P A I N focus on LBP and HEADACHE

3. P A I Nfocus on LBP and HEADACHE Department Of Neurology dr. Hasan Sadikin Hospital Padjadjaran University

4. Definition of PAIN Pain is unpleasent sensory and emotional experience associated with actual or potential tissue damage, or discribed in term of such damage ( IASP, 1986 )

5. Types of pain : Nociceptive pain, inflamatory pain Neuropathic pain  Combination

6. Pain Clinical Diagnosis • History taking • Physical examination, Neurological exam. • Laboratory examination : Lab. Neurophysiology exam. Neuroimaging

7. Visual Analog Scales Excruciatingpain Nopain 0 10 Completepain relief Nopain relief 0 10 Note: Lines must be exactly 100 mm long McQuay, 1998. FACES SCALES

8. THE DERMATOMES

10. Bagaimana Gejala Nyeri Neuropatik ? aaauuuw ! Nyeri Spontan Nyeri dibangkitkan stimulus HAS/Neuro/RSHS-FKUP

11. Syndromes of Epiconus, Conus and Cauda Equina Syndrome of lumbal-radiculopathy

12. LOW BACK PAIN(NYERI PUNGGUNG BAWAH) • Nyeri di antara sudut iga terbawah dan lipat bokong bawah yaitu di daerah lumbal atau lumbo-sakral dan sering disertai dengan penjalaran nyeri kearah tungkai-kaki

13. Pain sensitive L-S structures • Skin, subcutaneous, adipose tissue • Muscles • Facet joints, sacroiliaca joints • Post/ant.longitudinal lig. • Periosteum vertebra (fascia,tendon,aponeurosis) • Nerve roots • Blood vessels (spinal joint,sacroiliaca joint, verteb, L-S muscles)

14. Estimated Prevalence of NeP Indonesia : 40% population, men>women hospital based : 3-17% HAS/Neuro/RSHS-FKUP

15. Low Back Pain Triage diagnostik LPB Kelainanpatologik serius Sindromaradikuler LBP nonspesifik “ Red Flags “ HAS/Neuro/2005 (Agency for Health Care Policy and Research, Bigos 1994)

16. Low Back pain • Seriuos pathology: neoplasm infection fracture cauda equina syndrome • Ischialgia, radicular syndrome • Nonspecific LBP

17. Syndromes of Epiconus, Conus and Cauda Equina Syndrome of lumbal-radiculopathy

19. Low Back Pain • Diagnostic triage • History taking and physical examination to exclude red flags • Neurological examination (including Lassegue test) • Consider psychosocial factors if there is no improvement • X-rays, MRI ??

20. Red Flags of LBP • Cancer • Infection • Vertebral fractur • Cauda equina syndrome or Severe neurological deficit

21. Yellow Flags Acute  subacute  chronic • Recognition of psychosocial factors as predictors of chronicity and obstacles to recovery

22. Risk Factors of LBP • Physical : 35 – 55 y past history of LBP • Occupational : vibration bending, twisting heavy lifting low job satisfaction • Psychosocial : attitudes cognition fear-avoidance beliefs depression anxiety distress and related emotion

23. Management of acute LBP • Diagnostic classification, D/ triage • Reassurance • Early and progressive activation • Analgetics ?: acetaminophen NSAID consider muscle relaxants • Recognition yellow flags

24. HAS/P3D

25. Management of Chronic LBP • Behavioral therapy • Education • Intensive exercise therapy Multidisciplinary

26. HEADACHE HAS/P3D

27. HEADACHEDEFINITION : ALL ACHES AND PAINS LOCATED IN THE HEAD ORBITA OCCIPUT HAS/P3D

28. The International Classification of Headache Disorders ICHD 2 ( IHS 2004 ) The Primary Headaches Migraine Tension-type headache (TTH) Cluster headache Other primary headaches The Secondary Headaches Headache attributed to head and/or neck trauma Headache attributed to cranial or cervical vascular disorders Headache attributed to non-vascular intracranial disorders Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disorder of homoeostasis Headache or facial pain attributed disorder of cranial, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures Headache attributed to psychiatric disorders Cranial Neuralgias, central & primary facial pain & other headaches Cranial neuralgias & central causes of facial pain Others headache, cranial neuralgias & central or primary facial pain

29. The International Classification of Headache Disorders ICHD 2 ( IHS 2004 ) The Primary Headaches Migraine Tension-type headache (TTH) Cluster headache Other primary headaches The Secondary Headaches Headache attributed to head and/or neck trauma Headache attributed to cranial or cervical vascular disorders Headache attributed to non-vascular intracranial disorders Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disorder of homoeostasis Headache or facial pain attributed disorder of cranial, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures Headache attributed to psychiatric disorders Cranial Neuralgias, central & primary facial pain & other headaches Cranial neuralgias & central causes of facial pain Others headache, cranial neuralgias & central or primary facial pain

30. PAIN SENSITIVE CRANIAL STRUCTURES • Skin,subcutan., muscle • Extracranial arteries • Skull periosteum • Eye,ear, nasal cavities, sinuses • Intracran.venous sinuses, large vein, pericavernous structures • Basis dura, meningeal arteries, prox.ant/middle cerebral A, IC int.carotis A • Superf.temporal A • Cranial nerves:II.III,V,IX,X,C1-3

32. THE ROLE OF NEUROTRANSMITTER : • SEROTONIN (5 HT) • THE ENDOGENOUS PAIN CONTROL MECHANISM -> OPIOID • GABA

33. MECHANISMS OF CRANIAL PAIN : • TRACTION ON OR DILATATION OF THE INTRACRANIAL ARTERIES • DISTENTION OF EXTRACRANIAL ARTERIES • TRACTION ON OR DISPLACEMENT OF THE LARGE INTRACRANIAL VEINS OR DURAL ENVELOPE • COMPRESSION, TRACTION OR INFLAMATION OF THE CRANIAL AND SPINAL NERVES • SPASM, INFLAMATION & TRAUMA TO CRANIAL & CERVICAL MUSCLE

34. MECHANISM OF CRANIAL PAIN (con’d) • DISEASE OF THE TISSUES OF THE SCALP, FACE, EYE, NOSE, EAR AND NECK • MENINGEAL IRRITATION • INTRACRANIAL MASS LESION RAISED INTRACRANIAL PRESSURE LOWERED INTRACRANIAL PRESSURE : LP HEADACHE

35. HISTORY taking: • ATTACK ONSET • QUALITY • SEVERITY • LOCATION • MODE OF ONSET • TIME, INTENSITY, CURVE, DURATION • CONDITION WHICH EXACERBATE / RELIEVE THE PAIN • ASSOCIATED FEATURES • SOCIAL HISTORY, FAMILY HISTORY • PAST HEADACHE HISTORY • HEADACHE IMPACT

36. HAS/NEURO

37. Faktor pencetus Nyeri Kepala Stres Kurang/kebanyakan tidur Tidak/telat makan Bau menyengat : parfum,rokok Lingkungan: cahaya silau/berkedip,gaduh ketinggian,panas,lembab ruang berasap Makanan/minuman HAS/Neuro/Bdg/04

38. RED FLAGS of HEADACHE

40. Secondary Headache Red Flags “SSNOOP” • Systemic symtoms (fever, weight loss) or • Secondary risk factors : underlying diseases (HIV,systemic cancer) • Neurologic symtoms or abnormal signs (confusion, impaired alertness,or consciousness) • Onset: sudden,abrupt, or split-second (first,worst) • Older: new onset and progressive headache, especially in middle age>50 (giant cell arteritis) • Previous headache history or headache progression: pattern change, first headache or different (change in attack frequency, severity, or clinical pictures)

42. HAS/P3D

43. HAS/P3D

44. CLUSTER HEADACHE YOUNG ADULT MEN ( M : F = 5 : 1 ) UNILATERAL PAIN HAS/NEURO

45. Tension Type Headache • Psychologic factors • Muscle contraction and myofacial tenderness • Vascular factorsn : NO • Humoral factors : 5HT • Central factors : central pain control system

46. HAS/P3D

47. PHYSICAL EXAMINATION NEUROLOGICAL EXAMINATION

49. Trigeminal neuralgia HAS/P3D

50. PRIMARY HEADACHE TREATMENT Abortive Preventive SECONDARY HEADACHE TREATMENT Causal Symtomatic : Analgesic HEADACHE TREATMENT