What Should You Treat First? Rethinking Clinical Decision-making and

Modifying Your Treatment Plan

Nora Stern, PT, MSPT

Conflict of Interest Disclosure Nora Stern, PT, MS, PT

Has no real or apparent conflicts of interest to report.

Objectives

• Appreciate pain as an output• Evaluate neurophysiological processes of

nocioceptive, peripheral neurogenic, central and output driven pain experiences

• Identify appropriate treatment interventions• Examine case studies

• Pain as an output: what does that change?

Processes

• Looking at what is sensitizing the systems:• Nocioceptive input• Peripheral • Central• Output

Assessing: Features for nocioceptive contribution

• Pain is consistent w findings and proportionate to findings

• In same region as original pain sensations• Consistent w anatomy• Within normal healing time• Pain dull ache, sharp w movement• Swelling

Assessing nocioceptive/inflammatory

• Inflammatory response: prostaglandins, histamine, cytokines, substance P involved in membrane leakage, causes swelling

Treatment: nocioceptive

• Anything different?• What do pts need to hear?

Assessing: Peripheral neurogenic presentation

• Follows nerve pathway or adjacent pathway, but in new areas along pathway

• Shooting up or down along pathway

• Evaluated through neural tension testing and palpation of sensitivity along the nerve pathway

Peripheral Sensitization

ALTERED IMPULSE GENERATOR SITE

• Ion channels lay down on demyelinated segments of nerve and essentially create a new endplate.

Treatment: peripheral neurogenic

• Motion is lotion• Neurodynamics• Health of container: taping, manual therapy• Postural support• Decrease in threat value: pain education,

normalize experience• What does pt need to hear?

Assessing:Central sensitization features

• Pain searing, stabbing, like a knife, hot poker• Appearing on other side of body, pain in new area• Does not follow anatomy, not consistent w findings• Large or diffuse areas of pain• Black body diagram• Altered 2 point discrimination• Delay in laterality recognition > 1.5 sec, < 90% accuracy• High score on StarT

Fig. 1 Patient data: TPD threshold, normal distribution of pain, and body image. Two-point discrimination threshold (TPD) was assessed bilaterally at 16 levels, shown here superimposed over line drawings of the sense of physical self, or body image, of six...

Moseley, GL, “I Cant’ find it! Distorted body image and tactile dysfunction in patients with chronic back pain.” Pain Vol 140, Issue 1, 2008, 239-243

Assessing central involvement: cortical

reorganization: SmudgingAltered Two Point

Discrimination Associated with Distorted Body Image

in Back Pain

Assessing central involvement: cortical reorganization: smudging

Flor, H, Neuroscience 1997

Assessing central involvement:Mirror neuron function

Assessing central involvement: Quantifying

psychosocial issues:StarT Generic Screening Tool

Central: what aspects of the brain processing are contributing to central sensitization?

• Thinking• Feeling • Sensing • Acting/moving

Output

• Pain response assigned to a part of the virtual body

• ANS triggers Neuroendocrine system uses cortisol, immune response using proinflammatory cytokines

Immune response

• Proinflammmatory cytokines exist in PNS and CNS, signal between immune system and nervous system

• Delay of response to stressors: 10 days• Causes feelings of tiredness, loss of mobility,

achiness everywhere

Stress/pain relationship with CRPS

Allen, R, et al, Phys Ther, 2011 4:32-42

Allen, R, et al, Phys Ther, 2011 4:32-42

Immune Response

• Activated locally during injury• Activates myelin destruction and contribute to

AIGS• Pro-inflammatory cytokine activity can

increase w catastrophizing

Assessment: Output

• Swelling• Sweating• Itching• Cold sensitivity• Pain w thinking about movement, watching someone

move• Altered 2 point discrimination• Poor accuracy and speed on laterality recognition• Altered body schema• Poor motor planning

Treatment Interventions for Central Sensitization/output

Treatment interventions:Central

• Address fear avoidance through pain education

Treatment Interventions: Central

• Sensing:– Graded Motor Imagery– Body scan– General kinesthetic sensing with exercise– Whole body movement to restore virtual body

representation

Treatment for Central involvement and output drivenGMI used for:

– CRPS (rsd)– Phantom limb– Stroke– Neck pain– Back pain

Treatment: GMI Progression

• Laterality Recognition: Cards or Recognise Online– Activates pre-motor cortex but not primary motor

cortex• Imagined Movement

– Activates both pre-motor and primary motor cortex– Less challenging than actual movement, can imagine

movement perfectly• Mirror Box

– Harnesses use of mirror neurons to restore normal output and motor function

Treatment: GMILaterality Recognition

Treatment: GMIImagined movement

Treatment: GMIMirror therapy

Treatment:Graded Activity

• Moseley and Butler twin peaks model

Treatment: Graded exposure

• Movement: observed, imagined, actual: mirror and normal

• Components of movement complexity:simpler to more complex, eg break down a fwd bend

• Amount of time• Change the context, eg, do w friend, listening to music• Tune in to entire body: refresh homuncular map• Look at environment: non threatening to threatening

Treatment: Physiological quieting

Treatment Interventions:Central

• Stress response: physiological quieting

• www.meditationcenter.com: easy to follow meditations. • http://www.allaboutdepression.com/relax/ 8 free breathing

tapes, relaxation activities. • • • http://vcc.asu.edu/relaxaindex.shtml: free guided instruction

in progressive muscle relaxation and guided imagery.

Consider the immune system

• Consider how quickly we introduce stretching and strengthening after an injury

Case studies

Case study #1

• Patient w wrist pain. Limitation and pain w wrist flexion and extension. Tender at elbow medial and lateral.

• Pain began 1 month ago, while putting in long hours at keyboard, poor ergonomics, very engaged in writing a paper for publication.

• Start score 1/5• Body diagram: specific point of pain at R wrist• Exam: tender to passive wrist flexion and extension,

tender at metacarpals, tender to palpation at R flexor carpi ulnaris, extensor carpi ulnaris .

Case study #2• Pt with wrist pain and elbow pain on R x 3 months. Pain w

wrist flexion and extension and supination, and at R medial epicondyle, sometimes into fingers. Feels like it’s spreading, getting worse.

• Draws pain as a line along medial aspect of R arm• Pain increases w deadlines, long hours. Lots of stress at work• Wondering if she should stop playing softball, afraid she is

hurting herself because her arm hurts more when she does this.

• Start score 2/5• (Median neural tension testing +, cervical scan negative)

Case study #3

• Pain for 2 years, Pain at medial elbow and wrist R, now also in lateral elbow R, and shoulder, and has neck pain and low back pain, sleeping poorly

• Pain began with a lot of keyboarding at work, during staff cuts, spouse lost job at same location.

• Draws black area in entire R arm, and neck and low back and across to L shoulder, and head

• Start score 5/5.• Pt says she has stopped doing most of the things that

she enjoys because she doesn’t want to hurt herself.

Case study #4

• Pain x 1 yr, started as R wrist pain. Began after working long hours at computer to meet deadline, doing stretching and strengthening w PT, for about 2 months, got a virus, and then started to get severe pain and swelling in her R forearm and hand, now sweats when she tries to use it, avoids moving that hand.

• Starting to have some pain in her L hand and having nerve conduction testing soon for this. Has neck pain. Wearing protective wrist splint, holds hand close to her chest.

• Start score 5/5

• Questions