MODUL NYERI EKSTREMITAS Moh Adib Khumaidi, Dr , SpOT 1SKENARIO 2 Seorang laki-laki berumur 39 tahun dating ke poliklinik dengan keluhan nyeri pada bokong yang menjalar ke bagian posterolateral paha,tungkai bawah & tumit. Hal ini dirasakan sejak 5 hari yang lalu setelah penderita mengangkat barang berat di kantor .Nyeri ini bertambah berat bila penderita duduk dan berkurang bila penderita berdiri atau berjalan.Pada pemeriksaan fisik ditemukan penurunan sensoris pada sisi lateral tungkai bawah dan kaki serta 3 jari lateral kaki kanan .reflex

SKENARIO 3 Laki-laki umur 36 tahun datang ke poliklinik dengan keluhan utama nyeri pada daerah siku kanan menjalar ke lengan bawah yang dirasakan sejak 9 bulan lalu. Keadaan ini dirasakan semakin bertambah berat terutama bila penderita memflexikan sikunya. Ada riwayat fraktur supracondylar pada waktu berusia 5 tahun. Pada siku kanan terlihat valgus deformitas, gangguan sensoris pada ujung jari kelingking. Atrophy otot pada -1w0eb-spaceI.

NYERI Postoperative pain is a complex of unpleasant sensory, emotional, and mental experiences associated with autonomic, psychological, and behavioral responses precipitated by the surgical injuryHenrik Kehlet, ACS Surgery 2003. 4IASP 1979 : Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Perlu kita sadari bahwa

Pain is always subjective. Many people report pain in the absence of tissue damage or any likely pathopysiological cause. If they regard their experience as pain and if they report it in the same way as pain caused by tissue damage, it should be accepted as pain.

NominalstimulusModulationModulationNyeri berawal dari adanya rangsang di perifer yang disebut nociception.

Rangsang yang disebabkan antara lain oleh kerusakan jaringan ini dihantarkan ke medula spinalis.

Jalur transmisi dari perifer ke dorsal horn (cornu posterior) menggunakan serat A-delta dan C untuk nyeri somatik dan serat afferent sympathetic untuk nyeri visceral

Situasi di perifer dapat diperberat oleh adanya prostaglandins, serotonin, bradykinin, nerve growth factor, histamine dan substance P serta aktifitas simpatetik lainnya PeripheralnervePeripheralnociceptorsnociceptionDi dorsal horn medula spinalis terjadi modulasi. Setelah modulasi di cornu posterior, signal naik ke atas melewati tractus spinothalamicus dan spinoreticularis ke hipothalamus, brain stem, formatio reticularis dan cortex cerebri. Proses pengolahan ini dapat berupa excitation atau inhibition.

Modulasi di dorsal horn (Rexed's laminae I to IV) mengikutsertakan substance P, enkephalins, somatostatin, neurotensin, gamma-amino-butyric acid (GABA), glutamic acid, angiotensin II, vasoactive intestinal polypeptide (VIP), cholecystokinin octapeptide (CCK-8). Dorsal HornSpinothalamictractSetelah modulasi di cornu posterior, signal naik ke atas melewati tractus spinothalamicus dan spinoreticularis ke hipothalamus, brain stem, formatio reticularis dan cortex cerebri.

Otak juga mengirim modulasi lagi melalui descending inhibitory pathway menuju dorsal horn. SpinothalamictractPainDorsal HornDescendingmodulationObat anestesia umumObat anestesia spesifikOpioid

Pain is always subjectivePotentiationReduced doses ofeach analgesicImproved pain relief due to synergistic or additive effectsMay reduce severity of side effects of each drugBenefits of Multimodal Pain Therapy11Kehlet H et al. Anesth Analog. 1993;77:1048-1056.MorphineNSAIDs,acetaminophen,nerve blocks11Multimodal therapy may be beneficial from both efficacy and safety/tolerability perspectives.1 The obvious benefit in the use of 2 or more analgesics with differing mechanisms of action for the treatment of pain is the additive or synergistic analgesia. Multimodal analgesia may allow the use of lower doses of each agent than would be used during monotherapy. The use of lower doses is particularly appealing for analgesics with significant or dose-limiting adverse effects, such as opioids1When used as part of a multimodal pain strategy, DYNASTAT (parecoxib sodium for injection) was shown to enhance the analgesic effect of morphine (vs morphine alone)2This multimodal approach works on different mechanisms of pain. For example, a COX-2 specific inhibitor, such as DYNASTAT, may be added to an opioid to reduce the amount of opioids needed to achieve pain control while enhancing pain relief over opioids alone. Reducing opioid use can be instrumental in reducing traditional opioid side effects3

References: 1. Kehlet H, Dahl JB. The value of multimodal or balanced analgesia in postoperative pain treatment. Anesth Analg. 1993;77:1048-1056. 2. Hubbard RC, Naumann TM, Traylor L, Dhadda S. Parecoxib sodium has opioid-sparing effects in patients undergoing total knee arthroplasty under spinal anaesthesia. Br J Anaesth. 2003;90:166-172. 3. Cousins N, Power I. Acute and postoperative pain. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed. Edinburgh, UK: Churchill Livingstone; 1999:447-491. paracetNSAIDCOX-2 InhibOpioidAnestetikaAnalgesic Ladder WHOUntuk Nyeri KankerBack Pain & Treatment ModalitiesOverviewBack pain affects most people at least once over their lifetime.It can be a cause for lost wages & productivityMost people will become better in 6 weeks

Anatomy The back is composed of vertebrae, muscles, ligaments, intervertebral disc,& nerves.There are 7 cervical, 12 thoracic, 5 lumbar & 5 coccygeal vertebraeSpinal cord has cervical lordosis, Thoracic kyphosis, & lumbar lordosis

Assessment of Low Back PainHistory & Physical: Nocturnal exacerbation occurs w tumors or inf, w benign causes like herniated disc pain improves w bed rest Limitation of spinal motion correlates with the presence of lower back disabilityPalpation: Gentle & systemic palpation of the back, coccyx, sacrum, levator ani, coccygeus, & piriformis ms, & associated ligament doneMuscle spasm: has localized tenderness, & increase in ms tone

Assessment of Back PainPain on percussion occurs with metastases or inf, does not occur w disc protrusion & spasmRadiological test: Plain Xrays show degenrative disc ds, spondylitis, compression fx, metabolic bone disorder, bone tumors, congenital anomalies & transitional vertebraeOblique view of lumbosacral level is used to visualize facet & sacroiliac jointFlexion-extension view is added when ever spinal instability suspected

Straight leg raising testStraight leg raising test should be performed to detect nerve root irritationEven with a soft tissue pain source, SLR can be used as an index of improvement A +ve crossed SLR test has the highest correlation w myelographic finding of a herniated disc

Causes of back painPain sensitive structures are the supporting bone, articulations, meninges, nerves, muscles, & aponeurosesVertebral body despite being short is actually a long bone with end plates of hard bone & a center of cancellous bone It is innervated by dorsal roots Periosteum is pain sensitive as is facet joint which have a capsule & meniscus richly innervated w nociceptors

Muscular PainMost back pains are caused by sprain or strain of the back muscles & ligamentsPain will be in discrete area & tender to touchIt is of aching quality & may involve muscle spasmPain not involved shooting pain

Spinal causesOsteoporosisOsteomylitisHerniated DiscSpondylolisthesisSpondylolysisFacet hypertrophyIschemia of the spinal cord

OsteoporosisOsteoporosis is painful due to microfractureAbsence of wt bearing due to bed ridden leads to demineralization & fx upon wt bearingPostmenopause & pt Rx with corticosteroid is at riskOther cond r/o w serum protein electrophoresis, sed rate, alkaline phosphatase, ca, x-rays.Rx Biphosphonate, raloxifene

OsteomyelitisVertebral osteomyelitis presents as subacute back pain that increases over days to weeksPain in low back if unRx focal weakness, bowel & bladder problem resultsMost common in lumbar spine in men over 50With AIDS younger men & cervical spine affected

OsteomyelitisIn immunocompetent hosts, Staphylococcus aureus inf most commonInf involves vertebral bodies, endplates, & disc spaces, spares post elementsIn rare cases actinomycosis or coccidiodomycosis, posterior elements involved & spine becomes unstableVertebral metastasesVertebral metastasis presents as localized, deep, aching, back painIf nerves are involved, pain occurs in neural distributionThoracic spine is most commonly affectedEpidural spinal cord compression is a medical emergency & pt may present with paraparesis, sensory loss, bowl & bladder involvementVertebral metastasesOn plain film earliest sign of spinal metastasis is erosion of pedicleOver time vertebral body begins to lose heightMRI reveals change in signal intensity in vertebral bodyAs tumor progresses, it may be seen invading epidural space & compressing spinal cord

Facet joint painThe vertebral bodies have 4 facet joint, 1 pair above & 1pair belowSynovial joints mean they have fluid with in themBack pain caused by arthritis of the facet joints is mostly midline & may spread to the back & to the flanksGets worse with bending backward & side to side

Herniated DiscIntervertebral disc consists of an outer fibrous body called the annulus fibrosus & an inner gel like substance called the nucleus pulposusIt acts as a shock absorber & spacer for the spine giving room for the intervertebral neural foramina which are portals for the exit of the spinal nervesThe nucleus pulposus contains noxious chemicals which can be irritating to nerves

Herniated disc-cont-The intervertebral discs lie between the vertebral bodies. In front is the ant. longitudinal ligament & behind the post. longitudinal ligament & behind that is spinal cord.Wear & tear can cause annulus fibrosus to weaken allowing bulges of nucleous pulposisThese bulges may protrude out enough to touch the spinal cord causing irritation to nervesThese large disc bulges are called herniation

Herniated DiscWith extreme forces these disc bulges may tear the annulus fibrosus & allow leakage of nucleus pulposusThis is observed as sudden sharp pain radiating down the legThe chemicals of nucleus pulposus can cause swelling of nerves resulting in constant burning pain termed lumbar radiculopathy or sciatica, pain radiating down the leg & feet

Types of Herniate DiscDisc degenerationDisc prolapseDisc extrusionDisc seqestration

Radiographic herniated disc

SpondylosisIt can be described as arthritis of the spineThe bony surfaces may become roughened & bony spurs may develop & intrude upon the spinal canal

SpondylolisthesisIt is a slippage of the vertebra upon one anotherThe vertebra are usually aligned so that each one is stacked like legos so that the spinal canal is a fairly straight tube

SpondylolithesisIf there is a slippage, the spinal canal has a kink & is a smaller in that areaWhen spinal stenosis occurs, it squeezes upon the spinal cordThis may cause irritation or ischemia of the spinal cord & lead to cramping or aching of the legs

Grades of Spondylolisthesis

Piriformis SyndromeIt is a syndrome of low back & leg pain due to ch. Contracture of the piriformis muscle that causes irritation of sciatic nGluteal pain radiates to sciatic nerveIt occurs by compression of nerve between ms. Or ms & pelvis

Buttock painCommon causes arePiriformis syndromeIschial tuberosity inj.Rupture of gluteal ms.

Piriformis SyndromeIt is also called hip pocket neuropathy or wallet neuritisPiriformis ms is flat, pyramidal ms that originates from ant surface of sacrum from S2-S4 & sacrotuberous lig passes through the upper part of greater sciatic notch, & inserts on superior surface of great trochanter

Treatment of Back PainWalking is best exercisePhysical therapy for core stabilizationSpinal manipulation & manual therapyAnalgesics like acetaminophen, NSAIDS, antidepressantsApplication of heat or iceAcupunctureCorticosteroid injections

Treatment of Chronic Back PainTreat the cause like in osteomylitis, surgery with antibiotics is usedVertebral metastasis will respond to high doses of dexamethasone, definitive treatment with radiation & surgeryOsteoporosis treated with Biphosphonate, RobaxifeneMuscle spasms may respond to ms relaxants

Back ExercisesAnkle pumpHeel slidesAbdominal contractionWall squatsHeel raisesStraight leg raisesKnee to chest stretchHamstring stretchExercises with swiss ball

Epidural steroid injectionEpidural space identified w loss of resistance tech or fluroscopy60-80 mg of triamcilone with 0.25% bupivacaine injected

Intradiscal electrothermic therapyIDET is done using fluoroscopy, a hollow needle containing flexible tube & heating element is inserted into spinal discThe catheter placed in a circle in the annular layer of disc & slowly heated to 194 deg.The heat is meant to destroy the nerve fibers & toughen the disc tissue, sealing any small tear

VertebroplastyUnder fluoroscopy, a hollow needle is inserted & a cement is injected to restore the vertebra

KyphoplastyIn kyphoplasty a ballon is inserted through the hollow needle into the fractured bone to restore the height & shape of the vertebra.Once the ballon is removed, the cement mixture is injected.

Kyphoplasty / Vertebroplasty

Spondylolithesis

DiscectomyA scope is inserted through a small cannula to inspect disc surfacePeri-annular fat is removed & small capillaries are cauterizedSmall nerves in the annular fat can be removed with peri-annular tissue

WHO Pain ladderStep 3: Opioids for moderate-to-severe pain +/- non-opioid +/-adjuvant therapy

Step 2: Opioids for mild- to-moderate pain +/- non-opioid +/- adjuvant therapy

Step 1: Non-opioid +/- adjuvant therapy

STEP 1STEP 2STEP 3GOAL:Freedom From PainPain PersistsPain PersistsWHO Pain LadderStep 1 Mild (pain rating 1-3) Non opioid + co-analgesics e.g. NSAID+TCA/membrane stabilizer/ms.relax.Step 2 Moderate (pain rating 4-6) Opioid + Non opioid + co-analgesics Lorcet + NSAID+TCA/memb. Stab./ms. Relax.Step 3 Severe ( pain rating 7-10) Pure opioids + non-opioids + co-analgesics e.g. Morphine SR + NSAID + above.

Opioid combination productsDrugOpioidNon-opioidDosesLortab (vicodin) Hydrocodone5 mgAPAP 500 mg1-2 q 4 hrs.Max. 8 tabs/dayLorcetHydrocodone 10 mgAPAP 650 mg1 q 4 hrs.Max. 6 tabs/dayTylenol # 3 Codeine 30 mgAPAP 300 mg1-2 q 4 hrs.Max. 13 tabs/dayNorcoHydrocodone 10 mgAPAP 325 mg1-2 q 4 hrs.Max. 12 tabs/dayPercocetOxycodone 5 mgAPAP 325 mg 1-2 q 4 hrs. Max. 12 tabs/dayTylox 5/500Oxycodone 5 mgAPAP 500 mg 1-2 q 4-6 hrs.Max. 8 tabs/dayAcetaminophen (Tylenol)MoA: Cox-3 inhibter of PG in the CNS & peripheral pain impulse Pain indication: Use alone for mild painDo not exceed 4 gms / dayLorcet 6 tabs/day= 60 mgs morphineLortab- 8 tabs / day=40 mgs morphineAdverse effects: -Lightheadedness, dizziness, hepatotoxicity with high doses & chronic useNSAIDSIndications: anti-inflammatory, antipyretic, analgesicAcetylsalicylic acid ( ASA ) irreversibly inhibits plateletSide effects: Reversible antiplatelet effect, minimal w/ non-acetylated salicylates ( eg Disalcid, Dolobid ) - GI ulceration, less w ibuprofen, etodolac, salsalate, nabumentone - Nephrotoxity caution in CHF, dehydratation, elderly - Hepatotoxicity: caution in elderly & alcoholics - Avoid in asthmatics & nasal polypsMechanism of ActionPhospholipids, released from cell membrane are cenverted to Arachidonic acid by phospholipase A2Arachidonic acid is acted by lipo-oxygenase to be converted to LeukotrienesCyclo-oxygenase acts on Arachidonic acid to form Prostaglandin endoperoxides which are converted to Prostaglandin G & by isomerase into Prostaglandin E2, Prostaglandin D2, & F2 alphaProstaglandin H is formed from prostaglandin endoperoxides & converted by Thromboxane to Thromboxane A2 & Thromboxane B2. Prostacyclin synthetase converts prostaglandin endoperoxides to Prostacyclin ( PGI )Co-analgesic Pain MedicationsAntiepileptics AntidepressantsMuscle RelaxantsAnestheticsCorticosteroidsPsychostimulantsSubstance P inhibitorsAlpha-2 agonistsNeurolepticsAntiarryhmicsBenzodiazepinesAntiepilepticsMOA: Block Na+ & Ca+ channels>>inhibits release of glutamate>> stabilizes neural memb.Uses: Trigeminal neuralgia, peripheral neuropathies, herpetic neuralgia, phantom limb pain, migraines.Aniepileptics: Gabapentin, Carbamazepines, topiramate, phenytoin, oxycarbamazepine, pregabalinComared to TCAs: -equally efficacious in painful DN -some AED may be more expensive - differences in safty profile - synergy with AED plus TCA Gabapentin (Neurontin)MOA: a 2-delta ca+ channel subunit modulatorUses: Peripheral neuropathic pain, phantom limb pain, CRPS, post herptic & trigeminal neuralgia.Doses: adjust for elderly & renal failure -range 300- 3600 mg /day divided in 3-4 doses Somnolance, dizziness, constipation, fatigue, peripheral edema, difficulty concentrating Pregabalin (Lyrica)MoA: a 2 delta Ca+ channel subunit modulatorPain uses: Diabetic & post herpetic neuropathic pain at doses 300-600 mgs/day divided 2-3 X.Other neuropathic pain conditions, fibromyalgia, generalized anxiety disorder.Compared to gabapentin:Bioavailability remains 90% at all dosesTime to effective dose (150-300mg/day) is 1-3daysClass v schedules drug.Carbamazepine ( Tegretol)MoA: Na+ & Ca+ channel blockadePain uses: trigeminal neuralgia, glossopharyngeal neuralgia, DPNDosing: 200-1000mg divided 2-3X (with food)Side effects: N & V, dizziness, sedation, transient leukopenia, hepatic toxicity, thrombocytopenia, diplopia, hyponatremia, rash, Steven-Johnsons syndrome.Tricyclic antidepressantsMoA: inhibits re-uptake of NE, SE, antihistaminePain indications: Painful neuropathies, Phantom limb pain, migraine preventionDose: start low & adjust every 2- 3 daysDrug interactions - caution with other anticholinergics/serotonergics - CYP2D6 substrate ( all TCAs) - CYP3A4 substrate ( Elavil )Choice of A TCAAmitriptyline ( Elavil) - most widely studied - more side effects- hang over effect.Doxepin ( Sinequan ) - similar to Elavil, but shorter duration of sedationDesipramine ( Norpramin ), Nortriptyline ( Pamelor) - may cause insomnia - less anticholinergic effect - Desipramine may cause orthostatic hypotension

TCA Side EffectsSide effectsBlurred visionCognitine changesConstipationDry mouthOrthostatic hypotentionSexual dysfunctionTachcardiaUrinary retention

Desipramine

Nortriptyline

Doxapin

AmitriptylineDuloxetine ( Cymbalta )MoA : Dual reuptake inhibitor ( NE & SE )Indications : Neuropathic pain, depressionDosage : 30 mgs PO qd to 60 mgs PO bidSide effects : nausea, dry mouth, constipation decreased appetite, dizziness, insomniaDrug interaction : CYPIA2 & 2D6 substrate SSRIs , quinidine, cimetidine, quinolenes, may increase duloxitine levels. - mod. Inhibitor of CYP2D6 increases TCAs, phenothiazine, type 1C antiarrythmias

Muscle RelaxantsHeterogenous group of medications: - Spasticity from upper motor neuron syndrome - Muscular pain & / or spasm from peripheral musculoskeletal condition. - Dose : may dose 6-8 hrs ATC or give more hs if daytime drowsiness does not resolve ( e.g. Flexaril 10-30 mg po qhs )Side effects:Drowsiness,dizziness,blurred visionDrug interaction: Other CNS depressantsMuscle RelaxantsSpasticity:Baclofen ( Lioresal )Tizanidine ( Zanaflex)Dantrolene ( Dantrium )Diazepam ( Valium )Muscular pain & spasm - Methcarbamol (Robaxin) - Cylobenzaprine(Flexaril) - Carisoprodal ( Soma ) - Baclofen ( Lioresal ) - Tizanidine ( Zanaflex )Muscle RelaxantsSpasticity:Baclofen ( Lioresal )Tizanidine ( Zanaflex)Dantrolene ( Dantrium )Diazepam ( Valium )Muscular pain & spasm - Methcarbamol (Robaxin) - Cylobenzaprine(Flexaril) - Carisoprodal ( Soma ) - Baclofen ( Lioresal ) - Tizanidine ( Zanaflex )Baclofen ( Lioresal )Baclofen ( Lioresal ) gaba b agonistIndications : Neuropathic pain, spasticitySide effects : less sedating, ms weaknessWith drawl syndrome: spasticity, hallucination, anxiety,seizure when doses 80 mgs/ day or intrathecal baclofen are stopped abruptly Flexeril ( Cyclobenzaprine )Indications : muscle spasms, neuropathic pain Side effects : CNS & anticholinergic effectDrug interactions : w/TCAs additive anticholinergic side effects, CYPIA2 substrateSystemic / Topical anesth.Lidocaine 5% patch apply to intact skin at most painful site, 1- 3 patches for 12 hrsIndications : Post-herpetic neuralgia, post thoracotomy, mastectomy, pain syndrome.Side effects : site irritation, dizziness, arrythmias Lidocaine cream 5% apply to affected area 3-4 X / day for short term use. Mexileteine 150 mg po bid adjust q 2-3 days upto 400 mgs / day - Indications : resistant neuropathic pain - Side effects : dizziness, tremor, GI upset, arrythmiasTramadol ( Ultram ) MoA : mu opioid receptors, NE & SE reuptake inhibitorsMixed mild to moderate painSide effects: dizziness, nausea, constipation, somnolence, sweating, pruritus, sz, serotonergic syndromeMaximum dose: 400 mg / day10-20% pt. lack CYP2D6 needed to form MI ( metabolite ) impact or efficacy & safetyDose conversion: 50 mg = codeine 30 mg.Botulinum Toxin A ( Botox )MoA : direct antinociceptive effects, prolonged ms relaxation by inhibition of acetylcholine release at the neuromuscular junctionIndications : Blephrospasm, facial wrinkles, ms spasmDuration of effect : 3 4 monthsSide effects: OpioidsMoA : agonist on mu, kappa, & delta receptorsMethadone: also NMDA receptor antagonist & NE/SE reuptake inhibitorIndications: Acute & ch Moderate to severe painFor most type of pain with limited use in - Neuropathic pain - Spinal cord compression - Bone painJEPITAN NERVUS ULNARIS PADA SENDI SIKUDisebut juga Cubital Tunnel SyndromeKarena tekanan pd bagian belakang epikondilus medialTersering kedua setelah carpal tunnel syndromeEtiologi Valgus sendi sikuFraktur kondilus lateral humeriTraksi yg berulangOsteoartritisosteofitGambaran klinisRasa tebal dan nyeri pd distribusi n. ulnarisGangguan gerakan halus pd jariHilangnya persarafan sensorisAtrofi dan kelemahan otot yg dipersarafiKulit yg dipersarafi menjadi keringTinels sign positifParalisis/tardy paralisis (lanjut)

Atrofi m. interossea dorsalis

Tinels sign

Kelemahan otot Pengobatan Operatif dg pembebasan atau tranposisi n. ulnarisTransposisi n. ulnaris

Transposisi n. ulnaris

JEPITAN NERVUS ULNARIS PD CABANG PALMAR BAGIAN PROKSIMALNama lain Ulnar Tunnel SyndromeJepitan pd Guyons canal yg dibentuk : - os hamatum - os pisiformis - lig pisohamatum Banyak pd laki-laki umur 40 thnGuyons canal

Etiologi Adanya riwayat trauma tanganBiasanya ditemukan adanya ganglion/lipomaAneurisma Hipertrofi m. palmaris brevisLipoma

Gambaran klinisKelemahan otot hipotenarAtrofi otot hipotenarGangguan sensoris pd 1 mdial jari tangan

Area sensoris n. ulnaris pd volar

Area sensoris n. ulnaris pd dorsum manus

Area persarafan n. ulnaris

Diagnosis Gambaran klinisEMG (electromyografi)EMG

Pengobatan Konservatif - imobilisasi - menghindarkan dari traumaOperatif untuk dekompresi

Dekompressi pd Guyons canalWhat is the name of our galaxy?The Milky Way90How many planets in the solar system have rings?Four planets.Jupiter, Saturn, Uranus, and Neptune all have rings.91What is inertia?All of the aboveThe speed at which an object fallsMeasurement of electrical resistanceA ratio between mass and velocityResistance to motion or changeA.B.C.D.E.92Match the device to what it measures:Stop WatchScaleThermometerSpeedometerOdometerDistanceTemperatureElapsed TimeWeightRate of Travel93