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首页> 外文期刊>The Internet Journal of Anesthesiology >Integrating Interventional Pain Therapy And Cognitive Behavioral Therapy: What Comes First?
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Integrating Interventional Pain Therapy And Cognitive Behavioral Therapy: What Comes First?

机译：介入性疼痛疗法与认知行为疗法的整合：首先是什么？

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The multidimensional nature of the pain experience present a management challenge when the multidisciplinary team identify biomedical as well as psychosocial derangements that are amenable to specific treatments. The question becomes a prioritization issue as it is difficult to run both treatments simultaneously. In this case report, after the initial multidisciplinary assessment of this middle aged working man with low back and leg pain, several management approaches were utilized. These approaches included biomedical interventions (nerve blocks and neuroaugmentation) as well as cognitive behavioral therapy. Biomedical management can produce good results but they may also increase patient's reliance on passive approaches and fuel pain behaviours and sometimes fail to provide a solution to a multifaceted pain presentation. On the other hand, cognitive behavioral therapy (CBT) approaches have proven to have successful outcomes but they commonly emphasize on reducing reliance on passive approaches (use of medications and increasing demand for interventions), which sometimes can be contradictory to biomedical management if both are carried out simultaneously. Patients with such presentations still pose a challenge to the multidisciplinary team in deciding on what needs to be addressed first. There are many reports including clinical trials and systematic reviews that support each modality but when it comes to integrated management, the literature is scarce especially in terms of high quality randomized controlled trials. Case Report History of presenting complaintIn February 1999, Mr.H had a fall while walking up some stairs. He had a tool case in his hand at the time. Following the fall he had right-sided low back pain which he initially did not take much notice of. However, the pain persisted and he was then seen by his GP He was treated with physiotherapy, anti-inflammatories and Tylenol III.The pain was settling down and two months later when he had a physical examination for medical insurance purposes, he was asked to bend forward which he recalls resulted in a right leg pain. A CT-scan was done on the 5th of March, showing a posterior disc protrusion at the L5/S1 level. Mr.H continued to have increasing pain in the lower back and the right leg and was advised to take time off work on several occasions related to his pain. Due to the continuing report of pain and “numbness” in the right leg he was referred to a neurosurgeon who saw him in July, 1999, and ordered lumbar MRI scan that showed mild focal L5/S1 posteriolateral disc protrusion with slight thecal sac and right S1 nerve root compression. Surgery was not indicated, and was he told that it might not provide any benefit.Mr.H continued to have pain and continued taking analgesic medications in addition to using a TENS machine. He gradually returned to full time (6 hrs/ day) work by December 1999. He was advised to avoid heavy lifting and prolonged sitting (as when driving for long distances).Pain HistoryHe reported a right-sided low back pain, which radiates to the anterior thigh, the right calf and the dorsum of the right foot. He described the pain as continuous with variable intensities. He used the following McGill Pain Questionnaire (MPQ) words to describe his pain: shooting, stabbing, sharp, wrenching, aching, exhausting, radiating, and numb.On a numerical rating scale (NRS), he reported the following pain intensities:Intensity during the interview: 10/10 Highest and lowest intensities the week prior to the interview: 6/10 and 10/10Usual pain intensity: 8/10He described the following aggravating factors: movement especially lifting and bending, cold and wet weather, sex, and driving. He described the following to help when he is in pain: warm/hot showers, analgesic medications, hot packs, massage and the TENS unit.He denies any personal or family history of cancer, report no fever, sweats, bladder or bowel dysfunction or weakness in the lower limbs. He reports som
机译：当多学科团队确定适合特定治疗的生物医学和心理社会失调时，疼痛经历的多维性质提出了管理挑战。由于很难同时进行两种治疗，因此该问题成为优先事项。在本病例报告中，在对这名腰背和腿部疼痛的中年工人进行了初步的多学科评估之后，采用了几种管理方法。这些方法包括生物医学干预（神经阻滞和神经强化）以及认知行为疗法。生物医学管理可以产生良好的效果，但它们也可能增加患者对被动治疗方法和加油性疼痛行为的依赖，有时甚至无法为多方面的疼痛表现提供解决方案。另一方面，认知行为疗法（CBT）方法已被证明具有成功的结果，但它们通常强调减少对被动方法的依赖（药物的使用和干预需求的增加），如果两者都存在，有时这可能与生物医学管理相矛盾。同时进行。进行此类演示的患者在决定首先需要解决的问题时仍然对多学科团队构成挑战。有许多报告，包括支持每种方法的临床试验和系统评价，但是当涉及到综合管理时，尤其是在高质量的随机对照试验方面，文献很少。案例报告提出投诉的历史1999年2月，H先生上楼梯时摔倒了。当时他手里有一个工具箱。跌倒后，他有右侧下腰痛，最初他并未引起太多注意。然而，疼痛持续存在，他的全科医生看到了他，他接受了物理疗法，抗炎药和Tylenol III的治疗。疼痛减轻了，两个月后当他进行了体检以进行医疗保险时，他被要求他记得他弯腰导致右腿疼痛。 3月5日进行了CT扫描，显示在L5 / S1水平椎间盘后突出。 H先生的下背部和右腿疼痛持续加重，并建议他在几次与他的疼痛有关的情况下休假。由于右腿疼痛和“麻木”的持续报道，他被转介给神经外科医师，他于1999年7月见到他，并下令进行MRI检查，显示轻度局灶性L5 / S1后外侧椎间盘突出，伴有轻微的囊袋和右S1神经根受压。没有指明手术方法，他被告知可能没有任何好处.H先生除了使用TENS机外，还持续疼痛并继续服用止痛药。到1999年12月，他逐渐恢复了全职工作（每天6小时）。建议他避免过度举重和长时间坐着（如长途驾驶）。大腿前部，右小腿和右脚的背部。他将疼痛描述为持续不断的强度变化。他使用以下麦吉尔疼痛问卷（MPQ）来描述他的疼痛：射门，刺伤，尖锐，扭动，酸痛，疲惫，辐射和麻木。在数字评分量表（NRS）上，他报告了以下疼痛强度：强度在访谈中：10/10采访前一周的最高和最低强度：6/10和10/10通常的疼痛强度：8/10他描述了以下加重因素：运动，特别是举起和弯曲，寒冷和潮湿的天气，性别，和驾驶。他描述了以下在疼痛时提供帮助的方法：热水/热水淋浴，止痛药，热敷袋，按摩和TENS单位。他否认有任何个人或家族癌症史，没有发烧，出汗，膀胱或肠功能障碍或下肢无力。他报告了索姆

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