Physical Therapy to Manage Pain -...
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Physical Therapy to Manage Pain Christy C. Ciesla, PT, DPT, PRPC Clinical Coordinator, Women & Men’s Health Rehab Services The Miriam Hospital
Transcript of Physical Therapy to Manage Pain -...
PhysicalTherapytoManagePainChristyC.Ciesla,PT,DPT,PRPC
ClinicalCoordinator,Women&Men’sHealthRehabServicesTheMiriamHospital
ThePTCommitmenttoManagingPain
• PThaslongbeenconsideredaconservativeapproachtomanagechronicpain
• Thephysicaltherapistoftenencounterspatientsusingopioidslongtermtomanagetheirpain
• Chronicpainisoftenbeyond“physical”• TheAPTA’snationalcampaign- commitmenttoraiseawarenessoftherisksofopioidsandtopromoteconservativemanagementofsymptomswithPTintervention
PhysicalTherapyInterventionsandChronicPain
• PTcanofferavarietyofevidence-basedtreatmentapproachesforpatientwithchronicpain,suchas• ManualTherapy(softtissue/Jointmobilization,
strain/counterstrain,passivestretching,myofascialrelease,etc.)
• Exercise(ROM/stretching,strengthening/stabilization,yoga,homeprograms)
• Education(educatingpatientsonpaintheoriesandprovidinginfoonconservativetreatmentvs.medical/drugoptions)
• GuidedImagery,Bodymapping,mindfulnesswork• AquaticTherapy(deweighting,relaxation,mobility)• Taping/kinesiotaping• Dryneedling(neuromuscularre-educationatthe
musclespindleusingneedles)• Modalities(LLLT,Ultrasound,Electricalstim,Ice/heat,
etc.)
ButWhatElseDoWeDo??
• Blogpost:EducationandAdvice:TheFoundationsofourProfessionby,DavidLanfranco• “Neverforgetthatyouaretreatingapersonandnotapathology”• Dr.Lorimer Moseley– painexpertsaid,“Anythingthatchangesyourbrain’sevaluationofdangerwillchangethepain.”
• Painisnotasynonymofdamage.Itisinfluencedbyseveralfactorsnotalwaysbodyrelated.
• Testsandimagingsometimes“poisonthemindofthepatient”tobelievethereisaconnectionbetweenthephysicaldamageandthepains/heisexperiencing.
• ThePTisinauniquepositiontoaddressallofthedriversofthepainexperience- biological,psychologicalandsocial.
ButWhatElseDoWeDo??
ChronicPelvicPainandPelvicRehabilitation
• CPPSischaracterizedasanypaininthepelvis,lowerabdomen,vagina,perineum,anus,urethra,groinortailbone
• Oftenassociatedwithsitting,butcanoccurwithactivity• Canresultinburningduringurinationorurinaryurgencyandfrequency,orpainwithdefecation
• ConditionsassociatedwithCPPSinclude:• InterstitialCystitis• Pudendal/ilioinguinal/iliohypogastric Neuralgia• Levator ani Syndrome• Vulvodynia• Vaginismus
ChronicPelvicPainandPelvicRehabilitation
• CPPSisoftenassociatedwithconnectivetissue,softtissue,orjointdysfunctioninthespine,hipsorpelvicregion
• Patientswiththeseconditionsareoftenextremelydebilitatedandanxious,andweemployawidevarietyoftreatmentapproaches,includingrelaxationandguidedimagery.
• PatientsoftenfeelHOPELESS andthatnoonebelievesorunderstandsthem.
• MANYofourpatientsaretreatingpainwithopioids
• “Natalie”- 32y/opostpartum(12weeks)nursingfemalewhoreportsonsetofdyspareunia,rectalpainandseverelypainfulbowelmovementsfollowingvaginalbirth
• Painprogressedtorectalpainwithstanding• Abstainsfromsexualintercourse• Quitjobasattorneyduetoinabilitytotoleratedailyactivities• ConsultedwithCNM– scarhealedandgoodPFMcontraction• Referredtocolorectalsurgeonforconsult• Sigmoidoscopy x2,pelvicMRI,bloodwork– allneg.
• Dx’ed withanalfissureandunderwentbotox injections• FecalUrgencybecameanissueforsometime
• Surgeryrecommended:analsphincterotomy andreferredforpainmanagement
• Friendrecommendedpt.trypelvicPTandpt.askedforreferral
“Ithurts‘downthere’!”
• ProblemList:• Perineal hypomobility/tenderscar• Softtissuehypertonicity withsevereTTP• DecreasedPFMcoordinationwithattemptsatrelaxation• Lumbopelvic asymmetries• Decreasedbowelhealth/poordefecationdynamics• Inabilitytotoleratebowelmovementsorintercoursewithoutpain.• Havingdifficultycaringforherbabyduetoinabilitytostand
• Goals:• Improvesofttissuecondition/activity/ROMtoWNL• RestoreoptimalLPalignment/ms balanceandstabilize• DecreasepainwithpenetrationandBM’sto0-3/10worst• Restorefunctional,pain-freevoidingthroughadequatePFMrelaxation
• Preventneedforsurgicalorfurthermedicalintervention
“Ithurts‘downthere’!”
• Assessment:• Signsandsymptomsdidnotsuggestanalfissureassourceofpain• Recommended12-15PTsessionsbeforeconsiderationofsurgery
• Treatment• Myofascialreleaseandstrain/counterstrain toallpainfulstructureswithemphasisondeeptransverseperineal
• Jointmobilization/alignmentcorrectionstosacrumandspine• Bladder/bowelhealthtraining(fiber,colonmassage,waterintake)
• Chronicpelvicpaineducation(Fear/Tension/Paincycle)• Relaxation/downtraining/diaphragmaticbreathing/defecationdynamics
• Perineal Massage,dilators,stretchingforhomeprogram
“Ithurts‘downthere’!”
• Intervention– 1x/wk,45minsessions(17total)• Focusonmanualtherapy• Atvisit#5,pt.wasintears,reportingthatshewas“goingtohavesurgery”.
• Treatmentfocusedonvaginalportionofdeeptransverseperineal,whichREPRODUCEDrectalpain
• Byvisit#6,pt.reported75%improvementinsymptoms• Byvisit#12,sexwaspainlessandpt.couldstandtocareforbabyformostofthedaywithoutpain
• Dischargeatvisit#17,atwhichpt.reportedcompleteresolutionofsymptoms,includingpainfulBM’s
“Ithurts‘downthere’!”
• Whydidwedoit?Anyevidence?• Fitzgerald,etal(2012):RCTof87womenwithpelvicpain/urinaryissueswithtrialofmyofascial PT• 59%reportedimprovedorcompletelyresolvedsymptomsbyvisit10,
includingurinaryurgencyandfrequency• RosenbaumandOwens(2008):JofSexMed– Theroleofpelvicfloorphysicaltherapyinthetreatmentofpelvicandgenital-pain-relatedsexualdysfunction• PTRxofpelvicpainshouldbeconsideredanintegralcomponentofthe
teamapproachtoCPP/sexualdysfunction• Bortoloni,etal(2015):JofSexMed
• sexualdysfunctionappearstobesignificantlycorrelatedwithageandhighpelvicfloormuscletone.
• Vandyken &Hilton(2016):SexMedRev• “Itisreasonableforphysicaltherapiststoutilizeevidencebased
strategiessuchasCBT,painbiologyeducation,MindfulnessBasedStressReduction(MBSR),yogaandimagerybasedexercisestoaddressthebiopsychosocialcomponentsoffemalesexualpain”
“Ithurts‘downthere’!”
KeyPointstoConsider• ThispatientmayhavesufferedlongtermwithoutPTintervention
• Thispainwasdifficulttoassessandfind!• Inthiscase,physicaltherapyofferedthepatient• Timewithamedicalprovideronaregularbasisforongoingassessmentofsymptoms
• Accesstohealthcareweeklyintheeventareferralhadtobemade
• Educationandassurancethathersymptomsweretreatable• Anopportunitytotakecontrolofhersymptomsviaahomeprogram
HowIsPTAccessed?• Allphysicaltherapistsarepreparedthrougheducationandexperiencetotreatconditionsthatcarrythesymptomofpain.However,whenseekingaprovider,youmaywanttoconsider:• APTwhoisaboard-certifiedspecialistorwhohascompletedpost-graduateresidency
• APTwhoiswell-versedinthebio-psycho-socialmodelofcare• APTwhohascomehighlyrecommendedbyafriendorprovider,oronethroughthe“findaPT”linkontheAPTAwebsite.
• Ahealthcareprovidercanmakeareferraltophysicaltherapy,butinsomepractices,areferralisnotnecessary.Checkwithyourhealthinsuranceandthetherapist’sofficetofindoutwhatisneeded.
References• Bortolami A,Vanti C,Banchelli F,Guccione AA,Pillastrini P(2015).Relationship
betweenfemalepelvicfloordysfunctionandsexualdysfunction:anobservationalstudy.JSexMed.May;12(5):1233-41.
• FitzGeraldMP,PayneCK,Lukacz ES,YangCC,PetersKM,ChaiTC,NickelJC,HannoPM,Kreder KJ,BurksDA,MayerR,Kotarinos R,Fortman C,AllenTM,FraserL,Mason-CoverM,Furey C,Odabachian L,Sanfield A,ChuJ,Huestis K,TataGE,DuganN,Sheth H,Bewyer K,Anaeme A,NewtonK,FeatherstoneW,Halle-Podell R,CenL,LandisJR,Propert KJ,FosterHEJr,Kusek JW,NybergLM;InterstitialCystitisCollaborativeResearchNetwork(2012).Randomizedmulticenterclinicaltrialofmyofascialphysicaltherapyinwomenwithinterstitialcystitis/painfulbladdersyndromeandpelvicfloortenderness.JUrol187(6):2113-8.
• RosenbaumTY,OwensA(2008).Theroleofpelvicfloorphysicaltherapyinthetreatmentofpelvicandgenitalpain-relatedsexualdysfunction(CME).JSexMed.Mar;5(3):513-23;quiz524-5.anKampen M,Devoogdt N,DeGroef A,Gielen A,Geraerts I(2015).Theefficacyofphysiotherapyforthepreventionandtreatmentofprenatalsymptoms:asystematicreview.Int Urogynecol J.Nov;26(11):1575-86.
• Vandyken C,HiltonS(2017).Physicaltherapyinthetreatmentofcentralpainmechanismsforfemalesexualpain.SexMedRev.Jan;5(1)20-30.
