATION
S$"stan#e P
S&na%ti# #le(t
Posts&na%ti#ne$ron
Pres&na%ti#ne$ron
9l$tamate
AMPAre#e%tor
![Page 30: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/30.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 30/92
9l$tamate mole#$les #an no0 "ind to AMPA and NM!A re#e%tors
DEVELOPMENT OF CENTRAL SENSITIZATION
S$"stan#e P
S&na%ti# #le(t
Posts&na%ti#ne$ron
Pres&na%ti#ne$ron
9l$tamate
AMPAre#e%tor
![Page 31: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/31.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 31/92
In#reased im%$lses transmitted to %osts&na%ti# ne$ron
DEVELOPMENT OF CENTRAL SENSITIZATION
S$"stan#e P
S&na%ti# #le(t
Posts&na%ti#ne$ron
Pres&na%ti#ne$ron
9l$tamate
![Page 32: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/32.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 32/92
N0 P '
+ C C
&P
>lu B+N?
)"P)/#
)/#
Na
N4
>s>D044 N"+)/#
Ca
6P>s
)C
&cr
P) c)"P
CEF02EF
NE& NE*ncreased e$citability
P)
PCγ
c)"P+)>
*P<
TrkB
P2C )C
P>6
NE
P>6
Carpenter and +ickenson, --:"odified "eliala --
ATI=ATION AN! SENSI@ITATION!ORSAL HORN NEURONS Pre7s&na%ti#
Post7s&na%ti#
![Page 33: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/33.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 33/92
E(e- Analgeti- dan Ne$ro%rote-ti( dari
=itamin Ne$rotro%i-'@immerman, 2B*
4.N"+) receptor antagonism
.Block at Ca cannels
<.Blok of cytokine formation (eg% TN?/G! and
receptor Binding
![Page 34: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/34.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 34/92
Terima asih atasTerima asih atasPerhatiann,aPerhatiann,a
![Page 35: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/35.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 35/92
![Page 36: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/36.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 36/92
![Page 37: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/37.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 37/92
+ipe yeri $erdasar,an
![Page 38: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/38.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 38/92
+ipe yeri $erdasar,aneuro8siologi
• N&eri nosise%siN&eri nosise%si, diinduksi ole eksitasi nosiseptor
= yang memiliki fungsi proteksi
= yang dapat mengalami eksitasi kronik akibatpenyakit
• N&eri ne$ro%ati-, diinduksi ole kerusakan ataupenyakit pada sistim saraf
= )kibat eksitasi abnormal dari sistem nosiseptif.
• Sindroma n&eri #am%$ran= Terdapat komponen neuropatik dan nosiseptif secara
bersamaan atau berurutan.
![Page 39: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/39.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 39/92
lasi/asi N,eri
• Berdasarkan aAitan (onset!, maka nyeridapat di/kelompokkan dalam%
= Nyeri akut
= Nyeri kronik
= Breakthrough pain (Peningkatan intensitas nyeri pada
kondisi nyeri kronik!.
![Page 40: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/40.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 40/92
![Page 41: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/41.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 41/92
![Page 42: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/42.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 42/92
NE#")2 vs. E) 3E*NT
thi#-ened #a%s$lethi#-ened #a%s$le
Osteoarthriti# -neeOsteoarthriti# -neeNormal -neeNormal -nee
#&st (ormation#&st (ormation
s#lerosis ins#lerosis ins$"#hondral "ones$"#hondral "one
(i"rillated #artilage(i"rillated #artilage
s&no.ial h&%ertro%h&s&no.ial h&%ertro%h&
osteo%h&te (ormationosteo%h&te (ormation
#a%s$le#a%s$le
#artilage#artilage
s&no.i$ms&no.i$m
"one"one
ACR(PACR(PSource* 50S +raining 0odule
![Page 43: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/43.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 43/92
ACR(PACR(PSource* 50S +raining 0odule
![Page 44: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/44.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 44/92
Pain Rating S#ales
1 Pain Intensit& S#ale
- 4 < 7 : ; H 8 4-
Mild Moderate Se.erePain threshold
Pain toleran#e
![Page 45: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/45.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 45/92
PAIN MEDIATORS
Aa C ara#hidoni# a#id4 +? C "rad&-inin4 P9 C %rostaglandin
ell !amage
+rain
S%inal #ord
Aa ? > +?
P9
No#i#e%tor
Pe%tides, eg, SU+STANE P
HISTAMINE
SEROTONIN
Mast ell
Platelet
![Page 46: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/46.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 46/92
PERIPHERAL SENSITIZATION
ell !amage In(lammation S&m%atheti#Terminals
Release o( %ain and in(lammator& mediatorse3g3 "rad&-inin, H>, %rostaglandins
No#i#e%tor• entral sensiti/ation
• H&%eralgesia
• Allod&nia
High Threshold
Lo0 Threshold
S%inal #ord
![Page 47: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/47.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 47/92
H!PERALGESIA
Primar&• Sensiti/ation o( %rimar& ne$rons → ↓ threshold to
no)io$s stim$li within site of injury
• Ma& in#l$de res%onse to inno#$o$s stim$li
∀ ↑ %ain (rom s$%ra threshold stim$li
Se#ondar&
• Sensiti/ation o( %rimar& ne$rons in surroundinguninjured areas
Raja SN, et al3 In8 Dall P+, Mel/a#- R, eds3 Textbook of Pain3 th ed4 1811G3
![Page 48: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/48.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 48/92
ALLOD!NIA
• Pain e.o-ed "& inno#$o$s stim$li
• entral sensiti/ation→
%ain%rod$#ed "& A (i"ers1
• Possi"l& mediated "& s%inal NM!A
re#e%tors2
13 Dool( J3 Drugs3 14's$%%l *81G323 !olan S, Nolan AM3 Neuroreport3 141'6*8G23
![Page 49: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/49.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 49/92
Ung-a%an N&eri
• Aching I nyeri• Stabbing I tertusuk 0
tikam• Tender I nyeri tekan• Tiring I nyeri melelakan
• Numb I baal• Dull I nyeri tumpul• Crampy I nyeri kram• Throbbing I nyeri seperti
tercekik• Gnawing I nyeri seperti
digigit• Burning I rasa terbakar
• Shooting I rasa menyentak• Sharp I nyeri tajam• Exhausting I nyeri melelakan• Nagging I peri• nbearable I tidak
tertaankan• S!uee"ing I seperti diremas• #ressure I seperti ditekan• #enetrating I rasa tertembus• $iserable I menyusakan
• %adiating I menjalar• Deep I nyeri dalam
Pokdisus Nyeri. Penuntun Praktis Nyeri
Neuropatik, 2!
![Page 50: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/50.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 50/92
Terminologi Se%$tar N&eri
• Allod&nia= Nyeri yang disebabkan ole stimulus secara
normal tidak menimbulkan nyeri
• H&%eralgesia
= #espon yang berlebian teradap stimulusyang secara normal menimbulkan nyeri.
• H&%er%athia
= &indroma dengan nyeri bercirikan reaksi nyeriabnormal teradap stimulus, kususnyastimulus berulang, seperti peninggian batasambang.
Pokdisus Nyeri. Penuntun Praktis Nyeri Neuropatik, 2!
![Page 51: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/51.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 51/92
Terminologi Se%$tar N&eri
• H&%oalgesia= berkurangnya respon nyeri teradap stimulus
yang dalam keadaan normal menimbulkannyeri
Paresthesia
= &ensasi abnormal, yang tidak menyenangkanbaik spontan ataupun dengan pencetus .
• Ne$ralgia
= Nyeri pada daera distribusi saraf.
![Page 52: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/52.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 52/92
+erminologi Seputar yeri
• Analgesia= 1ilangnya respon nyeri teradap stimulus yang dalam
keadaan normal menimbulkan nyeri.
• Anesthesia dolorosa
= Nyeri pada area atau regio yang semestinya bersifatanestetik.
• a$salgia= &indroma yang timbul pada lesi saraf paska trauma
yang ditandai nyeri seperti terbakar, alodinia,iperpatia yang menetap, seringkali bercampurdengan disfungsi vasomotor serta sudomotor dankemudian diikuti ole gangguan trofik.
![Page 53: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/53.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 53/92
NE#")2 vs. #) &JNE'*K"
NormalNormal
Rhe$matoid S&no.itisRhe$matoid S&no.itis
"$rsitis"$rsitis
tendonitistendonitis
s&no.itiss&no.itis
"one"one
#artilage#artilage
lining #elllining #ellh&%er%lasiah&%er%lasia
%ann$s%ann$s
%ol&mor%h%ol&mor%he)$datee)$date
(i"rosis(i"rosis
mono#&temono#&te
monon$#learmonon$#learin(iltratein(iltrate
ACR(PACR(PSource* 50S +raining 0odule
![Page 54: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/54.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 54/92
ACR(PACR(PSource* 50S +raining 0odule
9$ideline8
![Page 55: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/55.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 55/92
Ameri#an Pain So#iet&Treatment o( hroni# Pain in OA
Yes
• Mild pain
• Acetaminophen*
• Moderate-to-severepain/inflammation
• COX-2 selectiveNSAID
Condct !I ris"factor anal#sis
Not hi$h ris"
• Nonselective NSAID
%i$h ris"
• Nonselective NSAIDpls &&I ormisoprostol
• Intra-articlarin'ection of h#alronicacid for "nee pain
• Intra-articlar$lcocorticoid in'ection
for other 'oint pain
YesContined
pain(
Continedpain(
&ls) as needed• Nonpharmacol
o$icinterventions
• !lcosamine
•
+ramadol• Ad'nctives
• Intra-articlarh#alronicacid
•
Sr$icalintervention
Contined pain(
*&aracetamol in some Adapted from A&S Arthritis !idelines)22,
9$ideline8
![Page 56: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/56.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 56/92
• Mild pain
• Acetaminophen.
• Moderate-to-severepain/inflammation
• COX-2 selectiveNSAID
YesContinedpain(
&ls) as needed
• Nonpharmacolo$icinterventions
• !lcosamine
• +ramadol
• Ad'nctives
• Intra-articlarh#alronic acid
• Sr$icalintervention
*DMAD 0 disease-modif#in$antirhematic dr$,
9$ideline8Ameri#an Pain So#iet&
Treatment o( hroni# Pain in RA
Condct !I ris" factoranal#sis 1as in OA
al$orithm
Contined painand
inflammation( Yes
More or lessa$$ressivedisease(
•
Slfasala3ine
• Slfasala3ine
• Methotre4ate
• 5eflnomide
• 6iolo$ictherap#
5ess
More
DMADs*
Adapted from A&S Arthritis !idelines)22,
" l i d l "
![Page 57: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/57.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 57/92
"ultimodal "anagementof E) and #)
Nonpharmacologic74ercise/8ei$ht loss
&h#sical therap#
Other
Surgical Osteotom#
Arthroplast#
Pharmacologic Anal$esics
Anti-inflammator# a$ents
DMADs
%arris C, Geriatrics, 9::;<=>;:-=?,%och@er$ MC et al, Arthritis Rheum, 9::<;>9;-=,%och@er$ MC et al, Arthritis Rheum, 9::<;>9=9-?,
AC Ad %oc Committee on Clinical !idelines, Arthritis Rheum,-
" di ti f ti i
![Page 58: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/58.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 58/92
"edications for neuropatic pain
N6% norepineprine9 :1T% :/ydro$ytryptamine9 N"+)% N/"etyl +/)spartate9
&N#*% selective norepineprine reuptake inibitor9 &&#*% selective serotonin reuptake inibitor9 TC)% tricyclicantidepressants
Al%ha adrenergi# agentsO%ioidsSNRIsSSRIsTramadol
TAs
!es#ending inhi"itor& %ath0a&s
'NEHT, o%ioid re#e%tors*
entral sensiti/ation
Peri%heral me#hanisms
9a"a%entinLamotrigineLe.etira#etam
O)#ar"a/e%inePrega"alin
!e)tromethor%han?etamineMethadoneMemantine
NM!A
a2>
ar"ama/e%ineLamotrigineLido#aineO)#ar"a/e%ineTo%iramateTAs
Na>
![Page 59: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/59.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 59/92
Pharma#ologi#al Treatment Strategies +asedPharma#ologi#al Treatment Strategies +ased
on Signs and S&m%tomon Signs and S&m%tom
PheriperalPheriperal
sensiti9ationsensiti9ation
+opical anaesthetic +opical anaesthetic
:%0;<:%0;<
;idocain local;idocain local
infusion or bloc,infusion or bloc,
+opical #apsaicin +opical #apsaicin
StaticStatic
0echanical0echanical
and +hermaland +hermal&yperalgesia&yperalgesia
Stimulus-evoked Signs:Stimulus-evoked Signs:
ProbableProbable
0echanism0echanismSuggestedSuggested
+reatment +reatmentSign=SymptomSign=Symptom
P b blP b blS t d + t tS t d + t tSi =Si =
![Page 60: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/60.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 60/92
%xperimentally *%xperimentally *
>ind-up>ind-up
#linically *#linically *
centralcentralsensiti9ation ofsensiti9ation of
δδ 8bres8bres
+opical anaesthetics :%0;< +opical anaesthetics :%0;<
;idocain local infusion or bloc,;idocain local infusion or bloc,
+opical #apsaicin +opical #apsaicin
nticonvulsant :#b9?Phenytoin<nticonvulsant :#b9?Phenytoin< nti-arrhytmics=anaestheticsnti-arrhytmics=anaesthetics
:0exiletine and ;ignocain:0exiletine and ;ignocain
+ricyclic antidepressant +ricyclic antidepressant
:mitriptyline<@:mitriptyline<@
PunctatePunctate
&yperal-&yperal-
gesiagesia
%ctopic%ctopic
dischargedischarge
:aA channel:aA channel
accumulation<accumulation<
nticovulsantnticovulsant
:#arbama9epin?Phenytoin<:#arbama9epin?Phenytoin<
nti-arrhytmics=anaestheticsnti-arrhytmics=anaesthetics
:0exiletine and ;ignocaine<:0exiletine and ;ignocaine<
+ricyclic antidepressant +ricyclic antidepressant
:mitriptyline<@:mitriptyline<@
euromaeuromaBSign/BSign/
ProbableProbable
0echanism0echanismSuggested +reatmentSuggested +reatmentSign=Sign=
SymptoSympto
mm
![Page 61: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/61.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 61/92
#entral#entral
sensiti9ation ofsensiti9ation of
ββ 8bres8bres #entral#entral
reorgani9ation ofreorgani9ation of
ββ 8bres8bres
;oss of inhibitory;oss of inhibitorycontrolscontrols
CabapentinCabapentin
$aclofen$aclofen
pioidspioids
#lonidine#lonidine +ricyclic +ricyclic
antidepressantantidepressant
:mitriptyline<:mitriptyline<
;ocal anaesthetic;ocal anaesthetic
bloc,bloc,
SympatheticSympathetic
ganglion bloc,adeganglion bloc,ade
0 anta onist0 anta onist
llodyniallodynia
ProbableProbable
0echanism0echanismSuggestedSuggested
+reatment +reatmentSign=Sign=
SymptomSymptom
![Page 62: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/62.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 62/92
•• %ctopic%ctopic
discharges of discharges of ββ
8bres8bres
•• nticonvulsantsnticonvulsants
:#arbama9epin?Phenytoin<:#arbama9epin?Phenytoin<
•• nti-nti-arrhytmics=anaestheticsarrhytmics=anaesthetics
:0exiletine and ;ignocaine<:0exiletine and ;ignocaine<
•• +ricyclic antidepressant +ricyclic antidepressant
:mitriptyline<@:mitriptyline<@
ysaesthesiysaesthesi
asas
•• %ctopic%ctopic
discharges of discharges of ββ 8bres8bres
•• nticonvulsantsnticonvulsants
:#arbama9epin? Phenytoin<:#arbama9epin? Phenytoin<
•• nti-nti-
arrhytmics=anaestheticsarrhytmics=anaesthetics
:0exiletine and ;ignocaine<:0exiletine and ;ignocaine<
•• +ricyclic antidepressants +ricyclic antidepressants
:mitriptyline<@:mitriptyline<@
ParaesthesiaParaesthesia
ss
Stimulus-independent symptoms:Stimulus-independent symptoms:
ProbableProbable
0echanism0echanismSuggestedSuggested
+reatment +reatmentSign=Sign=
SymptomSymptom
![Page 63: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/63.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 63/92
•• PheripheralPheripheral
sensiti9ationsensiti9ation
•• ;oss of inhibitory;oss of inhibitory
mechanismmechanism
•• %ctopic discharge of #%ctopic discharge of #
8bres8bres
+opical anaesthetics +opical anaesthetics
:%0;<:%0;<
;idocaine local infusion or;idocaine local infusion or
bloc,bloc,
+opical #apsaicin +opical #apsaicin CabapentinCabapentin
$aclofen$aclofen
#lonidine#lonidine
+ricyclic antidepressant +ricyclic antidepressant
:mitriptyline<:mitriptyline< PhenytoinPhenytoin
#ontinuou#ontinuou
s burnings burning
painpain
ProbableProbable
0echanism0echanism
SuggestedSuggested
+reatment +reatment
Sign=Sign=
SymptomSymptom
![Page 64: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/64.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 64/92
•• %ctopic%ctopic
discharge of #discharge of #
8bres8bres
•• nticonvulsantnticonvulsant
:#arbama9epin?Phenytoin<:#arbama9epin?Phenytoin<
••ntiarrhytmics=anaestheticsntiarrhytmics=anaesthetics
:0exiletine and ;ignocain<:0exiletine and ;ignocain<
•• +ricyclic antidepressant +ricyclic antidepressant
:mitriptyline<:mitriptyline<
•• Cabapentin @Cabapentin @
ParoxismaParoxisma
l shootingl shooting
ofoflancinatinlancinatin
g paing pain
ProbableProbable
0echanism0echanismSuggestedSuggested
+reatment +reatmentSign=Sign=
SymptomSymptom
![Page 65: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/65.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 65/92
1#S*!
![Page 66: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/66.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 66/92
affecting sleepmood
mobility
ability to Aork interpersonal relationsips overall self/Aort and independence.
PAINF"# !IA3ETICNE"ROPAT%'
impact on patients* +uality o lie
Cynthia,&.
/ain associated (ith neuropathy caused by D0
DIABETIC NEUROPATHY :1#S*!
![Page 67: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/67.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 67/92
DIABETIC NEUROPATHY :
SIGNS AND SYMPTOMS
SENSORY MOTOR AUTONOMIC
Post!eSpontaneous pain2urning
/ricking
S+uee3ing4ingling5
6nie-like
Lancinating
7lectric shock
#ching
4robbing
8ree3ing
4ightness
Stimulus-evoked pain
#llodynia5
1yperalgesia
Ne"at!e
9umbness5
Deadness
Loss o sensationLoss o balance
Weakness
atrophy
Sudomotor
/upilary
Cardiovaskular
rinary
;astrointestinal
Se)ualDistal /ro)imal 8ocal
allodynia foot ulceration
1#S*!
![Page 68: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/68.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 68/92
1#S*!
![Page 69: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/69.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 69/92
&tage of +PN
&tage of neuropaty %
• No neuropaty
• Clinical neuropaty %
Cronic painful
)cute painful
• Painless Ait complete0partial sensory loss
• 2ate complications
<=nternational 9europathy ;uidelines>
1#S*!
![Page 70: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/70.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 70/92
!IA9NOSIS OF !IA+ETIPERIPHERAL NEUROPATHY
• &ymptoms• &igns
• Test for autonomic function
• 6lectrodiagnostic• Luantitative sensory testing
)ssess pysical, emotional and social functionand psycological comorbidity
(depression, an$iety, substance abuse!
min4 256
1#S*!
![Page 71: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/71.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 71/92
!IA9NOSIS OF !IA+ETIPERIPHERAL NEUROPATHY '#onKt*
Eter metods of assesment %
• Nerve Biopsy
• Nerve 6$posure %
"icroelectrode and epineurial vessel potograpy @
fluorescein angiograpy "icroligt/guide spectropotometry
• &kin Biopsy
• Corneal Confocal "icroscopy
• "#* M
1#S*!
![Page 72: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/72.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 72/92
![Page 73: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/73.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 73/92
The presence o& symptom and'or sign
o& peripheral ner(e dys&unction in people with diabetes a&ter exclusion
o& other causes
Da#et$ Per%hera& Neuro%ath$:Da#et$ Per%hera& Neuro%ath$:
(Soliman & Gellido, 2002)(Soliman & Gellido, 2002)
C&assf$aton of Da#et$ Neuro%athyC&assf$aton of Da#et$ Neuro%athy
![Page 74: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/74.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 74/92
• +iffuse Neuropaty♣ +istal symmetric sensorimotor polyneuropaty
♣ )utonomic neuropaty• &udomotor neuropaty
• Cardiovascular autonomic neuropaty
• >astrointestinal neuropaty• >enitourinary neuropaty
♣ &ymmetric promi$al loAer limb motor neuropaty(amyotropy!
• ?ocal Neuropaty♣ Cranial neuropaty
♣ #adiculopaty0ple$opaty
♣ 6ntrapment neuropaty
C&assf$aton of Da#et$ Neuro%athyC&assf$aton of Da#et$ Neuro%athy
Thomas, 1997
![Page 75: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/75.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 75/92
Tiga &tase Neuropati +iabetika (N+!
Ne$ro%ati ($ngsional. Tidak tampak adanya kelainan patologik Perubaan biokimiaAi /// timbul gejala #eversibel
Ne$ro%ati str$-t$ral
Terjadi kerusakan struktural serabut saraf yangmenimbulkan gejala #eversibel
?ematian ne$ron ematian neuron menyebabkan penurunan kepadatan
serabut saraf
*rreversibel
Vinik, 2002
![Page 76: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/76.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 76/92
Teori Terjadinya N+• Teori metabolik
= 1iperglikemia
• Teori 'askuler= Terjadi penurunan aliran dara ke endoneurium yang
disebabkan ole adanya resistensi pembulu dara akibatiperglikemi.• ?e-$rangan Neurotrophic factor
= Penurunan Nerve >roAt ?actor (N>?! //// transportaksonal yang retrograde (dari organ target menuju badan
sel! terganggu.= Penurunan kadar N>? pada kulit pasien +" berkorelasi
positif dengan adanya gejala aAal small &ibers sensoryneuropathy
![Page 77: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/77.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 77/92
1yperglycemia and Nervous &ystem
• *ncreases te production and stabiliation ofreactive o$ygen species (#E&! damageperiperal neurons, particularly mitocondria= apoptosis via caspases and proapoptotic Bcl proteins
mitocondrial damage and neuronal impairment= 2oss of &cAann cells, myelinated a$ons, and sensory
neurons in +#>
• +N) content is decreased in a$onopaty associated
Ait diabetic neuropaty
Leininger, 2007
![Page 78: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/78.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 78/92
1yperglycemia and Nervous &ystem
• Neuronal mitocondrial +N) is more prone too$idative damage tan is glial mitocondrial +N)= possibly contributing to neuropatic progression
• +isruption of mitocondrial membranes indiabetic neuropaty induces local apoptosis
• NeA terapeutic potential% anti Bcl protein prevent Bcl action and apoptosis preserves
neuronal function= #esearc is still in progress
Leininger, 2007
"itocondria and +iabetic Neuropaty
![Page 79: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/79.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 79/92
O '
( )
O ' ( )
1 ?
e-
=
==
===
Co@!
e-
Cyto-C
e-
1?
1 ?
1?
=$
$
A&
O'( )
A& 1&A # D / ? /
i # 4 /
1&A&
1&
A
? A&
&1&A
& ;S1 ;SS;
CatalaseSAD
0itochondrial D9# Damage
9 # D 1
9 # D
?
=nner
0itochondrial
membrane0atri) 0itochondrial
membrane damage
=ntermembrane
space
Auter
0itochondrial
membrane
Leininger, 2007
p y
![Page 80: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/80.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 80/92
Polyneuropathy is caused by the degeneration of axon terminals and results in symmetricdistal sensory loss Dith shading to normal sensation" compression neuropathy oftenresults in demyelination Dith the axon left relatively intact" Sensory loss folloDs aradicular pattern" >hen the neuronal cell body dies the condition is calledEneuronopathy"E If the cell body is in the sensory ganglion the condition is often referredto as Eganglionopathy"E +he pattern is usually random
A-onal *ol,neuro*ath,!em,elinatin0 Neuro*ath,Neurono*ath, (7an0liono*at
FT:NP
![Page 81: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/81.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 81/92
&7CC&7$C
&7$C
&7$C
C3O8C#T7
7#"TAATE
PEPTI!E$Altere Pro*erties
Altere Acti+it,
5oDbotham et al? 2'''
#
Ca99
NMDA **
AMPA
+anate
Hy%ere,ta#&ty
O%o-s
GABA
&7$C
C3O8C#T7
Na9
Modifikasi Meliala, 2003
Ca'*
Ca'*
Ca'*Na'*
Na*
M"'*
3RAINPAINPAINN; PAINNO PAIN
%'PERA#7E$IA ANA#7E$IA
INTRACE..U.AR SECOND MESSENGERMECHANISM O/ NOCICEPTOR SENSITI0ATION O8C
![Page 82: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/82.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 82/92
A!EN'#C'C#A$E
cAPATP
PA
7I7s
A2 1a
:9
9
%'PERA#7E$IAP7I2
<(R)= 16($) A!EN 6:%TP7E2 i%ETE
ANA#7E$IAA!EN
A1
P
7s A!EN'#C'C#A$E
ATP cAP
PA
;evine F 5eichling? !11
Modifikasi Meliala, 2003
7I
Na 29
C3OPOI!
Na 29
Patopysiology of +N
![Page 83: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/83.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 83/92
• E$idative stress
• )dvance glycation end products ()>6&!
• Protein inase C (PC!
• Polyol PatAay ?lu$
Patopysiology of +N
Patopysiology of diabetic neuropaty
![Page 84: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/84.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 84/92
p y gy p y
![Page 85: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/85.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 85/92
![Page 86: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/86.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 86/92
![Page 87: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/87.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 87/92
lassi(i#ation o( !N
![Page 88: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/88.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 88/92
As&mmetri#ne$ro%athies
Cranial mononeuropaty&omaticmononeuropaties+iabetic toracicradiculoneuropaty
+iabetic radiculople$usneuropaty
S&mmetri# !istalPol&ne$ro%athies
2arge fiber0distalsymmetric polyneuropaty&mall/fiber neuropaty+iabetic autonomicneuropaty
+iabetic neuropaticcace$ia
lassi(i#ation o( !N
Dianna @uan" Diabetic 9europathy" e0edicine" pdate"ActB,& Cited"EE&F
![Page 89: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/89.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 89/92
![Page 90: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/90.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 90/92
c
![Page 91: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/91.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 91/92
![Page 92: Role of Neurotropic Vitamin](https://reader035.fdocuments.us/reader035/viewer/2022062317/5695d0381a28ab9b029182b7/html5/thumbnails/92.jpg)
7/23/2019 Role of Neurotropic Vitamin
http://slidepdf.com/reader/full/role-of-neurotropic-vitamin 92/92