NYOMAN KERTIA

Section of Rheumatology, Internal Medicine Department

Faculty of Medicine GMU / Dr. Sardjito General Hospital
LUMBOSACRAL SPONDYLOSIS
 LUMBOSACRAL SPONDYLOSIS
MAY CAUSE LOCALIZED LOW BACK PAIN
LBP INCREASES ET THE END OF THE DAY
AND RADIATES ACROSS THE LOW BACK
NARROWING OF THE SPINAL CANAL
SPINAL STENOSIS & COMPRESSION OF
NEURAL ELEMENTS
PAIN WORSENS WITH SPINAL EXTENSION
AND IPSILATERAL BENDING
RO: OSTEOPHYTE, FACET JOINT
NAROWING, PERIARTICULAR SCLEROSIS
SOME SOURCES OF LOW BACK PAIN
Posterior
Longitudinale
Ligament
Discus

Corpus
vertebrae Procesus
spinosus
Nucleus
Flavum
Annulus
Ligament

Joint
capsul

Spinal cordae and

Nerve capsule (dura)
OSTEOARTHRITIS
 Prevalence of Radiographic Evidence of
OA in the Population
70
60
Prevalence (%)

50
40
30
Knee, man
20 DIP, man

Knee, women
10
DIP, women
0
30 40 50 60 70
Age (years)
 PATHOGENESIS
CHANGES IN ARTICULAR CARTILAGE &
SUBCHONDRAL BONE
FAILURE OF CHONDROCYTES TO
MAINTAIN THE BALANCE BETWEEN
DEGRADATION AND SYNTHESIS OF
EXTRACELLULAR MATRIX
PROTEINASES AND PROINFLAMMATORY
CYTOKINES HAVE AN IMPORTANT ROLE
MECHANICAL STRESS CONTRIBUTES
SIGNIFICANTLY TO DISEASE INITIATION
& PROGRESSION
OSTEOARTHRITIS

ACRFP
INFLAMMATORY
ARTHROPATY
NORMAL versus OSTEOARTHRITIS

Normal Joint OA Joint

Thickness of Capsul
Capsul
Bone Cyst
Cartilage Subchondral
Sclerosis
Sinovium
Cartilage Fibrillation
Bone Sinovium Hypertrophy
Osteophyte Formation
 CLINICAL FEATURES
THE MOST COMMONLY AFFECTED ARE:
CERVICAL & LUMBAR SPINE, DIP, KNEE, HIP
STRONGLY AGED RELATED; ADDITIONAL
RISK: FEMALE, OBESITY, TRAUMA, FAMILY
HISTORY
SIGNS& SYMPTOMS: PAIN, SHORT-LASTING
STIFFNESS, CRACKING & CREPITUS, MILD
SWELLING, FUNCTIONAL LIMITATION
RADIOGRAPHS IS IMPORTANT IN MAKING
THE DIAGNOSIS
 ACR Guidlines
Drug Therapy Options in Osteoarthritis

Baseline program
(Weight loss / exercise)
Mild or moderate pain Moderate or severe pain
/ inflammation / inflammation

Acetaminophen Steroids COX-2 selective

intra articular Inhibitors NSAIDs

NSAIDs Hyaluronans Traditional NSAIDs

Tramadol intra articular ( plus gastroprotection)
Propoxyphene
Opioids
Surgery
 OSTEOPOROSIS
Osteoporosis is defined as a skeletal disorder
characterized by compromised bone strength
predisposing a person to an increased risk of fracture.
Bone strength primarily reflects the integration of
bone quantity and bone quality.

Normal Osteoporosis
NIH Consensus Development Panel on Osteoporosis. JAMA 285 (2001): 785-95
 Shifting the Osteoporosis Paradigm
Bone Strength
NIH Consensus Statement

Bone Bone Bone

Strength = Quality and Quantity

Architecture Bone size

Turnover rate Bone density
Damage Accumulation
Degree of Mineralization
Properties of the collagen/
mineral matrix
Adapted from NIH Consensus Development Panel on Osteoporosis. JAMA 285:785-95; 2001
 The Osteoporosis Continuum

Healthy Kyphotic
spine spine

50 Menopausal 55+ Postmenopausal 75+ Kyphotic

Experiencing At greater risk for vertebral At risk for
vasomotor fracture than any other hip fracture
symptoms type of fracture
Peak Bone Mass
 Bone Remodeling Process
Osteoclasts
Resorption
Cavities
Lining Cells

Bone

Lining Cells Osteoblasts

Mineralized Osteoid
Bone
 BONE REMODELLING/BONE TURN OVER
High Bone Turnover Leads to Development of Stress Risers and
Perforations
Osteoclasts

Lining
Cells

Bone

Perforations

Stress Risers
 Osteoporosis

Osteoblast

Osteoclast
 MANAGEMENT OF OSTEOPOROSIS
High risk population Minimally traumatic
fraktur or osteopenia

Change the life style

Diet, exercise,
avoid the cygarettes
Bone Densitometri

More than +1 SD +1 SD to 1 SD -1 SD to 2.5 SD Less than 2.5 SD

Repeat every 5 Repeat every 1 Estrogen/

years year SERM

Estrogen/ Bifosfonat Calcitriol Calcitonin

SERM
 DIFFERENTIAL DIAGNOSIS

INFLAMMATORY
VS DEGENERATIVE ARTHROPATY

RHEUMATOID ARTHRITIS OSTEOARTHRITIS

RHEUMATOID ARTHRITIS

ACRFP
SOFT TISSUE RHEUMATISM
CHEIROARTHROPATHY
TENDINITIS
BURSITIS
ANKYLOSING SPONDYLITIS
Non-pharmacologic Treatment Options for
Pain
Cognitive-Behavioral
Relaxation
Preparatory information
Imagery
Hypnosis
Physical Agents
Application of superficial heat and cold
Massage
Exercise
Immobilization
Electro-analgesia (eg, TENS)
Acupuncture
Carr DB, et al. AHCPR Pub. No. 92-0032. 1992.
 Pharmacologic Treatment
Options for Pain
Nonopioid analgesics
paracetamol
tramadol
anti-inflammatory agents
Opioid analgesics
Local anesthetics, nerve block
Co-analgesic such B-vitamin, anti-epilepticum
(carbamazephin, gabaphentin, pregabalin) &
tricyclic antidepressan
DMOADs (Disease Modifying Osteoarthritis Drugs)
SURGERY
 Weighing the Benefits and the Risks:
COX inhibitors
platelet
aggregation
COX-1
inhibitor
fewer heart attack Bleeding

platelet
bleeding
aggregation

Bleeding
more heart attack
COX-2
inhibitor
platelet
aggregation

 Hyaluronic acid

Bone

Cartilage
HA
Capsule
Chondrocytes

HA

Synovial
lining Osteoblast Osteoclast

Bone

Synthesis: Synoviocyte, chondrocyte

Hyaluronan works on cells that was involved in joint destruction

Hyaluronan

Inflammatory cells synoviocytes Chondrocytes

Decreases cells activity viscoinduction Improves cells metabolism

Neosynthesis of endogenous HA

JOINT CARTILAGE
Decreased inflammatory Reconstruction on Matrix synthesis
process supervicial level

Improves tissue integration

Pharmacologic activities of HA
 DIFFERENTIAL DIAGNOSIS
OF ARTHRITIS
ARTHRITIS

INFLAMMATION NO/MILD
INFLAMMATION
MONO/ OLYGO POLY
ARTICULAR ARTICULAR DEGENERATIVE

RECURRENCE SYMETRICAL NON-SYMETRICAL

GOUT, CPPD RA, SLE AS, Ps. A, REITER
NON- RECURRENCE
SEPTIC REMEMBER THE OTHER CLINICAL SIGNS,
SYMPTOMS AND LABORATORY RESULTS
Right Standing wrong

Right wrong
Sitting

Right Sleeping Wrong

BANYAK TERIMAKASIH

MATUR SEMBAH NUWUN

 CURRICULUM VITAE
DR. Dr. NYOMAN KERTIA SPPD-KR
LAHIR DI: BALI 16 SEPTEMBER 1960

RIWAYAT PENDIDIKAN
1987 DOKTER UMUM UNIV. UDAYANA
1998 INTERNIST UNIV. GADJAH MADA
1999-2001 PENDIDIKAN RHEUMATO - IMMUNOLOGY &
PHYTOPHARMACY ROYAL PERTH HOSPITAL
UNIVERSITY OF WESTERN AUSTRALIA
2000 KURSUS AKUPUNTUR DI BEIJING - CINA
2002 KONSULTAN REUMATOLOGI
2009 LULUS DOKTOR DI UNIVERSITAS GADJAH MADA

RIWAYAT PEKERJAAN
19998-2000 : PENELITI OBAT TRADISIONAL BADAN LITBANGKES DEPKES RI
2001-2004 : KEPALA BIDANG RISET KLINIK
PUSAT STUDI OBAT TRADISIONAL UNIV. GADJAH MADA
2003 SEKARANG : KEPALA. SUB.BAG. REUMATOLOGI
BAG IPD, FK-UGM / RS. DR. SARDJITO YOGYAKARTA
2004-2006 : PENELITI ETNOMEDICINE DAN OBAT ASLI INDONESIA
BADAN PENGAWAS OBAT DAN MAKANAN RI
2004- SEKARANG: STAF PENGAJAR FITOFARMAKA
FAKULTAS KEDOKTERAN UNIVERSITAS GADJAH MADA
2008-SEKARANG: KETUA TIM KEDOKTERAN HERBAL RSUP DR SARDJITO
2008-SEKARANG: KEPALA SENTRA PENGEMBANGAN DAN PENERAPAN
PENGOBATAN TRADISIONAL PROPINSI DAERAH ISTIMEWA
YOGYAKARTA
2010SEKARANG: KETUA KOMISI II DEWAN RISET DAERAH DIY
2010SEKARANG: ANGGOTA KOMISI NASIONAL SAINTIFIKASI JAMU

ORGANISASI

IDI, PAPDI, IRA, APLAR

IPS (Indonesian Pain Society)

IASP(International Association for the Study of Pain)