통증 물리치료학 및 실습
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1 통증물리치료학 및실습 Gachon University Department of Physical Therapy Hwi-young Cho, PT, PhD
2 Contents Introduction Definition Pain terms Pain physiology Pain assessment tools The types of PAIN
3 통증 (Pain) 이란? 뇌 (Brain) 로전달되는정보로서, 통증이란마음 (mind) 과신체 (body) 사이에관여되는전신체의경험과감정. 일반적으로신체의중요한보호기전 (p rotective mechanism) 으로몸을더욱조심스럽게해주는기능. 흔히, 괴로움 (suffering) 과고통 (distress) 를유발함. 사람들마다통증을다르게표현하며, 또한손상의종류에따라서동반되는통증의기전과원인이다름.
4 PAIN Definition An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. (International Association for the Study of Pain, 1994)
5 Pain 용어 Allodynia ( 이질통, 무해자극통증 ) 유해하지않은자극 (Non-noxious stimuli) 에대하여통증이유발되는상태. Type : Mechanical & Thermal Analgesia ( 진통, 무통증 ) 통증을유발할수있는정도의자극에대하여통증이나타나지않는상태. Anesthesia dolorosa ( 무감각통증 ) 무감각증이있는부위 ( 마취된부위 ) 의통증 예 ) 삼차신경통시, 치료를받았는데기존에있던원래의통증이자발적통증 ( 다른형태의통증 ) 으로변하는경우
6 Causalgia ( 작열통 ) 외상성신경손상후주로손과발부위에타는듯한통증, 이질통, 통각과민등이나타나는경우. 흔히혈관운동성 (vasomotor) 과땀샘운동성 (sudomotor) 의기능장애가동반됨. Dysesthesia ( 이상감각, 불쾌감각 ) - 불쾌하고비정상적인감각. 자발적 (spontaneous) 혹은유발적 (evoked) 으로나타날수있음. Hyperalgesia ( 통각과민 ) - 유해한자극에대하여더욱아파하는통증상태 Hyperpathia ( 통각과민 ) - 반복적인자극및낮아진신경역치에의하여통증을유발할수있는기존자극에대하여더욱아파하는현상. 단일자극의 pin prick 은통증으로인지되지않을수있으나, 반복적인자극에대하여심한통증을유발할수있음
7 Hypoalgesia ( 통각저하 ) 정상적으로통증을유발할수있는자극에대하여통증반응이감소된현상. Formication ( 스멀거림 ) - 벌레들이몸을기어다니는느낌. 보통정신적인문제에기인함. Referred pain ( 연관통 ) 심근경색시어깨가아프거나췌장문제시등이아프거나, 담낭 (Galbladder) 문제시 Rt. Shoulder 가아프거나느껴짐. 조직손상및과흥분후해당하는 spinal cord level 이 sensitization 되어동일한 level 의체성감각부분에서통증이나타나는경우 Phantom pain ( 환상통증 ) 외과적으로절제된부위에서통증이느껴지는경우. 사고및당뇨, 동상등으로인하여사지를절단후대부분의환자에서다리가계속있는것처럼느껴질뿐만아니라통증이나타남. 보통신경절단후 neuroma( 신경종 ) 이생기는데그부분에서통증이유발됨.
8 Neuralgia ( 신경통 ) - 신경및신경이분포된부위에통증이나타나는경우 Neuritis ( 신경염 ) - 신경및신경다발에염증이유발된경우 Central neuropathic pain - 중추신경계의병변및손상에의하여유발되는통증. Peripheral neuropathic pain - 말초신경계의병변및손상에의하여유발되는통증.
9 Neuropathy ( 신경병 ) - A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy. Nociception ( 통각 ) 유해한자극이입력 (encoding) 되는감각과정 (neural process) Nociceptive neuron ( 통각신경 ) A central or peripheral neuron of the somatosensory nervous system that is capable of encoding noxious stimuli. Nociceptive pain ( 침해성통증 ) Pain that arises from actual or threatened damage to nonneural tissue and is due to the activation of nociceptors. = Pain perception under normal condition.
10 Nociceptive stimulus 유해수용체 (nociceptor) 에의해부호화혹은변환되어실제적혹은잠재적으로조직손상을유발할수있다고판단되는자극. Nociceptor 유해한자극 (noxious stimulus) 를부호화 (encoding) 하거나입력을변환 (transducing) 할수있는수용체 (receptor). 체성감각 (somatosensory) 뿐만아니라내장감각 (visceral sense) 에고내재되어있으며, 고역치 (high-threshold) 수용체임. Noxious stimulus 정상조직에손상을유발할수있거나위협을가할수잇는정도의자극. Pain threshold 통증으로느껴지는자극에최소한의강도.
11 Pain tolerance level ( 통증내성수준 ) - 대상자가주어진상황에서최대로수용할수있는통증의역치. Paresthesia ( 감각이상 ) - 비정상적인감각. 자발적혹은유발적으로나타날수있음. Sensitization ( 민감화 ) - 외래의자극에대해생체가민감하게되어있는상태. - 정상적으로역치이하의자극이나유해하지않은자극에대하여유해수용성뉴런 (nociceptive neurons) 의반응이증가된상태
12 Central sensitization ( 중추성감작 ) - 유해하지않은자극및정상적인자극에대하여중추신경계의유해수용성뉴런의반응이증가된상태 Peripheral sensitization ( 말초성감작 ) - 유해하지않은자극및정상적인자극에대하여말초신경계의유해수용성뉴런의반응이증가된상태 (International Association for the Study of Pain, 1994)
13 Physiology of Pain 1. Nociceptor - 통각수용기 2. Stimulus Transmission - 자극전달로 ( 신경로 ) 3. Termination - 자극종료 4. Modulation - 조절 (
14 통증의측정 통증에관한질문은모든측정의가장중요한요인으로간주됨 환자를대하는모든사람은반드시통증을확인해야함. 통증을확인하고치료하는것은반드시지속되어야함. Elderly residents 는수시로통증을확인해야함. 측정방법 : Visual analogue scale (VAS) Algometer = pressure pain threshold Clinical tools (Neck disability index, Oswestry disability index)
15 Visual analogue scale (VAS) ( (
16 Algometer Measure the Pain pressure threshold Can assess the degree of the secondary pain (Cuff type)
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20 질환에의해동반되는통증의종류는다양함
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30 Pain 통증측정유의사항 강도 (Intensity) / 위치 (Location) / 관련된반응 (Affective response) / 신체적기능 (Physical Functioning) Psychological Factors ( 심리적요인 ) 장애 (Impairment) / 기능적제한 (Functional limitation) / 장애 (Disability) Objective indicators ( 객관적지표 ) Electromyography ( 근전도 )
31 Types of pain ( 통증의종류 ) 시기에따른분류 급성통증 (Acute pain) 신체에서무엇인가문제가있거나손상을피하기위한반응. 조직손상에의해유발됨. 만성통증 (Chronic pain) 오랫동안통증이유지되는상태 신체구조물의퇴행및조직손상보다는조직손상에의하여이차적으로유발되는신체의변화 ( 신경의변화등 ) 에의하여유발되는통증. ( _cmymajyi/aaaaaaaacl0/lpq2uqzd5fy/s1600/pain.jpg)
32 TYPES OF PAIN NOCICEPTIVE NEUROPATHIC Somatic bones, joints connective tissues muscles Visceral Organs heart, liver, pancreas, gut, etc. Central Sympathetic Maintained Peripheral
33 체성통증 (Somatic Pain) A type of nociceptive pain Area : the Skin & Deep tissues 통증양상 Aching ( 쑤시는, 아리는 ) Constant ( 거듭되는 ) Dull ( 둔한 ) or sharp ( 날카로운 ) 움직임 (movement) 시통증악화 국소적 (Localized) = 특정부위통증호소 근육의사용이나신장 (stretch) 시통증증가 Example Bone & soft tissue Chest wall
34 Somatic Pain 근원 : 피부 (Skin), 근육 (muscle), and connective tissue 예 : Strain, Sprains, Headaches, Arthritis, Fracture 기술 (Description): Localized, sharp/dull, worse with movement or touch 중재약물 : Most of pain medications can manage. If severe, need a stronger medication.
35 내장통증 (Visceral Pain) A type of nociceptive pain 통증양상 Constant ( 지속적 ) Crampy ( 경련형 ) Aching ( 쑤시는, 아리는 ) Poorly localized ( 국소적이지않은 ) Referred ( 관련된통증 ) Example 1 Cancer at pancreas or other visceral organs 2 Bowel obstruction ( 방광막힘, 장폐쇄 ) Constipation( 변비 ), abdominal swelling and abdominal pain
36 Visceral Pain 근원 : 내장기관 (Internal organs) 예 : 내장기관의종양에의한통증 (tumor growth in visceral organ), gastritis, chest pain 기술 (Description): Not localized, refers, constant and dull, less affected with movement 중재약물 : Stronger pain medications 참조 (YouTube)
37 Epigastric Lt. Hypochondrical Rt. Hypochondrical Umbrical Lt. Lumbarl Rt. Lumbarl Rt. Iliac Hypogastric Lt. Iliac (
38 Neuropathc Pain 근원 : 신경 (Nerves) = 신경손상에의해통증이유발 예 : Spinal cord injury ( 척수손상 ), Thalamic pain ( 시상통증 ), Diabetic neuropathy ( 당뇨병신경병증 ), Complex Regional Pain Syndrome (CRPS, 복합부위통증증후군 ), Phantom pain ( 환상통 ) 기술 : Burning, stabbing( 찌르는듯함 ), Pins and needles, shock-like, shooting 중재약물 : Opioates, antidepressants or other adjuvant Gabapentin, Pregabalin
39 다른종류의통증 Cancer Pain 통증은암치료가되거나혹은죽어야지통증이사라짐. 중재방법 : 공격적인치료 (Aggressive treatment) = Surgery or Chemotherapy 원인 : Cancer 가신경이나뼈로전이되어통증이발생 (65%), 중재방법에의해유발되는통증 (25%), 다른원인에의한통증 (10%) 신경병증성통증을유발할뿐만아니라, 신체기능장애및죽음에대한공포를유발함.
40 Treatment of Pain (
41 통증관리 (Pain Management) 목적 : 통증관리는모든질환에적용되며, 환자의주된불편 (chief complain) 의중재및삶의질개선에필수적인과정 손상및질환에의한통증의원인을확인후통증을인지하고약물적및비약물적인방법을이용하여통증을중재하는과정. 객관적이고타당한도구를이용해야함. VAS or algometer, valid clinical tools
42 Non-Pharmacological Pain Management Physical therapy Physical modalities (electrical therapy, phototherapy) Manual therapy (Hand) Acupuncture therapy Cognitive/behavioral therapy Relaxation TENS Therapeutic massage Exercise (Yoga, Pilates et al.)
43 (Electrical therapy on knee pain) (Manual therapy on low back pain) (Stretching effects) Y (Exercise effects) (Knee) (Upper back)
44 내성 (Tolerance) 진통효과를나타내기위하여, 현재투여되는약물의농도가기존진통시사용되던약물의용량이비하여증가된상태. 정상적인생리학적인현상 Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
45 신체적의존성 (Physical dependence) 아편제제 (Opioid) 를중단할시혹은아편양제제길항제 (antagonist) 를투여시손의떨림이나, 발한, 설사등의금단현상이생기는것을의미함. 정상적으로유발되는생리학적현상. Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
46 Opioid Side Effects Constipation ( 변비 ) need proactive laxative use Nausea ( 구역 ) /vomiting ( 토 ) consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol) Urinary retention ( 요폐 = 소변정체 ) Itch ( 가려움 ) /rash ( 발진 ) worse in children; may need lowdose naloxone infusion. May try antihistamines, however not great success Dry mouth Respiratory depression uncommon when titrated in response to symptom Drug interactions Neurotoxicity (OIN): delirium, myoclonus seizures
47 Untreated Pain 의결과 - 1 식욕저하및체중소실 수면장애 사회참여의결여및대화회피 슬픔, 화남, 우울증 신체적 & 언어적공격성 방황 (wandering) 및보행, 균형과이동기능의저하
48 Untreated Pain 의결과 - 2 요실금 (Incontinence) 중독및탐닉 (addiction & abuse) 피부궤양 (Skin ulcers) 일상생활동작수행의저하 면역기능저하
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체열진단과 12 채널 TENS 강사 - 유승모 MD. PhD. 2014. 10. 12. ( 일 ) Contents 체열진단 TENS : 12 채널 1 체열진단 (Thermography) 인정비급여 ( 노 -776 (EZ776)) 2 체열진단 (Thermography) 체열진단의정의 체열진단 (Thermography) 는간단하게 열의사진 체열진단이란사람의체표로부터나오는적외선을감지하고,
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