pain management certification workshop (july 2020) · certification workshop 1 2 what is pain? ......
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Pain ManagementCertification Workshop
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What is pain?
• “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” – International Association for the Study of Pain, updated 16 July 2020
• Margo McCaffrey, RN (1968) – “[pain is] whatever the experiencing person says it is, existing whenever and wherever the person says it does.”
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Six Key Notes
• 1. Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
• 2. Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
• 3. Through their life experiences, individuals learn the concepts of pain.
• 4. A person’s report of an experience as pain should be respected.
• 5. Although pain usually serves as an adaptive role, it may have adverse effects on function and social and psychological well-being.
• 6. Verbal description is only one of the several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.
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Chronic Pain Statistics
• 116 million—number of U.S. adults with common chronic pain conditions
• $560 to 635 billion—conservative estimate of the annual cost of chronic pain in America
• 80 %—percentage of patients undergoing surgery who experience postoperative pain; fewer than half report adequate pain relief: of these, 88% report the pain is moderate, severe, or extreme;
• 10 to 50% of patients with postsurgical pain develop chronic pain, depending on the type of surgery; and
• for 2 to 10% of these patients, this chronic postoperative pain is severe
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Comorbidities Attached to Chronicity
• 66% of combat veterans with diagnosed PTSD (estimated 28% return rate) report having chronic pain.
• 43% of patients with reported mTBI (10-20% returning from Iraq / Afghanistan) exhibit chronic pain patterns.
• 13.1% of patients demonstrated HTN and cardiovascular events.
• 27% reported depression and generalized anxiety disorder
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Prevalence of Pain Diagnoses
• 1997 to 2011 – joint and back pain increased 3-4x among active duty service members
- 45% reporting joint pain and 60% back pain
• 63% had at least one pain diagnosis
- 2/3rds report multiple pain diagnoses
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Prevalence of Pain Category Diagnoses
297,120 soldiers analyzed
59.2% primary pain diagnosis
“Other MSK” = 29.5%Non-traumatic joint disorder = 28.1%Back/Neck Pain = 22.4%
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Translation into Chronicity• Over 51,000 soldiers assessed between military
operations in Afghanistan and Iraq. Recent study of 2,597 those active-duty service members.
- 44% reporting pain lasting > 3 months
- 55.6% reporting pain almost daily or constantly
• Veterans assessment:
- 71% reported experience pain
- Of those 71%, 35% report constant pain and 85% report their pain has been “going on for a number of years”
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Veterans versus Nonveterans
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Health Seeking Behaviors
• Methodological Reporting:
- Military Management Analysis and Reporting Tool (M2) during January 1-Dec 31, 2009
- 1,691 cohort seeking consultation for low back or neck pain with at least one manual therapy treatment code.
• Mediated by:
- Predisposing factors (sex, age, cultural, ethnic, and social factors), enabling factors(organizational, access to care, financial), and need factors (both the patient and medical provider’s view and experiences)
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Health Seeking Behaviors Results• Average # of PCP visits = 6.82 (SD=6.25)
• Mean total healthcare visits = 16.13 (SD=18.35)
• Mean total healthcare costs = $7,043.14 (SD=$15,490.76)
• Status = Active Duty (66%), Dependents (16%), Retired Service Members (8%)
• Sex = Primarily male (56.8%)
• Age = Mean age 36.8 years (SD=11)
• Most common physical comorbidities = Sleeping Disorders (20.9%) and hypertension (18.4%)
• Most common mental health comorbidities = Anxiety (19.8%) and depression (18.5%)
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Health Seeking Behavior and Why it Matters• Healthcare super utilization = top 25%
“users” are reported to account for 86% of total healthcare costs
• HSB can be positively (or negatively) reinforced. In a free market health system, where reassurance, diagnostic labels, and medicine are readily available, positive reinforcement is easily attained.
• Clinical Implication Suggestion: to minimize provider being the enabler – educate, limit overuse of diagnostic imaging, reduce invasive treatment strategies
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Risk Factors for Opioid Misuse
• Categorization of patients based on comorbidities and situational history -> paramount to predictive risk of misuse.
• Seen across healthcare spectrum, not just in military.
• Proper subjective examination (history intake) necessary for screening.
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Relieving Pain in America
• “The Picture of Pain”, IOM (Institute of Medicine), 2011
- NOTE: People can move between and among these groupings and can be in more than one group simultaneously. Similar colors represent similar endpoints.
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Nociceptors and Nociception?
• The word nociceptor is a purely physiological term meaning a nerve fiber that responds to stimuli that damage tissue or would damage tissue if they were prolonged. They are meant to detect a noxious event. The word pain is a purely psychological term.
• Pain is all about protection.
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Neurophysiological Differentiation
• Sensory neurons: Afferent types
- Myelinated
- Type Aα, Aβ, Aδ
- Unmyelinated
- Type C
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What gets them fired up?
• Ion channel potentials – TRPs “transient receptor potential”; TRPV, TRPA, TRPM, ASIC, Piezo
• Voltage-/Ligand- gated channels – Nav1.7/1.8
• Local inflammation – interleukin, tumor necrosis factor, & interferons
These are danger sensors, not pain sensors!
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Not just a one-way street
• “Danger detectors – the great givers of life”
- Nociceptors aren’t just the harbingers of doom; they also facilitate growth, healing, & recovery. Aid in vasodilation and mobilization of immune cells.
- D. Butler describes them as “Power Peptides”
- CGRP, Substance P, & glutamate
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Power Peptides
• Mechanisms
- Axonal reflex
- Increased electrical energy must be released -> peptidergic inflammation
- [ex. Fingernail along forearm]
- Antidromic activation
- Action potential elicited proximally at the DRG/DH -> increased electrical energy must be released -> peptidergicinflammation
- [ex. Discussion of previous pain or traumatic experience creating vasodilation near previous point of insult]
Brain will upregulate spinal nociceptors via descending facilitation
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Inflammation: Not always the enemy
• Inflammation isn’t just about a healing response…
- Critical role in making us able to adapt to our environment and for survival – cognitively, too!
- Cognitive tasks increase the production of T lymphocytes which express interleukin 4 (IL-4) [anti-inflammatory cytokine].
- Make your own? Ok -> exercise and caloric intake restrictions yield improved cognitive performance and T cell counts.
“Well done you old self-healer.” –Tim Cocks
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Chronic Pain & Cognition
• IL-4 & IL-1 reduction shown in patients with chronic pain
• Spatial orientation/awareness, memory, and cognition suffer when IL-4/IL-1 reserves are low.
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Spinothalamic tract• Pain, temperature, & crude touch
• Input from nerve ending -> DRG enters via Lissauer’s fasciculus and synapse.
• The synapse is in the dorsal horn of SC neurons located inside substantia gelatinosaor nucleus proprius and then decussates across the anterior white commissure.
• Ascends via the spinothalamic fasciculus and synapses at the VPL nucleus in thalamus and is sent to PCG in somatosensory cortex (S1)
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Spinomesencephalic tract
• “Spinotectal Tract” also known as; terminates at the PAG
• Important for control and inhibition of pain
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Breaking Down the Brain
• Areas involved in pain modulation:
- Amygdala, periaqueductal grey (PAG), dorsolateral pontine tegmentum (DLPT), rostroventral medulla (RVM), rostral anterior cingulate cortex (ACC), insula, hippocampus, hypothalamus, and primary sensory cortex (S1)
- Higher areas of cognitive & emotional modulation include the prefrontal cortical areas - dorsolateral prefrontal cortex (DLPFC) and ventrolateral prefrontal cortex (VLPFC)
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Neuromatrix Model
• Neuromodules
- Sensory
- Affective
- Cognitive
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Mature Organism Model• Not just a function of the brain but of the
whole body and its interactions with the environment.
• Examples of outputs:
- Immune
- Endocrine
- Sympathetic
- Musculoskeletal
- Behavioral/Cognitive
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MOM: Sampling
• Central:
- Dorsal root ganglions
- Cerebral processing
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MOM: Sampling & Inputs
• Peripheral:
- Multiple receptor sites
- Thermal, chemical and mechanical
- Density of these can be determined by genetics, exposure, and previous insult.
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Temporal Summation
• Increase of pain through repeated stimuli
• Best quantitative sensory testing for chronic pain
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Homunculus
• Somatic sensory homunculus
• Map of our body in the brain’s cortex
• Compared pinpoint and two-point discrimination on small vs large surface areas
• Specialization & discrimination based on environment and vocation.
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Homunculus: Smudging
• Reorganization of sensory- and motor-controlled areas of the brain due to microscopic levels of inflammation and invasion of neighboring brain cells in somatosensory cortex.
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Experience Related to Pain• Multidimensional experience of pain;
subjective, real, and different for every individual.
• fMRI and PET studies show salience network activation and communication in midcingulate and anterior insula activation pre/post stimulation à Anticipation (or bias) of painful stimuli increases this connectivity.
• fMRI revealed cognitive load vs pain intensity have inverse relationship during color-word Stroop task and activation of the ACC, PAG, and posterior thalamus.
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fMRI in CRPS vs Control
• Executive function network (attention network) plays critical role in perception, anticipation, and modulation of pain. In chronic pain, the wiring is aberrant, and connectivity is mismatched.
• Functional connections between salience network + sensorimotor network and the attention network were enhanced in the CRPS group.
• Increased interaction between attention and salience networks are important in pain catastrophizing. Salience network activation increased in chronic pain state (perceived prolonged painful stimuli).
• Demonstrates altered intra-network functional ability within the attention network BUT enhanced inter-network connections between the salience and attention networks.
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Contextual Factors on Pain
• Subjects held a -20C rod in one hand for 0.5s while looking at a red (“hot” = more tissue damage) or a blue (“cold” = less tissue damage) visual cue.
• Pain was rated as more intense and as “hot” when the red cue was present.
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Understanding the Patient’s Perspective
• Louis Gifford’s 4 questions:
- “What’s wrong with me?”
- “How long’s it going to take to get better?”
- “Is there anything I can do to help myself?”
- “Is there anything that you can do to help me?”
Each and every pain problem has a thinking, reasoning, and emotional brain attached to it.
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Flag System
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Red Flag Screening
• All 23 items = 100% accuracy for red flag responders
• First 10 items had 94% accuracy
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Orange Flag Screening
• Patient Health Questionnaire-2
- “Over the past two weeks, have you been bothered by any of the following problems?
- 1. Little interest or pleasure in doing things?
- 2. Feeling down, depressed, or hopeless?
Answers: 0 – not at all; 1 – Several days; 2 – More than half the days; 3 – Nearly every day
If > 3, continue to PHQ – 9 but note that depression may be a limiting factor in rehabilitation prognosis.
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Yellow Flag Screening
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Yellow Flag Screening
• 17 item has 85% accuracy and good concurrent validity across anatomical regions.
• Accurate estimates of negative mood, negative coping strategies, and positive affect/coping domains
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Yellow Flag Screening
• Fear Avoidance Belief Questionnaire (FABQ) and Tampa Scale of Kinesiophobia (TSK) with fMRI
• Functional connectivity reduction and disrupted in the amygdala-PAG modulated by pain-related fear.
• Pronociceptive effects shown in psychological fear avoidance patterns in patients with chronic pain
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ABCDEFW Framework• Used in assessing for psychosocial factors
that may affect treatment efficacy:
- A: Attitudes/Beliefs
- B: Behaviors
- C: Compensation
- D: Diagnosis/Treatment
- E: Emotion
- F: Family
- W: Work
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Biopsychosocial & Multidiscipline approach
• Physical approach provides:
- Low evidence to support pain reduction and improved disability rating.
• Multidisciplinary approach provides:
- Moderate evidence to support pain reduction and improved disability rating.
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Factors Modulating Pain
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Flag Assessment Tools:Fear-Avoidance Belief Questionnaire
• R=0.685, strong correlative factor connecting physical performance to fear-avoidance patterns.
• Fear-avoidance cascade of catastrophizing, depression, deconditioning, and disability, was noted in individuals with low physical activity and high fear-avoidance.
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Flag Assessment Tools:Tampa Scale of Kinesiophobia
• Correlation has been accounted for higher TSK-11 scores in frail, older individuals.
• Poor self-perceived health and high pain intensity were also associated with higher scoring.
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Flag Assessment Tools:Pain Catastrophizing Scale
• Measures rumination, magnification, and helplessness.
• A score >29 represents a clinically significant catastrophization.
• Moderate evidence supporting higher score on PCS related to delayed recovery.
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Neurophysiology Pain Questionnaire
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EvaluationSubjective
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Patient Beliefs
• What a person thinks, feels, and believes about their condition will influence their examination, treatment, and ultimately, their prognosis.
• Address perceived threats / fears to guide your interview.
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SINSS / SPINSS Model
• Severity
• Pain Mechanism
• Irritability
• Nature
• Stage
• Stability
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Severity
• Not just a rating of pain (NPRS/VAS)
• What is the patient limited in doing? What is their impact on function?
• Tie in subjective questionnaires
• Rated: minimal, moderate, severe
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Pain Mechanisms
• Nociceptive
• Peripheral neuropathic
• Central sensitization
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Pain Mechanism:Nociceptive
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Pain Mechanism:Peripheral Neuropathic
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Pain Mechanism:Central Sensitization
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Irritability
• One of the best indicators to not “muddy” your examination
• Consists of three components:
1. What activity causes their symptoms?
2. What is the degree of exacerbation?
3. How long does it take to calm back down?
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Nature
• Multifactorial judgement -
- Pathological considerations (is this a chemical irritation, inflammation, mechanical, supraspinal, complex disorders)
- Patient-specific factors (think environmental, emotional, personal)
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Stage
• Acute - < 2 weeks(?)
• Sub-acute – 2-6 weeks(?)
• Chronic - > 6 weeks(?)
- Acute on chronic
- Sub-acute on chronic
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Stability
• Are the patient’s symptoms:
- Improving
- Worsening
- Staying the same
• Also, are they:
- Predictable
- Unpredictable
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Integration of the Pain Neuromatrix
• Marriage of the input and environment gathered by your subjective examination
- Key questions to understand what is going on in the patient’s life while respecting their subjective symptoms (SPINSS approach)
- How do we then tie in the concept of the pain neuromatrix to our clinical decision making?
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Clinical Decision Making:Hypothesis Generation
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EvaluationObjective
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Palpation Assessment
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2 Point Discrimination
• Generally thought to not be a deficit in tactile discrimination but more of a cortical change due to reorganization of S1 at the affected body region.
• Statistically significant relationship between tactile acuity and pain intensity, but not pain duration.
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Pain Pressure Threshold
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Adverse Neural Dynamics
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Evidence-Based ApproachesResearch
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Sleep
• Increased literature supporting benefit of sleep.
• Reliable predictor for new incidents and exacerbations of chronic pain.
• May impair key processes that contribute to the development and maintenance of chronic pain, including endogenous pain inhibition and joint pain.
• Improved sleep quality can reduce pain and fatigue, increasing the hypothesis that sleep dysfunction is a pathogenic stimulus for fibromyalgia.
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Manual Therapy
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Manual Therapy Mechanisms
• Biomedical / Biomechanical Models
- Stretching fascia / tissue, capsules, realigning joints
• “Mechanical force leads to a cascade of neurophysiological responses from the peripheral system to the central system – your outcome drivers.”
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Manual Therapy & Pain Sensitivity
• Spinal Manipulative Therapy (SMT) associated with changes in pain sensitivity, suggesting altered CNS response of process of nociceptive input.
• 110 participants with LBP received SMT, placebo SMT, placebo with instructional set, no intervention.
• Results: attenuation of pain sensitivity is greater in response to SMT than the expectation for receiving SMT.
• Suggests a potential mechanisms of SMT related to lessening central sensitization.
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Manual Therapy Sensitization
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Is Manual Therapy an option?• YES!
• Evidence of SMT/MT is effective in the treatment of multiple musculoskeletal disorders.
• Clinical Pearls:
- Maintain locus of control with patient.
- Careful to reduce patient dependence on SMT/MT.
- *** Temporary to promote activetreatments ***
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Exercise: Then? Or still now?
• Can’t go wrong getting strong
• Stretch it out
• Increase speed
• Better endurance
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Exercise: Literature supports!
• Cochrane Review (2017) suggests physical activity (PA) / exercise has few adverse events that may improve pain severity and physical function -> quality of life.
• Moderate effect size for improved physical function
• Small shift for pain severity but limitations in studies were methodologically unsound.
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Exercise Approaches
• nsCLBP data demonstrates significant reduction inf pain and disability compared to minimal care/no treatment/other conservative therapies (SMT/MT, NSAIDS)
• Aerobic > resistance for reducing pain in fibromyalgia.
• Strengthening +/- stretching > aerobic exercise alone for nsCLBP and neck pain.
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Exercise-induced Hypoalgesia
• All three types of exercise can produce large effects in healthy adults, small to large EIH (exercise-induced hypoalgesia) with regional pain with distal muscle activation (think regional interdependence)
• However, small effects for chronic widespread pain when exercising at moderate to high intensity – dosing matters!
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Exercise-induced Hypoalgesia• Acute Pain:
- Isometric, Aerobic, and Dynamic Resistance all resulted in EIH.
- Aerobic EIH -> dose dependent.
- Changes in Isometric / Dynamic Resistance whether local or remotely performed.
• Regional Chronic Pain:
- Local resistance exercise increased pain, but remote exercise resulted in EIH.
- Aerobic EIH response same as acute pain.
• Widespread Chronic Pain / Fibromyalgia:
- Local / remote isometrics increased pain if moderate-high intensity, EIH at low-intensity
- Aerobic exercise increased pain if moderate-high intensity, but EIH at low-moderate intensity
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Endogenous Opioid System
• Activation of endogenous opioid system -> reduces pain perception following exercise (of sufficient intensity and duration) via peripheral/central beta-endorphins with reduction in pain sensitivity.
• Non-opioid also play a role (endocannabinoid, serotonin, norepinephrine).
• Exercise parameters matter and may alter which system is activated.
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Aerobic Activity
• Moderately intense aerobic exercise (~50% HRR [heart rate reserve] + resting HR) capable of producing hypoalgesic effects.
• Vigorous aerobic exercise produced larger effects (~70% HRR)
HRR = (220-Age) – resting HR
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Aerobic Activity & Pain Perception
• CLBP – 8 patients
• Pain ratings measured pre, 2 minutes post and 35 minutes post – following 25 minutes of cycle ergometer.
• Significant decrease after exercise at both 2- and 32-minutes post.
• Pressure pain perception can be reduced for more than 30 minutes following aerobic exercise from leg cycling among people with CLBP.
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Aerobic Activity & Mood
• Valuable strategy for self-regulation of mood in many individuals.
• Some effects may last for hours after a wide-range of exercise intensities.
• Regular exercise training may also offer some protection from depression and is useful in enhancement of the acute improvements in mood from a single exercise session.
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Patient Education
• Mixed evidence for acute/subacute pain.
• Even less evidence for chronic pain.
• “The results showed that education programs were not effective in preventing and treating neck pain or low back pain.”
• Problems with this: used biomedical/biomechanical approaches, function, and pathophysiology
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Neurophysiology Education
• 31 subjects with LBP received Pain Neurophysiology Education (PNE)
• 27 subjects with LBP received structural / biomedical model on their back (BME)
• Conclusions:
- PNE more effective in normalizing pain beliefs, reduction in pain catastrophization, and improving physical performance than BME.
- Neither PNE nor BME were effective on perceived disability ratings.
- Behavioral changes require more than just knowledge dumping.
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Pain Neuroscience Education
• Change beliefs to alter pain experiences & behavior
• Seeks to do this by:
- Reconceptualizing tissue injury and its relation to chronic pain.
- Disassociate fear and catastrophization from the pain neuromatrix to the patient’s perspectives on their pain.
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Effects of PNE
• 13 RCTs combined to demonstrate PNE’s capability to potentially affect:
1. Decreased pain intensity.
2. Improving patient knowledge of pain.
3. Improving function and lowering disability.
4. Reducing psychosocial factors.
5. Minimizing healthcare utilization.
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Fact or Fiction on Explaining Pain
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Combined Approach of PNE
• 57 patients with cLBP
• Usual Care Group:
- Ongoing medical management from PCP with no PT treatment
• Combined Group:
- Manual therapy + Exercise
- One-hour neurophysiology session
• Combined PT more effective than usual care in improving function / decreasing symptoms.
• Usual Care Group -> averaged 13.2 additional healthcare visits for their pain.
• Combined Group -> averaged 3.6 additional healthcare visits for their pain.
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Current Clinical Guidelines
• Supervised moderate intensity exercise recommended following self-care.
• Multimodal (and multidisciplinary) treatment approach recommended
- Yoga
- CBT
- Spinal manipulative therapy / manual therapy
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Evidence-Based TreatmentPerformance
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Housekeeping: Terminology
• Placebo:
- A substance that has positive effects as a result of a patient’s perception that it is beneficial rather than as a result of a causative ingredient.
- Stimulates factors so that the influence they have on the brain and body is the same as that produced by an active treatment within the same therapeutic context.
• Nocebo:
- A detrimental effect on health produced by psychological or psychosomatic factors such as negative expectations of treatment or prognosis.
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Placebo
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Words that Harm, Words that Heal
• “Language is not merely a vehicle which carries ideas. It is itself, a shaper of ideas.”
• What about diagnoses?
- Instability
- Scoliosis
- Arthritis
- Degenerative Disc Disease / Degenerative Joint Disease
- Bulging Disc / Slipped Disc
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Talking to a Patient: Acute or Chronic doesn’t matter
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Put your game face on
• Real vs Sham acupuncture were delivered with either a “neutral” or “highly positive” endorsement from the practitioner.
• Both groups showed an equal improvement compared to no treatment group
• However -> those who received it from “highly positive” practitioner did better regardless if they received real or sham needle insertion.
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Explain Pain
• Limbic & Insular Systems – emotional aspects with pain intensity
• Somatosensory Cortex – where pain is felt in our bodies
• Limbic-Motor Cortex – select the correct behavioral and motor response to painful stimuli
• Prefrontal Cortex – understanding pain
• Brain Stem & Thalamus – mediate changes in pain perception
Pain Experience
Limbic & Insular Systems
Somatosensory Cortex
Limbic-Motor Cortex
Prefrontal Cortex
Brain Stem & Thalamus
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Explaining Pain & Fear
• Amygdala’s response explained:
- Use your own previous (maybe embarrassing experiences) of “wrongful” fear. ex) seaweed brushing against you in the ocean two years after a jellyfish had stung you
- Amygdala will quickly and automatically register this brushing response as danger, especially since you just experienced this pain two years ago.
- Emotional memory tags created in the original insult.
- Cortex will (slowly) kick in after your motor response to process this information for interpretation. Unfortunately, the fight or flight has already happened and changes in the system have occurred.
Amygdala• Quick, unconscious fear response• Increase sympathetic nervous system output
Cortex
• Conscious awareness of what we are sensing / feeling
• Interpretation of input in preparation for output
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Explain Pain: Hijacking the Amygdala
• Recall: just education alone may not be enough for patients
• Give the amygdala a new emotional response pair
- Tie in a painful experience with pain-reduced/free activity
- Have the patient demonstrate mindfulness of experience – repetition via graded exercise / exposure.
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Explain Pain – Clean up
• Qualitative studies show support that disabling CLBP may be partly iatrogenic.
• Many held biomedical beliefs -> structure / anatomical vulnerability of the spine.
• “The challenge for healthcare practitioners dealing with people with low back pain from any culture is to communicate in a way that builds positive beliefs about low back pain and its future consequences, enhancing resilience to disability.”
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Explain Pain - Imaging
• Cervical disc bulging, spinal cord compression, and increased signal intensity present in 87.6% of asymptomatic individuals (1211 healthy volunteers)
• Lumbar disc degeneration increases from 37% of asymptomatic 20-year-olds to 96% of 80-year-olds. Disc bulge went from 30% of 20s to 84% in 80s.
• Asymptomatic hip abnormalities in 73% of the patients (45 healthy volunteers) with 69% of them showing labral tears.
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Using the NPQ to EP:Purpose of Pain
NPQ #s 2, 4, 5, & 10• #2: “When part of your body is injured, special pain receptors convey the pain message to your brain.” FALSE
- Remember – pain is an output of the brain. Nociception can travel to the brain, but the brain decides if it is pain
- #4: “When you are injured, special receptors convey the danger messages to your spinal cord.” TRUE
- When there is tissue injury, our Aδ and C fibers transmit nociception to the spinal cord.
• #5: “Special nerves in your spinal cord convey “danger” messages to your brain.” TRUE
- Aβ, Aδ, and C fibers synapse with 2nd order neurons (ipsilaterally), cross and ascend in spinothalamic tract.
• #10: “Pain occurs whenever you are injured.” FALSE
- Plenty of examples supporting this throughout history.
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Explaining it for the patient• “The nervous system can be thought of as an alarm system –
meant to protect you by alerting you to danger or potential danger.”
• “When you’re injured – let’s say you slam your finger in the door on your way to work – danger messages travel to your spinal cord along special nerves.”
• “In the spinal cord, these nerves talk to other special nerves that carry that danger message to the brain – where it will later be processed so an appropriate response can occur.”
• “What I want you to realize is that we’re only talking about –danger-, not pain. Your body has mechanisms to either ramp up or block those danger signals. A smoke alarm senses smoke, not fire.”
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Using the NPQ to EP:Modulation of Nociception
NPQ #s 6, 7, 8, & 9• #6: “Nerves adapt by increasing their resting level of excitements.” TRUE
- Peripheral sensitization and “all or none” principle. In response to injury, chemicals are released that sensitize nociceptors and activate ion channels that lead to depolarization.
• #7: “Chronic pain means that an injury hasn’t healed properly.” FALSE
- In the absence of severe comorbidities, tissues will heal at an appropriate rate. Pay attention to sources surrounding the tissue that may have had previous insult.
• #8: “Worse injuries always result in worse pain.” FALSE
- Discussion of imaging and false positives are beneficial here.
• #9: “Descending neurons are always inhibitory.” FALSE
- Recall that your body is designed to protect its host! Descending input can inhibit or facilitate nociception.
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Using the NPQ to EP:Supraspinal ProcessingNPQ #s: 1, 3, 11, & 12
• #1: “It is possible to have pain and not know about it.” FALSE
- You can have danger signals and not be aware. Pain while sleeping. Remember – pain is a conscious decision made by the brain. Local anesthesia and witnessing surgery is powerful.
• #3: “Pain only occurs when you are injured or at risk of being injured.” FALSE
- Phantom limb pain description to your patients.
• #11: “When you injure yourself, the environment that you are in will not affect the amount of pain you experience, as long as the injury is exactly the same.” FALSE
- Pain is a multi-system output. Using the bear metaphor may be beneficial.
• #12: “The brain decides when you will experience pain.” TRUE
- Only discuss this with the patient if you are confident that they have understood everything else you have educated them on.
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Graded Exercise
• Graded exercise – slow increase in aerobic / anaerobic activity and tolerance (with some respects not focusing on pain resolution).
• Graded exposure - place patients in specific situations in which they are fearful. Smaller amount of fear into larger amounts of fear during rehabilitation.
• Both graded exercise and graded exposure are beneficial in an interdisciplinary setting (more so at reducing depressive symptoms and pain catastrophization).
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Adverse Neural Dynamics
• What makes it a “positive” A.N.D.?
- Reproduces comparable pain/sign
- Side to side difference (typically measured at elbow or knee) > 10 degrees
- Can be sensitized with distal or proximal movement of joints
• Neural mobilization – beneficial in management of nerve-related low back pain, neck and arm pain, and plantar heel pain.
- Cervical lateral glide mobilization and ULTTA/1 improved nerve-related neck and arm pain.
- Slump and SLR mobilization improved pain and disability in nerve-related low back pain.
• Average dosing – 30s x 3 repetitions with 1 min rest, twice per day (up to 3 per day if tolerated)
- More chronic complaints of nerve-related pain? Some suggested 20s light stretch with 10s rest, 5 repetitions, twice per day
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Upper Limb: ULTT1Median Nerve
• Shoulder depression and abduction (90-100 degrees)
• Elbow Extension
• Forearm Supination
• Wrist Extension
• Fingers + thumb extension
• Cervical contralateral side flexion
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Upper Limb: ULTT3Radial Nerve
• Shoulder depression and abduction (10 degrees)
• Elbow extension
• Forearm pronation
• Wrist flexion and ulnar deviation
• Fingers + thumb flexion
• Shoulder internal rotation
• Cervical contralateral side flexion
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Upper Limb: ULTT4Ulnar Nerve
• Shoulder depression and abduction (10-90 degrees)
• Elbow flexion
• Forearm supination
• Wrist extension and radial deviation
• Fingers + thumb extension
• Shoulder external rotation
• Cervical contralateral side flexion
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Lower Limb: SLR
SLR (Basic) Tibial N. Sural N. Common Peroneal N.
Crossed LegNerve root (disc
prolapse)
Hip Flexion and adduction
Flexion Flexion Flexion and IR Flexion
Knee Extension Extension Extension Extension Extension
Ankle Dorsiflexion Dorsiflexion Dorsiflexion Plantar Flexion Dorsiflexion
Foot --- Eversion Inversion Inversion ---
Toes --- Extension --- --- ---
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Manual Therapy:Interventions
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Graded Motor Imagery
• Thought to activate / improve cortical networks prior to limb movement by directly targeting cortical reorganization.. Remember – neuroplasticity
• Order is important!
• Graded Motor Imagery consists of:
1. Left / Right Discrimination
2. Explicit Motor Imagery
3. Mirror Therapy
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Graded Motor Imagery:Dosage
• Order is important! Unordered GMI as ineffective as control group. (moderate to large effect=0.79-0.99)
• Average dosage = 3x/waking hour (estimated 10-15 min spent) x 4-6 weeks.
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Implicit Motor Imagery:Left / Right Discrimination
• This is the brain’s ability to identify left or right images of their painful body part. Utilizes the higher-order aspects of motor output – the pre-motor cortex. These pre-motor cells modify the primary motor cells [usually pain neurotag located here] without activating them.
- Regaining this is important for normal recovery from pain.
• Assesses for accuracy and speed.
• Studies have shown that response times for imagined movements are influenced by the severity of pain.
- Accuracy of 80% or higher
- Response times for:
- Back/Neck: 1.6 seconds (+/- 0.5 seconds)
- Hands/Feet: 2 seconds (+/- 0.5 seconds)
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Implicit Motor Imagery:Left / Right Discrimination
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Implicit Motor Imagery:Left / Right Discrimination
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Explicit Motor Imagery:Imagined Movements
• ~25% neurons are mirror neurons, firing when you think or watch someone else do a movement.
• Pre-motor and primary motor cortices involved in this activity.
• Take this time to delve deeper into the ‘experience’. May not be as simple as imagining walking – add in sights, smells, temperature, pleasant experiences.
• Clinical Pearls:
- If irritable or anxious/fearful, begin imagining a non-painful area to begin with and slowly work towards the painful area.
- Tie in a non-threatening environment, working slowly into positions of discomfort [work, in-laws]
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Mirror Therapy
• Dosage: averaged 30 minutes per day, 5-7 days. May consider starting at 10 minutes per day, 5 days/week.
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Graded Motor Imagery
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Case Presentation Details
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