Chronic or Persistent Pain

Peter Tooley The George Washington University

7-22-13

Why is this Discussion Relevant?

• 20% of people experience pain > 3 months.1

• 100 million Americans experience chronic or persistent pain.2

• 1.5 billion sufferers worldwide3

• Pain is one of the greatest contributors to disability worldwide

PAINWHAT IS THE WORD “PAIN” USED TO DESCRIBE?

Traditionally Speaking…

• Pain has been described in regards to– Disease Oriented– Noxious Stimuli - Strictly Sensory – Acute or Chronic

What is Pain REALLY all about?

• Pain Relies on Context1

– Previous Experience– Common Activities– Age, Gender, Culture– Environment– Education

• Pain is dependent on its perceived cause.

• Pain is Individualized.

• Pain is NOT necessarily directly related to the amount of tissue damage or degeneration

The Key to Pain is the Brain!

Pain is Good, and it is Normal

• Pain is our Body’s Alarm System– The Brain is concerned about survival• Pain Protects the tissue that is damaged• It also decides when pain is not a good decision

– The Brain’s decision to use or not use pain as an alert is a message to the body to do something.

– Decision is based on information gathered from the tissues, and surroundings

Alarm System

• “Danger” sensors are located everywhere

• Enough stimulation = Action Potential

• Excitatory chemicals released at synapse of Spinal Cord

• When stimulated enough, message continues to the brain.– How much stimulation?

Pain is a complex and contextual experience.

• CNS involvement – Evaluator– Sight, Hearing, Taste, Touch, Smell– Cortical and Subcortical Centers– Memory, Reasoning, Emotional Centers– Parasympathetic, Sympathetic, Endocrine, Immune

• Age – Connecting pain and meaning early• Gender – popular myths, some research exists• Culture – Initiations, ceremonial

• Environment – geography, work, etc.

“Neurotag”1

The “Value Judgment”

• The brain takes all the information it has and responds in some way

• Fight vs. Flight• Immune Response

What do we know about Tissue Healing?

Citation: PT413 Physical Agents & Electrical ModalitiesScott C. Livingston, PhD, PT, ATC, SCSJanuary 9th & 14th, 2008

Inflammation

• Inflammation draws an immediate response from the brain’s Alarm System.– The brain is going through the same process of

considering contextual factors but we only pay attention to the fact that it hurts

– Inflammation increases sensitivity

This pain is persistent…

• So if the Tissue is healed why does pain persist?– Something has occurred to the brain perceives a

continued threat to your body

THE ALARM SYSTEM HAS MALFUNCTIONED!

Control Center Sensitivity

Multiple Control Centers• Spinal Cord

– Pain is magnified when it passes from neuron to the spinal cord

– Increase in sensitivity makes it easier for danger message to be produced

– Adapts

• Brain– Plasticity– Is “rewired” to an increase in

sensitivity, up-regulating triggers• ie: Car accident

– Adapts

Increased Sensitivity makes the Brain better at Producing the “Pain

Neurotag”

Other Inputs to Consider

Thoughts and Beliefs• These are input impulses

that effect our Neurotag as well.

• “I’m scared of my pain hurting again”1

Virtual Body• The brain has a map of your

body.• Phantom Limb Pain• Smudging

How does Physical Therapy fit in?

• What can we do to address chronic/persistent pain with our patients?

How do patients normally respond to persistent pain.

• Pain as your Guide (downward slope)– Fear avoidance

• Boom – Bust Cycle (ebb and flow)– Go until threshold is broken– Leads to limitations in activity and meaning in life.

TO START WE MUST RECOGNIZE THESE CONTRIBUTERS-Alarm system, fear avoidance, attitudes and

beliefs

Need to move away from the cycle

Educating Your Patient

• Patients have the ability to understand the biological concepts of pain

• Find out what their thoughts are behind their pain experience– No Pain, No Gain– Letting pain be their guide

• Understanding pain on the road to recovery– Eliminate fear; “Know Pain, or no gain”

Eliminate fear of further injury

• Resolving fear avoidance behaviors– ie: Pts. with low back pain4

• When I have pain, it doesn’t necessarily mean I have damaged a part of my body– This is not a green light to ignore the pain

• Have patient think through WHY the pain flared-up.

• Get to know your pain– Triggers, contextual factors, alleviation, etc.

Set a plan for returning to your PLOF

• “Pacing & Graded Exposure”1

– What do you want to increase in your life?– Determine Baseline• ie: How long can I run before it flares up?

– Progression– Avoid Flare-ups– Lifestyle Change

Graded Exposure

Strategies and Reaching the “Virtual Body”

• Laterality Training– Flashcards, apps, etc– 80% Success– Speed is important

• 1.6s – Spine• 2.0s – Hands and Feet

• Explicit Motor Imagery– Visualizing a task triggers

areas of brain used when actually performing a task

• Mirror Therapy• Movement & Touch help

restore the Actual and Virtual Body.

• Perform motions with neighbor tissues in a friendly state

• Bowering J, et al(2013) The Effects of Graded Motor Imagery and Its Components on Chronic Pain: A Systematic Review and Meta-Analysis. J. of Pain 14(1):3-13.

– GMI and Mirror Therapy alone my be effective; More rigorous studies needed.

Outcome Measures

• Fear Avoidance and Beliefs Questionnaire (FABQ)

• Pain Catastrophising Scale (PCS)

• Depression Scale- GCS- 2 questions

Questions?

Resources

WEB• www.noigroup.com• www.Bodyinmind.orgVIDEOS• Understanding Pain: What to do about it in less

then five minutes. - http://www.youtube.com/watch?v=4b8oB757DKc

• Lorimer Moseley: Why Things Hurt - http://www.youtube.com/watch?v=gwd-wLdIHjs

References• 1. Butler D, Moseley L. Explain Pain. 2003. NOI group. Adelaide, Australia. • 2. Institute of Medicine Report from the Committee on Advancing Pain

Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.http://books.nap.edu/openbook.php?record_id=13172&page=1.

• 3. AAPM Facts and Figures on Pain. The American Academy of Pain Medicine. http://www.painmed.org/PatientCenter/Facts_on_Pain.aspx#refer.

• 4. Delitto A, et al. Low Back Pain: Clinical Guidelines. JOSPT. 2012; 42(4): A1-A47.

• 5. Bowering J, et al(2013)The Effects of Graded Motor Imagery and Its Components on Chronic Pain: A Systematic Review and Meta-Analysis. J. of Pain 14(1):3-13.

References

• www.noigroup.com• www.bodyinmind.org