headache lbp

P A I Nfocus on LBP and HEADACHE

Department Of Neurology dr. Hasan Sadikin Hospital Padjadjaran University

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 )

Types of pain :

Nociceptive pain, inflamatory painNeuropathic pain Combination

Pain Clinical DiagnosisHistory takingPhysical examination, Neurological exam.Laboratory examination : Lab. Neurophysiology exam. Neuroimaging

Visual Analog Scales010No painExcruciating pain010Complete pain reliefNo pain reliefMcQuay, 1998.Note: Lines must be exactly 100 mm longFACES SCALES

THE DERMATOMES

Bagaimana Gejala Nyeri Neuropatik ?

HAS/Neuro/RSHS-FKUP

Nyeri SpontanNyeri dibangkitkan stimulus

Syndromes of Epiconus, Conus and Cauda Equina

Syndrome of lumbal-radiculopathy

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

Pain sensitive L-S structuresSkin, subcutaneous, adipose tissueMusclesFacet joints, sacroiliaca jointsPost/ant.longitudinal lig.Periosteum vertebra (fascia,tendon,aponeurosis)Nerve rootsBlood vessels (spinal joint,sacroiliaca joint, verteb, L-S muscles)

Estimated Prevalence of NePHAS/Neuro/RSHS-FKUP

Indonesia : 40% population, men>women hospital based : 3-17%

Low Back PainTriage diagnostik LPBLBP nonspesifikSindroma radikulerKelainan patologik serius Red Flags (Agency for Health Care Policy and Research, Bigos 1994)HAS/Neuro/2005

Low Back pain

Seriuos pathology: neoplasm infection fracture cauda equina syndromeIschialgia, radicular syndromeNonspecific LBP

Syndromes of Epiconus, Conus and Cauda Equina

Syndrome of lumbal-radiculopathy

Low Back PainDiagnostic triageHistory taking and physical examination to exclude red flagsNeurological examination (including Lassegue test)Consider psychosocial factors if there is no improvementX-rays, MRI ??

Red Flags of LBPCancer InfectionVertebral fracturCauda equina syndrome or Severe neurological deficit

Yellow FlagsRecognition of psychosocial factors as predictors of chronicity and obstacles to recoveryAcute subacute chronic

Risk Factors of LBPPhysical : 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

Management of acute LBPDiagnostic classification, D/ triageReassuranceEarly and progressive activationAnalgetics ?: acetaminophen NSAID consider muscle relaxantsRecognition yellow flags

HAS/P3D

Management of Chronic LBPBehavioral therapyEducationIntensive exercise therapy Multidisciplinary

HEADACHEHAS/P3D

ALL ACHES AND PAINS LOCATED IN THE HEAD

ORBITA OCCIPUTHEADACHE DEFINITION :HAS/P3D

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

PAIN SENSITIVE CRANIAL STRUCTURESSkin,subcutan., muscleExtracranial arteriesSkull periosteumEye,ear, nasal cavities, sinusesIntracran.venous sinuses, large vein, pericavernous structuresBasis dura, meningeal arteries, prox.ant/middle cerebral A, IC int.carotis ASuperf.temporal ACranial nerves:II.III,V,IX,X,C1-3

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

MECHANISMS OF CRANIAL PAIN :TRACTION ON OR DILATATION OF THE INTRACRANIAL ARTERIESDISTENTION OF EXTRACRANIAL ARTERIESTRACTION ON OR DISPLACEMENT OF THE LARGE INTRACRANIAL VEINS OR DURAL ENVELOPE COMPRESSION, TRACTION OR INFLAMATION OF THE CRANIAL AND SPINAL NERVESSPASM, INFLAMATION & TRAUMA TO CRANIAL & CERVICAL MUSCLE

MECHANISM OF CRANIAL PAIN (cond)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

ATTACK ONSETQUALITYSEVERITYLOCATIONMODE OF ONSETTIME, INTENSITY, CURVE, DURATIONCONDITION WHICH EXACERBATE / RELIEVE THE PAINASSOCIATED FEATURESSOCIAL HISTORY, FAMILY HISTORYPAST HEADACHE HISTORYHEADACHE IMPACT

HISTORY taking:

HAS/NEURO

Faktor pencetus Nyeri Kepala

StresKurang/kebanyakan tidurTidak/telat makanBau menyengat : parfum,rokokLingkungan: cahaya silau/berkedip,gaduh ketinggian,panas,lembab ruang berasapMakanan/minumanHAS/Neuro/Bdg/04

RED FLAGS of HEADACHE

Secondary Headache Red Flags SSNOOPSystemic symtoms (fever, weight loss) orSecondary 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)

HAS/P3D

CLUSTER HEADACHE

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

Tension Type HeadachePsychologic factorsMuscle contraction and myofacial tendernessVascular factorsn : NOHumoral factors : 5HTCentral factors : central pain control system

HAS/P3D

PHYSICAL EXAMINATION

NEUROLOGICAL EXAMINATION

HAS/P3DTrigeminal neuralgia

HEADACHE TREATMENTPRIMARY HEADACHE TREATMENT Abortive Preventive

SECONDARY HEADACHE TREATMENT Causal Symtomatic : Analgesic

PRIMARY HEADACHE TREATMENT TTHAbortive :Simple analg : acetaminophen/ ASA/NSAID

Preventive : Amitriptylin

Nonpharmacologic therapyMIGRAINEAbortive :Simple analg : acetaminophen/ ASA/ NSAIDSpecific analg : ergot alkaloids ( ergotamine/ DHE )/ triptanAntiemetics : metoclopramide/ domperidone

Preventive : Anticonvulsants / Adrenoceptor blockers (propranolol)/ Antidepressants/ Ca-channel blockers

Nonpharmacologic therapy

CLUSTER HAabortive : o2 inhalationergot alkaloids, triptans

preventive : verapamilergot alkaloid

Cranial Neuralgias,Central Pain(Neuropathic Pain) Treatment AntidepressantsAnticonvulsantsAntiarrhitmicLocal anesthetic

Penanganan tanpa obat

EdukasiMengenal & menghindari faktor pencetus

Modifikasi perilakuLatihanRelaksasiBiofeedbackTerapi perilaku kognisiTerapi fisikTENS (transcutaneus electric nerves stimulation)HAS/Neuro/Bdg/04

(PERDOSSI,2001)

HAS/Neuro/2004

(Rowbotham MC, Petersen KL, 2001)Antikonvulsants

(PERDOSSI,2001)HAS/Neuro/RSHS-FKUP

(I.C.H.E.)MononeuropahiesMononeuropahies

headache lbp

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