Pain Rehabilitation

Husnul Mubarak, Sp.KFR

Fakultas Kedokteran – RS Pendidikan
Universitas Hasanuddin
Pain?
• An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage
• International Association for the Study of Pain

• Pain  Adaptive function  warning

system design to protect one from harm
• Subjective and personal, influenced by
multiple psychosocial variables.
• Acute pain  direct response to a
“noxious” event
• Chronic pain  involves more dynamic
interplay of psychological and behavioral
mechanism  underlying tissue pathology
less correlate to pain level
• Chronic pain multiple problems :
– unnecessary suffering, increase medical care use,
medication overuse, excess disability, comorbid
emotional problem, and increase economic cost.
• Rehabilitation approach  maximizing
independent physical functioning, improving
psychosocial state, returning patients to work or
previous leisure pursuits  reintegration to
community
 Assessment
• Pain evaluation involves
– Thorough physical examination
– Comprehensive evaluation of pain intensity
– Psychosocial factors related to pain
experience
– Interference with sleep, daily activities, family
life and employment
• History taking
– Pain description : quality, location, radiation,
intensity, onset, duration, frequency, pattern
of progression, aggravating/relieving factor,
previous tests result, treatment effects, and
other associated manifestations
– Mechanisms of injury
– Chronical medical problems
– Limitation in functional
– Dependency
• Intensity  Visual analogue scale (0-10
scale)
– McGill Pain Questionnaire SF  sensory,
affective, and evaluative
• Psychometric measure  mood, attitude,
beliefs, functional capacity, activity
interference, and personality traits
• Physical examination  identify related
impairments, pain behaviours, and
postural abnormalities
• Pain disorder criteria  pain is in
one/more anatomic sites, causes clinically
significant distress, psychological factors
judged to play important role, not
intentionally produced, not better
accounted for by another condition.
• Functional assessment  observe the
patient changing position, sitting, standing,
and walking. Identify whether pain
interfere with function.
• Independency level  Barthel Index
• Provocative tests  Straight leg raising,
Tinel’s sign, Finkelstein test, Empty can
test.
 Rehabilitation approach
• Begins with assumption all pains  real
• Treating underlying etiology
• Acute pain treatment principle 
discontinuing source of damage, resting
the damage part, pain-relieving modalities,
short term use of non-narcotic analgesics
(acetaminophens and NSAIDs), muscle
relaxants
• Protection
• Rest
• Icing
• Compression
• Elevation
 Rehabilitation p.o.v
• 3 stages of Acute pain recovery
– Stage 1 : pain relieve by physical modalities
 Cold therapy, heat therapy, electrotherapy,
or Laser therapy
– Stage 2 : regaining of normal muscle length
through ROM and flexibility exercises
– Stage 3 : Gradual muscle strengthening and
aerobic exercise.
• Preventive and ergonomic measure has to
be educated
• Prevent chronicity of pain
• Anticipating significant psychosocial
issues
 Chronic pain, rehab intervention?
• Can be caused by persistence of organic
pathology (i.e cancer pain) or other non-
malignant source  persistence of pain
perception despite recovery of tissue
damage (i.e chronic pain syndrome)
• The treatment goal is aimed at helping the
patient control or cope with the residual
pain
Original
Chronic pain cycle
Tissue
Damage Percepts
Injury/harm to
The body part(s)
Avoid any
Movement/activty
That cause pain
PAIN

Fearfull of moving
/simple ADL
Physical
deconditioning
Increase level
of inactivity
• Principle of treatment : emphasized in
mobilization of affected areas, the use of
behavioral management, and avoidance
addictive medication
• Patient educations
– Planned learning pain experiences +
facilitating them adopt and maintain good
heath-conducive behaviour
– Patient education enhance compliance to the
therapeutic regimens, produce physiologic
and immunologic changes  significant
improvements in health outcome
• …patient education :
– Ensure successful education :belief systems
about the disease and efficacy of treatment,
motivation, locus of control, skill necessary to
make behavioral changes, and reinforcing
factors.
– Should be focused not only on improving
knowledge but also on changing attitudes,
beliefs, and behabiors.
• Physical modalities
– Therapeutic heat (superficial/deep heating
agents)
– Therapeutic cold (cold pack, vapocoolabt
spray)
– Hydrotherapy
– Electrotherapy
– Low power laser
– Phonophoresis
• …Physical modalities
– Must be combined with more active exercises
– Pain masking modulation mechanisms
– Prevent cascade physiological consequences
that evoke pain
– No phys modalities are superior than one
another
• Orthoses, gait aid, adaptive devices
– Can be prescribed if a specific joint or limb
must be rested or protected due to tissue
damage
Orthoses Wrist-Finger Ortheses
• Therapeutic exercises
– Important adjunct in pain therapy
– Isometric contraction exercise can be initiated
early (combination of phys. Modalities)
– Gentle ROM exercise and flexibility started as
soon as inflammation subside
– Strengthening exercise can be started when
pain improves
– Relaxation exercises
• Therapeutic exercises
– Basic principle of “dosage”
– Type : Strengthening, flexibility, endurance
– Timing : when to do?
– Frequency : How often?
– Intensity : How hard?
Occupational therapist
• With chronic pain, the therapist also needs to set out a
gradual progression of activities focused on improving
function in ordinary daily activities such as walking,
sitting, standing, climbing stairs, lifting and carrying
• The therapists give reinforcement for activities done
appropriately and do their best to ignore and not
reinforce pain behaviors.
• to desensitize patients to the ordinary activities they
have become fearful of and shows them that they can
do more and improve without significantly aggravating
their symptoms.
• Oral and parenteral medication
– Analgesics : Acetaminophen, Tramadol,
NSAID, steroids, opioid
– Adjuvant analgesics : antidepressant,
neuroleptics, anticonvulsant
• Topical analgesics agents : NSAID, topical
local anaesthetics, capsaicin
• Psychosocial and self-regulation technique
– Psychosocial support
– Coping-skill training
– Vocational councelling
 Rehabilitation intervention on pain
• All programs is very tailored to patient
condition
– No program can be applicable to everyone
– Every patient is unique so are the programs
• Successful rehab program relies on proper
assessment, cooperative patients, and
solid rehabilitation team.