How to use movement and graded exposure to reduce pain. Jordan Miller, MSc PT

Transcription

1 How to use movement and graded exposure to reduce pain Jordan Miller, MSc PT McMaster University, Hamilton, Ontario For Webinar Series: Chronic Pain Improving Life While Living It We acknowledge the financial assistance of the Province of British Columbia CIRBD2012

2 Outline: Changes in the nervous system when pain persists Neuroplasticity and the potential for change Influence of movement and activity on pain and ability to perform activity without increases in pain Three strategies to use this information: Frequent movement that doesn t increase your pain Novel movements Graded exposure or graded activity

3 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

4 Input to danger sensors Chemical Temperature Mechanical

5 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

6 The danger message reaches the spinal cord Butler DS, Moseley GL. Explain Pain.

7 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

8 The danger message reaches the brain

9 Changes in brain maps when pain persists Phantom limb pain After a limb is amputated, it can still itch, tingle, hurt Happens even when someone is born without a limb Pain despite no tissue to send a danger signal tells us a lot about the representation of the limb in the brain Nerves representing other areas of the body sprout into the area that would usually represent the missing limb, results in poorly defined areas of the body Referred to as smudging

10 Changes in brain maps when pain persists fmri image of brain during lip pursing movement Lotze M et al. Brain 2001; 124(11):

11 Changes in brain maps when pain persists Smudging doesn t only happen with phantom limb pain Less distinct brain maps have been shown with chronic low back pain, chronic shoulder pain, complex regional pain syndrome,

12 Changes in brain maps when pain persists Changes in the motor map with low back pain Tsao et al. Spine 2011; 36(21):

13 How do movement, activity and exercise influence pain and ability to participate in your usual activities?

14 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

15 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

16 Effect of exercise on the tissues Strength training can increase muscle mass and strength, which can result in making some tasks that require strength easier Aerobic training can increase the ability of your muscles to take up oxygen, which can increase your endurance

17 Is improving strength, mobility, and endurance important in improving pain and functional abilities? In people with low back pain, a treatment approach including exercise is effective at improving pain and function Who got better with treatment? People whose strength improved? People whose mobility improved? People whose endurance improved? Answer: Changes in strength, mobility, and endurance were not associated with improvements in pain or function! So, why did the exercise work? Steiger F et al. Eur Spine J 2012; 21:

18 Is improving strength, mobility, and endurance important in improving pain and functional abilities? So, why did the exercise work? Maybe the exercises were helpful because: They resulted in changes in the central nervous system (brain and spinal cord) that allowed the person to perform more activity before experiencing an increase in pain They increased the person s confidence and sense of control? They improved their expectations for change? They allowed the participant to feel like they were participating in more of their usual life roles? They helped them feel a little bit better about their current health? Many more possibilities Steiger F et al. Eur Spine J 2012; 21:

19 Summary of changes in the tissues Exercise can help your muscles adapt with increases in strength and endurance Changes in strength and endurance aren t necessary to create changes in your functional abilities, they are more likely to change down the road

20 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

21 Changes in the spinal cord with movement or exercise Butler DS, Moseley GL. Explain Pain.

22 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

23 Changes in the brain with movement or exercise Butler DS, Moseley GL. Explain Pain.

24 Changes in brain maps with movement and exercise Movement and exercise can help to re map the area of the brain that represents the painful area Example: in low back pain a series of exercises has been shown to change the map of the low back Tsau H et al. Eur J Pain 2010; 14(8):832 9.

25 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

26 Movement, activity, and thoughts An example: John has a sore back and even thinking about getting up from a chair hurts He practices getting up from a chair for 4 weeks using his armrests just enough to avoid feeling an increase in pain He slowly decreases the amount of help he needs from the armrests over the 4 weeks What do you think happened to his expectations of pain with the movement? What do you think happened to the pain he experienced with the movement?

27 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

28 Movement, activity and emotions Exercise has been shown to have a positive influence on the chemical changes associated with low mood Regular exercise and participation in activities is often associated with improvements in depression

29 Movement, activity and emotions Susan was asked by a friend to go to a show She really wanted to see the show, but told her friend she had another engagement because she knew she would have to park at her friend s house and walk 45 minutes to get there Currently, when she walks more than 20 minutes, she pays the price for a few days How would this make you feel?

30 Movement, activity and emotions Over the first two weeks of treatment, Susan added 2 minutes to her walk each week (10%/week) She was now able to walk 24 minutes instead of 20 How would that make you feel? Continuing to add 10% each week, in 8 weeks, she was able to walk for more than 45 minutes She called her friend and asked if she would like to go to a show How would that make you feel?

31 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

32 Exercise and stress Have you ever exercised and felt less stressed after doing so? Exercise can change the release of cortisol, which is one of the key chemicals associated with stress Prolonged increases in cortisol can increase sensitivity of the nervous system to danger signals, so exercise can help reduce stress and pain through chemical changes in our stress response systems

33 THOUGHTS BRAIN Pain EMOTIONS Overview In summary, STRESSES there are many ways that movement, activities, and TISSUE DANGER! DANGER! exercise can have a positive influence on pain + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

34 But it hurts when I move and exercise! In people without pain, what happens after exercise? Decreased sensitivity to incoming stimuli Example: pressure, cold, movement In some people with persistent pain, what happens after exercise? Increased sensitivity to incoming stimuli Nijs J et al. Pain Physician 2012; 15:ES205-ES213

35 To exercise or not to exercise? Increasing sensitivity to pressure, cold, and movement after exercise in people with pain may suggest exercise is not a good treatment strategy However, evidence suggests exercise and movement is an effective treatment for people with persistent pain So, what do we do?

36 To exercise or not to exercise Because many people with persisting pain do not have an analgesic effect with exercise, it can be hard to stay motivated to continue to participate The long term benefits can be substantial In order to succeed it is important that movement and exercise are carefully tailored to each individual Gradually increase activity while avoiding large flare ups

37 How do we do it?

38 Strategy #1: Frequent movement that doesn t increase your pain Best case scenario is a relieving movement Worst case scenario is a movement that does not increase your pain Try to move the painful area of the body in a direction that does not increase the pain, but if that doesn t work start by moving an adjacent area of the body Example: It hurts to much to move my wrist in all directions, so I am going to start with moving my elbow for a week or two

39 Strategy #1: Frequent movement that doesn t increase your pain Example: A person with low back pain who hurts more when bending forward, might choose to gently arch back This can be challenging, sometimes you have to be creative with the type of movement you are performing

40 Strategy #1: Frequent movement that doesn t increase your pain The hard part. When asking our nervous system to adapt (neuroplasticity), frequency is very important Do a small amount every 1 2 hours through the day

41 Strategy #2 Novel movements When most movements seem to hurt, we often need to be creative with finding ways to move without increasing our pain The goal is to activate the areas of the brain responsible for planning, organizing, and producing movement in the painful area of the body without increasing pain Novel movements (movements we don t do on a regular basis) can be helpful for re mapping the areas of the brain that are smudged Because they are novel, we can often explore more movement

42 Strategy #2 Novel movements 1) Adopt a supported position Often being supported by a bed or a chair can provide a context in which your nervous system feels comfortable exploring movement

43 Strategy #2 Novel movements 2) Alter your orientation relative to gravity Altering where throughout your range your body is moving against gravity can often allow you to explore more movement

44 Strategy #2 Novel movements 3) Move from below In our day to day lives, we often move the top part on the bottom part (ex: turn our body on our hips, turn our head on our neck), moving from below often allows us to move more because it is novel and new Blinkenstaff C.

45 Strategy #2 Novel movements 4) Imagined movements In some conditions, even novel movements reproduce pain If it is hard to perform any movement in the painful area of the body, you can still activate the areas of the brain responsible for moving the painful area by imagining yourself performing movements of the painful area of the body

46 Be creative! The previous slides were just examples remember that the goal is frequent movement that doesn t increase your pain

47 Strategy #3 graded exposure or graded activity Step #1: Decide what activity you would like to do more of Step #2: Find your baseline

48 Changes in thresholds when pain persists Before injury/pain Now Tissue tolerance Flare up Onset of pain What happens if we aim here? Tissue tolerance Flare up Onset of pain

49 Changes in thresholds when pain persists Before injury/pain Now Tissue tolerance Flare up Onset of pain Tissue tolerance Flare up What happens if we aim here? Onset of pain

50 Changes in thresholds when pain persists Before injury/pain Now Tissue tolerance Flare up Onset of pain Tissue tolerance Flare up What happens if we aim here? Onset of pain

51 Changes in thresholds when pain persists Tissue tolerance Before injury/pain Now Future Flare up Onset of pain TT FU TT FU Pain Pain

52 Changes in thresholds when pain persists Tissue tolerance Before injury/pain Now Future Flare up Onset of pain TT FU TT FU Pain Pain

53 Changes in thresholds when pain persists Before injury/pain Now Future Tissue tolerance Flare up Onset of pain TT FU TT FU Pain Pain

54 Changes in thresholds when pain persists Before injury/pain Now Tissue tolerance Flare up Onset of pain Tissue tolerance Flare up Aim here Onset of pain

55 Strategy #3 graded exposure or graded activity Step #1: Decide what activity you would like to do more of Step #2: Find your baseline Step #3: Plan your progression Don t plan to increase by too much and fight through pain Don t plan to let pain be your guide Rule of thumb = maximum 10 20% increase per week Step #4: Try not to flare up, but don t panic if you do The alarm is sensitive and its hard to completely avoid flare ups If you do flare up, don t stress out and give yourself a hard time, remember it s just your nervous system trying to protect you. Its easy to feel like giving up when you experience a flare up, but you have to be patient and persistent

56 An example: Robert would like to be able to go for a walk with his wife, an activity they used to do frequently in the past He is hesitant to suggest this to his wife because his wife walks for 30 minutes and he can only walk 10 minutes before his hip pain increases to the point where it lasts for a long period afterwards

57 An example: Step #1: Decide what activity you would like to do more of As already indicated, Robert would like to be able to walk more Step #2: Find your baseline I asked Robert what how much he could walk before he noticed it an hour later He said he was 90% confident that he could walk 10 minutes and would feel the same as when he started an hour later Note: be honest with yourself, you need to be at least 80% confident that you can achieve your baseline level of the activity you choose.

58 An example: Step #3: Plan your progression Robert knows getting to 30 minutes from 10 minutes won t happen overnight He is uncertain of how fast he should increase, so he works with the 10% rule of thumb

59 An example: Week of: Duration of walk Nov 3, Nov 10, Nov 17, Nov 24, Dec 1, Dec 8, Dec 15, Dec 22, Dec 29, Jan 5, Jan 12, Jan 19, Jan 26,

60 An example: Step #4: Try not to flare up, but don t panic if you do Not everyone will be able to increase by 10%, some may experience a flare up with 10% increases and may need to increase slower (ex: 5%) Others may feel they are not challenged by 10% increases and would like to increase by more (ex: 20%)

61 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! DANGER! + SPINAL CORD PROTECTION Pain Muscle spasm Weakness Run away Lay down/freeze Release hormones

62 Summary of Strategies 1) Frequent movement that does not increase your pain 2) Novel movements 3) Graded activity or graded exposure

63 A couple of additional references:

64 Thank you for attending. QUESTIONS? Contact us: Jordan Miller CIRDP We acknowledge the financial assistance of the Province of British Columbia PAIN BC CANADIAN PAIN COALITION