- Email: [email protected]
Pain and physical medicine
European Journal of Pain Supplements 3 (2009) 101–103
Contents lists available at ScienceDirect
European Journal of Pain Supplements journal homepage: www.EuropeanJournalPain.com
Pain and physical medicine Elena Dalla Toffola *,1, Maurizio Bejor 2 Department of Surgery, University of Pavia, 27100 Pavia, Italy Rehabilitation Department, University of Pavia, 27100 Pavia, Italy
a r t i c l e
i n f o
Article history: Received 12 May 2009 Received in revised form 10 August 2009 Accepted 24 August 2009
Keywords: Pain Rehabilitation Exercise Physical medicine
a b s t r a c t The first stage of any physical medicine intervention for a patient with pain is an accurate diagnosis. This allows a decision on the proposed therapy to be made according to the clinical picture. Recent classifications of pain allow us to divide pain management treatment into three specific groups, aimed at: (1) cancer pain, (2) pain (acute, sub-acute or chronic) as a symptom of a specific pathology, and (3) chronic non-malignant pain. In this article, we offer a summary of our clinical experience regarding the drafting of rehabilitation plans for patients with pain who have been referred to us. Published by Elsevier Ltd. on behalf of European Federation of International Association for the Study of Pain Chapters.
1. Introduction Referrals for rehabilitation assessments on patients with pain are very common, and usually require involvement of a number of health professionals in a well-designed and occasionally complex care plan. This complexity is reflected in the vast bibliography available: a Medline enquiry (April 2009), using ‘pain’ and ‘rehabilitation’ as key words, produced 3186 reviews, 20967 articles and 44 guidelines, whilst using ‘pain’ and ‘exercise’ produced 2195 reviews, 101 meta-analyses, 43 practical guidelines and 2938 randomised controlled clinical trials. A Cochrane Database search, using the argument treatment of pain in different conditions produced more than 10 systematic reviews. Despite the impressive amount of studies carried out, some difficulties in determining the effectiveness of rehabilitation interventions still need to be overcome: firstly, the lack of well-designed, prospective, randomised, controlled trials and secondly, no less important, the lack of research funding (Walsh et al., 2008). For this reason, management of painful conditions by the physical medicine team is not yet definitive. Although current evidence clearly supports the effectiveness and safety of moderate – to highintensity aerobic and strengthening exercises, no trials have addressed the optimal sequencing of therapies. In addition, methods
* Corresponding author. Address: Department of Surgery, University of Pavia, 27100 Pavia, Italy. E-mail address: [email protected] (E. Dalla Toffola). 1 IRCCS Fondazione Policlinico S.Matteo – Pavia. 2 Fondazione Don Gnocchi Salice Terme (Pavia).
for tailoring therapy to individual patients are still in the early stages of development (Schneider et al., 2008; Perret et al., 2006). The use of physical agents (magnets, TENS, traction, ultrasound and cold packs), water treatments (hydrotherapy, Spa Therapy), and physical aids (lumbar supports or other orthotics) in acute and chronic pain management programs is common. However, evidence supporting their effects is largely incomplete and sometimes contradictory, even though they have been reported as efficacious in some specific conditions (Allen, 2006). In this article, we offer a summary of our clinical experience regarding the drafting of rehabilitation plans for patients with pain who have been referred to us and, therefore, We will refer to just a few of the most recent articles.
2. Planning physical medicine interventions The first stage of any physical medicine intervention for a patient with pain is an accurate diagnosis. This allows a decision on the proposed therapy to be made according to the clinical picture (Saulino et al., 2008). Recent classifications of pain allow us to divide pain management treatment into three specific groups, aimed at: (1) cancer pain, (2) pain (acute, sub-acute or chronic) as a symptom of a specific pathology (therefore strongly related to the evolution of the illness), and (3) chronic non-malignant pain (different from symptomatic chronic pain both because its intensity is not strongly linked with either the severity of the underlying condition or the stage the illness has reached, and because it does not react well to standard treatments), which may be often an expression of Chronic Pain Syndrome (CPS).
1754-3207/$36.00 Published by Elsevier Ltd. on behalf of European Federation of International Association for the Study of Pain Chapters. doi:10.1016/j.eujps.2009.08.008
102
E. Dalla Toffola, M. Bejor / European Journal of Pain Supplements 3 (2009) 101–103
3. Interventions for patients with cancer pain The physical medicine specialist’s role in complex cancer pain management strategies is usually to suppress the causes of pain due to functional limitation. Functional limitation can be a result of either the illness itself, or the surgical/pharmacological interventions used in treating the underlying condition (Bausewein et al., 2008). Patients with cancer pain are usually given personalised rehabilitation care plans which range from short-term, to mediumor long-term (Solà et al., 2004). Short-term care plans are usually aimed at either preventing hypo mobility lesions (a syndrome of immobility), which develop as a result of general debility or the presence of weakness, or managing either post-surgical pain (for example shoulder pain following a mastectomy or a pneumonectomy) or pain from skeletal metastases. The techniques used in these care plans range from passive, active assistive and active mobilisation to respiratory re-education. Medium- and long-term care plans are usually aimed at managing pain both by compensating for the disability (using adaptive rehabilitation techniques), and by recovering motor function that can cause chronic pain (e.g. incorrect movement patterns following a mastectomy, or muscle contraction and limitation of joint mobility following orthopaedic surgery) (Markes et al., 2006).
4. Interventions for patients with acute, sub-acute or chronic symptomatic pain When dealing with acute and sub-acute pain associated with a specific illness, the most important step of the treatment process is to diagnose the illness, and thus the underlying cause of pain. Rehabilitation care plans are carried out alongside treatment for the illness itself (pharmacological, surgical or other). They are targeted at directly suppressing pain and reducing the disability. In order to determine the correct rehabilitation treatment, it is essential to perform a rehabilitative, functional and instrumental clinical assessment. The rehabilitation treatment will need to consider and identify the parts of the body affected, the possible biomechanical alterations (above all with degenerative illnesses), and determine whether the pain is associated with an existing phlogosis. Choosing the best rehabilitation treatment for persistent pain pathologies (resulting from both the locomotive apparatus and visceral syndromes such as pelvic pain (Montenegro et al., 2008) can be problematic due to difficulty in discriminating between two types of pain: nociceptive and neuropathic (Niederberger et al., 2008). Nociceptive pain is defined when the different nerve endings that respond to pressure, touch, heat, irritant chemicals or pain are stimulated or damaged and, for this reason, may be associated with actual or potential tissue damage, Neuropathic pain arises when the peripheral or central nervous system process somatosensory signals inappropriately and hyperalgesia and allodynia persist long after the initial noxa has disappeared. In disabling diseases showing anatomically defined lesion is not easy to decide if the lesion is still ‘‘active” in generating pain or not. Musculoskeletal illnesses, frequent in daily clinical practice, provide a model example showing how symptomatic pain can present itself as acute, sub-acute or chronic. In these cases, rehabilitation programs are probably the most effective tools in avoiding the passage from ‘‘symptomatic” pain to ‘‘illness” pain. The physical medicine clinical work-up of a patient with an osteoarticular illness should consider: – the joint/s affected by pain – any non-joint areas affected by pain – whether the pain is in the inflammatory phase or is dormant
– whether muscle weakness is present – whether bone deformities are present – whether there is swelling Limited passive range of motion (ROM) may be present due to mechanical obstacles resulting from joints deformations, or from muscle contractures occurring to reduce pain, or from disuse. Limited active ROM may be present due to muscle weakness, pain avoidance postures, or alterations in the subject loco motor patterns. In cases with mechanical limitation of joint mobility, rehabilitation should consist in determining the extent of movement without pain (possible therapies: postural and proprioceptive control, joint overload avoidance during activities of daily living, ergonomic aids) (Koldas et al., 2008; Shen et al., 2006; Jamtvedt et al., 2008; Bjordal et al., 2007; Minns et al., 2007). The presence of muscular contractures to reduce pain can be treated with muscle relaxant drugs, or with rehabilitation techniques: active relaxation, Thermotherapy (heat), exercises with load subtraction and hydrotherapy (Bender et al., 2005; Brosseau et al., 2003). Prolonged muscle contractures, which affect connective tissue, can be treated with physical therapy (ultrasound) and with positioning and stretching orthoses which are specifically designed not to cause pain (Wong et al., 2007). When treating a patient with pain as a symptom of a degenerative osteoarticular illness, it is essential to educate him or her to continue treatment at home. This can range from providing a personal handbook with instructions demonstrating how to carry out the exercises correctly, to periodically inviting the patient for reassessment. There are further interventions which can be carried out to reduce the static overload (weight loss) and the dynamic overload (learning how to move correctly), especially at neck and lower spine levels. Joint swelling requires very accurate diagnosis. Serous synovitis can be treated with evacuation and compressive bandaging. Physical therapy (magnetotherapy) and cryotherapy are common practice, especially in the acute and sub-acute phase. As osteodegenerative illnesses are generally associated with disuse, patients more commonly suffer from muscle weakness than from sub-acute or chronic pain. This can be treated with an appropriate muscle strengthening program (Marie et al., 2006). It is therefore fundamental to verify whether the weak muscle group is still acting within a correct motor pattern or not. If it is, a simple muscle strengthening program should suffice. However, if it is not, more demanding neuromotor re-education will be necessary.
5. Interventions for patients with chronic non-malignant pain and chronic pain syndrome Unsuccessful treatment of symptomatic acute or sub-acute pain can lead to chronic pain. Even though the new suggested definitions for chronic pain and acute pain are based on more than just time, when dealing with a patient with pain, it can still be useful to think of chronic pain as pain which persists even after the patient has undergone three months of therapy. This threemonth limit may seem arbitrary, but it can actually provide an opportune moment for a general reassessment of the patient’s care plan. This reassessment should not only consider which other physiotherapy techniques could be used to treat the patient, but it should also rethink the entire diagnostic process (Overton et al., 2008). This is because persistent chronic pain can lead to Chronic Pain Syndrome (CPS). The transition from a state of chronic pain to CPS is not easily perceptible because it is difficult to measure
E. Dalla Toffola, M. Bejor / European Journal of Pain Supplements 3 (2009) 101–103
pain intensity and to distinguish between pain avoidance postures and pain behaviour. If the patient has developed CPS, clinical reassessment of chronic pain will be redundant, and any further therapy will be doomed to fail (including surgery). CPS triggers a vicious circle: pain reduces movement, which in turn reduces muscular efficiency, which leads to physical decline, which eventually exacerbates the pain. Kinesiophobia is the term given to movement reduction and the tendency to avoid movement and it is rather common in several chronic pain conditions as fibromyalgia syndrome. It can be recognised and is maintained by many causative factors, the most relevant of which are depression and typical compulsive phobic behavioural changes. Rehabilitation intervention in these cases should obviously be multidimensional and multidisciplinary. However, exercise plays a topic role in an appropriate personal care plan. It is particularly important that the movement improvement gradually increases by means of a training program that should include the following characteristics: (a) recovery of the patient’s strength, flexibility and endurance, (b) awareness of the current physical condition of the patient and of possible comorbidity, which must be dealt with adequately, and (c) it should start slowly and be clearly-defined, particularly in terms of setting mobility goals and deadlines. Non-compliance with physiotherapy treatment is common, and there is a high rate of avoidance. Therefore, monitoring the course of the treatment to check whether patients achieve their goals must be accurately planned (Kornbluth et al., 2008). Sometimes goals have to be modified when the patient is unable to achieve them, or, in rarer cases, when the patient achieves them ahead of schedule. 6. Conclusion A carefully designed intervention plan must be always considered on an individual basis Even if a wide spectrum of physical medicine interventions may be considered when treating a painful patient it is possible to identify three main areas: (a) Rehabilitative interventions for patients with cancer pain aimed to suppress the causes of pain due to functional limitation (b) Rehabilitative interventions for patients with acute, subacute or chronic symptomatic pain associated with a specific illness. In this case the tecniques for restoring function losses must be associated and adapted to the treatment for the illness itself (pharmacological, surgical or other) (c) Rehabilitative intervention for patients with chronic nonmalignant pain and chronic pain syndrome. In this case the main target is often to restore motor function and mobility, in order to avoid Kinesiophobic behaviour. To reach this goal is often necessary a multidimensional evaluation and a multidisciplinary intervention that encompasses both physical and phsycological needs.
103
Conflict of interest statement None. References Allen RJ. Physical agents used in the management of chronic pain by physical therapists. Phys Med Rehabil Clin N Am 2006;17(2):315–45. Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev 2008;16(2). Bender T, Karagülle Z, Bálint GP, Gutenbrunner C, Bálint PV, Sukenik S. Hydrotherapy, balneotherapy, and spa treatment in pain management. Rheumatol Int 2005;25(3):220–4. Bjordal JM, Johnson MI, Lopes-Martins RAB, Bogen B, Chow R, Ljunggren AE. Shortterm efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials BMC Musculoskelet Disord; 2007. Brosseau L, Yonge KA, Welch V, Marchand S, Judd M, Wells GA, Tugwell P. Thermotherapy for treatment of osteoarthritis. Cochrane Database Syst Rev. 2003;(4), Article no. CD004522. doi:10.1002/14651858.CD004522. Koldasß Dog˘an S, Sonel Tur B, Kurtaisß Y, Atay MB. Comparison of three different approaches in the treatment of chronic low back pain. Clin Rheumatol 2008;27(7):873–81. Kornbluth ID, Freedman MK, Holding MY, Overton EA, Saulino MF. Interventions in chronic pain management. 4. Monitoring progress and compliance in chronic pain management. Arch Phys Med Rehabil 2008;89(3 Suppl 1):S51–5. Jamtvedt G, Dahm KT, Christie A, et al. Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther 2008;88:123–36. Marie D Westby, Linda Li. Physical therapy and exercise for arthritis: do they work? Geriatrics Aging 2006;9(9):624–30. Markes M, Brockow T, Resch KL. Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database Syst Rev 2006;(4), Article no. CD005001. doi:10.1002/14651858.CD005001.pub2. Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and metaanalysis of randomised controlled trials. BMJ 2007;335(7624):812. Montenegro MLLS, Vasconcelos ECLM, Candido dos Reis FJ, Nogueira AA, Poli-Neto OB. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract 2008;62(2):263–9. Niederberger E, Kühlein H, Geisslinger G. Update on the pathobiology of neuropathic pain. Expert Rev Proteomics 2008;5(6):799–818. Overton EA, Kornbluth ID, Saulino MF, Holding MY, Freedman MK. Interventions in Chronic Pain Management. 6. Interventional approaches to chronic pain management. Arch Phys Med Rehabil 2008;89(3 Suppl 1):S61–4. Perret DM, Rim J, Cristian A. A geriatrician’s guide to the use of the physical modalities in the treatment of pain and dysfunction. Clin Geriatr Med 2006;22(2):331–54. ix. Saulino MF, Kornbluth ID, Overton EO, Holding MY, Freedman MK. Interventions in chronic pain management. 3. Evaluation and management of lumbar pain syndromes. Arch Phys Med Rehabil 2008;89(3 Suppl 1):S47–50. Schneider H, Cristian A. Role of rehabilitation medicine in the management of pain in older adults. Clin Geriatr Med 2008;24(2):313–34. vii. Shen FH, Samartzis D, Andersson GB. Nonsurgical management of acute and chronic low back pain. J Am Acad Orthop Surg 2006;14(8):477–87. Solà I, Thompson EM, Subirana Casacuberta M, López C, Pascual A. Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database Syst Rev 2004;(4), Article no. CD004282. doi:10.1002/14651858.CD004282.pub2. Walsh NE, Brooks P, Hazes JM, Walsh RM, Dreinhöfer K, Woolf AD, et al. Bone and joint decade task force for standards of care for acute and chronic musculoskeletal pain. Standards of care for acute and chronic musculoskeletal pain: the bone and joint decade (2000–2010). Arch Phys Med Rehabil 2008;89(9):1830–45. Wong RA, Schumann B, Townsend R, Phelps CA. A survey of therapeutic ultrasound use by physical therapists who are orthopaedic certified specialists. Phys Ther. 2007;87(8):986–94.
Contents lists available at ScienceDirect
European Journal of Pain Supplements journal homepage: www.EuropeanJournalPain.com
Pain and physical medicine Elena Dalla Toffola *,1, Maurizio Bejor 2 Department of Surgery, University of Pavia, 27100 Pavia, Italy Rehabilitation Department, University of Pavia, 27100 Pavia, Italy
a r t i c l e
i n f o
Article history: Received 12 May 2009 Received in revised form 10 August 2009 Accepted 24 August 2009
Keywords: Pain Rehabilitation Exercise Physical medicine
a b s t r a c t The first stage of any physical medicine intervention for a patient with pain is an accurate diagnosis. This allows a decision on the proposed therapy to be made according to the clinical picture. Recent classifications of pain allow us to divide pain management treatment into three specific groups, aimed at: (1) cancer pain, (2) pain (acute, sub-acute or chronic) as a symptom of a specific pathology, and (3) chronic non-malignant pain. In this article, we offer a summary of our clinical experience regarding the drafting of rehabilitation plans for patients with pain who have been referred to us. Published by Elsevier Ltd. on behalf of European Federation of International Association for the Study of Pain Chapters.
1. Introduction Referrals for rehabilitation assessments on patients with pain are very common, and usually require involvement of a number of health professionals in a well-designed and occasionally complex care plan. This complexity is reflected in the vast bibliography available: a Medline enquiry (April 2009), using ‘pain’ and ‘rehabilitation’ as key words, produced 3186 reviews, 20967 articles and 44 guidelines, whilst using ‘pain’ and ‘exercise’ produced 2195 reviews, 101 meta-analyses, 43 practical guidelines and 2938 randomised controlled clinical trials. A Cochrane Database search, using the argument treatment of pain in different conditions produced more than 10 systematic reviews. Despite the impressive amount of studies carried out, some difficulties in determining the effectiveness of rehabilitation interventions still need to be overcome: firstly, the lack of well-designed, prospective, randomised, controlled trials and secondly, no less important, the lack of research funding (Walsh et al., 2008). For this reason, management of painful conditions by the physical medicine team is not yet definitive. Although current evidence clearly supports the effectiveness and safety of moderate – to highintensity aerobic and strengthening exercises, no trials have addressed the optimal sequencing of therapies. In addition, methods
* Corresponding author. Address: Department of Surgery, University of Pavia, 27100 Pavia, Italy. E-mail address: [email protected] (E. Dalla Toffola). 1 IRCCS Fondazione Policlinico S.Matteo – Pavia. 2 Fondazione Don Gnocchi Salice Terme (Pavia).
for tailoring therapy to individual patients are still in the early stages of development (Schneider et al., 2008; Perret et al., 2006). The use of physical agents (magnets, TENS, traction, ultrasound and cold packs), water treatments (hydrotherapy, Spa Therapy), and physical aids (lumbar supports or other orthotics) in acute and chronic pain management programs is common. However, evidence supporting their effects is largely incomplete and sometimes contradictory, even though they have been reported as efficacious in some specific conditions (Allen, 2006). In this article, we offer a summary of our clinical experience regarding the drafting of rehabilitation plans for patients with pain who have been referred to us and, therefore, We will refer to just a few of the most recent articles.
2. Planning physical medicine interventions The first stage of any physical medicine intervention for a patient with pain is an accurate diagnosis. This allows a decision on the proposed therapy to be made according to the clinical picture (Saulino et al., 2008). Recent classifications of pain allow us to divide pain management treatment into three specific groups, aimed at: (1) cancer pain, (2) pain (acute, sub-acute or chronic) as a symptom of a specific pathology (therefore strongly related to the evolution of the illness), and (3) chronic non-malignant pain (different from symptomatic chronic pain both because its intensity is not strongly linked with either the severity of the underlying condition or the stage the illness has reached, and because it does not react well to standard treatments), which may be often an expression of Chronic Pain Syndrome (CPS).
1754-3207/$36.00 Published by Elsevier Ltd. on behalf of European Federation of International Association for the Study of Pain Chapters. doi:10.1016/j.eujps.2009.08.008
102
E. Dalla Toffola, M. Bejor / European Journal of Pain Supplements 3 (2009) 101–103
3. Interventions for patients with cancer pain The physical medicine specialist’s role in complex cancer pain management strategies is usually to suppress the causes of pain due to functional limitation. Functional limitation can be a result of either the illness itself, or the surgical/pharmacological interventions used in treating the underlying condition (Bausewein et al., 2008). Patients with cancer pain are usually given personalised rehabilitation care plans which range from short-term, to mediumor long-term (Solà et al., 2004). Short-term care plans are usually aimed at either preventing hypo mobility lesions (a syndrome of immobility), which develop as a result of general debility or the presence of weakness, or managing either post-surgical pain (for example shoulder pain following a mastectomy or a pneumonectomy) or pain from skeletal metastases. The techniques used in these care plans range from passive, active assistive and active mobilisation to respiratory re-education. Medium- and long-term care plans are usually aimed at managing pain both by compensating for the disability (using adaptive rehabilitation techniques), and by recovering motor function that can cause chronic pain (e.g. incorrect movement patterns following a mastectomy, or muscle contraction and limitation of joint mobility following orthopaedic surgery) (Markes et al., 2006).
4. Interventions for patients with acute, sub-acute or chronic symptomatic pain When dealing with acute and sub-acute pain associated with a specific illness, the most important step of the treatment process is to diagnose the illness, and thus the underlying cause of pain. Rehabilitation care plans are carried out alongside treatment for the illness itself (pharmacological, surgical or other). They are targeted at directly suppressing pain and reducing the disability. In order to determine the correct rehabilitation treatment, it is essential to perform a rehabilitative, functional and instrumental clinical assessment. The rehabilitation treatment will need to consider and identify the parts of the body affected, the possible biomechanical alterations (above all with degenerative illnesses), and determine whether the pain is associated with an existing phlogosis. Choosing the best rehabilitation treatment for persistent pain pathologies (resulting from both the locomotive apparatus and visceral syndromes such as pelvic pain (Montenegro et al., 2008) can be problematic due to difficulty in discriminating between two types of pain: nociceptive and neuropathic (Niederberger et al., 2008). Nociceptive pain is defined when the different nerve endings that respond to pressure, touch, heat, irritant chemicals or pain are stimulated or damaged and, for this reason, may be associated with actual or potential tissue damage, Neuropathic pain arises when the peripheral or central nervous system process somatosensory signals inappropriately and hyperalgesia and allodynia persist long after the initial noxa has disappeared. In disabling diseases showing anatomically defined lesion is not easy to decide if the lesion is still ‘‘active” in generating pain or not. Musculoskeletal illnesses, frequent in daily clinical practice, provide a model example showing how symptomatic pain can present itself as acute, sub-acute or chronic. In these cases, rehabilitation programs are probably the most effective tools in avoiding the passage from ‘‘symptomatic” pain to ‘‘illness” pain. The physical medicine clinical work-up of a patient with an osteoarticular illness should consider: – the joint/s affected by pain – any non-joint areas affected by pain – whether the pain is in the inflammatory phase or is dormant
– whether muscle weakness is present – whether bone deformities are present – whether there is swelling Limited passive range of motion (ROM) may be present due to mechanical obstacles resulting from joints deformations, or from muscle contractures occurring to reduce pain, or from disuse. Limited active ROM may be present due to muscle weakness, pain avoidance postures, or alterations in the subject loco motor patterns. In cases with mechanical limitation of joint mobility, rehabilitation should consist in determining the extent of movement without pain (possible therapies: postural and proprioceptive control, joint overload avoidance during activities of daily living, ergonomic aids) (Koldas et al., 2008; Shen et al., 2006; Jamtvedt et al., 2008; Bjordal et al., 2007; Minns et al., 2007). The presence of muscular contractures to reduce pain can be treated with muscle relaxant drugs, or with rehabilitation techniques: active relaxation, Thermotherapy (heat), exercises with load subtraction and hydrotherapy (Bender et al., 2005; Brosseau et al., 2003). Prolonged muscle contractures, which affect connective tissue, can be treated with physical therapy (ultrasound) and with positioning and stretching orthoses which are specifically designed not to cause pain (Wong et al., 2007). When treating a patient with pain as a symptom of a degenerative osteoarticular illness, it is essential to educate him or her to continue treatment at home. This can range from providing a personal handbook with instructions demonstrating how to carry out the exercises correctly, to periodically inviting the patient for reassessment. There are further interventions which can be carried out to reduce the static overload (weight loss) and the dynamic overload (learning how to move correctly), especially at neck and lower spine levels. Joint swelling requires very accurate diagnosis. Serous synovitis can be treated with evacuation and compressive bandaging. Physical therapy (magnetotherapy) and cryotherapy are common practice, especially in the acute and sub-acute phase. As osteodegenerative illnesses are generally associated with disuse, patients more commonly suffer from muscle weakness than from sub-acute or chronic pain. This can be treated with an appropriate muscle strengthening program (Marie et al., 2006). It is therefore fundamental to verify whether the weak muscle group is still acting within a correct motor pattern or not. If it is, a simple muscle strengthening program should suffice. However, if it is not, more demanding neuromotor re-education will be necessary.
5. Interventions for patients with chronic non-malignant pain and chronic pain syndrome Unsuccessful treatment of symptomatic acute or sub-acute pain can lead to chronic pain. Even though the new suggested definitions for chronic pain and acute pain are based on more than just time, when dealing with a patient with pain, it can still be useful to think of chronic pain as pain which persists even after the patient has undergone three months of therapy. This threemonth limit may seem arbitrary, but it can actually provide an opportune moment for a general reassessment of the patient’s care plan. This reassessment should not only consider which other physiotherapy techniques could be used to treat the patient, but it should also rethink the entire diagnostic process (Overton et al., 2008). This is because persistent chronic pain can lead to Chronic Pain Syndrome (CPS). The transition from a state of chronic pain to CPS is not easily perceptible because it is difficult to measure
E. Dalla Toffola, M. Bejor / European Journal of Pain Supplements 3 (2009) 101–103
pain intensity and to distinguish between pain avoidance postures and pain behaviour. If the patient has developed CPS, clinical reassessment of chronic pain will be redundant, and any further therapy will be doomed to fail (including surgery). CPS triggers a vicious circle: pain reduces movement, which in turn reduces muscular efficiency, which leads to physical decline, which eventually exacerbates the pain. Kinesiophobia is the term given to movement reduction and the tendency to avoid movement and it is rather common in several chronic pain conditions as fibromyalgia syndrome. It can be recognised and is maintained by many causative factors, the most relevant of which are depression and typical compulsive phobic behavioural changes. Rehabilitation intervention in these cases should obviously be multidimensional and multidisciplinary. However, exercise plays a topic role in an appropriate personal care plan. It is particularly important that the movement improvement gradually increases by means of a training program that should include the following characteristics: (a) recovery of the patient’s strength, flexibility and endurance, (b) awareness of the current physical condition of the patient and of possible comorbidity, which must be dealt with adequately, and (c) it should start slowly and be clearly-defined, particularly in terms of setting mobility goals and deadlines. Non-compliance with physiotherapy treatment is common, and there is a high rate of avoidance. Therefore, monitoring the course of the treatment to check whether patients achieve their goals must be accurately planned (Kornbluth et al., 2008). Sometimes goals have to be modified when the patient is unable to achieve them, or, in rarer cases, when the patient achieves them ahead of schedule. 6. Conclusion A carefully designed intervention plan must be always considered on an individual basis Even if a wide spectrum of physical medicine interventions may be considered when treating a painful patient it is possible to identify three main areas: (a) Rehabilitative interventions for patients with cancer pain aimed to suppress the causes of pain due to functional limitation (b) Rehabilitative interventions for patients with acute, subacute or chronic symptomatic pain associated with a specific illness. In this case the tecniques for restoring function losses must be associated and adapted to the treatment for the illness itself (pharmacological, surgical or other) (c) Rehabilitative intervention for patients with chronic nonmalignant pain and chronic pain syndrome. In this case the main target is often to restore motor function and mobility, in order to avoid Kinesiophobic behaviour. To reach this goal is often necessary a multidimensional evaluation and a multidisciplinary intervention that encompasses both physical and phsycological needs.
103
Conflict of interest statement None. References Allen RJ. Physical agents used in the management of chronic pain by physical therapists. Phys Med Rehabil Clin N Am 2006;17(2):315–45. Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev 2008;16(2). Bender T, Karagülle Z, Bálint GP, Gutenbrunner C, Bálint PV, Sukenik S. Hydrotherapy, balneotherapy, and spa treatment in pain management. Rheumatol Int 2005;25(3):220–4. Bjordal JM, Johnson MI, Lopes-Martins RAB, Bogen B, Chow R, Ljunggren AE. Shortterm efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials BMC Musculoskelet Disord; 2007. Brosseau L, Yonge KA, Welch V, Marchand S, Judd M, Wells GA, Tugwell P. Thermotherapy for treatment of osteoarthritis. Cochrane Database Syst Rev. 2003;(4), Article no. CD004522. doi:10.1002/14651858.CD004522. Koldasß Dog˘an S, Sonel Tur B, Kurtaisß Y, Atay MB. Comparison of three different approaches in the treatment of chronic low back pain. Clin Rheumatol 2008;27(7):873–81. Kornbluth ID, Freedman MK, Holding MY, Overton EA, Saulino MF. Interventions in chronic pain management. 4. Monitoring progress and compliance in chronic pain management. Arch Phys Med Rehabil 2008;89(3 Suppl 1):S51–5. Jamtvedt G, Dahm KT, Christie A, et al. Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther 2008;88:123–36. Marie D Westby, Linda Li. Physical therapy and exercise for arthritis: do they work? Geriatrics Aging 2006;9(9):624–30. Markes M, Brockow T, Resch KL. Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database Syst Rev 2006;(4), Article no. CD005001. doi:10.1002/14651858.CD005001.pub2. Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and metaanalysis of randomised controlled trials. BMJ 2007;335(7624):812. Montenegro MLLS, Vasconcelos ECLM, Candido dos Reis FJ, Nogueira AA, Poli-Neto OB. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract 2008;62(2):263–9. Niederberger E, Kühlein H, Geisslinger G. Update on the pathobiology of neuropathic pain. Expert Rev Proteomics 2008;5(6):799–818. Overton EA, Kornbluth ID, Saulino MF, Holding MY, Freedman MK. Interventions in Chronic Pain Management. 6. Interventional approaches to chronic pain management. Arch Phys Med Rehabil 2008;89(3 Suppl 1):S61–4. Perret DM, Rim J, Cristian A. A geriatrician’s guide to the use of the physical modalities in the treatment of pain and dysfunction. Clin Geriatr Med 2006;22(2):331–54. ix. Saulino MF, Kornbluth ID, Overton EO, Holding MY, Freedman MK. Interventions in chronic pain management. 3. Evaluation and management of lumbar pain syndromes. Arch Phys Med Rehabil 2008;89(3 Suppl 1):S47–50. Schneider H, Cristian A. Role of rehabilitation medicine in the management of pain in older adults. Clin Geriatr Med 2008;24(2):313–34. vii. Shen FH, Samartzis D, Andersson GB. Nonsurgical management of acute and chronic low back pain. J Am Acad Orthop Surg 2006;14(8):477–87. Solà I, Thompson EM, Subirana Casacuberta M, López C, Pascual A. Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database Syst Rev 2004;(4), Article no. CD004282. doi:10.1002/14651858.CD004282.pub2. Walsh NE, Brooks P, Hazes JM, Walsh RM, Dreinhöfer K, Woolf AD, et al. Bone and joint decade task force for standards of care for acute and chronic musculoskeletal pain. Standards of care for acute and chronic musculoskeletal pain: the bone and joint decade (2000–2010). Arch Phys Med Rehabil 2008;89(9):1830–45. Wong RA, Schumann B, Townsend R, Phelps CA. A survey of therapeutic ultrasound use by physical therapists who are orthopaedic certified specialists. Phys Ther. 2007;87(8):986–94.