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Prevention of Chronic Pain: A Human Systems Approach
“Divine is the task to relieve pain.” -Hippocrates
Dr. James Fricton Professor, University of Minnesota (umn.edu) HealthPartners Ins;tute for Educa;on and Research (hpier.org) Minnesota Head & Neck Pain Clinic (mhnpc.com) President, Interna;onal Myopain Society (myopain.org)
The Body The Risk and Protective Factors in the Musculoskeletal System
This module has 6 parts
• Musculoskeletal Pain Mechanisms • Repe;;ve Strain • Postural Strain • Exercise for Range of Mo;on, Strength and Condi;oning
• Preven;ng Injuries • Experien;al Learning: Do the exercises
By the end of this module…
you will be able to: • Ar;culate some of the mechanisms of musculoskeletal pain
• Explain how posture and repe;;ve strain can play a role in chronic pain
• Review how exercise can build strength, condi;oning and range of mo;on to prevent musculoskeletal pain
• Review how injuries can play a role in chronic pain • Perform five different types of exercise to protect you from chronic pain.
Musculoskeletal Pain Mechanisms
Module: The Body
So where is the pain coming from?
Musculoskeletal Afferent Sensory Nerves
Mense, 2004"
Type I muscle spindle (movement) • Responds to muscle length and velocity when
muscle contracted (a if muscle, b if tendon) Type II stretch receptor (posture) • Responds to position sense when muscle or
joint is at rest Type III Nociceptor (pain) • Responds to strain/ injury with continuous
pain (dull ache) Type IV Nocicepter (tenderness) • Responds to strain/ injury with tenderness
Mechanisms of Musculoskeletal Pain"
!!!
Sensitization: Increased synaptic efficiency due to repeated firing of synapse at the peripheral and central nervous system level"
Allodynia: An enhanced pain report from normal stimuli"
Primary hyperalgesia: Decreased threshold for pain in an injured tissue"
Secondary hyperalgesia: Decreased threshold for pain in the surrounding tissues"
""
Sensi;za;on
Hyperalgesia
Hyperalgesia is hypersensitivity to pain that occurs directly as a result sensitization due to damaged peripheral tissues or dysregulation of the central nervous system
Peripheral Sensi;za;on
• Hypersensi;vity of nocicep;ve primary afferent neurons (pain nerves) in the ;ssues
• Mediators include bradykinin, prostaglandins, neuropep;des, and cytokines
• Upregulated (promoted) during inflamma;on, injury, and repe;;ve strain
Central Sensi;za;on
• Hypersensi;vity of nocicep;ve neurons in the central nervous system (spinal cord and brain)
• Mediators include glutamate through N-‐methyl-‐d-‐aspartate (NMDA), substance P and calcitonin gene-‐related pep;de (CGRP)
• Upregulated (promoted) during sustained pain and threat to body
Wind-Up An increase in pain over
time when a painful stimulus is delivered repeatedly above a critical rate.
Expanding Pain Pattern
As stimulation of the pain receptors from the strain continues, the tissues let you know it by expanding the pain pattern through convergence facilitation.
• First, tenderness (X) • Then, localized pain • Finally, referred pain
Body Realm
Protective Factors Balanced posture Relaxation exercise Stretching exercise Strengthening exercise Conditioning exercise Genetics
Risk Factors Sustained or eccentric postures Repetitive strain Loss of flexibility and range of motion Weak muscles Poor conditioning Injuries Conditions such as obesity and hypo- or hyper-mobile joints
Repetitive Strain
Module: The Body
Repe;;ve Strain Injury (RSI)
An injury due to strain of the muscles and joints from: • repe;;ve tasks (e.g. bracing phone) • forceful exer;ons (e.g. liUing) • Vibra;ons (e.g. equipment) • mechanical compression (e.g.
shoulder bag) • sustained or awkward posi;ons (e.g.
computer work) • and many other types of sustained
tension
http://www.safework.sa.gov.au
10%
38%
12%
28%
2%
7%
Occupational RSI
Also called repetitive stress injury, repetitive motion injuries, cumulative trauma disorder (CTD), occupational overuse injury, overuse syndrome, myofascial pain, and regional musculoskeletal disorder.
Jaw
Feet
Hands
First, understand the muscles
Red Type I fibers for posture
White type II fibers for strength
Type I and II fiber types are distributed throughout all skeletal muscles !
Muscle Fiber Type I (red, slow)!
l Postural muscle tone
l High endurance
l Slow twitch (red)
l High oxidative phosphorylation with high O2, ATP production, mitochondria, and increased vascularity
l Marathon runner
Muscle Fiber Type II (white, fast)!
l Large forces over brief period"
l Low endurance"l Fast twitch (white)"
l Anaerobic glycolysis with low O2, low mitochondria, high lactic acid"
l Sprinter "
Muscle fibers are like chameleons !
Type I (slow) ! Type II (fast)!
Increased demand from high forces for short periods
Increased demand from postural strain for longer periods
Who wins?
Type I Slow
posture
Type II Fast
strength
With repetitive strain, muscle fibers of type I compensates but often loses
-Larsson, et al, 1988, Bengsston, et al, 1986, Dennett, Fry, 1988""
l Abnormal Metabolic Activity in Type I Fibers l Low Oxygen and ATP (fuel depleted) l Increased and ragged Type I Posture Fibers l Decreased Type II strength fibers with atrophy l Abnormal mitochondrial changes on EM on Type I"
Type I (slow) ! Type II (fast)!
Increased conversion due to repetitive postural strain
The Slippery Slope of Chronic Pain
Acute to Chronic Muscle Pain"Acute Muscle
Injury!Peripheral Factors (e.g.
(injury, posture, trauma, repetitive strain)!
Central Factors (e.g. inactivity, anxiety, depression, sleep)!
Convergence facilitation, broadening of pain and
more muscle strain!
High muscle tone and low removal of pain
alogens!
Sensitization of muscle
nociceptors!
Sensitization of central processing!
PNS !
CNS !
Sensitization, wind-up, expansion of receptor fields,
and hyperalgesia!
An injury starts the pain cycle…
Tensing due to pain, inactivity to
avoid pain
Muscle pain and repe<<ve strain
Muscle strain and more pain
Poor posture, protect muscles,
weakness
Jaw pain and headache results from…
Daytime Clenching 72.2 42.1 Night Clenching 66.7 32.2 Biting tongue/cheek 61.0 23.7 Jaw sore in A.M. 59.3 42.3 Tongue thrust 52.8 41.2 Night Bruxism 50.0 25.1 Unilateral Chewing 50.0 42.0 Daytime Bruxism 47.2 27.3 Biting nails/objects 30.6 28.4 Chewing Gum 27.8 18.2 musical instruments/ scuba/ singing
Patients Gen. Pop.
Fricton, et al J Orofacial Pain. 1996
Neck pain results from…
Ariens GA et al Physical risk factors for neck pain. Scan J Work Environ Health.. (2000)
• Awkward tense computer posture
• Bend or twist neck repeatedly
• Look up or down for hours
• Tense neck and shoulders
• Brace phone with shoulder
• Forceful arm movements
• Holding arm in tense posture
• Long duration of sitting
• Twisting or bending of the trunk,
• hand-arm vibration
Back pain results from…
Björck-van Dijken C1 et al J Rehabil Med.(2008), Kelsey JL, Golden AL. Occup Med. 1988, Yilmaz E, Health Science Journal, (2012)
• Rotation or bending of the trunk
• Lifting repeatedly by bending at waist
• Heavy physical workload
• Lack of exercise
• higher body mass index
• Prolonged sitting or standing
• Monotonous work
• Frequent manual operations
• whole body vibration
Occupa;onal RSI risk factors
• Poorly designed workstation • Cluttered workstation • Cold setting • Awkward posture to work • Vibrating equipment • No rest or stretch breaks • Tripping on equipment and
cables
Douglas, AY et al American J of Preventive Medicine (2009)!
Short-term and… Long-term
Postural Strain
Module: The Body
Do we only have five senses?
Proprioception and pain is the sixth sense..
Gallace A et al The analgesic effect of crossing the arms. Pain. (2011)
…designed to protect us from repetitive strain
What is good posture?
Body posi;ons that balance the musculoskeletal system against gravity to reduce sustained muscle tension and strain
Good posture is…
• Efficient. Lets you rest pain free in a posi;on with a minimum of muscle strain and energy expenditure.
• Effec<ve. Facilitates ongoing ac;vi;es in si^ng, standing, walking, running, and others
• Effortless. Allows a quick and easy transi;on into the next relevant movement.
And….
• It makes one attractive and attentive
• It feels natural and relaxed • It is not about holding your
body still and tense
• It does not require any extra effort or constant attention.
…and, it’s not how it looks but how it feels that
counts
Good sitting body mechanics can prevent; • back pain • pelvic pain • knee pain • neck pain • arm pain • Headaches • hand pain!
Si^ng Posture Head up and back Shoulders down and back
Sit with boFom to back of chair
Jaw posture • Tongue up • Teeth apart • Jaw relaxed • Lips open or closed
The head is heavy…
…if it’s not balanced on the neck chin in, shoulders back, and chest up
12 lbs 30 lbs
12 lbs 32 lbs 42 lbs
Walking Posture
Sleeping Posture
Somewhere, something went terribly wrong
Exercise
Module: The Body
Exercise is the original protector
Five types of exercise
Musculoskeletal Goal Exercise Strategy Range of motion Stretching and yoga Strength Weights and resistance Endurance Conditioning and aerobic Balance Maintaining posture Reduce repetitive strain Relaxation
Range of motion: we all try to maintain it…
Yoga is dynamic stretching Significantly improved; • pain • quality of life • disability • stress • depression • medication usage in 8 of the 10 chronic back pain clinical trials
Diaz AM, et al. American Journal of Lifestyle Medicine April 16, 2013
Principles of Stretching
• Do it slowly, gently and frequently (several times per day) • Stretch to pain but not beyond. Feel each of muscle being
stretched. • Push to full joint range of motion and hold it. Count to 20. • Breath slowly and deeply as you stretch. • Do not hurry or bounce with the stretch. Hold it steady
Strengthening: Use it or lose it
Strengthening to prevent chronic back pain
• More effective than no exercise. • Increasing intensity and motivation increases results. • Strengthening equal to conditioning and stretching
exercises.
Systematic Reviews. Bell J, et al J. of Occupational Medicine (2010) and Slade SC et al J. Manipulative and Physiological Therapeutics (2006)
Condi;oning for chronic pain Significantly improved; • Pain • Function • Quality of life • Disability • Psychosocial status 9 systema;c reviews, comprising a total of 224 trials and 24,059 pa;ents with fibromyalgia, osteoarthri;s, rheumatoid arthri;s, back, neck and shoulder pain
Hagen et al BMC Medicine 2012
High Intensity Interval Training
Preventing Injury
Module: The Body
Abuse it and lose it
Delayed-‐onset muscle soreness
• Post-‐exercise muscle pain • Normal response to unusual exer;on
• Adapta;on process that leads to greater stamina and strength
• Muscles recover and build strength and bulk
Distinguishing muscle injury from post-exercise muscle soreness
Muscle or Joint Injury Delayed Onset Muscle Soreness
From pulled, torn, strained or sprained muscle or joint
From post-‐exercise, over-‐exer;on, and over-‐use
Abrupt onset Gradual pain aUer exercise Sharp localized pain Diffuse soreness over most of
muscle or joint Inability to con;nue the ac;vity and cannot put force on it
Can con;nue if choose and can put force on it
Weakness,, tenderness, and No weakness, no swelling, no bruising, can con;nue the ac;vity
swelling and bruising No surface signs of injury
Preventing Sports Injuries
• Warm-up exercises cut knee injuries by 50% among female college soccer players
• Dynamic warm-up exercises with a gentle walk or jog then static stretching to increase the range of mo;on of various joint
www.aclprevent.com/pepprogram.html
Preventing injuries from becoming chronic
Not R.I.C.E. Rest, Ice, Compression and Elevate Use M.E.A.T. Movement, Exercise, Analgesics and Treatment
Identify co-morbid conditions can lead to chronic pain
• Obesity • Hyper-mobile joints • Osteoarthritis • Rheumatoid arthritis • Auto-immune disorders • Migraine • Diabetes • Depression and Anxiety • Addiction including tobacco • Many more…
Trigger Point Massage
http://www.pressurepositive.com
The Knobble
Take Home: Love the body you are in
1. Give yourself permission to love your body. 2. Celebrate one thing you love about your body. 3. Send love to your “troubled” body parts. 4. Find the cosme;c balance. 5. Don’t verbally cri;cize your body. 6. Accept what you cannot change, then forget about it.
http://empoweredsustenance.com/love-your-body/!
1. 90/10 rule. 90% protective factors, 10% risk factors.
2. Posture. Live balanced against gravity
3. Strain. Relax when using your muscles
4. Exercise. An hour per day, six days a week.
5. Cross train. Stretching, conditioning, and strengthening.
6. Massage. Identify and reduce trigger points
7. Track. Monitor pain, range of motion, steps, calories, blood pressure, heart rate, workouts, and other health measures.
8. Be positive. It’s all about your energy
The Body: Take Home
Now, just do it… watch the videos do the exercises