Therapeutic Neuroscience Eduction Know Pain; Know Gain
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1 Therapeutic Neuroscience Eduction Know Pain; Know Gain Kory Zimney, PT, DPT, CSMT, CAFS without permission 1
2 10 Visits 64 year old lady with 3 years of CLBP Numerous treatments Numerous clinicians Pain rating 9/10 (NRS) Oswestry 54% (Severe disability) FABQ-W= 25/42,; FABQ-PA = 20/24 Zung depression scale = 58 And more Ultrasound Name the treatment Posture Spinal Mobilization Ergonomics Spinal Stabilization Spinal Manipulation Traction Aquatic Therapy Soft Tissue Treatment Electrical Stimulation TENS Triggerpoint Therapy Myofacial Release Cranio Sacral Up to 2/3 of the 70+ million have been living with this pain for more than five years (AAPM, 1999) IOM Relieving Pain in America 2011 Report: Chronic Pain affects about 100 million American adults. x 25 without permission 2
3 Chronic Pain Numbers Epidemiological data suggest that chronic, widespread, nonspecific musculoskeletal pain is on the rise, especially in the area of chronic low back pain(clbp), adding to the ever increasing costs of health care (Magni et al, 1993; McMahon and Koltzenburg, 2005). The prevalence of chronic pain was 35.5% (Raftery, Sarma et al. 2011) We all practice a bio-psycho-social approach right? Example 1 What is this? How long will it take? What do you want the patient to do? What should the patient NOT do? What will you as the clinician be doing for this? Example 2 What is this? How long will it take? What do you want the patient to do? What should the patient NOT do? What will you as the clinician be doing for this? Evolutionary Biology Onion skins Representation Pain mechanisms Underpinning the bio-psycho-social approach & held together with reasoning glue Beliefs/fears/threats Biomechanics Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Pathoanatomy Anatomy without permission 3
4 Representation Pain mechanisms Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Pathoanatomy Evolutionary Biology Onion skins Underpinning the bio-psycho-social approach & held together with reasoning glue Anatomy Beliefs/fears/threats Biomechanics Representation Pain mechanisms Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Biomechanical models Pathoanatomy Evolutionary Biology Underpinning the bio-psycho-social approach & held together with reasoning glue Anatomy Onion skins Beliefs/fears/threats Biomechanics Representation Pain mechanisms Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Tissue Pathology Pathoanatomy Evolutionary Biology Underpinning the bio-psycho-social approach & held together with reasoning glue Anatomy Onion skins Beliefs/fears/threats Biomechanics without permission 4
5 ihavewhiplash.com myanklehurts.com 1. Anatomy 2. Biomechanics 3. Pathoanatomy These models are very prevalent Prevailing biomedical models focus on tissues and tissue injury.(houben, Ostelo et al. 2005; Henrotin, Cedraschi et al. 2006; Weiner 2008) Orthopedic-based professions such physical therapy commonly use anatomy and patho-anatomy based models to explain pain to their patients. (Houben, Ostelo et al. 2005; Henrotin, Cedraschi et al. 2006; Spoto and Collins 2008; Weiner 2008) Research into anatomy, biomechanical and pathoanatomy models Not only have these models shown limited efficacy in decreasing pain and disability, but they may increase fear in patients, which in turn, may increase their pain.(greene, Appel et al. 2005; Morr, Shanti et al. 2010) Research into anatomy, biomechanical and pathoanatomy models Degenerative terms Wear and tear Deterioration Disc space loss Crumbling Collapsing without permission 5
6 representation Pain mechanisms Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; pathoanatomy Would this hurt? evolutionary biology onion skins Underpinning the bio-psycho-social approach & held together with reasoning glue anatomy Beliefs/fears/threats biomechanics Louw A. Why You Hurt: A Neuroscience Approach to Pain. Minneapolis: OPTP; Would this hurt if.? How Dangerous is this? This is dangerous More information Louw A. Why You Hurt: A Neuroscience Approach to Pain. Minneapolis: OPTP; Facilitation Neuronal adaption 34 Consider this. How Dangerous is this? This is not dangerous Inhibition Endogenous without permission 6
7 Perception can change based on context Pain relies on context Pain relies on context Pain relies on context Simotas, A. C. Shen, T. Neck pain in demolition derby drivers. Arch Phys Med Rehabil (4): without permission 7
8 Pain mechanisms Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Our view of pain processing is old Representation Pathoanatomy Evolutionary Biology Underpinning the bio-psycho-social approach & held together with reasoning glue Anatomy Onion skins Beliefs/fears/threats Biomechanics Wade, D., Why physical medicine, physical disability and physical rehabilitation? We should abandon Cartesian dualism. Clin Rehab, : p Pain is viewed as a Thing Fundamental Beliefs: It s a Trigger Point It s Fasci a It s a Disc It s the Face Pain only occurs when you are injured. The amount of pain one feels is a direct indication of the amount of tissue damage one has incurred. t It s the Core It s Postur e Fundamental Reality: Pain Injury An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. without permission 8
9 An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain viewed as a Personal Experience HABITS EMOTIONS An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. THOUGHTS DISABILITY DREAMS DEPRESSION HOPES BELIEFS BEHAVIORS FEARS FINANCES ANXIETIES IDENTITY STRESSORS Mature Organism Model RESOND via OUTPUTS: Pain Action programs Stress regulation Tissues Environment SCRUTINIZE via BODY-SELF NEUROMATRIX: Sensory Cognitive Affective Gifford, L.S., Pain, the tissues and the nervous system. Physiotherapy, : p Evolutionary Biology Onion skins Representation Pain mechanisms Underpinning the bio-psycho-social approach & held together with reasoning glue Beliefs/fears/threats Biomechanics Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Pathoanatomy Anatomy without permission 9
10 Evolutionary Models Parents to offspring Survival Consider: Pain protects Inflammation protects Some dysfunctions protect Evolutionary Biology Onion skins Representation Pain mechanisms Underpinning the bio-psycho-social approach & held together with reasoning glue Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Pathoanatomy Anatomy Beliefs/fears/threats Biomechanics Evolutionary Biology Onion skins Representation Pain mechanisms Underpinning the bio-psycho-social approach & held together with reasoning glue Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Pathoanatomy Anatomy Butler D, Moseley G. Explain Pain. Adelaide: Noigroup; Beliefs/fears/threats Biomechanics Could also be emotional overload Pull back Do less Increased fear Choice made Importance of early education? Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85: Irrational thoughts Limited knowledge Knowledge Threatening and provocative words; Medical tests; Various opinions; Internet information; Experiences Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85: without permission 10
11 Since this I have not gone out much No going to the movies I m good No big deal I ll be OK Lots I can do for this Keep moving No pain, no gain Couple of beers I ll be OK This must be bad I will never be able to I will be cripple at 65 I will be in a wheelchair I have a bulging disc I have arthritis No one agrees No one can find it My dad had severe Saw on the Internet My neighbor May have never experienced good pain Remembers various pain experiences quite vividly Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85: Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85: Pain is a %$#@ more complex than just tissue A fundamental flaw: The Predominant Model for Pain If the main reason for pain is a stiff joint If the main reason for pain is a tight muscle Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. Dec ;27(24): Fernandez-de-Las- Penas C, Alonso- Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA. Are manual therapies effective in reducing pain from tension-type headache?: a systematic review. Clin J Pain. Mar-Apr 2006;22(3): without permission 11
12 If the main reason for pain is altered muscle recruitment Hodges PW. Core stability exercises for chronic low back pain. Orthopedic Clinics of North America. 2003;34: My pain is due to the bulging disc I hurt because I have arthritis Movement will damage tissue and increase pain Pain means something is wrong I am not doing anything until all pain is gone I am afraid my pain will get worse I have a very rare case of But what if the pain and disability is due to faulty cognitions? It is well established that psychological and socioeconomic factors are correlated to pain Fear Catastrophization Knowledge Anticipation and consequence of pain 1. Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioural performance. Pain. 1995;62: Kovacs FM, Seco J, Royuela A, Pena A, Muriel A. The correlation between pain, catastrophizing, and disability in subacute and chronic low back pain: a study in the routine clinical practice of the Spanish National Health Service. Spine. Feb ;36(4): Moseley GL, Hodges PW, Nicholas MK. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain. 2004;20: Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther. Aug 2003;8(3): Returning to our patient I have bulging discs I have arthritis Louw A, Puentedura EL, Mintken P. Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: A case report. Physiotherapy theory and practice. Jul Cognitive Processing Afraid; poorly understood; movement = pain due to tissues being damaged High Threat What about The Top Down Effect PAIN to defend Tissues Environment Adapted from Gifford LS. Pain, the tissues and the nervous system. Physiotherapy. 1998;84: Louw A, Puentedura EL, Mintken P. Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: A case report. Physiotherapy theory and practice. Jul without permission 12
13 That ultrasound thing works every time My pain story So Current clinical educational models don t really work We need to change beliefs Is there a better way to educate? Why educate patients in PAIN about anatomy and biomechanics? Origins of Neuroscience Education Why not just teach them more about.pain? Image: Clinical Journal of Genius 2013 The origins of neuroscience education Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4): without permission 13
14 Efficacy Neuroscience Education Conclusions: Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement and minimizing healthcare utilization. Louw A, Zimney K, Puentedura EJ, Diener I. The Efficacy of Pain Neuroscience Education on Musculoskeletal Pain A Systematic Review of the Literature. Physiotherapy Theory and Practice. In Press Therapeutic Neuroscience Education Metaphors and examples Pictures One-on-one Therapist 82 Too many numbers? 34 year-old female 4.5 years of pain Started as LBP, then spread to her buttocks and now into both legs Pain would flare up with stress at work First child 2.5 years ago horrible labor, delivery and pain Now constant LBP Not able to return to work Now severe spasms in both legs CT, MRI and X-Ray WNL Meds: High doses of pain killers and narcotics A brain that feels extremely threatened, confused, hopeless A brain that understands, is less threatened and has hope Moseley GL. Widespread brain activity during an abdominal task markedly reduced after 85 pain physiology education: fmri evaluation of a single patient with chronic low back pain. Aust J Physiother. 2005;51(1): Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fmri evaluation of a single patient with chronic low back pain. Aust J Physiother. 2005;51(1): without permission 14
15 Key message of this study Every PT clinic should have an fmri One last time People in pain want to know more about pain The more they know about pain, the less pain they experience! The Neuroscience of Pain 91 Mature Organism Model RESOND via OUTPUTS: Pain Action programs Stress regulation SCRUTINIZE via BODY-SELF NEUROMATRIX: Sensory Cognitive Affective 92 Transduction Tissues Tissues Environment Gifford, L.S., Pain, the tissues and the nervous system. Physiotherapy, : p Environment without permission 15
16 Receptor - Ion channels Action/Generator Potential Various kinds of channels Genetic Coding DNA mrna Proteins DNA mrna Proteins without permission 16
17 Name the ion channel Name the channel 101 Key point: Ion channels 102 Key point: Ion channels Transduction 104 Pain relies on context Tissues Environment without permission 17
18 105 Pain relies on context 106 Tissues Environment 107 There are NO pain fibers in the body First Pain Aδ fiber Second Pain C fiber 108 Key Point: Damaged or Removed Myelin Mechanical Immune Chemical 109 Clinical Example 110 Modulation without permission 18
19 111 Melzack and Wall s Gate Control Theory Central Modulation Second Order Nociceptive Specific Second Order Wide Dynamic Ranging Neuron A-Beta fibers Interneuron C fibers Action Potential Wind-up Second Order Nociceptive Specific Other Side Sympathetic Second Order Wide Dynamic Ranging Neuron A-Beta fibers Other Levels Interneuron VS. C fibers without permission 19
20 How Dangerous is this? How Dangerous is this? This is dangerous More information This is not dangerous Facilitation Neuronal adaption Inhibition Endogenous 119 Perception SCRUTINIZE via BODY-SELF NEUROMATRIX: Sensory Cognitive Affective The Brain s Processing Grandma GRANNY Tissues Environment The Brain s processing of LBP Louw A, Butler DS, Diener I, Puentedura E and Peoples, R; 2013 Preoperative Neuroscience Education for Lumbar Radiculopathy: A Single Case fmri Study Common areas are frequently ignited Via connections, backfiring neurons, and neurotransmitters, pain is perceived the pain neural signature 1. Flor, H. The image of pain. in Annual scientific meeting of The Pain Society (Britain) Glasgow, Scotland. 2. Flor, H., The functional organization of the brain in chronic pain, in Progress in Brain Research, Vol 129, J. Sandkühler, B. Bromm, and G.F. Gebhart, Editors. 2000, Elsevier: Amsterdam. 3. Casey, K.L. and M.C. Bushnell, Pain imaging. Pain: Clinical Updates, : p Petrovic, P. and M. Ingvar, Imaging cognitive modulation of pain processing. Pain, (1-2): p Moseley, G.L., Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fmri evaluation of a single patient with chronic low back pain. Aust J Physiother, (1): p without permission 20
21 123 A TYPICAL PAIN NEUROTAG 1. PREMOTOR/ MOTOR CORTEX organize and prepare movements 1 5 But 2. CINGULATE CORTEX 2 concentration, focusing 3. PREFRONTAL CORTEX problem solving, memory 4. AMYGDALA fear, fear conditioning, addiction There s more complexity 5. SENSORY CORTEX sensory discrimination 9 6. HYPOTHALAMUS/ THALAMUS stress responses, autonomic regulation, motivation 7. CEREBELLUM movement and cognition 8. HIPPOCAMPUS memory, spacial recognition, fear conditioning 9. SPINAL CORD gating from the periphery Denotes synaptic modulation Denotes synaptic modulation Beliefs Denotes synaptic modulation Denotes synaptic modulation Beliefs Knowledge, logic Beliefs Knowledge, logic Social context without permission 21
22 Denotes synaptic modulation Denotes synaptic modulation Beliefs Knowledge, logic Social context Anticipated consequences Beliefs Knowledge, logic Social context Anticipated consequences Other sensory cues Beliefs Denotes synaptic modulation Knowledge, logic Social context Anticipated consequences Other sensory cues Physical therapy 132 Melzack s Pain Neuromatrix 133 Modulation Bulging Discs and Pain 40% of the general population has a significant bulging disc, but no pain without permission 22
23 No Correlation Between LBP and DJD More info on imaging % of general population: Hypointense disc signal Annular tears High intensity zones Disc protrusions Endplate changes Zygapophyseal joint degeneration Asymmetry Foraminal stenosis. Kjaer P, Leboeuf-Yde C, Korsholm L, Sorensen JS, Bendix T. Magnetic resonance imaging and low back pain in adults: a diagnostic imaging study of 40-year-old men and women. Spine. May ;30(10): Shoulder After successful rotator cuff repairs and clinically sound examination: 90% abnormal signaling 16% partial tears 20% complete tears 33% sub-acromial effusion 16% joint effusion 20% bone marrow edema (Spielmann, Forster et al. 1999) Shoulder The over-all prevalence of tears of the rotator cuff in all age-groups was 35% (Sher, Uribe et al. 1995) Over age 70: 2 out of 3 have asymptomatic RC tear(milgrom, Schaffler et al. 1995) 40% of normal asymptomatic people have RC tears (Reilly, Macleod et al. 2006) Knee TISSUES HEAL 15% of MRI s show meniscus degeneration (Munk, Lundorf et al. 2004) 50% correlation between knee pain and arthritis (Bedson and Croft 2008) 35% of collegiate basketball players with no knee pain significant abnormalities on MRI (Major and Helms 2002) Louw A, Puentedura EJ. Therapeutic Neuroscience Education. Vol 1. Minneapolis, MN: OPTP; without permission 23
24 Output (Interpretation and Behavior) Pain Sympathetic Motor Immune Adrenaline Cortisol Respiration Language Etc Nerves that fire together wire together -Hebbian Plasticity Theory PERIPHERAL AND CENTRAL SENSITIZATION without permission 24
25 Long Term Potentiation (LTP) Pain Neurosignature Memory Learning Representation 149 Central and Peripheral 150 Sensor y Shift / Time Emotional Central Sensitization 152 Clinical Example: Phantom Limb Pain without permission 25
26 153 Clinical Example: Smudging Definition of Pain: Update Pain is produced by the brain after a person s neural signature has been activated and concluded the body is in danger and action is required (Moseley 2003; Moseley 2007). The Big Picture OUTPUTS Pain Action programs Stress regulation PROCESSING via BODY-SELF NEUROMATRIX: Sensory Cognitive Affective Tissues Environment Gifford, L.S., Pain, the tissues and the nervous system. Physiotherapy, : p So How Do You Do It? 1. The Brain is Key Alter/Challenge Beliefs without permission 26
27 Taking it to patients PART 1 Taking it to patients They want it We underestimate their ability to take on the information Metaphors and examples Pictures We already have the script Let s Start: So Many Paths to Take Neurophysiology of pain how we view pain Nociception and nociceptive pathways Neurons Synapses Action potential Spinal inhibition and facilitation Peripheral sensitization Central sensitization Plasticity of the nervous system without permission 27
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36 Focus on Function 3. Don t tell me you don t know what to do From Steve Schmidt 1. Skillful delivery of medication 2. Therapeutic Neuroscience Education (make the threat smaller) 3. Aerobic exercise 4. General stabilization (versus specific) 5. Posture likely self-correct and no prolonged sessions 6. Relaxation 7. Meditation 8. Diet 9. Sleep hygiene 10. Journaling 11. Coping skills 12. Social interaction 13. Humor 14. Manual therapy 15. Modalities 16. Aquatic therapy 17. Welcoming, safe, healing environment 18. Goal setting 19. Other 4. Consider ALL treatment this way 5. Bottom Up has it s place BOTH 6. Top Down: Change Beliefs 7. Make lions smaller without permission 36
37 8. Aerobic Exercise Incredible high-level evidence Flush the system That s it? Thank you & acknowledgements Kory.zimney@usd.edu Tina, Tyler, Ella, and Lanie Zimney Dr. Adriaan Louw Dr. Louie Puentedura ISPI/EIM staff and faculty University of South Dakota Nova Southeastern University without permission 37
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