Pain Science: Is it all in their head? (Lecture 7) Flashcards
Cartesian model: stimulus/sensory driven model. For pain to cease, the input must be removed
* I poke you here that brings on pain, only way to get rid of pain is to get rid of the stimulus
* 1600s model
What is the gate control therpy?
Creating another stimulus to offset the other pain pain stimulus
Describe what nociceptive classification of pain is described as?
* Is it all the time or intermittent pain?
* Is it all over the place or localized
* Do we know what what causesd the pain typically?
Very acute pain
You bump your toe and it hurts right then and there
Intermittent pain, dull, throb, ache, sharp
Very localized
Clear aggravting and easing factors (things are easily introduced that bring on pain and take it away)
What is peripheral neuropathic pain?
Typically reffered / radicular types of pain
Often follows a dermatomal distribution
What is central sensitization pain?
This is our chronic pain pts. Doesnt fit a traditional model
Doesnt really fit a deromatal model - can change side to side. can be non mechanical in origin / unpredicatable pattern of pain. Maladatptive psychological behaviors (fear avodant patterns / catasirzation)
* Pts don’t know what makes them feel better
KNOW: Assessing for common pain mechanisms:
* Nociceptive (easiest to treat - very acute)
* Peripheral neuropathic: Less easy to treat but normally still follows a dermatomal distribution / some hx / provocations w/ movement (we still have some idea whats causing it)
* Central sensitization: This is our chronic pain pts. We don’t know whats going on because its its been an issue for so long - unpredicatble pattern of pain / dont fit within normal healting times - often pscyological driven
What are the 3 subjective questionaries we can use do quantify their level of maladaptive / pscyosocial behaviors?
FABQ
Tampa scale of kinesophobia
Pain catatraization scale
Test question: Pt has pscyological symptoms . maladaptive behaviors (taking them longer to heal than it should). What 3 questionsairs should I use?
FABQ / Tampa scale of kinesophobia / pain catastraization scale (no one of these is better than another)
Don’t pick things like oswetury distability index / neck disability index / moores questionaire for LBP - because these are about function and not about maladaptive pattersn
Nociceptive pain
We know exactly what happened
* typically will respond well to simple analygisics (nsaids)
* realtively recent
* normally it has an anatomical pattern of pain (I can move it and bring on pain where I would expect pain to come on)
* No hyperalgasia (excessive pain not)
* No allodynia: Pain proportional to the stimuli provided
* Normally can get out of pain w/ postural changes
Hyperalgesia defintion:
Excessive pain
Allodynia defintion
Pain not proportional to the stimulus applied
“I brushed her shoulder w/ my fingertips and she screams”
Neuropathic Pain
* pain normally in a reffered or dermatomal distribution
* Normally other neurological symptoms (pins needling / tingling / weakness)
* Burning shooting electric pain
* Nsaids don’t normally work
* Do respond well to CNS depressors (triptaline)
* Pain relatively high severity / irritability (proved easy calms down slowly)
* Spontaeous symptoms (just sitting there they get symptoms going down arm / back)
* Would expect nervy symptoms (dermatomes / myotomes / check reflexes / SLR test / Upper limb tension testing) - test the nerves
* Can palpate nerves and get their symptoms to come on
* May have hyperalgesia / allodynia - but normally in normal nerve distributions
Central sensitization pain (these are your typical chronic pain pts)
* unpredicatble pain (won’t follow dermatomal / myotomal patterns)
* Hx of failed itnerventions
* Unresponsive to nsaids
* More responsive to CNS depressors (because this is a brain mediated issue not a tissue mediated issue - the brain / nerves are whats creating this pain)
* reports of spontaenous pain and / or paroxsysmal pain (pain that comes and goes)
* Pain is associated w/ high levels of functional distability - they may not have the soft tissue issue but still arent able to do everyday chores around the house due to pain (that the brain is creating not the tissues themselves)
* Night pain / disturbed sleep
* Unremitting pain (doesnt stop)
* High severity / high irritability
Clinical examionation:
* inconsistent (doesnt follow typical patterns)/ non mechanical
* very diffuse pain (spread out all over the place) - could’ve originally been shoudler pain but now the spine hurts as well (its more diffuse)
* Doesnt really follow any typical patterns
* Positive identifyication of varous psycological factors (catastrophoization, fear avoidance behavior, distress) (look for anxiety / distress / depression w/ these pts)
Typically do well w/ PT but need a mutidisplanary approach
* Might need to refer to psycologist
* Document along the way to make it more easy to refer out
perseverate
Going back and repeating the same thing over and over
Know: often mioechanical explanation falls short
* direct infurlance on increased fucntion is questionable
* lots of times techniques that “put something back in place” lack specificity
more psyological approach normally works better
Pain neuroscience education = how do we talk to pts about pain w/o telling them its all in their brain
* Great for chronic MSK disorders (because at this point the brain is creating the pathology not damaged tissue)
* Improvment in this knowledge reduces fear avoidance belief
Treatment that works along pain neuroscience education for chronic pain pts:
* Manual therapy (Trigger point dry needling / mobilization and manipulation [moving it around] soft tissue mobilization)
* Exercise based acitivityes: (grades exposure - gradually introduce pt to activity that puts them into pain / Neural mobilization (sliders / gliders / tensioners) / aerobic EX / genreal EX / aquatic EX)
KNOW:
In hyperacute phase we do sliders and gliders away from pain - so if the wrist was hurting we would move the head / neck around
KNOW: Pain neuroscience education + EX + Manual therapy = best outcomes
* PNE by itself doesnt work nearly as well - they just need that pain education along w/ it
Doing PNE saves the entire healthcare system lots of visits (worth extra time at the start)
Catastrization means
making it worse than what it really is
amplifying pain thats present
However, what pain neuroscience is not is me telling you its all in your head
* need to find very selective ways to do this
* tell them tissue isnt whats causing the pain but its coming from the brain
* talk about average healing times - discs normally heal within 6-8 weeks - so we know the local injury has been calmed down but you’re still feeling the after affects so its proably coming from your brain
* show them over and over again that they’re able to do the task
Explain the pain alarm system
Think about it as that minimal threshold for the AP to be elicited
Any type or normal stress shouldnt put you over the threshold for a pain response. However, if you’ve had something previously set of this alarm (much like the stimulus your feeling) it will lower that threshold making a small stimulus more likely to cause a large pain response
* think having a stick scratch your ankle as you’re talking. If you’ve been bit by a snake this stimuli may feel the same and make you jump - your stimuli for an event like this was much lower because of previous experience
* Something has happened so you’re hyperalert - “fear avoidance - “I’m not doing this activity because im scared something is going to happen that will cause pain so i’m just not gonna move it””
Brain drops threshold for pain so increase protection for that area
* decreased threshold
Someone in chronic pain will have much lower sensitivty to pain everywhere because their brain has lowered this threshold
Another example is if you hear a window breaking at night and you think someone broke in. then the next night you hear some movement outside and freakout way more - your threshold to this activity is much lowered and you are hypersensitive to everything
* your system is hyperalert to everything
* So we just need to show body that not everything is going to hurt you
* We basically show alert system that it can be shut off by graded exposure / education - to raise threshold so we can do more activities
Pain is 100% made in the brain
The brain also picks the location of pain (ted talk w/ virtual relaity glasses making the pain seem like its somewhere its not)
What does immobilization do to the humonculus?
What happens to the pts ability to describe symptoms / discrimate from L/R?
Immobization can cause the humuculis to show less representation of the affected area in the motor / somatosensory homculus
Ability to describe symptoms becomes worse
Ability to discrimate where symptoms are coming from becomes worse
KNOW: Someone being in pain for a long time will also alter someones representation of the homonculus
Cortical reorganization increases w/ the duration of pain (hominculus becomes disorganized - and we don’t know exactly where pain is coming from)
* This causes smudging
What is smudging?
The longer someone is in chronic pain the more the homunculus starts to beld together
Everything overlaps
It makes it where they can no longer pinpoint where the pain is coming from because all the areas have blended togther
Is smudging reverseable? if so how? (2)
Yes
Patients can use graded motor imagery and education of pain (neuroscience education)
Complex regional pain syndrome is more distal than proximal
What are the 3 phases of motor imagery (ORDER IS IMPORTANT)
1) Left right discrimination
2) Explicit motor imagery
3) Mirrior therpay
Explain what left right discrimination is
pt is able to quickly identify if the picture is a left picture or a right picture
* This is the first step of graded motor imagery
What is explicit motor imagery?
* Why can just thinking about it bring on pain?
Thinking about movement w/o moving
* positive thinking / medidiation /
Start by thinking about being in a scenerio where your hand isnt hurting then progress it to a scenerio where your hand is hurting (until it no longer hurts at that point)
This is the second step of graded imagery
25% of our neurons are mirrior neurons and begin firing if you think about moving or observe someone else moving. These are activated in the corresponding area of the premotor cortex (if I just think about something those neurons are firing)
* thats why just thinking about hand can sometimes bring on pain
For left right discrimimation (step 1 of graded motor imagery) what % should the pt get right? In what time should they get it correct?
* if they get this % correct for how long until we progress them
85% accuracy
<1.5 seconds per picture
KNOW: Starts easy and moves into harder pictures (its an app)
Pts w/ smudging have a really hard time determining what a left hand looks like vs what a right hand looks like
If they can do this for 2 weeks at 85% accruacy progress them to explicit motor imagery
Explain what you do in explicit motor imagery
Imagination of tasks w/ the involved extremity
* mediation - be as specific as possible - imagine smell, temperature, sounds, heaviness of the limb, space around them, environment
Once imagined movements are not painful in various contexts and situations, then consider moving to stage 3 - mirror therapy
Explain what mirrior therapy is (stage 3 of graded motor imagery)
They have a mirrior box.
Start by putting uninjuired hand in the box and it will show the injuired side moving fine
essentially will trick the brain into thinking the painful side is moving
introduction of this to early can be detramental
KNOW: Can do manual therapy on someone w/ chronic pain
* we don’t alter the tissue - we want to change the persons nerves / brain (neurologic change)
manual therapy acts to block nociceptive signals
* releases opioids into the system to calm down pain response
* effects are temporary to promoate active treatments (EX)
KNOW: EX is important for chronic pain
* However, it will def improve physical function but it might not completely fix the pain
* So lots of functional benefits but less pain improvement for pts w/ chronic pain
Whats better for decreasing pain in fibromyalgia - strenghten training or aerobic EX?
why?
Aerobic
because fibromyalgia is just like pain all over and aerobic adresses more of your body because you have to move the entire thing around
KNOW: strengthening is better than aerobic for nonspecific chronic LBP / neck pain
Exercise induced hypoalgesia = decreased pain
* however, you cant just do low intensity EX
Exercise induced hypoalgesia (decreased pain) in the acute phase:
Isometric, aerobic, and dynamic resistance all resulted in exercise induced hyperalgesia
Aerovic exercise induaced hypoalgesia = dose dependent
changes in isometric / dynamic resistance whether local or remotely performed
Exercise induced hypoalgesia (decreased pain) in the regional chronic pain phase:
Local reisstance EX increased pain, but remote EX resulted in exercise induced hypoalgesia
* Meaning that if back pain is causing the issue I could workout my legs or my shoulders (something remote to the area) and see EX induced hypoalgesia
* So don’t go straight for pathologic tissue
Aerobic exercise induced hypoalgesia response was the same as acute pain
* it is dose dependent
Exercise induced hypoalgesia (decreased pain) in the widespread chronic pain / fibromyalgia phase
Local / remove isometrics increase pain at moderate-high intensity, extercise induced hypoalgesia at lower intensity
Aerobic EX increased pain if moderate-high intensity, but EIH at low moderate intensity
REMEMBER BEST BET IS LOW FOR AEROBIC AND RESISTANCE
Know: Pain is reduced hours after EX because of the opoids that are released into the blood
* its also systemic feeling good because they go into the bloodstream
For endogenous opooid release you typically want to hit in the moderate zone which is 50% of your HRR
HRR = (220-Age) - resting HR
Good rule of thumb is 50%-70% of HRR to land in the moderate to vig zone
The last thing someone in pain wants to do is EX. We need to show them that it makes them feel better and can even increase their mood
graded EX: Slowly introducing an EX into the system
Graded expsoure: Slowly introducing an activity into system that doesnt feel good
* flexion hurts so we do slight flexion
