NYERI AKUT

DAN PERMASALAHANNYA

dr. H. Noegroho Harbani, MSc. SpS

Pokdi NYERI PERDOSSI Cabang Banyumas
 CURICULUM VITAE
Nama dr. Noegroho Harbai, SpS, MSc
Tempat/ tanggal lahir Banyumas, 25 Juni 1968
Pekerjaan Dokter di RSUD Ajibarang
Riwayat Pendidikan S1/ profesi dokter – FK UGM
Spesialis – FK UGM
S2 – FK UGM
Riwayat Pekerjaan - RSUD Ajibarang
- RST Wijaya Kusuma
Organisasi - IDI
- Perdosi
- Subpokdi Pain Intervensi
 Definisi Nyeri

Nyeri adalah pengalaman sensorik dan

emosional yg tidak menyenangkan akibat
kerusakan jaringan baik aktual maupun
potensial atau yg digambarkan dalam bentuk
kerusakan tersebut

(Meliala, 2000)
 Pain Is the 5th Vital Sign

Respiration Pulse Blood pressure Temperature

Pain

Phillips DM. JAMA 2000; 284(4):428-9.

 Kontinum Nyeri/
Rangkaian Perjalanan Nyeri
Rangsang
nyeri
Waktu penyembuhan

Nyeri akut Nyeri kronik

Normal, respons sementara

Nyeri bertahan meskipun telah terjadi
terhadap rangsang nyeri berupa
penyembuhan luka
pengalaman yang ‘berbahaya’
(biasanya lebih dari 3 bulan)
(kurang dari 3 bulan)
• Ada kerusakan jaringan • Biasanya bukan merupakan fungsi
• Memberikan fungsi proteksi proteksi
• Nyeri berkurang sejalan dengan • Menurunkan kualitas hidup dan
penyembuhan luka kesehatan

Nyeri akut bisa menjadi kronik

Chapman CR, Stillman M. In: Kruger L (ed). Pain and Touch. Academic Press; New York, NY: 1996; Cole BE. Hosp Physician 2002; 38(6):23-30;
International Association for the Study of Pain. Unrelieved Pain Is a Major Global Healthcare Problem.
Available at: http://www.iasp-pain.org/AM/Template.cfm?Section=Press_Release&Template=/CM/ContentDisplay.cfm&ContentID=2908. Accessed: July 24: 2013;
National Pain Summit Initiative. National Pain Strategy: Pain Management for All Australians.
Available at: http://www.iasp-pain.org/PainSummit/Australia_2010PainStrategy.pdf. Accessed: July 24, 2013;
Turk DC, Okifuji A. In: Loeser D et al (eds.). Bonica’s Management of Pain. 3rd ed. Lippincott Williams & Wilkins; Hagerstown, MD: 2001.
 Klasifikasi Nyeri
NOCICEPTIVE PAIN
Noxius Pheripheral Stimuli Pain
Heat Autonomic Response
Witdrawal Reflex
Cold Brain

Nosiseptif Intense
Mechanical
Nociceptor
Force
sensory neuron
Heat

Cold Spinal cord

Adaptif Inflammation
INFLAMANTORY PAIN
Spontaneous Pain
Pain Hypersensitivity
Macrophage Reduced Threshold : Aliodyna
Mast Cell Increased Response : Hyperalgesia
Neutrophil
Granulocyte
Brain

Inflamasi Tissue Damage

Nociceptor
sensory neuron

Spinal cord

Nyeri NEUROPATHIC PAIN

Spontaneous Pain
Pain Hypersensitivity
Brain

Neuropatik Peripheral Nerve

Damage

Spinal cord Injury

Maladaptif FUNCTIONAL PAIN

Spontaneous Pain
NOCICPTOR Pain Hypersensitivity
Brain

Fungsional NOCICPTOR
Normal Peripheral
Tissue and Nerves
NOCICPTOR Abnormal Central
Processing
 Prevalence of Acute Pain

• Lifetime prevalence in general population:

– Approaches 100% for acute pain leading to use
of analgesics1
• Emergency room patients:
– Pain accounts for >2/3 of emergency room visits2
• Hospitalized patients:
– >50% report pain3

1. Diener HC et al. J Headache Pain 2008; 9(4):225-31; 2. Todd KH, Miner JR. In: Fishman SM et al (eds). Bonica’s Management of Pain.
4th ed. Lippincott, Williams and Wilkins; Philadelphia, PA: 2010; 3. Dix P et al. Br J Anaesth 2004; 92(2):235-7.
 Epidemiology of Pain in
General Practice
• 1 in 3 patients reported pain
• Of patients in pain:
– 47.2% had acute pain
– Location of pain was mainly in musculoskeletal
areas and the limbs
– 2 in 3 pain patients had a drug prescription
• Pain was more frequent in women

Koleva D et al. Eur J Public Health 2005; 15(5):475-9.

 Most Common Types of Pain
in General Practice

Note: types of pain are based on ICD-9 codes

*The use of the symptom code suggests clinician could not identify the underlying cause of the pain
**MSK – other refers to musculoskeletal pain at sites other than the neck, back or soft tissue
ICD = International Classification of Disease; MSK = musculoskeletal
Hasselström J et al. Eur J Pain 2002; 6(5):375-85.
 Most of patients have moderate to severe pain
(bigger proportion in neurologist group)

Pain Intensity in
100% Pain Intensity
Neurologist
100%
15%
in other specialist 20%
80% 80%

7-10 (Severe)
60% 60%
57% 7-10 (Severe)
4-6
64%
(Moderate)
40% 4-6 (Moderate) 40%
0-3 (Mild)
20% 0-3 (Mild)
20%
28%
16%
0%
0%
All Pain Patients
All Pain Patients

72% of patients suffer 84% of patients suffer

moderate-severe pain moderate-severe pain
However,
there is gap in pain treatment…

72% of patients suffer moderate-severe pain

but there’s only 18% patients get ladder

2&3 painkiller
73%

17% 1% 6%
3%
Ladder 1 Ladder 2 Ladder 3 Adjuvant NA
 Skrining dan Assessment

• Skrining untuk menentukan apakah ada nyeri

atau tidak

• Assessment untuk menentukan tipe nyeri,

intensitas, akut/kronik
3L untuk pendekatan klinis
 Assessment Nyeri
• SOCRATES
• S: site/dimana letak nyeri?
• O: onset/mulai kapan nyeri?
• C: characteristic/bagaimana rasa nyeri?
• R: radiation/menjalar atau tidak?
• A: associated symptomps/ada gejala penyerta atau tidak?
• T: time/kapan muncul nyeri?
• E: exacerbating/yang memunculkan nyeri
• S: severity/seberapa berat rasa nyeri
 Konsep Assessment
• OPQRSTUV
• O: onset
• P: provocating/paliating (yang
memicu/meringankan nyeri)
• Q: quality (kualitas)
• R: radiation (penjalaran)
• S: severity (seberapa hebat)
• T: time (kapan muncul)
• U: understanding the impact (dampak nyeri)
• V: value (nilai dan harapan)
 Prinsip Pengobatan

• Tergantung onset
• Tergantung tipe
• Tergantung intensitas
• Tergantung penyebab
• Tergantung ada/tidaknya komorbid
Prinsip Terapi
 Discussion Question

HOW DO THESE MEDICATIONS WORK TO

REDUCE ACUTE PAIN?
 Physiology of Pain
PERCEPTION

PAIN

MODULATION

TRANSMISSION

TRANSDUCTION
19
 Mechanism-Based Pharmacological Treatment
of Nociceptive/Inflammatory Pain
Brain

α2δ ligands Perception

Acetaminophen
Opioids
Antidepressants
nsNSAIDs/coxibs
Noxious Opioids
stimuli nsNSAIDs/coxibs
Local anesthetics Local anesthetics
Descending Ascending
Transduction Transmission modulation input

Nociceptive afferent fiber

Spinal cord
Inflammation
Peripheral sensitization Central sensitization
nsNSAIDs/coxibs, opioids
Coxib = COX-2 inhibitor; nsNSAID = non-specific non-steroidal anti-inflammatory drug
Scholz J, Woolf CJ. Nat Neurosci 2002; 5(Suppl):1062-7.
 Step 3: Strong Opioids
Morphine, Transdermal fentanyl

Step 2: Weak Opioids

Tramadol, Codeine

Step 1: NSAIDs

Transdermal fentanyl : an effective analgesic for severe pain and

can be used in stable pain states as an alternative to morphine.
 Algorithm for Treatment of
Acute Pain Based on Severity
Acute pain due to: Mild or moderate
• Sport injury Severe acute pain
acute pain
• Traumatic or
inflammatory condition Inadequate
• Musculoskeletal injury analgesia

Step 1: acetaminophen
(4 g/day maximum dose;
4 h minimum interval between each 1 g dose)
Inadequate
analgesia
Step 2: coxib or nsNSAID
(make choice based on patient risk profile)
Inadequate
analgesia
Topical nsNSAID Step 3: add 1 of following:
Opioids
(with or without combined •Acetaminophen/codeine
(refer patient to pain clinic
oral acetaminophen, •Acetaminophen/tramadol
or specialist)
coxib or nsNSAID) •Tramadol
Coxib = COX-2 inhibitor; nsNSAID = non-specific non-steroidal anti-inflammatory drug
Ayad AE et al. J Int Med Red 2011; 39(4):1123-41.
23
 Recommendations for Management of
Acute Pain

Acetaminophen
If ineffective

Add nsNSAIDs/coxibs
If ineffective

Add opioids
(preferably short-acting agents at regular intervals;
ongoing need for such treatment requires reassessment)

Coxib = COX-2-specific inhibitor; nsNSAID = non-selective non-steroidal anti-inflammatory drug

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine.
Acute Pain Management: Scientific Evidence. 3rd ed. ANZCA & FPM; Melbourne, VIC: 2010.
 Ideal Characteristics for
Acute Analgesic Therapy
• Ideal drug characteristics for
acute pain therapy:

Rapid onset Limited

Long duration adverse
Effective analgesia effects

Baumann TJ. In: DiPiro JT et al (eds). Pharmacotherapy: A Pathophysiologic Approach. 5th ed. McGraw-Hill; New York, NY: 2002.
 How do nsNSAIDs/coxibs work?
Arachidonic acid

COX-2 (induced by
COX-1 (constitutive)
inflammatory stimuli)

Coxibs BLOCK

BLOCK nsNSAIDs BLOCK

Prostaglandins Prostaglandins

Gastrointestinal
cytoprotection, Inflammation, pain, fever
platelet activity

Coxib = COX-2-specific inhibitor; NSAID = non-steroidal anti-inflammatory drug Pain relief

nsNSAID = non-specific non-steroidal anti-inflammatory drug
Gastrosource. Non-steroidal Anti-inflammatory Drug (NSAID)-Associated Upper Gastrointestinal
Side-Effects. Available at: http://www.gastrosource.com/11674565?itemId=11674565.
Accessed: December 4, 2010; Vane JR, Botting RM. Inflamm Res 1995;44(1):1-10.
Inhibisi COX oleh OAINS
pada sel darah manusia
 Paracetamol

Analgesik yang efektif untuk nyeri akut

Efek samping sebanding dengan placebo ( Level I [Cochrane Review]).

• Paracetamol + opioid  menurunkan penggunaan opioid

20%-30%, efek samping opioid kadang masih ditemukan
(Romsing et al, 2002 Level I).

• Paracetamol + NSAID : lebih efektif daripada paracetamol

saja
– Lebih unggul dibanding nsNSAID saja, namun hanya sedikit bukti
klinis yang menyatakan hal tsb (Hyllested et al, 2002 Level I; Romsing et al, 2002
Level I ).

(Acute Pain Management: Scientific Evidence, 3th Ed, 2010)

 Ns-NSAID

1. Efektif untuk mengobati nyeri akut post

operatif, LBP, kolik renal and dysmenorrhea primer
(Level I [Cochrane Review]).

2. Ns NSAID + opioid  menurunkan konsumsi

opioid dan insiden mual, muntah dan sedasi ( Level I).

(Acute Pain Management: Scientific Evidence, 3th Ed, 2010)

 COXIB

1. Coxib dan nsNSAID  analgetik yang efektif, memiliki efikasi yang

sama untuk nyeri akut (Level I) tetapi efek samping GI dari coxib lebih
rendah sebanyak ~50%. (Romsing & Moiniche, 2004 Level I, Roelofs et al, 2008 Level I).
2. Coxib preoperatif :
– Menurunkan nyeri post operatif dan menurunkan konsumsi opioid
(Straube et al, 2005 Level I6).

– Menurunkan insiden efek samping yang berkaitan dg opioid (Malan

et al, 2003 Level II; Gan et al, 2004 Level II)

(Acute Pain Management: Scientific Evidence, 3th Ed, 2010)

 COXIB: Gastrointestinal (cont)

• Komplikasi GI: berkurang dengan penggunaan coxib vs nsNSAID

(Moore et al, 2007 Level I).

• Strategi gastroprotektif terbaik: Coxib + PPI (Targownik et al, 2008 Level III-2;
Chan et al, 2007 Level II).

COXIB: Bone Healing (cont)

• Tidak ada bukti klinis yang signifikan yang menyatakan bahwa coxib
memiliki efek inhibisi terhadap penyembuhan tulang. (Gerstenfeld &
Einhorn, 2004; Bandolier, 2004).

(Acute Pain Management: Scientific Evidence, 3th Ed, 2010)

 KETOROLAC

• Merupakan salah satu NSAID, agen antiinflamasi dg

efek analgesik dan antipiretik, digunakan untuk
mengobati OA dan nyeri akut.
• Mekanisme : inhibisi terhadap COX-1 dan COX-2 
inhibisi sintesis PG
• Indikasi : manajemen jangka pendek nyeri sedang-
berat
• Dosis : 10-30 mg IM/IV setiap 4-6 hr jika dibutuhkan
 TRAMADOL
• Merupakan analgetik sentral yang bekerja sebagai
agonis reseptor µ (mu) opioid & menghambat
ambilan kembali serotonin & noradrenalin
• Efek samping: mual, muntah, pusing, mulut
kering, sedasi, sakit kepala
 TRAMADOL-PARACETAMOL
• Kombinasi tramadol/paracetamol 37.5mg/325mg
• Kerja cepat, durasi lebih lama, analgesik multimodal  lebih
efektif, karena mengaktivasi multiple pain-inhibitory pathways
• Digunakan untuk nyeri sedang-berat
• Insiden efek samping yg berkaitan dg opioid lebih sedikit
• Efektif untuk
– Nyeri akut post operasi minor, nyeri muskuloskeletal
(akut, subakut, maupun kronik), neuropati
diabetik, migrain
– Sbg analgetik tambahan untuk nyeri sedang berat pd
pasien OA, RA (disamping pemberian
nsaid&antirheumatic)
Dhillon S et al. Tramadol/paracetamol fixed-dose combination: a review of its use in the management of moderate to severe pain. Clin Drug Investig. 2010.
 DEXKETOPROFEN
• Antiinflamasi non steroid
• Dosis
 tablet 12.5 mg/4-6 jam atau 25 mg/8 jam, dosis
maksimal 75 mg/hari
 injeksi 3 x I ampul
• Cara kerja  menghambat produksi prostaglandin
• Digunakan untuk nyeri ringan - sedang
• Efektif untuk
– Nyeri akut muskuloskeletal
• Efek samping
• Pusing, mual, muntah, nyeri ulu hati,diare,
mengantuk
 1. Golongan COX 1
Efek Analgesik Kuat
Efek Samping Gastrointestinal BESAR

2. Golongan COX 2
Efek Anti Inflamasi Kuat
Efek Samping Cardiovascular BESAR

DEXKETOPROFEN
Efek Analgesik SETARA Cox 1
Efek Anti inflamasi SETARA Cox 2
Efek Samping GASTROINTESTINAL < Cox1
Efek Samping CARDIOVASCULAR < Cox2
Onset LEBIH CEPAT dari KETOPROFEN
 Upper GI bleed risks for ns-NSAIDs (cont)

Ibuprofen
Diclofenac
Sulindac
Naproxen
Indomethacin
Ketoprofen
Piroxicam
1 10
Relative risk for upper GI bleed/perforation
Compared with not taking NSAIDs

Hernández-Diaz & Garcia Rodríguez, Arch Intern Med 2000 160: 2093-2099
 Risk Factors for Gastrointestinal Complications
Associated with nsNSAIDs/Coxibs

History of GI bleeding/perforation
1
13.5
1
Concomitant use of anticoagulants 6.4
History of peptic ulcer
1
6.1
Age ≥60 years 2 5.5
Single or multiple use of NSAID 1 4.7
Helicobacter pylori infection
3
4.3
4
Use of low-dose ASA within 30 days 4.1
3
Alcohol abuse 2.4
Concomitant use of glucocorticoids 1 2.2
3
Smoking 2.0
0 5 10 15
Odds ratio/relative risk for ulcer complications

ASA = acetylsalicylic acid; coxib = COX-2-specific inhibitor; GI = gastrointestinal; NSAID = non-steroidal anti-inflammatory drug;
nsNSAID = non-specific non-steroidal anti-inflammatory drug; SSRI = selective serotonin reuptake inhibitor
1. Garcia Rodriguez LA, Jick H. Lancet 1994; 343(8900):769-72; 2. Gabriel SE et al. Ann Intern Med 1991; 115(10):787-96;
3. Bardou M. Barkun AN. Joint Bone Spine 2010; 77(1):6-12; 4. Garcia Rodríguez LA, Hernández-Díaz S. Arthritis Res 2001; 3(2):98-101.
 Efektivitas digambarkan
dengan nilai NNT

• Number Needed to Treat: jumlah pasien yang

harus mendapat terapi untuk pengurangan
nyeri >50% dari nyeri awal
• Lebih kecil lebih bagus
• Dasar pemilihan terapi: tipe nyeri,
akut/kronik, intensitas, komorbid
 BENEFITS
The 2007 Oxford league table of analgesic efficacy (commonly used analgesic doses)

(Acute Pain Management: Scientific Evidence, 3th Ed, 2010)

 Tindakan Invasif Minimal

• Injeksi steroid dan anestesi lokal

• Mulai dari injeksi di miofascial trigger point
sampai dengan radiofrekuensi untuk
penghilangan nyeri yang lebih persisten
• Sebelum operasi
• Pemilihan pasien hati-hati
 Terapi Non Farmakologik

• Teknik stimulasi kutaneus

• Teknik distraksi
• Teknik relaksasi
• Massage
• Tindakan fisioterapi dan rehabilitasi
• Akupuntur
 Cognitive Behavioral Interventions
for Acute Pain
Intervention Potential utility
Reassurance and • Evidence that information is effective in
provision of information reducing procedure-related pain is tentatively
supportive and not sufficient to
make recommendations
Relaxation training • Evidence is weak and inconsistent
Attentional techniques • Listening to music produces a small reduction
(e.g., imagery, distraction, in post-operative pain and opioid requirement
music therapy) • Immersive virtual reality distraction is effective
in reducing pain in some clinical situations
Hypnosis • Evidence of benefit is inconsistent
Coping methods/ • Training prior to surgery reduces pain, negative
behavioral instruction affect and analgesic use

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine.
Acute Pain Management: Scientific Evidence. 3rd ed. ANZCA & FPM; Melbourne, VIC: 2010.
 Hipnosis
Membayangkan
Plasebo
Musik/hiburan

Systemic
Opioid

Tricyclics
Anticonvulsan

NSAIDs

44
 Assessment Ulang

• Tergantung assessment awal

• Bila tidak nyeri, setelah 3 x 24 jam, atau
setelah prosedur
• Nyeri ringan, setiap 24 jam, atau pasca
intervensi
• Nyeri sedang, setiap shift, atau pasca
intervensi
• Nyeri berat, setiap jam, atau pasca intervensi
 Red Flags
untuk Nyeri Muskuloskeletal
• Usia lanjut dengan • Berkeringat
gejala nyeri onset baru • Disertai kelainan
• Nyeri malam hari neurologi
• Demam • Ada riwayat keganasan
sebelumnya

Littlejohn GO. R Coll Physicians Edinb 2005; 35(4):340-4.

 Acute Pain Evaluation and Treatment
Patient presenting with acute pain

Perform diagnostic evaluation

Perform assessments

Yes
Pain is severe/disabling: requires opioids Refer to specialist
No
Treat appropriately

Re-evaluate and adjust treatment if indicated

Ayad AE et al. J Int Med Res 2011; 39(4):1123-41.

 Multimodal Treatment of Pain Based on
Biopsychosocial Approach

Lifestyle management

Sleep hygiene Stress management

Interventional pain
Physical therapy Pharmacotherapy management

Occupational therapy

Education
Complementary therapies Biofeedback

Gatchel RJ et al. Psychol Bull 2007; 133(4):581-624; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.; National Academies
Press; Washington, DC: 2011; Mayo Foundation for Medical Education and Research. Comprehensive Pain Rehabilitation Center Program Guide. Mayo Clinic; Rochester, MN: 2006.
 Kesimpulan

• Nyeri adalah keluhan utama di pelayanan

kesehatan
• Terapi nyeri meliputi terapi farmaka dan
nonfarmaka
• Pilihan terapi farmaka adalah OAINS, opioid,
agonis opioid, anestesi, dan adjuvan
• Pilihan pengobatan disesuaikan dengan tipe
nyeri, intensitas, dan onset nyeri
KASUS
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Kasus 1

• 38 th
• 1HSMRS nyeri punggung
bawah + kedua bokong
• ROM terbatas, terutama pada
gerakan fleksi dan rotasi.
• Nyeri tekan diatas vertebra
lumbal 4-5 dan dibokong (+).
• NPS 5-6
• Suhu tubuh 37.5 C.
 P.1. Menurut Pendapat TS, bagaimana intensitas
nyeri pasien tersebut?
A. Nyeri ringan
B. Nyeri sedang
C. Nyeri berat
P2. Pemeriksaan penunjang yang dianjurkan:

A. Lumbal X-Ray
B. Lumbal CT Scan
C. Lumbal MRI
D. ENMG
E. Belum perlu
 Causes of Low Back Pain
• Lumbar “strain” or “sprain” : 70%
• Degenerative changes : 10%
• Herniated disk : 4%
• Osteoporosis compression fractures : 4%
• Spinal stenosis : 3%
• Spondylolisthesis : 2%
• Spondylolysis, diskogenic LBP
or other instability : 2%
• Traumatic fracture : < 1%
• Congenital disease : < 1%
• Cancer : 0.7%
• Inflammatory arthritis : 0.3%
• Infections : 0.01%
• “Psychological” : ?
(Stoltz, 2003)
 Red Flags
• Significant trauma history, or minor in older adults
• Nocturnal pain in supine position with history of cancer
• Bladder or bowel incontinence or dysfunction
• Constitutional symptoms:
• Fever / chills
• Weight loss
• Lymph node enlargement
• Risk factors for spinal infection
• Recent infection
• IV drug use
• Immunosuppression

• Major motor weakness

 P.3. Manakah terapi yang paling rasional?

A. Acetaminofen 3 x 1000 mg
B. K-diclofenac 2x 50 mg
C. Diazepam 3 x 2 mg
D. Morfin sulfat 2x10 mg
E. Metilpredisolon 8 mg-8mg-0mg
 Summary of Evidence on Medications
for Acute Low Back Pain (Chou & Huffman, 2007)
Drug Net Effective Inconsistency Overall Comments
Benefit vs. ? Quality of
Placebo? Evidence
Acetaminophen Moderate Unclear Some Good Few data on serious adverse events
inconsistency
Antidepressants No evidence No evidence No evidence No evidence -

Antiepileptic drugs No evidence No evidence No evidence No evidence Evaluated only in patients with
radicular LBP

Benzodiazepines Moderate Unable to Some Fair No reliable data on risks of abuse or

determine inconsistency addiction.
NSAIDs Moderate Yes No Good May cause serious gastrointestinal and
cardiovascular adverse event. Insufficient
evidence to judge benefits and harms of
aspirin and celecoxib for LBP
Opioids Moderate No evidence Not applicable Fair No reliable data on risks of abuse or
addiction
Skeletal Muscle Moderate Yes No Good Little evidence of antispasticity skeletal
Relaxant muscle relaxants baclofen and dantrolene
for LBP
Systemic Not Effective No No Fair Mostly evauated in patients with radicular
Corticosteroids LBP

Tramadol Unable to No evidence Not applicable Poor The only trial compared tramadol with an
estimate NSAID not available in US
 Kasus

• Jika pada pemeriksaan ditemukan:

– Nyeri tekan epigastrium (+).
– TD : 150/90
– Ureum: 28
– Creatinin : 2,5
– SGOT: 30
– SGPT: 28
 P.4. Pilihan NSAIDs yang paling rasional?

A. Ibuprofen 2-3 x 400 mg

B. K-Diclofenac 2x50 mg
C. Asam Mefenamat 3x500 mg
D. Paracetamol –Tramadol fixed dose
E. Celecoxib 2x200 mg
 P.5. Berapa lama pasien harus bedrest?

A. 1-2 hari
B. 5 hari
C. 1 minggu
D. 10 hari
E. Tidak perlu bedrest, langsung aktifitas
 P.6. Apakah boleh pijat?

A. Boleh
B. Tidak boleh
Semoga bermanfaat.