Pain Science: Is it all in their head? (Lecture 7)

Question 1

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

Question 2

What is the gate control therpy?

Answer 2

Creating another stimulus to offset the other pain pain stimulus

Question 3

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?

Answer 3

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)

Question 4

What is peripheral neuropathic pain?

Answer 4

Typically reffered / radicular types of pain

Often follows a dermatomal distribution

Question 5

What is central sensitization pain?

Answer 5

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

Question 6

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

Question 7

What are the 3 subjective questionaries we can use do quantify their level of maladaptive / pscyosocial behaviors?

Answer 7

FABQ
Tampa scale of kinesophobia
Pain catatraization scale

Question 8

Test question: Pt has pscyological symptoms . maladaptive behaviors (taking them longer to heal than it should). What 3 questionsairs should I use?

Answer 8

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

Question 9

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

Question 10

Hyperalgesia defintion:

Answer 10

Excessive pain

Question 11

Allodynia defintion

Answer 11

Pain not proportional to the stimulus applied

“I brushed her shoulder w/ my fingertips and she screams”

Question 12

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

Question 13

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

Answer 13

Question 14

perseverate

Answer 14

Going back and repeating the same thing over and over

Question 15

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

Question 16

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)

Question 17

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

Question 18

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

Question 19

Doing PNE saves the entire healthcare system lots of visits (worth extra time at the start)

Question 20

Catastrization means

Answer 20

making it worse than what it really is

amplifying pain thats present

Question 21

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

Question 22

Explain the pain alarm system

Answer 22

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

Question 23

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)

Question 24

What does immobilization do to the humonculus?

What happens to the pts ability to describe symptoms / discrimate from L/R?

Answer 24

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

Question 25

What is smudging?

Answer 25

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

Question 26

Is smudging reverseable? if so how? (2)

Answer 26

Yes

Patients can use graded motor imagery and education of pain (neuroscience education)

Question 27

Complex regional pain syndrome is more distal than proximal

Question 28

What are the 3 phases of motor imagery (ORDER IS IMPORTANT)

Answer 28

1) Left right discrimination
2) Explicit motor imagery
3) Mirrior therpay

Question 29

Explain what left right discrimination is

Answer 29

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

Question 30

What is explicit motor imagery?
* Why can just thinking about it bring on pain?

Answer 30

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

Question 31

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

Answer 31

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

Question 32

Explain what you do in explicit motor imagery

Answer 32

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

Question 32

Explain what mirrior therapy is (stage 3 of graded motor imagery)

Answer 32

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

Question 33

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

Question 34

Whats better for decreasing pain in fibromyalgia - strenghten training or aerobic EX?

why?

Answer 34

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

Question 35

KNOW: strengthening is better than aerobic for nonspecific chronic LBP / neck pain

Question 36

Exercise induced hypoalgesia = decreased pain
* however, you cant just do low intensity EX

Question 37

Exercise induced hypoalgesia (decreased pain) in the acute phase:

Answer 37

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

Question 38

Exercise induced hypoalgesia (decreased pain) in the regional chronic pain phase:

Answer 38

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

Question 39

Exercise induced hypoalgesia (decreased pain) in the widespread chronic pain / fibromyalgia phase

Answer 39

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

Question 40

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

Question 41

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

Question 42

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

Question 43

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

Question 44