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Manag ing the Chron i c Pa in Pa t i en t
Manag ing the Chron i c Pa in Pa t i en t
Dr Anthony Nicholson DACNB FIANM(aus)
CEO, Chiropractic Development International (CDI)
Adjunct Lecturer in Neuromusculoskeletal Diagnosis
Macquarie University
Chiropractor & Partner, Spine Partners Wahroonga
www.cdi.edu.au / www.spinepartners.com.au
Mary is 36 years old. She is referred by her General Practitioner for
assessment and management of chronic spinal pain. She was diagnosed
with fibromyalgia 10 years ago and has since been under the
management of a rheumatologist. Earlier this year she was also
diagnosed with seronegative rheumatoid arthritis. Whilst Mary
experiences widespread pain, her most troubling symptoms include lower
back and neck pain along with variable tingling sensations in both arms
from the shoulders down to the fingers. Mary has also had long standing
pain and stiffness in both knees. She has played netball for many years
and her knees seemed to be the start point of her broader pain syndrome.
Her medication list includes Lyrica, Micardis, Salazopyrin, Sinequan,
Solone and Trifeme. Mary also suffers anxiety, "brain fog" and frequent
headaches.
Adam is 26 years old. He has suffered from persistent lower back pain for the past
three years. This began during a basketball game and worsened a few weeks later as
he performed a side-step in a game of football. MRI demonstrated a bulging disc and
annular ‘tear’ and he was given rehab exercises. A further MRI was done a year later.
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O R I G I N A L I M A G I N G
O R I G I N A L I M A G I N G
I M A G I N G 1 Y E A R L A T E R
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I M A G I N G 1 Y E A R L A T E R
Currently Adam goes to the gym, although he can only manage to walk on the
treadmill and use an exercise bike, as resistance training seems to provoke back pain
almost immediately. Adam now feels constant stiffness and aching in the lower lumbar
region.
Adam has tried multiple treatment approaches from other musculoskeletal clinicians.
These have typically focussed upon mechanical explanations, such as ongoing ‘disc
injury’, ‘weak core muscles’ and ‘pelvic imbalance’.
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CNSA N A G I N G T H E C H R O N I C P A I N P A T I E N T
Understand the neurology of tissue protection
Gain a clear conceptual understanding of what pain represents
Identify the dominant pain mechanism
Identify faulty beliefs held by the patient
Appreciate the power of words & explanations
Use a brain-based treatment approach
Communicate using the latest concepts in pain science
CNS
Genetic tendency
It remembers…
It predicts…
It selects…
It decides…
The nociceptive system - the peripheral machinery for protection
Nociception is the detection of noxious stimuli – a high threshold system in its normal mode of operation
A noxious stimulus is one that is capable of producing tissue damage
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Withdrawal reflex for immediate protection
An intensely unpleasant experience linked to the stimulus to change future behaviour
Noxious stimulus
The second order neuron -
accessing the central pain
pathways
Reflex connections onto
lower motor neurons
Limbic system
Autonomic centres
Thalamus
Cortical areas
C E N T R A L P A I N N E U R O M A T R I X
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C E N T R A L P A I N N E U R O M A T R I X
Nociceptive inputs
Internal evaluation
This image cannot currently be displayed.
It is an output from the pain neuromatrix that alters the function of sensory, motor and autonomic systems.
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MEANING
Peripheral sensitisation
Central sensitisation
CNSD E S C E N D I N G I N H I B I T I O N
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Spinal cord
Midbrain
Pons
Medulla
Periaqueductal gray
Locus coeruleus
Nucleus raphe magnus
Dorsal horn
Inputs from hypothalamus, amygdala and cortex
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Loss of fine motor control
Tissue deconditioning
Activation of our protection system
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It is seen to represent
‘nothing’ – an inert
ingredient with no effect.
The skilful clinician recognises
and recruits the non-specific
effects of a clinical interaction.
Is this the same as placebo?
What does the term
‘Contextually Aided
Recovery’ actually mean?
Placebo is thought to
have emerged from
medieval Europe.
“The placebo pill or intervention is merely a trigger, wrapped in contextual meaning that
initiates an innate ability of the CNS to directly modulate ascending nociception.
Evidence is now incontrovertible that patient expectation of benefit as constructed by the use of
such contextual cues can also powerfully modulate motor and immune function. Some authors
have suggested alternative language to describe this phenomenon to decouple the historically
negative semantics of placebo from what are ostensibly desirable effects. For example,
Moerman suggested the ‘meaning effect’ while ‘contextual effect’ or ‘contextual healing’ have
also been suggested.”
“The contextual effect i.e., the analgesia, modulated immune or motor response - can be
triggered by a raft of contextual factors commonly present in therapeutic encounters. These may
include administration of a pill or treatment, powerful words as used by a clinician, the clinical
environment itself or the cultural signals engendered by the use of a white coat or the title of
‘doctor’ amongst many others.”
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“A recent review included general categories of known factors that support contextual
healing; patient-physician relationship (verbal communication, nonverbal communication),
treatment features (clear diagnosis, overt therapy and observational learning, patient centred
approach, global process of care, therapeutic touch), and healthcare setting features
(environment, architecture and interior design).
In short, how a patient understands and interprets the words and actions of a clinician and
the clinical environment within a clinical encounter, can switch on or off neurobiological
pathways that directly reduce or enhance pain.”
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Intermittent sharp, dull ache or throb at rest
Aggravating and easing factors
Proportionate painProportionate pain
N O C I C E P T I V E D O M I N A N T P A I N
No night pain, dysesthesia, burning,shooting or electric
Also consider how localised thepain is on the body chart
History of nerve pathology or compromise
Positive neurodynamic testsand palpation (mechanical tests)
Pain in dermatomal or cutaneous distributionPain in dermatomal or cutaneous distribution
P E R I P H E R A L N E U R O P A T H I C D O M I N A N T P A I N
Psychosocial issues – consider therisk rating from the intake forms
Diffuse palpation tenderness
Disproportionate aggravatingand easing factors
Disproportionate painDisproportionate pain
D O M I N A N T C E N T R A L P A I N M E C H A N I S M
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I D E N T I F Y F A U L T Y B E L I E F S
“Understanding the patient’s unique experience is essential to discovery of the patient-
specific beliefs and risk factors that will serve as the ‘target’ when educating a patient about the
biology and physiology of their pain experience in the therapeutic neuroscience education (TNE)
approach.”
“What do you think is causing your pain?”
“What have you been told is the reason for your pain?”
“What do you think is preventing you from getting past this?”
“When you bend over / lift your arm / and it hurts what do you think is happening to cause the pain at that moment?”
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T H E P O W E R O F W O R D S
“Explain Pain (EP) is an educational intervention aimed at reconceptualising pain itself. It’s a
conceptual change strategy.”
“Conceptual change learning is specifically shaped around challenging existing knowledge
and knowledge structures rather than simply learning new information.”
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“The core objective of EP approach to treatment is to shift one’s conceptualization of pain
from that of a marker of tissue damage or disease to that of a marker of perceived need to
protect body tissue.”
B R A I N - B A S E D A P P R O A C H
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Re-mapping the brain with novel and amplified sensory input
How could this relate to manual treatment?
S E N S O R Y D I S C R I M I N A T I O N T R A I N I N G
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CNSP R O F E S S I O N A L C O M M U N I C A T I O N
Working Diagnosis and Management:
Mary is neurologically intact at a gross level, with no signs ofuncontained disc pathology or focal insult to either the nerveroots or spinal cord.
While Mary does exhibit numerous areas of articular andmyofascial dysfunction that are viable targets for manualintervention, careful consideration is also given to the broadercontext of brain-amplified spinal pain mechanisms with whichher peripheral tissues interact.
CNSP R O F E S S I O N A L C O M M U N I C A T I O N
Research interest into Fibromyalgia as a prototypical central paindisorder continues to swell, and our clinical approach to patientslike Mary is constantly being refined accordingly. When thinkingperipherally, a worthwhile aim of manual treatment is to reduceobvious localised areas of tissue nociception that continue toactivate Mary’s peripheral pain pathways. Pain invariably leadsto the avoidance of movement and a shrinking physical capacity.Deconditioned tissues then become more potent paingenerators.
CNSP R O F E S S I O N A L C O M M U N I C A T I O N
From the perspective of Fibromyalgia being a centrally-augmented pain experience, manual treatment is beingconsidered in a different light. Patients with chronic pain areknown to exhibit distorted representations of body parts in thesensory and motor cortices, as well as impairments indescending pain inhibitory controls.
Gently applying passive joint movements as part of a moreglobal approach is seen as a way of amplifying theproprioceptive awareness of body movements again andrestoring a normal central representation – essentially breakinglearned associations between movement and pain. An effectivedose and blend of proprioceptive stimulation is also known tomodulate descending inhibitory control of spinal painprocessing.
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CNSP R O F E S S I O N A L C O M M U N I C A T I O N
Ensuring that Mary is actively engaged in her management asearly as possible is also considered highly important. A strongfocus on education to distinguish between ‘hurt’ and ‘harm’, aswell as exercises that gently challenge perceived movementlimitations are known to increase the chance of treatmentsuccess
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