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Advanced Musculoskeletal > Intervention Strategies for Pt's with Persistent Pain > Flashcards

Intervention Strategies for Pt's with Persistent Pain Flashcards

1
Q

Who needs pain neuroscience education?

A
  • Chronic pain
  • Central sensitization
  • Multiple treatment “failures”
  • Referred specifically for PNE
  • High levels of fear avoidance
  • Pain Catastrophization Characteristics
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2
Q

is a smaller or larger group better for PNE

A

smaller

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3
Q

starting “the pain talk”

A
  • “has anyone explained to you why you hurt”
  • ask permission to talk about/explain pain
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4
Q

PNE dosage

A
  • first visit is key
  • 10-20 mins
  • 1-2 times per week
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5
Q

PNE content

A
  • neurophysiology of pain (no reference to pathoanatomical models, no discussion of emotional/behavioral aspects of pain)
  • nociception/pathways
  • neurons/synapses
  • resting/action potential
  • peripheral sensitization
  • spinal inhibition/facilitation
  • central sensitization
  • plasticity of the nervous system
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6
Q

PNE- homework

A
  • cognitive and physical
  • application of knowledge
  • empowers patient to help themselves/take ownership
  • improves compliance
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7
Q

pacing of treatment is based on…

A
  • symptom irritability
  • psychological irritability
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8
Q

symptom irritability

A
  • high irritability: start low, go slow
  • low irritability: more aggressive
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9
Q

psychological irritability

A
  • education is a treatment and needs to be paced
  • if you put the patient on the defensive, you’ve lost
  • not just about education - consider psychological readiness to move into fearful activities
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10
Q

PNE billing

A
  • neuro re-ed
  • Therapeutic activity/ ADL
  • therapeutic exercise
  • make sure it fits with what you document
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11
Q

Aerobic exercise

A
  • movement is the biggest pain killer on the planet
  • “know pain, know gain”
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12
Q

thresholds for endogenous analgesia

A
  • intensity: 50% of VO2 max
  • HR: >120 bpm
  • Duration: >10 mins
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13
Q

sleep dysfunction is predictive of…

A
  • next day and next month pain increases
  • new onset of tension type and migraine HAs
  • increased incidence of new onset chronic pain in pain-free individuals
  • poorer long term prognosis in chronic pain
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14
Q

pain may…

A

predict sleep quality for the next night

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15
Q

quantity of sleep

A
  • 7-9 hours
  • calculate bedtime by counting back from wake time
  • most people over-estimate by 20%
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16
Q

quality of sleep

A
  • goal > 85%
  • total sleep time - time to fall asleep - time awake throughout the night = total sleep time
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17
Q

sleep hygiene

A
  • set a time to go to bed
  • turn off non-essential lights and TV an hour before bed
  • no naps during the day (>20 mins)
  • no caffeine late in the day
  • park your ideas
  • darken and cool room
  • no kids or pets
  • no alcohol
  • limit water intake in the evening
  • stay in bed
  • exercise
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18
Q

building a sleep hygiene checklist

A

add one item per night

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19
Q

explanation of findings for nociceptive pain patient

A
  • validates the patient experience
  • builds therapeutic alliance
  • gives reason for the symptoms that are dethreatening, fear reducing
  • instills hope
  • sets contextual foundation
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20
Q

explanation of findings for peripheral neuropathic pain patient

A
  • validates the patient experience
  • builds therapeutic alliance
  • gives reason for the symptoms that are de-threatening, fear reducing
  • instills hope
  • sets contextual foundation (shifts beliefs, expectations, and compliance)
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21
Q

neurodynamic treatment for peripheral neuropathic pain patient

A
  • container: joints/soft tissues along n tract
  • nerve: sensitized nervous tissue
  • system: CNS and holistic approach
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22
Q

nerves need:

A

space
movement
blood

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23
Q

treating the container

A
  • joints: mobilization/manipulation of spinal segments or peripheral joints
  • soft tissues: STM/IASTM/TrPDM along nerve tract
24
Q

Treating the nerve

A
  • nerve glides/flossing
  • nerve tensioning
25
Q

nerve glides/flossing

A
  • variations of ND testing
  • work into symptoms
  • progress by increasing degree of system tensioning
  • incorporate active movements ASAP
26
Q

Nerve tensioning

A
  • may be necessary for chronic cases
  • dont hold tensioners –> 8% strain decreases blood flow to nerve
27
Q

peripheral neuropathic pain - treating the system

A
  • desensitize the system
  • cardio program daily
  • strength training/functional activities (3+/wk)
  • lifestyle factors
28
Q

desensitize the system

A
  • therapeutic alliance
  • fear reducing education
  • graded exposure
29
Q

cardio program

A
  • whole body mobilization
  • increases blood flow to nerves
  • “flush” system of inflammatory and stress chemicals that sensitize the system
30
Q

strength training/functional activities

A
  • 3+/week
  • general global strength exercises
  • relate to patient goals
31
Q

how to approach interventions for central sensitization pain

A
  • top down, psychologically informed approach, focusing on cortical/spinal neuroplastic changes
  • promote the “return of physical confidence” - thoughtless, fearless movements
32
Q

3 targets for central sensitization interventions

A
  • prefrontal/ Mesolimbic system
  • cortical reorganization
  • system
33
Q

why we are addressing pre-frontal/ mesolimbic system for patients with central sensitization pain

A
  • strong control over midbrain descending inhibition
  • address yellow flags/psychosocial factors
34
Q

cortical reorganization

A
  • changes in motor/sensory cortical maps
  • graded motor imagery
35
Q

system

A

holistic approach to health/wellness/function
- graded exposure

36
Q

graded motor imagery phases

A
  • PNE
  • laterality
  • motor imagery
  • sensory discrimination
  • mirror movements
37
Q

laterality timing

A

1-2 hours per day in short sessions

38
Q

laterality training considerations

A
  • dose/pace progress based on irritability
  • consider homunculi areas - if ankle increases pain, show images of knee
  • orientation of page matters
  • dont allow physical manipulation
  • watch of pain behaviors
39
Q

when are you done with laterality?

A
  • > 80% accuracy
  • 2 sec hands/feet
  • 1.6 back/neck
40
Q

Phase 3: Motor Imagery

A
  • activate sensory and motor maps without activating pain map or pain behavior maps
  • sharpening out “smudged” maps
  • systematic and progressive
  • focused on repetition in a safe, non- threatening environment
  • exerciseing the brain map without moving the sensitive extremity
41
Q

phase 4: sensory discrimination training

A
  • localization of stimulus
  • impaired tactile acuity relates to impaired motor control
42
Q

types of sensory discrimination training

A
  • 2PD
  • sharp dull
  • identification of stimulus
  • graphesthesia
  • localization of stimulus (“which side am I pressing on?”)
43
Q

Phase 5: Mirror Therapy

A
  • using mirrors to trick the brain
  • most “aggressive” of imagery techniques
  • avoid distortion/confused image
  • patient must have decent maps
44
Q

mirror therapy technique

A
  • involved side is hidden
  • patient can see the uninvolved side and reflection in mirror
  • progress: static, simple movement, functional movements with objects
45
Q

3 main targets for interventions for CSP patient

A
  • pre-frontal/mesolimbic system
  • cortical reorganization
  • system
46
Q

pre-frontal/mesolimbic system

A
  • strong control over midbrain descending inhibition
  • address yellow flags/ psychosocial factors
  • education
  • therapeutic alliance
47
Q

graded exposure

A
  • establish a baseline with specific movements –> consider physical and psychological irritability
  • decrease the threat –> break down into components, change the context/add distraction, change position, body tricks
48
Q

body tricks

A
  • shoulder flexion painful –> relax arm, bend forward at waist
  • pain with lumbar flexion –> cat/camel activity
  • pain with cervical rotation –> seated trunk rotation while focusing on point on the wall
49
Q

Graded exposure - 50% rules

A
  • patient picks a task and determines load/reps/time to flare ip
  • start program sub-baseline
  • patient picks a goal and timeframe - set time frame double that
50
Q

graded exposure rules

A
  • be diligent in establishing a baseline so you avoid flareups
  • start low and go slow
  • use 50% to ensure success
  • Avoid boon-bust cycle
  • targets/goals/timelines are patient driven
  • focus on function
  • flare ups will happen
51
Q

when flare ups happen

A
  • reinforce PNE: Paine does not equal damage
  • see flare up as temporary set back not failure
  • slowly increase exercise program back to previous baseline once flare up settles
52
Q

what is the ultimate goal

A

patient independence

53
Q

work towards

A
  • independent functional movement and exercise
  • self driven progress toward goals
  • self driven coping skills
54
Q

tapering

A
  • graded exposure to less therapy
  • fewer sessions, spaced further apart
  • check in via email/phone
55
Q
A

Advanced Musculoskeletal (21 decks)

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