Week 6- Pain Neuroscience Education (PNE) Flashcards
PART 1: CLINICAL ASSESSMENT OF CHRONIC PAIN
PART 1: CLINICAL ASSESSMENT OF CHRONIC PAIN
- What is the difference between the biomedical and biopsychosocial model?
- If we take a biomedical approach, we typically see that pain is explained from a _______ perspective.
- Biomedical model has a heavy focus on pathophysiology and biological approaches to disease. Biopsychosocial model takes complex pain issues into account such as psychological and social factors.
- tissue
Does the biomedical or biopsychosocial model explain chronic pain?
biopsychosocial
Which is biopsychosocial and which is biomedical?
- ) Anatomy → Biomechanics → Pathoanatomy
- ) Biological → Psychological → Social Factors
1 = Biomedical 2 = Biopsychosocial
Biomedical Model:
- _________ efficacy in regards to pain alleviation and resolution of disability.
- May result in increased_____, ________, and _______.
- limited efficacy
- fear, anxiety, and stress
Biopsychosocial Model:
- Fear of movement, pain catastrophizing, anxiety and nervous system sensitization are often ________ of a primary pathology. (Considered main contributors to pain and disability)
- Treatment for chronic pain that incorporates a ___________ model currently viewed as the most effective approach.
- consequences
- biopsychosocial
What are some psychosocial considerations for individuals with chronic pain?
- Likely have seen several medical practitioners by the time they get to you.
- Likely have had at least 1 negative encounter with a medical practitioner.
- Their pain/condition may have been discounted by someone they have encountered.
- Common that they may have heard several different explanations for their pain, resulting in confusion.
- Common that these individuals feel a sense of desperation.
Where Do We Begin?:
- __________ focused assessment (includes both somatic and psychosocial assessment)
- __________ and ________-___________
- Includes Pain Neuroscience ___________
- biopsychosocial
- individualized and patient-centered
- Pain Neuroscience Education
What are the 3 big components for Screening and Examination?
- Skilled Patient Interview and Examination
- Screen for Red/Yellow Flags
- Assessing Underlying Pain Mechanism
PNE should take the individuals pain __________ and ________ into consideration.
experience and complexity
- With a skillful interview we should aim questions to gain a better understanding of the patient’s _________, ________ and _____.
- List some fundamental questions to ask.
-experiences, suffering, and beliefs
- “What do you think is going on with your back?”
- “Why do you think you hurt?”
- “What do you think should be done for your back?”
- “Where do you see yourself in five years?”
Therapeutic alliance cannot be achieved without __________. _______ and __________ listening are utilized to gain patient trust.
- empathy
- active and reflective listening
What are some things we want to find out that can also help to create a therapeutic alliance?
- How the patient is doing
- Their perception of their own problem
- How the problem impacts their life
- How their lifestyle impacts their problem
- Identifying patient expectations
Utilization of outcome measures help to measure ________.
progress
What are the 2 different types of outcome measures to include when working with this population?
- Functional Outcome Measure
- Outcome Measure Addressing Fear
Functional Outcome Measures Examples:
- ODI = _______ pain
- NDI = _______ pain
- DASH = ____
- LEFS = _____
- FAAM = _____
- ODI = back pain
- NDI = neck pain
- DASH = UE
- LEFS = LE
- FAAM = ankle
What are some outcome measures that address fear?
- Fear Avoidance Belief Questionnaire (FABQ)
- Pain Catastrophization Scale
- Tampa Scale for Kinesiophobia
Fear Avoidance Belief Questionnaire about work (FABQ w):
- Total Possible Points = ___
- High Score = >___
Fear Avoidance Belief Questionnaire about physical activity (FABQpa):
- Total Possible Points = ___
- High Score = >___
- 42
- > 34
- 24
- > 14
Pain Catastrophizing Scale (PCS):
- What are the 3 distinct dimensions?
- Score =/>___ indicates clinically relevant level of catastrophizing.
- Rumination, Magnification, Helplessness
- =/>30
Tampa Scale for Kinesiophobia (TSA):
-Score =/>___ indicates patient likely has fear of _______.
- =/>37
- movement
Medical Screening involves looking for ____/______ flags.
red/yellow
Red Flags:
- Looking for patterns to suggest __________ or ________ origin.
- Do these require immediate medical attention?
- viscerogenic or systemic
- Yes, pursue further screening and make the appropriate referral.
Yellow Flags:
- __________ barriers to recovery including things such as fear, catastrophization, beliefs, emotions, depression, anxiety, stress, etc.
- Considered to be main contributors to _____ and ______ and have the potential to increase risk of ____-____ disability and work loss.
- psychosocial
- pain and disability, long-term
Patient Health Questionnaire:
- PHQ-2 score >/=___ should be further evaluated with PHQ-9.
- PHQ-9 score >/=___ indicates depression.
- 2
- 10
State Trait Anxiety Inventory:
-Score of >/= __-__ indicates clinically significant symptoms of anxiety.
Older adults Score of ≥ __-__.
- 39-40
- 54-55
Physical Examination:
- Focus on ________, __________ movements.
- Discuss results without using “inflated, ____-inducing” words.
- Focus here again is on enhancing the _________ relationship which aides in patients being more receptive to treatment, including PNE.
- Include an assessment of general fitness.
- Include testing for sensitive _________ system if appropriate.
- May even introduce ____ at this time. (“Has anyone explained to you why you (still) hurt?”)
- global, functional
- fear-inducing
- therapeutic
- nervous system
- PNE
What is pain neuromatrix?
-Widespread brain activity associated with pain experience.
The way we asses pain can actually ignite the pain neuromatrix. What is an example?
Using the word “pain”.
What are the 3 pain mechanisms?
- Nociceptive
- Neuropathic
- Central sensitization (CS)
- Ankle sprain = ___________ pain
- Herniated disc causing radicular pain = ________ pain
- No Hx of lesion/damage = _________ pain
- Nociceptive
- Neuropathic
- Central sensitization (CS)
What are the 2 criteria for CS pain?
1.) Perceived pain/disability disproportionate to nature of injury/pathology.
AND
2.) Diffuse/neuro-anatomically illogical distribution OR hypersensitivity present.
What 2 outcome measures may be helpful with patients who we suspect have CS pain?
- Widespread Pain Index
- Central Sensitization Inventory
Widespread Pain Index:
- Maps pain locations of ___ body regions.
- Score of __ or greater suggestive of widespread pain.
- 19
- 7
Central Sensitization Inventory:
-Cutoff score of ___ indicates possibility of predominant CS pain.
40
PART 2: INTERVENTIONS FOR CHRONIC PAIN
PART 2: INTERVENTIONS FOR CHRONIC PAIN
- Conventional rehab is often time unsuccessful in the chronic pain population. Why?
- What should be done instead?
- Conventional pain treatment focuses on finding pain-relieving medication or exercise or pain management strategy to manage life with constant pain
- Use the biopsychosocial approach to provide patient with knowledge, understanding and skills to decrease pain and disability.
The _____ __________ shows that there are 2 pathways. Describe these two pathways.
Fear-Avoidance Model
- Injury → Pain Experience → No Fear → Confrontation → Recovery
- Injury → Pain Experience → Pain Catastrophizing → Pain-Related Fear → Avoidance Hypervigilance → Disuse/Depression/Disability → Pain Experience
What is PNE?
“PNE aims to explain to patients the biological and physiological processes involved in a pain experience and, more importantly, defocus the issues associated with the anatomical structures.”
What does research say about PNE?
STRONG evidence show improvements in pain ratings, pain knowledge, disability, pain catastrophization, fear-avoidance, attitudes and behaviors regarding pain, physical movement and healthcare utilization.
What are the 3 main components of education?
- Communicate the results of physical examination
- Educate regarding the nature of the problem
- “De-educate” prior to “re’educating”.
Communicating Results of Physical Examination:
- Describe in terms that the patient can understand, avoiding the use of the _________ model which may result in increased fear, anxiety and stress.
- Avoid using terminology that increases ____ and _______. (“tear”, “deterioration”, “herniation”, “wear and tear”, “degeneration”)
- Establish __________ and set realistic expectations. (complete elimination of pain may not be possible, flare ups are normal)
- biomedical
- fear and anxiety
- prognosis
- How to educate about nociceptive pain?
- How to educate about neuropathic pain?
- How to educate about central sensitization pain?
- Explain source of nociception and role of the brain.
- Explain pain neuroscience and underlying neuropathic pain mechanisms.
- Explain pain neuroscience underlying central sensitization pain.
Educate Regarding the Nature of the Problem:
- PNE is most successful with the use of ______, ______, and ________.
- What is the “Alarm System”?
- _________ the pain.
- Core objective “to shift one’s conceptualization of pain from that of a marker of tissue damage or pathology, to that of a marker of the perceived need to ________ body tissue.”
- metaphors, examples, and pictures
- A common story used to describe pain.
- reconceptualize
- protect
With education, what do we want to do before “re-education”?
De-educate
De-Education:
- Shift from ________ education mode.
- Discuss psychosocial barriers if any were identified in the screening examination using ________, _______, and data sharing data to overcome misbeliefs. (40% of individuals with similar “bulging discs” have no pain and continue on with life)
- Using a _________ approach because there are many factors outside of their pain that can cause issues.
- Using _________ approach if necessary.
- biomedical
- compassion, empathy
- holistic
- multidisciplinary
Principles of Pain Rehabilitation:
- Observe and listen. Why?
- Explain Pain’s core objective. What is it?
- Do we need to avoid pain with our interventions?
- Potential modulators of pain include what we say, do, think, and hear.
- “To shift one’s conceptualization of pain from that of a marker of tissue damage or pathology, to that of a marker of the perceived need to protect body tissue.”
- No
It is recommended to bill PNE as _______________.
Neuro re-education, but be sure to ask billing department.
PART 3: INTERVENTION
PART 3: INTERVENTION
What are the 3 main components of Intervention?
- Individualized POC
- PNE
- Multidisciplinary Approach
- Treat the _______, not the ______.
- Chronic pain interventions that incorporates a ___________ model is currently viewed as the most effective approach.
- patient, label
- biopsychosocial
What are the 4 pillars of PNE+?
- Pain Education
- Aerobic Exercise
- Sleep Hygiene
- Goal Setting
Why PNE+?
PNE combined with a physical intervention, such as exercise or manual therapy, is far superior.
Summary of PNE Principles:
- Pain is an _______ of the brain. (Best guess for protection)
- Pain is not always an indicator of _______ damage.
- The amount of pain you perceive ________ = the amount of damage.
- In ________ pain, the brain believes you are in danger and need protecting.
- output
- tissue
- doesn’t
- chronic
Exercise:
- It is important to encourage physical activity as early as possible. Why?
- Provide frequent ________ that becoming active gradually is safe. (“sore but safe”, “hurt does not = harm”)
- Implement principles of ______ and _______ Exposure.
- Benefits of physical activity on chronic MSK pain are widely accepted.
- reassurance
- Pacing and Graded Exposure
What is Pacing and Graded Exposures?
- Pacing- Breaking tasks into manageable portions without exacerbating symptoms.
- Graded Exposure- Gradually moving towards where pain is at, slowly increasing as we go.
Effectiveness of Exercise in Individuals w/ Chronic Pain:
- PNE combined with exercise or manual therapy is far superior. (Discuss patient _________ of exercise/fears associated with exercise)
- Unclear whether ________ or ________ exercise is superior in chronic conditions.
- Exercise induced changes include reduced fear, anxiety & catastrophization, improved self-efficacy, exercise-induced analgesia & positive functional/structural adaptations in the brain.
- perception
- aerobic or resistance
What are the current national guidelines on exercise?
-150m of moderate intensity activity per week.
OR
-75m of vigorous activity per week.
Biopsychosocial Approach to Exercise:
- Must be perceived as _____ and ___________.
- May need to temporarily _____/_______ specific activities per patient tolerance.
- Take caution not to draw frequent _______ to pain.
- safe and meaningful
- stop/modify
- attention
It is recommended to provide __-__ exercises to do at home.
-4-5
Principles for Exercise Prescription:
- Provide the patient with a treatment ________.
- Establish ______ of activity within first session.
- Discuss activity ______.
- Continue to provide patient education (“____-____”).
- Utilize activity ______/______ to monitor physical activity.
- expectation
- baseline
- pacing
- “flare-ups”
- tracker/diary
What are some consequences of significantly increasing pain during/following 1st session?
- Erode confidence with movement/exercise.
- Strengthen relationship between movement and pain.
- Decrease patient motivation for participation.
What is “Tease It; Touch It; Nudge It”?
Reaching point of pain without going past.
Different modes of exercise?
- Aerobic
- Resistance
- Land vs Aquatic
What are some recommendations for aerobic exercise for this population?
- 20-60m
- > 2x/week for 6 weeks
- “Turn down the pain volume or dampen the pain response.”
Land vs Aquatic:
-Land-based exercises may facilitate greater improvement in muscle function.
Aquatic program may be necessary for individuals with very poor functional tolerance or heighted pain/distress.
-Ultimate goal is to transition to _____-based program.
land
Sleep Hygiene:
- Sleep deprivation is growing problem.
- Lack of sleep _________ affects wellness and is associated with increased rates of pain, obesity, depression and increased risk for cancer and other health-related disorders.
- Utilize sleep hygiene education for patients with identified sleep difficulties.
negatively
Goal Setting:
- Create a list of __ goals. (“If I could flip a switch and get rid of your pain, what would you do again?”)
- Patient will likely return with _____ goals.
- Help the patient develop _______ and _________ goals.
- 5
- vague
- measurable and functional
4 Simple Tasks for a HEP.
- ) Questions
- ) Exercise
- ) Aerobic Exercise Program
- ) Goals
If the stressors remain present for months, the stress response of increased adrenaline is then followed by __________ changes in the body.
cortisol
- Strong evidence to support the use of a __________ approach in individuals with chronic LBP.
- Key component to successful implementation of multidisciplinary approach is that everyone on the team is utilizing similar language & pain science model.
multidisciplinary
PART 4: GRADED MOTOR IMAGERY
PART 4: GRADED MOTOR IMAGERY
What is Graded Motor Imagery (GMI) aimed at?
Aimed at cortical reorganization, specifically of primary sensory cortex.
What are the 3 parts of GMI?
- Left/Right Discrimination
- Explicit Motor Imagery
- Mirror Therapy
What Does the Research Say:
- ___________ effect of mirror therapy and GMI (Based on limited evidence)
- _____ effect for left/right discrimination.
- _________ results for stand-alone motor imagery techniques.
- Positive
- No
- Conflicting
GMI Clinical Pearl:
- Important to “______ ____ _____” by describing what GMI is.
- Remind the patient that their recovery requires _________/__________ and _______/_________.
- “prepare the soil”
- patience/persistence, courage/commitment
Stage 1- L/R Discrimination:
- Research demonstrates that left/right discrimination is impaired in individuals with ______ pain.
- Normalization of left/right discrimination is important for recovery from chronic pain.
chronic
Stage 1- L/R Discrimination:
Suggestings for Norms from noi group:
-Accuracy = ___%
-Speed = ___s +/- 0.5s for neck/back, ___s +/_ for hands/feet/shoulders/knees
-Maintain above parameters for at least a _____ and despite _______.
-Instructed to make as _______ as possible.
-Easiest to perform at __ degrees and without distractions.
-Repeated __-__x per day.
- 80%
- 1.6s, 2.0s
- week, stress
- quickly
- 0 degrees
- 4-5x
What are some things that can be modified to make L/R discrimination more difficult?
- Length of display time
- Number of images
- Context of images
- Where it is performed
- External environment (quiet room verses background noise)
- Time of day
- Mood
- In different postures (lying on floor, sitting, standing up)
Stage 2- Explicit Motor Imagery:
- Imagining movements can be hard work.
- Time to perform or imagine the task is roughly the same.
- Important to perform in as many different ______ as possible.
- Begin with an ___________ body part and work towards the affected area.
- Goal is to visualize yourself moving but you can begin by visualizing someone else move if it is too difficult.
- places
- unaffected
Stage 3- Mirror Therapy:
- Ensure the mirror is an accurate reflection.
- Quality mirror at ________ of the body.
- Remove or cover anything that would identify the limb as right or left (ie rings, tattoos, etc).
midline
It is important for the patient to ____ exceed the predetermined training load.**
NOT
