Neuralgia Trigeminal-English

TRIGEMINAL NEURALGIA – A DEBILITATING FACIAL PAIN dr. Hermilawaty Abubakar, SpKFR Instalasi Rehabilitasi Medik RSUD Undata

Trigeminal Neuralgia (TN) “ S u dd e n us ua l l y u ni l atera l s eve re , br i ef, sta b bi n g , re c u r re nt e pi s o d es o f p a i n i n t he d i s tr i b ut i o n o f o ne o r mo re bra n c he s o f t he t r i g em i n a l n e r v e ” (The International Association for The Study of Pain (IASP))

Trigeminal Neuralgia (TN) “A di s o rder c h a ra c ter i ze d by re cu r re nt u ni l atera l b r i ef el e c t r i c s ho c k - l i ke p a i n , a b r u pt i n o ns et a n d ter mi na ti o n, l i mi te d to t h e d i s tr i b uti o n o f o ne o r mo re d i v i s i o n s o f t he tr i g em i n a l ner ve a n d t r i g ge re d by i n n o c u o u s s t i m u l i ” (The International Classification of Headache Disorders)

Trigeminal Neuralgia (TN) • The most common diseases of cranial nerves • Most frequently diagnosed form of facial pain • Nicolaus Andre (1756): “tic douloureux” = the facial spasms accompany the attacks • Also known as : • Prosopalgia • Fothergill's Disease • Suicide Disease

Trigeminal Neuralgia (TN) • prevalence of 4 per 100,000 • higher incidence in females • peak incidence between 45 and 59 years • Decreasing the quality of life of the patients • Pokdi Nyeri Perdossi (2002) : di 14 rumah sakit pendidikan di seluruh Indonesia • 9,5% dari 4456 kasus nyeri merupakan kasus nyeri neuropatik yang merupakan gabungan nyeri neuropati diabetika, nyeri paska herpes, dan neuralgia trigeminal

Anatomy

Aetiology of Trigeminal Neuralgia (TN)

Most of patients TN  no identifiable cause Sabalys G; et al: Aetiology and Pathogenesis of Trigeminal Neuralgia: a Comprehensive Review, J Oral Maxillofac Res 2012 (Oct-Dec) | vol. 3 | No 4

Disease Characteristics • Intermittent, stabbing pain in at least one trigeminal nerve dermatome unilaterally • rare cases  from bilateral trigeminal neuralgia • The pain disease process normally affects the V2 and V3 distributions of suffering patients • autonomic symptoms occurred in 31% of patients with trigeminal neuralgia on the same side as the pain • conjunctival injection or tearing, miosis, ptosis, sweating, and clogged nose that occurs unilaterally with the intermittent pain • pain in the cheek, jaw, teeth, gums, and lips • tingling or numbness in the face before starting to feel pain

NT triggered by : • • • • • • • •

brushing teeth shaving rubbing touching the painful area of the face putting on makeup eating or drinking speaking being exposed to the wind

Diagnosis 1. Clinical 2. based on the International Classification of Headache Disorders

Jones M; et al : A Comprehensive Review of Trigeminal Neuralgia, Current Pain and Headache Reports (2019) 23: 74C

Magnetic Resonance Imaging (MRI) the most usefull imaging technique to determine the presence of lesions : • cysts or tumor • vascular malformations • plaque of multiple sclerosis • vascular compression of the trigeminal nerve.

International Classification of Headache Disorders edition 3 (ICHD-3) Diagnostic Criteria for Trigeminal Neuralgia

Lambru G, et al. Pract Neurol 2021;0:1–12. doi:10.1136/practneurol-2020

Differential Diagnose

Lambru G, et al. Pract Neurol 2021;0:1–12. doi:10.1136/practneurol-2020

Lambru G, et al. Pract Neurol 2021;0:1–12. doi:10.1136/practneurol-2020

International Dental Journal of Student Research; June 2016;4(2):79-82

Pharmacology Treatment

Lambru G, et al. Pract Neurol 2021;0:1–12. doi:10.1136/practneurol-2020

ELSEVEIR JOURNAL,WORLD NEUROSURGERY: X 6: 100070, APRIL 2020

Physical Medicine & Rehabilitation Programs The goal of Rehabilitation Programs : • • • • • •

Pain Relief Decrease pain frequency and severity of attack Eliminate perpetual fatique Lessen psychological distress Improve the ability to perform normal activities Improve quality of life

Consideration of Physical Medicine and Rehabilitation Programs • Effect of pharmaco therapy may be temporary and eliminate the symptom only for a short periode. • Surgery  have a lot side effect and the cost is not affordable to all patients. • Physical medicine and Rehabilitation program as non-invasive treatment in relieving the burden of symptom TN

Physical Medicine and Rehabilitation Modalities : 1. Transcutaneus Electrical Nerve Stimulation (TENS) • Reducing pain through: • nociceptive inhibition in the presynaps level in the dorsal horn • Endogenous pain inhibitory system (increasing endorphin and met-encephalin) • Gate control theory  preventing the central transmission of the nociceptive information to the cortex by stimulation of the large diameter afferent

• Application : • • • • •

Frequency 150 Hz Pulsed width 20 µs Intensitas executively set at subject sensory threshold Time 20 minute Self adhesive electrode pad site on the side of face of pain

2. Ultrasound Diathermy (USD) • Non thermal effect US • pulsed wave exposure  cavitation & acoustic streaming effect : anti inflammatory & tissue stimulating effects • Application : • • • •

Pulsed ratio 50% Intensity 50 w/cm2 Frequency 1 MHz Site : anterior to opening ear canal

3. Low Level LASER Therapy • • • •

Anti inflamatory Increase cell proliferation & collagen production Reduces prostaglandin E2 (PGE2) & Cyclooxygenase-2 (COX-2) in cell level Application : • Frequency 1500 Hz • Dose 2 J/cm2/point

4. Superfisial moist heat (Hot Pack)  to reduce muscular tension in cervical and Trapezius 5. Massage: Trapezius, Scalenus, SCM, Masseter, Temporalis Muscles, pterygoid • Relaxation reducing muscle tension to relief the pain

Zamani S, et al : Physiotherapy approachin Treatment NT , Journal of Clinical Physiotherapy Research, 2018

7. Exercises • • • •

Releasing endorphin Reliave stress Improve mood and sleep Biofeedback training due to perpetual tension in facial muscles  make patients aware of the abnormality activities of the facial muscles  to eliminate abnormal behaviour patterns • Stretching Exercises : Trapezius, Scalenus, SCM, flexor & extensor cervical muscles • Strenghening Exercise : Isometric strengthening  progressed to the resistive exercise

Zamani S, et al : Physiotherapy approachin Treatment NT , Journal of Clinical Physiotherapy Research, 2018

PROGNOSIS • TN is characterised by recurrences and remissions • Many people have periods of remission with no pain lasting months or years • but in many, TN becomes more severe and less responsive to treatment over time, despite increasing pharmacological intervention

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