Exercise for Pain Management: Brain Aerobics?

Size: px

Start display at page:

Download "Exercise for Pain Management: Brain Aerobics?"

Sara Holland
6 years ago
Views:

1 Exercise for Pain Management: Brain Aerobics? Dr. Julia Alleyne University of Toronto Toronto Rehab University Health Network

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Disclosures No financial investment No conflicts of interest

4 Objectives To describe the current understanding of the brain s role in pain perception and pain modulation To identify which exercise methods are effective for pain management control and the prescribing parameters for best outcomes

5 PAIN: Describe Pain in One Word

6 PAIN: Describe Pain in One Word

7 PAIN: An unpleasant sensory and emotional experience associated with actual or potential tissue damage OR described in terms of such damage

8 What s Missing?

9 What s Missing? Function Disability Impact on role Impact on Self Perception Fears, Anxieties and Sleep disorders

10 Approach to the Patient with Chronic Pain Anatomical Physiological Emotional

11 Applying Exercise Principles to Pain How does Pain effect the body? Tight Muscles Hypersensitivity Inactivity Cognitive Fog Does exercise work on Pain? Strength Flexibility Aerobics Balance

12 What are the types of chronic pain conditions? Headache Osteoarthritis Fibromyalgia Low Back Pain Neuropathic Pain Post Surgical Prolonged Pain MSK related Oncology Pain

13 What is Pain?

14 Past Theories of Pain Specificity of Pain The Intensity of Pain is directly related to the amount of tissue Injury Rene Descartes, 1600 The meaning associated with the injury was related to the experience of pain Henry Beecher, 1945

15 Pain Pathways and Chemical Modulation Nociceptors A-delta C Silent - skin viscera Joints muscle Peripheral Bradykinen Substance P Prostanoids Serotonin Cytokines Dynorphin A Central Prostanoids EAA NMDA Substance P NO / CCK NGF / CGRP 5HT / NK GABA / CGRP

16 Gate Control Theory Melzak & Wall, 1960 s

17 Gate Control Theory The spinal cord is processing Sensory signals of pressure, temperature and vibration. Heat/Cold Acupuncture Massage Neuro reception Exercise?

18 Gate Control Factors that Open the Gate Factors that Close the Gate

Factors that Close the Gate Feel- Relaxation and

19 Gate Control Factors that Open the Gate Feel Stress and Tension Think Focus and Boredom Do - Weak and Stiff Factors that Close the Gate Feel- Relaxation and Contentment Think Distraction and Learning Do- Activity and Fitness

20 Heel Raises

21 The Brain in Pain Production of Endorphins may inhibit pain Exercise, Stress, Excitement Cognitive & Emotional Factors a) Increase Pain Focus, Analysis, Worry and Negative Fears b) Decrease Pain Positive Outlook, Purpose, Control, Tasks

22 The Brain in Pain New Theories - Neuro Chemical Receptors - Neuro Sensitivity and Increased Reaction - Neuro Processing Blocks

23 The Brain in Pain Central Sensitization Pain itself can change how pain works, resulting in more pain with less provocation

24 New Theories of Chronic Pain Education 1. Pain does not always reflect Pathology 2. Normal Investigations don t mean it s in your Head 3. Physiology is the key to Function 4. Pain Perception is based in genetics and personality development. 5. The Mind-Body Connection is Key.

25 Loesser s Onion Theory

26 Assessing the Severity of Pain The patient report is valid! Verbal: 5 or 10 point scale VAS, Brief Pain Inventory Pain and activity diaries

Clinical Questions to detect Chronic Pain

27 Clinical Questions to detect Chronic Pain Psychosocial Risk Factors that predict risk or probability of Chronic Pain Predictive of Poor Outcome in Rehabilitation Indicate the need for early multi-disciplinary treatment including Cognitive Behavioural Counselling

30 Assess the Impact on the Patient s Life Activities of daily living Sleep Downtime vs. uptime Relationships Coping strategies Collateral information

31 Risk Factors for Poor Prognosis - Intensity of Initial Pain - Nature of Collision - Women more than Men - Not Prior Personality Features - Physical Deconditioning - Hypervigilance of Body Awareness

32 Green Flags Involved in Fitness and sport Good Family Life Satisfied in Career Insight and Intelligence Low Anxiety Factor Response versus Resistance

Formative Concept Acute < 3 months Localized Symptoms Localized Pain Therapeutic Exercise Injury Specific Goals Central Sensitization Pain Identifying Yellow flags for risk of

33 Formative Concept Acute < 3 months Localized Symptoms Localized Pain Therapeutic Exercise Injury Specific Goals Central Sensitization Pain Identifying Yellow flags for risk of developing Chronic Pain Syndrome Chronic > 3 months Generalized Symptoms Multi- focus etiology Ineffective Rehab Delayed Healing Factors Yellow Flags Sleep Disturbance Mood Changes

34 Pain Spiral Surgery Stigma Injury Withdrawal from social activities Tissue Damage Rest/Passive Surgery Depression Pain Centred Life Deconditioning Weak, tight muscles Harm vs. Hurt Limits Activities

35 Pain Spiral Breaking Free Improved social Functioning Improved Self Esteem Function Centred Life Improved Conditioning Pain Centred Life Improved Motivation Adequate Analgesia + Education Increased Activity

36 Pain Centered Exercise Prescription Increase Strength Target Large Muscles with Functional Activities Increase Flexibility Target Tight Postural with Frequent Micro-stretches Increase Aerobic Endurance Sub-optimal threshold with goal of minutes

37 Case Study Frau Jaeger is a 41 year old office worker who began to experience generalized aching and stiffness in her back, legs and shoulders over the last year. She does not recall a trigger event. She is irritable and frustrated and wants to be investigated and diagnosed.

38 History Probe - Sleep patterns are disrupted - Difficulty falling asleep - Frequent waking during the night - Pain is described as frequent aching which intensifies with prolonged positioning or fatigue - Tingling experiences intermittently circumferentially in hands and legs

39 Patient Symptom Inventory - Fatigue - Generalized weakness, hard to climb a hill - Lumbar pain with occasional associated neck pain - Morning stiffness in her hips, shoulders and back x 10 min - Mood Swings described as irritability with some sadness

40 F. I.T.T. Is exercise or activity a usual part of your week? I like to walk when I m not sore but that isn t very often When was the last time that you were able to walk? About 2 weeks ago, I walked with a friend for an hour and really hurt for the next week When you walked, did you have to stop and start? Did you recall if you were sweating? I usually stop every 5 minutes and sit down, I don t think I sweat when I walk

41 F. I.T.T. I like to walk when I m not sore but that isn t very often About 2 weeks ago, I walked with a friend for an hour and really hurt for the next week F Sedentary to Occasional I Low T Walking T 5 minutes I usually stop every 5 minutes and sit down, I don t think I sweat when I walk

42 Disruptive Sleep & Exercise Partial Truth : Exercise will help your Sleep Full Truth: Sleep disturbance is reduced by 27% in Active Healthy Adults 12 Population based studies that report better sleep patterns with physically active adults 2 Studies indicate a lower risk of Sleep Apnea with regular physical activity Sleep Disturbance and Depression Strength Training Exercise reduces sleep disturbance symptoms by 30% Strength training > General Exercise High Intensity > Low Intensity P.J. O Connor et al, American Journal of Lifestyle Medicine4(5) Mental Health Benefits of Strength Training in Adults,September 2010Volume, 4(Issue5)Page, p.377to-396

43 Sleep Disturbance R- Routine E- Exercise S- Stimulants T- Turmoil Medications Shifting Time Zones

45 Frau Jaeger

46 Risk Factors for Chronic Pain - History of Motor Vehicle Collision, 9 months ago - Treated with medication, no rehab. - Sedentary Lifestyle - Underweight - Family History of Rheumatoid Arthritis - Susceptible to Anxiety and Stress

47 Psychological Screen - Anxiety related headaches and increased muscle soreness - Feels stressed and overwhelmed - Cries more easily - No vegetative depression signs - Complains of poor memory and concentration - Mental Status is normal

48 Muscle Tension Reduction Physical Posture ADL Tight Muscle Groups Stretching Techniques Injury Prevention Rest Ice Psychological Stressors Anxiety Pain Cycle Sleep Quality Deep Breathing

49 Stress Management Personality Preferences Priorities & Planning Decision Making Circle of Support Assertiveness Attitudes Motivation

50 Exercise and Anxiety Systematic Review: Healthy Adults/ Chronic Pain/ Anxiety Disorders Strengthening in sequence like Circuit Training Mind-body cognitive exercise with therapeutic effect More Research needed to define anxiety disorders with type of exercise M. Herring et al, The Effects of Exercise Training on Anxiety November 2014Volume, 8; American Journal of Lifestyle Medicine

51 Physical Exam - Strength - Static- normal - Endurance- sit to stand or ¼ squat - Stability- single stand or heel raise - Neurological - Normal dermatomes, myotomes, reflexes - Special Tests - Pain Behaviours - Joint Specific

52 Physical Exam - Observation: - Facial pain expression, slowness in movement - Active R.O.M. - Full with painful stretch at the end of range - Passive R.O.M. normal - Positive Trigger points 11/14

53 Planning Priorities Education Correct the Sleep Disturbance Reduce the Muscle Tension Stress Management and Relaxation Increase Daily Physical Activity/ Exercise Targeted Strengthening Increase Endurance

54 Education Fears and Myths and Language Physiology Good Pain/ Bad Pain Triggers and Reactions Guidelines and Acronyms

55 Daily Physical Activity Energy Conservation Energy Spenditure Choosing when to use automation Good Day Activity Bad Day Activity Using rest wisely

56 Treatment Plan Exercise and Chronic Pain Osteoarthritis Moderate Strengthening of lower extremity is very effective and can be done as aerobic walking or resisted movements (8 RCT s) Low Back Pain Moderate strengthening yielded functional change and 40% reduced pain levels equal to aerobic training. (5 RCT s) Fibromyalgia- Strength training demonstrated more benefit than flexibility. Aerobic benefit was equal to strength but patient compliance was low. (4RCT s )

57 Targeted Strengthening Address Large muscles first Flexors tend to tighten Extensors tend to weaken Postural muscles are a priority Trunk Stabilization Assessment must be detailed to customize program Consider Right, Left, Upper, Lower

58 Aerobic Exercise Retrain the Brain Increase chemical changes Overall coordination Neuromuscular Benefits Mindfulness Movement Mind-Body Movement

59 Urbanpoling.com

60 Endurance Guidelines The One Minute Manager Increase 10% every 3 sessions Increase one parameter at a time Repetitions, Length of Hold, Weight, Time Reduce 25% for every week off Off one month, restart at Baseline Warm-up, cardio, strengthen, stretch, cool down

61 Exercise Prescription Frequency General Daily Activity Every other Day Exercise Dose Response Accumulated Daily Activity Interrupt Sedentary Activity Goal: Every other Day Intensity Moderate I feel some challenge and I get muscle fatigue with increased repetitions Type Time Strengthening Mind-Body Aerobics Large Muscle Function based Graduated Progression (10%)

62 Summary 1. Exercise is evidence-informed treatment for Acute and Chronic Pain conditions targeting pain pathways, mood changes & sleep disorder 2. Combine with Education, Activities of Daily Living and Pain Medication 3. Start with Strengthening Large muscles, Low Repetition, Long Holds 4. Add mind-body awareness movement Function based, Posture based 5. Add Endurance/ Aerobics

64 Case 2: My Aching Bones 58 year old male with complaints of bilateral knee pain and left hip pain. - morning stiffness lasting an hour - reduced walking tolerance to 15 minutes painfree - using acetominophen on a regular basis - Wants to continue with jogging and tennis

65 Physical Exam - Medial Joint line tenderness - Mild effusions - 5 degree flexion contractures - Valgus mal-alignment - Decreased proprioception

66 Osteoarthritis

67 American College of Rheumatology Guidelines for Care: 1) Control Pain 2) Improve of Quality of Life 3) Avoidance of Drug Toxicity Arthritis & Rheumatism, Vol 43, No. 9, Sept. 2000, pp

68 Non-Pharmacological Treatment of Knee Osteoarthritis Patient Education Self management Programs Weight Loss Exercise: ROM, Strength, Aerobics Gait Assistance Joint Protection Assistive Devices Hot water exercise therapy

69 Pharmacological Treatment Decrease Pain = Increase Function Oral: - Acetominophen - NSAID s - Topicals - Tramacet - Injectables

Getting at the CORE of Low-back pain Treatment Dr. John Flannery Dr. Carlo Ammendolia

Disclosure & Acknowledgment Getting at the CORE of Low-back pain Treatment Dr. John Flannery Dr. Carlo Ammendolia Disclosures - None Acknowledgements Dr. Andrea Furlan Dr. Julia Alleyne Dr. Hamilton Hall