CHRONIC MUSCULOSKELETAL PAIN SYNDROMES:
OCCUPATIONAL THERAPY EVALUATION AND INTERVENTIONS
FOR THE CHILD AND ADOLESCENT PATIENT
Ashley Binkowski, MS, OTR/L, CKTP
Rachel Bambrick, MS, OTR/L
The Center for Rehabilitation
LEARNING OBJECTIVES
• Define chronic pain
• Understand the OT evaluation process for children with AMPS
• Identify client factors in creating an evidence-based treatment plan for AMPS
• Implement OT treatment interventions including desensitization, self-care re-training, and therapeutic activities
DEFINITION AND SIGNIFICANCE OF CHRONIC PAIN
• https://vimeo.com/user8989405/review/346551813/482674a293
3
DEFINING PAIN
• “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
• Subjective experience
• May be present without any specific, identifiable injury or disease
4
International Association for the Study of Pain. Pain, IASP Pain Terminology. 1994.
DEFINITION OF CHRONIC PAIN
• Recurrent or persistent pain lasting longer than the normal tissue healing time
• Pain ≥ 3 – 6 months*
* Not required for AMPS
5
American Pain Society Task Force on Pediatric Chronic Pain Management, 2012
IMPACT OF PEDIATRIC CHRONIC PAIN
• Affects 2-6% of school-aged children
• Increased healthcare utilization
• Psychosocial problems
• Economic costs
• Increased risk of continued chronic pain into adulthood
6
Sherry DD, et al. J Pediatr, 2015. King S, et al. Pain, 2011.Hoffart CM, Wallace DP. Curr Opin Rheumatol, 2014. Sleed M, et al. Pain, 2005.
AMPLIFIED MUSCULOSKELETAL PAIN SYNDROME
• Umbrella term for chronic non-inflammatory musculoskeletal pain conditions
• Descriptive
• Does not assume an etiology
• Body amplifies the pain• Child is not willfully exaggerating the pain
7
8
Amplified Musculoskeletal Pain Syndrome
Chronic Pain Syndrome
Primary pain disorder
Chronic Non-inflammatory
Musculoskeletal Pain Syndrome
Juvenile Fibromyalgia
Syndrome
Myofascial Pain
Syndrome
Neuropathic pain
Chronic Fatigue
Syndrome
Sudekatrophy
Complex Regional
Pain Syndrome
Reflex Neurovascular
Dystrophy (RND)
Reflex Sympathetic
Dystrophy (RSD)
Causalgia
Algodystrophy
Shoulder-hand
syndrome
Chronic Widespread
Pain
Fibrositis
TERMINOLOGY
EPIDEMIOLOGY
• Median age at diagnosis 14 years (IQR: 12-16)
• More common in females
• Predominantly non-Hispanic Caucasians
• Median duration of pain: 12 months (IQR: 7-30)
9
MEASURES OF PAIN
• Verbal pain score (0-10)
• Visual analog scale
10
Zompo F, Mangiola et al. 2016
PAIN INTERFERENCE
• Functional disability inventory (FDI)
• Scores range from 0 – 60
• Higher scores indicate worse function
11
Level of disability FDI Score
No/minimal 0-12
Moderate 13-29
Severe ≥ 30
Flowers and Kashikar-Zuck 2011
12
AMPS
≤ 2 body regions
CRPS 1Localized
AMPS
≥ 3 body regions
Diffuse AMPS
autonomic dysfunction?
YES NO
Pain frequency: Constant vs. Intermittent
*All subjects were treated between February 2001 and October 2015 at CHOP or Seattle Children’s.
COMPLEX REGIONAL PAIN SYNDROME, TYPE 1
• Pain accompanied by ≥ 1 sign of autonomic dysfunction
• Type 1 occurs without a definable nerve lesion
• Leg is usually involved
14
AUTONOMIC SIGNS
• Cold
• Cyanotic
• Clammy
• Decreased pulse
• Dystrophic skin
• Increased perspiration
• Edema
15
Courtesy of Dr. David D. Sherry
16
Courtesy of Dr. David D. Sherry
17
Courtesy of Dr. David D. Sherry
KEY POINTS FROM THE HISTORY
• Pain for extended period of time
• No improvement with medicine
• Pain with hugging, light touch, etc.
• History of concussions, fractures, hospital stays and “poor healing”
• Pan-positive review of systems
• Very detailed descriptions and ratings of pain
18
SOCIAL HISTORY THEMES
• Tendency to identify stress as a pain trigger
• Recent major life events
• Family members with chronic pain
• Personality: mature, people-pleaser, high-achieving, perfectionist
• Withdrawal from activities – school, sports, etc.
19
CLUES FROM PHYSICAL EXAM
• Incongruent affect• Smiling despite pain
• La belle indifference
• Allodynia with variable borders• Not a dermatomal distribution
20
OVERARCHING TREATMENT APPROACH
• Non-pharmacologic
• Multi-disciplinary
• Emphasis on restoring function
• Counter-intuitive to typical approach to pain• Push through the pain
• May get worse before it gets better
• Providing reassurance that pain is not damaging
21
THE A-B-C’S OF TREATMENT
• Aerobic Exercise including PT/OT
• Behavioral Health Referral• Psychological Counseling
• Curbing over-medicalization and discontinuing medications
• Desensitization techniques
• Education
22
TREATMENT SUCCESS WITH MULTIDISCIPLINARY APPROACH
• Cognitive behavioral therapy (CBT) alone does not increase physical activity
• CBT + exercise found to have greater decreases in pain than CBT alone, as well as improvements in disability
23
Kashikar-Zuck, Black et al. J Pain. 2018
Kashikar-Zuck, S., et al. Arthritis Care Research, 2013
CONCLUSIONS
• Multi-disciplinary, non-pharmacologic approach is key to long-term success
• Focus on restoring function > pain reduction
• Empower patients and their families to take ownership over their own treatment plan
24
THERAPY EVALUATION PROCESS
CHOP OT/PT EVALUATION
• Specific blocks in OP schedule• 1-2 days a week at various sites
• 90 minute co-evaluation
• Often 1st time getting evaluated and provided education
• By end of evaluation, a clinical decision made by OT/PT on plan of care
26
WHY A CO-EVALUATION?
• Limits repetitive intake process
• Allows for two trained professionals to come together on a holistic clinical decision
27
Examination
Fin e motor
Fu n ctional Mobility
A DL’s
Gr oss Motor
REFERRAL SOURCE
• Script from MD/CRNP/PA• PCP vs. Specialist
• May or may specify AMPS diagnosis
• Direct Access (PT only)• Can be a tricky diagnosis to differentiate
28
INTAKE
29
https://dharmacomics.com/dharma-comics/tell-me-where-it-hurts/
PAST MEDICAL HISTORY
• Review of previous injuries, illnesses, and/or diagnoses
• Thorough review of potential comorbidities• EDS, POTS, concussion, Lyme, CP
30
CO-EXISTENCE/COMORBIDITIES
31
Ca n be seen with a n other
dia gnosis
S/p su rgery
S/p fr a cture/
or thopedic in jury
CV A
GI
POTs (Postural
Or thostatic Ta chycardia Sy ndrome)
S/p con cussion
Ca n cer
EDS
Con v ersion
HISTORY OF PRESENT ILLNESS
• Date of onset• Coinciding with triggering event?
• History of progression
• Services received/receiving• Physicians, specialists, PT/OT, etc.
• Counseling• Type
• Frequency & Length
32
PRECAUTIONS
• Usually see a large variation
• Any general concerns• BMI
• Hypermobility
• Previous or current• Changes in weight bearing status over time
• Major Surgeries
• Medications
• Asthma
33
PAIN ASSESSMENT
Location Level Quality
FrequencyAggravating
FactorsAlleviating
Factors
34
Current, Best, Worst
Descriptors
HotTu gging
Piercing
A ching
Gloom y
Splashing
Squ eezing
Du ll
Freezing
Extreme
ColdCu tting
Sore
Cru shing
Bu rning
stinging
pu l ling
tight
stabbing
shooting
Sharp
35
PAIN ASSESSMENT
36
PAIN ASSESSMENT
37
Assess Allodynia
Light Touch
Deep Touch
Vibration
SOCIAL HISTORY
• Housing environment
• School environment
• Activity level
• Other Therapies?
• Any Counseling?
• Sleep
• Appetite
38
SOCIAL HISTORY - HOUSING
• Type
• Layout• Bathroom
• Bedroom
• Stairs
• Who lives with them
• Modifications secondary to pain?
39
SOCIAL HISTORY - SCHOOL
• Missed Days due to pain
• Leaving Early/Going Late
• Able to write in school
• Able to keep up with peers
• Transportation to/from
• Nurse visits
• Any specific accommodations?• How often are they used?
40
SOCIAL HISTORY- ACTIVITY LEVEL
Current
GoalPrevious
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PATIENT GOALS
• Encourage patient to focus on function
• 3 most difficult activities to complete due to pain
• Goal activity level• What do they want to return to?
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SOCIAL HISTORY
• Sleep• Difficulty staying/falling
• Average sleep nightly
• Appetite• Meal schedule
• Nausea
• Vomiting
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EXAMINATION
44
http://bestptbilling.com/funny-physical-therapy-cartoon-its-a-stretch/
SYSTEMS REVIEW
• Cardiopulmonary screen• Asthma?
• Integumentary screen• Color/temperature/skin changes
• Abrasions indicating self harm?
• Neuromuscular screen• Balance, motor control
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MUSCULOSKELETAL EXAM
• Range of Motion• Cervical
• Trunk
• Bilateral UE/LE
• Screening for muscle tightness
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MUSCULOSKELETAL EXAM
• Tone• Quick screen if necessary
• Can be helpful with screening out conversion symptoms
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MUSCULOSKELETAL EXAM
• Strength testing• MMT bilateral UEs
• Gross grasp
• Pinch• Lateral
• Tripod
• Tip to tip
• MMT bilateral LEs
• Be aware of true muscle weakness vs. “breaking” for pain or conversion
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JOINT LAXITY – BEIGHTON SCALE
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MUSCULOSKELETAL EXAM
Transition Pain level Form
Supine <> Sit
Sit <> Stand
Squat <> Stand
Floor <> Stand
Heel sit
Tall kneel
Half kneel
Side sit
Tailor sit
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MUSCULOSKELETAL EXAM
• Balance • Sitting
• Posture
• Standing• Posture
• Rhomberg
• Tandem
• Single leg• Eyes open, eyes closed
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MUSCULOSKELETAL EXAM
• Mobility• Gait assessment
• Mechanics & speed
• Question ability to ambulate community distances
• Stair assessment• Mechanics & speed
• Note use of handrail
• Question typical pattern at home
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MUSCULOSKELETAL EXAM - FUNCTIONAL STRENGTH
Activity Pain Level Form
Double & single leg squat
Step down
Lunge
Double & single leg hop
Running
Skipping
Push up
Plank & side planks
Double & single leg bridging
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MUSCULOSKELETAL EXAM
• Fine Motor Assessment• Reach
• Grasp
• Pinch
• Release
• Manipulation
• Writing
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MUSCULOSKELETAL EXAM
• Standardized Assessments• Bruce Treadmill Protocol
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Stage Time (Min) Incline (%) Speed (m/s)
1 0-3 10 1.7
2 3-6 12 2.5
3 6-9 14 3.4
4 9-12 16 4.2
5 12-15 18 5.0
6 15-18 20 5.5
7 18-21 22 6.0
MUSCULOSKELETAL EXAM
• Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)
• 8 subtests that assessed together provides a comprehensive picture of motor development
• Assists in development of plan of care as well as goal writing
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MUSCULOSKELETAL EXAM
• Functional Disability Inventory (FDI)• Parent version
• Patient version
• 9 Hole Peg
• Complete Minnesota Dexterity Test (CMDT)
• Box & Blocks
• The GOAL
57
FUNCTIONAL DISABILITY INVENTORY
58
Flowers and Kashikar-Zuck, 2011
• No/Minimal0-12
• Moderate13-29
• Severe≥ 30
ACTIVITIES OF DAILY LIVING
• Can use Pedi as reference
• Go through each ADL• Any Modification?
• Avoidance present?
• Is pain impacting?
• Looking for accommodations during self help skills• May need to probe a little
59
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
• Leisure• Participates in the following?
• Stopped participating in the following?
• Any accommodations?
• Chores• What do you do around the house?
• Does pain impact?
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EVALUATION OF FINDINGS
61
http://bestptbilling.com/lets-start-with-some-trunk-rotation/
PLAN OF CARE DEVELOPMENT
Level of Service Needed
Consultative OutpatientIntensive program
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EDUCATION
Education
Psy chology
Function
Diagnosis
Activity level
Desensitization
Parent Education
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RECOMMENDATIONS
• Goals for Treatment
• Family/Patient buy-in
• Home Exercise Program
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GOAL WRITING
• OT Example: • Patient will accept various types of desensitization (both light and
deep touch) x 25 consecutive minutes with min to no pain behaviors or compensations 3/4 observed occasions in preparation for showering and leisure participation.
• PT Example: • Patient will independently ambulate community distances with age
appropriate gait speed, without AD, with no-min pain behaviors and compensations in preparation for ambulation within school environment without accommodations.
HOME EXERCISE PROGRAM DEVELOPMENT
HEP
Desensitization
Endurance
Strengthening
66
MODIFYING EVALUATION FOR SPECIFIC CONDITIONS
67
http://bestptbilling.com/yup-definitely-case-frozen-shoulder/
COMPLEX REGIONAL PAIN SYNDROME (CRPS)
• What else do you need to assess?• Edema – circumferential measurements
• Skin integrity (shiny, dry, cracked, color, temperature)
• Use of mobility devices
• Willingness to use affected extremity
• Extent of allodynia with border checks
• Active movement
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UPPER EXTREMITY
Start of Program 7 Days later with
exercise only
CRPS with Conversion
Admission
After exercise x 7 days
Wrapping
LOWER EXTREMITY
CRPS PROGRESSION
January 17, 2016 February 2, 2016 February 4, 2016 March 8, 2016 April 6, 2016
CONVERSION DISORDER
• Stiffness
• Paralyzed
• Shaking
• Conversion gait
• Non-epileptic (pseudo-seizure)
• Blind, Deaf, memory loss
• Lack of ROM
• Fluctuating weakness
73
CONCUSSION/DIZZINESS
• Observe behaviors with examination prior to questioning about sensation
• Look for inconsistencies
74
TAKE HOME MESSAGES
• These patients are truly experiencing pain
• It is critical to initiate treatment immediately• Physical & Psychological
• Be considerate of AMPS vs. Organic system impairments• These can co-exist
• Up next…• A clinical application to the evaluation process
• Presentations on OT & PT interventions for AMPS
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REVIEW OF INITIAL EVALUATION
• Address goals • These are your guide to treatment
• Clearly understand the problem areas
• What are the patient’s strengths
• Do they know coping strategies and how to use them
• What are the motivating factors for this patient?
TREATMENT
TYPES OF INTERVENTIONS
• Desensitization
• Functional activities• ADLS
• IADLS
• Leisure activities
• Strengthening
• Endurance
• School Simulation
78
ALLODYNIA
• Pain due to stimulus that does not normally provoke pain
• Approximately 80% of patients who present at CHOP have allodynia
• As quickly as possible-transition to self-desensitization except for hard to reach areas
79
TYPES OF DESENSITIZATION
Tactile stimulation
Vibration
Temperature
TACTILE STIMULATION
• Towel rub
• Lotion massage
• Brushing
• Body Painting
• Textured mats and balls
• Audible tapping
• Tubigrip
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TOWEL RUB
• Instructions:
• Briskly rub the sensitive area with a towel.
• Use firm pressure in all directions in the areas that are painful.
• Integrate into daily routine
82
LOTION MASSAGE
• Instructions: • Apply lotion
• Massage body part with pressure to decrease sensitivity.
• Integrate into daily routine
83
RETROGRADE MASSAGE
• Instructions: • Position your extremity on pillows or hold extremity in the air
resting on a table.
• Apply lotion to the hand.
• Begin at your distal end (finger tips) and use firm pressure with long, smooth strokes to rub down your fingers towards the hand and wrist.
84 Before After
BRUSHING
• Instructions:• Using brush, rub in all directions, with firm pressure.
85
BODY PAINTING
• Multi-faceted
• Cold paint
• Paint brush
• Cracking when it dries
• Scrubbing
• Washing it off
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TEXTURED EQUIPMENT
87
Small Textured Disks The Stick
(The Hawley Company)
Rock Mat
TEXTURED EQUIPMENT
88
Happiness in a Bag
Large Textured Disc
AUDIBLE TAPPING
• Instructions: • Cup your hand.
• Tap area with enough pressure to create a loud tapping sound.
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COMPRESSION
• Instructions:• Instruct patient to wear tight clothes or Tubigrip.
• Check circulation
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VIBRATION
• Shaker
• Handheld massager• Size
• Intensity
• iPalm
• iHelmet
91
SHAKER OPTIONS
• Standing
• Single leg stance
• Squat
• Supine
• Prone
• Quadruped
• Horseback riding
• Sitting
• Sitting with feet on the shaker (car simulation)
92
SHAKER
HAND HELD MASSAGERS
• Instructions:• Using handheld massager, move in all directions with firm
pressure.
94Can use all with or without
lotion.
LOCATION SPECIFIC VIBRATION
Breo iPalmhand
Massager
Helmet Vibrating Mat
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TEMPERATURE
96
IceContrast
Bath
Warm
PacksParaffin
Fan
ICE
• Instructions: Slowly rub ice cup on sensitive area. • Time: 3-10 min
97
https://www.amazon.com/Cryocup-Ice-Massage-Therapy-Tool/dp/B000VGFY04
CONTRAST BATH
• Instructions:• Fill up two large buckets or bowls with ice water in one and
hot/warm water in the other.
• Place painful area completely in the cold water for 30 seconds
• Quickly switch to the warm water for 30 seconds.
• Repetitions vary by patient.
98
https://www.google.com/search?q=contrast+bath&sou rce=lnms&tbm=isch&sa=X&ved=0ahUKEwiN4cyjkPrdAhXhdd8KHahPCKwQ_AUIDygC&biw=1008&bih=665#imgrc=DOv0k6--fwQpwM:&spf=1539114493031
WARM PACKS
• Instructions:• Apply warm packs with towels to affected extremity.
99
http://soa.md/blog/wp-content/uploads/2016/10/PT-hot-pack.jpg
PARAFFIN
• Instructions:• Wash/sanitize extremity.
• Two Methods:
1. Paper Towels: rip paper towel, place in paraffin bath, remove paper towels, and place on extremity.
2. Pour Method: grab an extra bucket, dip plastic cup in paraffin bath, and pour over extremity over additional bucket.
• Can cover with plastic wrap and towel to intensify heat.
100
FAN
• Instructions:• Position fan to have it blow on affected extremity.
101
DESENSITIZATION
DESENSITIZATION- HOME EXERCISE PROGRAM
• Complete 1x/day at night during week
• Complete 2x/day on weekends
• Patients completes themselves
• Best results if integrated into daily routine
• Education on progression and purpose is key to treatment
HOME DESENSITIZATION (HEP)
104
FUNCTIONAL ACTIVITIES
• Functional ambulation
• Chores• Washing windows
• Sweeping
• Dishes
• Making bed
• Laundry
• Gardening
• Baking/Cooking
FUNCTIONAL ACTIVITIES
• School simulation• Carrying books/backpack
• Changing classes
• Handwriting/typing
• Prolong sitting
• Carrying lunch tray
• Locker use
FUNCTIONAL ACTIVITIES
• Return to • Sports
• Dance
• Cheerleading
• Band/musical instrument
• Laying in bed • Position
• Blankets
107
FUNCTIONAL ACTIVITIES
• Dressing/tolerating types of clothing (sitting versus standing)
• Shoes – sneakers, flip-flops, high heels, dance shoes, athletic shoes
• Pants –skinny jeans, leggings, loose fitting pants
• Shirts – tight, loose, long sleeve
• Manicure/pedicure
• Hair cut
108
IMPORTANT REMINDER
• Exercises should be monitored in order to diminish common compensations which are often used to alleviate pressure on painful area(s) and promote safety.
109
STRENGTHENING
• Standard of Care• Theraband• Weights• Weight-bearing• Arm Bike• Core strengthening
• Plank bolster walks outs
• Prone on scooter board
• Overhead writing• Standing• Supine• Side-lying
110
STRENGTHENING (CON’T)
• Tall kneel <> stands
• Hallway drills
• Hand air hockey
• Weighted dowel rod
• Biometrics
• Heavy ropes
• Cervical strengthening- “Neck 4 ways”
• Escape from the Hospital
• Bodyblade
111
PLANK BOLSTER WALK OUTS
• Instructions: • Use a large bolster.
• Place horizontally on floor with a yoga mat behind it.
• Have patient tall kneel on yoga mat and lay over bolster so they are perpendicular to the bolster.
• Have them walk them selves out forward into a plank position. The bolster will roll from their chest to thighs.
• Then walk hands backward to starting position.
112
PLANK BOLSTER WALK OUTS
113
SCOOTER BOARD
Instructions:• Have patient lay prone on scooter board.
• Have their knees flexed so they do not try to use their feet.
• Have them move forward, by self propelling with palms of hands on floor.
• Depending on strength can do unilateral or bilateral forward motion.
• Can use disks under hands to increase resistance.
114
OVER HEAD WRITING
• Standing• Instructions: Patient stands (feet, SLS) in front of flat surface.
Place patient at or above shoulder level and have them sustain this position while completing writing/coloring task against wall.
• Can increase/decrease time• Stand on textured surface• Or change positions (tall kneel/ ½ kneel)
• Supine• Instructions: Patient lays supine under table. Patient holds arms
at 90 degrees shoulder flexion to stabilize the paper under the surface. Complete coloring tasks in this position.
• Can add textured surface for desensitization • Can elevate legs to add pressure to back
115
OVERHEAD WRITING
116
Both Feet Single leg stance Standing on textured disc
TALL KNEEL <> STANDS
• Instructions:• Use padded surface, i.e yoga mat
• Have patient step over yoga mat and lower self in half kneeling position.
• Bring opposite knee down onto mat for tall kneel position.
• Patient then brings opposite leg into half kneel position.
• Push up to return to standing position.
• With/without weighted ball
• On static vs dynamic surface
• Add desensitization (textured mats/surfaces)
117
TALL KNEEL TO STANDS
118
HALLWAY DRILLS
• Instructions: • Distance can vary.
• With/without weighted ball
• Watch for speed/form
119
Activities
Butt kickers
High knees
Grapevines
Galloping
Skipping
Lateral squats
HAND AIR HOCKEY
• Instructions:
120
WEIGHTED DOWEL ROD
• Instructions:• Take a dowel rod at least 2-3 feet long and attach a rope.
• Knot rope onto dowel.
• Add any size weight to rope at the bottom.
• Have patient activate wrist flexion and extension to bring the weight from the floor to the rod.
121
“ESCAPE FROM THE HOSPITAL”
• Instructions:• Open a sheet and tie diagonally opposite corners to another sheet
tightly
• Tie one end to another surface
• If on tile floor, have patient sit on folded sheets
• Have them pull on sheet hand over hand so they travel to where sheet is tethered
• Then push on floor with hands to return to start
• When exercise is finished, have patient take knots out of sheet for hand strengthening
122
DESENSITIZATION WITH EXERCISE
• Tennis balls,
• Vibrating mat
• Textured disk/mat
• Feathers
• Fan
• Rug surface
• Grass doormat
• Roller stickhttp://soa.md/blog/wp-content/uploads/2017/01/foam-roller.jpg
ENDURANCE
• Arm bike
• Zoom ball
• Jump rope
• Hula hoop
• Rebounder
• Virtual reality
• Skip-it
124
REBOUNDER
125
TREATMENT BASED ON PAIN AREA
• Total body
• Abdomen
• Back
• Head/neck
• CRPS
126
TREATMENT TOTAL BODY
• Desensitization• Shaker- Standing, single leg stance, sitting
• Vibration- Brookstone to most painful area
• What activities?• Core Strengthening via plank program
• Arm bike
• Functional ambulation with weighted back pack
127
TREATMENT OF ABDOMEN
• Desensitization• Vibration • Ice cup• Laying on textured surface
• Eating• Snack breaks• Non- preferred foods
• Exercise • Trunk rotation• Supine -> sits• Plank program• Prolong sitting for simulated school• Hula hoop targets both
128
TREATMENT-BACK
• Desensitization:• Vibration via Brookstone
• Supine on shaker
• Laying on textured mat
• What Activities?• Supine overhead writing
• Prone extension
• Prolong sitting
129
TREATMENT HEAD/NECK
• Desensitization:• Breo helmet
• Scalp massager tool
• Brushing hair
• Braiding hair
• What Activities?• Neck 4 ways
• Prone extension
• Carrying back pack
130
DOCUMENTATION
131
HOW DO WE MEASURE PAIN?
• Therapist never ask about pain or pain score (except evaluation/Re-evaluation if warranted)
• Documenting pain: NA out of NA; write in pain behaviors.
• Pain behaviors classified as:• Zero to maximum pain behaviors
• Use description – facial grimacing, crying, moaning, moving from stimulus
LOOKING BACK AT COMPLEX REGIONAL PAIN SYNDROME (CRPS)
133
TREATMENT FOR CRPS
• Remove mobility aids as quickly as possible
• Start weight-bearing
• Start everyday functional activities
• Start with just doing the activity then move towards quality
• Retrograde massage or wrapping for edema
• Desensitization
UE CRPS
Initial Presentation 7 days later
UE CRPS
136
Initial Presentation 7 days later
TREATMENT
• Wrapping
• Retrograde massage
• Active movement- proximal and distal
• Open container/lids
137
CRPS OF HAND WITH CONVERSION
138
TREATMENT
139
REFERENCES
• Black WR, Kashikar-Zuck S. Exercise intervensions for juvenile fibromyalgia: current state and recent advancements. Pain Manag. 2017 May;7(3):143-148. doi: 10.2217/pmt-20160066. Epub 2017 Feb 3.
• Gmuca S, Sherry DD. Fibromyalgia: Treating Pain in the Juvenile Patient. Paediatr Drugs. 2017 Aug;19(4):325-338. doi: 10.1007/s40272-017-0233-5. Review.
• Hoffart CM, Wallace DP. Amplified pain syndromes in children: treatment and new insights into disease pathogenesis. Current opinion in rheumatology. 2014;26(5):592-603.
• Kashikar-Zuck S. et al. Long-term outcomes of adolescents with juvenile-onset fibromyalgia in early adulthood. Pediatrics. 2014 Mar;133(3):e592-600. doi: 10.1542/peds.2013-2220. Epub 2014 Feb 24.
• Kaufman EL, Tress J, Sherry DD. Trends in Medicalization of Children with Amplified Musculoskeletal Pain Syndrome. Pain Med. 2017 May 1;18(5):825-831. doi: 10.1093/pm/pnw188.
• Sherry DD et al. The Treatment of Juvenile Fibromyalgia with an Intensive Physical and Psychosocial Program. J Pediatr. 2015 Sep;167(3):731-7. doi: 10.1016/j.jpeds.2015.06.036. Epub 2015 Jul 21.
• Weissmann R, Uziel Y. Pediatric complex regional pain syndrome: a review. Pediatric rheumatology online journal. 2016;14(1):29.
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REFERENCES
• Black WR, Kashikar-Zuck S. Exercise interventions for juvenile fibromyalgia: current state and recent advancements. Pain Manag. 2017 May;7(3):143-148. doi: 10.2217/pmt-20160066. Epub 2017 Feb 3.
• Coverly, D. (2016, Fevurary). Gingerbread [Photo]. Retrieved from http://www.cartoonistgroup.com/subject/The-Knee-Comics-and-Cartoons-by-Speed+Bump.php
• Dharamcomics. Where does it hurt [Photo]. Retrieved from https://dharmacomics.com/dharma-comics/tell-me-where-it-hurts/
• Gmuca S, Sherry DD. Fibromyalgia: Treating Pain in the Juvenile Patient. Paediatr Drugs. 2017 Aug;19(4):325-338. doi: 10.1007/s40272-017-0233-5. Review.
• Hoffart CM, Wallace DP. Amplified pain syndromes in children: treatment and new insights intodisease pathogenesis. Current opinion in rheumatology. 2014;26(5):592-603.
• Kashikar-Zuck S. et al. Long-term outcomes of adolescents with juvenile-onset fibromyalgia in early adulthood. Pediatrics. 2014 Mar;133(3):e592-600. doi: 10.1542/peds.2013-2220. Epub 2014 Feb 24.
• Kaufman EL, Tress J, Sherry DD. Trends in Medicalization of Children with Amplified Musculoskeletal Pain Syndrome. Pain Med. 2017 May 1;18(5):825-831. doi: 10.1093/pm/pnw188.
• Konold, G. (2014, August). Elephant [Photo]. Retrieved from http://bestptbilling.com/lets-start-with-some-trunk-rotation/
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• Weissmann R, Uziel Y . Pediatric complex regional pain syndrome: a review. Pediatric rheumatology online journal. 2016;14(1):29.
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REFERENCES
• Black WR, Kashikar-Zuck S. Exercise intervensions for juvenile fibromyalgia: current state and recent advancements. Pain Manag. 2017 May;7(3):143-148. doi: 10.2217/pmt-20160066. Epub 2017 Feb 3.
• Gmuca S, Sherry DD. Fibromyalgia: Treating Pain in the Juvenile Patient. Paediatr Drugs. 2017 Aug;19(4):325-338. doi: 10.1007/s40272-017-0233-5. Review.
• Hoffart CM, Wallace DP. Amplified pain syndromes in children: treatment and new insights intodisease pathogenesis. Current opinion in rheumatology. 2014;26(5):592-603.
• Kashikar-Zuck S. et al. Long-term outcomes of adolescents with juvenile-onset fibromyalgia in early adulthood. Pediatrics. 2014 Mar;133(3):e592-600. doi: 10.1542/peds.2013-2220. Epub 2014 Feb 24.
• Kaufman EL, Tress J, Sherry DD. Trends in Medicalization of Children with Amplified Musculoskeletal Pain Syndrome. Pain Med. 2017 May 1;18(5):825-831. doi: 10.1093/pm/pnw188.
• Sherry DD et al. The Treatment of Juvenile Fibromyalgia with an Intensive Physical and Psychosocial Program. J Pediatr. 2015 Sep;167(3):731-7. doi: 10.1016/j.jpeds.2015.06.036. Epub 2015 Jul 21.
• Weissmann R, Uziel Y. Pediatric complex regional pain syndrome: a review. Pediatric rheumatology online journal. 2016;14(1):29.
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