Pain Rehabilitation

Husnul Mubarak, Sp.KFR

School of Medicine Teaching Hospital
Hasanuddin University

Pain?
An unpleasant sensory and emotional
experience associated with actual and/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 correlate tissue damage
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

community

reintegration to

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 I,e. Straight leg
raising, Tinels sign, Finkelstein test,
Empty can test.

Rehabilitation approach
Acute Pain
real tissue damage
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 progression to chronic pain
Anticipating significant psychosocial
issues

Chronic pain, rehab intervention?

Can be caused by persistence of organic
pathology (i.e cancer pain) or other nonmalignant 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

Chronic pain - deconditioning cycle

Percepts
Injury/harm to
The body part(s)

Original
Tissue
Damage

PAIN

Avoid any
Movement/activty
That cause pain

Pain threshold
lower

Physical
deconditioning
Increase level
of inactivity

Behaviour change
Fearfull of moving

 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 Exc
Therapeutic Exercise is medicine
Important adjunct in pain therapy
Reeducate involved tissue creating
proper behavior of tissue, mostly neural
and muscular
Like other medicine, it has dosage
can be proper dosage, under dosage, or
overdosage

 Therapeutic exercises

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?

 Vertebral traction
Release compression on narrowing of
foramine intervertebra source of nerve root
irritation
Relieve muscle spasm
Cervical and lumbar

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.

Thank you

for your kind attention