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
Normal Nerve
Abnormal Nerve
cord.)

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
(inflammatory)
Somatic Visceral
Superficial

Neuropathic

Peripheral

Central

Deep

neuropathic

Acute : < 3-6 months, mostly nociceptive

Chronic : > 3-6 months, mostly

PAIN SYNDROME IN CLINIC

Neuropathic
Pain

Mixed
Pain

Nociceptive
Pain

Examples
Examples
Examples
Peripheral
Postherpetic neuralgia Low back pain
Pain due to
Trigeminal neuralgia
with
inflammation
Diabetic peripheral
radiculopathy
Limb pain after a
neuropathy
Cervical
fracture
Postsurgical
radiculopathy
Joint pain in
neuropathy
Cancer pain
osteoarthritis
Posttraumatic
Carpal tunnel
Postoperative
neuropathy
syndrome
visceral pain
1. International
CentralAssociation 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
Poststroke pain

NEUROPATHIC PAIN vs NOCICEPTIVE PAIN

NOCICEPTIVE PAIN
Localized at site of injury
dysfunctioned nerve
Sensationstimulus
tingling
throbbing, aching,stiff
Acute, time-limited
Resolve as damage
healed
healed

NEUROPATHIC PAIN
Distal at territory of
Injured /
Burning, stabbing,
lancinating
Chronic
Persists after injury

CLINICAL MANIFESTATIONS OF
NEUROPATHIC PAIN

POSITIVE
Spontaneous
Evoked
Continuous or paroxysmal

Hyperalgesia
Sensation:

Allodynia
stabbing,paresthesia, shooting,
lancinating, electric-shock-like

IMPACT OF PAIN
PAIN
NOCICEPTIVE

NEUROPATHIC

(Acute)
Avoid tissue damage
Psychological triad:

(Chronic)
Physical
Impairment
Disability

Mood
Protective function

Pain
Sleep

PAIN TRIAD
PAIN

FUNCTIONAL
IMPAIRMENT

MOOD

- Anxiety

- Depression
Insomnia
- OCD

QOL

SLEEP

- Deprivation

- Poor

Patients with Peripheral Neuropathic Pain

Experience Significant Comorbid Symptoms

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

STAGING
No-no

symptoms or signs of
neuropathy

N1-asymptomatic,signs

of

neuropathy
N2-symptomatic
N3-disabling

neuropathy

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 finger tips
become involved.

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
0
No
No pain
pain

10
10

Worst
Worst Pain Intensity Scale (NPIS)
Numeric
pain
pain

Faces Pain Rating Scale (untuk anak)

THANK YOU

TUTORIAL
PEMERIKSAAN
REFLEX