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Casey Hansen, PT, DPT, TPS

• The listener will understand the pain neuromatrixand how it affects our perception of pain

• The listener will understand neuroplasticity’s role in the pain neuromatrix

• The listener will understand current treatments to help desensitize a sensitive nervous system

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} Doctor of Physical Therapy from the University of North Dakota

} Therapeutic Pain Specialist Certification from the International Spine and Pain Institute

} Currently working in the outpatient setting with a focus on neck and back pain as well as chronic pain including complex regional pain syndrome, chronic fatigue, and fibromyalgia.

◦ Focus on pain neuroscience education◦ Using different techniques to calm down a

sensitive nervous system◦ Use this in conjunction with standard

therapy practices to begin to resume activities of daily living

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} To understand where we are headed we need to know where we started

} René Descartes theorized that the body was more similar to a machine, and that pain was a disturbance that passed down along nerve fibers until the disturbance reached the brain. (Moayedi and Davis 2013)

} Specificity Theory-First to recognize specific sensory receptors and fibers, eventually lead to the idea of nociception.

} Intensity Theory of Pain-Looked at summation of input as a potential for pain

} Pattern Theory of Pain-Pain was determined by specific and particular patterns of neural firing. (Moayedi and Davis 2013)

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} The gate control theory of pain asserts that non-painful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain

} First proposed in 1965 by Ronald Melzack and Patrick Wall, the theory offers a physiological explanation for the previously observed effect of psychology on pain perception. (Moayedi and Davis 2013)

} Shortcomings noted in all models, none of the previous theories accounted for the complexity of pain.

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} Neuromatrix Theory-Pain is an output of the central nervous system that occurs when the organism perceives a threat

} Pain is very complex and involves all the systems of the body from central nervous system to the endocrine system.

} Tissue injury does not necessarily mean pain} 25-50% of general population (Kjaer et al 2005) :

� –Hypointense disc signal � –Annular tears � –High intensity zones � –Disc protrusions � –Endplate changes � –Zygapophyseal joint degeneration � -Asymmetry � –Foraminal stenosis.

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} After successful rotator cuff repairs and clinically sound examination (Spielmann, Forster et al. 1999) : ◦ •90% abnormal signaling ◦ •16% partial tears ◦ •20% complete tears ◦ •33% sub-acromial effusion ◦ •16% joint effusion ◦ •20% bone marrow edema

} Over age 70: 2 out of 3 have asymptomatic RC tear(Milgrom, Schaffler et al. 1995)

} The increased sensitivity to outside forces◦ Allodynia-Non painful stimulus that causes pain◦ Hyperalgesia-Increased pain experience

with stimulus} Changes in the pain experience◦ Mirrored pain◦ Spreading pain◦ Inflammatory responses◦ Increased activation in different systems in the body

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} We have 45 miles of nerves in the human body

} Ion channels◦ Located along areas of decreased myelin along the

nerve◦ Many different types of channels that can sense

chemicals surrounding the nerve, mechanical input and electrical voltage◦ The more ion channels the more sensitive the nerve◦ We replace ion channels every 48 hours

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} Dorsal Horn and the interneuron

} Interneuron Inhibition causes input from levels above and below to now send signals to the brain as well and input from the other side of the body

} This bombardment of signals causes mirror pain as well as spreading pain, begins to cause allodynia as sensory input is no longer inhibited as well.

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} Neuromatrix-Pain affects multiple areas of the brain (Puentedura and Louw 2012) :◦ Premotor/Motor Cortex-Organize and prepare

movement◦ Cinculate Cortex-Concentration, focusing◦ Prefrontal Cortex-Problem Solving Memory◦ Amygdala-Fear, Fear Conditioning, Addiction◦ Sensory Cortex-Sensory Discrimination◦ Hypothalamus/Thalamus-Stress, Autonomic

Regulation, Motivation

} Neuromatrix Continued◦ Cerebellum-Movement and cognition◦ Hippocampus-Memory, Spatial Recognition, Fear

Conditioning◦ Spine Cord-Gating from the periphery

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} Neuromatrix Continued◦ So if the same areas of the brain are affected why is

everyone's pain different?◦ The neuromatrix pain map can overlap with other

“maps” such as beliefs, knowledge, social context, anticipated consequences and other sensory cues.

} Other systems are involved with the pain experience including the immune system, endocrine system, and sympathetic nervous system.

} The hypothalamic–pituitary–adrenal axis (HPA axis) is a description of the interaction between the Hypothalamus, Pituitary gland and Adrenal glands on the kidneys.

} This is responsible for our stress reaction and involves many body processes including Digestion, Immune system, Mood, Emotions, Sexuality, Energy storage and expenditure

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} Increasing substance P release can cause the HPA axis to blunt corticotrophin-releasing hormone causing allodynia, hyperalgesia and dysautonomia(Rodriguez-Pinto, I., N. Agmon-Levin, et al. (2014)

} HPA axis causes the release of Cortisol as well. } During a pain experience we also release cytokines

which can be both pro-inflammatory and anti-inflammatory and in a health system these are well balanced.

} Neuroplasticity is the mechanism by which the brain encodes experience and learns new behaviors.

} This is also the mechanism by which the damaged brain relearns lost behavior

} Research strongly suggest that neurons as well as other brain cells have the ability to alter their structure and function in response to internal and external input

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} 1)Use it or lose it} 2)Use it and improve it} 3)Specificity} 4)Repetition matters} 5)Intensity matters} 6)Time matters} 7)Salience matters} 8)Age matters} 9)Transference } 10)Interference} (Kleim and Jones, 2008)

} Pain Neuroscience Education} Laterality-left/right discrimination} Motor Imagery} Sensory Discrimination and Graphesthesia} Mirror therapy

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} Pain Neuroscience Education◦ Neuroscience education is described as an educational

intervention which aims to reduce pain and disability by explaining the biology of the pain experience to a patient.(Moseley 2005; Ryan, Gray et al. 2010)◦ � Neurophysiology of pain ◦ � No reference to anatomical or patho-anatomical models ◦ � No discussion of emotional or behavioral aspects to pain ◦ � Nociception and nociceptive pathways◦ � Neurons ◦ � Synapses ◦ � Action potential ◦ � Spinal inhibition and facilitation ◦ � Peripheral sensitization ◦ � Central sensitization ◦ � Plasticity of the nervous system

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} 1st off does it work?◦ In 2011 a systematic review of TNE was

conducted for musculoskeletal pain. (Louw, Diener et al. 2011)� This review includes 8 studies comprising 6

high-quality RCTs, 1 pseudo-RCT, and 1 comparative study involving 401 subjects.

� Narrative synthesis of results, based on effect size, established compelling evidence that TNE may be effective in reducing pain ratings, increasing function, addressing catastrophization, and improving movement in chronic MSK pain.

} Laterality◦ We use flash cards, phone apps, magazines to help patients

get more accurate and faster with the ability to discern left and right. ◦ If the area that is affected is to painful or emotional we can

use adjacent areas first.} Motor Imagery◦ We know now that the same neurons that fire during an

activity also fire when watching someone else do the act, this is the reason yawns seem to be contagious. ◦ Start with static positions and progress to dynamic

positions◦ Create flash card based on patient goals and progress as

tolerated

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} Sensory discrimination◦ Moseley has shown that discrimination is more

effective that integration due to the brain being active vs passive (Mosely, Zalucki et al. 2007)◦ Treatment options include two point discrimination,

sharp/dull, feather, cotton wool. � Verbally teaching themselves keeps the brain more

active� Just like laterality we can start with a neighbor if

needed.

} Graphesthesia-begin with easy to discriminate shapes and progress to more similar shapes

} Stereognosis-Start with less options and progress to similar objects, focus on time, place into beans/rice, combining objects, etc.

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} Usually towards the end, if the brain does not understand and becomes more confused pain will increase.

} Must prepare the patient as it can be very emotional

} Try to limit distortions, make sure the box is sturdy, sit evenly, remove jewelry and cover tattoos.

} Progress tasks with noninvolved extremity

} PNE is one part of the pain puzzle, traditional therapy still works and we know that there are many things that we can do to help calm down the nervous system

} PNE, Goal Setting, Aerobic Exercise and Sleep Hygiene are requirements for our patients.

} Other treatments include: Meditation, Diet, Journaling, General Stabilization, Manual Therapy, Social Interaction, Graded Motor Imagery, Welcoming/Safe/Healing Environment, Humor, Mindfulness, Diaphragmatic breathing, Appropriate Bracing, Modalities, Home Exercise Program, Coping Skills, Relaxation, Skillful Delivery of Medication

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} This is why a multidisciplinary approach is so important, there are so many options to help our patients and when everyone is on the same page we can create a significant decrease in pain by calming down the sensitive nervous systems and begin to normal the pain experience.

} Thank you all for your time!

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