Yuli - Kuliah Blok 15 - 1. Nyeri leher bahu tengkuk - 2012.ppt

Nyeri Lengan, Bahu dan Tengkuk

dr.TW.Yuliati,Sp.S,M.Kes

Nociceptive pain

means pain causedby an injury or disease outside the nervous system. It is often an on-going dull ache or pressure, rather than the sharper, trauma-like pain morecharacteristic of neuropathic pain. Examples of chronic nociceptive pain include pain from cancer or arthritis.

Neuropathic pain is

pain that is caused by damage to nerve tissue. It is often felt as a burning or stabbing pain. One example of a neuropathic pain is a "pinched nerve." .

TISSUE INJURY

NOCICEPTOR

TNF-

IL-6

IL-1

IL-8

SYMPATHETICNERVE

PG

KININS

MACROPHAGES

POLYMORPHS

H+

MAST CELLS

HISTAMINE

FIBROBLASTS

COX-2

NGF

PLATELETS

5-HT

INFLAMMATION

PGPGPG

Senyawa kimia Senyawa kimia sebagai respon jaringan yang rusaksebagai respon jaringan yang rusak

Senyawa kimia Senyawa kimia sebagai respon jaringan yang rusaksebagai respon jaringan yang rusak

1.1. Asam amino eksitatori, glutamat, dan Asam amino eksitatori, glutamat, dan aspartataspartat

2.2. GABAGABA3.3. Asetilkolin Asetilkolin 4.4. AdenosinAdenosin5.5. ATPATP6.6. SerotoninSerotonin7.7. ProtonProton8.8. Neuropeptida bradikinin dan substansi-PNeuropeptida bradikinin dan substansi-P9.9. NorepinefrinNorepinefrin10.10.Eikosanoids (prostasiklin,prostaglandin EEikosanoids (prostasiklin,prostaglandin E2) 2)

11.11.Growth factor (misal NGF) dan sitokins Growth factor (misal NGF) dan sitokins (enterleukin-I(enterleukin-I, tumor necrosis factor , tumor necrosis factor

Beberapa situs NosiseptifBeberapa situs Nosiseptif

Ligamen Ligamen Annulus terluar ( outer )Annulus terluar ( outer )DuraDuraKapsul ( simpai ) fasetKapsul ( simpai ) fasetOtotOtotLigamenLigamen

Mekanisme Patofisiologi NyeriMekanisme Patofisiologi Nyeri

Nurmikko et al., 1999

1. Pada Sistem Saraf Perifer

a. sensitisasi nosiseptorb. tunas kolateralc. naiknya aktivitas akson yang rusak dan tunas-tunasnyad. hantaran impuls abnormal dari sel ganglion radiks dorsalise. invasi ganglionik radiks dorsalis oleh serabut pasca ganglionik simpatisf. pergantian fenotipe

2. Pada Sistem Saraf Pusat

a. hipereksitabilitas dari neuron sentral (sensitisasi sentral)b. reorganisasi hubungan sinaptik dalam medula spinalis dan dimana saja dalam sistem saraf pusatc. kerusakan inhibisi

Cont…..

Anatomi dan Anatomi dan BiomekanikBiomekanik

Leher –> bagian spina yg paling mobileLeher –> bagian spina yg paling mobile 3 fungsi utama :3 fungsi utama :

- menopang dan memberi stabilitas kepala- menopang dan memberi stabilitas kepala

- memungkinkan kepala bergerak disemua bidang- memungkinkan kepala bergerak disemua bidang

- melindungi struktur yang melewati spina - melindungi struktur yang melewati spina

(medulla spinalis, akar saraf, arteri vertebra)(medulla spinalis, akar saraf, arteri vertebra)

Sensory dermatomes.

Suprascapular N.

• Menginervasi ekstremitas atas dan bahu.• Berasal dari C 5 dan C6 melalui trunkus superior

pleksus brachialis.• Ke arah lateral sebelah dalam ke m. trapezius dan

m. omohyoid kemudian melewati skapular notch masuk ke fossa supraspinosus. Bergerak ke lateral menuju fossa infraspinosus dan mempercabangkan saraf ke:1. M. supraspinatus (arm abduction) 2. M. infraspinatus (lateral rotation and partial

abduction /adduction of the arm) • N. suprascapular juga menginervasi serabut sensoris

yang mensuplai Shoulder, acromioclavicular joints, kulit 1/3 proksimal lengan atas

Suprascapular Nerve

m. Supraspinatus

m. Infraspinatus

m. Deltoideus

Posterior view

Gel proteoglikan=80% air, < 5% kolagenGel proteoglikan=80% air, < 5% kolagen

Myelography

Sifat NyeriSifat Nyeri

•Nyeri Transient (sekilas)

•Nyeri Akutrusak substansial jaringan; aktivasi hantaran nosiseptif impuls dihantarkan serabut A- (trauma, tindakan bedah, penyakit

•Nyeri kronikjaringan rusak atau penyakit kronik, proses patologik kronik, kambuh selang waktu beberapa bulan atau tahun impuls dihantarkan serabut C (nyeri sendi, neuralgia, fibromialgia)

AKUT: AKUT: Sindroma nyeri tulang belakang servikalSindroma nyeri tulang belakang servikalSprainSprain

KRONISKRONISsindroma nyeri myofasial sindroma nyeri myofasial sindroma fibromialgia sindroma fibromialgia gangguan somatoform gangguan somatoform

Nyeri traumatik akutNyeri traumatik akut Immobilisasi, menggunakan suatu collar Immobilisasi, menggunakan suatu collar

servikal lunak untuk membantu menegakkan servikal lunak untuk membantu menegakkan kepala pada posisi netral atau fleksi ringan kepala pada posisi netral atau fleksi ringan

Analgetik termasuk codein 30 mg atau 60 mg Analgetik termasuk codein 30 mg atau 60 mg setiap 4 jam, atau NSAID.setiap 4 jam, atau NSAID.

Muscle relaxant dapat digunakan. Muscle relaxant dapat digunakan. Pilihan lain; panas, transcutaneus electrical Pilihan lain; panas, transcutaneus electrical

nerve stimulation (TENS) dan injeksi titik picu nerve stimulation (TENS) dan injeksi titik picu Traksi --- kontroversialTraksi --- kontroversial

Sumber NyeriSumber Nyeri

1. Tulang, akibat kenaikan tekanan intrameduler yang merusak tulang subkondral

2. Periosteum, akibat elevasi osteofid3. Sinofium, akibat tekanan atau stimuli

kimiawi4. Kapsul, akibat penebalan, ragangan, tarikan5. Struktur periartikuler:perlekatan tendo,

ligamentum dan bursa1. Stimulus mekanis 2. Stimulus kimiawi

Reseptor

1. Mekanoreseptor2. Termoreseptor3. Nosiseptorpolimodal

Efek mekanis dihantar serabut A- dan C Efek termis dihantar serabut C

ALGORITHM FOR CHRONIC PAINALGORITHM FOR CHRONIC PAINJames A. Haley Veterans Hospital, Tampa, FloridaJames A. Haley Veterans Hospital, Tampa, Florida

ALGORITHM FOR CHRONIC PAINALGORITHM FOR CHRONIC PAINJames A. Haley Veterans Hospital, Tampa, FloridaJames A. Haley Veterans Hospital, Tampa, Florida

CHRONIC PAIN PATIENTS(persistent pain > 3 months)

Negative NeurologicalDeficits

Positive NeurologicalDeficits

Conservative Treatment(By PC or Specialty Clinic: bed

Rest, NSAIDS, traction, etc.)

PM&RS(Physical modalities,

On call m-f 9-4; ext. 6089)•Motor weakness•Objective sensory (dermatomal)•Bowel/Bladder dysfunction•Must be new pain if + for previous surgery

NEUROSURGERY

MRI and NEUROLOGY *

Conservative Treatment(rest, NSAIDS, traction, etc.)

Not better

Consult to CHRONIC PAIN CLINICS(2CW, M-F 9-12, 1-4)

ANESTHESIOLGY(Nerve blocks for RSD, neuropathic pain,trigger points, neuromas, radiculopathy,

complex acute pain problems, etc.)

PSYCHOLOGY(evaluation, coping skills training,

biofeedback, relaxation, etc.. On-siteACS area M-F 8-4:30)

NOTES:*Send to Neurology if headache or TMJ. Send to Neurology or Oncology if cancer pain.

NOTES:*Send to Neurology if headache or TMJ. Send to Neurology or Oncology if cancer pain.

Not better

Diagnosis

anamnesis (sifat nyeri, lokasi, triger, faktor yg mengurangi, terapi sebelumnya)

pemeriksaan fisik (I,P,P,ROM,manuver-valsava, lermitte, navzigger)

Px penunjang: Ro, ENMG, Imaging (CT atau MRI) Lab

Physical examination - which may include looking for physical abnormalities—swelling, deformity or muscle weakness—or feeling for tender areas, and observing the range of shoulder motion—how far and in which direction you can move your arm.

External RotationThe patient is positioned sitting and the elbow is flexed 90 degrees. While the elbow is held against the patient's side, the examiner externally rotates the arm as permitted.

Internal RotationThe patient should be positioned sitting. Again with the elbows at the patient's side, the examiner should raise the thumb up the spine, and record the position in relation to the spine (reaching T7 is normal, unless bilateral symmetry is observed).

Shoulder Abduction: Active TestThe arm is again kept straightened, while raised and abducted. Observe the twisting of hand -- facing outward, not forward, as in forward flexion. The ROM is measured in degrees as decribed for forward flexion. As pictured, this test is being done actively by the patient, but may be performed by the examiner as well.

External Rotator Cuff (RC) StrengthPosition the patient sitting, with his arms at his sides and elbows at 90 degrees. It is important to maintain the elbow positioning at the sides while the external rotation is attempted by the patient (the examiner applies internal resistance).

Tendon reflexes grading system Tendon reflexes grading system

gradegrade reflexreflex

zerozero absentabsent

11 hypoactivehypoactive

22 "normal""normal"

33 Hyperactive without clonusHyperactive without clonus

4u or 44u or 4 reduplicated reflex or unsustained clonusreduplicated reflex or unsustained clonus

4s or 54s or 5 sustained clonussustained clonus

Grading muscle strengthGrading muscle strength

gradegrade IndicatesIndicates

zerozero No muscle movement.No muscle movement.

11 Visible muscle movement, but no movement at the jointVisible muscle movement, but no movement at the joint

22 Movement at the joint, but not against gravity.Movement at the joint, but not against gravity.

33Movement against gravity, Movement against gravity, but not against added but not against added resistance.resistance.

44Movement against resistance, but does not attain normal Movement against resistance, but does not attain normal strength.strength.

55 Normal strength. Normal strength.

NORMAL SHOULDER RANGES OF MOTION

FlexionFlexion 0 - 180 degrees0 - 180 degrees

ExtensionExtension 0 - 30 degrees0 - 30 degrees

Internal RotationInternal Rotation 0 - 80 degrees0 - 80 degrees

External RotationExternal Rotation 0 - 90 degrees0 - 90 degrees

AbductionAbduction 0 - 180 degrees0 - 180 degrees

AdductionAdduction Arm at side of Arm at side of bodybody

Table: ASIA impairment scale - Grade Description

A Complete: No motor or sensory function is preserved In the sacral segments S4-S5.B Incomplete: Sensory but not motor function is preserved below the neurological level and extends through the sacral segments S4-S5.C Incomplete: Motor function is preserved below the

neurological level, and the majority of key muscles below the neurological level have a muscle grade

less than 3D Incomplete: Motor function is preserved below the

neurological level, and the majority of key muscles below the neurological level have a muscle grade greater than 3.

E Normal: Motor and sensory function is normal.

SHORT FORM-36SHORT FORM-36Outcome measureindicator of general health status1. Physical functioning : 102. Role limitation due to physical health problems : 43. Bodily pain : 24. Social functioning : 25. General mental health, covering psychological

distress & well being : 56. Role limitation due to emotional problems :

37. Vitality, energy or fatigue : 48. General health perception : 59. Health status over past year : 1

The Shoulder Disability Questionnaire (SDQ) - SDQ items :1 I wake up at night because of shoulder pain.

2 My shoulder hurts when I lie on it.

3 Because of pain in my shoulder it is difficult to put on a coat or a sweater.

4 My shoulder hurts during my usual daily activities

5 My shoulder hurts when I lean on my elbow or hand

6 My shoulder hurts when I move my arm.

7 My shoulder hurts when I write or type.

8 My shoulder is painful when I hold the driving wheel of my car or handle bars of my bike

9 When I lift and carry something my shoul-der hurts.

10 During reaching and grasping above shoul-der level my shoulder hurts.

11 My shoulder is painful when I open or close a door

12 My shoulder is painful when I bring my hand to the back of my head.

13 My shoulder is painful when I bring my hand to my buttock.

14 My shoulder is painful when I bring my hand to my low back.

15 I rub my painful shoulder more than once during the day.

16 Because of my shoulder pain I am more irritable&bad tempered with people than usual

Peny. degeneratif sendi, jar. ikat, spondilosis

1. Cervical syndr, Cervical disc disorder / HNP2. Frozen shoulder / capsulitis adhesiva (p/s)3. Entrapment Neuropaty (CTS, Lesi plex.

Brach) 4. Tendinitis (Tennis/Golfer’s elbow )4. Trauma = sprain, strain / Whiplash5. Penyakit inflamasi : Rematoid arthritis,

osteoarthritis, spondylo- arthropathies, crystal arthropathies

6. Nyeri Miofasial, Fibromialgia7. Tumor

Causes

Nyeri Sendi Nyeri Sendi

Nyeri imobilisasi Nyeri akibat tumpuan beban berat Nyeri pada gerakan, akibat regangan jaringan ikat, kontraksi kapsul sendi Nyeri akibat inflamasi: kaku pagi hari, memar pada sendi dan efusi Nyeri karena trauma Nyeri diperberat faktor psikogenik

Kekerapan Keterlibatan Sendi

pada Artritis Reumatoid TemporomandibularTemporomandibular 30 %30 % ServikalServikal 40%40% Kriko-aritenoidKriko-aritenoid 10%10% AkromioklavikularAkromioklavikular 50%50% BahuBahu 60%60% SternoklavikularSternoklavikular 30%30% SikuSiku 50%50% PanggulPanggul 50%50% Pergelangan tanganPergelangan tangan 80%80% LututLutut 80%80%

ARTRITIS REUMATOIDARTRITIS REUMATOID

PENYAKIT SENDI INFLAMASI PENYAKIT SENDI INFLAMASI BERATBERAT

MENYERANG PRIA & WANITAMENYERANG PRIA & WANITA

SEMUA UMURSEMUA UMUR

INSIDENS PUNCAK DEWASA MUDA INSIDENS PUNCAK DEWASA MUDA & PREMENOPAUSAL& PREMENOPAUSAL

Diagnosis RA

Diagnosis RA

ACR Criteria, revisi 19871. Morning stiffness2. Artritis pada 3 kelompok sendi3. Artritis persendian tangan (wrist, MCP,

PIP)4. Artritis simetris5. Nodul reumatoid6. RF positif7. Radiologik

4 dari 7 kriteria !

Indeks kapasitas fungsional

Petanda biokimiawi

Gambaran radiologik

Kwesioner dampak kehidupan dan

disabilitas

Parameter evaluasi RA

Parameter evaluasi RA

Indeks prognosis buruk RA

Indeks prognosis buruk RA

Awitan usia lanjut o

Gender wanita o

Poliartritis o

Poliartritis sulit dikendalikan o

Kerusakan struktural sendi / tulang o

Disabilitas fungsional o

Keterlibatan organ ekstra artikular o

Masalah psikososial o

Titer RF tinggi o

HLA-DR4, monozigotik,shared epitop o

Kriteria remisi RA

Kriteria remisi RA

Lima dari kriteria di bawah ini harus terpenuhi minimal selama 2 bulan berurutan

Kaku pagi hari < 15 menit Tidak ada kelelahan Tidak ada nyeri sendi Tidak ada nyeri sendi pada pergerakan Tidak dijumpai pembengkakan jaringan lunak

sekitar sendi atau pada tendon sheats LED (Westergren) < 30 mm/jam (wanita) < 20 mm/jam (pria)

04/18/2304/18/23 PIR 200PIR 200

OsteoartritisOsteoartritisOsteoartritisOsteoartritis Definisi: Penyakit yang diakibatkan kejadian

biologik dan mekanik yang menyebabkan gangguan keseimbangan antara proses degradasi dan sintesis dari kondrosit rawan sendi, matriks ekstraseluler dan tulang subkondral

OA melibatkan seluruh jaringan sendi diartrodial

Perubahan morfologik, biokimia, molekuler dan biomekanik dari sel dan matriks

Flow chart for the therapy of OAFlow chart for the therapy of OA

Physical Measures Patient Education

Physical Measures Patient Education

Surgery

COX 2 inhibitors Misoprostol

PPI Subst Salicylate

Low Dose NSAID

High Dose NSAIDScheduled Opioids

Medications

Antiinflammatory Drugs

Tramadol Capsaicin Propoxyphe

ne Codeine

Acetaminophen

Analgesics

Hyaluronate

Diagnosis

GI Low Risk GI High Risk Corticosteroids

Intraarticular Agents

TUJUAN TERAPI OA

1. Hilangkan gejala inflamasi aktif

2. Cegah Destruksi jaringan

3. Cegah Deformitas & pelihara fungsi sendi.

4. Kembalikan fungsi organ / sendi senormal mungkin.

04/18/2304/18/23 PIR 200PIR 200

OsteoartritisOsteoartritis Definisi: Penyakit yang diakibatkan

kejadian biologik dan mekanik yang menyebabkan gangguan keseimbangan antara proses degradasi dan sintesis dari kondrosit rawan sendi, matriks ekstraseluler dan tulang subkondral

OA melibatkan seluruh jaringan dalam sendi diartrodial

Perubahanmorfologik, biokimia,molekuler dan biomekanik dari sel dan matriks

04/18/2304/18/23 PIR 200PIR 200

Osteoartritis (Cont)Osteoartritis (Cont)

Osteoartritis ditandai dengan hilangnya keseimbangan normal diantara sintesis dan degradasi makromolekuler yang dibutuhkan dalam menjaga fungsi dan kemampuan biomekanikal rawan sendi artikuler.

Perubahan pada struktur dan metabolisme sinovium dan tulang subkondral.

Proses ini akan mengakibatkan destruksi dari rawan sendi dan gangguan fungsi dari sendi yang terserang.

PERBEDAAN NYERI OA dan RA

PERBEDAAN NYERI OA dan RA

OSTEOARTRITIS----------------• SENDI PENYANGGA

BERAT BADAN• NYERI JIKA BERJALAN• NYERI & KAKU BILA

DITEKUK• NYERI KALAU

BERDIRI• NYERI MALAM HARI

REUMATOID ARTRITIS--------------------• SENDI - SENDI KECIL• POLIARTRITIS• NYERI KRONIK RESIDIF

JENIS & SUMBER NYERI OA DAN ARJENIS & SUMBER NYERI OA DAN AR

OSTEOARTRITIS• NYERI NOSISEPTIF• PERIOSTITIS• MIKROFRAKTUR SUB KONDRAL• IRITASI SNE OLEH OSTEOVIT• INFLAMASI SINOVIUM• ANGINA TULANG• TENDINITIS,BURSITIS,MYOSiTiS• NYERI NEUROGENIK * OA FACET JOINT * NYERI RADIKULEr

• NYERI PSIKOGENIK * DEPRESI, CEMAS, LELAH• NYERI KRONIK BERBAGAI ETIOLOGI

ARTRITIS REUMATOID

• NYERI NOSISEPTIFNYERI NOSISEPTIF * INFLAMASI SINOVIUM * PEREGANGAN KAPSUL SENDI * TENDINITIS, BURSITIS, MYOSITIS,

ENTESOPATI, VASKULITIS

• NYERI NEUROGENIK * CARPAL TUNNEL SYNDROME * KISTA SINOVIAL~ MASSA EPIDRAL * DESAKAN RUANG SUB ARAHNOID• NYERI PSIKOGENIK * DEPRESI, CEMAS, LELAH• NYERI KRONIK BERBAGAI ETIOLOGI

PENGELOLAAN NYERI OA DAN RA PENGELOLAAN NYERI OA DAN RA PENILAIAN

NYERI JENIS, KUALITAS, SUMBER, INTENSITAS,

LOKASI, SAAT TERJADINYA TERAPI NON

FARMAKOLOGI EDUKASI, RENCANA PENGELOLAAN, MENYIKAPI

NYERI, MENUJU BB IDEAL FISIOTERAPI TERAPI FARMAKOLOGI

OA

RA ASETAMINOFEN

DMARDs + ASETAMINOFEN OAINS

OAINSKORTIKOSTEROID INTRA ARTIKULER KORTIKOSTEROID

ORAL DOSIS RENDAH HYALURONAN INTRA ARTIKULER

KORTIKOSTEROID INTRA ARTIKULER TRAMADOL, OPIOID

TRAMADOL, OPIOID

KONDROITIN, GLUKOSAMIN SULFAT KALSIUM, VITAMIN D

PEMBEDAHAN TERAPI

PENDAMPING

Frozen ShoulderFrozen Shoulder1.1. Gejala klinis Gejala klinis

• • NNyeri pada sendi bahuyeri pada sendi bahu

• • Gerakan sendi terbatasGerakan sendi terbatas

• • Nyeri pada gerak aktif & pasifNyeri pada gerak aktif & pasif

ADHESIVE CAPSULITIS (FROZEN SHOULDER)ADHESIVE CAPSULITIS (FROZEN SHOULDER)ADHESIVE CAPSULITIS (FROZEN SHOULDER)ADHESIVE CAPSULITIS (FROZEN SHOULDER)

Suatu kondisi dimana Suatu kondisi dimana shoulder joint shoulder joint capsule capsule menjadi menebal dan kontraksi menjadi menebal dan kontraksi (kaku).(kaku).

Penyebab: imobilisasi, Penyebab: imobilisasi, DiabetesDiabetes, , Thyroid Thyroid Tiga Fase/periode:Tiga Fase/periode:a)a) The painful period – The painful period – 6 mgg- 8 bln. Pada 6 mgg- 8 bln. Pada

akhir periode biasanya nyeri berkurang akhir periode biasanya nyeri berkurang b)b) The frozen or stiff period – The frozen or stiff period – 76 mgg-1 tahun 76 mgg-1 tahun

minimal pain minimal pain, keterbatasan ROM, keterbatasan ROMc)c) The recovery period – The recovery period – 6 bulan-2 thn6 bulan-2 thn

peningkatan ROM, bisa full recovery, peningkatan ROM, bisa full recovery, kadang tak bisa recovery. kadang tak bisa recovery.

X-rays cannot identify frozen shoulder X-rays cannot identify frozen shoulder ArthrogramArthrogram//MRI can be ordered but MRI can be ordered but

they are not usually requiredthey are not usually required shoulder problems that may have shoulder problems that may have caused frozen shoulder.caused frozen shoulder.

ADHESIVE CAPSULITIS (FROZEN SHOULDER)

ADHESIVE CAPSULITIS (FROZEN SHOULDER)

Terapi :Terapi :

1.1. A program of stretching and strengtheningA program of stretching and strengthening

2.2. Ice therapy. Ice therapy.

3.3. Anti-inflammatory or pain medications. Anti-inflammatory or pain medications.

4.4. Active release therapy / traction Active release therapy / traction

5.5. Cortisone injections. Cortisone injections.

6.6. AcupunctureAcupuncture

7.7. Rehab medik (Fisiotherapy, massage, Rehab medik (Fisiotherapy, massage, stabilisasi / collar, heating / TENS dll) stabilisasi / collar, heating / TENS dll)

Lokasi suntikan :

Titik nyeri = lokasi suntikan

1. Tendo supraspinatus, bursa subdeltoid

2. Tendo kaput longus

3. Kapsul sendi

Jarum 26 kedalaman 1 cm Obat : Metilprednisolon 20 – 40 mg

Triamsinolon 5 – 20 mg

Posterior approach to the glenohumeral joint.

The patient sitting, the patient’s arm resting comfortably at the side,and the shoulder externally rotated. Essential landmarks to palpate before performing this injection include the head of the humerus, thecoracoid process, and the acromion.

FIGURE 8. Anterior approach to glenohumeral joint injection for adhesive capsulitis.

Steroid Injection

Manfaat mengurangi nyeri dengan cara menurunkan reaksi inflamasi (osteoarthritis, dan rheumatoid arthritis) dan dapat menghilangkan nyeri sampai beberapa bulan.

Tiap preparat memiliki durasi yang berbeda tergantung pada solubility dan struktur kristalnya. Insoluble preparations memiliki durasi aksi yang lebih lama. Contoh: Triamcinolone HEXACETONIDE : 6 bulan Triamcinolone ACETONIDE : 3 bulan Depo-medrol (Methylprednisolone acetate): 5

minggu.

Vial 40 mg/ml, 1 mlDepomedrol I: joint, muscle or skin lesion, IA or

periarticular inj for local effect. IM inj For systemic effect

E: anti inflamatory steroid and potentiates the sensory block produced by bupivacaine

MethylprednisoloneMethylprednisolone

Nasehat :

Pasien perlu menghindari

1. Kecemasan (Emosi)

2. Kelelahan (jasmani & rokhani)

3 Kedinginan (AC / angin, mandi air dingin)

4 Gerakan yang menimbulkan nyeri

Module :Module :

TOBACCO & NERVOUS SYSTEMTOBACCO & NERVOUS SYSTEM

Mini-Lecture

NEURO-PHARMACOLOGY OF NICOTINE

Learning ObjectivesLearning Objectives

To understand the pathways of nicotine action To understand the pathways of nicotine action on the brainon the brain

To understand how nicotine causes craving and To understand how nicotine causes craving and addictionaddiction

ContentsContents

Core Slides:Core Slides:1.1. NicotineNicotine2.2. Pathways of Nicotine ActionPathways of Nicotine Action3.3. How Nicotine Acts in Brain? (1-4)How Nicotine Acts in Brain? (1-4)

Optional Slides:Optional Slides:1.1. Nicotine & Nicotinic ReceptorsNicotine & Nicotinic Receptors2.2. Alternate Pathway: GABAAlternate Pathway: GABA


Core SlidesCore Slides

Nicotine Nicotine

Each cigarette contains Each cigarette contains approx. 10 milligrams of approx. 10 milligrams of nicotine nicotine a smoker a smoker gets approx. 1 to 2 gets approx. 1 to 2 milligrams from each milligrams from each cigarette cigarette 11

Nicotine shaped like the Nicotine shaped like the neurotransmitter neurotransmitter acetylcholineacetylcholine 2 2

http://www.chm.bris.ac.uk/org/gallagher/nAChR.gif

1. Benowitz NL. Epidemiol Rev 1996;18:188-204 2. National Institute on Drug Abuse. http://www.drugabuse.gov/JSP4/MOD2/page3.html

Core Slide

Pathways of Nicotine Action Pathways of Nicotine Action 11

http://www.nature.com/nri/journal/v2/n5/images/nri803-f3.gif

Nicotine activates nicotinic Nicotine activates nicotinic receptors in brain → receptors in brain → modulates immune response modulates immune response by by aa or or bb pathways (figure): pathways (figure):

a a →→ activation of the activation of the hypothalamus–pituitary–hypothalamus–pituitary–adrenal axisadrenal axis

b b → activation of the → activation of the autonomic nervous system autonomic nervous system via sympathetic & para-via sympathetic & para-sympathetic innervationssympathetic innervations

a b

1. Sopori M. Nature Reviews Immunology 2002;2:372-377. http://www.nature.com/nri/journal/v2/n5/fig_tab/nri803_F3.html

Core Slide

How Nicotine Acts in Brain? (1)How Nicotine Acts in Brain? (1)

1) Nicotine (half-life: 40 1) Nicotine (half-life: 40 minutes) mimics minutes) mimics actions of actions of acetylcholineacetylcholine

2) Directly activates 2) Directly activates dopamine systems in dopamine systems in brain → responsible brain → responsible for mediating for mediating pleasure responsepleasure response

http://www.treatobacco.net/en/uploads/image/nach_receptors.jpg

1. School of Chemistry, Bristol University, UK. http://www.chm.bris.ac.uk/motm/nicotine/E-metabolisme.html

Core Slide


3) Blocks reabsorption of 3) Blocks reabsorption of dopamine & stimulates dopamine & stimulates release of more dopamine release of more dopamine through glutamatethrough glutamate

4) Prolonged nicotine 4) Prolonged nicotine exposure → excessive & exposure → excessive & chronic activation → ↓ chronic activation → ↓ dopamine efficiency → ↓ dopamine efficiency → ↓ no. of available receptors no. of available receptors

http://www.chm.bris.ac.uk/motm/nicotine/E-synapse.html


Core Slide


5) Reduction in no. of 5) Reduction in no. of active receptors → ↓ active receptors → ↓ psychotropic effect of psychotropic effect of nicotinenicotine

6) Leads to phenomenon 6) Leads to phenomenon of tolerance → smoker of tolerance → smoker needs to smoke more needs to smoke more cigarettes cigarettes just to create just to create normal levels of dopaminenormal levels of dopamine http://www.chm.bris.ac.uk/motm/nicotine/E-concentr.html


Core Slide


7) After brief abstinence (e.g. overnight) →↓ brain 7) After brief abstinence (e.g. overnight) →↓ brain nicotine → receptors partially recover → ↑ dopamine nicotine → receptors partially recover → ↑ dopamine receptor sensitivity → ↑ neurotransmission rate receptor sensitivity → ↑ neurotransmission rate abnormally → induces cravingabnormally → induces craving

http://www.chm.bris.ac.uk/motm/nicotine/E-dependance.html


Core Slide


Optional SlidesOptional Slides

Nicotine & Nicotinic Receptors Nicotine & Nicotinic Receptors 11

Continuous exposure to tobacco

Nicotine substitutes for acetylcholine and over stimulates the nicotinic receptor. The receptor is long-term inactivated and its regeneration is prevented by nicotine.

Physiological normal conditions

After the opening of the canal by binding to acethylcholine, the receptor becomes desensitized before it goes back to the state of rest or it is regenerated.

http://www.chm.bris.ac.uk/motm/nicotine/E-metabolisme.html


Optional Slide

Alternate Pathway: GABA Alternate Pathway: GABA 11

Nicotine also acts on Nicotine also acts on neurons producing neurons producing glutamate and GABAglutamate and GABA

Leads to a combination Leads to a combination of effects → amplifies of effects → amplifies rewarding properties of rewarding properties of nicotine → promotes nicotine → promotes addictionaddiction

1. National Institute on Drug Abuse. http://www.drugabuse.gov/NIDA_Notes/NNVol17N6/Nicotine.html

Optional Slide

BAHAN BACAAN

1. Bradley, Daroff, Fenichel, Marsden - Neurology in Clinical Practice, 2nd Ed, Butterworth-Heinemann, Newton, MA, 1996.

2. McCaffery, Pasero -Pain Clinical Manual, 2nd Ed., Mosby, New York.3. Meliala, Suryamihardja, Purba - Konsensus Nasional Penanganan Nyeri Neuropatik,

Kelompok Studi Nyeri, Perhimpunan Dokter Spesialis Saraf Indonesia, 20004. Rowbotham - Neuropathic Pain and Quality of Life: The State of Our Current Knowledge,

dalam: Raj, P. (Ed.), Pain Practice (2nd World Congress of World Institute of Pain: Pain Management in the 21st Century, Istanbul), Blackwll Science, Inc., Massachussets, 2001.

5. Sang - An Individualized Approach to the Management of Neuropathic Pain, dalam: Raj, P. (Ed.), Pain Practice (2nd World Congress of World Institute of Pain: Pain Management in the 21st Century, Istanbul), Blackwll Science, Inc., Massachussets, 2001.

6. Wall, Melzack - Textbook of Pain, Churchill Livingstone, Edinburgh, 19997. Bonica, JJ – Neck Pain. In : Bonica JJ – The management of pain, 2 nd edition.

Philadelphia, Lea & Febriger, 1990,pp 848 - 867

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