Chronic Pain syndromes

Physiotherapy in systemic conditions

A. Thangamani ramalingam PT, MSc(psy),PGDRM, ACspss MIAP

Pain

Acute Pain: It is an unpleasant sensory and

emotional response to a stimulus associated with potential tissue damage lasting less than 2 months. The characteristics are:

Results from micro-traumatic or macro-traumatic tissue injury.

It has temporal features with Pain behaviours (morning limitation of movement, splinting etc.)

Anxiety Examples: Muscle strains, Tendinitis,

Contusions or Ligament injuries, Dislocations and Overuse injuries.

Strong pressure by Chemical irritants (Bradykinin, Substance P histamine), heat and cold Nocioceptors (pain receptors) A-δ fibres in Spinal Cord Central Nervous System (CNS)

Chronic Pain: It is the pain that persists after the

noxious stimulus has been removed. Chronic pain has strong Psychological, Social and Emotional effects. The characteristics are:

It is not short lived, ill-defined onset.

Intensity variable. Irritability/Depression. Recurrent in nature. Examples: Fibromyalgia, Chronic

Fatigue Syndrome, Myofascial Pain Syndrome, RA and Low Back Pain.

Commonly seen in slowly progressive diseases like Hemophilia, IBD, OA and many neuropathic pain.

‘C’ Fibers are Transducer.

o Fibromyalgia/WPS o Myofascial paino Chronic fatigue syndromeo Chronic regional pain syndromeo IBD

Acute and Chronic Pain Syndromes

Myofascial Pain

Myofascial Pain Syndrome (MPS) /Muscle Pain Syndrome:

Characterized by (used for diagnosis also)

Trigger points (usually in mid-portion or belly of the affected muscle)

A Taut Band (<1cm2) Local twitch response

followed by “Snapping Palpation”

Pathophysiology Acute muscle strain

Tissue damage Tears in Sarcoplasmic Retinaculum Free Ca++ Sustained Contraction Increased strain on Vulnerable areas Free Ca++ and so on Hyper metabolic state and Vasoconstriction (locally)

Criteria: (Simons

&Travell ) Major criteria

Regional Pain Referred Pain or Altered Pain

from trigger point Taut band in an accessible

muscle Exquisite Spot tenderness Some degree of restricted ROM

Minor criteria Reproduction of Symptoms by

pressure on Tender Spot Elicitation of local twitch

response by palpation /needle insertion

Pain alleviated by elongation (stretch) or injecting tender spot

Five major + 1 minor criteria indicate disease.

Fibromyalgia

Fibromyalgia (FM) A common condition of uncertain pathology in which generalized muscle pain with localized tender area occurs without objective clinical or laboratory abnormalities. Psychiatric Symptoms commonly co-exist. Mechanism central or

peripheral

Widespread pain of 3 months duration

Pathological multiple regions of pain & tenderness

Sleep disturbances Alpha-delta Sleep Pattern Associated Symptoms Fatigue,

Stiffness, Subjective swelling, Tension-type headache, Anxiety, Irritable Bowel Syndrome (IBS)

Aggravating Factors Cold, Humidity, Change of weather & Physical activity

Depression & Panic disorder may accompany

Criteria: (American College of

Rheumatology, 1990)

1. History of widespread pain for at least 3 months. Example: Pain on left

side of the body, Pain on

right side of the body, Pain above

the waist & below the waist + Axial Skeletal Pain 

2. Pain in 11 of 18 tender point sites on digital palpation. Occiput – 2 Lower cervical – 2 Trapezius – 2 Supraspinatus – 2 Second rib – 2 Lateral epicondyle – 2 Gluteal – 2 Greater trochanter – 2 Knee (medial side) – 2

Chronic Fatigue

Syndrome Chronic Fatigue

Syndrome (CFS) Fatigue of at least 6

months duration.

Centres for disease

Control and Prevention (CDC) Criteria

Major: (Two) New onset Fatigue

lasting 6 months and reducing activity to 50 %

Other conditions producing Fatigue must be ruled out

Minor: (8 of 11 Symptom Criteria + 2 Physical Criteria)

Symptom Criteria :- Low grade fever Sore throat Painful Cervical /Axillary lymph nodes Generalized muscle weakness Muscle Pain Post exertional fatigue lasting 24 hours Headache Migratory arthralgias Neuro-psychological Complaints

(Irritability, depression, forgetfulness, decreased concentration)

Sleep disturbances Acute onset of Symptoms (few hours to

days)  Physical Criteria :- (documented by a Physician twice, at least 1 month apart) Low grade fever Non-exudative Pharyngitis Palpable axillary/ cervical lymph nodes

Chronic reginal pain

syndromecharacterized by severe pain and sensitivity, swelling, and

changes in the skinClassificationType I, formerly known as reflex sympathetic dystrophy (RSD), Sudeck's atrophy, or algoneurodystrophy, does not exhibit demonstrable nerve lesions. Type II, formerly known as causalgia, has evidence of obvious nerve damage. Type II CRPS tends to feature the more painful and difficult-to-control symptoms of CRPS; The Type II disease scores 47 out of 50 on the McGill pain scale. Despite there being evidence of nerve injury, the cause of the mechanisms of CRPS Type II are as unknown as the mechanisms of Type I.

CRPS is associated with dysregulation of the central nervous system[ and

autonomic nervous system resulting in multiple functional loss, impairment and disability.

.

CRPS I &II

The International Association for the Study of Pain (IASP) lists the diagnostic criteria for complex regional pain syndrome I (CRPS I) (RSDS) as follows:The presence of an initiating noxious event or a cause of immobilizationContinuing pain, allodynia (perception of pain from a nonpainful stimulus), or hyperalgesia (an exaggerated sense of pain) disproportionate to the inciting eventEvidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the area of painThe diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction.

According to the IASP, CRPS II (causalgia) is diagnosed as follows:The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerveEvidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of painThe diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction

Management

Medications Surgery Physiotherapy Psychological

interventions Education Recreational

activities Improve QoL

NSAIDs&overthecounter

drugs

Physiotherapy-tens

Behavioral therapies .Adjunct therapies

Corrective surgery

Long term oral opioids

Advanced pain therapies

Neuro ablation

Peripheral Techniques Central Techniques

a) Nerve blocks (phenol, alcohol used) a) Precentral Cortex Stimulation

a) Dorsal Rhizotomy b) Deep brain stimulation

a) Facet joint injection c) Mesen Cephalotomy

a) Trigger point injections d) Hypophysectomy

a) Spray and Stretch techniques e) Percutaneous anterolateral cordotomy

a) Manipulation f) Myelotomy

a) Epidural blocks g) Multiple radio frequency heat lesions

a) Sympathetic block h) Spinal Cord Stimulation

a) TENS/ Acupuncture  

a) Cryoanalgesia/ Neurolysis  

a) Steroid injection  

a) Radio Frequency Thermo Coagulation (RFTC)  

Psychological Interventions

Relaxation methods Biofeedback Hypnosis REST (Restricted Environment Stimulation Therapy) Cognitive distraction Guided imagery Rational emotive therapy CBT /Psychotherapy Psychoanalytic approach Assertiveness training Counseling Vocational counseling /rehab

Physiological measures

EMG – muscle tensionHeart rateSkin temperatureEEG and brain imaging

Behavioral pain measuresPhysical symptoms ;Clusters: guarding, bracing,

rubbing, grimacing, and sighing(Bio-psycho-social approach (by Turkey and Rudy,1987)

Self-report measures

Pain assessment

McGill Pain Questionnair

e - sensations

- feelings- intensity

Pain Rating Scales

Visual Analog Scale(VAS)Graphic Rating Scale(GRS)Simple Descriptor Scale(SDS)Numerical Rating Scale(NRS)Faces Rating Scale(FRS)

Pain Rating Scales

Pain Discomfort Scale

Generic tools (Functional Evaluation) : Quality of Well-Being

scale (QWB) Sickness Impact

Profile (SIP) Duke Health Profile

(DUKE) Short Form-36 (SF-36)

Disease Specific Tools : Oswestry low back

disability questionnaire

Waddell Disability Index

Arthritis Impact Measurement Scales (AIMS)