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10/11/56 1กมลทพย หาญผดงกจ เวชศาสตรฟนฟ ศรราชMusculoskeletal Pain

Contents• อาการนา

• Musculoskeletal pain• การรกษา

คณะแพทยศาสตรศรราชพยาบาล มหาวทยาลยมหดล


อาการนา

• ปวด

• บวม

• แดง

• รอน


MUSCULOSKELETAL PAIN


อาการปวด

ความรสกไมสบายทรวมไปถงสภาพอารมณดวยทตอบสนองตอ

สงเรา (stimuli) ทสมพนธกบการทาลายของเนอเยอทงทเกดขน

จรงหรอมแนวโนมวาจะเกดขน

10/11/56 5กมลทพย หาญผดงกจ เวชศาสตร

ฟนฟ ศรราช

Musculoskeletal Pain

การจดแบงอาการปวด

• ระยะเวลา

• สาเหต

• ตาแหนง


อาการปวดเฉยบพลน (acute pain)

• เปนอาการทรางกายตอบสนองตอสงเราชนด nociceptive ทเหน

ไดชดเจน • เนอเยอไดรบบาดเจบจากอบตเหตหรอโรค

• โดยทวไปมกหายเมอสงเราหรอตวกระตนดงกลาวหมดไป


อาการปวดเฉยบพลน (acute pain)

• เรองปกตทรางกายตอบสนองตอสงเราทเปนอนตราย

– เพอเตอนใหทราบถงปญหาทเกดขน

– จะไดดาเนนการรกษาหรอขจดปจจยตนเหต

• ปวดเฉยบพลน >>>>> ปวดเรอรง




อาการปวดเรอรง (chronic pain)

เปนภาวะผดปกตทอาการปวดคงอยนานกวาระยะเวลาทโรค

หรอเนอเยอซอมแซม


อาการปวดเรอรง (chronic pain)

• อาการปวดไมสมพนธกบการบาดเจบของเนอเยอทชดเจน

• แตเปนปฏสมพนธของการรบรหรอมตตางๆทงทาง กาย จต และสงคม

• ปญหาอนๆ

– สภาพอารมณหรอพฤตกรรมเปลยนแปลง

– ระดบความสามารถลดลง

– ปญหาดานสงคมโดยเฉพาะการประกอบอาชพ




Musculoskeletal Pain Remove pathological processNeurologic, psychological, and physiologic components

Type of pain

• Nociceptive pain• Neuropathic pain• Inflammatory pain• Functional pain

Woolf, C. J. Ann Intern Med 2004;140:441-451

Neurophysiologic Classification of Pain

Nociceptive pain Nonnociceptive pain

somatic visceral neuropathic psychogenic

- Well localized - Poorly localized- Constantly aching - Paroxysmal aching- Throbbing - Squeezing- Gnawing - Colicky

Neuronal pathway of pain

• Transduction– Different forms of energy action potentials

• Transmission– Action potentials conducted through the

nervous system• Modulation• Perception

How do we feel pain?Somatosensory cortex

Thalamus

Ascending tracts

Midbrain

Medulla

Descending pathway

Dorsal horn area

Noxious stimuli activate receptors in periphery

2. Pain transmission

2. Pain transmission1. Pain nociception

(transduction)

3. Pain perception

ตาแหนง

• ศรษะ

• ฟน กราม

• สะโพก

• เขา

• เทา

• คอ

• ไหล

• หลง

• เอว




Pain

• ความสามารถ

• สภาวะจตใจ

• สงคม เศรษฐฐานะ

• คณภาพชวต




ปญหาทพบรวมกบอาการปวด

• Contracture/deformity• Weakness, disuse atrophy, deconditioning• Fatigue• Mobility impairment• Psycholgical• Social




เปาหมายของการดแลรกษาและฟนฟอาการปวด

• ระงบอาการปวด

• ฟนฟระดบความสามารถ

– ROM– Strength– Endurance– ADL

• ปองกน แกไข ปญหาอนทพบรวม

• ปองกนการเปนซารวมถงการปองกนไมใหเกดอาการปวดเรอรงและลดหรอตดวงจรทจะกระตนใหอาการปวดเรอรงเปนมากขน




MUSCULOSKELETAL PAIN





• bones, • joints, • muscles, • tendons, • ligaments, • bursae, or • a combination





a known consequence of • repetitive strain, • overuse, and • work-related musculoskeletal disorders

Global year against Musculoskeletal Pain Oct2009-Oct20102009 International Association for the Study of Pain10/11/56 26

กมลทพย หาญผดงกจ เวชศาสตร




• Acute or chronic, • Focal or diffuse

• Low back pain is the most common example of chronic musculoskeletal pain






Epidemiology and Economics• from overuse affects 33% of adults and

accounts for 29% of lost workdays due to illness

• The economic burden of musculoskeletal pain is second only to that of cardiovascular disease.






Pathophysiology• is not completely clear, but inflammation,

fibrosis, tissue degradation, neurotransmitters, and neurosensory disturbances have been implicated






Pathophysiology• Inflammation• Fibrosis• Tissue degradation• Neurotransmitters• Neurosensory/neuroimmune factors






Clinical Features• acute or chronic, • focal or diffuse






Symptoms• local symptoms of pain or widespread and

persistent pain • Tenderness • Peripheral nerve irritation• Weakness• Limited motion and stiffness






Symptoms• Symptoms progressively increase with greater

tissue injury and inflammation, with an increase in affected anatomical sites

• Symptoms are exacerbated by work-related or personal stress






Symptoms• Nerve conduction velocity decreases in an

involved peripheral nerve.• Symptoms have diurnal fluctuation.

Global year against Musculoskeletal Pain Oct2009-Oct20102009 International Association for the Study of Pain





Diagnosis • bones, • joints, • muscles, • tendons, • ligaments, • bursae, or • a combination

10/11/56กมลทพย หาญผดงกจ เวชศาสตร


Musculoskeletal Pain 35

Global year against Musculoskeletal Pain Oct2009-Oct20102009 International Association for the Study of Pain

Diagnosis is important.




Musculoskeletal Pain Treatment

Management is typically multimodal:

• Exercise

• Physical therapy

• Splinting and/or orthoses

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Reduction in workload or increased rest

• Stress management/behavioral intervention





• Low Back Pain• Neck and Shoulder Pain• Knee Pain




Low Back Pain




Definition of Low Back Pain

Any pain or tenderness that occurs between the lowest rib and the glutealfolds

“Pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain”

•

•

Adapted from Papageorgiou AC et al Spine 1995;20:1889–1894; Hillman M et al J Epidemiol Community Health 1996;50:347–352; Manek NJ, MacGregor AJ Curr Opin Rheumatol 2005;17:134–140; Rivero-Arias O et al BMJ 2005;330:1239.Musculoskeletal Pain กมลทพย หาญผดงกจ เวชศาสตร

ฟนฟ ศรราช10/11/56 41

Presenter

Presentation Notes

•Low back pain is an important clinical and public health problem1 •Estimates of its impact have been hampered by the absence of a clear, standardized definition •It is a symptom rather than a disease or diagnosis, and no objective standard can be used to�confirm its presence1,2 •One approach to defining low back pain is to specify the location of pain2,3 –Two groups of investigators defined low back pain as pain or tenderness between the lowest�rib and the lower gluteal folds –A mannequin with shaded areas was used to assist patients in identifying the site of pain –Other investigators have defined low back pain as pain, muscle tension, or stiffness localized�below the costal margin and above the inferior gluteal folds, with or without leg pain4 •Low back pain can also be defined by the specific duration of pain –In a comparative study of treatment strategies, chronic low back pain was defined as pain�lasting more than three months 5 –The report of the Québec Task Force on Spinal Disorders defined chronic pain as pain lasting�longer than seven weeks6 •Low back pain may originate from many spinal structures: Ligaments, facet joints, vertebral�periosteum, paravertebral musculature and fascia, blood vessels, anulus fibrosus, and spinal�nerve roots •Low back pain may be attributable to a variety of physical causes and organic diseases: �musculoligamentous injuries, disk herniation, infection, and cancer4,7 •As many as 90% of cases of low back pain have no identifiable cause4 •Although a wide range of therapeutic strategies are used to relieve low back pain, conclusive�evidence supporting the effectiveness of many of these interventions is limited8-10 –Medications (e.g., analgesics, muscle relaxants, nonsteroidal anti-inflammatory drugs [NSAIDs]) –Educational and behavioral programs (e.g., back schools) –Physical treatments (e.g., traction, back exercises, surgery) •The evaluation and treatment of low back pain present a challenge to clinicians

Temporal Classification

• Acute < 6 wks• Subacute6 wks – 3 mths• Chronic > 3 mths

Musculoskeletal Pain กมลทพย หาญผดงกจ เวชศาสตรฟนฟ ศรราช

10/11/56 42

Low back pain (LBP)

• The most common Musculoskeletal pain• Point prevalence 15-45%• Age 35-55 yr


10/11/56 43

Prevalence of back pain in the adult population varies with age.

An atlas of back pain 2002 / Scott Haldeman,William H. Kirkaldy-Willis, Thomas N.Musculoskeletal Pain กมลทพย หาญผดงกจ เวชศาสตร

ฟนฟ ศรราช10/11/56 44

• a point-prevalence of 17–30%,

• a 1-month prevalence of 19–43% and

• a lifetime prevalence of 60–80%.

An atlas of back pain 2002 / Scott Haldeman,William H. Kirkaldy-Willis, Thomas N.Musculoskeletal Pain กมลทพย หาญผดงกจ เวชศาสตรฟนฟ ศรราช

10/11/56 45

Anatomy




Lumbar spine

Three-joint

complex

• Muscles• The most critical component

• Ligaments• Intervertebral discs• Z-joints

Segmental stability




Lumbar and Abdominal muscles




Pain generators of the L-spine

Innervated structures

• Bone : vertebrae• Joints : zygapophyseal• Disc : ext annulus,

potentially decreased disk• Ligaments : ALL, PLL,

interspinous• Muscles & fascia• Nerve root

Non-innervated structures

• Ligamentum flavum• Internal annulus• Disk : nucleus pulposus




Classification (Macnab’s)

Spondylogenic

Neurogenic

Viscerogenic/Vascular

Psychogenic




Classification of low back pain

– Non specific low back pain

– Nerve root pain

• Disc herniation with radiculopathy

• Spinal stenosis with radiculopathy

– Serious spinal pathology




What Causes Acute Low Back Pain?

• In around 95% of cases it is not possible to pinpoint the cause of the pain.




• อาย < 18 ป หรอ > 55 ป• ประวตอบตเหต

• ปวดหลงระดบอก

• ปวดเพมขนProgressive non-mechanical pain • มประวต

– มะเรง

– ใชยาสเตยรอยด

– Drug abuse– HIV

Red flags




• Constitutional symptoms– นาหนกลด

– มไขกลางคน

• อาการออนแรง

• ควบคมการขบถายไมได

• โครงกระดกผดรป

• หลงแขง เคลอนไหวไมได

Red flags




Spondyloarthropathy

• Ankylosing spondylitis

• Reiter’s disease

• Psoriasis arthritis

• Arthritis associated with inflammatory bowel disease

• Undifferentiated spondyloarthropathy

5510/11/56Musculoskeletal Pain กมลทพย หาญผดงกจ เวชศาสตร


Yellow flags

• The presence of catastrophic thinking– there is no way the patient can control the pain,

that disaster will occur if the pain continues, etc.

• Expectations that the pain will only worsen with work or activity

• Behaviors such as avoidance of normal activity, and extended rest

• Poor sleep




Yellow flags

• Compensation issues• Emotions such as stress and anxiety• Work issues, such as poor job satisfaction and

poor relationship with supervisors• Extended time off work




Non specific low back pain

• Postural low back pain• Mechanical low back pain• Simple back pain• Back strain• Myofascial pain




Simple backache

• Onset 20-25 years

• Lumbosacral, buttock and thighs

• Mechanical pain

– Varies with physical activity

• Patient well, no serious disease



Back Pain

Back pain > Leg pain• L-spondylosis• L- disk disease

– Disruption– Herniation– Disk degeneration

• Spondylolysis• Spondylolisthesis• Spinal fracture/

Osteoporosis Fx• Mechanical

Leg pain > Back pain• LS radiculopathy• L-stenosis• Non – L spine cause

– Hip– SI – Soft tissue


10/11/56 61

Lumbar disk disease

classified into 3 types• Degenerative disk disease• Internal disk disruption• Disk herniation



• Lumbar disc herniation

• L-spondylosis




Disk Herniation




Presenter

Presentation Notes

A disk protrusion is defined as a herniation with the distance of the edges of the herniated material less than the distance of the edges at its base. A disk extrusion occurs when the distance of the edges of the herniated material is greater than the distance of the edges at its base. A disk extrusion can be further subclassified as sequestrated if the extruded disk material has no continuity with the disk of origin. Disk herniations can also be described as contained or uncontained depending on the integrity of the outer annular fibers. If the outer annular fibers are still intact, it is described as a contained disk herniation. This classification has no relevance to the integrity of the posterior longitudinal ligament. More than 95% of lumbar disk herniations occur at the L4–L5 and L5–S1 levels. Posterolateral disk herniations are most common because the annulus fibrosus is weakest posterolaterally. …Disc herniation: localized displacement of disc material beyond the normal margins of the disc, which is defined circumferentially by the outer edges of the ring apophyses of the vertebral body end plates and, craniad and caudad, by the end plates above and below the disc space (Fig. 28-2). A disc herniation may take the form of either a protrusion or an extrusion. Disc protrusion: localized displacement of disc material beyond normal disc margins in which the distance between the P.655 �edges of the base of the displaced disc material is greater than the distance between the edges of the disc material beyond the disc space. Disc extrusion: localized displacement of disc material beyond normal disc margins in which the distance between the edges of the base of the displaced disc material is smaller than the distance between the edges of the disc material beyond the disc space. Sequestration of a disc extrusion occurs when the displaced disc material has lost continuity with the original disc. Broad-based disc herniation: applies when the herniation involves between 25% and 50% of the total disc circumference. Disc bulge: โ€�circumferentialโ€� extension of disc material beyond the margins of the ring apophyses of the vertebral end plate, involving 50% to 100% of the total disc circumference, not considered a form of disc herniation.

Spondylolisthesisanterior slippage of one vertebra on another




Lumbar stenosis

Definition• defined as any type of narrowing of the lumbar

spinal canal, causing compression of its content




Gordon waddell, the back pain revolution second edition6710/11/56Musculoskeletal Pain กมลทพย หาญผดงกจ เวชศาสตร


Mixed Nociceptive/neuropathic painlow back pain

Ex. Nonpharmacologic• Acupuncture• Cognitive-behavioral

therapy• Exercise• Intensive rehabilitation • Massage • Progressive relaxation• Spinal manipulation• Yoga

Ex. Pharmacologic • Acetaminophen• Benzodiazepine• NSAIDs• Opioids• TCA




Medication

NSAIDs Muscle relaxants Antidepressant

Opioids Anticonvulsants




Injection & needle therapy

Trigger point injection

Acupuncture

TEN

Massage

Traction




Lumbar Traction

Contraindication/precaution




Lumbar support




Acupuncture




• Pain on extension load of back– Hand above head activities– Forward flexion– Sit in soft chair eg. car– Stand for long time

• Aggravated by – Abdominal muscle weakness– Obesity– Tightness of TFL

Recurrent aggravating backache




Activity Modification• Firm mattress• Sitting: chair with back

support, frequent stretching exercise

• Adjust height of table and keyboard

• Thinking before lifting– No twitch of spine– Use assistive devices

• Sport / recreation activity– Adjust for intensity

• Avoid prolong certain position10/11/56 75กมลทพย หาญผดงกจ เวชศาสตร

ฟนฟ ศรราชMusculoskeletal Pain

Back Exercise

• ROM exercise • Strengthening and endurance exercise• Flexion / extension / aerobic exercise




Back Exercise

• ROM exercise – Stretching low back muscle




• Modification of exercise that aggravate pain– Curl up sit up

Specific exercise for LBP




Back Exercise

• Strengthening and endurance exercise– Back Flexion Exercise




• 1 Minute Lower Back Pain Exercises.mp4




NECK PAIN




Neck Pain

• pain perceived as arising from anywhere within the region bounded superiorly by the superior nuchal line, inferiorly by an imaginary transverse line through the tip of the first thoracic spinous process and laterally by sagittal planes tangential to the lateral borders of the neck (Merskey and Bogduk 1994)




ปวดคอ

• 9-18%

10/11/56 84กมลทพย หาญผดงกจ เวชศาสตรฟนฟ ศรราช


กายวภาคศาสตร

• เนอเยอออน

• กระดก

• เนอเยอระบบประสาท เสนประสาท ไขสนหลง




Soft tissue




ปวดคอ

• เชงกล

• โรคขอ

• ตดเชอ

• เนองอก

• จตใจ

• ปวดราว

• อน



Evidence-based Management of Acute Musculoskeletal Pain10/11/56 89กมลทพย หาญผดงกจ เวชศาสตร



Neck strain

• อาการปวดคอทไมมอาการราวไปไหน สมพนธกบการใชงาน

หรอ อยในทาใดทาหนงนาน

• พบไดบอย

• อาย 30-50 ป

• กลามเนอ เนอเยอออนบรเวณคอ




Neck strain & sprain• ปวดตอๆ บรเวณคอ ชวงกลางหรอชวงลาง อาจราวไปทบา ไหล สะบก

ปวดเพมขนเมอเคลอนไหว

• อาจปวดศรษะรวมดวย

อาการ

• เคลอนไหวคอไดจากด

• มจดกดเจบ

• ไมพบความผดปกตของระบบประสาท และ ขอไหล

ตรวจ

รางกาย

• Plain film : loss of lordosisการสบคน




Whiplash syndrome

• C-hyperextension injury• Whiplash is an

acceleration-deceleration mechanical of energy transfer to the neck.

Syndrome

Injury

Event




Whiplash Syndrome• Discomfort at the scene → 12-14 hrs later neck

stiffness, pain at base of neck, ↑with movement• Headache• Pain on opening the mouth or chewing• Hoarseness, difficulty swallowing, visual disturbance,

dizziness• Paresthesias in the arm, dysesthesia of the face below

the ear

Symptom

• Muscle tenderness & contraction• Limit ROM

PE.

• Plain film : loss of lordosis• MRI

Inv.




Myofascial pain syndromeUpper trapezius• พบบอย

• Pain & fatique• Referred pain :• ขางและหลงคอ

• มมคาง

• หลงกกห

• ขมบ

• หลงเบาตา




Myofascial pain syndrome

Levator scapulaePain : มมลางกานคอ, stiff neck, ↑ pain when neck rotate to lesion

Referred pain :

มมลางกานคอ,

ขอบดานในscapular,

ดานหลงหวไหล




Treatment• Controlled physical activity

and immobilization• Medication (NSAID, muscle

relaxant)• Cold and heat.• Lightweight C-traction• Anesthesia and/or

corticosteroid injection.• Isometric exercise.



ROM

Isometric exercise




Postural exercise




Early Acupuncture




• 1 Minute Neck Stretches.mp4




ปวดบา ปวดไหล




• เหตภายใน ภายนอก

104

ปวดไหล



Anatomy

• Bones– Scapula– Clavicle– Humerus

• Joints– Sternoclavicular jt.– Acromioclavicular jt.– Glenohumeral jt.

• Interface : scapulothoracic



Presenter

Presentation Notes

Shoulder เปน jt. ทเชอมระหวาง UEs กบ ลำตว ทำหนาท เปนจดหมนขณะทแขนขยบไปมา Stabilize แขนใหอยนงขณะทม activity ของมอทตองใชความละเอยด เชน เขยนหนงสอ สวนประกอบของ shouldercomplex ไดแก Bones คอกระดก humerus, clavicle และ scapula Jointsไดแก sternoclavicular, acromioclavicular, glenohumeral นอกจากนยงม interface ททำหนาทเหมอนเปนขอคอ scapulothoracic interface

Myofascial pain syndrome

• Myofascial trigger points in certain muscles : provoke pain in shoulder region

• Pattern of radiating pain



MPS : Upper thoracic

108

Scalene Levator scapulae Trapezius



• 1 Minute Shoulder Stretches.mp4




OSTEOARTHRITIS - KNEE




WHO Report: OA Was Among the Most Widespread Health Problems1

WHO estimated that 151.4 million people worldwide suffered from OA in 2004

45 40

2722

10 6

01020304050

WesternPacific

Europe SoutheastAsia

TheAmericas

Africa EasternMediterranean

OA

pre

vale

nce,

mill

ions

WHO = World Health Organization; OA = osteoarthritis.1. WHO. The Global Burden of Disease: 2004 Update. Available at: www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf. Accessed 8-March-2011. 10/11/56 113




Presenter

Presentation Notes

The Global Burden of Disease: 2004 Update was a comprehensive assessment of the health of the world‘s population in 2004, which drew upon the extensive databases of the World Health Organization (WHO) and information provided by Member States to provide detailed estimates of premature mortality, disability, and loss of health for 135 causes by age and sex for the world, for regions of the world, and for countries grouped by average income per capita.1 This report built upon the work of technical programs within WHO at country, regional and global levels, and collaboration with partners, including United Nations agencies, the private sector, and academic institutions.1 WHO estimated that osteoarthritis (OA) affected about 151.4 million people across its 192 member states in 2004.1 On a regional level, OA affected1: 45 million people in the Western Pacific region 40.2 million in Europe 27.4 million in Southeast Asia 22.3 million in the Americas 10.1 million in Africa 6 million in the Eastern Mediterranean

WHO estimated that OA was one of the causes of moderate-to-severe disability in 43.4 million people worldwide in 2004

WHO Report: OA Was One of the Leading Causes of Moderate-to-Severe Disability Worldwide1

1. WHO. The Global Burden of Disease: 2004 update. Available at: www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf. Accessed 8-March-2011.

14.1

19.4

1.9

8.1

0

10

20

30

Low-to-middle–income countries

High-income countries

OA

-rel

ated

mod

erat

e-to

-sev

ere

disa

bilit

y pr

eval

ence

, mill

ions

Aged0–59 years

Aged60+ years

Aged0–59 years

Aged60+ years

WHO = World Health Organization; OA = osteoarthritis.10/11/56 114




Presenter

Presentation Notes

The data depicted on this slide are from the Global Burden of Disease: 2004 Update that was introduced 2 slides previously, which drew upon the extensive databases of the World Health Organization (WHO) and information provided by Member States and was a comprehensive assessment of the health of the world‘s population in 2004. In addition to being highly prevalent, osteoarthritis (OA) was one of the leading causes of moderate-to-severe disability across the globe.1 The WHO 2004 update estimated that OA was the 6th most common cause of moderate-to-severe disability across its member states in 2004, affecting an estimated 43.4 million people.1 In high-income countries, OA was the cause of moderate-to-severe disability in 10 million people.1 8.1 million were aged 60 years or older. 1.9 million were under 60 years of age. In low- to middle-income countries, OA was the cause of moderate-to-severe disability in 33.5 million people.1 19.4 million were aged 60 years or older. 14.1 million were under 60 years of age.

Pathogenic Features of OA• A metabolically active,

dynamic process that can involve all joint tissues1

• Key pathologic features1:– Loss of articular

cartilage– Remodeling of

adjacent bone– New bone formation

atjoint margins

1. National Collaborating Centre for Chronic Conditions. Osteoarthritis: National Clinical Guideline for Care and Management in Adults. Royal College of Physicians; 2008. 2. Hunter DJ et al. BMJ. 2006;332:639–642. Reprinted with permission.

Pathogenic Features Consistent With OA2

OA = osteoarthritis.




Presenter

Presentation Notes

Osteoarthritis (OA) is a metabolically active disease that can develop at any synovial joint; the knees, hips, and small hand joints are the most commonly affected sites.1 OA involves all joint tissues, including cartilage, bone, the synovium/capsule, ligaments, and muscle.1 Some of the key pathologic changes in OA include localized loss of articular cartilage and remodeling of adjacent bone with new bone formation at the joint margins.1 The combination of tissue loss and synthesis of new tissue suggests that OA is a repair process.1

Mechanisms Implicated in OA Pain1

OA pain is a complex integration of sensory, affective, and cognitive processesinvolving a number of abnormal cellular mechanisms in the PNS and CNS

OA = osteoarthritis; PNS = peripheral nervous system; CNS = central nervous system.1. Dray A et al. Arthritis Res Ther. 2007;9:212. Reprinted with permission.

Altered cortical processingAffective, cognitive integration

Altered spinal cord gating

PNSIncreased innervation density

Elevated receptor and neuropeptide expression

Structural pathology

Referred painMuscle hyperalgesia

NeuroinflammationNeuroimmunomodulation

Neuronal control of bone metabolism

Dysfunction of descending noxious inhibitory control

Episodic synovitis, nerve injury, bone sclerosis, meniscal damage, cartilage erosion, capsular thickening, angiogenesis




Presenter

Presentation Notes

Osteoarthritis (OA) pain is a complex condition consisting of both nociceptive and neuropathic mechanisms that are mediated by joint damage, as well as peripheral and central pain pathway hyperexcitability.1 The fact that OA pain often resolves following intra-articular anesthetic or joint replacement surgery suggests that OA pain originates from a peripheral site in the majority of patients.1 In the periphery, structural pathology is responsible for setting pain signaling in motion, and the release of inflammatory mediators (bradykinin, prostaglandins, etc) leads to nervous system hyperexcitability.1 Continuous nociceptor activity mediates structural/functional changes in primary nociceptive afferents and dorsal root ganglia that further drive pain signaling; these changes include increased membrane receptor/channel (eg, Na+) expression and innervation density.1 In addition, malfunction of descending noxious inhibitory control can also contribute to the pain of OA.1

Nociceptive pain: osteoarthritis

Nonpharmacologic• Exercise

– Aerobic – Strengthening– ROM

• Assistive devices for– ADL– Ambulation

• Jt, protection and energy conservation

• OT• Pt. education• Social suport• Self management• Wt.loss if overweight

Pharmacologic • Oral

– Acetaminophen– COX-2- specific inhibitor– NSAID+ PPI– Opioids, tramadol

• Intraarticular– Glucocorticoids– Hyarulonic acid

• Topical– Capsaicin– Methylsalicylate




OARSI Guidelines Recommended Medications* for OA Pain1

Acetaminophen

NSAIDs

COX-2 Inhibitors

Opioids (weak and strong)

*Recommended oral, non–disease modifying analgesics.OARSI = Osteoarthritis Research Society International; OA = osteoarthritis; NSAIDs = nonsteroidal anti-inflammatory drugs; COX-2 = cyclooxygenase-2.

1. Zhang W et al. Osteoarthritis Cartilage. 2008;16:137–162. 10/11/56 118กมลทพย หาญผดงกจ เวชศาสตร



Presenter

Presentation Notes

The Osteoarthritis Research Society International (OARSI) recommends a number of nondisease modifying oral medications for osteoarthritis (OA) pain management, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) selective agents, and opioids (both weak and strong).1

Insoles and footwear offer great potential, as simple, inexpensive-treatment strategies for knee osteoarthritis.

lateral wedge orthotics in the conservative management of medial compartment osteoarthritis




Aquatic exercise




การฝงเขม



• 1 Minute Knee Strengthening Exercises.mp4




TOPICAL ANALGESIA




Common Topical Analgesics

Drug Use FormulationCapsaicin Neuropathic pain,

MSK painPatch, gel

Lidocaine Neuropathic pain,MSK pain

Patch,Spray

Menthol, Methyl salicylates

MSK pain Ointment, liniment, cream

NSAID MSK pain Patch, gel, cream

MSK= musculoskeletalNSAID= Non-steroifal antiinflammatory drugs10/11/56 126




Forms

• Ointment• Patch• Cream

พลาสเตอรบรรเทาปวดยาหมอง




Counterirritants

• Capsaicin• Camphor• Menthol

• are a category of analgesics that excite and subsequently desensitize nociceptive sensory neurons




Capsaicin• By reversibly depleting sensory nerve endings

of substance P and

• By reducing the density of epidermal nerve fibers, also in a reversible fashion

• Capsaicin 0.025%-0.075%




Menthol

ระงบปวด

• กระตน endogenous opioid system and/or *• ลดปวดเฉพาะท แต ไมลดอกเสบ*

• ชวยเพมการดดซม**• ขยายหลอดเลอด**

*Taniguchi, Y., Y. Deguchi, et al. (1994)."[Antinociceptive effects of counterirritants]." Nippon Yakurigaku Zasshi 104(6): 433-446.

**Stitik TPMD, Altschuler EMD, Foye PMMD. Pharmacotherapy of Osteoarthritis. American Journal of Physical Medicine & Rehabilitation Osteoarthritis and Physiatry. 2006 November;85(11):S15-S28.




• ชอในตารายา พรมเสง, พะยก, อบเชยญวน

• ชอไทย การบร

• ชอวทยาศาสตร Cinnamomum camphora• วงศ Lauraceae

http://www.botanical.com/botanical/mgmh/c/campho13.html

Camphor การบร




TAKE HOME MESSAGE




เปาหมายของการดแลรกษาและฟนฟอาการปวด

• ระงบอาการปวด

• ฟนฟระดบความสามารถ

– ROM– Strength– Endurance– ADL

• ปองกน แกไข ปญหาอนทพบรวม

• ปองกนการเปนซารวมถงการปองกนไมใหเกดอาการปวดเรอรงและลดหรอตดวงจรทจะกระตนใหอาการปวดเรอรงเปนมากขน




Diagnosis is important.




Musculoskeletal Pain Treatment

Management is typically multimodal:

• Exercise

• Physical therapy

• Splinting and/or orthoses

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Reduction in workload or increased rest

• Stress management/behavioral intervention





Capsaicin

• By reversibly depleting sensory nerve endings of substance P and

• By reducing the density of epidermal nerve fibers, also in a reversible fashion

• Capsaicin 0.025%-0.075%




Prevent Recurrence

• Correct posture• Activity modification • Exercise




Ergonomic Set Up for Desk Top Computer

http://www.wristassuredgloves.com/2012/03/14/ergonomic-set-up-for-desk-top-computers/10/11/56 138




http://www.wristassuredgloves.com/2012/03/14/ergonomic-set-up-for-desk-top-computers/

• Vodafone- Power to you.mp4




THANK YOU FOR YOUR ATTENTIONS.




สรรวทยา




Musculoskeletal Pain Treatment • Management is typically multimodal: • Physical therapy, primarily with an exercise program

(aerobic, strengthening, stretching), together with physical modalities, such as heat or ice

• Splinting and/or orthoses• Use of nonsteroidal anti-inflammatory drugs (NSAIDs),

e.g., ibuprofen • Reduction in workload or increased rest • Stress management/behavioral intervention





Ergonomic Set Up for Desk Top Computers






rgonomic Set Up for Desk Top






Back pain > leg pain

• L-spondylosis• L-disk disease• Internal disk disruption• Disk herniation• Disk degeneration

• Spondylolysis• Spondylolisthesis• Spinal fractures

(+osteoporotic Fx)• Mechanical LBP

Leg pain > back pain

• LS radiculopathy• L-stenosis• Non – L spine cause : • SI/ hip jt disease• Soft tissue Dz

(piriformis synd, greater troch pain, ITB synd, MPS)

• Vascular disorder• Peripheral n disorders




Acute pain

4 basic processes involved in nociception

• transduction;• transmission;• perception;• modulation




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