L1 Intro to Pain Flashcards
US healthcare costs in 2016 for LBP
134 billion
What is the number one reason someone gets an opioid prescription?
low back pain
myths of LBP
awareness increasing means situation has improved
persistent LBP is indicative of serious problem and requires imaging
lumbar spine is so unique that it must be treated uniquely
it will get better on its own
What percentage of people will experience a significant episode of LBP in their lifetime?
80%
Regardless of intervention ____ will get better within ______.
80%
6-12 weeks
PT’s jobs for LBP
identify pts that won’t get better
help people get better faster
prevent people from getting worse
reduce the likelihood of another episode
What has been shown to help LBP?
education
activity modification
exercise
manual therapy
postural re-ed
ownership
self-efficacy
sleep
modalities
Framework for MSK patient exam and management
- Pain Behavior
- Pain Phenotype
- Impairment classification
- Plan
SINSS Model (Pain Behavior)
- Severity
- Irritability
- Nature
- Stage
- Stability
The SINSS model helps to…
- Create a framework for subjective history
- determine appropriate type and level exam
- prioritize patient’s problem list
- synthesize information after exam
- modify treatment plan including intervention scope, intensity
- create prognosis and need for referral
Severity
can be influenced by illness perceptions, psychological distress, and pain catastrophizing
negatively impacts prognosis
impacts ADLs and functional abilities
How to assess severity and irritability
VAS
pain behavior
START back screening tool
Irritability
impacts prognosis
recommend only AROM for exam initially
may need to adjust activities initially
tailor treatment to level of irritability
Patient with high severity and low irritability
OK to go into passive end ranges during exam
Nature
overall presentation, status of patient
biopsychosocial
medical/pathoanatomic diagnosis
Stage
inflammatory, proliferation, maturation OR known as acute, subacute, chronic
includes protection, level tissues can be stressed, and whether or resistance causes pain
Stability
worsening, improving, unchanging
worsening conditions may not provide immediate feedback of response to intervention
improving conditions may get better no matter what you do
unchanging conditions can be frustrating for providers and patients
Nociceptive pain
pain elicited by the injury of body tissues and activation of nociceptive transducers at the site of local tissue damage
commonly acute traumatic injury and inflammatory mediators
thermal, mechanical, chemical
Neuropathic pain
pain caused by a lesion or disease of the somatosensory system
can be caused by maladapative structural changes, cell-cell interactions, molecular signaling
described as burning, pricking, squeezing
examples include trigeminal neuralgia, polyneuropathy, postherpetic neuralgia
Nociplastic pain
persistent pain that arises from altered nociception, despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors, or evidence for disease or lesion of somatosensory system causing the pain
What type of pain originates primarily from the peripheral tissues?
nociceptive
What type of pain originates primarily from the feedback loop in the cortex?
nociplastic
pain is not…
directly related to tissue damage
a direct linear link
equivalent to nociception and damage
low back conditions that were found to not exhibit pain
disc degeneration
disc bulge
disc height loss
facet joint degeneration
disc protrusion
Pain is…
adaptive
signal to change behavior
survival mechanism
construct
descriptive
contextual
individual experience
hierarchical
Pain is hierarchical
difficult to feel more than one pain at once
allows us to filter
descending inhibitory pathways can close feedback loop
Cognitive Function and Chronic Pain
Causes elevated levels of cortisol, prefrontal cortex activation is smaller, decision making and problem solving is impaired
pain becomes consuming and distracting
pain also interferes with sleep and exercise, which also influences cognitive function
The practitioner that a pt sees first for LBP…
influences how much health care they use over the next year
those who choose PT have lowest healthcare use
Pain should be targeted first through the CNS by
cognitive, emotional, and motor aspects
you need to find out what they know first, listen, provide digestible bites, use stories.
Ultimate goal is to help change how patients make sense of pain, build confidence, and optimize function
Points from Moseley Pain Video
- Pain is always real
- Pain relies on context and clues
- Anything that suggests you need protecting takes pain up and anything that suggest you don’t, takes pain down
- Pain and tissue state are poorly related
- Humans are adaptable and bioplastic learners
- Movement is king
- Understand and retrain the pain system
Cognitive Behavioral Therapy
involves the efforts to change thinking patterns and behavioral patterns
thinking = recognizing distorsions
Behavior = facing fears vs avoid
LBP and exercise
get patients to do anything, as long as they are moving will help them
exercise are more effective than no intervention
will help to modulate pain and improve QOL
PT combied with psychological interventions
caused decreased pain in short and long term, and decreased disability in short term
Increased PT causes decreased
opioid usage
less costs over coming year
Most LBP patients..
will improve over time regardless of treatment
clinicians should select nonpharrmacologic treatment first like yoga, motor control exercise, biofeedback, etc
Should use for LBP
exercise, manual therapies (thrust first, then massage), patient education (neuroscience and active education)
IF patient has high disability with volatile S/S
directional preference exercises
manipulation
traction
active rest
If patient has moderate disability
sensorimotor exercises, stabilization exercise, flexibility exercises
If patient has low disability
strength and conditioning exercises, work or sport tasks, aerobic, general fitness exercises
If patient is irritable and inflamed
address the inflammation by active rest
If patient peripheralize with extension and flexion or has positive SLR test
prescribe traction
Patient centralizes with flexion or extension
prescribe specific exercises that centralize the symptoms
Does the patient stop to centralize and have no symtpoms distal to knee?
prescribe manipulation
