PHTY209 Lecture 19: Pain management
Pain management
1. Demonstrate an ability to integrate the patient assessment into an appropriate
management plan using the concepts and strategies of clinical reasoning
o Perspectives/modals
• Condition specific (e.g. LBP, neuropathic pain, cancer pain, post-surgical pain)
▪ Will learn condition specific management throughout discipline specific
subjects.
▪ Guidelines in place for various areas: guidelines for those with pain of
recent onset, low back pain, cancer pain etc.
▪ For example
• European guidelines for the management of non-specific low
back pain
• WHO Normative Guidelines on Pain Management
• APA guidelines - Physiotherapy Management of Ankle Injuries in
Sport, Knee joint osteoarthritis, patellofemoral pain.
• Acute vs. Chronic pain
▪ In acute pain management:
• Goal of therapy aimed at pain reduction, decreasing peripheral
inflammatory processes, allowing healing and remodelling,
maintaining function and restoring strength, flexibility,
endurance
▪ In chronic pain management:
• Pain reduction but also restoration and promotion of optimal
physical function and improved quality of life in spite of pain.
• Using a biopsychosocial (BPS)approach/model
▪ Rx the biomedical (mechanical), physiological, and
social/environmental factors
▪ The ICF
• Promoting optimal function
• The range of factors influencing a person’s function will be
considered as treatment targets
• E.g. Fall on stairs resulting in LBP - client has restricted Lx
movement (body function and structure impairments)
• Fear of walking up and down stairs at home without rail
(activity limitations and participant restrictions – with
influence from contextual factors)
• Focus of Rx to incorporate this context
• Rx goals:
• Address restriction in movement and/or
• Discuss option of rail with OT
• Build patients confidence in climbing stairs without
rail
• Graded exposure, transfer of confidence to
other environmental situations.
• Deactivating/desensitising the systems
▪ Deactivating peripheral mechanisms of nociception
▪ Deactivating spinal mechanisms of nociception
▪ Deactivating brain mechanisms of nociception and pain
2. Develop a treatment plan based on the differences between acute and chronic pain
3. Identify the indications and evidence for and the proposed mechanisms underlying
commonly used interventions, including but not limited to exercise, manual therapy,
therapeutic movement, pacing and graded exposure, electrotherapeutic agents such as
TENS and graded motor imagery
o Acute pain mechanisms
• Peripheral nociception
• Spinal transmission of nociception at DHG
• Central perception of pain
• Peripheral dominant pain mechanisms
▪ Nociceptive pain
•
Inflammatory driven
•
Ischemic driven
▪ Peripheral sensitisation: well localised area of hyperalgesia
▪ Likely to be more associated with acute injury, with damaged and
healing tissues (inflammatory driven) and postural pain (ischemic
driven)
▪ It may also be part of the pain mechanisms in weakened and
deconditioned tissues, maladaptive movement patterns in chronic pain
states.
▪ Treatment techniques/Manual therapy/therapeutic exercise that has
effect on mechanical status of tissues should improve pain i.e. Reduce
the load, improve mobility (taping, stretching etc.)
▪ Deactivating peripheral mechanisms of nociception Management
Principles:
•
Address the tissues/inflammation
• RICE
• Passive movements
• Massage
• Promote gradual increase in movement and activity (within
a clinical reasoning framework – need to understand tissue
healing)
• Pharmacology: e.g. anti-inflammatory medication – advice
needs to be given from those with expertise and medico-
legal jurisdiction: “discuss with your GP or pharmacist”
•
Remove the peripheral irritant
• Treat the interface component of neurodynamics
• Reduce the muscle spasm/scar tissue
• Chronic pain - maladaptive adaptations keep the peripheral
nociceptive barrage going
• Changed posture
• Incorrect movement patterns (bending, getting out of chair)
• Muscle tension
• Extended bed rest/avoidance of activity = deconditioned
tissues – source of reinjury in the tissues
•
Consequently – address the peripheral sensitisation
• Centrally dominant pain mechanisms
▪ Need to consider if pain has a central component
•
Chronic pain
•
Neuropathic pain
•
Dysfunctional pain
▪ Pain started as soft tissue injury but persists beyond normal tissue
healing time
▪ Difficult to localise pain i.e. Diffuse pain, secondary hyperalgesia
(outside area of injury)
▪ Can be non-consistent in its behaviour (spontaneous or provoked)
▪ The stimulus intensity and sensation are often unrelated – allodynia.
▪ Consider brain’s involvement – facilitatory/inhibitory
▪ Psychosocial factors – fear, previous experiences, expectation,
emotions, distress, anxiety
▪ Lack of response to analgesics and NSAIDS
▪ History of failed treatments – locally applied (mechanically driven –
aimed solely at the tissues) treatments had little effect.
▪ Erratic response to Rx – something works one day and not next
(?psychosocial factors involved)
• Deactivating spinal mechanisms of nociception
▪ Modulation at the dorsal horn: Sensory information is received and
modified in the dorsal horn by competing stimulation and descending
control from the brain
▪ Therefore, use management principles that aim to:
•
Segmentally inhibit pain – at spinal cord level
•
Shift the balance of descending modulation towards inhibition.
▪ The ‘gate control theory’
▪ Supraspinal modulation of pain
▪ Management Principle: modulation at the dorsal horn
•
Modulation of transmission of nociceptive impulses by activity in
non-noxious mechanoreceptive fibres
•
Mechanoreceptors synapse in a pool of projection neurons which
can be inhibited by an interneuron
•
Activity in the nociceptive neurons disinhibits this projection neuron
and increases this projection neuron transmission
•
The activity in the mechanoneuron inhibits the projection neuron
further and decreases this transmission further
Document Summary
For example: european guidelines for the management of non-specific low back pain, who normative guidelines on pain management, apa guidelines - physiotherapy management of ankle injuries in. Sport, knee joint osteoarthritis, patellofemoral pain: acute vs. In acute pain management: goal of therapy aimed at pain reduction, decreasing peripheral inflammatory processes, allowing healing and remodelling, maintaining function and restoring strength, flexibility, endurance. Fall on stairs resulting in lbp - client has restricted lx movement (body function and structure impairments) Fear of walking up and down stairs at home without rail (activity limitations and participant restrictions with influence from contextual factors) Identify the indications and evidence for and the proposed mechanisms underlying commonly used interventions, including but not limited to exercise, manual therapy, therapeutic movement, pacing and graded exposure, electrotherapeutic agents such as. Tens and graded motor imagery: acute pain mechanisms, peripheral nociception, central perception of pain.
