NYERI

MUSKULOSKELETAL
DAN
PENATALAKSANAANNYA

Susatyo P. Hadi
SMF SARAF RSUD KUDUS
 POKOK-POKOK BAHASAN
 PENDAHULUAN
 BATASAN NYERI MUSKULOSKELETAL
 MEKANISME NYERI
 GEJALA KLINIK DAN SIMTOM
 DIAGNOSIS
 TATALAKSANA
 KESIMPULAN
 POKOK-POKOK BAHASAN

 PENDAHULUAN
 BATASAN NYERI MUSKULOSKELETAL
 MEKANISME NYERI
 GEJALA KLINIK DAN SIMTOM
 DIAGNOSIS
 TATALAKSANA
 KESIMPULAN
 PENDAHULUAN

 The INTERNATIONAL ASSOCIATION for the

STUDY of PAIN (IASP) : “the 2009 – 2010 GLOBAL
YEAR AGAINST THE MUSCULOSKELETAL PAIN”.

 NYERI MUSKULOSKELETAL MERUPAKAN

MASALAH KESEHATAN BESAR YANG DIDERITA
JUTAAN MANUSIA DI BUMI.

 NYERI MUSKULOSKELETAL MERUPAKAN

PROBLEM YANG KOMPLEK DAN MASIH
KURANG DIPAHAMI DENGAN BAIK.
 LIMB PAIN
JOINT
NECK PAIN
PAIN

MACAM – MACAM
NYERI
MUSKULOSKELETAL

BONE OTHERS’
CHRONIC
PAIN LOW BACK PAIN
PAIN
 TERAPI TERAPI PATOFISIOLOGI
TIDAK SIMTOMATIK KURANG
ADEKWAT DIPAHAMI

ETIOLOGI CHALLENGES BIAYA

TIDAK & MAHAL
JELAS
ISSUES

USIA TUA
KASUS &
MENINGKAT GEMUK

HILANG PRODUKTIVITAS
HARI MENURUN
KERJA
 POKOK-POKOK BAHASAN

 PENDAHULUAN
 BATASAN NYERI MUSKULOSKELETAL
 MEKANISME NYERI
 GEJALA KLINIK DAN SIMTOM
 DIAGNOSIS
 TATALAKSANA
 KESIMPULAN
 BATASAN
NYERI MUSKULOSKELETAL

NYERI MUSKULOSKELETAL MELIBATKAN :

 MUSKULUS
 LIGAMENTUM
 TENDON
 TULANG
 ETIOLOGI

POSTURAL REPETITIVE OVERUSE

TRAUMA STRAIN MOVEMENTS

 Gerakan kejut
 Kecelakaan
PROLONGED
 Jatuh
IMMOBILIZATION
 Fraktur
 Sprint
 Dislokasi
 Benturan
 POKOK-POKOK BAHASAN

 PENDAHULUAN
 BATASAN NYERI MUSKULOSKELETAL
 MEKANISME NYERI
 GEJALA KLINIK DAN SIMTOM
 DIAGNOSIS
 TATALAKSANA
 KESIMPULAN
 Perception Pain Pathway/Perception
Pain

Modulation
Descending
modulation Dorsal Horn

Ascending
input
Dorsal root
ganglion
Transmission

Transduction
Spinothalamic
Peripheral
tract
nerve

Trauma
Peripheral
nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
 The PAIN CYCLE
 MUSCLE ATROPHY &
WEAKNESS
 WEIGHT LOSS/GAIN

PAIN DISABILITY
 POOR SLEEP
 MISSING WORK  LESS ACTIVE
 NEGATIVE SELF-  DECREASED
TALK MOTIVATION
DISTRESS  INCREASED
ISOLATION
 DIFFERENCES OF PAIN CONCEPT

DISEASE
PAIN
DISEASE PAIN

PATIENT
DOCTOR
 POKOK-POKOK BAHASAN

 PENDAHULUAN
 BATASAN NYERI MUSKULOSKELETAL
 MEKANISME NYERI
 GEJALA KLINIK DAN SIMTOM
 DIAGNOSIS
 TATALAKSANA
 KESIMPULAN
 GEJALA KLINIK DAN SIMTOM
SELURUH BADAN
SAKIT SEMUA
TANDA – TANDA
YANG LAZIM

PAIN FATIGUE GANGGUAN

(NYERI) (LELAH) TIDUR
 POKOK-POKOK BAHASAN

 PENDAHULUAN
 BATASAN NYERI MUSKULOSKELETAL
 MEKANISME NYERI
 GEJALA KLINIK DAN SIMTOM
 DIAGNOSIS
 TATALAKSANA
 KESIMPULAN
 GOLD-STANDARD
of PAIN ASSESSMENT

Pain is always subjective

Beli
eve
Pain
Patients’
Self-report of pain is the
Gold standard for assessment

IASP 1999; Portenoy RK, Lesage P. lancet, 1999

 PEMERIKSAAN
FISIK

TEKNIK RIWAYAT
DIAGNOSIS PENYAKIT

PENUNJANG
DIAGNOSTIK
 POKOK-POKOK BAHASAN

 PENDAHULUAN
 BATASAN NYERI MUSKULOSKELETAL
 MEKANISME NYERI
 GEJALA KLINIK DAN SIMTOM
 DIAGNOSIS
 TATALAKSANA
 KESIMPULAN
BEBERAPA PERTIMBANGAN DALAM PEMILIHAN
TERAPI NYERI MUSKULOSKELETAL

 TENTUKAN JENIS / MACAM NYERI

 TENTUKAN KWANTITAS NYERI
 PEMILIHAN JENIS ANALGETIK
 MACAM-MACAM NYERI

NYERI NOSISEPTIF TIPE CAMPURAN NYERI NEUROPATIK

AKIBAT KERUSAKAN AKIBAT KOMBINASI AKIBAT LESI PRIMER

JARINGAN/RESEPTOR TRAUMA PRIMER DAN PADA SERABUT SARAF
SEKUNDER

 PASCA OPERASI  SAKIT KEPALA (HEADACHE)

 LOW BACK PAIN  NEURALGIA POST HERPES
 ARTHRITIS ZOOSTER
 NEURALGIA TRIGEMINAL
 TRAUMA OLAHRAGA
 NYERI KANKER
 TRAUMA PANAS,
 RADICULOPHATY IN LOW BACK
DINGIN,KIMIAWI, PAIN
DLL.  POLINEUROPATI DISTAL (MIS.
DM, HIV)
 PEMERIKSAAN SARAF

MOTORIK :KEKUATAN OTOT

REFLEK FISIOLOGIS / PATOLOGIS

SENSORIK : NYERI
RABA
SUHU
VIBRASI
POSISI

OTONOM : MIKSI, DEFEKASI, KELJ. KERINGAT

 INTENSITAS NYERI
(PENGUKURAN SKALA NYERI )

1. VISUAL ANALOG SCALE (VAS)

2. NUMERIC PAIN RATING SCALE (NPRS)

1 – 3 NYERI RINGAN
4 – 6 NYERI SEDANG
7 – 10 NYERI BERAT

3. FACES PAIN RATING SCALE (untuk anak)

   VISUAL ANALOG SCALE (VAS)

NUMERIC PAIN RATING SCALE (NPRS)

FACES PAIN RATING SCALE (untuk anak)

Tramadol+
APAP
 COX-PATHWAY
Glucocorticoids
Arachidonic acid (-) (block mRNA expression)
(a fatty acid)

(-) (-)
COX-1 NSAIDs COX-2
Coxibs

Normal Normal
Inducible
constituent constituent

 inflammation
 brain
 gastric cytoprotection
 kidney
 renal sodium / water balance  pain
 ovary
 platelet aggregation  fever  uterus
 ACR 2006 Updated Guideline for OA Management

Physical measures – patient education

Medication

Anti- inflammatory Analgesics Intra - articular

Paracetamol
NSAIDs plus PGE2/PPI, Depot steroids
COX-2 Non-acetylated Hyaluronate
salicylate Tramadol
Capsaicin
Opioids

Antispasmodics / Antidepressants / Sugars / Anthraquinone / Lipids

Surgery

Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29

 2006 New Guideline in Treatment Moderator- to-Severe
Pain in OA patients with Risk Factors

Paracetamol up to 4g/day

Cardiovascular Renal Gastrointestinal

risk risk risk

Avoid NSAIDs/ Flares Long term

COX-2 inhibitors

Moderate COX-2 NSAIDs Paracetamol /

• Paracetamol / tramadol inhibitor +PPI Tramadol
weak opioid combinations*
• Tramadol •Tramadol
• Strong opioid •Strong opioids
Severe
* 2nd choice

Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29

WGPM ( The Working Group on Pain Management ) Recommendation at the 2 nd meeting in EULAR 2005
 2006 New Guideline in Treatment
Moderator-to-Severe Low Back Pain

NOCICEPTIVE +/- NEUROPATHIC PAIN

LONG TERM

ELDERLY YOUNG / HEALTHY

Moderate
• Weak opioid combinations eg. • COX-2 inhibitors /NSAIDs
Paracetamol / tramadoll low dose)
+/or paracetamol/ tramadol
(NSAIDs-sparing)
Severe •Tramadol
•Tramadol*
• Strong opioid
•Strong opioids IR

*Tramadol is efficacious for both nociceptive and neuropathic pain

Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29

WGPM ( The Working Group on Pain Management ) Recommendation at the 2 nd meeting in EULAR 2005
 THERAPEUTIC CHOISE

BRAIN

DESCENDING INHIBITION
(5HT, NE)
TERAPI :
NOCICEPTOR • TCA, SSRI, SNRI
SPINAL • TRAMADOL
• OPIOID
CORD
NA -CHANNEL GLUTAMATE, CA++
( PERIPHERAL SENSITIZATION ) ( CENTRAL SENSITIZATION )
TERAPI :
• NA CHANNEL BLOCKER TERAPI :
• CARBAMAZEPINE • PREGABALIN
• OXCARBAZEPINE • GABAPENTIN
• PHENYTOIN • OXCARBAZEPINE
• GABAPENTIN • LAMOTRIGIN
• LIDOCAIN • NMDA ANTAGONIST
 KESIMPULAN
 The INTERNATIONAL ASSOCIATION for the STUDY
of PAIN (IASP) : “the 2009–2010 GLOBAL YEAR
AGAINST THE MUSCULOSKELETAL PAIN”.

 NYERI MUSKULOSKELETAL MERUPAKAN MASALAH

KESEHATAN BESAR YANG DIDERITA JUTAAN MANUSIA
DI BUMI.

 NYERI MUSKULOSKELETAL MERUPAKAN PROBLEM YANG

KOMPLEK DAN MASIH KURANG DIPAHAMI DENGAN
BAIK.
 BEBERAPA PERTIMBANGAN DALAM PEMILIHAN TERAPI
NYERI MUSKULOSKELETAL :
 TENTUKAN JENIS/MACAM NYERI
 TENTUKAN KWANTITAS NYERI
 PEMILIHAN JENIS ANALGETIK
THANK
YOU......