Intervention Strategies for Pt's with Persistent Pain Flashcards
Who needs pain neuroscience education?
- Chronic pain
- Central sensitization
- Multiple treatment “failures”
- Referred specifically for PNE
- High levels of fear avoidance
- Pain Catastrophization Characteristics
is a smaller or larger group better for PNE
smaller
starting “the pain talk”
- “has anyone explained to you why you hurt”
- ask permission to talk about/explain pain
PNE dosage
- first visit is key
- 10-20 mins
- 1-2 times per week
PNE content
- 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
PNE- homework
- cognitive and physical
- application of knowledge
- empowers patient to help themselves/take ownership
- improves compliance
pacing of treatment is based on…
- symptom irritability
- psychological irritability
symptom irritability
- high irritability: start low, go slow
- low irritability: more aggressive
psychological irritability
- 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
PNE billing
- neuro re-ed
- Therapeutic activity/ ADL
- therapeutic exercise
- make sure it fits with what you document
Aerobic exercise
- movement is the biggest pain killer on the planet
- “know pain, know gain”
thresholds for endogenous analgesia
- intensity: 50% of VO2 max
- HR: >120 bpm
- Duration: >10 mins
sleep dysfunction is predictive of…
- 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
pain may…
predict sleep quality for the next night
quantity of sleep
- 7-9 hours
- calculate bedtime by counting back from wake time
- most people over-estimate by 20%
quality of sleep
- goal > 85%
- total sleep time - time to fall asleep - time awake throughout the night = total sleep time
sleep hygiene
- 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
building a sleep hygiene checklist
add one item per night
explanation of findings for nociceptive pain patient
- validates the patient experience
- builds therapeutic alliance
- gives reason for the symptoms that are dethreatening, fear reducing
- instills hope
- sets contextual foundation
explanation of findings for peripheral neuropathic pain patient
- 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)
neurodynamic treatment for peripheral neuropathic pain patient
- container: joints/soft tissues along n tract
- nerve: sensitized nervous tissue
- system: CNS and holistic approach
nerves need:
space
movement
blood
treating the container
- joints: mobilization/manipulation of spinal segments or peripheral joints
- soft tissues: STM/IASTM/TrPDM along nerve tract
Treating the nerve
- nerve glides/flossing
- nerve tensioning
nerve glides/flossing
- variations of ND testing
- work into symptoms
- progress by increasing degree of system tensioning
- incorporate active movements ASAP
Nerve tensioning
- may be necessary for chronic cases
- dont hold tensioners –> 8% strain decreases blood flow to nerve
peripheral neuropathic pain - treating the system
- desensitize the system
- cardio program daily
- strength training/functional activities (3+/wk)
- lifestyle factors
desensitize the system
- therapeutic alliance
- fear reducing education
- graded exposure
cardio program
- whole body mobilization
- increases blood flow to nerves
- “flush” system of inflammatory and stress chemicals that sensitize the system
strength training/functional activities
- 3+/week
- general global strength exercises
- relate to patient goals
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
3 targets for central sensitization interventions
- prefrontal/ Mesolimbic system
- cortical reorganization
- system
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
cortical reorganization
- changes in motor/sensory cortical maps
- graded motor imagery
system
holistic approach to health/wellness/function
- graded exposure
graded motor imagery phases
- PNE
- laterality
- motor imagery
- sensory discrimination
- mirror movements
laterality timing
1-2 hours per day in short sessions
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
when are you done with laterality?
- > 80% accuracy
- 2 sec hands/feet
- 1.6 back/neck
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
phase 4: sensory discrimination training
- localization of stimulus
- impaired tactile acuity relates to impaired motor control
types of sensory discrimination training
- 2PD
- sharp dull
- identification of stimulus
- graphesthesia
- localization of stimulus (“which side am I pressing on?”)
Phase 5: Mirror Therapy
- using mirrors to trick the brain
- most “aggressive” of imagery techniques
- avoid distortion/confused image
- patient must have decent maps
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
3 main targets for interventions for CSP patient
- pre-frontal/mesolimbic system
- cortical reorganization
- system
pre-frontal/mesolimbic system
- strong control over midbrain descending inhibition
- address yellow flags/ psychosocial factors
- education
- therapeutic alliance
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
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
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
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
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
what is the ultimate goal
patient independence
work towards
- independent functional movement and exercise
- self driven progress toward goals
- self driven coping skills
tapering
- graded exposure to less therapy
- fewer sessions, spaced further apart
- check in via email/phone
