Rehab Medicine Flashcards
Heat and cold for pain
- Metabolic and enzymatic processes can be slowed or accelerated with slight temperature change (e.g. of 3-7C)
- Alters nerve conduction, blood flow, and collagen extensibility (stretching)
Heat
- induce analgesia, hyperemia, reduce muscle tone
Cold
- Reduces perfusion, induces analgesia, reduces tone
Main use is for MSK system where there is support for its benefit in pain control
Effect of cancer on MSK system
- Cancer may alter ability to bear weight, move, or tolerate forces due to ADLs and result in altered biomechanics such that other MSK elements may also be sources of pain
Examples:
- Contracted soft tissue from radiation fibrosis
- Pectoralis muscle tension from breast implants
- Compromised core muscle strength from extensive abdo surgery
Rehab: Stabilizing and Unloading strategies
- Used for MSK related pain
Four approaches:
- Displacing loads onto external supports (assistive devices - cane, quad cane, etc.)
- Improve the load bearing capacity of intact anatomic elements - Therapeutic exercise (‘dynamic stabilization’) is especially useful for low back and knee pain
- Immobilize painful joints (typically with orthotics - spinal braces including moulded body jackets)
- Reducing the work required by a painful activity - typically trough positioning to support joints to a pain-free range of motion
Rehab: Assistive devices for pain management
- Typically chosen with the help of a PT (for mobility) and OT (for function)
Transfers
- Hoyer lift, scooter or wheelchair
Ambulation
- Cane, quad cane, rolling walker, platform walker
Rehab: Compensatory strategies for pain management
Concept of daily activities consisting of a combination of coordinated and isolated movements
- Deconstruct these movements to isolate those that are painful and devise alternative strategies to minimise pain
- E.g. elastic shoe laces to avoid patient having to bend to tie shoes
Rehab: Therapeutic exercise for pain management
Muscles provide effective stabilization and immobilization - use of them in the form of ‘dynamic stabilization’ may be helpful
- Mainstay of treatment for low back and knee pain (e.g. strengthening of abdo to de-weight painful vertebrae, or hip abductors to deweight painful hip joints)
- PT devises exercises intended to enhance the strength and stamina of muscles capable of splinting a painful body part
- Typically isometric contractions to avoid painful changes in muscle length or the angle of the joint
Rehab: Orthotics for pain management
- Braces used to deweight, stabilise, and protect MSK structures
- May immobilise the entire affected body part OR apply pressure at select points to restrict motion
Spinal braces
- Moulded body jackets (custom fabrication) to stabilise an unstable spine
- Jewett braces - apply pressure at two anterior points on the upper and lower trunk, third point on the mid back in between to limit flexion and minimise pain generation from the vertebral column
Lumbosacral orthoses
- E.g. Bell Horn Brace
- Variations on abdominal corset with rigid struts and supports
- Alleviates pain by deweighting the spine, compresses abdominal contents to generate a load bearing fluid column
Cervical orthoses
- Primarily intended to limit cervical motion
Rehab: Positioning for pain management
Use of pillows, bolsters, environment, adaptive equipment to constrain patients to a pain-free range of motion
Light and laser therapy for pain management
- Wide variety of modalities with different wavelengths and joules/cm2
- Tissue temperatures not elevated more than a few tenths of a degree Celcius
- Irradiation at these intensities and energies can produce effects on metabolic processes and DNA synthesis that could improve healing/function of damaged nerves
Evidence:
- Evidence is poor, but approved by the FDA as an adjunct
- Reviews of evidence find no benefit to low back pain and venous stasis ulcers, ‘limited benefits’ for oral mucositis and rheumatoid arthritis
- Further research needed, but risks of treatment are minimal
Manual lymphatic drainage
- Technique designed to enhance sequestration and transport of lymph
- Requires specific stroke duration, orientation, pressure, and sequence
- Stimulates smooth muscles to enhance contracility and increases removal of inflammatory/pro-nociceptive macro-molecules
Use:
- Lymphedema
- Pain syndromes where congested lymph may play a role
Well tolerated, even if there is mod/severe allodynia
Benefit is dependent upon clinician skill
Mechanisms of MSK system contributing to cancer pain syndromes:
- Direct tumour invasion
- Maladaptive changes due to cancer treatment or local tumour effects
- Exacerbation of pre-existing MSK pain
- Secondary hypertonicity and spasm related to maladaptive changes or pre-existing MSK pain
Resti/Ice/Compression/Elevation for MSK pain
- Effective and safe in controlling acute inflammation
- Use for MSK pain of abrupt onset or with a clear precipitant such as overuse or trauma
- Use with or without NSAIDs
Rest
Ice (BID immersion for 20 minutes in crush iced/water more effective than ice packs)
Compression
Elevation
Injections for MSK pain
- Intent is to deliver anti-inflammatory or analgesic directly to a pain generator to maximise pain relief while minimizing systemic effects
- Steroids and local anesthetics most common
- Limit to no more than three per year to a single joint
Evidence for long term benefits of steroid suggests less effective than PT alone, though benefit of PT is slower onset
- For patients with advanced illness with limited prognosis, PT may not survive to experience delayed/sustained benefits of PT
Myofascial pain - syndrome
- Most common in upper back
- Tenderness on palpation and finding of ‘taut bands’ of increased muscle tone and tenderness in association with a trigger point (small area of increased tenderness that when pressed generates repeatable patterns of referred pain
- Treatment involves massage, exercise, and trigger point injections
Massage for myofascial pain
- Often accompanied with heat
- Builds in intensity according to patient’s tolerance
Spray and stretch may be used
- Spray of a cooling agent applied to a trigger point and along the pattern of pain radiation
- Spray followed by gentle, sustained stretch for 30-60 seconds
