CV

• Name : YUDIYANTA
• Adress: Jl Rajawali Raya 45 C Condong Catur Depok Sleman
• Staff in Neurology Dept. Faculty of Medicine, Gadjah Mada University –
Sardjito Hospital Jogjakarta in:
– Pain Division
– Neurophysiology-Neuromuscular Division
• Chief of Pain Study Group, Perdossi Chapter Jogjakarta
• Vice of Pain Team-Pain Clinic in Sardjito Hospital
• Sub Specialization: Pain and Headache Consultant, 2013
• Neurologist, 2006 Neurology Department, Faculty of Medicine, University
of Gadjah Mada, Jogjakarta
• FMD: Faculty of Medicine UGM, 1998
ASSESSMENT in MIXED PAIN

Yudiyanta
Neurology Dept. Faculty of Medicine UGM/
RSUP Dr Sardjito
 Curriculum Vitae
• Name : YUDIYANTA
• Adress: Jl Rajawali Raya 45 C Condong Catur Depok Sleman
• Staff in Neurology Dept. Faculty of Medicine, Gadjah Mada University –Sardjito
Hospital Jogjakarta in:
– Pain Division
– Neurophysiology-Neuromuscular Division
• Chief of Pain Study Group, Perdossi Chapter Jogjakarta
• Vice of Pain Team-Pain Clinic in Sardjito Hospital
• Sub Specialization: Pain and Headache Consultant, 2013
• Neurologist, 2006 Neurology Department, Faculty of Medicine, University of Gadjah
Mada, Jogjakarta
• FMD: Faculty of Medicine UGM, 1998
 Undertreated Pain vs Over-Prescribing
Contributing Factors

•Lack of knowledge among prescribers about :

– Philosophy of pain
– Pathophysiology
– Assessment of Pain
– Current pain management guidelines/Treatment
modality,
– Risk management practices/ Comorbidity and side effect
– Research in pain medicine
– Management value and expectations.
 TYPE OF PAIN

Superficial Somatic Pain

Somatic
Nocicepthic Deep Somatic Pain
Visceral

Peripheral NP

Central NP
TYPES OF PAIN Neuropathic

SMP
Central Sensitization
Syndrome: FM
MFPS etc
Dysfunctional
Psychiatric Dis.
Somatoform etc (Idiopatik)
 Mixed Pain
• Most pain is mixed
• Even “nociceptive pain” can lead to central sensitization
– Eg, osteoarthritis
• fMRI and PET changes
– Increased activation in brain areas involved with affect, aversive
conditioning and motivation than experimental pain
• These patients display hyperalgesia locally and in areas distant
from the arthritic joint
– After THA, these patients display reduced pain in both areas

• ALL pain has a psychological component!

Aranda-Villalobos P et al. Arthritis & Rheumatism 2013; 65: 1262-1270.
Sofat et al. Rheumatology 2011; 50: 2157-2165
 Mixed Pain
• Cancer pain,
• Back Pain with Radicular,
• CTS,
• Cervicogenic Headache/occipital neuralgia
• Migraine headaches
• Osteoartritis
• Piriformis syndrome
• TMJ Disorder
• etc
 Definitions of Mixed Pain
• There are no clear guidelines for diagnosing mixed pain as a
syndrome

• In the case of mixed pain syndromes, healthcare professionals are

likely to hear elements of both neuropathic and nociceptive pain
described by the patient (Ritchie, 2010)

• So it seems reasonable to combine the diagnosis and management

of the two components in this case.

• The problem once having diagnosed their patient’s pain is to decide

whether there is a neuropathic component to the pain or not
 Pain

Assessment of Disease Assessment of Pain

Diagnosis of Disease Diagnosis of Pain

Management of Disease Management of Pain

 Pain

Assessment of Disease Assessment of Pain

Nociceptic Pain Neuropathic Pain Disfunctional Pain

Mixed Pain

Pain Intensity Comorbidity & Side Effects

Treatment
 Nocicepthic

Somatic Visceral

• Well localized • Diffuse and poorly localized

• Intermittent or constant
• “aching,” “stabbing,”
“gnawing,” “throbbing”
• Intermittent or constant
• “dull,” “colicky,” “squeezing”
• Refers to other locations.
• Accompanied by motor and
autonomic reflexes (Eg, nausea,
vomiting, muscle tension, etc)
 Neuropathic Pain

Peripherally Centrally Sympathetically

generated pain generated pain maintained pain

• may be generated peripherally or centrally

• characterized by localized autonomic
dysregulation
• vasomotor or sudomotor changes, edema,
sweating, trophic changes, including
atrophy (ex: CRPS )
 Neuropathic Pain
1.Possible neurophatic pain : Riwayat perjalanan penyakit pasien
merupakan lesi atau penyakit yang relevan menimbulkan gejala nyeri dan
sesuai dengan distribusi neuroanatomi saraf yang terkena
2.Probable neurophatic pain : mencakup kriteria possible dan salah satu
temuan :
1. Konfirmasi tes diagnostik adanya lesi neuropati
2. Ditemukan gejala sensorik negatif atau sensorik positif sesuai area
neuroanatomi
3.Definite neurophatic pain : kriteria possible dan probable (Haanpaa M., Attal N.,

Backonja M., et al. NeuPSIG guidelines on neuropathic pain assessment. Pain 2011;152:14-27)

• Anamnesis + Pemeriksaan fisik neurologik bedside adalah satu-

satunya cara menentukan gejala nyeri neuropatik dari nyeri non-
neuropatik
 Penilaian Objektif Nyeri Nuropatik
1. Tes diagnostik laboratorium
2. Tes kuantitatif sensorik
3. Pemeriksaan fisik bedside.
4. Istrumen penapisan kuesioner nyeri neuropatik
Serabut Saraf Sensorik Pemeriksaan Objectif
Klinis Tes Kuantitatif Laboratorium
Ab sentuh Kapas Halus VonFrey NCS, SEPs
Filaments
Ad Getar, Pinprick, Garputala, Vibrator NCS, SEPs, LEPs
Nyeri tajam Wooden
Cocktail Stick
C Dingin, Thermoroller Thermode NA
Panas, Thermoroller Thermode LEPs
Terbakar NA Thermode LEPs

Gruccu et al., Tools for Assasing Neuropathic Pain, Medicine, 2009

SMP
 NEUROPATHIC PAIN
Perbandingan Ketepatan Kuesioner Penapisan Nyeri Neuropatik
 NEUROPATHIC PAIN

1. Pin Pricks
2. Electric Shock Like
3. Burning/Hot INTENSITY
4. Numbness
5. Alodinia

Gruccu G & Truini A, Tools for Assessing Neuropathic Pain, Plos Medicine, 2009
1. Burning
2. Pricking
3. Light Touch Allodinia
4. Electricshock like
5. Heat Allodinia
6. Numbness <13 13-18 > 18
7. Mecanical Allodinia
Margreta et.al., 2014
 PAIN INTENSITY

ACUTE PAIN CHRONIC PAIN

(<3 Mo) (> 3 Mo)

Multi-Dimensional Scale

Uni-Dimensional Scale McGill Pain Questionnaire (MPQ)

The Brief Pain Inventory (BPI)
The Memorial Pain Assessment Card
 * Tools pengkajian nyeri
1.Numeric Rating Pain Scale/VAS/VRS

2.Wong Baker Faces

3. NIPS Pain Scale

4.FLACC Pain Scale

5.COMFORT Pain Scale

10/15/2017
 COMORBIDITY & Side Effects

Gastrointestine

Cardiac
Vascular Brain
COMORBIDITY Peripheral

Renal

Respiratory

Contraindication And Side Effect

 Assessment of Pain

Management of Pain

Neurorestoration in Pain

Neuro- Neuro- Neuro Neuro Neuro

Regeneration Repair Plasticity Modulation Rehabilitation

Self Restoring Pain Non Self Restoring Pain?

 ASSESSMENT IN MIXED PAIN

Nociceptic

TYPE OF PAIN Neuropathic

Dysfunctional

PAIN INTENSITY OF PAIN

COMORBIDITY & SIDE EFFECT