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14 October, 2019 00:00 00 AM

Pain Management of older persons: physiotherapy is the hope

JAMES GALLAGHER
Pain Management of older persons: physiotherapy is the hope

Every year on 1st October, WHO has been playing a significant role in celebrations, and actively promoting public awareness of the “International Day of Older Persons”. There are currently around 700 million people over the age of 60. It is predicted that by 2050, this figure will have risen to 2 billion. These figures have prompted a lot of attention and various initiatives have been started to try and address the problems that will arise. For example, the Vienna Plan of Action on Ageing which was adopted in 1982. The United Nations Principles for Older Persons was adopted in 1991.

2019 Theme: "The Journey to Age Equality"

But in this journey pain and loss of functioning is the biggest challenge. Pain in older people is highly prevalent and widely accepted as something to be expected and regarded as ‘normal’ in later life. Hence, suffering associated with persistent pain in older people often occurs without the appropriate assessment and treatment.

The impact of persistent pain on older people and on the health and social care system is significant and of great concern. Pain in older people is an increasingly important health issue, and one that requires urgent attention.

‘“Living with pain” is a contradiction in terms.

Why? If you are constantly in pain, you don’t have a life.’                                                                                         …….Vanessa Wilson

Medication use in the elderly

Treating pain in the elderly is complicated further by the fact that 75% of people age 65 and older have 2 or more chronic conditions—such as heart disease, diabetes, chronic lung disease etc. NSAIDs are used commonly to treat musculoskeletal pain in the elderly, with some prescribers favoring NSAIDs over opioids for pain management.

NSAID use is frequent among the elderly, but these agents pose considerable risks to this population. They interfere with certain necessary medications for blood disorders, heart problems, renal problems, or may be contraindicated with certain medications.

Elderly patients are at increased risk for gastrointestinal toxicity associated with NSAIDs, specifically peptic ulcers. Gastro-protective drugs, such as misoprostol and proton pump inhibitors, could help those taking NSAIDs for long-term pain relief therapy.

So!!!  What is the solution???

Yes, physiotherapy is the solution.

Chronic musculoskeletal pain is the most common, non-malignant disabling condition that affects at least one in four older people. The most musculoskeletal pain in the joints of the upper and lower extremities, especially hips, knees, and hands, is associated with the degenerative changes of osteoarthritis. Older adults may also develop tendonitis and bursitis, as well as inflammatory joint and muscle disease. The most common painful musculoskeletal conditions among older adults are osteoarthritis, low back pain, fibromyalgia, chronic shoulder pain, knee pain, myofascial pain syndrome and previous fracture sites.

Physiotherapy interventions reduce stress and correct malalignments of joint structures, correct muscle imbalances, and enhance the shock absorption capacity of tissue structures. Selection of appropriate treatments must include consideration of contraindications associated with the patient’s comorbid conditions (e.g., osteoporosis or osteopenia).

Manual therapy

There are evidences on the use of joint mobilization, stretching, neural mobilization  and manipulation specifically for older adults, research has addressed the use of these treatments for knee and hip osteoarthritis (OA), conditions common in older adults . The benefit of manual therapy on pain and function for knee or hip OA is higher.

A Cochrane systematic review concludes that manual therapy alone is insufficient in the management of persistent neck pain. However, there is strong evidence that either manipulation or mobilization combined with exercise is effective in reducing pain. This review also concluded that manual therapy with exercise improves function and the patients’ global perceived effect of treatment.

Electrotherapy

Superficial heating agents (e.g. hot packs, warm hydrotherapy, paraffin, fluidotherapy and infrared) or deep heating agents (e.g. short-wave and microwave diathermy, and ultrasound) can be used to increase blood flow, membrane permeability, tissue extensibility and joint range of motion in ways that can contribute to decreasing pain. Heat and cold alter both peripheral and central nervous system excitability, and can thus serve as a means of modulating pain

Protective and supportive devices

Protective and supportive devices assist a decrease in pain and increase in function for patients with joint instability or malalignment. Therapeutic taping for patellar realignment is effective in reducing pain and improving function in patients with osteoarthritis of the knee

Transcutaneous electrical nerve stimulation

High-frequency TENS appears to be the most effective TENS application for postsurgical pain and can be used with modulating frequencies to control neurologic accommodation.

Cognitive-behavioral therapy

The American Psychological Association recognizes cognitive-behavioral therapy (CBT) as an empirically supported intervention in management of chronic musculoskeletal pain; including rheumatoid arthritis, osteoarthritis, fibromyalgia, and low back pain. Its foundation is the gate control theory integrating the sensory, affective, and cognitive components of pain. Cognitive processes are thoughts, self-statements, or evaluations about the pain and beliefs, interpretations, or attributions regarding this condition.

Exercise

In recent years exercise, which is one of the non-pharmacological approaches, is getting the most important component of Chronic Pain management. Regular exercise, interventions to increase physical activity, strengthening the muscles, accompanied with weight loss are effective methods in the management of CMP such as OA, low back pain etc. in older adults.

Regular moderate level exercise training or increased physical activity does not aggravate pain and joint symptoms as expected in OA according to RCTs and elicit significant health benefits.

But pain, swelling, fatigue and weakness during activity or lasting more than 1-2 hours after exercise should be always considered as sign of excessive stress. Any activity that worsens pain or the other symptoms, and in acute flare-up periods of rheumatoid arthritis should be discontinued.

Benefits of exercise in chronic musculoskeletal pain

Regular exercise also as an important adjunct to other interventions (e.g. thermal agents, patient education, etc.) is the most frequently preferred pain management strategies after medication in some older adult populations .

Various forms of exercise can modulate pain either directly or indirectly. Passive or active exercise has a direct effect on pain through increasing input from joint mechanoreceptors.

Indirect effects of exercise on pain may be related to increased blood flow, decreased edema, inhibition of muscle spasm, enhanced ROM, flexibility, strength and weight loss which may improve biomechanical factors and decrease joint stress, and provide  improved sleep, enhanced mood, relaxation, reduction in anxiety and general well-being.

Types of exercise used in chronic musculoskeletal pain

A professional Physiotherapist is the right person to decide a comprehensive exercise program for any individual. Exercises are not general to all. Every individual are unique and for that reason, exercise should be very much individual. Some common types of exercises:  

Flexibility exercises

Aerobic exercises

Strengthening exercise

Aquatic exercise

Only high quality Physiotherapy treatment can ensure pain free life of our older community. Proper Physiotherapy treatment can enrich their quality of life and turn them to human resource for the development of our beloved country. 

Dr. Bijoy Das. PT

In Charge, Physiotherapy Department

BRB Hospitals Limited

Email: dr.bjoy@gmail.com

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Editor : M. Shamsur Rahman

Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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