By Kyle Wolfe Learning Objectives Participants will be able to describe the anatomy and mechanisms that contribute to the pain systems in the body Participants will be able to describe changes that can be found in chronic pain patients based on current research ID: 928537
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Slide1
Chronic Pain Adaptations and Interventions
By Kyle Wolfe
Slide2Learning Objectives
Participants will be able to describe the anatomy and mechanisms that contribute to the pain systems in the body.
Participants will be able to describe changes that can be found in chronic pain patients based on current research.
Participants will be able to identify potential novel interventions to treat patients in chronic pain based on new research on pain systems.
Participants will be able to apply combinations of intervention to create a treatment plan for a patient with chronic pain.
Slide3Chronic Pain 1
Pain that is:
“persisting more than a specified amount of time, typically 3-6 months”
“Long-lasting, persistent, and of sufficient duration and intensity to adversely affect a patient’s well-being, function, and quality of life”
“persists past the healing phase following an injury with impairment greater than anticipated based on the injury or occurs in the absence of injury or tissue damage”
Also called “Persistent Pain”
Slide4Pain Anatomy Review 1
Receptors:
Processed peripherally by nociceptors found in the skin and subcutaneous tissue
Free nerve endings are the main type of receptor
Found superficially in skin and subcutaneous tissue, deep in joint receptors, and within muscle and tendon fascia
GTO and other receptors can also transmit some pain info, especially paresthesia
Processed along different nerves for different stimuli
A-delta, C, etc.
Slide5Slide6Pain Processing
1
Combination of input from nociceptors, mechanoreceptors, chemoreceptors, and other smaller contributors
Processed via the anterolateral spinothalamic pathway from peripheral -> central
Processed initially in the brain in the somatosensory (s1 and s2) areas prior to cortical areas
Slide7Pain Processing – Gate Theory
1
pain fibers synapse with inter/secondary neurons to transmit signals
Interneurons also get input from other nerves, mostly a-alpha and a-beta
Stimulation of a-
a
and a-
b
neurons can “close the gate” which inhibits the pain signal at the interneuron
Slide8Pain Processing – Descending Inhibition
1
Appear to work via opioid system and using Ach, serotonin, noradrenaline, and glycine to modulate pain
Many brain areas involved (hypothalamus, amygdala, rostral anterior cingulate cortex, periaqueductal gray, rostral ventromedial medulla) as well as dorsal horn of spine
Slide9Descending Inhibition 1
When is a situation in which you might suffer an injury but not feel the pain from it until later?
Slide10Pain Processing – Changes in Chronic Pain
2,3,8
In chronic widespread pain (fibromyalgia) – reduced serotonin, NE, dopamine found in descending pathways
Prolonged sensation of pain following repetitive stimuli
Increased temporal summation
More widespread brain activity occurs in central pain areas in those with chronic pain compared to controls
Chronic pain patients have reduced exercise-induced hypoalgesia, and even increases in pain with exercises
Slide11Pain Processing – Changes in Chronic Pain
2,3
Nociceptive Flexion Reflex:
Controls: reflex decreases when the contralateral limb is submerged in ice water
In chronic pain patients:
Less stimulation needed to excite NFR
NFR does not decrease in one limb when other is submerged
Less descending modulation of the reflexes
Slide12Peripheral Sensitization
1, 9
Nociceptive input or sensation is increased based on:
Decreased threshold
Increased responsiveness
And/or increased receptive field
Inflammation in neural or peripheral tissues contributes
Substance P, cytokines, etc.
Lowered pain pressure threshold at site of injury compared to contralateral side
Slide13Central sensitization
1,9
Wind-up
: repeated, low-frequency stimulation results in an increase action potential in dorsal horn
Hyperalgesia occurs based on amplified synapses in dorsal horn
Hypothalamic-Pituitary-Adrenal
Axis:
activated during physical or emotional stress, starts a cascade that results in sympathetic activation of pain systems
Changes in glia,
astrocytes, synapses, inflammation, immune
responses
, etc.
Can occur in visceral conditions as well, such as IBSCan create new synapses
from
efferent neurons on peripheral nociceptors
Can lead to
widespread
pain, fatigue,
sleep
disturbances
, cognitive
difficulties
,
altered
CNS
processing
, and
even
changes
with
secondary
hyperalgesia
or
referred
pain
Slide14Mechanism Model 9
Biological Mechanisms:
Nociceptive (Peripheral)
Typically localized to area of injury during normal tissue healing time frame
Nociplastic
(Central)
Modulated signals in CNS by cortex and pathways
Neuropathic
Usually has some sort of positive neural signs
Slide15Mechanism Model
9, 10, 11
4. Psychosocial
Negative emotional factors
Pain catastrophizing and Kinesiophobia are predictive of pain and disability following induction of injury
5. Movement Systems
Ex: antalgic gait, overuse syndromes, withdrawal reflex
Pain causes changes in muscle tone, fear-avoidance, disuse and changes surrounding muscle groups
Shoulder pain reduces muscle output and strength in deltoids, and this is reduced when pain is reduced
Slide16Brain Plasticity
1,4
Can occur at any age on a large scale, but young brains continuously change while older brains change based on behavioral functions and context
Changes are based on modulatory neurotransmitters (Ach/DA/NA)
“What Fires Together, Wires Together”
Weakens or eliminates synapses that do not contribute to these behaviors
Plastic changes are typically reversible
Intensive training can reorganize brain pathways:
Violin players and braille readers have changing cortical areas and pathways based on the amount of experience they have in playing
Slide17Adaptions to Pain – Smudging
5
Chronic back pain patients have lower proprioceptive acuity, cortical changes related to sensation of their back, and less movement capabilities of pelvis and trunk
Moseley Study:
5/6 back pain patients stated they couldn’t find their back and had trouble drawing it
6/6 back pain patients did not draw all the vertebrae, leaving out ones in the specific areas of pain
Vertebrae were shifted towards the side with pain in all patients
Increase in TPD was proportional with disrupted body image levels
Slide18Adaptation to pain – Tactile Acuity
4,6
Patients with chronic pain have a larger two-point discrimination touch distance at the site of pain that compared to unaffected limbs or controls
Positive correlation between pain intensity and TPDT
Treatments for tactile acuity have been shown to have benefits in patients with chronic pain
Slide19Potential Cortical Changes
1,4,5,7
Sensitization leads to larger pain focused areas in S1, gray matter atrophy, and brain morphology changes
In CRPS patients: perceived affected limb to be larger, but it had a smaller cortical area
Back pain patients: affected LB area seems smaller to patients, but is larger in cortical area
Recent CRPS study did not find cortical changes based on pain severity or location
Restoring cortical representation compared to unaffected sides reduced pain levels
Slide20Interventions
Slide21Pain Neuroscience Education
3,6,12,13
Educational intervention with goal of teaching pain physiology and the nervous system processing of pain to increase understand and reduce patient experiences
Aim: pain = body feels a threat more than safety; pain =/= injury!
Use of images, stories, details and explanation of sensitization, synaptic changes, and regulation of the nervous system to show complexities of how the pain experience changes
Provides reassurance to patients about their diagnosis, prognosis, and pain experiences
Slide22Pain Neuroscience Education
3,6,12,13
Slide23Patient Example
Steve is 55 years old. Steve comes to you with a history of low back pain on and off for about 4 years, but worsened in the last 9 months
Steve tells you he got an MRI and his back has “a really bad slipped disc” and “it’s out of place”
The MRI report from 4 months ago shows a moderate bulge of the disc at L4/L5
What can you tell
steve
before you do any other treatments that could help?
Slide24Pain Neuroscience Education
3,6,12-13, 20-21
Ex: “No correlation between MRI stenosis findings and severity of pain”
Ex: 64% of asymptomatic people had at least some level of bulge in lumbar spine, with 27% having a full protrusion
Can also utilize:
Metaphors/stories
Booklets
Drawings
Workbooks or assignments
Slide25Pain Neuroscience Education
3,6,12,13
Some studies have shown:
Use pre-operatively improved post-operative outcomes for lumbar discectomy
Improvements in pain and QOL with PNE > traditional pain education for LBP
Decreased fear of injury, catastrophizing and function; increased ROM, movement capabilities, and positive feelings towards control of pain at up to 1 year follow-up
Immediate improvements following PNE in attitudes towards pain and patient diagnosis, pain threshold during activity, therapeutic exercise outcomes, and more
Is not as effective as a stand-alone treatment for all outcomes
Slide26Pain Neuroscience Education
3,6,12,13
Slide27Graded Motor Imagery 14,15
Intervention with goal of engaging cortical motor networks without producing pain response to rewire circuits
Typically prescribed in 3-stages with each being 2-weeks long:
Left-Right Judgements
Motor/Mental Imagery
Mirror Therapy
Slide28Graded Motor Imagery 14,15
Ordered GMI reduces pain in chronic pain patients compared to unordered GMI
Ordered GMI reduced pain and improved function in patients with CRPS
Mirror therapy has the most support as a stand-alone intervention for pain
Slide29Tactile Discrimination Training
4
Used to try to reverse cortical changes and restore sensory-motor interactions without painful response
Self-Paced Training daily using:
Bi-Manual Training
Speed Training
Memory Game
Significant improvements in pain level, disability levels, and two-point discrimination training
Greater improvements when combined with mirror training
Slide30Exercise Based Interventions
1,11,16-19
General Concepts:
Graded exposure reinforces hurt
=/=
harm and decreases fear-avoidance behaviors
Helps habituation to dulled pain response with movement
Exercise has shown improvements for all 5 pain mechanisms
Regular exercise reduces central excitability and increases both pain thresholds and pain inhibition
Combined with pain education shows greater benefits than no education or anatomy education
Benefits seen with aerobic, strength, Tai Chi, Yoga, and Aquatic for pain
Slide31Exercise Based Interventions
1,11,16-19
Need some strengthening component
In Fibromyalgia patients: Strengthening, strengthening + Aerobic improved pain, just aerobic exercise did not
Chronic neck/shoulder pain: strength training significantly improved both pain and motor function compared to aerobic exercise or education
Neck Pain: adhering to strength program for 1 year gives significant benefits in pain and function that are still seen after 3 years, even if program is stopped
Isometric Contractions
In patellar pain patients, 5 reps x 45 seconds had greater immediate pain relief compared to isotonic 4 x 8 at same intensity
Slide32Resources to utilize
Explain Pain
by David Butler and Lorimer Moseley
Reconciling Biomechanics with Pain Science – Greg Lehman
Pain Neuroscience Education: Teaching People About Pain
&
Why Do I Hurt?
–
Adriaan
Louw
Tame the Beast
Slide33Questions
?
Slide34References
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I, Arik MI,
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Gokpinar
HH. The short-term effects of neuroscience pain education on quality of life in patients with chronic low back pain: A single-blinded randomized controlled trial. European Journal of Integrative Medicine. 2020;33:101046. doi:10.1016/j.eujim.2019.101046
Traeger AC, O’Hagan ET, Cashin A, McAuley JH. Reassurance for patients with non-specific conditions - a user’s guide.
Braz
J Phys
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Bowering KJ, O’Connell NE, Tabor A, et al. The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. J Pain. 2013;14(1):3-13. doi:10.1016/j.jpain.2012.09.007
Smart KM, Wand BM, O’Connell NE. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database Syst Rev. 2016;2:CD010853. doi:10.1002/14651858.CD010853.pub2
Rio E, van Ark M, Docking S, et al. Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain: An In-Season Randomized Clinical Trial. Clin J Sport Med. 2017;27(3):253-259. doi:10.1097/JSM.0000000000000364
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Wang C, Schmid CH,
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