TO

Nyeri Kronis dan Kanker

O
R
B
E
SO
T
O
Dr. Heri Pujiono, SpAn., FIP., cHt., cMMH

AT
SMF Obsgyn Departemen Anestesi
G
AD
Ketua Unit Pelayanan Nyeri Terpadu
SP

RSPAD Gatot Soebroto

R

Jakarta
P
SI
AR

Dibawakan pada Webinar Dalam Rangka HUT RSPAD GATOT AOEBROTO ke-73
 Definisi Nyeri

TO
 IASP 1979 “ Pain is define as: an unpleasant sensory and

O
emotional experience, associated with actual or potential tissue

R
damage or describe in term of such damage. (Harold Merskey )

B
E
SO
T
Makna dari definisi ini adalah:

O
AT
 Pain is unpleasant sensory and emotional experience (rasa yang
tidak menyenangkan sensorik dan emotional).
 G
AD
Associated with actual tissue damage ( Nyeri akut, atau nyeri
inflamasi).
SP

 Due to potential tissue damage (Nociceptive pain = Physiological

R

pain  withdrawal Reflex)

P
SI

 Described in term of such damage (digambarkan seperti adanya

AR

kerusakan jaringan .(tapi tidak)  chronic pain .

 Emosi  cemas, Lokalisasi dan

Transmisi takut, menangis. dll

Limbic System
intensitas nyeri

Cortex

TO
O
Nyeri selalu bersifat 2 dimensi,

R
dimensi fisik dan emosi (psikis).

B
E
Thalamus

SO
T
Midbrain

O
Projection

AT
To PGA
Noxious
stimulus

G
Spinoreticular Brainstem
tract Reticular
AD
formation
Dorsal horn
Nociceptors
SP

Of spinal cord

C fiber
R

A fiber
P

Spinothalamic
SI

Cell body in tract

DRG
AR
 1. Chronic pain

TO
O
R
B
Chronic pain is a pain that persists

E
SO
beyond normal tissue healing time,

T
which is assumed to be three – six

O
AT
months.
G
AD
SP

The International Association for study of pain (IASP)

R
P

 Pain that continues when it should not.

SI
AR
 Chronic pain after surgery or trauma

TO
O
The pain is the same

R
B
The cause is different

E
Pain more

SO
associated with the
nervous system

T
O
AT
PAIN LEVEL

Inflammation
, scarring,
G
AD
remodeling
Pain more
SP

associated
with tissues
R
P
SI
AR

HEALING TIME (DAYS/WEEKS)

Butler & Moseley 2003 Explain Pain
 TO
O
R
B
All chronic pain was once acute,

E
SO
T
O
but not all acute pain becomes
AT
G
chronic.
AD
SP
R
P
SI
AR

Shipton EA Anaesth Intensive Care. 2011;39(5):824-36.

 Chronic Pain

TO
O
 This terminology is misleading as the key

R
B
distinction between acute and chronic pain is not

E
SO
the duration of pain, but for chronic pain its:

T
 Persistence beyond nociception

O
AT
 (Pain without nociception)
G
AD
 Beyond expectation
SP

“Acute
 and chronicto
Difficultes pain have nothing in common but
treat
R

the four-
P

 Produce suffering and reduced QoL

SI
AR
 TO
O
R
B
E
Chronic Pain

SO
T
… is not prolonged acute pain

O
AT
… must be considered and treated
G
AD
as a disease.
SP
R
P
SI
AR
 TO
O
R
B
E
SO
Basic mechanism of Chronic Pain

T
O
AT
G
AD
SP
R
P
SI
AR
AR
SI
P
R
SP
AD
Central Sensitization

G
AT
O
T
SO
E
B
R
O
TO
Central Sensitization
Spontaneous Allodynia

TO
Hyperalgesia
Tissue damage pain

O
R
B
E
SO
T
PERIPHERAL CENTRAL

O
ACTIVITY
SENSITIZATION

AT
G
AD
SP

Lowered Increased
R

threshold to spontaneous
P

peripheral Expansion of activity

Nerve damage
SI

stimuli receptive
field
AR

Increase in the excitability of neurons within CNS, so that normal Inputs begin to
produce abnormal response.
AR
SI
P
R
SP
AD
G
AT
O
T
SO
E
B
R
O
TO
 The Biopsychosocial Model

TO
of Chronic Pain

O
R
B
E
SO
T
O
AT
G
AD
SP
R
P
SI
AR
 Types of Pain: mechanism-based

TO
O
Centralized pain/

R
Idiopathic pain (Chronic pain)

B
Pain without identifiable nerve

E
or tissue damage; hypothesized to be a result

SO
persistent neuronal dysregulation or dysfunction

T
O
AT
Nociceptive pain MIXED Neuropathic pain
G
Pain caused by
an inflammatory or Pain arising as a direct
AD
non-inflammatory consequence of a
response to an overt or lesion or disease
SP

potentially tissue-damaging affecting the

somatosensory system2-3
R

stimulus1,3
P
SI
AR

1. Adapted from Julius D et al. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier;
2006, p. 35. 2. Jensen TS, et al. Pain 2011;152(10):2204-2205. 3. Treede RD, et al. Neurology 2008;70(18):1630-1635.
 Possible causes of chronic pain

TO
O
R
Neuropathic Pain Nociceptive Pain
Mixed Pain

B
Pain initiated or caused by a Pain with Pain caused by injury to

E
primary lesion or dysfunction neuropathic and body tissues

SO
in the nervous system nociceptive (musculoskeletal,
(either peripheral or components cutaneous or visceral)2

T
central nervous system)1

O
AT
G
Examples Examples
Peripheral Examples
AD
• Phantom Limp pain • Pain due to inflammation
• Postherpetic neuralgia • Low back pain with • Limb pain after a fracture
• Trigeminal neuralgia radiculopathy •
SP

Joint pain in osteoarthritis

• Diabetic peripheral neuropathy • Cervical radiculopathy • Postoperative visceral pain
• Postsurgical neuropathy • Cancer pain
R

Central • Carpal tunnel Common descriptors2

P

• Poststroke pain syndrome • Aching

SI

Common descriptors2 • Sharp

• Burning • Throbbing
AR

• Tingling
• Hypersensitivity to touch or cold 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
 Chronic Pain is a

TO
Biopsychosocial Phenomenon

O
R
Cognitive Behavior therapies

B
E
Functional restoration
Antidepressants/

SO
Pain Behaviors
psychotropics
Opioids

T
O
Suffering Relaxation

AT
Spiritual
Adjuvan drugs
Neural-augmentation G
Pain Perception
AD
Local blocks
Ablative Surgery NSAIDS
SP

Nociception
XXXXXXXX Opioids
Central
R

Physical
Sensitization Modalities
P

(wind-up)
SI
AR

Loeser JD.Cousins MJ.Med J Aust. 1990;153;208-212,216

 TO
O
R
B
SEKIAN

E
SO
T
O
Terima Kasih Banyak
AT
G
AD
SP

Semoga Ada Manfaatnya

R
P
SI
AR
 TO
2. Cancer pain

O
R
B
E
SO
Of all the symptoms caused by

T
O
Cancer

AT
PAIN is the most feared
G
AD
SP
R

 69 % of severe cancer pain patient to cause consideration

P

of suicide. (Wisconsin 1985)

SI
AR

(Wisconsin 1985)
 What is cancer pain?

TO
O
Cancer Pain is not 1 entity, it’s more

R
B
complex and multifactorial in nature.

E
SO
T
O
AT
G
AD

“TOTAL PAIN”
SP
R
P
SI
AR

Dame
Cicely Mary Sounders in 1967 called it as:
 BIOLOGICAL DISTRESSS

TO
O
R
B
E
SO
SPIRITUAL EMOTIONAL

T
O
DISTRESS DISTRESS

AT
G
AD
SP
R

SOCIAL DISTRESS
P
SI
AR

(Biopsychosociospiritual Disesase)
Modified by AHT
 Anxiety

TO
Co-morbid causes Fear of suffering

O
R
Depression

B
Caused by treatment

E
SO
Past
Caused by cancer Psychological experience
Physical of illness

T
pain
pain

O
AT
Total Pain
Loss of role in Anger at
social status
Social G Spiritual fate/anger with
AD
god
Loss of job pain pain
SP

Loss of faith
R

Financial concerns
Fear of death
P

Worrier about future

SI

of family
Fear of the unknown
AR

Dependency
Modified by AHT
 Physical cancer pain

TO
O
R
Physical pain is the major sources of

B
E
SO
cancer pain, consist of :

T
1. 1. Cancer-related 93%

O
AT
2. 2. Treatment –related 21%
G
AD
3. 3. Non related to cancer 2%
SP
R
P
SI
AR

Carenceni & Portenoy Pain 82:263-274, 1999

 TO
1. Cancer related pain

O
R
B
Due to cancer invasion or metastases:

E
SO
• Local tissue damage with inflammation

T
O
• Invading nerves or nerve complexes

AT
• G
Pressure effects on nerves/ hollow organs
AD

• Eating into bone / fracture

SP
R
P
SI
AR
 TO
2. Due to cancer treatment:

O
R
B
1. Cancer surgery – post-mastectomy,

E
SO
post-thoracotomy

T
O
2. Chemotherapy – peripheral neuropathy

AT
G mucositis, enterocolitis
AD

3. Radiation therapy - dermatitis, radiation burn

SP
R

post-radiation fibrosis
P
SI
AR
 TO
DUE TO SURGERY

O
R
B
E
Pain after mastectomy

SO
Chronic pain after sugery is seen in

T
as many as 50% of mstectomy.

O
AT
 Pain in the scar
 Phantom breast pain G
AD

 Pain in the arm and

SP
R

shoulder.
P
SI
AR
 DUE TO CHEMOTHERAPY

TO
O
Mucositis

R
B
E
SO
T
O
AT
G
AD
SP
R
P
SI
AR
 DUE TO RADIATION THERAPY

TO
O
• RADIATION THERAPY

R
B
E
SO
T
O
AT
G
AD
SP
R
P
SI
AR

COBALT RADIATION BURN

PAIN that non related to cancer:

TO
(Co-morbid causes)

O
R


B
Herpes zoster ( acute or chronic)

E
SO
 Mucositis

T
O
 Osteo arthritis

AT
 G
Musculoskeletal pain
AD

 Etc.
SP
R
P
SI
AR
 Non related to Cancer

TO
O
R
B
Immunocompromised state

E
SO
T
O
AT
G
AD
SP
R
P
SI
AR

Pain at Early stage of HZ Postherpetic pain

Non related to Cancer

TO
O
Mucositis

R
B
E
SO
T
O
AT
G
AD
SP
R
P
SI
AR
AR
SI
P
R
SP
AD
G
AT
O
T
SO
E
B
R
O
DUE TO OSTEOARTHRITIS

TO
 Type of Cancer Pain

TO
O
R
B
1. Nociceptive pain

E
SO
 Somatic pain or
 Visceral pain

T
O
2. Neurophatic pain

AT
3. Mixed pain (Nociceptive + Neurophatic pain)
G
AD
4. Episodic, transient, periodic pain 40-80% (is challenging to
manage)
SP

1. Spontaneous Breakthrough pain

R

2. Incident pain (antecendent cause)

P
SI

3. End of dose pain (pharmacokinetic factors)

AR
 Breakthrough Pain

TO
O
(episodic, transient or periodic pain).

R
B
E
“Is pain that comes on very quickly and severely in

SO
patient who are already being treated with long
acting opioid”.

T
O
AT
Prevalence of BTP is 40-80% depend on the setting
G
AD
1. Spontaneous breakthrough pain
2. Incident pain
SP

3. End of dose pain

R
P
SI
AR

Hagen, NA et al Assessment and Management of Breakthrough Pain in Cancer Patients:

Tom Baker Cancer Centre, Alberta Cancer Board, Division of Palliative Medicine. University of Calgary, 1331 29 th Street NW, Canada
Copy right 2008.
 1. Spontaneous Breakthrough Pain

TO
O
Over Medication

R
B
E
Around-the-Clock Breakthrough pain

SO
Medication

T
O
AT
G
AD
SP
R
P
SI

BTP is commonly occurs to patient who are already in baseline pain, treated
AR

with long acting opioid.

BTP is difficult to manage, and often negatively impacts patents’ quality of life.
 2. Incident pain

TO
O
R
B
• Incident pain refers to physical activities

E
SO
such as weight-bearing in bone

T
metastases, or dressing changes.

O
AT
• Also my occur when patient coughing,
G
AD
moving or walking.
SP

• Clear antecedent cause.

R
P
SI
AR
 TO
End of Dose Pain

O
R
B
E
1. Inadequate dose

SO
T
2. Interval is longer

O
AT
3. Is pharmacokinetic factors, baseline
G
pain increase before next schedule
AD

dose of analgesic.
SP
R
P
SI
AR
 End-of-dose Pain

TO
O
R
B
E
SO
T
O
Morphine

AT
level
G
AD
SP
R
P

Pain Pain
SI
AR

Time
 TO
O
R
B
SEKIAN

E
SO
T
O
Terima Kasih Banyak
AT
G
AD
SP

Semoga Ada Manfaatnya

R
P
SI
AR
AR
SI
P
R
SP
AD
G
AT
O
T
SO
E
B
R
O
TATA LAKSANA NYERI

TO
 Use WHO Three Step Ladder, (1986)

TO
O
R
B
5 essential concepts

E
SO
1. By mouth
2. By the clock

T
O
3. By the ladder

AT
4. By individual
G 5. With attention to
AD
detail
SP
R
P
SI

By this stepwise about 90% of cancer pain can be relieved, should start with a non-opioid and
AR

if pain is not controlled progress to a weak opioid and then to a strong opioid.
PENGUKURAN NYERI
• PENGALAMAN SUBYEKTIF → PSIKOLOGIS,KULTURAL

TO
dan VARIABEL LAIN

O
R
• DEFINISI → DESTRUKSI JARINGAN, REAKSI EMOSIONAL

B
E
• SKALA NYERI → RINGAN, SEDANG, BERAT

SO
→ NUMERIK VERBAL
→ BELUM MEMUASKAN

T
O
• VISUAL ANALOG SCALE dan ME GILL PAIN QUESTIONNA

AT
IRE
( VAS ) G ( MPQ )
AD
→ SERING DIGUNAKAN
SP

-VAS → GARIS HORISONTAL 0 ←→10

R

→ SIMPEL, EFISIEN
P
SI

→ INTENSITAS TIDAK QUALITAS

AR
- MPQ → CHECKLIST SIMPTOM :

TO
• DISKRIMINATIF SENSORI (NOC PATH) →10

O
R
•EFEKTIF MOTIVASIONAL (RET dan LIMB) →5

B
E
• VEALUASI KOGNITIF ( KORTEX SER ) →1

SO
• LAIN – LAIN

T
O
AT
G
→ ANSIETAS dan GANGGUAN PSIKOLOGIS LAIN MENGABURKAN
AD
NILAI
SP
R
P
SI
AR
EVALUASI PSIKOLOGIK

TO
O
• SERING DIGUNAKAN TEST MINNESOTA MULTI

R
B
PHASIC PERSONALITY INVENTORY ( MMPI )

E
SO
dan BECK DEPRESSION INVENTORY

T
• MMPI KWESIONER DENGAN 566 ITEM

O
AT
• BECK DEPRESSION INVENTORY → DEPRESI
BERAT G
AD
SP
R
P
SI
AR
ELEKTROMIOGRAFI dan HANTARAN SYARAF

TO
• STUDI SALING MELENGKAPI

O
R
• KONFIRMASI DIAGNOSIS DARI SYNDROMA

B
E
SO
- SINDROMA RADIX
- TRAUMA NEURAL

T
O
- POLINEUROPATI

AT
• MEMBEDAKAN NEUROGENIC dan MYOGENIC
G
AD
SP
R
P
SI
AR
Pyramid of Pain Management in

TO
Cancer Pain

O
R
Nerve blocks

B
1-

E
5%
Interventions

SO
2-5% Epidural / intratechal

10-15% Intravenous

T
O
AT
PYRAMID OF PAIN

G MANAGEMENT
AD
SP

Oral and
Transdermal
R

75-85%
P
SI
AR
 Pain management:

TO
WHO 3 steps ladder vs NCCN 2 steps Guidelines

O
R
B
WHO 1986
NCCN 2011

E
SO
T
O
AT
G
AD
SP
R
P
SI
AR

1. World Health Organization. Cancer pain relief: with a guide to opioid availability. 2nd ed. Geneva:The Organization;1996.
2. National Comprehensive Cancer Network (NCCN) GuidelinesTM Ver. 2.2011: Adult Cancer Pain
 TO
Pain

O
R
B
E
Chronic pain

SO
Acute pain

T
O
AT
Cancer pain
G
AD
Non-Cancer pain
SP
R
P
SI

Nociceptive Neuropathic Dysfunctional

AR

pain pain pain

 TO
O
R
B
E
SO
Acute pain vs Chronic Pain

T
O
in Pain Management
AT
G
AD
SP
R
P
SI
AR
 Acute vs Chronic pain

TO
Acute Pain Chronic Pain

O
Duration Hours to days Months to years

R
Present

B
Tissue injury Commonly none

E
Nerve conduction Fast Slow

SO
Autonomic NS Activated Generally no activation
Biological value High Low or absent

T
Uncommon Depression, anxiety, suicide

O
Social effects
Profound

AT
Associated problems Few
Multimodal:
Treatment Analgesics
G
• Behavioral
• Drugs have a moderate role:
AD
Adjuvan: Antidepressants
SP

Anticonvulsants
Prognosis Predictable • Unpredictable
R

Aim: cure • Treatment aim of decreasing pain

P

and
SI

• suffering and improving functioning.

AR

• Coping with pain, increase QoL

Adapted from Ashburn and Straats, 1999
 TO
O
R
B
E
SO
T
O
AT
Post herpetic Neuralgia
G
LBP
Low Back Pain
AD

“Pain is unpleasant sensory and emotional experience,

SP

or….. ..described in terms of such damage”

R

• beyond the healing period

P
SI

• no more tissue damage Chronic Pain

AR

• Longer than 3-6 months (persistent pain)

 Biomedical vs. Biopsychosocial

TO
pain Management

O
R
1
B
Acute pain

E
Chronic pain

SO
• goal of • goal of treatment is

T
O
treatment is to to improve function

AT
obtain pain relief in occupational,
G social and
AD

emotional domains;
SP

pain relief is de-

R

emphasised
P
SI
AR
 Biomedical vs. Biopsychosocial

TO
Pain Management

O
R
2
B
E
SO
Acute pain Chronic pain

T
O
• patient is ill, and • patient is not ill, and

AT
therefore should be should maintain
free from normal G normal activity levels
AD

responsibilities as far as possible

SP
R
P
SI
AR
 Biomedical vs. Biopsychosocial

TO
Pain Management

O
R
3
B
E
SO
Acute pain Chronic pain

T
O
 primary  primary responsibility

AT
responsibility for for improvement lies
improvement lies G with the patient -
AD
with the doctor; patient’s role is active.
patient’s role is
SP

passive.
R
P
SI
AR
 TO
Pain and Cancer

O
R
B
E
Not all cancer patients will have pain but,

SO
for many cancer pain patients, pain is not

T
single pain.

O
AT
• 1/5 have 1 pain
G
• 4/5 have 2 or more pain
AD
SP

• 1/3 have 4 or more pains

R
P
SI
AR
 TO
O
R
B
E
SO
Cancer Pain Management

T
O
AT
What we need to know ?
G
AD
1. Pain Intensity
SP

2. Type of pain
R
P
SI
AR
INTEGRATION OF OTHER INTERVENTIONS

TO
TO THE WHO LADDER

O
R
B
E
Anaesthetic
physiotherapy

SO
interventions

Occupational

T
O
Cancer 1 therapy

AT
therapies

G 2 psychology
AD
surgery
SP
R

3 Spiritual care
P
SI
AR

Kedokteran Nuklir
NYERI KRONIK

TO
- NEUROENDOKRIN STRESS RESPON (-)

O
R
-- NYERI DIHUBUNGKAN DG PARAPLEGIA

B
- GANGGUAN TIDUR

E
SO
- DEPRESI
-GANGGUAN NAFSU MAKAN

T
O
AT
EVALUASI PASIEN DENGAN NYERI G
AD

- BEDAKAN NYERI AKUT dan KRONIS

SP

- NYERI AKUT →TERAPEUTIK

R

- NYERI KRONIK → INVESTIGATIVE MEASURE

P
SI
AR
TARMOGRAFI

TO
O
• DIAGNOSIS DINI REFLEK DISTROFI

R
B
• MYOFASCIAL SYNDROMA dan GANGGUAN LIGA

E
SO
MENTUM
→ TRIGER POINT “ SPASME OTOT “

T
O
AT
INTERVENSI FARMAKOLOGIS G
AD

• INHIBITOR, OPIOID, ANTIDEPRESANT, AGENT NEU

SP
R

ROLEPTIK, ANTIKONVULSAN, KORTIKOSTEROID

P
SI

DAN PENGGUNAAN SISTEMIK LOKAL ANESTETIK

AR
• ANTIDEPRESANT : → AMITRIPTILIN

TO
- DOSIS LEBIH RENDAH
- BLOKADE REUPTAKE SEROTONIN , NOREPINEFRIN ATAU

O
R
KEDUANYA

B
E
- PALING BERMANFAAT UNTUK NYERI NEROPATIK

SO
seperti : NEURALGIA POST HERPETIK, NEUROPATI

T
DIABETIK

O
- MEMPERKUAT AKSI OPIOID dan MENORMALKAN SLEEP

AT
PATTERN

G
- SIDE EFEK : MULUT KERING, GANGGUAN VISUAL, RETENSI
AD

URIN, KONSTIPASI, SEDASI pH LAMBUNG ↑, HIPOTENSI

SP
R

ORTOSTATIK
P

- METABOLISME HEPAR, PROTEIN BINDING ↑ LIPOFILIK

SI
AR

VOLUME DISTRIBUSI, BESAR T ½ ELIMINASI 1-4 HARI

ANTI KONVULSAN

TO
• SANGAT BERGUNA UNTUK NYERI NEROPATIK

O
(NEURALGIA TRIGEMINAL, NEUROPATI DIABETIK)

R
B
• SUPRESI DISCHARGE NEURAL SPONTAN

E
• FENITOIN, CARBAMAZEPIN, ASAM VALPROIC,

SO
KLONAZEPAM dan GABAPENTIN

T
•PROTEIN BINDING TINGGI

O
AT
G
AD
SP
R
P
SI
AR
NEUROLEPTIK

TO
• BERMANFAAT UNTUK NYERI NEROPATIK REFRAKTER

O
R
•AGITASI dan SIMPTOM PSIKOTIK

B
•HALOPERIDOL, KLOPROMAZINE, FLUFENAZIN, PERTEN

E
SO
SIN
•BLOKADE RESEPTOR DOPAMINERGIK

T
O
•SIDE EFEK → EXTRA PYRAMIDAL

AT
G
AD
SP
R
P
SI
AR
•KORTIKO STEROID

TO
• GLUKOKORTIKOID ANTI INFLAMASI dan ANALGETIK

O
•TOPIKAL, ORAL, INTRAVENA, SUBCUTAN INTRA ARTERI

R
B
EPIDURAL

E
•SIDE EFEK :

SO
- Hipertensi

T
- Hiperglikemi

O
AT
- Peningkatan insiden infeksi

G
- Ulkus peptikum
AD
- Osteoporosis
SP
R
P
SI
AR
ANESTETIK LOKAL

TO
• KADANG DIPAKAI NYERI NEROPATIK

O
• SEDASI dan ANALGESI SENTRAL

R
• LIDOKAIN, PROKAIN, KLORPROKAIN

B
E
• SLOW BOLLUS ATAU INFUS

SO
• MONITORING EKG :

T
- EKG

O
- TEKANAN DARAH

AT
- RESPIRASI
- STATUS MENTAL
G
AD
• ALAT RESUSITASI TERSEDIA
SP

• TANDA-TANDA TOKSISITAS
R

1. TINNITUS
P

2. SLURING
SI

3. SEDASI EKSESIF
AR

4. NISTAGMUS
TERAPI TAMBAHAN

INTERVENSI PSIKOLOGIK

TO
• PSIKOLOG, PSIKIATER

O
R
• TERAPI KOGNITIF, BEHAVIORAL, BIOFEEDBACK, RELAKSASI DAN

B
HIPNOSIS

E
SO
TERAPI FISIK

T
• SUPERFICIAL HEATING :

O
- HOT PACK

AT
- PARAFFIN BATHS
- FLUIDA THERAPY G
AD

- HIDROTHERAPHY
SP

- INFRARED
R

•COLD
P
SI

- INJURI KUAT
AR

- EDEMA
AKUPUNKTUR
 NYERI KRONIK

TO
- NYERI MUSKULOSKLETAL

O
R
- NYERI KEPALA

B
E
STIMULASI ELEKTRONIK

SO
• STIMULASI SISTEM SYARAF

T
→ NYERI AKUT DAN NYERI KRONIK

O
AT
• DAPAT SECARA TRANSKUTANEUS, PIDURAL

G
• TENS (TRANCUTANEOUS ELECTRIC NERVE STIMULA
AD
TION )
→STIMULASI SERABUT SYARAF EFFERENT BESAR
SP

→NYERI AKUT MODERAT, NPB, ARTHRITIS, NYERI

R
P

NEROPATIK
SI

→ BLOK KONDUKSI SERABUT NYERI KECIL

AR
STIMULASI SPINAL CORD

TO
• STIMULASI SERABUT AB BESAR DI KOLUMNA DORSALIS

O
R
• AKTIVITASI SISTEM MODULASI DESCENDING dan INHIBI

B
SI SIMPATIK

E
SO
• EFEKTIF UNTUK NYERI NEROPATIK

T
STIMULASI INTRASEREBRAL

O
AT
• STIMULASI DEEP BRAIN

→KANKER INTRAKTABEL
G
AD
→NYERI NEUROPATIK
SP

• ELEKTRODE DITANAMKAN
R

→PERIAQUEDUKTAL
P
SI

→PERIVERI VENTRIKULER
AR
 Guide to pain management
THREE STEP LADDER WHO, 1986

TO
O
R
B
E
Severe pain 7-10

SO
3

T
O
Moderate

AT
Pain 4-6

G 2
AD
Mild pain 1-3
SP
R

1
P
SI

By this method 90% of cancer pain

can be relief.
AR

World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability. World Health Organization; 1986.
AR
SI
P
R
SP
AD
G
AT
O
T
SO
E
B
R
O
TO
Having a steady level of enough opioid to

TO
treat the peaks of incident pain...

O
R
B
E
SO
...would result in
excessive dosing for

T
the periods between

O
incidents

AT
Pain

G
AD
SP
R

Incident Incident Incident

P
SI
AR

Time
 KOMPLIKASI

TO
•

O
→ HEMORAGIK

R
B
( PERDARAHAN)

E
SO
T
O
AT
G
AD
SP
R
P
SI
AR
 TO
O
R
B
SEKIAN

E
SO
T
O
Terima Kasih Banyak
AT
G
AD
SP

Semoga Ada Manfaatnya

R
P
SI
AR