标题: Secondary and Tertiary Prevention of Chronic Pain [打印本页] 作者: libingccmb 时间: 2020-8-12 02:10 标题: Secondary and Tertiary Prevention of Chronic Pain 疼痛的二、三级预防
Secondary and Tertiary Prevention of Chronic Pain
IntroductionPrevention of pain and its chronic forms will reduce the burden of suffering for individuals and society,respectively. Secondary prevention aims to detect disease in the early stages and limits its progression[1, 2], whereby tertiary prevention aims to reduce or avoid complications or limiting consequences ofthe disease already present [1]. For pain, the definitions state to prevent individuals from developingchronic pain after initial onset of acute pain (secondary prevention), or to reduce ongoing disability,disuse or loss of social contacts and occupation, once pain has become chronic (tertiary prevention).Even though the research body for secondary pain prevention has grown during the past years, thefocus remains on treating chronic pain.
The Global Year for the Prevention of Pain is a chance to raise awareness on strategies and interventionsfor the primary and secondary stages of disease development, supporting sufferers in maintaining dailyphysical, personal and social activities the best way possible to reduce the development of chronic pain.Recommendations in designing prevention trials have been published [3], which will hopefully generatereliable evidence.
Secondary Prevention of Pain: Preventing Chronicity
The secondary prevention of pain was first described by Fordyce in the 1970s [4], when distinguishingbetween pain and pain behaviour (disabling behaviour). A prevention regime was applied to reduce painbehaviour, leading to preliminary promising results in terms of prevention strategies [2, 4] includingtime-contingent training and medication. Secondary prevention requires an understanding of the factorsinvolved in chronification, validated instruments to detect patients at risk, and validated clinicalstrategies addressing these risk factors with specific interventions [5]. Several reviews report risk factorsfor maintaining different forms of pain; red (biological) and yellow (psychosocial) flags formusculoskeletal pain is the most common construct, followed by blue (occupational), black(compensation) and white (socio-cultural) [6] flags, where evidence is still pending regarding theirimpact in secondary prevention of pain. Specific mechanism-based risk factors would help designingpreventive strategies providing future base of tailored interventions [5, 7]. Such risk factors have beenidentified in catastrophizing/maladaptive cognitions and depressive mood for developing chronic knee[8] or low back pain [9] as yellow flags, or joint damage as red flag for knee pain [8]. Others reportedseveral risk factors for developing chronic pain after surgery (e.g. [10-12]) with sound evidence for age,gender, type of surgery, genetic factors, preceding pain or history of chronic pain of other origin and avariety of psychosocial factors. Screening instruments are available especially for back pain withpreliminary evidence for their prognostic value [13]. Preliminary evidence is also provided thatsubgrouping patients regarding their risk for chronification and specifically tailored treatment is
effective in the short and middle terms [14]. Education and exercise in preventing back pain frombecoming chronic seems to be of best evidence at the moment [5, 7], primarily in the short and middleterms
In contrast, iatrogenic factors (factors lying in the health care system) seem to contribute tochronification of pain, especially when solely focusing on somatic factors, ignoring multi-causal genesisof pain, overestimating the impact of somatic or radiologic findings on wellbeing of the patient andoveruse of diagnostic procedures and rather passively oriented interventions in long term (e.g. massage)[15]. In light of these findings, responsibility of health care providers in treating pain in an evidencebased manner should not be underestimated and should be included into research activities.
Intensified effort in establishing models [3] such as the avoidance-endurance model [16] or, from basicscience, deriving tailored treatments and generating evidence by pain researchers is needed.Incorporating spontaneous recovery from initial pain, saluto-genetic models and patient preferences forspecific interventions [17] should be taken into future considerations.
Tertiary Prevention of Pain: Reducing Disability, Work Loss, Negative Emotionality and Social Isolationfor Sufferers with Chronic Pain
Tertiary prevention aims to reduce secondary effects of those suffering from chronic pain. Models suchas the fear avoidance model [18, 19] or the avoidance and endurance model [16, 20-23] incorporate thefunctional, psychological and social impairment in leading a satisfying life by the affected individuals.The biopsychosocial model of pain [24-26] led to the development of biopsychosocial (synonymouslymultidisciplinary, interdisciplinary, multi component) treatment approaches. A corresponding definitionwas devised by an IASP Task Force in 2017 and published at IASP homepage (https://www.iasppain.org/Education/Content.aspx?ItemNumber=1698).
Mayer and Gatchel [27] introduced the biopsychosocial treatment approach in the 1980s. Its main aimis the restoration of physical, psychological and social functioning, involving a core team of multidisciplinary healthcare professionals (physicians, physiotherapists, occupational therapists, psychologistsand nurses)working in an integrated team setting [27].
Interdisciplinary treatment has been acknowledged as an appropriate answer to the comprehensivesuffering of patients with chronic pain worldwide [28], but evidence is controversially discussed [29].The heterogeneity of involved professions, providing interventions and the treatment composition, doseand duration of treatment, and the outcome assessment tools in clinical trials hampers considerablycomparative effectiveness research and valid meta analyses [30]. Conceptual frameworks andmechanism based treatment designs, harmonized outcome assessment (considering comprehensivemultidimensional outcomes [31]), carefully reported studies and carefully performed systematicresearch is needed to distinguish beneficial treatment from non-beneficial and, finally, to identify besttreatment to specific groups of patients regarding their characteristics [32].
REFERENCES
[1] Loisel P. Developing a new paradigm: Work disability prevention. Occupational Health Southern Africa 2009;15(2):56-60.[2] Linton SJ, Chronic pain: the case for prevention. Behaviour research and therapy 1987;25(4):313-317.
AUTHORDr. Ulrike KaiserLead. Clinical psychologistComprehensive Pain CenterUniversity Hospital Carl Gustav Carus DresdenDresden, GermanyREVIEWERSBrona M. Fullen, PhDAssociate ProfessorUCD School of Public HealthPhysiotherapy and Sports ScienceDublin, IrelandProfessor Esther Pogatzki-Zahn, MD, PhDDepartment of Anesthesiology, Intensive Care and Pain MedicineUniversity Hospital MuensterMuenster, Germany