Κυριακή 21 Ιουλίου 2013

Κατευθυντήριες γραμμές για την αλγοδυστροφία τύπου Ι (Ολλανδία)

των Roberto S Perez, Paul E Zollinger, Pieter U Dijkstra, Ilona L Thomassen-Hilgersom, Wouter W Zuurmond, Kitty CJ Rosenbrand, Jan H Geertzen and the CRPS-I task force

(VU University Medical Center, dept of Anaesthesiology, Amsterdam, the Netherlands - Research consortium Trauma Related Neuronal Dysfunction (TREND), the Netherlands - The EMGO Institute for Health and Care Research, Amsterdam, the Netherlands - Rivierenland Hospital, dept of Orthopaedic Surgery, Tiel, the Netherlands - University Medical Centre Groningen, Center for Rehabilitation, University of Groningen, Groningen, the Netherlands - Dutch Association of Posttraumatic Dystrophy Patients, Nijmegen, the Netherlands -  Dutch Institute for Healthcare Improvement CBO, Utrecht, the Netherlands) 


Η θεραπεία της αλγοδυστροφίας τύπου Ι (CRPS-I) είναι αντικείμενο πολλών συζητήσεων. Ο σκοπός αυτής της μελέτης ήταν η ανάπτυξη κατευθυντήριων γραμμών για πολλές ειδικότητες της υγείας, για τη θεραπεία της CRPS-Ι.

Μια διεπιστημονική ομάδα εργασίας αξιολόγησε την βιβλιογραφία που αναφέρεται στα αποτελέσματα διαφόρων μορφών θεραπείας για την CRPS-I, τα οποία δημοσιεύθηκαν από το 1980 έως τον Ιούνιο του 2005. Διάφορες συστάσεις θεραπείας με βάση τα πορίσματα της βιβλιογραφίας διατυπώθηκαν και έχουν εγκριθεί επισήμως από όλες τις Ολλανδικές επαγγελματικές ενώσεις υγειονομικών, που ασχολούνται με CRPS-Ι.

Για τη θεραπεία του πόνου, η Π.Ο.Υ. συνιστά όλη την γκάμα των αναλγητικών, με την εξαίρεση τη χρήση των ισχυρών οπιοειδών. 
Για τον νευροπαθητικό πόνο, μπορούν να δωθούν σπασμολυτικά, όπως και τρικυκλικά αντικαταθλιπτικά.  
Για φλεγμονώδεις καταστάσεις, συνιστάται η χρήση ελεύθερων ριζών (διμεθυλσουλφοξείδιο ή ακετυλοκυστεΐνης).  
Για την προώθηση της περιφερικής ροής αίματος, μπορεί να δωθεί αγγειοδιασταλτική φαρμακευτική αγωγή.   
Για την αποκατάσταση των λειτουργικών περιορισμών, συνίσταται πρόγραμμα φυσικοθεραπείας και εργοθεραπείας. 
Για την πρόληψη της εμφάνισης CRPS-Ι μετά από κατάγματα του καρπού, συνίσταται η χορήγηση βιταμίνης C. Τέλος, ο περιορισμός του χρονου της περιεγχειρητικής αναλγησίας και η προσεκτική χρήση των τουρνικέ, συνιστώνται για την δευτερογενή πρόληψη της CRPS-I.
Συμπερασματικά, με βάση όσα εντοπίστηκαν στη βιβλιογραφία και την έκταση των αποδεικτικών στοιχείων που βρέθηκαν για θεραπευτικές παρεμβάσεις για την CRPS-I, καταλήγουμε στο συμπέρασμα ότι απαιτείται περαιτέρω έρευνα σε κάθε μία από τις θεραπευτικές μεθόδους που συζητήθηκαν στις κατευθυντήριες γραμμές.



 
Ας δούμε όμως πιό λεπτομερειακά τις παρεμβάσεις για την αντιμετώπιση της αλγοδυστροφίας τύπου Ι (CRPS-I), στο χώρο της Αποκατάστασης: 

Φυσικοθεραπεία 
Δημοσιευμένα άρθρα συστήνουν συχνά «φυσικοθεραπεία» ως επικουρική θεραπεία, χωρίς να προσδιορίζεται ακριβώς τι συνεπάγεται αυτή η φυσικοθεραπεία. Σε γενικές γραμμές, τονίζεται ότι η λειτουργική αποκατάσταση είναι απαραίτητη και αποτελεί το κλειδί για την ανάκαμψη.
Μια τυχαιοποιημένη ελεγχόμενη μελέτη (n = 135) έδειξε ότι η φυσικοθεραπεία εκτός από την αντιμετώπιση των συμπτωμάτων, έχει και επίδραση στη βελτίωση των σοβαρών λειτουργικών βλάβών [73,74]. 
Η Φυσικοθεραπεία συμβάλλει κυρίως στην ταχύτερη μείωση του πόνου, την εξομάλυνση της θερμοκρασίας του δέρματος, την μειωμένη κινητικότητα και το οίδημα. Λόγω της ταχείας βελτίωσης των διαταραχών, συνιστάται ότι η έναρξη της φυσικοθεραπείας στο πρώιμο στάδιο, αμέσως μετά η διάγνωση [73-75]. Μπορεί βέβαια, να έχει καλά αποτελέσματα, ακόμη και σε χρόνιες μορφές CRPS-I [76,77]. 
Τα καλύτερα αποτελέσματα από τη φυσικοθεραπεία, αναφέρονται στην Mirror Therapy (κινησιοθεραπεία με τη χρήση καθρέφτη) (n = 8-13) για τη μείωση του πόνου [78,79]. Τα τυποποιημένα προγράμματα φυσικοθεραπείας με στόχο τη βελτίωση της ικανότητας των ασθενών να αντιμετωπίσουν την κατάσταση τους, έχει αποδειχθεί ότι είναι αποτελεσματικά και στη μείωση των συμπτωμάτων της CRPS-Ι [73,74,80].
Η φυσικοθεραπεία για την αποκατάσταση CRPS-I των άνω άκρων, είναι πιθανό να έχει ευεργετικό αντίκτυπο στις γενικότερες διαταραχές, καθώς και στο πώς οι ασθενείς μπορούν να αντιμετωπίσουν την κατάστασή τους καλύτερα (Oerlemans et al (Α2), McGabe et al (Β), Fialka et al ( Γ)).
Η φυσικοθεραπεία μπορεί να είναι επωφελής και σε χρόνιες μορφές CRPS-I (Moseley (Β), Van Wilgen et al (D)).
Τέλος, η φυσικοθεραπεία αποτελεί πολύτιμο τμήμα της συνήθους θεραπείας της CRPS-I. 

Διαδερμική Ηλεκτρική Νευρική Διέγερση (TENS)
Άρθρα με περιορισμένη μεθοδολογική ποιότητα βρέθηκαν να περιγράφουν τις ευεργετικές επιδράσεις των TENS, σε μικρές ομάδες πασχόντων από CRPS-I (n = 10-11) ασθενείς [81,82].Δεν υπάρχουν επαρκείς ενδείξεις ότι η χρήση TENS είναι αποτελεσματική στη θεραπεία της CRPS-I.

Εργοθεραπεία 
Βρέθηκε μία μελέτη που αξιολογεί την αποτελεσματικότητα της εργοθεραπείας στην CRPS-Ι (n = 135) [74]. Η εργοθεραπεία έχει επίσης θετική επίδραση στη σοβαρότητα των λειτουργικών περιορισμών, και φαίνεται να έχει θετικό αντίκτυπο στο επίπεδο της δραστηριότητας [73,74].
Η εργοθεραπεία έχει επίσης θετική επίδραση στους λειτουργικούς περιορισμούς του ασθενή και είναι πιθανό να έχει θετική επίδραση στο επίπεδο δραστηριότητας των ασθενών με CRPS-I των άνω άκρων (Oerlemans et al (A2)).

Φυσική Ιατρική και Αποκατάσταση
Δεν υπάρχουν μελέτες που να έχουν διεξαχθεί μέχρι σήμερα για την αξιολόγηση της αποτελεσματικότητας της ολοκληρωμένης και συντονισμένης διεπιστημονικής παρέμβασης για CRPS-I. Οι ειδικοί υποστηρίζουν μια διεπιστημονική προσέγγιση, λόγω του σύνθετου χαρακτήρα της κατάστασης και τη διαφορετικής φύσης της προόδου της [6,83]. 
Δεν υπάρχουν όμως ενδείξεις, ότι η διεπιστημονική θεραπεία είναι ευεργετική για CRPS-I ασθενείς (Stanton-Hicks et al (D), Rho et al (D)). 

Ψυχολογική θεραπεία 
Υπάρχει η θεωρία ότι η CRPS-I μπορεί να προκληθεί ή να επιδεινωθεί και να συντηρείται από μη βιολογικούς παραγόντες [23,84]. Βρήκαμε μια μελέτη (n = 28) για την αξιολόγηση της γνωστικής συμπεριφορικής θεραπείας, σε παιδιά με CRPS-I [85]. Αναδρομικές ομαδικές έρευνες ή συγχρονικές μελέτες χωρίς ομάδα ελέγχου και περιορισμένη παρακολούθηση υπάρχουν πολλές. Δεν υπάρχουν όμως, επιστημονικές δημοσιεύσεις ψυχολογικών θεραπειών που εφαρμόστηκαν σε ενήλικες με CRPS-I.

πηγή:  http://www.biomedcentral.com/1471-2377/10/20


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