Merging Pain Science and Movement in a Biopsychosocial ... conference/Annual... · Objectives For...

Merging Pain Science and Movement

in a Biopsychosocial Treatment

Chris Joyce PT, DPT, SCS

Assistant Professor

Doctoral Student

Objectives For Today

• To understand the general processes of nociception, peripheral and central

sensitization

• To be able to beneficially apply this understanding to comprehensible education for

patients

• To merge pain neurophysiology, movement into a biopsychosocial treatment of a

patient in pain

• To apply learned concepts to patient cases

Objectives 1 and 2

• To understand the general processes of nociception, peripheral and central

sensitization

• To be able to beneficially apply this understanding to comprehensible

education for patients

Your Body

Your Shoulder/Back/Knee

Nociceptors

Pain Neuromatrix

(Brain)

Your Shoulder/Back/Knee

If You Broke Your Toe, Would It Hurt?

If You Broke Your Toe, Would It Hurt?

Results:

Significant differences were observed between the control

and intervention groups in external rotation and posterior

tilt after 6 weeks of training and in external rotation,

posterior tilt, and upward rotation after 12 weeks of

training

Results (cont.):

All groups showed improvement in self-

reported pain and disability scores; however,

there were no significant differences between

the groups.Conclusion: Hip and knee strengthening is effective and superior to

knee strengthening alone for decreasing pain and

improving activity in persons with patellofemoral pain,

Conclusion(cont.):

…however these outcomes were achieved

without a concurrent change in strength.

Results:

Moderate evidence of relationship in cross-

sectional studies, Moderate evidence of no

relationship in prospective studies Results:

Minimal relationship between changes in pain and

changes in: mobility, trunk extension strength,

trunk flexion strength and back muscle mobility

Imaging and Pain

Lesniak et. al (Am. J Sports Med 2013)-MRI of 21 Asymptomatic Shoulders

• 50% Rotator Cuff tears

• 47% SLAP tears

Navarro-Ledesma et. al (Musculoskelet Sci Pract 2017)-Ultrasonography of 97 patients with chronic shoulder pain

• No correlation between acromio-humeral distance and shoulder pain function and ROM

Schwartzeberg et. al (Orthop J Sports Med 2016)-MRI of 53 Asymptomatic Shoulders

• 55% and 72% had SLAP tears

49 Distinct Findings

0 Findings consistent in all 10 reports

37% Findings appeared only once

Fleiss kappa statistics = .20 (poor overall agreement)

The Pain System becomes the problem

Nociceptors

Pain Neuromatrix

(Brain)

Decreased ROM

Decreased Strength

Increase Swelling

Nociceptors

Pain Neuromatrix

(Brain)

Peripheral and Central Sensitizationhttps://www.youtube.com/watch?time_continue=287&v=YwDMmSwUOOU

Conclusion

For chronic MSK pain disorders, there is compelling evidence that an

educational strategy addressing neurophysiology and neurobiology of pain

can have a positive effect on pain, disability, catastrophization, and physical

performance.

Objectives 3 and 4

• To merge pain neurophysiology, movement into a biopsychosocial treatment of a

patient in pain

• To apply learned concepts to patient cases

Movement Based Interventions

• Task-Specific Training

• Graded Exposure

Task-Specific

BACKGROUND: Recent evidence suggests that traditional impairment-based rehabilitation

approaches for patients with knee pain may not result in improved function or reduced disability.

Bove et. al 2017, JOSPT

Task Specific Training

1. Identify tasks that are commonly difficult or painful

a. Patient-reported

b. Evidence-informed

2. Prescribe task-specific interventions

a. Utilize neuromotor learning principles

b. Neuroplasticity?

• Example: Pain with ascending/descending stairs

• Part Practice: Weight shifting, weight bearing, contralateral push-ing

• Blocked Practice: Repeating the same part over and over again without interruption i.e. step ups on small step using only one leg, then switching

• Random Order: Interspersing variability in practice i.e. switching legs, going up/down, changing foot position, changing weight bearing support or amount, change technique

• Open Environment Practice: Real staircase, with people, with distractions, carrying things, talking on phone

• Maximize Repetitions

Task Specific Training

Bove et. al 2017, JOSPT

Bove et. al 2017, JOSPT

Case Example-Task Specific Training

Your patient states when they raise their arm overhead they have anterior

shoulder pain. They’ve been told that they have “impingement” and that their

rotator cuff is fraying like a rope when it gets jammed in between the acromion

and head of humerus. They’ve heard that impingement is a precursor to rotator

cuff surgery, which they do not want, but they feel like they can’t lift their arm

above their shoulder without having any pain. This pain has been going on for

2 months despite rest, ice, NSAIDs, and activity modification to avoid OH

activities.

Task Specific Training

1. Identify tasks that are commonly difficult or painful

a. Patient-reported

b. Evidence-informed

2. Prescribe task-specific interventions

a. Utilize neuromotor learning principles

b. Neuroplasticity?

Task Specific Training

1. Identify tasks that are commonly difficult or painful-Shoulder Elevation

a. Patient-reported

b. Evidence-informed

2. Prescribe task-specific interventions

a. Utilize neuromotor learning principles

b. Neuroplasticity?

• Example: Shoulder Elevation

• Part Practice: Isometrics, Modified ROM exercises, Mirror therapy

• Blocked Practice: Repeating the same part over and over again without interruption

• Random Order: CKC shoulder elevation, sidelying elevation, prone PROM, OKC into CKC elevation

• Open Environment Practice: Reaching while on the phone, sitting and reaching, throwing a ball, waving,

• Maximize Repetitions

Task Specific Training

Bove et. al 2017, JOSPT

Graded Exposure

Graded Exposure to Fear vs. Graded Exposure to Painful Movements

1. Identify the movement or activity that patient is fearful of

• Fear of Daily Activities Questionnaire17 – VAS Scoring System

• Fear Avoidance Belief Questionnaires18 – Likert Scale Questionnaire

2. Involve the movement or activity in your treatment

3. Reassess fear

4. Increase the intensity of the activity or movement

• Can increase duration, load, volume or any other progressive variable

July, 2009

40

50

60

20

4020

40

10

2030

60

60

Folding laundry

Walking up incline George et. al

2009, JOSPT

George et. al

2009, JOSPT

Initial Session:• Identify most fearful activities (FDAQ)

• Patient reports level of activity he/she is willing to perform with increase in fear

Subsequent Sessions:• Patient performs fearful activities (level of determined based on previous session)

• PT monitors session

• FDAQ reassessment

Does patient have less fear of activities?

YES NO

+ Reinforcement

Increase activity level ≥10%

(duration, frequency, intensity)

Reinforcement of Importance

No change in activity level

(duration, frequency, intensity)

Repeat Process Repeat Process George et. al

2009, JOSPT

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10. Öte Karaca Ş, Demirsoy N, Günendi Z. Effects of aerobic exercise on pain sensitivity, heart rate recovery, and health-related quality of life in patients with chronic musculoskeletal pain. International Journal Of Rehabilitation Research. Internationale Zeitschrift Fur Rehabilitationsforschung. Revue Internationale De Recherches De Readaptation [serial online]. June 2017;40(2):164-170.

11. Hoffman MD, Shepanski MS, Mackenzie SP, Clifford PS. Experimentally induced pain perception is acutely reduced by aerobic exercise in people with chronic low back pain. J Rehabil Res Dev. 2005;42:183–190.

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13. Tanaka, Ryo, et al. "Efficacy of strengthening or aerobic exercise on pain relief in people with knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials." Clinical rehabilitation 27.12 (2013): 1059-1071.

14. Hoffman, Martin D., and Debi Rufi Hoffman. "Does aerobic exercise improve pain perception and mood? A review of the evidence related to healthy and chronic pain subjects." Current pain and headache reports 11.2 (2007): 93-97.

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17. George SZ, Valencia C, Zeppieri G, Robinson ME. Development of a Self-Report Measure of Fearful Activities for Patients With Low Back Pain: The Fear of Daily Activities Questionnaire. Physical Therapy. 2009;89(9):969-979. doi:10.2522/ptj.20090032.

18. Waddell G, Newton M, Henderson I, Somerville D, Main C. Research report: A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability.Pain [serial online]. January 1, 1993;52:157-168. Available from: ScienceDirect, Ipswich, MA. Accessed October 12, 2017.

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