Promotion of early mobility in the patient with chronic pain Daniel W Mackie, PT, DPT, OCS Scott W Lowe, PT, DPT, OCS Outline Introduction Evidence Background Screening and self-report tools Examination Manual techniques Therapeutic exercise Patient education Conclusion and references Operational Definitions -Early- in the disease process or plan of care? -Mobility: the ability to move or be moved freely and easily. -Chronic Pain: A chronic disease is one lasting 3 months or more, by the definition of the US National Center for Health Statistics -Manual Therapy: joint mobilization/manipulation, soft-tissue mobilization -Central Sensitization 1
Evidence review -Physical therapy as an effective strategy for management of chronic pain -Financial impact of physical therapy vs. medications, imaging, or procedures -Which intervention is best? Exercise, manual therapy, education? Evidence-Based Practice Perhaps even more so than typical, those in the chronic pain population require use of all 3 As a therapist gains exposure to those in this population, they will learn from experience about conversations and methods which he or she may have success using. http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021 Initial screening tools Demographic data and risk factors for Chronic pain, including central sensitization and disability include the following; -Female Gender -Fibromyalgia -Irritable Bowel Syndrome -Depression/Anxiety Self-report tools Tampa scale of kinesiophobia Catastrophizing score FAB-Q Cervical and lumbar disability questionnaires Depression screening (Beck, 3 question) -High BMI -Duration of symptoms 2
Kinesiophobia Central Sensitization The responsiveness of central neurons to input from unimodal and polymodal receptors is augmented, resulting in a pathophysiological state corresponding to central sensitization, characterized by generalized or widespread hypersensitivity An amplification of neural signaling within the CNS that elicits pain hypersensitivity Often accompanies chronic pain conditions Pain vs. nociception Initial musculoskeletal nociceptive issue Sensitization- Peripheral vs. central Methods for detection/clinical screening Examination 3
Examination Cervical Spine Mobility Assessment 4
Concepts of manual intervention Positive effects Adverse effects Therapeutic touch Potential mechanisms behind benefit- Biomechanical vs. neurophysiological Placebo, expectation, and psychosocial factors Does specific technique matter? Neurodynamics Can be very complex, much more in-depth training available through several different sources General concept involves use of combined or isolated peripheral and central movements to affect remote changes via neuromodulation theory. Use as continued assessment of both objective and subjective elements Therapeutic Exercise Concepts -Graded Exposure -gradual increases in use of movements or positions that are perceived as threatening -Good research for use in chronic low back pain scenarios - Early Mobility -Depending on irritability, may be direct or indirect movement of primary region of complaints -Consider progression variables such as hold times, duration of activity, WB or gravity reduced positions. Videos of therapeutic exercise elements 5
Videos of therapeutic exercise elements continued Videos of therapeutic exercise elements continued 6
Peripheral Considerations Although more widely researched and considered in relation to the spine, chronic pain is also possible in the periphery. Peripheral sensitization involves lasting up-regulation of nociceptive signalers Consider possibility of Complex Regional Pain Syndrome in cases where hyperalgesia is noted Techniques may include desensitization, neurodynamics, soft tissue techniques and graded therapeutic exercise Patient education Pain Neuroscience Education/ Therapeutic Neuroscience Education Utilizing appropriate and reassuring language is important- what does the patient hear when you say degenerative? Framing the subjective examination- What level is your pain today? How are you doing? Utilize helpful metaphors- Hurt doesn't equal harm. Pain is the body s alarm system. Various online resources are available to patients including retrainpain.org. Useful resources must, however, be implemented alongside in-clinic strategies by provider Majority of accessible patient-directed online information is, however, geared towards negative pathoanatomical mindsets. Per APTA Statement on billing for patient education, The time associated with providing skilled services in the form of patient education is reported based on the outcomes the physical therapist is trying to achieve with the patient education. Implementation Keys -Clinic environment- consider a private treatment room or a location in the gym that is more isolated. -Use of techniques for treatment of multiple patients per hour vs 1-on-1 - Be mindful of your communication style, including body language and demeanor - Above all, utilize clinical reasoning when implementing any treatment plan. - Education, education, education -Coding and ethics -Parameters? 7
Conclusion -Resist the urge to panic or have a negative response during initial meeting/intake. -Remember that you are helping an underserved population with significant needs. -Practice and become comfortable with phrases and activity cues -Ensure all other staff are familiar with goals and concepts -Consider what is a successful outcome and how you measure that - Physical therapy is only one part of the management program for chronic pain -Ask Questions and Research! References Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016;32(5):332-55. Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20(5):324-30. Louw A, Zimney K, O'hotto C, Hilton S. The clinical application of teaching people about pain. Physiother Theory Pract. 2016;32(5):385-95. Nijs J, Paul van wilgen C, Van oosterwijck J, Van ittersum M, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines. Man Ther. 2011;16(5):413-8. Naugle KM, Fillingim RB, Riley JL. A meta-analytic review of the hypoalgesic effects of exercise. J Pain. 2012;13(12):1139-50. Blickenstaff C, Pearson N. Reconciling movement and exercise with pain neuroscience education: A case for consistent education. Physiother Theory Pract. 2016;32(5):396-407. Oliveira A, Gevirtz R, Hubbard D. A psycho-educational video used in the emergency department provides effective treatment for whiplash injuries. Spine. 2006;31(15):1652-7. References continued Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain. 2001;94(1):7-15. Clark LV, Pesola F, Thomas JM, Vergara-williamson M, Beynon M, White PD. Guided graded exercise self-help plus specialist medical care versus specialist medical care alone for chronic fatigue syndrome (GETSET): a pragmatic randomised controlled trial. Lancet. 2017; Roelofs J, Van breukelen G, Sluiter J, et al. Norming of the Tampa Scale for Kinesiophobia across pain diagnoses and various countries. Pain. 2011;152(5):1090-5. Nijs J, Lluch girbés E, Lundberg M, Malfliet A, Sterling M. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Man Ther. 2015;20(1):216-20. Larun L, Brurberg KG, Odgaard-jensen J, Price JR. Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev. 2015;(2):CD003200. 8
References Continued Taken from http://www.apta.org/payment/coding/faqs/patienteducation/ 1/8/2018 9