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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]8/7/2019 Gulseren Chronic Pain
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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=171777638/7/2019 Gulseren Chronic Pain
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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=171777638/7/2019 Gulseren Chronic Pain
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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