Pain Rehabilitation

Husnul Mubarak, Sp.KFR

School of Medicine – Teaching Hospital
Hasanuddin University
• Pain is An Alarm
• Acute Pain is A Bless
• Chronic Pain is A Curse
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  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  I,e. Straight leg
raising, Tinel’s 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 therap, 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 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
 Chronic pain - deconditioning cycle
Percepts
Original
Injury/harm to
Tissue
The body part(s)
Damage Avoid any
Movement/activty
That cause pain
PAIN

Pain threshold
lower Behaviour change
Fearfull of moving

Physical
deconditioning
Increase level
of inactivity
 Central sensitazion
Pain Perception
Noxious Stimulation

Modulation

Modulation

Modulation
• 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
– 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
 Invasive pain management
• USG-Guided Corticosteroid Injection
• 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