PERSISTENT PAIN & Physical Therapy Melanie Mailand PT, DPT

Review from previous class: Persistent Pain comes from a sensitized nervous system Hyper-excitable Structural and functional changes Pain thresholds in the whole body are lowered Cortical disorganization

The issue is NOT the tissue There is no pain input to the brain light/sound waves Processing occurs in many parts of the brain Thalamus Amygdala Primary motor & sensory cortex Cerebellum Hypothalamus Cingulate gyrus Pain is an output and perfectly normal Pain is an indication that the brain believes there is danger, a call to action. It is not a damage meter.

Neurophysiology of pain

Acute vs. chronic pain Acute pain Chronic pain Short lived Lasts longer than 6 months Area of pain becomes bigger and more diffuse Pain may intensify Things that didn’t cause pain before now cause you pain Acute pain Short lived Related to injury Area of pain is the injured anatomy **And the more persistent the pain is, the less the pain has to do with any tissues or anatomy

5 Signs of Central Sensitization Pain spreads out Hyperalgesia Allodynia Spontaneous pain Twitching in pain Decrease activation thresholds of spinal neuron International Association for the Study of Pain

Other Clinical Signs Loss of L/R discrimination Altered limb perception (neglect) Pull away from attempts to touch painful part of body Latent pain response Treatment response varies

Sensitizers Diabetes Depression PTSD Decreased blood flow Medications Caffeine Poor Diet Poor Sleep Inactivity Stress Alcohol Smoking/Tobacco

De-Sensitizers Exercise Routine Active Lifestyle Body Awareness Pacing Self-management TENS Social Support Intimacy Quit Smoking Medications Reduce Stress Improve Sleep Improve Diet Humor

Only you can change your pain Because when you know pain… you know gain

If you had a choice…. What would you choose? …nervous system dysfunction or orthopedic dysfunction Stroke or a broken Leg Parkinson’s disease or a sprained ankle

Neuro Plasticity The brain’s ability to re-organize itself by forming new neural connections. The Brain can Change Repetition, intensity, duration are key

Neuro Tag Brain’s network of cells that produce pain The nervous system is plastic and can be changed Pain that is NOT bio-mechanical, but IS chronic, is the result of the sensitized nervous system.

Imaging and Pain Degenerative changes that are seen on imaging is normal Degenerative changes are NOT pathological You should show signs of degenerative changes after the age of 19

Pain with function is expected that doesn’t mean that there is tissue harm. It means that the brain is sensitive 25% of Total Knee Arthroplasty’s still have pain after surgery Anatomy does not dictate pain Imaging is not recommended unless there is evidence of progressive neurologic deficits. Images do not reveal beliefs, feelings, or context and persistent pain involves all of these. “It appears you are not 19 years old anymore” Use healing language

So, What do we do about persistent pain? Knowledge is power Education is therapy It has to occur before any reconceptualization occurs. Education WITH exercise is superior to education alone Focus on desensitizing strategies

What does Physical Therapy Have to offer Remember the issue is NOT with the tissue PT will look at: Strength ROM Balance Activity tolerance

There will be deficits due to hypo-mobility and sedentary life style These deficits do not cause back pain, but physical therapy will address them Posture Body mechanics Heat and Ice Dry needling TENS Restores central descending inhibition Neuroscience education

Exercise is medicine http://exerciseismedicine.org/ Exercise induced analgesia Aerobic Isometric Isotonic Pain is not the limiting factor Goal will be quota based

Sitting decreases the effectiveness of exercise Be gentle…your brain is in training Hurt does not equal harm How much exercise do you do now?

Motion is Lotion If you keep cells moving and functioning, it decreases, cancer risk, systemic disease risk and a host of other chronic diseases. Motion promotes healthy nerves and gets the spinal cord and brain headed in the right direction.

Smudging Pain spreads out as a result of the brain’s changes and disorganized cortical representation. Smudging makes movement without pain difficult.

Graded motor imagery & movement dysfunction therapy Training the brain promotes neuro plasticity and desensitization Laterality cards (disengages the motor cortex) Organize first Community limb identification Training load Motor imagery Mirror therapy Graded Exposure Function

Relaxation Coloring Chill drills Explain Pain video - https://www.youtube.com/watch?v=C_3p hB93rvI

Goal: To create an accurate cortical representation of the body by remapping the brain

Summary Activity Self management Self efficacy **Goal Resuming Life