Das biopsychosoziale Modell als Leitfaden für die Behandlung von muskuloskelettalen Schmerzen und Behinderungen durch bewegungsbasierte Therapie

Zusammenfassung

Hintergrund: Ob Schmerzpatienten aus physiotherapeutischer Sicht geeignete Kandidaten für die Rehabilitation in Form einer bewegungsbasierten Therapie sind, hängt vor allem von der zugrunde liegenden Pathologie ab.

Ziel/Methode/Ergebnisse: Sowohl für geeignete als auch ungeeignete Pathologien werden Beispiele angeführt. Selbst bei fehlender Kontraindikation sind die Erfolgschancen klinischer Entscheidungen, die auf dem mittlerweile als überholt geltenden „biomedizinischen” (strukturbasierten) Modell basieren, als recht gering einzuschätzen.

Die Evidenz der „Best Practice” zeigt, dass sich bessere klinische Ergebnisse und eine bessere Wahrnehmung der Selbstwirksamkeit durch die Therapeuten am wahrscheinlichsten durch Strategien erreichen lassen, die auch die psychologischen „Triebfedern” der muskuloskelettalen Schmerzen berücksichtigen. Anhand von Beispielen und Evidenz wird dargelegt, dass sich gut ausgebildete Physiotherapeuten in einer idealen Position befinden, um auf den Prinzipien und der Praxis der kognitiven Verhaltenstherapie basierende Strategien anzuwenden.

Schlussfolgerung:Die kognitive Verhaltenstherapie ist ein Produkt des heutzutage bevorzugten biopsychosozialen Modells von Schmerzen und schmerzbedingter Behinderung.

Abstract

Background: Whether or not pain patients presenting to physiotherapists are suited for rehabilitation using movement-based treatments depends critically on the nature of the underlying pathology.

Objective/Method/Results: Examples are given of suitable and unsuitable pathologies. However, even when not contraindicated, where clinical decisions are based on the outmoded ”biomedical” (structure-based) model, which often seems to be the case, the chances of success are seriously limited.

”Best practice” evidence indicates that better clinical outcomes, along with therapists’ improved perceptions of self efficacy, are likely to be achieved by strategies that also address psychological drivers of musculoskeletal pain. On the basis of examples and evidence it is argued, that well-trained physiotherapists are ideally positioned to utilise appropriate strategies based on the principles and practice of cognitive behavioural therapy.

Conclusion:Cognitive behavioural therapy is a product of the now preferred biopsychosocial model of pain and pain-related disability.

Schmerzen - Rehabilitation - Physiotherapie - biopsychosoziales Modell - kognitive Verhaltenstherapie

pain - rehabilitation - physical therapy - biopsychosocial model - cognitive behavioural therapy

Literatur

• 1 Ali N, Thomson D. A comparison of the knowledge of chronic pain and its management between final year physiotherapy and medical students.  European Journal of Pain. 2009;  13 38-50
• 2 Amir R, Argoff C E, Bennett G et al. The role of sodium channels in chronic inflammatory and neuropathic pain.  The Journal of Pain. 2006;  7 S1-S29
• 3 Apkarian A V, Scholtz J. Shared mechanisms between chronic pain and neurodegenerative disease.  Drug Discovery Today: Disease Mechanisms. 2006;  3 319-326
• 4 Arnetz J, Almin K, Bergström Y et al. Active patient involvement in the establishment of physical therapy goals: effects on treatment outcome and quality of care.  Adv Physiother. 2004;  6 50-69
• 5 Åsenlöf P, Denison E, Lindberg P. Individually tailored treatment targeting activity, motor behavior, and cognition, reduces pain-related disability: a randomised controlled trial in patients with musculoskeletal pain.  The Journal of Pain. 2005;  6 588-603
• 6 Åsenlöf P, Denison E, Lindberg P. Idiographic outcomes analyses of the clinical significance of two interventions for patients with musculoskeletal pain.  Behav Res Ther. 2006;  44 947-965
• 7 Åsenlöf P, Denison E, Lindberg P. Long-term follow-up of tailored behavioural treatment and exercise based physical therapy in persistent musculoskeletal pain: a randomised controlled trial in primary care.  European Journal of Pain. 2009;  13 1080-1088
• 8 Bennett G. Can we distinguish between inflammatory and neuropathic pain?.  Pain Research & Management. 2006;  11 11A-15A
• 9 Bialosky J E, Bishop M D, Price D D et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model.  Manual Therapy. 2009;  14 531-538
• 10 Burton A K, Waddell G. Clinical guidelines in the management of low back pain.  Bailliere’s Clinical Rheumatology. 1998;  12 17-35
• 11 Campbell J N, Meyer R A. Mechanisms of neuropathic pain.  Neuron. 2006;  52 77-92
• 12 Campbell W W, Landau M E. Controversial entrapment neuropathies.  Neurosurg Clin N Am. 2008;  19 597-608
• 13 Clauw D J, Crofford L J. Chronic widespread pain and fibromyalgia: what we know, and what we need to know.  Best Practice & Research Clinical Rheumatology. 2003;  17 685-701
• 14 Costigan M, Befort K, Karchewski I et al. Replicate high-density rat genome oligonucleotide microarrays reveal hundreds of regulated genes in the dorsal root ganglion after peripheral nerve injury.  BMC Neurosci. 2002;  3 16-34
• 15 Crombez G, Damme van S, Eccleston C. Hypervigilance to pain: an experimental and clinical analysis.  Pain. 2005;  116 4-7
• 16 Daykin A R, Richardson B. Physiotherapists’ pain beliefs and their influence on the management of patients with chronic low back pain.  Spine. 2004;  29 783-795
• 17 Derbyshire S W, Whalley M G, Stenger V A et al. Cerebral activation during hypnotically induced and imagined pain.  Neuroimage. 2004;  23 392-401
• 18 Devor M. Sodium channels and mechanisms of neuropathic pain.  The Journal of Pain. 2006;  7 S3-S12
• 19 Devor M. Cellular processes associated with ectopia.  European Journal of Pain. 2007;  11 S10
• 20 Djouhri L, Koutsikou S, Lawson S N. Spontaneous pain behaviour is related to spontaneous firing frequency in uninjured nociceptive C-fibre neurons after spinal nerve axotomy.  European Journal of Pain. 2007;  11 S63
• 21 Dyson M. Inflammation, wounds and wound healing. In: Shamley D, (ed) Pathophysiology: An Essential Text for the Allied Health Professions.. Edinburgh: Elsevier; 2005
• 22 Edwards R R, Bingham C O, Bathon J et al. Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases.  Arthritis & Rheumatism. 2006;  55 325-332
• 23 Eisenberger N I, Lieberman M D, Williams K D. Does rejection hurt? An FMRI study of social exclusion.  Science. 2003;  302 290-292
• 24 Evers A, Kraaimaat F, Riel van P et al. Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: a randomized controlled trial.  Pain. 2002;  100 141-153
• 25 George S, Fritz J, Bialosky J E et al. The effect of fear-avoidance-based physical therapy intervention for acute low back pain: results of a randomized controlled trial.  Spine. 2003;  28 2551-2560
• 26 Gracely R H, Geisser M E, Giesecke T et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia.  Brain. 2004;  127 835-843
• 27 Hahn C, Schwartz M A. Mechanotransduction in vascular physiology and atherogenesis.  Nature Reviews Molecular Cell Biology. 2009;  10 53-62
• 28 Harding V, Williams A C. Extending physiotherapy skills using a psychological approach: cognitive-behavioural management of chronic pain.  Physiotherapy. 1995;  81 681-688
• 29 Haythornthwaite de J, Benrud-Larson L. Psychological aspects of neuropathic pain.  The Clinical Journal of Pain. 2000;  16 S101-S105
• 30 Hinz B. Formation and function of the myofibroblast during tissue repair.  Journal of Investigative Dermatology. 2007;  127 526-537
• 31 Hinz B, Phan S H, Thannickal V J et al. The myofibroblast: one function, multiple origins.  The American Journal of Pathology. 2007;  170 1807-1816
• 32 Jensen T, Madsen C S, Finnerup N B. Pharmacology and treatment of neuropthic pains.  Current Opinion in Neurology. 2009;  22 467-474
• 33 Keefe F J, Dunsmore J, Burnett R. Behavioral and cognitive-behavioral approaches to chronic pain: recent advances and future directions.  J Consult Clin Psychol. 1992;  60 528-536
• 34 Keefe F J, Dixon K E, Pryor R W. Psychological contributions to the understanding and treatment of pain. In: Merskey H, Loeser J D, Dubner R, (eds) The Paths of Pain 1975 – 2005.. Seattle: IASP; 2005
• 35 Koes B, Tulder van M, Ostelo R et al. Clinical guidelines for the management of low back pain in primary care.  Spine. 2001;  26 2504-2514
• 36 Legrain V, Guérit J M, Bruyer R et al. Attentional modulation of the nociceptive processing into the human brain: selective spatial attention, probability of stimulus occurrence, and target detection effects on laser evoked potentials.  Pain. 2002;  99 21-39
• 37 MacDonald M R. Catastrophizing, coping and validation for chronic pain: a comment on Boothby et al (2004).  Pain. 2004;  112 221
• 38 Mackinnon S E. Pathophysiology of nerve compression.  Hand Clinics. 2002;  18 231-241
• 39 Main C J, Watson P J. Psychological aspects of pain.  Manual Therapy. 1999;  4 203-215
• 40 Maitland G D, Banks K, English K et al. Maitland’s vertebral manipulation. Butterworth-Heinemann. Oxford; 2005 7th ed
• 41 Mayer E A, Bushnell M C. Functional pain syndromes: presentation and pathophysiology. IASP. Seattle; 2009
• 42 Méchaly I, Bourane S, Piquemal D et al. Gene profiling during development and after a peripheral nerve traumatism reveals genes specifically induced by injury in dorsal root ganglia.  Mol Cell Neurosci. 2006;  32 217-229
• 43 Moalem G, Tracey D J. Immune and inflammatory mechanisms in neuropathic pain.  Brain Research Reviews. 2006;  51 240-264
• 44 Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behavioural therapy for chronic pain in adults, excluding headaches.  Pain. 1999;  80 1-13
• 45 Neugebauer V. Subcortical processing of nociceptive information: basal ganglia and amygdala. In: Cervero F, Jensen T S, (eds) Handbook of Clinical Neurology: Pain. Vol. 81.. Edinburgh: Elsevier; 2006
• 46 Ohara S, Crone N E, Weiss N et al. Attention to painful cutaneous laser stimulus modulates electrocorticographic event-related desynchronization in humans.  Clinical Neurophysiology. 2004;  115 1641-1652
• 47 Ossipov M H, Porreca F. Descending excitatory systems. Handbook of Clinical Neurology: Pain. Vol. 81.. Edinburgh: Elsevier; 2006
• 48 Overmeer T, Linton S J, Boersma K. Do physical therapists recognise established risk factors? Swedish physical therapists’ evaluation in comparison to guidelines.  Physiotherapy. 2004;  90 35-41
• 49 Overmeer T, Boersma K, Linton S J. Psychosocial factors in back pain: a comparison of factors listed by health care providers with the evidence. In: Flor H, Kalso E, Dostrovsky J O, (eds) Proceedings of the 11th World Congress on Pain.. Seattle: Elsevier; 2006
• 50 Pertovaara A, Almeida A. Descending inhibitory systems. In: Cervero F, Jensen T S, (eds) Handbook of Clinical Neurology: Pain. Vol. 81.. Edinburgh: Elsevier; 2006
• 51 Pham K, Gupta R. Understanding the mechanisms of entrapment neuropathies.  Neurosurg Focus. 2009;  26 1-8
• 52 Price D D. Psychological and neural mechanisms of the affective dimension of pain.  Science. 2000;  288 1769-1772
• 53 Robinson D A, Calejesan A A, Wei F et al. Endogenous facilitation: from molecular mechanisms to persistent pain.  Current Neurovascular Research. 2004;  1 11-20
• 54 Rose M, Stanley I, Peters S et al. Wrong problem, wrong treatment.  Physiotherapy. 1999;  85 322-328
• 55 Schofferman J. Restoration of function: the missing link in pain medicine.  Pain Medicine. 2006;  7 S159-S165
• 56 Singer T, Seymour B, O’Doherty J et al. Empathy for pain involves the affective but not sensory components of pain.  Science. 2004;  303 1157-1162
• 57 Söderlund A. Evidence based physiotherapy of chronic pain.  European Journal of Pain. 2009;  13 S3
• 58 Söderlund A, Lindberg P. An integrated physiotherapy/cognitive-behavioural approach to the analysis and treatment of chronic Whiplash-Associated Disorders, WAD.  Disability and Rehabilitation. 2009;  23 436-447
• 59 Strong J, Unruh A M. Psychologically based pain treatment. In: Strong J, Unruh A M, Wright A, (eds) Pain – A Textbook for Therapists.. Edinburgh: Churchill Livingstone; 2002
• 60 Sullivan M JL, Linton S, Shaw W S. Risk-factor-targeted psychological interventions for pain-related disability. In: Flor H, Kalso E, Dostrovsky J O, (eds) Proceedings of the 11th World Congress on Pain.. Seattle: Elsevier; 2006
• 61 Suzuki R, Rygh L J, Dickenson A H. Bad news from the brain: descending 5-HT pathways that control spinal pain processing.  Trends in Pharmacological Sciences. 2004;  25 613-617
• 62 Tracey I, Mantyh P W. The cerebral signature for pain perception and its modulation.  Neuron. 2007;  55 377-391
• 63 Turk D. Biopsychosocial perspective on chronic pain. In: Gatchel R, Turk D, (eds) Psychological Approaches to Pain Management.. New York: Guilford; 1996
• 64 Turk D C. Understanding pain sufferers: the role of cognitive processes.  The Spine Journal. 2004;  4 1-7
• 65 Vicenzino B, Wright A. Physical treatments. In: Strong J, Unruh A M, Wright A, (eds) Pain – A Textbook for Therapists.. Edinburgh: Churchill Livingstone; 2002
• 66 Vlaeyen J WS, Linton S J. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.  Pain. 2000;  85 317-332
• 67 Vlaeyen J WS, Jong de J, Geilen M et al. The treatment of fear of movement/(re)injury in chronic low back pain: further evidence of the effectiveness of exposure in vivo.  The Clinical Journal of Pain. 2002;  18 251-261
• 68 Vlaeyen J WS, Nielson W R, Houdenhove B. Overuse as a risk factor for pain disability: cognitive-behavioral models and interventions. In: Flor H, Kalso E, Dostrovsky J O, (eds) Proceedings of the 11th World Congress on Pain.. Seattle: Elsevier; 2006
• 69 Wang N, Tytell J D, Ingber D E. Mechanotransduction at a distance: mechanically coupling the extracellular matrix with the nucleus.  Nature Reviews Molecular Cell Biology. 2009;  19 75-82
• 70 Wipff P J, Hinz B. Integrins and the activation of latent transforming growth factor &beta1 – an intimate relationship.  European Journal of Cell Biology. 2008;  87 601-615
• 71 Woby S R, Watson P J, Roach N K et al. Are changes in fear-avoidance beliefs, catastrophising, and appraisals of control, predictive of changes in chronic low back pain and disability?.  European Journal of Pain. 2004;  8 201-210
• 72 Woby S R, Roach N K, Urmston M et al. The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy.  European Journal of Pain. 2007;  11 869-877
• 73 Woolf C J. Pain: moving from symptom control toward mechanism-specific pharmacologic management.  Annals of Internal Medicine. 2004;  140 441-451
• 74 Wyke B. Articular neurology – a review.  Physiotherapy. 1972;  58 94-99
• 75 Zhuo M. Cortical excitation and chronic pain.  Trends in Neurosciences. 2008;  31 199-207
• 76 Zubieta J K, Stohler C S. Neurological mechanisms of placebo responses.  Ann N Y Acad Sci. 2009;  1156 198-210
• 77 Zusman M. The meaning of mechanically produced responses.  The Australian Journal of Physiotherapy. 1994;  40 35-39
• 78 Zusman M. Mechanisms of musculoskeletal physiotherapy.  Physical Therapy Reviews. 2004;  9 39-49
• 79 Zusman M. Associative memory for movement-evoked chronic back pain and its extinction with musculoskeletal physiotherapy.  Physical Therapy Reviews. 2008;  13 57-68
• 80 Zusman M. Mechanisms of peripheral neuropathic pain: implications for musculoskeletal physiotherapy.  Physical Therapy Reviews. 2008;  13 313-323
• 81 Zusman M. Pain science and mobilisation of painful compressive neuropathies.  Physical Therapy Reviews. 2009;  14 285-289
• 82 Zusman M. Übersicht über Schmerzmechanismen: Implikationen fur Diagnose und physiotherapeutische Behandlung „problematischer” Schmerzpatienten.  manuelle Therapie. 2009;  13 167-172
• 83 Zusman M. There’s something about passive movement.  Medical Hypotheses. 2010;  (in press)