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
nerve glides/flossing
- variations of ND testing - work into symptoms - progress by increasing degree of system tensioning - incorporate active movements ASAP
26
Nerve tensioning
- may be necessary for chronic cases - dont hold tensioners --> 8% strain decreases blood flow to nerve
27
peripheral neuropathic pain - treating the system
- desensitize the system - cardio program daily - strength training/functional activities (3+/wk) - lifestyle factors
28
desensitize the system
- therapeutic alliance - fear reducing education - graded exposure
29
cardio program
- whole body mobilization - increases blood flow to nerves - "flush" system of inflammatory and stress chemicals that sensitize the system
30
strength training/functional activities
- 3+/week - general global strength exercises - relate to patient goals
31
how to approach interventions for central sensitization pain
- top down, psychologically informed approach, focusing on cortical/spinal neuroplastic changes - promote the "return of physical confidence" - thoughtless, fearless movements
32
3 targets for central sensitization interventions
- prefrontal/ Mesolimbic system - cortical reorganization - system
33
why we are addressing pre-frontal/ mesolimbic system for patients with central sensitization pain
- strong control over midbrain descending inhibition - address yellow flags/psychosocial factors
34
cortical reorganization
- changes in motor/sensory cortical maps - graded motor imagery
35
system
holistic approach to health/wellness/function - graded exposure
36
graded motor imagery phases
- PNE - laterality - motor imagery - sensory discrimination - mirror movements
37
laterality timing
1-2 hours per day in short sessions
38
laterality training considerations
- 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
when are you done with laterality?
- > 80% accuracy - 2 sec hands/feet - 1.6 back/neck
40
Phase 3: Motor Imagery
- 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
phase 4: sensory discrimination training
- localization of stimulus - impaired tactile acuity relates to impaired motor control
42
types of sensory discrimination training
- 2PD - sharp dull - identification of stimulus - graphesthesia - localization of stimulus ("which side am I pressing on?")
43
Phase 5: Mirror Therapy
- using mirrors to trick the brain - most "aggressive" of imagery techniques - avoid distortion/confused image - patient must have decent maps
44
mirror therapy technique
- involved side is hidden - patient can see the uninvolved side and reflection in mirror - progress: static, simple movement, functional movements with objects
45
3 main targets for interventions for CSP patient
- pre-frontal/mesolimbic system - cortical reorganization - system
46
pre-frontal/mesolimbic system
- strong control over midbrain descending inhibition - address yellow flags/ psychosocial factors - education - therapeutic alliance
47
graded exposure
- 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
body tricks
- 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
Graded exposure - 50% rules
- 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
graded exposure rules
- 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
when flare ups happen
- 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
what is the ultimate goal
patient independence
53
work towards
- independent functional movement and exercise - self driven progress toward goals - self driven coping skills
54
tapering
- graded exposure to less therapy - fewer sessions, spaced further apart - check in via email/phone
55