Gulseren Chronic Pain

8/7/2019 Gulseren Chronic Pain

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Chronic Pain Rehabilitation:

The Evidence?

Gulseren AKYUZ

MD

Professor, Chief of Department

of Physical Medicine &

Rehabilitation, Marmara

University, Istanbul TURKEY

Secretary General ofMediterranean Forum of Physical

Medicine and Rehabilitation

Interest: Algology/Pain rehabilitation

Clinical Neurophysiology

Osteoporosis

Cancer rehabilitation

Enjoys : Travel, sudoku Contact: [email protected]
mailto:[email protected]:[email protected]


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Chronic pain syndromes

Chronic pain syndrome (CPS) is a common problem that

presents a major challenge to healthcare providers

because of its complex natural history, unclear etiology,

and poor response to therapy

Most authors consider ongoing pain lasting longer than 6

months as diagnostic, and others have used 3 months as

the minimum criterion


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Sternbach's 6 D 's of CPS

Dramatization of complaints

Drug misuse

Dysfunction/disuse

Dependency

Depression

Disability

http://emedicine.medscape.com/article/310834-overview


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Classification of CPS

Fibromyalgia (FMS)

Chronic fatigue syndrome

(CFS)

Myofascial pain syndrome

(MPS)

Restless leg syndrome

Irritable colon syndrome

Irritable bladder syndrome

TMJ syndrome

Migraine

Primary dysmenorrhea

Chemical hypersensitivity

All type of diseases have the potential to turn to

chronic pain syndrome


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Common problems in CPS - I

Reduced activity

Impaired sleep

Depression Suicide attempts

Social withdrawal

Irritability and fatigue

Strong somatic focus

Memory problems Cognitive impairment

Less interest in sex


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Common problems in CPS - II

Guilty conscience

Anxiety

Poor self-esteem

Loss of employment

Kinesiophobia

Relationship problems

Medication abuse

Helplessness

Hopelessness

Alcohol abuse


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The goals of pain rehabilitation - I

Improvement of physical function (e.g., increase range ofmotion, standing, walking) and prevention further loss

Increase functional independence (e.g., increase activities of

daily living (ADLs), social - recreational activities, home -

domestic activities) Maintain quality of life for individuals living with CPS

Improvement of vocational/disability status (e.g., return to

work, start job retraining)

Evidence-based clinical practice guidelines for interdisciplinary rehabilitation of chronic

nonmalignant pain syndrome patients. Sanders SH, Harden RN, Vicente PJ. Pain Pract 2005

Dec;5(4):303-15. PubMed
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17177763http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17177763


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The goals of pain rehabilitation - II

Reduction/discontinuation of opiate and sedative-hypnotic medications

Reduction of healthcare utilization for the CPS (e.g.,

reduce medical procedures, inpatient admissions,

outpatient office visits) Reduction of pain level (e.g., reduce visual analogue scale

scores, verbal rating scores, verbal descriptor scores)

Evidence-based clinical practice guidelines for interdisciplinary rehabilitation of chronic

nonmalignant pain syndrome patients. Sanders SH, Harden RN, Vicente PJ. Pain Pract 2005

Dec;5(4):303-15. PubMed
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17177763http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17177763


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The Rehabilitation Team

Physiatrist

Physiotherapist

Occupational therapist

Swallowing therapist

Speech therapist

Nurse

Social worker

Psychologist

Consultant physicians


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Types of rehabilitation therapy

Physical therapy

Occupational therapy

Cognitive/psychological therapy

Speech/respiratory/recrational therapy

Social services therapy


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Phsical therapy - I

has a wide variety of techniques, ranging from soft tissue massage

to acupressure, to help restore and improve flexibility of muscles,

tendons, and joints

also uses various techniques for soft tissue healing, such as

hydrotherapy, electrical stimulation, application of cold or heat

through the use of shortwave diathermy, microwave, and US

FluidotherapyInfraredShort wave diathermy

US

TENS


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Phsical therapy - II

Therapeutic exercise is an important part of physical therapy,

helping to stretch and strengthen muscles and joints weakened by

disease and injury

Range of motion (ROM)

Stretching

Strengthening

General cardiovascular conditioning


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Relaxation therapy

beneficial to reduce anxiety, autonomic

hyperactivity, and muscle tension, all seen in

chronic pain states

techniques such as imagery, progressive musclerelaxation, controlled breathing, or listening to

relaxation tapes are commonly used in programs

designed to manage CPS


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Manual therapy

is defined as a clinical approach utilizing skilled, specifichands-on techniques, including but not limited to

manipulation/mobilization, used by the PT to diagnose and

treat soft tissues and joint structures for the purpose of

modulating pain increasing range of motion (ROM)

reducing or eliminating soft tissue inflammation

inducing relaxation

improving contractile and non-contractile tissue repair, extensibility

and/or stability

facilitating movement

improving function


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Massage Soft tissue mobilization

Various connective tissue techniques

Myofascial release

Craniosacral techniques

Mobilization of joints

Mobilization of neural tissue

Joint manuplation Visceral mobilization

Strain and counterstrain

The styles of manual therapy

Manuplation

Soft tissue mobilization

Massage


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Biofeedback

helps training patients toeliminate co-contraction, and

teaches them return their muscles

to electrical silence aftercontraction

In this technique, multiple musclesites are scanned and activity areas

are targeted for specific relaxationexercises


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Psychotherapy

Treat emotional, behavioral, or mental dysfunction

Remove negative symptoms such as anxiety or depression

Modify or reverse problem behaviors

Help the individual cope with situational crises such as bereavement, pain,

or prolonged medical illnesses

Improve the individual's relationships

Manage conflict

Enhance positive personality growth and development

There are a number of therapeutic approaches and techniques but all of

them try to establish a relationship between the therapist and theindividual who seeks to unlearn old or maladaptive patterns, gain insight,

and learn more effective patterns of thinking and behavior


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Cognitive behavioral therapy (CBT)

It is to identify and correct negative, distorted, or irrational thoughts that

have become "automatic" through repetition

Automatic thoughts occur when an individual is experiencing a particular

situation or is recalling significant events from the past

Individuals with depression and anxiety have many more negative orfearful automatic thoughts than others, and these distorted thoughts

usually cause painful emotional reactions

In addition, negative automatic thoughts can be associated with behaviors

(e.g., helplessness, withdrawal, or avoidance) that worsen the problem

Individuals with depression or anxiety disorders experience a repeatingcycle of problematic thoughts, emotions, and behaviors


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Current evidence about rehabilitation in

the treatment of chronic pain syndromes

Chronic pain

syndromes

Rehabilitation


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Recommend activity

Inform the patient

Manual therapy is effective Exercise;

Aerobic

Strecthing

Strengthening

Arrangement of movements

Postural control

Physical Activity and Exercise

NICE 2009-LBP


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Recommended

Acupuncture can be recommended

Performing local injection

Combine physical and psychological

approaches

NICE 2009-LBP


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Not Recommended

Laser therapy

Ultrasound

Interferential currents TENS

Traction

Orthosis

NICE 2009-LBP


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Van Tulder MW, Koes BW, Assendelft WJ, Bouter LM, Maljers LD, Driessen AP. Chronic low back pain:

exercise therapy, multidisciplinary programs, NSAID's, back schools and behavioral therapy effective;

traction not effective; results of systematic reviews. Ned Tijdschr Geneeskd. 2000 Jul 29;144(31):1489-94


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Primary care treatment recommendations for chronic

low back pain-I

Mayer JM,Haldeman S, Tricco AC,Dagenais S: Management of Chronic Low Back Pain in ActiveIndividuals. Curr Sports Med Rep 2010 9 (01) 0060-66


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Primary care treatment recommendations for chronic

low back pain-II

Mayer JM,Haldeman S, Tricco AC,Dagenais S: Management of Chronic Low Back Pain in ActiveIndividuals. Curr Sports Med Rep 2010 9 (01) 0060-66


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Levels of evidence and strength of

recommendations about Fibromyalgiasyndrome


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http://www.reproline.jhu.edu/english/2mnh/2ppts/evidence/gifs/slide6.gif


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Fibromyalgia - Pain

Eur J Pain 2010 14 (01) 0005-10


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Effect of amitriptyline vs. physiotherapy in

management of fibromyalgia syndrome

Therapy with amitriptyline or

physiotherapy is equally

effective in improving outcome

in patients of fibromyalgia over

a period of six months

Joshi MN, Joshi R, Jain AP. Effect of amitriptyline vs. physiotherapy in management of

fibromyalgia syndrome: What predicts a clinical benefit? J Postgrad Med. 2009 Jul-Sep;55(3):185-

9. PubMed PMID: 19884743.


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Comparison the efficacy of phonophoresis and

ultrasound therapy in myofascial pain syndrome

Ay et al found that bothdiclofenac

phonophoresis andultrasound therapywere effective in thetreatment of patients

with MPS

Ay S, Doan SK, Evcik D, Baer OC. Comparison the efficacy of phonophoresis and ultrasound therapy

in myofascial pain syndrome. Rheumatol Int. 2010 Mar 31


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Ultrasound therapy versus ischemic compression techniques for

the treatment of trapezius latent myofascial trigger points in

healthy subjects

Aguilera et al

recommended usingultrasound in management

of MPS

Aguilera FJ, Martn DP, Masanet RA, Botella AC, Soler LB, Morell FB. Immediate effect of ultrasound

and ischemic compression techniques for the treatment of trapezius latent myofascial trigger

points in healthy subjects: a randomized controlled study. J Manipulative Physiol Ther. 2009

Sep;32(7):515-20.


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Conclusion

In recent years point of view in chronic pain

rehabilitation changed substantially

Physical modalities seem to loose their importance

However, therapeutic exercises, aerobic physical

activities are in the most recommended preferences

Pharmacotherapy is not sufficient alone

Treatmet programmes should be planned

individually and should be modified if necessary


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Marmara University School of MedicineDept of PM&R, Istanbul, TURKEY

Gulseren Chronic Pain

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