1070614 慢性疼痛的診斷和最新治療

慢性疼痛的診斷和最新治療 高雄市立小港醫院復健科 李佳玲

李佳玲 高雄市立小港醫院復健科 2

學歷

私立高雄醫學大學醫學系 國立成功大學環境醫學研究所碩士班

經歷

高雄醫學大學附設中和紀念醫院復健科主治醫師 小港醫院復健科主治醫師 中華民國復健科專科醫師 中華民國環境與職業醫學專科醫師 中華民國醫用超音波學會專業醫師 部定助理教授 台灣復健醫學會學術委員會委員 台灣復健醫學雜誌編輯委員會委員 勞動部職業病鑑定委員會委員

Pain 3

one of the most common presenting symptoms to the primary care clinician only a percentage of patients ultimately develop a chronic pain syndrome.

Chronic pain syndrome 4

Pain lasts for more than 3 months Any pain that persists longer than the expected healing time for the pathological tissues

Chronic pain syndrome 5

In a study based on a survey of representative population in the United States from 1999 to 2002 (the National Health and Nutrition Examination Survey, NHANES), chronic pain : defined as > three months of pain back pain 10.1 percent, leg/foot pain 7.1 percent, arm/hand pain 4.1 percent, headache 3.5 percent, chronic regional pain 11.1 percent, widespread pain 3.6 percent

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the majority of patients who reported chronic pain reported more than one type of pain

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Pain categories 8

Neuropathic pain • resulting from damage to or pathology within the nervous system, can be central or peripheral.

• causes : diabetes mellitus, postherpetic neuralgia, and stroke.

Nociceptive pain • is caused by stimuli that threaten or provoke actual tissue damage.

• causes : musculoskeletal conditions, inflammation, or mechanical/compressive problems.

Pain categories 9

Neuropathic pain

Musculoskeletal pain

Inflammatory pain

Mechanical/compressive pain

Pain categories 10

Neuropathic pain • peripheral, including post-herpetic neuralgia, diabetic neuropathy; • central, including post-stroke pain or multiple sclerosis Musculoskeletal pain Inflammatory pain Mechanical/compressive pain

Pain categories 11

Neuropathic pain Musculoskeletal pain • eg, back pain, myofascial pain syndrome, ankle pain Inflammatory pain Mechanical/compressive pain

Pain categories 12

Neuropathic pain Musculoskeletal pain Inflammatory pain • eg, inflammatory arthropathies, infection Mechanical/compressive pain

Pain categories 13

Neuropathic pain Musculoskeletal pain Inflammatory pain Mechanical/compressive pain • eg, renal calculi, visceral pain from expanding tumor masses

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Management pharmacologic physical medicine behavioral medicine neuromodulation interventional approaches surgical approaches

PHARMACOLOGIC OPTIONS 16

Nonopioid analgesic medications Opioids Adjuvants (used to treat the side effects associated with pain medications or potentiate analgesia)

PHARMACOLOGIC OPTIONS 17

Nonopioid analgesic medications

Opioids

Adjuvants

PHARMACOLOGIC OPTIONS 18

Nonopioid analgesic medications • aspirin, • acetaminophen, • nonsteroidal anti-inflammatory drugs [NSAIDs], • COX-2 Inhibitors Opioids Adjuvants

PHARMACOLOGIC OPTIONS 19

Nonopioid analgesic medications Opioids Adjuvants • Alpha 2 adrenergic agonists • Antidepressants (tricyclics and serotoninnorepinephrine reuptake inhibitors [SNRIs]) • Antiepileptic drugs (gabapentin, pregabalin, and other anticonvulsants) • Muscle relaxants • N-methyl-d-aspartate (NMDA) receptor antagonists

By pain categories 20

Neuropathic pain • First-line options : • antidepressants (tricyclic antidepressants or dual reuptake inhibitors of serotonin and norepinephrine) • calcium channel alpha 2-delta ligands (gabapentin and pregabalin) • adjunctive topical therapy (eg, topical lidocaine) when pain is localized.

• Opioids should be considered a second-line option.

• Combination therapy is often required

Nociceptive pain

By pain categories 21

Neuropathic pain Nociceptive pain • First-line options : • Acetaminophen • NSAIDs • Opioids should be considered a second-line option.

• adjunctive topical therapy (eg, topical lidocaine) when pain is localized.

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Choices by risk factors considerations 23

Chronic kidney disease, advanced age - avoid NSAIDs and COX-2 inhibitors.

Peptic ulcer disease, glucocorticoid use - avoid NSAIDs. Hepatic disease - avoid NSAIDs, COX-2 inhibitors, and acetaminophen (APAP); use TCAs or duloxetine first line.

Cardiovascular disease or risk - use lowest effective dose of NSAIDs; in patients who require treatment, suggest naproxen.

Nonpharmacologic therapies 24

psychoeducational interventions • such as cognitive-behavioral therapy, family therapy, psychotherapy, and patient education.

physical interventions • including physical therapy, acupuncture, chiropractic manipulation, massage, and others

combination therapies are more effective than any single approach for maintaining long-term gains 25

Psychoeducational interventions 26

●Behavioral medicine approaches •Cognitive behavioral therapy •Biofeedback •Relaxation therapy •Psychotherapy and individual or group counseling

Physical medicine interventions 27

●Exercise ●Electrical neuromodulation ●Ultrasonic stimulation ●Thermal applications (heat/cold)

Exercise 28

ROM exercises Stretching is a key component to restoring normal range of motion (ROM) passive (in which there is no voluntary muscle contraction and with the application of total external force) to active assisted (in which there is partial contraction and external force).

Muscle conditioning is addressed to improve stability, function, and pain. three areas: strength, endurance, and re-education

伸展運動～ 29

伸展運動～ 30

伸展運動～ 31

肌力訓練運動～ 32

有氧運動～ 33

規律運動 34

Neuromodulation approaches 35

External peripheral Internal peripheral Spinal Supraspinal

Neuromodulation approaches 36

External peripheral transcutaneous nerve stimulation (TENS) low voltage electrical current from a small battery-operated device to the skin via surface electrodes four main modes of TENS: conventional TENS (high frequency, short pulse duration, low intensity); acupuncturelike TENS (low frequency, long pulse duration, high intensity); burst TENS (high frequency trains of pulses delivered at a low frequency); and brief-intense TENS (high frequency and long pulse duration pulses delivered at a high intensity)

Internal peripheral Spinal Supraspinal

Neuromodulation approaches 37

External peripheral Enternal peripheral Spinal Spinal cord stimulation (SCS) minimally invasive and reversible treatment option which can be permanently implanted after an appropriately conducted temporary screening trial with an external pulse generator to assess therapeutic efficacy and adverse effects failed back surgery syndrome, complex regional pain syndrome, intractable angina, and painful peripheral vascular disease

Supraspinal

Neuromodulation approaches 38

External peripheral transcutaneous nerve stimulation (TENS).

Internal peripheral Spinal Supraspinal deep brain stimulation and motor cortex stimulation central post-stroke and facial pain

Thermal applications 39

Acupuncture 40

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Spinal manipulation 42

Chiropractics and osteopathic manipulation provides relief for musculoskeletal pain related to the back and neck manual therapy that involves the movement of a joint near the end of the clinical range of motion Types of manipulation nonspecific manipulations : long-lever, low- to high-velocity; uses one of the long bones of the limbs (frequently the femur) to amplify the load applied by the clinician‘s hands to one or several spinal joints. specific spinal adjustments : short-lever, high-velocity manipulations; short, forceful thrust on a specific vertebral transverse process

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Postulated mechanisms of benefit ●Relaxation of hypertonic muscle by sudden stretching ●Disruption of articular or periarticular adhesions ●Unblocking of motion segments that have undergone disproportionate displacements ●Alteration of pain-related reflexes by proprioceptive bombardment ●Changes in central pain pathways ●Reflexive muscle activation due to increased afferent output

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Applications acute and chronic low back pain nonspecific neck pain migraine, tension-type, or cervicogenic headache

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RISKS OF SPINAL MANIPULATION Minor complaints Common dizziness/light headedness, headache, and numbness increased neck pain or stiffness

Serious adverse events disk herniation, the cauda equina syndrome, and vertebrobasilar accidents (vertebrobasilar dissection or occlusion)

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Interventional approaches 47

•Ablative techniques •Botulinum toxin injections •Nerve blocks •Trigger point injections •Epidural steroid injections

Ablative techniques 48

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Nerve blocks 50

Interventional approaches 51

intercostal nerve blockade, spinal injections (epidural steroid injections, selective nerve root injections, and medial branch nerve injections of the facet or zygapophyseal joint), occipital nerve injections, and multiple other peripheral nerve injections

Epidural steroid injections 52

Trigger point injections 53

Botulinum toxin injections 54

Surgical approaches 55

Minimally invasive techniques Surgical neuroablative techniques of the spinal cord pain pathway

Regenerative Therapy 56

增生注射治療

震波治療

Extracorporeal Shock Wave Therapy (ESWT) 57

ESWT biphasic acoustic energy arises from positive high peak pressures to negative phase with short rising times short duration.

Focused v.s. Radial shockwave 58

The focused shock waves • generate single acoustic pulses by electrohydraulic principle, electromagnetic principle or piezoelectric principle.

• the acoustic pulses are converted into a focused acoustic pressure wave with the highest pressure at the target pathological tissue.

• the energy decreased within the target tissue consists of bone, calcifications, water, etc., more than 50% in occasionally.

The radial shock waves • generate a projectile pressure wave within a guiding tube that attacks a metal applicator targeted on the pathological tissue.

• consistent energy flux density.

震波治療 59

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Effect on soft tissue and musculoskeletal tissue 61

(1) increase cell membrane permeability and microscopic circulation of tissues which enhance the metabolism, healing and dissolution of calcification; (2) cavitation bubbles which are the result of high pressure energy wave will expand to a maximum size, then collapse, like a bubble popping creating the high force for breaking down the calcification deposit in soft tissues; (3) the micro jets which are the smaller secondary energy force after cavitation bubbles collapse also breaks down the calcification; (4) thousands of cavitation bubbles formed from several thousand shockwaves being treated at the injured tissues cans breakdown calcification deposit in joints, soft tissues and spur; (5) enhance the healing process of bone by stimulation of osteoblasts; (6) enhance the healing process of connective tissues such as tendon, ligaments, and fascia by stimulation of fibroblasts

In myofascial fascial pain syndrome ~ 62

the mechano-transduction effect of ESWT may increase perfusion and promote angiogenesis. free nerve endings degeneration and transient dysfunction of nerve excitability at the neuromuscular junction, a pure mechanism of breaking-up the actin myosin links with the overstimulation lead to a diminished transmission of pain signals to the brainstem.

For pain transmission, in animal studies revealed substance P, calcitonin gene-related peptide (CGRP) expression in the dorsal root ganglion and on neurovascular sprouting

For osteoarthritis ~ 63

There are evidences of improving motor dysfunction, slower the joint degeneration and amelioration of pain in osteoarthritis by ESWT. The mechanisms are as (1) Inhibition of nitric oxide production in knee synovia and reduce chondrocyte apoptosis; (2) Reduction of cartilage degradation biomarkers as shown in Mankin score and Safranin O strain with reduction of matrix metalloproteinase 13 (MMP-13), type II collagen, nitric oxide, DKK-1 (Dickkopf WNT Signaling Pathway Inhibitor; (3) Promote bone healing and tissue repair with ingrowth of neovascularization and upregulation of angiogenic and osteogenic growth factors, such as vessel endothelial growth factor (VEGF), proliferating cell nuclear antigen (PCNA), and bone morphogenetic protein 2 (BMP-2), osteocalcin.

In spastic pain ~ 64

the mechanism of ESWT in relief of spasticity might be as follows: (1) the generation of nitric oxides play important role in neurotransmission at neuromuscular junction, memories, and synaptic plasticity in the central nervous system; (2) the effect on excitability of the spinal cord; (3) the effect of mechanical vibration; (4) the effect on the Golgi tendon organ; (5) the passive stiffness of muscles determined by inactive connective tissues

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Established PRM indications 66

Myofascial pain/ trigger points, Tendinopathies, Calcifying tendonitis of the shoulder, Sub acromial pain syndrome, Primary long bicipital tenosynovitis, Tennis elbow (epicondylitis humeralradialis), Golfer‘s elbow, Greater trochanteric pain syndrome, Patellar tendinopathy, Achilles tendinopathy, Plantar fasciopathy, Idiopathic low back pain/ pseudoradicular syndrome, Idiopathic cervical pain, Osgood Schlatter disease, Pseudarthrosis/nonunion.

Emerging PRM indications 67

persisting pain after partial or total joint replacement, primary osteoarthritis, painful neuropathy, secondary lymphedema, spasticity, acute and chronic soft tissue wounds

The advantage for treatment with ESWT 68

(1) effectively relieves pain in more than 80 percent of patients even after just three treatments; (2) can replace surgery in many cases of diseases of the musculoskeletal system; (3) requires compliance by the patient that can easily be achieved (three times five to ten minutes treatment, usually once a week); (4) can be fully performed on an outpatient basis; (5) can be combined with other PRM treatments; (6) No medication; (7) Gentle and effective

Contraindications of ESWT 69

treatment over air-filled tissue (lung, gut), tissue with local tumors or local bacterial and/or viral infections, pre-ruptured tendons, pregnant women, patients under the age of 18 (except of the treatment of Osgood-Schlatter), patients with blood-clotting disorders (including local thrombosis), patients treated with oral anticoagulants, patients treated with local cortisone injections

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Prolotherapy 72

Prolotherapy, sclerotherapy, regenerative injection therapy repeated injection of irritants into ligaments and tendinous attachments in order to trigger an inflammatory response that theoretically will lead to subsequent strengthening of ligaments and decrease in pain and disability. are often supplemented by co-interventions such as trigger point injections, manipulation, and exercises.

增生療法 – 有什麼武器？ 73

雅節

自體高濃度血

（玻尿酸）

（PRP）

高濃度葡萄糖

小板血漿

彌可保 (methycobal)

雅節（玻尿酸） 74

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彌可保(methycobal) 76

高濃度葡萄糖 77

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自體高濃度血小板血漿（PRP） 79

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增生注射治療 – 哪一個好？ 82

雅節

自體高濃度血

（玻尿酸）

（PRP）

高濃度葡萄糖

小板血漿

彌可保 (methycobal)

THANKS FOR ATTENTIONS THE END