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Physical Therapy, Pain, The Brain

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Title: Physical Therapy, Pain, The Brain


1
Physical Therapy, Pain, The Brain
  • GOBHI May 17, 2012
  • Dr. Tom Watson PT MEd DAAPM
  • Bend, Oregon

2
Conflict of InterestFinancial Disclosure
  • Dr. Tom Watson DPT PT MEd
  • Diplomate American Academy
  • of Pain Management
  • Rebound Physical Therapy
  • 541-382-7875 Bend, Oregon
  • painfree_at_ix.netcom.com
  • No conflicts of interest

3
American Academy of Pain Management
  • The mission of the American Academy of Pain
    Management is to advance the field of pain
    management using an integrative model of
    patient-centered care by providing evidence-based
    education for pain practitioners, as well as
    credentialing and advocacy for its members.
  • http//www.aapainmanage.org/
  • (209) 533-9744

4
AAPM Annual Conference
  • The 2012 Annual Clinical Meeting will be held in
    Phoenix, Arizona, September 20-23, 2012
  • Founded in 1988, the Academy is the largest pain
    management organization in the nation and the
    only one that embraces an integrative model of
    care, which is patient-centered, focuses on the
    whole person, is informed by evidence, and
    brings together, all appropriate therapeutic
    approaches to reduce pain and achieve optimal
    health and healing. The Academy offers continuing
    education, publications, and advocacy.

5
Pain Anatomy
6
PAIN
  • Pain, according to the IASP (International
    Association for the Study of Pain), is "an
    unpleasant sensory or emotional experience
    associated with actual or potential tissue damage
    and described in terms of such damage."

7
PAIN (www.rosPAIN (www.ro
PAIN (www.rosstoons.com)PAIN
(www.rosstoons.com)m)stoons.com)
8
PAIN
  • "Pain is a part of being alive, and we need to
    learn that. Pain does not last forever, nor is it
    necessarily unbeatable, and we need to be taught
    that." Harold Kushner

9
Freud on Pain
  • The pleasure-pain principle was originated by
    Sigmund Freud in modern psychoanalysis, although
    Aristotle noted the significance in his
    'Rhetoric', more than 300 years BC.
  • 'We may lay it down that Pleasure is a movement,
    a movement by which the soul as a whole is
    consciously brought into its normal state of
    being and that Pain is the opposite.
  • http//changingminds.org/disciplines/psychoanalysi
    s/concepts/pleasure_pain.htm

10
Hippocrates on Pain
  • Men ought to know that from the brain, and from
    the brain only, arise our pleasures, joys,
    laughter and jests, as well as our sorrows,
    pains, griefs and tears.
  • The Sacred Disease, in Hippocrates, trans. W. H.
    S. Jones (1923), Vol. 2, 175

11
Incidence of Pain
  • National Center for Health Statistics National
    Household Survey (Aug 2009)
  • Pain 100 million Americans (not
    including Vets and children IOM 2011)
  • Diabetes 20.8 million
  • CAD 18.7 million
  • Cancer 1.4 million

12
Cost of Pain
13
PAIN
  • Pain is the primary reason for visits to a
    clinician
  • Pain always evokes a sensory or emotional
    response
  • When pain occurs, suffering and pain behaviors
    follow
  • A very complex perception- Albert Schweitzer-
    may be worse then death

14
Classification
  • Pain is classified in three categories
  • 1. Acute- lasting 4-6 weeks
  • 2. (Subacute-lasting 6-weeks to 6 months)
  • 3. Chronic pain- starting at six months or
    symptoms lasting longer than the anticipated time
    for recovery.

15
Chronic Pain Syndrome
  • Mood
  • Memory- short and long term
  • Concentration
  • Sleep
  • Sex drive

16
Types of Pain
17
Neuropathic Pain
  • spontaneous burning pain with an intermittent
    sharp stabbing or lancinating character, an
    increased pain response to noxious stimuli
    (hyperalgesia), pain elicited by non-noxious
    stimuli (allodynia)
  • structural and/or functional nervous system
    adaptations secondary to injury
  • centrally or peripherally large and small fiber
  • Diabetic neuropathy

18
RSD, CRPS, SMP
19
CRPS Treatment- ECT
  • ECT (electro convulsive therapy)
  • 1940s-chronic pain
  • 1957-CRPS I, Retrograde amnesia
  • RUL (Right Unilateral) ECT without persistent
    cognitive side effects
  • 6-12 sessions
  • Increase in thalamic blood flow, PET Scan changes
    in thalamus-parietal-frontal lobes - relief of
    CRPS symptoms

20
CRPS Treatment
  • VIT D3, Red Krill Fish Oil
  • Microcurrent Stimulation, Cold Laser,
  • Neuro mobilization
  • Mirror Therapy
  • NMDR
  • Hypnosis
  • Acupuncture
  • Meds Opioids, Psychotropic, Neuroleptics,
    steroids, non-steroidals

21
Pain Combinations
22
Central Pain
  • Central pain -IASP "pain initiated or caused by
    a primary lesion or dysfunction in the central
    nervous system" (Merskey, Bogduk, 1994).
  • Caused by wind-up phenomena
  • Thalamic or other area in Brain
  • "Neuropathic" vs. "neurogenic", a term used to
    describe pain resulting from injury to a
    peripheral nerve but without necessarily implying
    any "neuropathy

23
Psychogenic Pain
  • "Psychogenic" pain arises due to maladaptive
    thought processes
  • Somatization-bowel disorder, palpitations,
    fatigue, respiratory, all disproportionate
  • Hypochondriasis- fear of condition
  • Factitious Disorder-Munchausen syndrome

24
Pain of Youth
25
Nociception
  • Pain is transmitted to the brain through
    neurological process of nociception
  • Nociception is pain in which normal nerves
    transmit information to the central nervous
    system about trauma to tissues (nocere to
    injure, Latin).

26
Nociception
  • Nociception normal nerves transmit information to
    the central nervous system about trauma to
    tissues (nocere to injure).
  • A-beta fibers thickly myelinated mostly sensory,
    10 transmit pain
  • A-delta fibers thinly myelinated, transmit
    sharp/lancinating pain
  • C-fibers non-myelinated fibers, dull or chronic
    pain

27
Nociception
  • Special nerve endings or type IV
    mechanoreceptors, i.e. free nerve endings, absorb
    chemicals, transfer information to the spinal
    cord.
  • Noxious stimuli via peripheral A delta and C
    fibers release of excitatory amino acid
    neurotransmitters (glutamate), neuro-peptides,
    substance P

28
Nociceptive Agents
  • Nociception occurs with damage to tissue and
    chemical or endogenous agents are released
  • bradykinins, serotonin, cytokines, protons,
    sensory neuropeptides, and arachidonic acids
    leukotrienes prostaglandins, substance P, K,
    ATP

29
Site of Trauma
30
Nociception
  • Type IV Mechanoreceptors
  • Location joint capsule, blood vessels, articular
    fat pads, anterior dura mater, Ant. Long. Lig.,
    PLL, connective tissue
  • NOT in muscle, Ligamentum flavum, nerve,
    articular cartilage
  • Non-adapting- keep firing until noxious stim
    (mechanical, chemical, thermal) removed.
  • Pain causes tonic reflexogenic-guarding tonic
    muscles proximal to joint-ischemia, no guarding
    with phasic muscles

31
Dorsal root ganglia
  • DRG The free nerve ending in the tip of your
    finger that feels the paper cut, cell body in
    dorsal root ganglion.

32
Response
  • Motor protective
  • Perceptual- cross over, pain response can
    increase or decrease
  • Sympathetic- vasoconstriction, sweat, cool/moist
    increase output
  • Remove stimulus- type IV non-adapting, deformity
    3, thermal below 44.8 C
  • Emotional, memory, response

33
Cancer Pain
  • 70 of all cancer patients have pain, 50 have
    severe to intractable pain
  • Somatic Cancer Pain neoplastic invasion of bone,
    joint, muscle, or connective tissue.
  • Bone Pain direct tumour invasion of bone. Not all
    bone metastases are painful
  • Visceral Cancer Pain. Solid organs - lung, liver,
    and kidney parenchyma are insensitive,. Harmful
    stimuli ie. burning or cutting of visceral tissue
    do not cause pain, whereas natural stimuli such
    as hollow organ distension readily produce pain
  • Neuropathic Cancer Pain- herpes zoster(Shingles)

34
CIPA
  • Congenital Insensitivity to Pain with Anhidrosis,
    Hereditary Sensory and Autonomic Neuropathies
    (HSAN) (4)
  • impaired autonomic, sensory, motor functions
  • Insensitivity to superficial and deep pain,
    neuropathic joints, risk of unrecognized injury
    (burns, fractures), corneal ulceration
  • No cure exists, death

35
Spinal Cord Transmitters
  • many neurotransmitters in dorsal horns
  • substance P has a prime role, may promote later
    release of EAA
  • NMDA (glutamate), aspartate, CGRP-facilitates
    pain
  • GABA-pain inhibition

36
Central Assent
  • Pain information ascends via spinal thalamic
    tract or Lissaurs track, terminates in thalamus,
    somatosensory cortex, limbic system, midbrain,
    hypothalamus, or thalamic nuclei.
  • Facilitation-pathology, environment, emotional
    stress
  • Facilitation-sensory, motor, sympathetic

37
Distribution of neurotransmitters

38
Descending control
  • major descending modulation pathway originates
    periaquaductal gray area, the locus ceruleus, the
    nucleus raphe magnus and the dorsal horn of the
    spinal cord terminating in laminae I, II, and IV.
  • Descending noradrenergic antinociceptive systems
    originating in the brainstem contribute to pain
    control, in the substantia gelatinosa of the
    dorsal horn

39
Descending Control
  • Inhibitory- 36 different brain opiods (Korr)
  • Endorphins- 15-20 minutes of continuous activity
    to be produced, half life 6-8 hours
  • Takes another 15-20 minutes to reach target site
    Axoplasmatic flow of nerves, blood, CSF via
    lymphatics

40
Descending control
  • Pharmacological
  • Cannabis decreases pain-cortical reticular
  • Alcohol can increase or decrease pain cortical or
    rostral reticular
  • Caffeine-increases- rostral reticular
  • Barbiturates (Soma) increase cortical reticular -
    increase pain

41
Descending Control
  • Periaquecductal of Gray Releases Opiods
    receptors enkephlins, endorphins
  • Opiods inhibit the neurons that suppress the
    activity of Bulbospinal tract
  • morphine and electrical stimulation produce
    potent anti-nociception
  • High Intensity afferent input Manipulation,
    high frequency e-stim, sex, baroque music, pain
    (Grimsby)

42
Women and Pain
  • Extra Nerve Fibers May Heighten Female Pain
    Perception By Jeff Minerd , MedPage Today Staff
    Writer, Reviewed by Zalman S. Agus, MD Emeritus
    Professor at the University of Pennsylvania
    School of Medicine.
  • average fiber density in female samples was 34
    19 fibers/cm2.
  • - average density in male samples was 17 8
    fibers/cm2 (P0.038.)
  • favors physical (organic) not psychosocial
    explanation for more pronounced pain perception
    in female patients

43
Men and Pain
  • Pain

44
The 4 As of Pain Treatment Outcomes
  • A successful outcome in pain therapy involves
    more than the lowering of pain intensity scores
  • Analgesia
  • Pain relief
  • Activities of daily living
  • Psychosocial functioning
  • Adverse effects
  • Side effects
  • Aberrant drug-taking
  • Addiction-related outcomes
  • Passik et al. J Support Oncol. 20053(1)83-86

.
45
Pain Tolerance
  • Wheres Mommy??

46
Psychology and Pain
  • Hypnosis- opiate/endorphin release
  • CBT
  • Meditation, prayer
  • Group therapy
  • midbrain and cortical structures
  • Personality, gender, age, culture,
    fear/avoidance, pre-existing conditions
  • Interdisciplinary approach-best

47
Psychology and Pain
  • MPD/Dis-associative Identity Disorders(DID)
  • BPD, Bi-Polar
  • and
  • Chronic Pain
  • Symptomatic changes in 1 area may manifest or
    decrease other diagnosis

48
Ancient Times and Today
  • Greeks, Egyptians, Chinese, Romans Heat, sun,
    geodes, eels, massage, manipulation
  • Modalities-Thermal, Sound ,Traction, Magnets
  • Lasers, electrical stimulation
  • Manual therapies
  • Therapeutic exercise

49
Modalities
50
Effectiveness of Evidence-Based Modalities
  • Philadelphia Panel Evidence-Based Clinical
    Practice Guidelines (EBCPG) in Selected
    Rehabilitation Intervention for Low Back Pain
  • Cochrane Collaboration, and literature review
    using meta-analysis and observational studies

51
Modalities
  • Feel Good
  • Heat Radiant-sun-fire-hot coals-sound
  • Conductive Hot water, heated agents
  • Cold Ice, chemical freezing agents
  • High Intensity Afferents-e-stim, TENS, IFC
  • Pain management in 5 minutes
  • EVIDENCED BASED
  • CES-Microstimulation, Laser

52
Microcurrent Stimulation
  • Mercola Kirsch, "microcurrent electrical
    therapy" (MET)
  • Based on the Arendt-Schultz physics principal of
    low intensity stimulation causing profound
    biophysical response, Works on the cellular
    level, using microamp current
  • Effective reducing chronic headaches,improving
    serotonin levels, depression, insomnia, chronic
    pain, fibromyalgia, PTSD
  • 120 human studies and 19 animal by Daniel Kirsch,
    PhD, Mineral Wells, Texas

53
Microcurrent Stimulation-CES
  • serotonergic (5-HT) raphe nuclei at brainstem.
  • 5-HT inhibits brainstem cholinergic (ACh) and
    noradrenergic (NE) systems that project
    supratentorially. Release dopamine
  • Suppression thalamo-cortical activity, arousal,
    agitation, alters sensory processing and induces
    EEG alpha rhythm.
  • 5-HT acts directly to modulate pain sensation in
    dorsal horn of the spinal cord, alter pain
    perception, cognition and emotionality within the
    limbic forebrain.

54
Laser
  • Einstein-1916

55
Laser
  • Light Amplification by Stimulated Emission of
    Radiation 1950s
  • Photo-biostimulation principal
  • Helium neon laser, with 632.8 nm
  • superficial wound healing, acute and chronic
    pain, with or without inflammation
  • Gallium Arsenide or infrared laser 830nm
  • deep pain, deep wound healing, scar tissue,
    calcium deposits, neuropathies

56
Laser
  • Jedi squirrels of Oregon with light sabers

57
Laser
  • 475 RCDBCS
  • Decrease pain, decrease inflammation, increase
    healing, Krebs cycle ATP increased by 150
    1000
  • Activates mitochondria
  • Decreases bradykinins-histamine
    anti-inflammatory analgesic
  • Regenerative increases mitosis
  • No thermal effects below 500 mW
  • 6 12 treatments
  • www.laser.nu, www.microlightcorp.com

58
Laser Indications
  • Acute and chronic pain, TMJD
  • Neuropathies, FMS, Post polio syndrome
  • Headaches, Arthritis
  • Acupuncture points
  • Open wounds
  • Athletic Injuries Sprains, Strains, Hematomas

59
Manual Therapy
60
Manual Therapy
  • Dorland manipulation skillful or dexterous
    treatment by the hand and in physical therapy,
    forceful pressure/movement of a joint within or
    beyond its active limit of motion.
  • Massage, mobilization, manipulation- highly
    effective in reducing pain and muscle guarding,
    increasing range of motion. Hypermobility or
    hypomobility
  • Manipulation/mobilization date back to
    Hippocrates in 460 BC
  • Basmajian documented Laying on of hands in the
    Old Testament of the Bible

61
Manual Therapy
  • Andrew Taylor Still introduced osteopathic
    manipulation in late 1800s, diseases were due to
    abnormal bony situations
  • Bonesetters were prominent in Mexico and famous
    for stamping or trampling techniques that are
    still practiced today.
  • Sarah Mapps, aka Crazy Sally or Cross Eyed Sally,
    was in high demand in London during the early
    1700s for her bone setting ability.

62
Manual Therapy
  • Cyriax disagreed with osteopathic techniques,
    advocated manipulation by PTs
  • Hippocrates straightened kyphosis, Galen
    replaced outward dislocated vertebrae, and Pare
    wrote about subluxation of the spine. bone
    setters replaced out of place bones, osteopaths
    treated the osteopathic lesion, orthopedic
    surgeons manipulated the SI joint, chiropractors
    replaced subluxed vertebrae, and neurologist have
    stretched the sciatic nerve.

63
Manual Therapy
  • Soft Tissue Therapies
  • manual contact, pressure, or movements primarily
    to myofascial(soft) tissues
  • myofascial release, muscle energy, traditional
    massage, Rolfing, movement therapies such as
    Feldenkrais, Traegering, PNF, classical massage
  • manual manipulation of soft tissue administered
    for producing effects on nervous, muscular,
    lymph, and circulatory systems

64
Manual Therapy
  • The Ultimate Goal of joint mobilization or
    manipulation techniques is to lower the threshold
    of activity at a joint or muscle via dorsal horn
    inhibition
  • EMG studies
  • manipulation/mobilization increased active range
    of motion and decreased muscle tone
  • massage/stretching demonstrated increased range
    of motion but increased EMG activity

65
Immobilization
  • The musculoskeletal system does not respond well
    to immobilization.
  • The end result is the deterioration and weakness
    of the bodys tissue.
  • Recovery is a slow process and care must be taken
    during activity and exercise to avoid further
    tissue damage.
  • For every 1 day in a brace or cast 2 days of
    mobilization and exercise

66
Therapeutic Exercise
  • BUFF?

67
Therapeutic Exercise
  • Reducing pain and increasing stability
  • Programs begin with exercises aimed at increasing
    circulation into a muscle, improving endurance,
    facilitating coordination - motion occurs around
    a normal physiological axis, increasing strength
    and power.
  • Release endorphins, improve self esteem, decrease
    depression

68
Therapeutic Exercise
  • Steps
  • Phase 1 coordination, mobility, and stability
    around a physiological axis throughout the range
    of motion
  • Phase 2 increasing tissue tolerance to levels
    corresponding to the demands of activities of
    daily living and restoring function
  • 5000 to 6000 repetitions to regain the former
    coordination of the tonic or phasic muscles in a
    joint system following an injury

69
Therapeutic Exercise
  • Phase 3 Stabilizing exercises combining
    concentric and eccentric contractions
  • Phase 4 Coordinate tonic and phasic throughout
    full AROM such as in PNF patterns to finalize
    strengthening and coordination. Plyometric
    training.
  • The patients are pain free and are preparing to
    return to their pre-injury levels of activity or
    sports participation at this time.

70
Therapeutic Exercise
  • Ball Therapy, Theraband, running, swimming,
    skiing, weight lifting
  • Feldenkrais, Yoga
  • Pool therapy, Pilates, Plyometrics

71
Other Therapies
  • Mirror Therapy for CRPS
  • Dry needling for trigger points
  • Nutritional counseling, Anti-inflammatory Diet,
    Vit D3, Red Krill fish oil
  • Placebo up to 40

72
EMDR
  • Eye Movement Desensitization and Reprocessing
    (EMDR) or "eye movement therapy" for anxiety,
    stress, trauma
  • The Breakthrough Therapy for Overcoming Anxiety,
    Stress, and Trauma by Francine Shapiro PhD,
    published 1997
  • currently fairly widely accepted, controversial,
    FMS, chronic pain
  • equivalent to cognitive behavioral and exposure
    therapies

73
Conclusions
  • Physical therapy is a skill and an art
  • Head learns anatomy, physiology, pain symptoms,
    evidence based outcomes various types of
    modalities, exercises, and manual therapies
  • Hands apply modalities, manual therapies, and
    exercises
  • Heart empathy and understanding that pain
    patients need more than just modalities and
    exercise

74
Remember
  • Pain does not have to be a
  • Way of Life

75
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76
References
  • www.heinricher.net/pain_lecture/index.htm
  • www.westmeadanaesthesia.org/Meetings/pain-physiolo
    gy/ Pain20Physiology.htm
  • Weiners Pain Management, A Practical Guide for
    Clinicians, 7th Ed., 2006,Boswell and Cole
    Editors, CRC Press, Taylor and Francis Group LLC,
    Boca Raton, Fla., chap 36, 3 4
  • laser.nu
  • http//www.sigmaaldrich.com/Area_of_Interest/Life_
    Science/Cell_Signaling/Key_Resources/Pathway_Slide
    s__Charts/Ascending_Pain_Pathway.html
  • RUL ECT for Treatment of CRPS Practical Pain
    Management Vol 8 2 March 2008 pps 68-74 (AAPM)
  • http//www.associatedphysicians.com/psychology-of-
    pain.html

77
References
  • Kirsch D, Smith R. The use of cranial
    electrotherapy stimulation in the management of
    chronic pain a review. Neuro Rehabilitation.
    20001485-94.
  • Brotman P. Low intensity transcranial electrical
    stimulation improves the efficacy of thermal
    biofeedback and quieting reflex in the treatment
    of classical migraine headache. Am J Electromed.
    19896(5)120-123.
  • Philadelphia Panel. Philadelphia Panel
    evidence-based clinical practice guidelines on
    selected rehabilitation interventions for low
    back pain. Phys Ther. 2001811641-1674. Review.
  • Harris JD. History and development of
    mobilization and manipulation. In Basmajian J.
    ed. Rational Manual Therapies. Baltimore
    Williams and Wilkins 19937-22.
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