AĞRI 2012;24(3):97-103 REVIEW - DERLEME doi: 10.5505/agri.2012.46320 Evidence based rehabilitation in chronic pain syndromes Kronik ağrı sendromlarında kanıta dayalı rehabilitasyon Gülseren AKYÜZ, Özlem ÖZKÖK Summary Chronic pain syndrome (CPS) is a complex condition that presents a major challenge to physicians because of its unknown etiology and poor response to all kinds of therapies. It has been suggested that chronicity should be considered when pain persists longer than the acceptable healing time. The impact of chronic pain on patients’ lives varies from minor limitations to complete loss of independence. The rehabilitation in CPSs is multi-disciplinary and involves physical, occupational, and manual therapy, aquatherapy, cognitive/behavioral therapy, biofeedback, psychotherapy, and some new therapies. In recent years, the point of view in chronic pain management has changed substantially and CPS is managed best with a multidisciplinary approach, including a rehabilitative process. The treatment protocol should be planned and modified individually. A combination of several methods has been tried, but long-term evidence-based studies are needed for new treatment modalities. Key words: Chronic pain syndromes; new rehabilitative methods; pain rehabilitation. Özet Kronik ağrı sendromu kompleks bir durum olup etyolojisinin net olmaması ve değişik tedavilere iyi yanıt alınamaması ile hekimler tarafından büyük bir bilinmezlik olarak kabul görmektedir. Kronisite, beklenen iyileşme sürecinden sonra da ağrının devam etmesi şeklinde yorumlanır. Hastaların yaşamı üzerine kronik ağrının etkisi hafif kısıtlanmadan bağımsızlığın tümden kaybedilmesine kadar değişen bir yelpazede ortaya çıkar. Kronik ağrı sendromlarının rehabilitasyonu çok alanlı yaklaşım gerektirir ve fizyoterapi, uğraşı terapisi, manuel terapi, akuaterapi, bilişsel/davranışsal terapi, biofeedback, psikoterapi ve diğer birçok yeni tedavi yöntemini içerir. Son yıllarda, kronik ağrı tedavisine bakış büyük oranda değişmiş ve en iyi yaklaşımın çok alanlı olduğu, rehabilitatif sürecin tedaviye dahil edilmesi gerektiği anlaşılmıştır. Tedavi protokolü bireysel olarak planlanmalı ve gerektiğinde modifiye edilmelidir. Birçok metodun kombine edilmesi söz konusu ise de özellikle yeni tedavi seçenekleri üzerinde uzun dönemde yapılmış kanıta dayalı çalışmalara ihtiyaç vardır. Anahtar sözcükler: Kronik ağrı sendromları; yeni rehabilitatif yöntemler; ağrı rehabilitasyonu. Department of Physical Medicine and Rehabilitation, Marmara University Faculty of Medicine, Istanbul, Turkey Marmara Üniversitesi Tıp Fakültesi, Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı, İstanbul Submitted (Başvuru tarihi) 28.11.2011 Accepted after revision (Düzeltme sonrası kabul tarihi) 24.05.2012 Correspondence (İletişim): Dr. Gülseren Akyüz. Cafer Ağa Mah., Şair Latifi Sok., Aksu Apt., No: 19/5 Kadıköy, İstanbul, Turkey. Tel: +90 - 216 - 657 06 06 / 1628 e-mail (e-posta): [email protected] TEMMUZ - JULY 2012 97 AĞRI Introduction CPS. CPS patients typically have reduced physical Pain is one of the most popular titles of medicine activity, impaired sleep, depressive symptoms, social that can be classified according to neurophysiologi- withdrawal, fatigue, strong somatic focus, memory cal mechanisms, duration, etiology, region and a lot and cognitive impairments, less interest in sex, rela- of other properties. There is no standardization in tionship problems, medication abuse, helplessness, any of these classifications. When the duration is hopelessness, alcohol addiction, guiltiness, anxiety, taken into account, pain can be categorized as acute poor self-esteem and loss of employment. Each and chronic pain. Acute pain which is a symptom of patient can be unique in the distribution of these a medical problem, has been seen as a vital protec- symptoms and conditions. tive mechanism. On the contrary, chronic pain is a useless and unpleasant condition. There are several Pain rehabilitation expectations for the duration of chronic pain in dif- Rehabilitation in CPS requires a multidisciplinary ferent resources. International Association for the approach. The physician should evaluate the pa- Study of Pain (IASP) determined the time limita- tients with CPS not only for pain but also physical, tion of chronic pain as 3 months. However, chronic social and psychological aspects of the patient.[4] pain is not a symptom, it is a syndrome. It has been shown that duration is not important in patho- In the rehabilitation process we aim to; physiology because chronic pain response can occur • Improve physical abilities (e.g., increase range even in a short period. This situation that develops of motion, standing, walking) independent of duration is not a protective reaction • Prevent further loss of function, as acute pain is. Chronic pain is also independent • Increase functional independence (e.g., increase of tissue damage. So the pathophysiology of chron- activities of daily living, social-recreational ac- ic pain is multifactorial and little is known in the tivities, home-domestic activities), transition from acute to chronic pain. Chronic pain • Maintain quality of life, syndrome (CPS) is a complicated situation. There • Improve the vocational/disability status (e.g., are a lot of neurophysiological studies about the return to work, start job retraining), [1] conduction of pain. It is concerned with multiple • Reduce/discontinue opiate and sedative-hyp- factors. If a patient does not improve himself despite notic medications, a proper medical treatment or if his pain behavior, • Decrease healthcare utilization for the CPS exaggerate over the expected response, we should (e.g., reduce medical procedures, inpatient ad- consider CPS. It has been suggested that CPS might missions, outpatient office visits) be a learned behavioral syndrome that occurring • Reduce the pain level.[5] from noxious stimuli. Patients with CPS demon- strate some typical characteristics which are called Providing the person highest possible level of func- [2] Sternbach’s 6 Dimensions. These typical charac- tion can only be possible with a team work. This teristics are; dramatization of complaints, drug mis- team includes physiatrist, physiotherapist, occupa- use or overuse, dysfunction, dependency, depression tional therapist, recreational therapist, speech thera- and disability. There are many CPSs in dealing with pist, nurse, social worker, psychologist, and consul- musculoskeletal, neurological systems, and visceral tant physicians if necessary. Each member of this organs, e.g. sometimes multiple contributing fac- team works in different components of pain reha- tors may be seen in the same patient. Fibromyalgia bilitation with leading of the physiatrist (Table 1). syndrome (FS), chronic fatigue syndrome (CFS), myofascial pain syndrome (MPS), osteoarthritis (OA), mechanical low back pain and chronic over- Physical therapy use syndromes are the most common musculoskel- Physical therapy has a wide variety of physiotherapy etal system disorders.[3] Indeed, the list is so long to techniques, ranging from heat or cold applications, demonstrate here but we should keep in mind that traction, massage, ultrasound (US) therapy, trans- all type of diseases have the potential to turn into cutaneous electrical nerve stimulation (TENS), 98 TEMMUZ - JULY 2012 Evidence based rehabilitation in chronic pain syndromes Table 1. Rehabilitation therapies physical function and pain in previously minimally active adults with FS.[12] Twenty eight RCTs com- Conventional and new rehabilitation techniques in the treatment of CPS paring aerobic exercises with controls and seven RCTs comparing different types of aerobic exercises Physical therapy with a total of 2.494 patients were reviewed. When Occupational therapy the efficacy of aerobic exercises were evaluated, the Manual therapy/ massage authors decided that an aerobic exercise program for Aquatherapy FS patients should consist of land-based or water- Biofeedback based exercises with slight to moderate intensity two Relaxation therapy or three times per week for at least 4 weeks. How- Cognitive behavioral therapy ever, the patients should be motivated to continue Psychotherapy the long term exercise program.[13] Other therapies There are many studies about the applications of physical agents in patients with MPS. Both di- stretching and strengthening exercises to manipula- clofenac phonophoresis and US have been found tions to alleviate pain, increase flexibility and muscle effective equally in the treatment of patients with strength and improve function.[6] MPS.[14] Ultrasound was also compared with isch- emic compression techniques for the treatment of When hot pack and TENS applications which are latent myofascial trigger points of trapezius muscle self-administered, safe and inexpensive in women in healthy subjects. At the end of the study, the au- with fibromyalgia were compared with each other, thors suggested that US was highly effective in the it was found that the efficacies of both of these mo- management of MPS.[15] When pharmacotherapy dalities were equal in temporary pain reduction.[7] and physiotherapy were compared in fibromyalgia Also different modalities of TENS have equal ef- [8] patients, it was found that amitriptyline and physio- fect on fibromyalgia patients. Acupuncture like therapy had equal efficacy in 6 month follow-up.[16] TENS application and stretch and spray technique In a study that was designed for CFS patients, that are both effective methods in the treatment of myo- [9] is