NEUROPATI DIABETIK

dr. Shinta wulansari SpS

RSUD DAMANHURI - BARABAI

INTRODUCTION

DIABETIC NEUROPATHY is a syndrome

comprising a series of separate clinical
disorder that affects distinct components
of the peripheral nervous system.

Prevalence
-66% for type I and 59% for type II

Peripheral Neuropathy
Peripheral neuropathy is therefore loss
of nerve fiber function in the peripheral
nerves (nerves outside of the brain and
spinal cord.)
Normal Nerve

Abnormal Nerve

DEFINITION
1. PAIN
An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage.
(IASP: International Association for the Study of Pain)
2. NOCICEPTIVE PAIN
Pain caused by stimuli leading to tissue damage
3. NEUROPATHIC PAIN
Pain initiated or caused by a primary lesion or
dysfunction in the nervous system.

CLASSIFICATION OF PAIN
CLINICAL PAIN

PHYSIOLOGIC PAIN

Nociceptive Psychogenic Neuropathic

(inflammatory)
Somatic Visceral
Superficial

Peripheral

Central

Deep

Acute : < 3-6 months, mostly nociceptive

Chronic : > 3-6 months, mostly neuropathic

PAIN SYNDROME IN CLINIC

Neuropathic

Mixed
Pain

Nociceptive

Pain
Examples
Peripheral
Postherpetic neuralgia
Trigeminal neuralgia
Diabetic peripheral
neuropathy
Postsurgical neuropathy
Posttraumatic neuropathy
Central
Poststroke pain

Pain
Examples

Low back pain

with
radiculopathy
Cervical
radiculopathy
Cancer pain
Carpal tunnel
syndrome

1. International Association for the Study of Pain. IASP Pain Terminology.

2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57

Examples

Pain due to

inflammation
Limb pain after a
fracture
Joint pain in
osteoarthritis
Postoperative visceral
pain

NEUROPATHIC PAIN vs NOCICEPTIVE PAIN

NOCICEPTIVE PAIN

Localized at site of injury

Sensationstimulus
throbbing, aching,stiff
Acute, time-limited
Resolve as damage
healed
Protective function

NEUROPATHIC PAIN

Distal at territory of
Injured / dysfunctioned nerve
Burning, stabbing, tingling
lancinating
Chronic
Persists after injury healed
No protective function

CLINICAL MANIFESTATIONS OF NEUROPATHIC

PAIN

POSITIVE
Spontaneous
Evoked
Continuous or paroxysmal

Hyperalgesia
Sensation:
Allodynia
stabbing,paresthesia, shooting,
lancinating, electric-shock-like
NEGATIVE
Hypoesthesia, hypoalgesia

IMPACT OF PAIN
PAIN
NOCICEPTIVE
(Acute)
Avoid tissue damage

Mood
Protective function

NEUROPATHIC
(Chronic)
Physical
Psychological triad:
Impairment
Pain
Disability
Sleep

PAIN TRIAD
PAIN

FUNCTIONAL
IMPAIRMENT

MOOD

- Anxiety
- Depression
- OCD

SLEEP

QOL

- Deprivation
- Insomnia
- Poor

Patients with Peripheral Neuropathic Pain

Experience Significant Comorbid Symptoms
Difficulty sleeping
Lack of energy
Drowsiness
Concentration difficulties
Depression
Anxiety
Poor appetite
0

10

20

30

40

50

60

% patients with moderate to very severe discomfort (n=126)

Meyer-Rosberg et al. Eur J Pain. 2001;5:379-389

70

STAGING

No-no symptoms or signs of neuropathy

N1-asymptomatic,signs of neuropathy

N2-symptomatic neuropathy

N3-disabling polyneuropathy.

DISTAL SYMMETRICAL SENSORIMOTOR

POLYNEUROPATHY

-Most common form of diabetic neuropathy

-DSDP is a mixed neuropathy with small and large
fiber sensory, autonomic and motor involvement
in various combinations.
-DSDP can easily be diagnosed when other
complications such as retinopathy and
nephropathy are present.
-In a patient with DM ,if there are clinical
autonomic abnormalities, a DSDP is invariably
present.
-DSDP has insidious onset and progressive
course.

Symptoms
-Numbness or feeling of walking in cotton
-Sharp shooting or stabbing pain
-Dull constant or boring pain.
-Tingling pins & needles
-Hot or cold sensation
-Allodynia
-Cramps

SIGNS:
Significant distal weakness is uncommon
but EDB weakness may be there.
Ankle reflexes are absent .
Sensory loss in a length related
distribution with the toes and feet being
most affected.
Loss or impairment of all sensory
modalities with vibration sense often the
first to go.
As the sensory loss extends proximally
from a sock to stocking distribution the

TREATMENT OF
NEUROPATHIC PAIN

Advanced treatment in
Neuropathic Pain
Traditional
Treating pain

New paradigm
Treating pain

Treating sleep interference

Treating mood disorder

New Paradigm in Neuropathic Pain Management

Whole-patient management approach

through a Biopsychosocial model

by Multidisciplinary team approach

Therapy: Pharmacologic + Non-pharmacologic
Goal :
Alleviate pain
Treat comorbid conditions
( sleep, mood )
Improve function

BETTER
QUALITY
OF LIFE

WHO ANALGESIC LADDER

Freedom from pain
Step 3

Opioid for moderate to severe pain

+/- Adjuvant

Persisting Pain
Opioid for mild to moderate pain
+/- Non opioid , +/- Adjuvant

Step 2

Persisting Pain
Non opioid +/- Adjuvant

Step 1

PHARMACOLOGIC THERAPY
1. Non-opioid Analgesic

NSAIDs, paracetamol, tramadol, local anesthetic

2. Opioid Analgesic
- Weak: codein, hydrocodein.
- Strong: morphin,methadon, fentanyl.
3. Adjuvant Analgesic
- Antidepressant: TCA, venlafaxine, duloxetine
- Anticonvulsant: pregabalin,gabapentin, CBZ, Ox-CBZ,
phenytoin

FDA-approved adjuvant analgesic

5 FDA-approved co-analgesic agents indicated for
neuropathic pain :
1. Carbamazepine for trigeminal neuralgia,
2. Gabapentin for postherpetic neuralgia
3. Lidocaine transdermal patch for posthrpetic
neuralgia
4. Duloxetine for diabetic neuropathy
5 Pregabalin for both diabetic neuropathy and
postherpetic neuralgia.

PAIN MEASUREMENT
Visual Analog Scale (VAS)
0

No pain

Numeric Pain Intensity Scale (NPIS)

Faces Pain Rating Scale (untuk anak)

10

Worst
pain

THANK YOU

TUTORIAL
PEMERIKSAAN REFLEX