Chronic Pain Rehabilitation:

The Evidence?
• Professor, Chief of Department
of Physical Medicine &
Rehabilitation, Marmara
University, Istanbul TURKEY
• Secretary General of
Mediterranean Forum of Physical
Medicine and Rehabilitation
• Interest:
• Algology/Pain rehabilitation
• Clinical Neurophysiology
• Osteoporosis
Gulseren AKYUZ • Cancer rehabilitation
• Enjoys : Travel, sudoku
MD
• Contact: gulserena@gmail.com
 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
 Sternbach's 6 D 's of CPS

• Dramatization of complaints
• Drug misuse
• Dysfunction/disuse
• Dependency
• Depression
• Disability

http://emedicine.medscape.com/article/310834-overview
 Classification of CPS

• Fibromyalgia (FMS) • Irritable colon syndrome

• Chronic fatigue syndrome • Irritable bladder syndrome
(CFS) • TMJ syndrome
• Myofascial pain syndrome • Migraine
(MPS) • Primary dysmenorrhea
• Restless leg syndrome • Chemical hypersensitivity

All type of diseases have the potential to turn to

chronic pain syndrome
 Common problems in CPS - I

• Reduced activity • Irritability and fatigue

• Impaired sleep • Strong somatic focus
• Depression • Memory problems
• Suicide attempts • Cognitive impairment
• Social withdrawal • Less interest in sex
 Common problems in CPS - II

• Relationship problems • Guilty conscience

• Medication abuse • Anxiety
• Helplessness • Poor self-esteem
• Hopelessness • Loss of employment
• Alcohol abuse • Kinesiophobia
 The goals of pain rehabilitation - I
• Improvement of physical function (e.g., increase range of
motion, 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
 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
 The Rehabilitation Team
• Physiatrist
• Physiotherapist
• Occupational therapist
• Swallowing therapist
• Speech therapist
• Nurse
• Social worker
• Psychologist
• Consultant physicians
 Types of rehabilitation therapy
• Physical therapy
• Occupational therapy
• Cognitive/psychological therapy
• Speech/respiratory/recrational therapy
• Social services therapy
 Phsical therapy - I
• has a wide variety of techniques, ranging from soft tissue massage
to acupressure, to help restore and improve flexibility of muscles,
TENS 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

US

Short wave diathermy

Infrared Fluidotherapy
 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
 Relaxation therapy
• beneficial to reduce anxiety, autonomic
hyperactivity, and muscle tension, all seen in
chronic pain states
• techniques such as imagery, progressive muscle
relaxation, controlled breathing, or listening to
relaxation tapes are commonly used in programs
designed to manage CPS
 Manual therapy
• is defined as a clinical approach utilizing skilled, specific
hands-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
 The styles of manual therapy
• Massage
• Soft tissue mobilization
• Various connective tissue techniques
• Myofascial release
• Craniosacral techniques Manuplation
• Mobilization of joints
• Mobilization of neural tissue
• Joint manuplation
• Visceral mobilization Massage

• Strain and counterstrain

Soft tissue mobilization
 Biofeedback

• helps training patients to

eliminate co-contraction, and
teaches them return their muscles
to electrical silence after
contraction
• In this technique, multiple muscle
sites are scanned and activity areas
are targeted for specific relaxation
exercises
 Occupational therapy
• a rehabilitation process that helps individuals perform their
daily activities despite the presence of any illness, disability,
or injury
• The goal of occupational therapy is to help individuals with
compromised physical functioning adapt to their
impairment(s) to regain optimal function
• Three categories of activities are addressed by occupational
therapy:
– activities of daily living
– work and productive activities
– recreational or leisure activities
 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 the
individual who seeks to unlearn old or maladaptive patterns, gain insight,
and learn more effective patterns of thinking and behavior
 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 or
fearful 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 repeating
cycle of problematic thoughts, emotions, and behaviors
 Current evidence about rehabilitation in
the treatment of chronic pain syndromes

Rehabilitation

Chronic pain
syndromes
 Physical Activity and Exercise
• Recommend activity
• Inform the patient
• Manual therapy is effective
• Exercise;
– Aerobic
– Strecthing
– Strengthening
– Arrangement of movements
– Postural control NICE 2009-LBP
 Recommended
• Acupuncture can be recommended

• Performing local injection

• Combine physical and psychological

approaches

NICE 2009-LBP
 Not Recommended
• Laser therapy
• Ultrasound
• Interferential currents
• TENS
• Traction
• Orthosis

NICE 2009-LBP
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
 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 Active
Individuals. Curr Sports Med Rep 2010 9 (01) 0060-66
 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 Active
Individuals. Curr Sports Med Rep 2010 9 (01) 0060-66
 Levels of evidence and strength of
recommendations about Fibromyalgia
syndrome
http://www.reproline.jhu.edu/english/2mnh/2ppts/evidence/gifs/slide6.gif
Fibromyalgia - Pain

Eur J Pain 2010 14 (01) 0005-10

 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.
 Comparison the efficacy of phonophoresis and
ultrasound therapy in myofascial pain syndrome

• Ay et al found that both

diclofenac
phonophoresis and
ultrasound therapy
were effective in the
treatment of patients
with MPS

Ay S, Doğan SK, Evcik D, Başer OC. Comparison the efficacy of phonophoresis and ultrasound therapy
in myofascial pain syndrome. Rheumatol Int. 2010 Mar 31
 Ultrasound therapy versus ischemic compression techniques for
the treatment of trapezius latent myofascial trigger points in
healthy subjects

• Aguilera et al
recommended using
ultrasound in management
of MPS

Aguilera FJ, Martín 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.
 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
Marmara University School of Medicine
Dept of PM&R, Istanbul, TURKEY