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Physical Therapy, Pain, The Brain. GOBHI May 17, 2012 Dr. Tom Watson PT MEd DAAPM Bend, Oregon. Conflict of Interest Financial Disclosure. Dr. Tom Watson DPT PT MEd Diplomate American Academy of Pain Management Rebound Physical Therapy 541-382-7875 Bend, Oregon

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Physical therapy pain the brain

Physical Therapy, Pain, The Brain

GOBHI May 17, 2012

Dr. Tom Watson PT MEd DAAPM

Bend, Oregon


Conflict of interest financial disclosure

Conflict of InterestFinancial Disclosure

Dr. Tom Watson DPT PT MEd

Diplomate American Academy

of Pain Management

Rebound Physical Therapy

541-382-7875 Bend, Oregon

[email protected]

No conflicts of interest


American academy of pain management

American Academy of Pain Management

  • The mission of the American Academy of Pain Management is to advance the field of pain management using an integrative model of patient-centered care by providing evidence-based education for pain practitioners, as well as credentialing and advocacy for its members.

  • http://www.aapainmanage.org/

  • (209) 533-9744


Aapm annual conference

AAPM Annual Conference

  • The 2012 Annual Clinical Meeting will be held in Phoenix, Arizona, September 20-23, 2012

  • Founded in 1988, the Academy is the largest pain management organization in the nation and the only one that embraces an integrative model of care, which is patient-centered, focuses on the “whole” person, is informed by evidence, and brings together, all appropriate therapeutic approaches to reduce pain and achieve optimal health and healing. The Academy offers continuing education, publications, and advocacy.


Pain anatomy

Pain Anatomy


Physical therapy pain the brain

PAIN

  • Pain, according to the IASP (International Association for the Study of Pain), is "an unpleasant sensory or emotional experience associated with actual or potential tissue damage and described in terms of such damage."


Pain www ros pain www ro pain www rosstoons com pain www rosstoons com m stoons com

PAIN (www.rosPAIN (www.ro PAIN (www.rosstoons.com)PAIN (www.rosstoons.com)m)stoons.com)


Physical therapy pain the brain

PAIN

  • "Pain is a part of being alive, and we need to learn that. Pain does not last forever, nor is it necessarily unbeatable, and we need to be taught that."– Harold Kushner


Freud on pain

Freud on Pain

  • The pleasure-pain principle was originated by Sigmund Freud in modern psychoanalysis, although Aristotle noted the significance in his 'Rhetoric', more than 300 years BC.

  • 'We may lay it down that Pleasure is a movement, a movement by which the soul as a whole is consciously brought into its normal state of being; and that Pain is the opposite.”

  • http://changingminds.org/disciplines/psychoanalysis/concepts/pleasure_pain.htm


Hippocrates on pain

Hippocrates on Pain

  • “Men ought to know that from the brain, and from the brain only, arise our pleasures, joys, laughter and jests, as well as our sorrows, pains, griefs and tears.”

  • The Sacred Disease, in Hippocrates, trans. W. H. S. Jones (1923), Vol. 2, 175


Incidence of pain

Incidence of Pain

  • National Center for Health Statistics National Household Survey (Aug 2009):

  • Pain 100 million Americans (not including Vets and children – IOM 2011)

  • Diabetes 20.8 million

  • CAD 18.7 million

  • Cancer 1.4 million


Cost of pain

Cost of Pain


Physical therapy pain the brain

PAIN

  • Pain is the primary reason for visits to a clinician

  • Pain always evokes a sensory or emotional response

  • When pain occurs, suffering and pain behaviors follow

  • A very complex perception- Albert Schweitzer- “may be worse then death”


Classification

Classification

  • Pain is classified in three categories:

  • 1. Acute- lasting 4-6 weeks

  • 2. (Subacute-lasting 6-weeks to 6 months)

  • 3. Chronic pain- starting at six months or symptoms lasting longer than the anticipated time for recovery.


Chronic pain syndrome

Chronic Pain Syndrome

  • Mood

  • Memory- short and long term

  • Concentration

  • Sleep

  • Sex drive


Types of pain

Types of Pain


Neuropathic pain

Neuropathic Pain

  • spontaneous burning pain with an intermittent sharp stabbing or lancinating character, an increased pain response to noxious stimuli (hyperalgesia), pain elicited by non-noxious stimuli (allodynia)

  • structural and/or functional nervous system adaptations secondary to injury

  • centrally or peripherally –large and small fiber

  • Diabetic neuropathy


Rsd crps smp

RSD, CRPS, SMP


Crps treatment ect

CRPS Treatment- ECT

  • ECT (electro convulsive therapy)

  • 1940s-chronic pain

  • 1957-CRPS I, Retrograde amnesia

  • RUL (Right Unilateral) ECT without persistent cognitive side effects

  • 6-12 sessions

  • Increase in thalamic blood flow, PET Scan changes in thalamus-parietal-frontal lobes - relief of CRPS symptoms


Crps treatment

CRPS Treatment

  • VIT D3, Red Krill Fish Oil

  • Microcurrent Stimulation, Cold Laser,

  • Neuro mobilization

  • Mirror Therapy

  • NMDR

  • Hypnosis

  • Acupuncture

  • Meds: Opioids, Psychotropic, Neuroleptics, steroids, non-steroidals


Pain combinations

Pain Combinations


Central pain

Central Pain

  • Central pain -IASP: "pain initiated or caused by a primary lesion or dysfunction in the central nervous system" (Merskey, Bogduk, 1994).

  • Caused by “wind-up” phenomena

  • Thalamic or other area in Brain

  • "Neuropathic" vs. "neurogenic", a term used to describe pain resulting from injury to a peripheral nerve but without necessarily implying any "neuropathy


Psychogenic pain

Psychogenic Pain

  • "Psychogenic" pain arises due to maladaptive thought processes

  • Somatization-bowel disorder, palpitations, fatigue, respiratory, all disproportionate

  • Hypochondriasis- fear of condition

  • Factitious Disorder-Munchausen syndrome


Pain of youth

Pain of Youth


Nociception

Nociception

  • Pain is transmitted to the brain through neurological process of nociception

  • Nociception is pain in which normal nerves transmit information to the central nervous system about trauma to tissues (nocere = to injure, Latin).


Nociception1

Nociception

  • Nociceptionnormal nerves transmit information to the central nervous system about trauma to tissues (nocere = to injure).

  • A-beta fibers thickly myelinated mostly sensory, 10% transmit pain

  • A-delta fibers thinly myelinated, transmit sharp/lancinating pain

  • C-fibers non-myelinated fibers, dull or chronic pain


Nociception2

Nociception

  • Special nerve endings or type IV mechanoreceptors, i.e. free nerve endings, absorb chemicals, transfer information to the spinal cord.

  • Noxious stimuli via peripheral A delta and C fibers: release of excitatory amino acid neurotransmitters (glutamate), neuro-peptides, substance P


Nociceptive agents

Nociceptive Agents

  • Nociception occurs with damage to tissue and chemical or endogenous agents are released

  • bradykinins, serotonin, cytokines, protons, sensory neuropeptides, and arachidonic acids: leukotrienes & prostaglandins, substance P, K+, ATP


Site of trauma

Site of Trauma


Nociception3

Nociception

  • Type IV Mechanoreceptors:

  • Location: joint capsule, blood vessels, articular fat pads, anterior dura mater, Ant. Long. Lig., PLL, connective tissue

  • NOT in: muscle, Ligamentum flavum, nerve, articular cartilage

  • Non-adapting- keep firing until noxious stim (mechanical, chemical, thermal) removed.

  • Pain causes: tonic reflexogenic-guarding tonic muscles proximal to joint-ischemia, no guarding with phasic muscles


Dorsal root ganglia

Dorsal root ganglia

  • DRG: The free nerve ending in the tip of your finger that feels the paper cut, cell body in dorsal root ganglion.


Response

Response

  • Motor –protective

  • Perceptual- cross over, pain response can increase or decrease

  • Sympathetic- vasoconstriction, sweat, cool/moist increase output

  • Remove stimulus- type IV non-adapting, deformity 3%, thermal below 44.8 C

  • Emotional, memory, response


Cancer pain

Cancer Pain

  • 70% of all cancer patients have pain, 50% have severe to intractable pain

  • Somatic Cancer Pain neoplastic invasion of bone, joint, muscle, or connective tissue.

  • Bone Pain direct tumour invasion of bone. Not all bone metastases are painful

  • Visceral Cancer Pain. Solid organs - lung, liver, and kidney parenchyma are insensitive,. Harmful stimuli ie. burning or cutting of visceral tissue do not cause pain, whereas natural stimuli such as hollow organ distension readily produce pain

  • Neuropathic Cancer Pain- herpes zoster(Shingles)


Physical therapy pain the brain

CIPA

  • Congenital Insensitivity to Pain with Anhidrosis, Hereditary Sensory and Autonomic Neuropathies (HSAN) (4)

  • impaired autonomic, sensory, motor functions

  • Insensitivity to superficial and deep pain, neuropathic joints, risk of unrecognized injury (burns, fractures), corneal ulceration

  • No cure exists, death


Spinal cord transmitters

Spinal Cord Transmitters

  • many neurotransmitters in dorsal horns

    • substance P has a prime role, may promote later release of EAA

    • NMDA (glutamate), aspartate, CGRP-facilitates pain

    • GABA-pain inhibition


Central assent

Central Assent

  • Pain information ascends via spinal thalamic tract or Lissaurs track, terminates in thalamus, somatosensory cortex, limbic system, midbrain, hypothalamus, or thalamic nuclei.

  • Facilitation-pathology, environment, emotional stress

  • Facilitation-sensory, motor, sympathetic


Distribution of neurotransmitters

Distribution of neurotransmitters


Descending control

Descending control

  • major descending modulation pathway originates: periaquaductal gray area, the locus ceruleus, the nucleus raphe magnus and the dorsal horn of the spinal cord terminating in laminae I, II, and IV.

  • Descending noradrenergic antinociceptive systems originating in the brainstem contribute to pain control, in the substantia gelatinosa of the dorsal horn


Descending control1

Descending Control

  • Inhibitory- 36 different brain opiods (Korr)

  • Endorphins- 15-20 minutes of continuous activity to be produced, half life 6-8 hours

  • Takes another 15-20 minutes to reach target site: Axoplasmatic flow of nerves, blood, CSF via lymphatics


Descending control2

Descending control

  • Pharmacological

  • Cannabis decreases pain-cortical reticular

  • Alcohol can increase or decrease pain cortical or rostral reticular

  • Caffeine-increases- rostral reticular

  • Barbiturates (Soma) increase cortical reticular - increase pain


Descending control3

Descending Control

  • Periaquecductal of Gray: Releases Opiods receptors: enkephlins, endorphins

  • Opiods inhibit the neurons that suppress the activity of Bulbospinal tract

  • morphine and electrical stimulation produce potent anti-nociception

  • High Intensity afferent input: Manipulation, high frequency e-stim, sex, baroque music, pain (Grimsby)


Women and pain

Women and Pain

  • Extra Nerve Fibers May Heighten Female Pain Perception By Jeff Minerd , MedPage Today Staff Writer, Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.

  • average fiber density in female samples was 34 ± 19 fibers/cm2.

  • - average density in male samples was 17 ± 8 fibers/cm2 (P=0.038.)

  • favors physical (organic) not psychosocial explanation for more pronounced pain perception in female patients


Men and pain

Men and Pain

  • Pain


The 4 a s of pain treatment outcomes

The 4 “A’s” of Pain Treatment Outcomes

“A successful outcome in pain therapy involves more than the lowering of pain intensity scores”

  • Analgesia

    • Pain relief

  • Activities of daily living

    • Psychosocial functioning

  • Adverse effects

    • Side effects

  • Aberrant drug-taking

    • Addiction-related outcomes

    • Passik et al. J Support Oncol. 2005;3(1):83-86

.


Pain tolerance

Pain Tolerance

  • Where’s Mommy??


Psychology and pain

Psychology and Pain

  • Hypnosis- opiate/endorphin release

  • CBT

  • Meditation, prayer

  • Group therapy

  • midbrain and cortical structures

  • Personality, gender, age, culture, fear/avoidance, pre-existing conditions

  • Interdisciplinary approach-best


Psychology and pain1

Psychology and Pain

  • MPD/Dis-associative Identity Disorders(DID)

  • BPD, Bi-Polar

  • and

  • Chronic Pain

  • Symptomatic changes in 1 area may manifest or decrease other diagnosis


Ancient times and today

Greeks, Egyptians, Chinese, Romans: Heat, sun, geodes, eels, massage, manipulation

Modalities-Thermal, Sound ,Traction, Magnets

Lasers, electrical stimulation

Manual therapies

Therapeutic exercise

Ancient Times and Today


Modalities

Modalities


Effectiveness of evidence based modalities

Effectiveness of Evidence-Based Modalities

Philadelphia Panel Evidence-Based Clinical Practice Guidelines (EBCPG) in Selected Rehabilitation Intervention for Low Back Pain

Cochrane Collaboration, and literature review using meta-analysis and observational studies


Modalities1

Feel Good:

Heat— Radiant-sun-fire-hot coals-sound

Conductive — Hot water, heated agents

Cold — Ice, chemical freezing agents

High Intensity Afferents-e-stim, TENS, IFC

Pain management in 5 minutes

EVIDENCED BASED:

CES-Microstimulation, Laser

Modalities


Microcurrent stimulation

Microcurrent Stimulation

Mercola & Kirsch, "microcurrent electrical therapy" (MET)

Based on the Arendt-Schultz physics principal of low intensity stimulation causing profound biophysical response, Works on the cellular level, using microamp current

Effective: reducing chronic headaches,improvingserotonin levels, depression, insomnia, chronic pain, fibromyalgia, PTSD

120 human studies and 19 animal by Daniel Kirsch, PhD, Mineral Wells, Texas


Microcurrent stimulation ces

Microcurrent Stimulation-CES

serotonergic (5-HT) raphe nuclei at brainstem.

5-HT inhibits brainstem cholinergic (ACh) and noradrenergic (NE) systems that project supratentorially. Release dopamine

Suppression thalamo-cortical activity, arousal, agitation, alters sensory processing and induces EEG alpha rhythm.

5-HT acts directly to modulate pain sensation in dorsal horn of the spinal cord, alter pain perception, cognition and emotionality within the limbic forebrain.


Laser

Laser

  • Einstein-1916


Laser1

Laser

Light Amplification by Stimulated Emission of Radiation: 1950s

Photo-biostimulation principal

Helium neon laser, with 632.8 nm:

superficial wound healing, acute and chronic pain, with or without inflammation

Gallium Arsenide or infrared laser 830nm:

deep pain, deep wound healing, scar tissue, calcium deposits, neuropathies


Laser2

Laser

Jedi squirrels of Oregon with light sabers


Laser3

Laser

475+ RCDBCS

Decrease pain, decrease inflammation, increase healing, Krebs cycle ATP increased by 150% –1000%

Activates mitochondria

Decreases bradykinins-histamine: anti-inflammatory analgesic

Regenerative: increases mitosis

No thermal effects below 500 mW

6 –12 treatments

www.laser.nu, www.microlightcorp.com


Laser indications

Laser Indications:

Acute and chronic pain, TMJD

Neuropathies, FMS, Post polio syndrome

Headaches, Arthritis

Acupuncture points

Open wounds

Athletic Injuries: Sprains, Strains, Hematomas


Manual therapy

Manual Therapy


Manual therapy1

Manual Therapy

Dorland: manipulation skillful or dexterous treatment by the hand and in physical therapy, forceful pressure/movement of a joint within or beyond its active limit of motion.

Massage, mobilization, manipulation- highly effective in reducing pain and muscle guarding, increasing range of motion. Hypermobility or hypomobility

Manipulation/mobilization date back to Hippocrates in 460 BC

Basmajian documented “Laying on of hands” in the Old Testament of the Bible


Manual therapy2

Manual Therapy

Andrew Taylor Still introduced osteopathic manipulation in late 1800s, diseases were due to abnormal bony situations

Bonesetters were prominent in Mexico and famous for “stamping or trampling” techniques that are still practiced today.

Sarah Mapps, aka Crazy Sally or Cross Eyed Sally, was in high demand in London during the early 1700s for her “bone setting ability.”


Manual therapy3

Manual Therapy

Cyriax disagreed with osteopathic techniques, advocated manipulation by PT”s

“Hippocrates straightened kyphosis, Galen replaced outward dislocated vertebrae, and Pare wrote about subluxation of the spine.” ‘bone setters’ replaced out of place bones, osteopaths treated the osteopathic lesion, orthopedic surgeons manipulated the SI joint, chiropractors replaced subluxed vertebrae, and neurologist havestretched the sciatic nerve.”


Manual therapy4

Manual Therapy

Soft Tissue Therapies

manual contact, pressure, or movements primarily to myofascial(soft) tissues

myofascial release, muscle energy, traditional massage, Rolfing, movement therapies such as Feldenkrais, Traegering, PNF, classical massage

manual manipulation of soft tissue administered for producing effects on nervous, muscular, lymph, and circulatory systems


Manual therapy5

Manual Therapy

The Ultimate Goal of joint mobilization or manipulation techniques is to lower the threshold of activity at a joint or muscle via dorsal horn inhibition

EMG studies

manipulation/mobilization increased active range of motion and decreased muscle tone

massage/stretching demonstrated increased range of motion but increased EMG activity


Immobilization

Immobilization

The musculoskeletal system does not respond well to immobilization.

The end result is the deterioration and weakness of the body’s tissue.

Recovery is a slow process and care must be taken during activity and exercise to avoid further tissue damage.

For every 1 day in a brace or cast 2 days of mobilization and exercise


Therapeutic exercise

Therapeutic Exercise

BUFF?


Therapeutic exercise1

Therapeutic Exercise

Reducing pain and increasing stability

Programs begin with exercises aimed at increasing circulation into a muscle, improving endurance, facilitating coordination - motion occurs around a normal physiological axis, increasing strength and power.

Release endorphins, improve self esteem, decrease depression


Therapeutic exercise2

TherapeuticExercise

Steps

Phase 1 : coordination, mobility, and stability around a physiological axis throughout the range of motion

Phase 2: increasing tissue tolerance to levels corresponding to the demands of activities of daily living and restoring function

5000 to 6000 repetitions to regain the former coordination of the tonic or phasic muscles in a joint system following an injury


Therapeutic exercise3

Therapeutic Exercise

Phase 3: Stabilizing exercises combining concentric and eccentric contractions

Phase 4: Coordinate tonic and phasic throughout full AROM such as in PNF patterns to finalize strengthening and coordination. Plyometric training.

The patients are pain free and are preparing to return to their pre-injury levels of activity or sports participation at this time.


Therapeutic exercise4

Therapeutic Exercise

Ball Therapy, Theraband, running, swimming, skiing, weight lifting

Feldenkrais, Yoga

Pool therapy, Pilates, Plyometrics


Other therapies

Other Therapies

Mirror Therapy for CRPS

Dry needling for trigger points

Nutritional counseling, Anti-inflammatory Diet, Vit D3, Red Krill fish oil

Placebo up to 40%


Physical therapy pain the brain

EMDR

  • Eye Movement Desensitization and Reprocessing (EMDR) or "eye movement therapy" for anxiety, stress, trauma

  • The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma by Francine Shapiro PhD, published 1997

  • currently fairly widely accepted, controversial, FMS, chronic pain

  • equivalent to cognitive behavioral and exposure therapies


Conclusions

Conclusions

Physical therapy is a skill and an art

Head: learns anatomy, physiology, pain symptoms, evidence based outcomes various types of modalities, exercises, and manual therapies

Hands: apply modalities, manual therapies, and exercises

Heart: empathy and understanding that pain patients need more than just modalities and exercise


Remember

Remember

Pain does not have to be a

Way of Life


References

References

  • www.heinricher.net/pain_lecture/index.htm

  • www.westmeadanaesthesia.org/Meetings/pain-physiology/ Pain%20Physiology.htm

  • Weiner’s Pain Management, A Practical Guide for Clinicians, 7th Ed., 2006,Boswell and Cole Editors, CRC Press, Taylor and Francis Group LLC, Boca Raton, Fla., chap 36, 3 & 4

  • laser.nu

  • http://www.sigmaaldrich.com/Area_of_Interest/Life_Science/Cell_Signaling/Key_Resources/Pathway_Slides__Charts/Ascending_Pain_Pathway.html

  • RUL ECT for Treatment of CRPS: Practical Pain Management Vol 8 #2 March 2008 pps 68-74 (AAPM)

  • http://www.associatedphysicians.com/psychology-of-pain.html


References1

References

  • Kirsch D, Smith R. The use of cranial electrotherapy stimulation in the management of chronic pain: a review. Neuro Rehabilitation. 2000;14:85-94.

  • Brotman P. Low intensity transcranial electrical stimulation improves the efficacy of thermal biofeedback and quieting reflex in the treatment of classical migraine headache. Am J Electromed. 1989;6(5):120-123.

  • Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain. Phys Ther. 2001;81:1641-1674. Review.

  • Harris JD. History and development of mobilization and manipulation. In: Basmajian J. ed. Rational Manual Therapies. Baltimore: Williams and Wilkins; 1993:7-22.


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