Physical Therapy, Pain, The Brain

GOBHI May 17, 2012Dr. Tom Watson PT MEd DAAPM

Bend, Oregon

Dr. Tom Watson DPT PT MEdDiplomate American Academy

of Pain ManagementRebound Physical Therapy

541-382-7875 Bend, [email protected] conflicts of interest

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

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.

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."

"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

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/psychoanalysis/concepts/pleasure_pain.htm

“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

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

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”

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.

Mood Memory- short and long term Concentration Sleep Sex drive

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

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

VIT D3, Red Krill Fish Oil Microcurrent Stimulation, Cold Laser, Neuro mobilization Mirror Therapy NMDR Hypnosis Acupuncture Meds: Opioids, Psychotropic, Neuroleptics,

steroids, non-steroidals

ArthritisArthritisMechanical lowMechanical low

back painback painSports/exercise injuriesSports/exercise injuriesPostoperative painPostoperative pain

NeuropathicNociceptive Mixed

Peripheral neuropathyPeripheral neuropathyPHNPHNNeuropathic low back painNeuropathic low back painRadiculopathyRadiculopathyCentral poststroke painCentral poststroke painComplex regional painComplex regional pain

syndromesyndrome

Caused bylesion or dysfunctionin the nervous system

Caused bytissue damage

Caused bycombinationof primaryinjury andsecondary

effects

Fractures*Fractures*Dislocations*Dislocations*Postopertive*Postopertive*BackBack pain painFibromyalgiaFibromyalgiaCancer painCancer painBurn painBurn 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

"Psychogenic" pain arises due to maladaptive thought processes

Somatization-bowel disorder, palpitations, fatigue, respiratory, all disproportionate

Hypochondriasis- fear of conditionFactitious Disorder-Munchausen

syndrome

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).

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

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

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

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

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

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

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)

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

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

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

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

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

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

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)

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 (P=0.038.)

favors physical (organic) not psychosocial explanation for more pronounced pain perception in female patients

Pain

“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. 2005;3(1):83-86

.

Where’s Mommy??

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

MPD/Dis-associative Identity Disorders(DID) BPD, Bi-Polar and Chronic Pain

Symptomatic changes in 1 area may manifest or decrease other diagnosis

Greeks, Egyptians, Chinese, Romans: Heat, sun, geodes, eels, massage, manipulation

Modalities-Thermal, Sound ,Traction, Magnets

Lasers, electrical stimulation

Manual therapies

Therapeutic exercise

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

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

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

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.

Einstein-1916

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

Jedi squirrels of Oregon with light sabers

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

Acute and chronic pain, TMJD Neuropathies, FMS, Post polio syndrome Headaches, Arthritis Acupuncture points Open wounds Athletic Injuries: Sprains, Strains,

Hematomas

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

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.”

Cyriax disagreed with osteopathic techniques, advocated manipulation by PT”s

“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.”

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

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

The musculoskeletal system does not respond well to immobilization.

The end result is the deterioration and weakness of the body’s 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

BUFF?

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

StepsPhase 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

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.

Ball Therapy, Theraband, running, swimming, skiing, weight lifting

Feldenkrais, Yoga

Pool therapy, Pilates, Plyometrics

Mirror Therapy for CRPS

Dry needling for trigger points

Nutritional counseling, Anti-inflammatory Diet, Vit D3, Red Krill fish oil

Placebo up to 40%

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

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

Pain does not have to be a Pain does not have to be a Way of LifeWay of Life

• www.heinricher.net/pain_lecture/index.htm • www.westmeadanaesthesia.org/Meetings/pain-physiology/ Pain

%20Physiology.htm• Weiner’s 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_Slides__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

References

• Kirsch D, Smith R. The use of cranial electrotherapy stimulation in the management of chronic pain: a review. Neuro Rehabilitation. 2000;14:85-94.

• 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. 1989;6(5):120-123.

• Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain. Phys Ther. 2001;81:1641-1674. Review.

• Harris JD. History and development of mobilization and manipulation. In: Basmajian J. ed. Rational Manual Therapies. Baltimore: Williams and Wilkins; 1993:7-22.

References