1. What Should You Treat First? Rethinking Clinical Decision-making and Modifying Your Treatment Plan Nora Stern, PT, MSPT

2. Conflict of Interest Disclosure Nora Stern, PT, MS, PT Has no real or apparent conflicts of interest to report.

4. Objectives Appreciate pain as an output Evaluate neurophysiological processes of nocioceptive, peripheral neurogenic, central and output driven pain experiences Identify appropriate treatment interventions Examine case studies

5. Pain as an output: what does that change?

6. Processes

7. Looking at what is sensitizing the systems: Nocioceptive input Peripheral Central Output

8. Assessing: Features for nocioceptive contribution Pain is consistent w findings and proportionate to findings In same region as original pain sensations Consistent w anatomy Within normal healing time Pain dull ache, sharp w movement Swelling

9. Assessing nocioceptive/inflammatory Inflammatory response: prostaglandins, histamine, cytokines, substance P involved in membrane leakage, causes swelling

10. Treatment: nocioceptive Anything different? What do pts need to hear?

11. Assessing: Peripheral neurogenic presentation Follows nerve pathway or adjacent pathway, but in new areas along pathway Shooting up or down along pathway Evaluated through neural tension testing and palpation of sensitivity along the nerve pathway

12. Peripheral Sensitization

13. ALTERED IMPULSE GENERATOR SITE Ion channels lay down on demyelinated segments of nerve and essentially create a new endplate.

14. Treatment: peripheral neurogenic Motion is lotion Neurodynamics Health of container: taping, manual therapy Postural support Decrease in threat value: pain education, normalize experience What does pt need to hear?

15. Assessing: Central sensitization features Pain searing, stabbing, like a knife, hot poker Appearing on other side of body, pain in new area Does not follow anatomy, not consistent w findings Large or diffuse areas of pain Black body diagram Altered 2 point discrimination Delay in laterality recognition > 1.5 sec, < 90% accuracy High score on StarT

16. Fig. 1 Patient data: TPD threshold, normal distribution of pain, and body image. Two-point discrimination threshold (TPD) was assessed bilaterally at 16 levels, shown here superimposed over line drawings of the sense of physical self, or body image, of six... Moseley, GL, “I Cant’ find it! Distorted body image and tactile dysfunction in patients with chronic back pain.” Pain Vol 140, Issue 1, 2008, 239-243 Assessing central involvement: cortical reorganization: Smudging Altered Two Point Discrimination Associated with Distorted Body Image in Back Pain

17. Assessing central involvement: cortical reorganization: smudging Flor, H, Neuroscience 1997

18. Assessing central involvement: Mirror neuron function

19. Assessing central involvement: Quantifying psychosocial issues: StarT Generic Screening Tool

20. Central: what aspects of the brain processing are contributing to central sensitization? Thinking Feeling Sensing Acting/moving

21. Output Pain response assigned to a part of the virtual body ANS triggers  Neuroendocrine system uses cortisol,  immune response using proinflammatory cytokines

22. Immune response Proinflammmatory cytokines exist in PNS and CNS, signal between immune system and nervous system Delay of response to stressors: 10 days Causes feelings of tiredness, loss of mobility, achiness everywhere

23. Stress/pain relationship with CRPS Allen, R, et al, Phys Ther, 2011 4:32-42

25. Immune Response Activated locally during injury Activates myelin destruction and contribute to AIGS Pro-inflammatory cytokine activity can increase w catastrophizing

26. Assessment: Output Swelling Sweating Itching Cold sensitivity Pain w thinking about movement, watching someone move Altered 2 point discrimination Poor accuracy and speed on laterality recognition Altered body schema Poor motor planning

28. Treatment Interventions for Central Sensitization/output

29. Treatment interventions: Central Address fear avoidance through pain education

30. Treatment Interventions: Central Sensing: – Graded Motor Imagery – Body scan – General kinesthetic sensing with exercise – Whole body movement to restore virtual body representation

31. Treatment for Central involvement and output driven GMI used for: – CRPS (rsd) – Phantom limb – Stroke – Neck pain – Back pain

32. Treatment: GMI Progression Laterality Recognition: Cards or Recognise Online – Activates pre-motor cortex but not primary motor cortex Imagined Movement – Activates both pre-motor and primary motor cortex – Less challenging than actual movement, can imagine movement perfectly Mirror Box – Harnesses use of mirror neurons to restore normal output and motor function

33. Treatment: GMI Laterality Recognition

34. Treatment: GMI Imagined movement

35. Treatment: GMI Mirror therapy

36. Treatment: Graded Activity Moseley and Butler twin peaks model

37. Treatment: Graded exposure Movement: observed, imagined, actual: mirror and normal Components of movement complexity: simpler to more complex, eg break down a fwd bend Amount of time Change the context, eg, do w friend, listening to music Tune in to entire body: refresh homuncular map Look at environment: non threatening to threatening

38. Treatment: Physiological quieting

39. Treatment Interventions: Central Stress response: physiological quieting www.meditationcenter.com: easy to follow meditations. www.meditationcenter.com http://www.allaboutdepression.com/relax/ 8 free breathing tapes, relaxation activities. http://www.allaboutdepression.com/relax/ http://vcc.asu.edu/relaxaindex.shtml: free guided instruction in progressive muscle relaxation and guided imagery. http://vcc.asu.edu/relaxaindex.shtml

40. Consider the immune system Consider how quickly we introduce stretching and strengthening after an injury

41. Case studies

42. Case study #1 Patient w wrist pain. Limitation and pain w wrist flexion and extension. Tender at elbow medial and lateral. Pain began 1 month ago, while putting in long hours at keyboard, poor ergonomics, very engaged in writing a paper for publication. Start score 1/5 Body diagram: specific point of pain at R wrist Exam: tender to passive wrist flexion and extension, tender at metacarpals, tender to palpation at R flexor carpi ulnaris, extensor carpi ulnaris.

43. Case study #2 Pt with wrist pain and elbow pain on R x 3 months. Pain w wrist flexion and extension and supination, and at R medial epicondyle, sometimes into fingers. Feels like it’s spreading, getting worse. Draws pain as a line along medial aspect of R arm Pain increases w deadlines, long hours. Lots of stress at work Wondering if she should stop playing softball, afraid she is hurting herself because her arm hurts more when she does this. Start score 2/5 (Median neural tension testing +, cervical scan negative)

44. Case study #3 Pain for 2 years, Pain at medial elbow and wrist R, now also in lateral elbow R, and shoulder, and has neck pain and low back pain, sleeping poorly Pain began with a lot of keyboarding at work, during staff cuts, spouse lost job at same location. Draws black area in entire R arm, and neck and low back and across to L shoulder, and head Start score 5/5. Pt says she has stopped doing most of the things that she enjoys because she doesn’t want to hurt herself.

45. Case study #4 Pain x 1 yr, started as R wrist pain. Began after working long hours at computer to meet deadline, doing stretching and strengthening w PT, for about 2 months, got a virus, and then started to get severe pain and swelling in her R forearm and hand, now sweats when she tries to use it, avoids moving that hand. Starting to have some pain in her L hand and having nerve conduction testing soon for this. Has neck pain. Wearing protective wrist splint, holds hand close to her chest. Start score 5/5

47. Questions