Dr Keith Laubscher. Dr Jonathan Kuttner. Dr Ian Wallbridge. Dr Giresh Kanji. 16:30-18:30 WS #24: Musculoskeletal Medicine 4.
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1 Dr Jonathan Kuttner Musculoskeletal & Pain Specialist Auckland Dr Keith Laubscher Pain Specialist Auckland Dr Giresh Kanji Musculoskeletal Pain Specialist Auckland Dr Ian Wallbridge Musculoskeletal Physician Rotorua 16:30-18:30 WS #24: Musculoskeletal Medicine 4
2 The sensory amplification of pain Headache Migraine Fibromyalgia Dr Giresh Kanji Musculoskeletal Pain Specialist One Health 122 Remuera Rd Auckland Fixyourstress.com
3 Pain is electrical First rule of MSK pain
4 Second rule of MSK pain impulse creates action potentials
5 Rule 3 Everyone is different Pain threshold migraine/ sympathetic nervous system
6 Determinants of pain Migraine SNS Tone State of disc/cartilage Loading
7 Migraine Migraine Definition: Genetic predisposition to sensory amplification Light Sound Smell Pain Touch
8 Migraine Channelopathy A variation of sodium/calcium/potassium channels Net result is increased action potentials in sensory cortex.
9 Migraine Channelopathies
10 Migraine
11 What is the role of SNS Tone stress in chronic pain?
12 Sympathetic Nervous System Hypothalamic pituitary adrenal SNS Tone Serotonin, Adrenaline, Noradrenaline CRH, Histamine, Acetylcholine Serotonin Noradrenaline Adrenaline Noradrenaline Cortisol
13 Second Messengers SNS Tone
14 Widespread connections SNS Tone
15 Sensory amplification
16 Sensory amplification
17 Pain, Insomnia, anxiety
18 ically relevant. Impulse Impulse mass x gravity x time Time is most important factor Impulse 1 min vs 1 hour Time Loading
19 Loading
20 Impulse cervical spine Loading
21 Spinal curves Loading
22
23 Pain spectrum Minimal pain Migraine Migraine with aura
24
25 State of disc/cartilage
26 State of disc/cartilage 27 y F LBP 2 years
27 State of disc/cartilage Fusion L4/5 L5/S1
28 Fibromyalgia SNS/HPA activation Convergent referred pain Temporal summation Spatial summation
29 Co-morbidities Insomnia and fatigue Anxiety depression IBS, fatigue Headache (50%) Fibromyalgia
30 N = 102 Neck injury 21 % fibrombyalgia 3/12 N = 59 leg fractures 1.7% fibromyalgia
31 MVA Neck pain 50% have no change at one year 50% are 30% better
32 N=16 Fibromyalgia N=16 healthy controls Sympathetic overactivity parasympathetic underactivity
33 CPS/Fibromyalgia INCREASED SNS TONE INSOMNIA FATIGUE PAIN AMPLIFIES SPREADS FIBOMYALGIA ANXIETY DEPRESSION
34 Management Medications analgesics/pain modifying agents Reduce SNS/HPA Treat muscle contraction Treat underlying joint/disc pathology
35 Analgesics Nsaids Opioids Cannabinoids PGs mu, K CB Pain modifying agents antidepressants adrenergic, Ach, 5HT, Dop anti-epileptics Na, Ca, GABA Antipsychotics 5HT, dop Gabapentin/Pregabalin? Amitriptyline NA, Ach, 5HT, adrenergic, histamine Inhibits Na, Ca, K channels
36 Management of MSK pain Reduce sympathetic tone Exercise (above 50% HRmax) Sauna Yoga Meditation/slowbreathing - 6/min Tai Chi
37 Exercise Avoid loading painful joint/spine 20 min 3-4 times a week
38 Patients achieving 50% reduction in Headache Index (intensity x duration) Control 1 2 Sauna
39 Sauna CTTH Meditation CTTH Relaxation therapy CTTH Exercise Headache/Migraine Waon Therapy Yoga LBP RCTs
40 Muscles Tenderness due to sensory amplification reduces by reducing SNS/HPA Muscle spasm due to muscle contraction Acupuncture/trigger point needling/massage/cupping Followed by stretching/strengthening program
41 Joints/Disc Once pain localises underlying structure needs evaluation and management Remember underlying pathology may not match patients symptoms Reducing nociception will reduce ongoing SNS/HPA activation
42 Case 1 Fibromyalgia 38 y F (15 Years)
43 Case 1
44 Case 2 61 M 40 years nose pain
45 Summary Migraine predisposes to action potentials in sensory cortex hence increases risk FM, CRPS, all musculoskeletal pain HPA/SNS activation leads to cycle sensory amplification and stress related symptoms insomnia, anxiety, depression, IBS etc
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