Last AR, Hulber K. Chronic Low Back Pain: Evaluation and Management. Am Fam Physician.

may reveal motor and sensory deficits in the distribution of a nerve root. In cervical radiculopathy, Spurlings test may elicit or reproduce symptoms radiating down the arm. In the case of lumbosacral radiculopathy, a Straight leg raise maneuver may exacerbate radiculopathic symptoms. Deep tendon reflexes may be diminished or absent in areas innervated by a particular nerve root. Little is known about the natural history of radiculopathy. The pathogenesis involves an inflammatory process initiated by nerve root compression. Radiography of the spine is usually the first diagnostic test ordered in patients who present with neck and back symptoms. MRI has become the method of choice for imaging to detect significant soft-tissue pathology, such as disc herniation. There are few controlled randomized studies comparing operative with nonoperative treatment for this condition. There is no clear evidence that surgical treatment provides better long-term outcomes than nonoperative measures. Initial treatment should be directed at reducing pain and inflammation. The treatment can begin with local icing, NSAIDs, and measures that reduce the forces compressing the nerve root: relative rest; avoiding positions that increase symptoms; manual traction; and, if necessary, mechanical traction. Epidural steroids have been used in patients whose conditions have not had satisfactory responses to medications, traction, and a well-designed physical therapy program. Patients whose condition fails to improve with a comprehensive rehabilitation program and selective injections should be offered a surgical evaluation. Generally, patients should show progressive improvement over the first 6-8 weeks with conservative treatment. If there is no significant improvement in this time frame, consider a surgical evaluation. Self assesment. 1. What is the definition of radiculopathy ? 2. Why it happened most often in cervical and lumbar spine ? 3. Explain the mechanism of radiculopathy 4. Explain the diagnostic work-up for radiculopathy Scenario : A 20 years old man, bodybuilder complaint low back pain suddenly after trained in fitness centre. The pain is radiating pain accompanied by paresthesia that spreading to the right lateral side of thigh ntill toe. There were no micturition and defection disturbances. Learning task : 1. What is the differential diagnosis of this patient? 2. If etiology of back pain in this patient is HNP hernia nukleus pulposus L4-L5, what is the symptoms and signs ? 3. What is diagnostic work-up for this patients ? 4. What is the management for this patients? Learning Resources : 1. Eubanks JD.Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms. Am Fam Physician. 2010;811:33-40

2. Last AR, Hulber K. Chronic Low Back Pain: Evaluation and Management. Am Fam Physician.

2009;7912:1067-1074 3. Taylor LP, Lemming SE. Neck and Back Pain. American Academy of Neurology. 4. Ropper AH, Samuels MA, Klein JP. Pain in the Back, Neck, and Extremities. Principles of Neurology 10th ed. 2014: 198-225 50 Faculty of Medicine Udayana University, DME ACUTE AND REFERED PAIN Dr.dr.Pt. Pramana, Sp.AN., KMN.,M.Kes. Aims Describe mechanism and function of pain Learning Outcomes Apply its concepts and principles in acute pain patient setting Curriculum Contents Describe basic mechanism of pain Describe neuronal circuit processing of pain Describe role of neurotransmitter in central and peripheral nervous system Abstracts Of Lectures Pain is a personal, subjective experience that involves sensory, emotional and behavioural factors associated with actual or potential tissue injury. What patients tell us about their pain can be very revealing, and an understanding of how the nervous system responds and adapts to pain in the short and long term is essential if we are to make sense of patients’ experiences. Although acute pain and associated responsescan be unpleasant and often debilitating, they serve importantadaptive purposes. They identify and localize noxious stimuli,initiate withdrawal responses that limit tissue injury, inhibitmobility thereby enhancing wound healing, and initiate motivationaland affective responses that modify future behavior. Nevertheless,intense and prolonged pain transmission, as well asanalgesic undermedication, can increase postsurgicaltraumaticmorbidity, delay recovery, and lead to development of chronicpain. The wide area of discomfort surrounding a wound, or even a wound that has healed long ago, such as an amputation stump, is a natural consequence of the plasticity of the nervous system. An understanding of the physiological basis of pain is helpful to the sufferer, and the professional who have to provide appropriate treatment. Understanding the anatomical pathways and neurochemicalmediators involved in noxious transmission and pain perception is key to optimizing the management of acute and chronicpain. According to the International Association for the Study of Pain IASP, pain is defined as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in term of such damage. “IASP 1979. With regard to a more recent classification, pain states maybe characterized as physiologic, inflammatory nociceptive, orneuropathic. Physiologic pain defines rapidly perceived nontraumaticdiscomfort of very short duration. Physiologic pain alertsthe individual to the presence of a potentially injurious environmentalstimulus, such as a hot object, and initiates withdrawalreflexes that prevent or minimize tissue injury.Nociceptive pain is defined as noxious perception resultingfrom cellular damage following surgical, traumatic, ordisease-related injuries. Nociceptive pain has also been termedinflammatory 6 because peripheral inflammation and inflammatorymediators play major roles inits initiation and development.In general, the intensity of nociceptive pain is proportional tothe magnitude of tissue damage and release of inflammatorymediators.Neuropathic pain is defined by the International Associationfor the Study of Pain as “pain initiated or caused by apathologic lesion or dysfunction” in peripheral nerves and CNS.Some authorities have suggested that any chronic pain stateassociated with structural 51 Faculty of Medicine Udayana University, DME remodeling or “plasticity” changesshould be characterized as neuropathic.Neuropathic painis usually constant and described as burning, electrical, lancinating,and shooting. Case A 45 years old woman was admitted to emergency unit with broken left lower arm and bruishing in her left foot due to motorcycle accident. She was fully conscious. She was crying for those pain. It was so painful, she told the physician at the emergency unit. She brought to the OR for close reduction and wound toilette under general anesthesia. The anesthesiologist gave some opioid analgesic and non steroid anti-inflamation drug post anesthesia. She looks comfortable in post anesthesia care unit and discharge at the same day. Learning Task Describe mechanismpathophysiology of pain in this patient? How should we manage the pain in this patient? What is the risk of under-treatment in the acute pain patients? Self Assesment What is meant by analgesia? What is the difference between analgesia anesthesia? What is hyperalgesia? What is a dysesthesia? What is neuroplasticity in pain and explain the mechanism? DAY 6 th June 2 nd 2016 NEUROPATHIC PAIN AND NEUROPATHY Dr.dr. Thomas Eko Purwata, Sp.S K, FAAN Aims : Know the current definition of neuropathic pain, the epidemiology, classification and etiological, anatomical or mechanism based of neuropathic pain. Clinical characteristic ,diagnostic work-up including history, clinical examination and treatment of neuropathic pain. Learning outcome 1. Definition Recognize that neuropathic pain is a consequence of injury or disease affeting the somatosensory system. 2. Epidemiology - Know that painful peripheral neuropathy is common complication in HIVAIDS, diabetes, alcoholism and vasculitis. - Know that 4 out of 5 patients with idiopathic polyneuropathy and 1 in 3 patients with Guillain Barré syndrome have neuropathic pain - Know that peripheral neuropathic is common after surgical procedure, as well as during treatment with chemotherapeutic agents. 52 Faculty of Medicine Udayana University, DME 3. Etiology. - Know the common causes for neural damaged and subsequent pain i.e.: metabolic disease, infection, ischemia, injury, entrapment, connective tissue disease, AIDS, malignancy, drugs and toxins. - Know that neuropathic pain may develop without any identifiable cause e.g., intercostal neuralgia, idiopathic polyneuropathy. - Know that painful neuropathy may be the first manifestation of a systemic disease. 4. Clinical characteristic of neuropathic pain - Know the common symptoms associated with neuropathic pain e.g., burning pain, electric shock-like pain, pain paroxysm, dysesthesia and paresthesia. - Know the common signs associated with neuropathic pain including positive mechanical and thermal allodynia and hyperalgesia, temporal and spatial summation, negative sensory loss, weakness and muscle atrophy and other signs neuroma signs, referred sensation, swelling, skin flare and discoloration, hyperhidrosis and trophic changes. - Know that the patient with neuropathic pain may have concomitant non-neuropathic pain. - Know that questionnaires have been developed to differentiate neuropathic pain from non- neuropathic pain, e.g., the LANSS Pain Scale and the Neuropathic Pain Questionnaire or to measure various characteristics, e.g., the Neuropathic Pain Scale and the Neuropathic Pain Inventory . 5. Pathological changes in nervous system - Know the pathological changes that occur the affected nerves e.g. Wallerian degeneration, sprouting and neuroma formation. 6. Know pathophysiological mechanisms in peripheral and central nervous system. 7. Know diagnostic work-up including history, clinical examination and treatment of neuropathic pain. Abstract . The new definition ofneuropathic painaccording International Association for Study of Pain IASP is a consequence of injury or disease affeting the somatosensory system. For the vast majority of neuropathic pain diagnostic entities, there is no precise information about percentage of subjects reporting neuropathic pain. However it has been estimated that about 5 of patient with traumatic injury suffer from pain. Further about 8 of stroke patients suffer from central neuropathic pain as do about 28 of patients with multiple sclerosis and about 75 of patients with syringomyelia. Neuropathic pains are classified according either to the etiological diagnosis of the neuropathy e.g., painful diabetic neuropathy, postherpetic neuralgia or post traumatic neuralgia, or to the anatomical site of the lesion e.g., central or peripheral pain. Basic research in animal models of neuropathic pain indicates that multiple pathophysiological mechanism may be at play in neuropathic pain condition. Clinical characteristic of neuropathic pain were varied. The common symptoms associated with neuropathic pain e.g., burning pain, electric shock-like pain, pain paroxysm, dysesthesia and paresthesia. The symptoms of neuropathic pain including positive mechanical and thermal allodynia and hyperalgesia, temporal and spatial summation, negative sensory loss, weakness and muscle atrophy and other signs neuroma signs, referred sensation, swelling, skin flare and discoloration, hyperhidrosis and trophic changes. Diagnostic work-up including collection of medical history, focused at exploring the onset of pain and posssible association with current diseases, trauma, surgery etc. 53 Faculty of Medicine Udayana University, DME Therapeutic intervention applied in neuropathic pain consist of pharmacological and non pharmacological approach. Common pharmacological approaches used for neuropathic pain including : sodium and calcium channel blocker, NMDA receptor blocker, anti depressant, anti convulsant and opioid. NSAID is not responsive for treatment neuropathic pain. Scenario A 55 years old man complaint parasthesia in both his legs accompanied by electric shock like pain especially in bed time. Patient refused use blanked when he sleeps although the weather is very cool , the reasons were he felt pain on his legs when contact with contact with blanked. Past history he has been suffering diabetes since 6 years ago, with un controlled blood glucose. Learning task : 1. What is the type of the pain in this patient ? 2. Describe the pathophysiology of the pain in this patient. 3. What is the management of this patient ? Self assesment. 1. What is the classification of neuropathic pain ? 2. Explain the mechanism of neuropathic pain 3. Explain the clinical manifestation of neuropathic pain 4. Explain the management of neuropathic pain Learning Resource : 1. Justins DM. Pain an Update Review. IASP Press, Seattle, 2005 2. Bonica Management of Pain, 2001 3. Loeser JD. The Kyoto protocol of IASP Basic Pain Terminology Pain 137 2008, 473-7 4. Mogil J. Pain 2010 an Updated Review. IASP Press, seattle, 2010. NEUROPATHY Dr.dr. Thomas Eko Purwata, Sp.SK, FAAN Aims : Know the current definition of neuropathy, the epidemiology, classification and etiological, anatomical or mechanism based of neuropathy. Clinical characteristic ,diagnostic work-up including history, clinical examination and treatment of neuropathy. Learning outcome: 1. To Describe the definition of neuropathy 2. To describe patophysiology of neuropathy 3. To describe diagnosis and differential diagnosis of neuropathy 4. To describe how to manage neuropathy Curiculum contens: 1. Epidemiology of neuropathy 2. Clinical presentation of neuropathy 54 Faculty of Medicine Udayana University, DME 3. Risk factor of neuropathy 4. Pathophysiology of neuropathy 5. Diagnosis and Differential diagnosis of neuropathy 6. Treatment of neuropathy Abstract Neuropathy is a general term that refers to diseases or malfunctions of the nerves. Any nerves at any location in the body can be damaged from injury or disease. Neuropathy is often classified according to the types or location of nerves that are affected. Neuropathy can also be classified according to the disease causing it. For example, neuropathy from the effects of diabetes is called diabetic neuropathy. Types of Neuropathy are Peripheral neuropathy: Peripheral neuropathy is when the nerve problem affects the nerves outside of the brain and spinal cord. These nerves are part of the peripheral nervous system. Accordingly, peripheral neuropathy is neuropathy that affects the nerves of the extremities- the toes, feet, legs, fingers, hands, and arms. The term proximal neuropathy has been used to refer to nerve damage that specifically causes pain in the thighs, hips, or buttocks.Cranial neuropathy: Cranial neuropathy occurs when any of the twelve cranial nerves nerves that exit from the brain directly are damaged. Two specific types of cranial neuropathy are optic neuropathy and auditory neuropathy. Optic neuropathy refers to damage or disease of the optic nerve that transmits visual signals from the retina of the eye to the brain. Auditory neuropathy involves the nerve that carries signals from the inner ear to the brain and is responsible for hearing.Autonomic neuropathy: Autonomic neuropathy is damage to the nerves of the involuntary nervous system, the nerves that control the heart and circulation including blood pressure, digestion, bowel and bladder function, the sexual response, and perspiration. Nerves in other organs may also be affected.Focal neuropathy: Focal neuropathy is neuropathy that is restricted to one nerve or group of nerves, or one area of the body. Symptoms of focal neuropathy usually appear suddenly CARPAL TUNNEL SYNDROME CTS, TARSAL TUNNEL SYNDROME AND PERONEAL PALSY dr. I.A. Sri Wijayanti, M.Biomed, Sp.S Aims: Describe pathophysiology, diagnosis, early management and referral patient with CTS Learning outcome: 1. To Describe the definition of CTS 2. To describe patophysiology of CTS 3. To describe diagnosis and differential diagnosis of CTS 4. To describe how to manage CTS Curiculum contens: 1. Epidemiology of CTS 2. Clinical presentation of CTS 3. Risk factor of CTS 4. Pathophysiology of CTS 5. Diagnosis and Differential diagnosis of CTS 6. Treatment of CTS 55 Faculty of Medicine Udayana University, DME Abstract of lecture Carpal Tunnel Syndrome CTS remains a puzzling and disabling condition present in 3.8 of the general population. CTS is the most well-known and frequent form of median nerve entrapment, and accounts for 90 of all entrapment neuropathies. The pathophysiology of CTS involves a combination of mechanical trauma, increased pressure and ischemic injury to the median nerve within the carpal tunnelThe various methods of diagnosis are explored; including nerve conduction studies, ultrasound, and magnetic resonance imaging. The treatment of CTS falls under two categories: conservative and surgical. The treatment of CTS falls under two categories: conservative and surgical Triggerscenario A woman25years old present withparasthesiain the fingers ofthe right handaccompanied bypain.Complaintsbecome worsenedat night. Learning Task. 1. What other symptom we should know to diagnose this case? 2. What could be the possible diagnosis? 3. What is the management of this patient? Self assesment. 1. What is the definition of CTS 2. Explain patophysiology of CTS 3. Explain the diagnosis and differential diagnosis of CTS 4. Explain the management of CTS Learning Resource : 1. Ibrahim., Khan W.S., Goddard N.,and P. Smitham, 2012. Carpal Tunnel Syndrome: A Review of the Recent Literature. The Open Orthopaedics Journal, 2012, 6, Suppl 1: M8 69-76. TARSAL TUNNEL SYNDROME dr. IA Sri WIjayanti, M. Biomed, Sp.S AIM: Describe the anatomy of tarsal tunnel, tibial and sural nerve, know the current definition of TTS, etiology, mechanism based of TTS, clinical characteristic, diagnostic work-up including history, clinical examination and early management of TTS. LEARNING OUTCOMES: 1. Know the anatomy of tarsal tunnel, tibial and sural nerve 2. Understand and be able explain etiology and mechanism based of TTS 3. Be able to explain a comprehensive history , clinical examination and assessment of patients with TTS. 2. Understand early management of TTS 56 Faculty of Medicine Udayana University, DME ABSTRACT The tarsal tunnel is a fibro-osseus space located posterior to the medial malleolus. Tarsal Tunnel Syndrome TTS is an entrapment neuropathy of the posterior tibial nerve under the flexor retinaculum of the medial ankle. It is probably uncommon, but is both misdiagnosed and unrecognized because of the vagaries of the symptoms and signs and the difficulties in electrodiagnostic confirmation. It can be confused with many sources of neuropathic and non-neuropathic foot pain or paresthesia. A Variety of test performed on physical exam as well as imaging studies improve the detection and diagnosis of TTS. Conservative therapy is initially employed in most cases without space occupying lesion. Good clinical outcomes are often reported with surgical release of the flexor retinaculum. SCENARIO A 39 years old female came to clinic with pain and burning of 5 months duration in her right ankle and sole. More recently, pain has occurred at rest waking her at night. She expressed losing ability to walk, if the pain continued to progress. LEARNING TASK 1. What other history taking, other symptoms that we should explore to diagnosis this case? 2. What other examination that we should do to diagnosis this case? 3. What could be the possible diagnosis? 4. What is management of this patient? SELF ASSESSMENT 1. What is the definition of TTS 2. Explain etiology and mechanism based of TTS 3. Explain the diagnostic work- up and differential diagnosis of TTS 4. Explain the treatment of TTS Learning resources Herskovitz S, Scelsa NS, Schaumburg HH. Focal Neuropathies: Nerve Injuries, Entrapments, and Other Mononeuropathies. In Peripheral Neuropathies in Clinical Practice. 2nd ed. Oxford University Press; 2010:chap 18. PERONEAL PALSY dr. IA Sri WIjayanti, M. Biomed, Sp.S AIM Describe the anatomy of peroneal nerve, know the current definition of peroneal nerve palsy, etiology, mechanism based of peroneal nerve palsy, clinical characteristic, diagnostic work-up including history, clinical examination and early management ofperoneal nerve palsy. LEARNING OUTCOMES: 1. Know the anatomy of peroneal nerve 2. Understand and be able explain etiology and mechanism based of peroneal nerve palsy 3. Be able to explain a comprehensive history , clinical examination and assessment of patients with peroneal nerve palsy. 57 Faculty of Medicine Udayana University, DME 4. Understand early management of peroneal nerve palsy ABSTRACT Peroneal nerve palsy is the most common entrapment neuropathy in the lower extremity. Most often, peroneal nerve palsy occurs at fibular neck, where the nerve is superficial and vulnerable to injury. Patients usually present with a foot drop and sensory disturbance over the lateral calf and the dorsum of foot. The most common site of injury is the fibular head, but focal neuropathies have also been reported at the level calf, ankle and foot. Electrophysiology can localize the level of the nerve palsy, reveal the underlying pathology, and establish the prognosis. SCENARIO A 45 years old male came to clinic with chief complaint of left leg pain. His symptoms began after she fell of on her left hip 3 months ago. He had some weakness when walking and his symptoms had progressed. The patient also complained of left-sided lower back and buttock pain with movement and intermittent “lightning bolt’ sensation to thighs. LEARNING TASK 1. What other history taking, other symptoms that we should explore to diagnosis this case? 2. What other examination that we should do to diagnosis this case? 3. What could be the possible diagnosis? 4. What is management of this patient? SELF ASSESSMENT 1. What is the definition of peroneal nerve palsy 5. Explain etiology and mechanism based of peroneal nerve palsy 6. Explain the diagnostic work- up and differential diagnosis of peroneal nerve palsy 7. Explain the treatment of peroneal nerve palsy Learning Resources 1. Herskovitz S, Scelsa NS, Schaumburg HH. Focal Neuropathies: Nerve Injuries, Entrapments, and Other Mononeuropathies. In Peripheral Neuropathies in Clinical Practice. 2nd ed. Oxford University Press; 2010:chap 18. 2. Masakado Y, Kawakami M, Suzuki K, Abe L, Ota T, Kimura A. Clinical Neurophysiology in The Diagnosis of Peroneal Nerve Palsy. 2008. Available at www.kjm.keio.ac.jppast57284 accessed 13 Mei 2016 DAY 7 th June 3 rd 2016 DEMENTIA ALZHEIMER Dr.dr. AA Putri Laksmidewi, Sp.S K Aims : Provide initial assessment and management, established tentative diagnosis and refer patient with Alzheimer Dementia AD and vascular dementia VaD Learning outcome : 58 Faculty of Medicine Udayana University, DME

1. Describe different types of dementia 2. Describe signs and symptoms of dementia