I GRANDI AMBITI NELLA RIABILITAZIONE E
TERAPIA DEL DOLORE
Marco Paoloni
PAIN
An unpleasant sensory and emotional experience
associated with actual or potential tissue
damage, or described in terms of such damage
In a patient in rehabilitation, pain can be present in two
different and often overlapping variants:
a functional disability primarily caused by pain or
a disabling condition triggering a painful state that
further aggravates the functional disability
Pain rehabilitation
TEAM MULTIDISCIPLINARE
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Fisiatra
Algologo
Medici specialisti d’organo
Fisioterapista
Terapista occupazionale
Tecnico ortopedico
Psicologo
Assistente sociale
Paziente
Familiari
Progetto e programmi riabilitativi individuali
Da Basaglia N. Progettare la Riabilitazione –edi-ermes 2002
Simplified graphical representation of the Bone and Joint Decade 2000–2010 Task Force on Neck
Pain and its Associated Disorders Conceptual Model for the onset, course, and care of neck pain
Guzman et al., Spine 2008
Factors Affecting the Onset and Course of Neck Pain
“Factor”
Any attribute of the person or his/her environment that
can affect the onset, course, or care of neck pain and
its consequences.
Independently of its origin, a factor should be
classified as either modifiable
or not
modifiable
This is important for identifying interventions that are
likely to have an impact on the onset, course, and
care of neck pain.
Guzman et al., Spine 2008
The “Care” Complex
The particulars of assessment,
diagnosis, and management will
vary according to the setting, the
chosen (or available) health care
provider, and personal
preferences.
Different health care disciplines
have different standards for
assessing, diagnosing and
managing neck pain
Guzman et al., Spine 2008
The “Participation” Complex
A person experiencing an episode
of interfering
neck pain would need to consider whether to modify his/her
participation (defined in the ICF model as involvement in life
situations, such as paid employment, leisure, or household
responsibilities).
Guzman et al., Spine 2008
The “Claim” Complex
Guzman et al., Spine 2008
The Impacts and Outcomes of Neck Pain
Guzman et al., Spine 2008
The Impacts and Outcomes of Neck Pain
Guzman et al., Spine 2008
Ambiente sociale
Comportamenti associati a
malattia
Distress
psicologico
Attitudini e
pregiudizi
DOLORE
Over the past 25 or so years (since we first became
“enlightened”), incidence and prevalence rates have
remained relatively constant, while costs, particularly in
terms of lost productivity, are outrageous and rising
• the largest mean cost (17%) for low back pain is for
physiotherapy
• the mean proportion of patients under the care of a
medical physician for low back pain was 20% compared
with 30% for nonphysicians (physiotherapy,
chiropractic and osteopathy, mental health).
Evidence such as this indicates that, if the intent to
reduce costs is serious, evidence-based
professional education must involve not just
orthodox clinicians but also alternative providers,
specifically dispensers of hands-on therapy.
Is It Time to Rethink the Typical Course of
Low Back Pain?
• Setting: Thirty clinical practices (primary care, physical
therapy, chiropractic, and surgical spine) in North
America and Europe.
• Patients: A convenience sample of 589 respondents
with LBP. There were no exclusions based on type of
LBP, history of onset, or comorbidities
Donelson R, et al. PM R 2012;4:394–401
Research Question 1:
How Commonly Do Patients With LBP Experience Recurrences?
• 73% of the respondents reported a previous episode.
– Age category 18-33 years: 57%
– Age category 34-42 years: 82%
– Age category 43-52 years: 83%
– Age category 53 + years: 77%
• 34.9% reported that their first episode lasted >3 months
• 54% reported 10 or + episodes in their lifetime
• 19.4% reported > 50 episodes in their lifetime
• There were no statistically significant differences among
primary care, chiropractic, and surgical spine practices,
but those from physical therapy clinics had significantly
higher frequencies (P.05).
Donelson R, et al. PM R 2012;4:394–401
Research Question 2:
Do Patients Seeking care for LBP Perceive Their Recurrent
Episodes as Worsening?
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pain intensity
interference with leisure activities
interference with work activities
duration of episodes
extent of most distal pain
Donelson R, et al. PM R 2012;4:394–401
Research Question 3:
Does the Location of Pain Change in a Discernible Pattern
During Onset and Recovery?
• 75.6% reported that their pain location changed during a
single episode.
• Of those individuals, 63.2% (or 48.3% overall) reported a
very specific proximal-to-distal-to-proximal pattern of
change in pain location
Donelson R, et al. PM R 2012;4:394–401
Ambiente sociale
Comportamenti associati a
malattia
Distress
psicologico
Attitudini e
pregiudizi
DOLORE
Pain:
‘‘whatever the experiencing person
says it is, existing whenever he
says it does’’
Margo McCaffery (1968)
Patients with chronic pain syndrome
demonstrate some typical characteristics
• Dramatization of complaints
• Drug misuse or overuse
• Dysfunction
• Dependency
• Depression
• Disability
In various studies during the last decade, woman with
chronic muscular pain such as fibromyalgia, and chronic
fatigue syndrome have reported negative experiences
during medical encounters.
They repeatedly find themselves being questioned and
judged either to be not ill, suffering from an imaginary
illness or given a psychiatric label
“It is difficult to accept that I can’t do everything
that I want to do, and to abandon hope of
being the kind of person who never gives up,
which I’ve always considered myself to be.
I’ve always been so strong and robust, but I feel
very much alone with these things; like a
neurotic, whining woman. In the end you wonder
whether the others are right and that it’s you that
there is something wrong with.
But my back will never be cured by going to a
psychologist.”
‘Reality is not something out in the universe
to be discovered, but rather is contingent
upon people who construct it,’
Impact of Disbelief in Chronic Pain
Summary of Recommendations for Health Care Professionals
•
Using psychologic explanations of pain can be experienced as a denial of
the individual’s pain.
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Be aware of the tension that patients can experience in the expression of
their pain.
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To address not only the patient’s experience of isolation but also the anger
and frustration that can stem from not being taken seriously.
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Empowering the patient with health care options could be an essential step
toward countering experiences of helplessness, particularly given the lack of
control many patients experience in the persistence of their pain
“Sono nato con la spondilolistesi, cioè con una vertebra lombare ribelle che si è staccata
dalle altre e sporge. Quell’unica vertebra spostata riduce lo spazio all’interno della
colonna e il minimo movimento fa sì che i nervi si sentano costretti. Se a ciò si
aggiungono due ernie e un osso che non vuole smettere di crescere nel vano sforzo di
proteggere l’area danneggiata, quei nervi finiscono per soffrire di claustrofobia. E quando
protestano per l’angustia del loro alloggio, quando segnalano la loro sofferenza, su e giù
per la gamba mi saetta un dolore che mi fa boccheggiare e parlare in turco. In quei
momenti l’unico sollievo è sdraiarmi e aspettare. ….
Sto negoziando con lui (il mio corpo) chiedendogli di rientrare in attività per qualche ora
ogni tanto. Gran parte delle trattative riguarda un’iniezione di cortisone che attenua
temporaneamente i dolori. Prima che faccia effetto, però, anche l’iniezione provoca i suoi
tormenti…
Il medico ha spiegato che doveva far penetrare l’ago, lungo diciotto centimetri, più vicino
possibile ai nervi infiammati. Ma non poteva arrivarci direttamente, perché le ernie e
l’osso sporgente gli ostruivano il percorso. I suoi tentativi di aggirarli mi hanno fatto
vedere le stelle. Prima ha inserito l’ago, poi ha posizionato una grossa macchina per le
radiografie sopra la mia schiena per vedere quanto fosse vicino al nervo. … Gira e rigira,
alza e abbassa, ha manovrato l’ago fino a farmi venire le lacrime agli occhi. Alla fine ha
trovato il punto. Centro, ha detto. Ecco il cortisone. Mi sono morso il labbro per il bruciore.
Poi è arrivata la pressione. Mi sono sentito pervaso, imbalsamato. …
Ben presto il dolore mi è sembrato meraviglioso, quasi dolce, perché riconoscevo quel tipo
di sofferenza che precede il sollievo. Ma a ben pensare, forse, il dolore è sempre così”