physical therapy pain the brain n.
Skip this Video
Download Presentation
Physical Therapy, Pain, The Brain

Loading in 2 Seconds...

play fullscreen
1 / 77

Physical Therapy, Pain, The Brain - PowerPoint PPT Presentation

  • Uploaded on

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

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Physical Therapy, Pain, The Brain' - verdad

Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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

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.
  • (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, 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 ( 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.”
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
  • 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”
  • 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
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
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
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 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).
  • 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
  • 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
  • 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.
  • 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)
  • 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
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
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
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

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


CES-Microstimulation, Laser

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.

  • Einstein-1916

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


Jedi squirrels of Oregon with light sabers



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,

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 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


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 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


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%

  • 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

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


Pain does not have to be a

Way of Life

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