理学療法ジャーナル52巻7号

2018年07月発行

特集 疼痛管理

疼痛管理のための運動療法

著者： 下和弘¹²

所属機関： ¹愛知医科大学運動療育センター ²愛知医科大学学際的痛みセンター

ページ範囲：P.619 - P.627

はじめに

　運動療法は疼痛管理のなかでも非薬物的な介入の1つであり，特に薬物療法や手術療法だけでは取りきれない慢性の運動器疼痛に対して重要な役割を果たす．運動療法は慢性痛患者の痛みによる生活への影響を改善するほか，筋力や柔軟性，全身持久力の向上だけでなく心血管イベントやメタボリックシンドロームのリスク低減，骨密度の維持，さらには認知機能や気分の改善といったさまざまな効果が期待される．したがって，慢性痛患者には積極的に運動療法を導入するべきである．しかし，慢性の運動器疼痛を訴える患者の多くは，動かすと痛みが出現するため安静にしようとする傾向に陥りやすく，不活動によって筋力や全身持久力の低下といった運動器のデコンディショニングが生じ，運動耐容能が下がることでさらに運動によって痛みが生じやすくなるという悪循環を形成しており，運動療法の導入に抵抗を示すことが少なくない．慢性痛患者に運動療法を処方する際には，生物心理社会的アプローチに基づいた患者の理解と適切な評価が必要であり，それぞれの患者に応じたテーラーメイドのプログラムが必要となる^1〜3）．

参考文献

1）Bennell KL, et al：A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport 14：4-9, 2011

2）O'Riordan C, et al：Chronic neck pain and exercise interventions：frequency, intensity, time, and type principle. Arch Phys Med Rehabil 95：770-783, 2014

3）Meeus M, et al：Moving on to movement in patients with chronic joint pain. Pain：Clinical Updates 24（1）：1-8, 2016

4）Jordan JL, et al：Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev：CD005956, 2010

5）Busch AJ, et al：Resistance exercise training for fibromyalgia. Cochrane Database Syst Rev：CD010884, 2013

6）Bidonde J, et al：Aquatic exercise training for fibromyalgia. Cochrane Database Syst Rev：CD011336, 2014

7）Fransen M, et al：Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev：CD004376, 2015

8）Hayden JA, et al：Systematic review：strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med 142：776-785, 2005

9）van Middelkoop M, et al：A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J 20：19-39, 2011

10）Busch AJ, et al：Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev：CD003786, 2007

11）Moseley L：Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother 48：297-302, 2002

12）Pires D, et al：Aquatic exercise and pain neurophysiology education versus aquatic exercise alone for patients with chronic low back pain：a randomized controlled trial. Clin Rehabil 29：538-547, 2015

13）Steiger F, et al：Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect（s） of performance? A systematic review. Eur Spine J 21：575-598, 2012

14）Stagg NJ, et al：Regular exercise reverses sensory hypersensitivity in a rat neuropathic pain model：role of endogenous opioids. Anesthesiology 114：940-948, 2011

15）Chen YW, et al：Forced treadmill running suppresses postincisional pain and inhibits upregulation of substance P and cytokines in rat dorsal root ganglion. J Pain 15：827-834, 2014

16）Mazzardo-Martins L, et al：High-intensity extended swimming exercise reduces pain-related behavior in mice：involvement of endogenous opioids and the serotonergic system. J Pain 11：1384-1393, 2010

17）Martins DF, et al：High-intensity swimming exercise reduces neuropathic pain in an animal model of complex regional pain syndrome type Ⅰ：evidence for a role of the adenosinergic system. Neuroscience 234：69-76, 2013

18）Naugle KM, et al：Self-reported physical activity predicts pain inhibitory and facilitatory function. Med Sci Sports Exerc 46：622-629, 2014

19）Meeus M, et al：Reduced pressure pain thresholds in response to exercise in chronic fatigue syndrome but not in chronic low back pain：an experimental study. J Rehabil Med 42：884-890, 2010

20）Lannersten L, et al：Dysfunction of endogenous pain inhibition during exercise with painful muscles in patients with shoulder myalgia and fibromyalgia. Pain 151：77-86, 2010

21）Van Oosterwijck J, et al：Lack of endogenous pain inhibition during exercise in people with chronic whiplash associated disorders：an experimental study. J Pain 13：242-254, 2012

22）Van Oosterwijck J, et al：Pain inhibition and postexertional malaise in myalgic encephalomyelitis/chronic fatigue syndrome：an experimental study. J Intern Med 268：265-278, 2010

23）Vierck CJ Jr, et al：The effect of maximal exercise on temporal summation of second pain（windup）in patients with fibromyalgia syndrome. J Pain 2：334-344, 2001

24）Meeus M, et al：Endogenous pain modulation in response to exercise in patients with rheumatoid arthritis, patients with chronic fatigue syndrome and comorbid fibromyalgia, and healthy controls：a double-blind randomized controlled trial. Pain Pract 15：98-106, 2015

25）Sluka KA：Peripheral and central mechanisms of chronic musculoskeletal pain. Pain Manage 3：103-107, 2013

26）Moseley GL, et al：Bodily illusions in health and disease：physiological and clinical perspectives and the concept of a cortical‘body matrix’. Neurosci Biobehav Rev 36：34-46, 2012

27）Wallwork SB, et al：Are people who do yoga any better at a motor imagery task than those who do not? Br J Sports Med 49：123-127, 2015

28）Wand BM, et al：Cortical changes in chronic low back pain：current state of the art and implications for clinical practice. Man Ther 16：15-20, 2011

29）Peyron R, et al：Motor cortex stimulation in neuropathic pain. Correlations between analgesic effect and hemodynamic changes in the brain. A PET study. Neuroimage 34：310-321, 2007

30）Dall'Agnol L, et al：Repetitive transcranial magnetic stimulation increases the corticospinal inhibition and the brain-derived neurotrophic factor in chronic myofascial pain syndrome：an explanatory double-blinded, randomized, sham-controlled trial. J Pain 15：845-855, 2014

31）Kroll HR：Exercise therapy for chronic pain. Phys Med Rehabil Clin N Am 26：263-281, 2015

32）城　由起子：疼痛の理学療法評価と臨床推論．理学療法33：409-415，2016

33）Traeger AC, et al：Effect of primary care-based education on reassurance in patients with acute low back pain：systematic review and meta-analysis. JAMA Intern Med 175：733-743, 2015

34）Louw A, et al：The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil 92：2041-2056, 2011

35）下　和弘：疼痛に関する患者教育の基礎的背景とエビデンス．理学療法33：448-454，2016

36）Nijs J, et al：How to explain central sensitization to patients with‘unexplained’chronic musculoskeletal pain：practice guidelines. Man Ther 16：413-418, 2011

37）Nijs J, et al：A modern neuroscience approach to chronic spinal pain：combining pain neuroscience education with cognition-targeted motor control training. Phys Ther 94：730-738, 2014

38）Vlaeyen JW, et al：Fear-avoidance and its consequences in chronic musculoskeletal pain：a state of the art. Pain 85：317-332, 2000

39）Kernan T, et al：Observed outcomes associated with a quota-based exercise approach on measures of kinesiophobia in patients with chronic low back pain. J Orthop Sports Phys Ther 37：679-687, 2007

40）Von Korff M, et al：A trial of an activating intervention for chronic back pain in primary care and physical therapy settings. Pain 113：323-330, 2005

41）Cormier S, et al：Expectations predict chronic pain treatment outcomes. Pain 157：329-338, 2016

42）Colloca L, et al：Nocebo hyperalgesia：how anxiety is turned into pain. Curr Opin Anaesthesiol 20：435-439, 2007

43）Gardner T, et al：Patient led goal setting in chronic low back pain-What goals are important to the patient and are they aligned to what we measure? Patient Educ Couns 98：1035-1038

44）Jones KD, et al：A comprehensive review of 46 exercise treatment studies in fibromyalgia（1988-2005）. Health Qual Life Outcomes 4：67, 2006. doi：10.1186/1477-7525-4-67

45）Andrews NE, et al：Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain：a systematic review and meta-analysis. Arch Phys Med Rehabil 93：2109-2121, 2012

46）Booth J, et al：Exercise for chronic musculoskeletal pain：a biopsychosocial approach. Musculoskeletal Care 15：413-421, 2017

47）Slade SC, et al：What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain? A systematic review of qualitative studies. Clin J Pain 30：995-1005, 2014

48）Busch AJ, et al：Exercise therapy for fibromyalgia. Curr Pain Headache Rep 15：358-367, 2011

49）O'Connor SR, et al：Walking exercise for chronic musculoskeletal pain：systematic review and meta-analysis. Arch Phys Med Rehabil 96：724-734, 2015

50）Burrows NJ, et al：Acute resistance exercise and pressure pain sensitivity in knee osteoarthritis：a randomised crossover trial. Osteoarthritis Cartilage 22：407-414, 2014

51）Vaegter HB, et al：Similarities between exercise-induced hypoalgesia and conditioned pain modulation in humans. Pain 155：158-167, 2014

52）Häuser W, et al：Efficacy of different types of aerobic exercise in fibromyalgia syndrome：a systematic review and meta-analysis of randomised controlled trials. Arthritis Res Ther 12：R79, 2010. doi：10.1186/ar3002

53）Kristensen J, et al：Resistance training in musculoskeletal rehabilitation：a systematic review. Br J Sports Med 46：719-726, 2012

54）Limke JC, et al：Randomized trial comparing the effects of one set vs two sets of resistance exercises for outpatients with chronic low back pain and leg pain. Eur J Phys Rehabil Med 44：399-405, 2008