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CENTRAL SENSITIZATION AND PROVIDING EFFECTIVE REIKI TREATMENT
FOR INDIVIDUALS WITH CHRONIC PAIN CONDITIONS
Presented by Julia Kajen, PT, DPT
➤ Definitions of pain ➤ Misconceptions of pain ➤ Neuroscience of pain ➤ Central sensitization ➤ Cortical changes in chronic
pain ➤ CBT skills for communicating
effectively with clients ➤ CBT skills for pain reduction
to teach clients ➤ Putting it together with Reiki
➤ Physical Therapist
➤ Trained in Psychologically-Informed Physical Therapy (PIPT)
➤ Reiki Practitioner
PRESENTER PRESENTATION
DEFINITIONS OF PAIN
➤ “Pain is whatever the experiencing person says it is, existing whenever they say it does” -McCaffery, 1968
➤ Pain is always subjective
➤ The patient, not the clinician, is the authority on the pain
➤ “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” - IASP, 1979
➤ It is a sensation in a part or parts of the body and also always unpleasant, so it is always an emotional experience
➤ People reporting pain in the absence of a pathophysiological cause are experiencing pain, and their report should be accepted as pain
CARTESIAN MODEL OF PAIN
➤ Proposed by Rene Descartes in 1664 continues to be an (incorrect) driving force in the delivery of medicine today
➤ If you place your foot into or too close to a fire, then a pain message was sent to the brain via pathway or wire
PERSISTENT MISCONCEPTIONS ABOUT PERSISTENT PAIN
➤ More than 350 years after his death, the model proposed by Descartes continues to exert influence on how healthcare professionals view and treat pain
➤ Incorrect assumptions that: ➤ There is a direct link between the amount of tissue damage and the level of pain
experienced ➤ All pain is caused by injury and increased pain means more damage ➤ Prior experience with pain teaches a person to become more tolerant or pain ➤ Nociception and pain are synonymous ➤ Pain is an input driven system ➤ There is a division of mind and body where pain is either physical or
psychological, or a mental illness versus a physical illness
POOR CORRELATION BETWEEN HEALTH OF TISSUES AND A PAIN EXPERIENCE
➤ 40% of asymptomatic people have a bulging disc on MRI (Viderman, Battie et al., 2003; Turner et al., 2007) ➤ Lumbar spine degeneration starts in a person’s early 20’s and there is little correlation between
arthritis and LBP (Twomey and Taylor, 1987; Kjaer, Leboeuf-Yde et al. 2005) ➤ In 40-year-old asymptomatic people, between 25-50% will demonstrate disc degeneration and
signs of injury, endplate changes, foramina stenosis and facet joint degeneration on spinal
imaging (Kjaer, Leboeuf-Yde et al. 2005) ➤ Imaging of the asymptomatic general population shows a 35-40% prevalence of rotator cuff
term across all age groups (Sher, Uribe et al., 1995; Reilly, Macleod et al, 2006) ➤ In patients over the age of 70, two out of three will have an asymptomatic rotator cuff tear
(Milgrom, Schaffer et al., 1995)
➤ In the general population, 25% of MRIs will show meniscus degeneration (Munk, Lundorf et al., 2004)
➤ There is only a 50% correlation between knee pain and arthritis (Bedson and Croft, 2008)
➤ 35% of collegiate basketball players with no knee pain will have significant abnormalities on their MRI scans (Major and Helms, 2002)
NOCICEPTORS
➤ Nociceptors are receptors that relay sensory information from the tissues to the spinal cord and then to the brain
➤ Nociceptors are located in the skin, muscles, joints, bones, viscera
➤ Nociceptors detect changes in the tissues: mechanical, temperature, chemical
➤ When a tissue is damaged, there is an influx of cells that cause inflammation which sensitizes the nociceptors and reduces their threshold
➤ When nociceptors are activated, this information will be passed via sensory afferent nerves to the dorsal horn of the spinal cord
➤ The ascending pathways that mediate pain consist of three different spinothalamic tracts which originate in different spinal cord regions and terminate in different areas of the brain via second-order neurons
PRODUCTION OF PAIN
➤ Once the information has reached the brain, the brain can react in a number of ways, only one of which is to create the experience of pain
➤ Pain is a decision by the brain based on perception of threat; nociception is not pain and nociception alone is never enough to cause pain
➤ It’s the tissues that contain nociceptive fibers, but it is the brain that decides if pain is needed or not
➤ The brain interprets all of the incoming messages and past experiences and determines if a perceived threat is legitimate or not
NEUROTAG➤ There is no one pain
center in the brain
➤ Many parts of the brain are activated and creating a pain experience
➤ Memories, environmental cues, attitudes and beliefs all contribute
➤ Each person has a unique neurotag
DESCENDING INHIBITION
➤ Option 1: The brain may decide the nociceptive information received is not a threat
➤ Periaqueductal gray area produces opioids, enkephalins, serotonin and endorphins which inhibit nociception, and ultimately the pain experience
➤ Option 2: Nociception may be blocked at the spinal cord level, party due to actions of the interneuron
➤ The interneuron may receive a nociceptive message, and then block that message with a release of GABA
➤ The message ends and the sensation is not cortically registered, and you are not aware of that sensation
WHAT GOES WRONG LEADING TO PERSISTENT PAIN?
➤ Nociceptive fibers may send repeated messages to the dorsal horn of the spinal cord in a injury or degenerative process
➤ Due to high levels of amino acids from the constant nociceptive signals, the interneuron may die, and not regenerate if there is a persistent toxic environment
➤ The end result is a decreased ability to modulate the nociception and ultimately the experience of pain
➤ Second-order receptors change
➤ From a primitive survival standpoint, the brain will want to know about danger in order to protect
➤ Receptors in the second-order neurons are replaced with receptors that will facilitate an increase of danger messages to the brain for analysis
➤ During normal activity, receptors open and close in milliseconds, but in response to this threat, receptors that are fast are replaced with receptors that stay open longer, up to several minutes
➤ The end result is an open gate and the second-order neuron is more easily stimulated and fires faster, creating increased sensitivity
CENTRAL SENSITIZATION
➤ In the spinal cord, repeated stimulation at constant strength of dorsal root afferents can lead to a progressive increase in the number of action potentials generated
➤ This amplification is known as “action potential windup.”
➤ Simply put: with persistent input from the periphery, changes to the spinal cord second-order neurons (and ultimately brain pathways) lead to a heightened sensitization
➤ Overall hyper-excitement of nociceptive pathways and impaired functioning of deciding inhibitory mechanisms in the brain
CENTRAL SENSITIZATION
➤ Dysfunction of the nervous system, endocrine system, immune system
➤ Widespread reaction to threat causing widespread symptoms:
➤ Sore muscles, sensitive nerves, postural problems
➤ Mood swings, depression, decreased concentration/focus
➤ Appetite changes, weight gain, irritable bowel
➤ Sleep disturbance, fatigue, low libido
CORTICAL CHANGES IN PERSISTENT PAIN
➤ Decreased gray matter in dorsolateral prefrontal cortex, right anterior thalamus, the brainstem, the somatosensory cortex, and the posterior parietal cortex
➤ Direct correlation between amount of gray matter loss and pain intensity
➤ Patients with chronic pain have lower increases in blood flow to periaqueductal gray when exposed to painful stimuli
➤ Shift in representation in painful areas in the primary somatosensory cortex which is closely associated with pain chronicity
CORTICAL CHANGES: PSYCHOLOGICAL AND COGNITIVE
➤ Impairments in emotional decision making tasks
➤ Memory, language skills, mental flexibility adversely affected
➤ Reduced ability to shift attention away from images of physical activities associated with threat of back injury
RELATIONSHIP BETWEEN DEPRESSION AND CHRONIC PAIN
➤ Chronic pain and major depression have a shared neuroanatomy and chemistry with similar HPA-axis, ANS, and inflammatory cytokine disturbances
COGNITIVE BEHAVIORAL THERAPY
➤ A psychotherapy approach designed to improve coping and has been adapted for treatment of patients with chronic illness and pain
➤ Thoughts, emotional responses, physiological and behavioral responses interact and influence one another
➤ Individuals’ behaviors also influence the environment
➤ Treatment must address the cognitive, emotional and behavioral dimensions of the presenting problem
➤ The patient must become an active participant in the treatment
THE ‘VICIOUS CYCLE OF PAIN’
➤ The other side of the story:
➤ Repeated visits to healthcare providers
➤ Increased sense of helplessness
➤ Healthcare provider angry, rejecting
➤ Client’s isolation increases
HOW CBT SKILLS HELP YOU HELP YOUR CLIENTS
➤ Enhance communication and understanding
➤ Active partnership with agreement on realistic goals
➤ Simple skills for managing pain and increasing resilience
➤ Empower the client toward good self-care
THERAPEUTIC ALLIANCE IN PAIN EDUCATION
➤ Allow the patient to tell their story without interruption
➤ You can use direct, open-ended questions
➤ “What do you think is causing your pain?”
➤ Don’t focus on what they’ve been told about their condition by healthcare providers
➤ Listen to what they are telling you
➤ Do they have a patho-anatomical explanation for their symptoms?
➤ Focus on a structural label for pain may heighten attention on that pain, emphasize the vulnerability of the body to damage, and increase the client’s pain experience
THERAPEUTIC ALLIANCE IN PAIN EDUCATION
➤ Information must be presented in a manner that is respectful of the client and acknowledges their suffering
➤ Understand that they may have been told incorrect explanations for their chronic pain including both patho-anatomical dysfunction or psychological dysfunction
➤ You need to be an expert and be perceived as such by the client
➤ You need to be respectful and compassionate and be perceived as such by the client
SOCIAL DESIRABILITY FACTOR VERSUS EXAGGERATION
➤ Clients may respond in a manner they perceive will be viewed favorably by others
➤ Clients may exaggerate symptoms or emotional responses in order to receive understanding or treatment
➤ We all do this!
SKILLS TO DEVELOP
➤ Communication skills
➤ Active listening
➤ Goal setting
➤ Pain coping skills
➤ Breath-focus
➤ Physiologic relaxation
➤ Distraction
➤ Reframing unhelpful thinking patterns
ACTIVE LISTENING STRATEGIES
➤ Undivided attention to the client with direct eye contact
➤ Listen with genuine interest and appreciation without interruption
➤ Posture and gestures indicating involvement and engagement
➤ Facial expression reflecting empathy
➤ Discussion based; avoid temptation to lecture
➤ Statements or questions of clarification to gain accurate perception of patient concerns
➤ Summarize what patient has described
➤ Can serve as a transition to a new topic or bring an encounter to an end
ACTIVE LISTENING COMMON ERRORS
➤ Judging
➤ Criticizing, shaming, labelling, expressing personal biases
➤ Suggesting solutions
➤ Risk of disempowering client
➤ Forcing the client to share their story or provide details
➤ Avoiding client concerns
➤ Defensive arguments
➤ Diverting (at times)
OPEN QUESTIONS
➤ Open questions provide insight into the client’s current mental state, thoughts or fears
➤ Open the interaction with clients with an open question
➤ “What is the most important thing you want to address in our session today?”
➤ Toward the end of the discussion or session, use an open question
➤ “What else do we need to discuss before we end?”
➤ “What questions do you have?”
AFFIRMATIONS (VALIDATING STATEMENTS)
➤ Identify and comment on a positive behavior or comment made by the client that speaks to the quality of their character and commitment to health
➤ Examples
➤ I appreciate you being on time for the session today
➤ These headaches are hard on you - you are doing a good job finding time during the day for diaphragmatic breathing and neck stretches
➤ You are continuing to exercise despite your busy schedule - you are commitment to your health and recovery
REFLECTIONS
➤ Your hypothesis about what the client means or might mean
➤ Reflective listening reduces resistance, conveys empathy and reinforces engagement
➤ Examples
➤ You are not sure if these Reiki sessions are helping you
➤ The pain is really frustrating for you and is affecting your relationships with your children
➤ You think the medications from your doctor are working, but the side effects are causing problems for you especially at your job
GOAL SETTING
➤ Goal Setting Versus “Setting an Intention” ➤ Empowers client ➤ Collaborative process between practitioner and client ➤ Think about client confidence, commitment and barriers to reaching
these goals ➤ Can be goals that include domains outside of what is being
accomplished in a Reiki session ➤ Discussions with spouse, children, employer about realistic
expectations because of chronic pain ➤ Adherence to regular exercise, medication, healthcare appointments ➤ Taking a break every hour at work for breathing techniques or
positive self-talk
PAIN COPING SKILLS
PHYSIOLOGICAL RELAXATION
➤ What it is:
➤ Muscle tension reduced
➤ Heart rate slows
➤ Increased temperature in hands and feet
➤ Feelings of calmness
➤ What it isn’t:
➤ Reading a book
➤ Watching the game
➤ Socializing
PHYSIOLOGICAL RELAXATION
➤ Pain often leads to bracing, guarding, tensing the muscles
➤ Pain puts people into sympathetic nervous system activity with increased heart rate, increased blood pressure, increased stress hormones
➤ All of this can INCREASE PAIN
➤ Physiological relaxation counters the stress reaction to pain
➤ Goal is to downregulate the nervous system, promote parasympathetic nervous system activity and decrease the pain response
PHYSIOLOGICAL RELAXATION
➤ Deep breathing
➤ Diaphragmatic breathing
➤ Progressive muscle relaxation
➤ Work with your client to perform these techniques and discuss how your client can do these throughout the day
➤ One Reiki session per week may not be beneficial if the client returns at the same level of pain and stress each week
PLEASANT PLACE IMAGERY
➤ Human attention is limited
➤ Pleasant memory, visualization of pleasant place can help distract from pain or worry
➤ Can be done alone, in conjunction with physiological relaxation techniques, or during a Reiki session
REPLACING UNHELPFUL THINKING/COGNITIVE DISTORTIONS
➤ Step 1: Identify the unhelpful pattern(s)
➤ “I feel my neck pain is terrible and it’s never going to get any better”
➤ Tendency to catastrophize and “predict the future”
➤ “I have not enjoyed all the things I used to enjoy”
➤ Possible clue to depression
➤ “I have worrying thoughts going through my mind all the time”, “I can’t take my mind off of my foot pain”
➤ Rumination
➤ “I don’t think I can make this pain go away”
➤ Feeling helpless
REPLACING UNHELPFUL THINKING/COGNITIVE DISTORTIONS
➤ Step 2: Acknowledge the importance of thinking styles and that thoughts and beliefs may seem “true” but may slow progress toward recovery as they influence mood and behavior
➤ Keeping an open mind, being willing to consider alternative beliefs may improve mood, energy and pain
REPLACING UNHELPFUL THINKING/COGNITIVE DISTORTIONS
➤ Step 3: Communication for more balanced thinking
➤ Brainstorm with client for more realistic ways of thinking, using the client’s own words if possible
➤ “I have no control over my pain”
➤ “I can cope. I am learning new skills.”
➤ “This shouldn’t happen to me, it isn't fair”
➤ “Back pain is really common, and so is recovery.”
➤ “This pain makes me so anxious that I can’t stand it”
➤ “I’ve managed difficulties before and will do so again”
➤ Ultimately we want our clients to recognize these unhelpful thinking patterns for themselves and replace them with more realistic statements
➤ Patient empowerment!
BUT WHEN DO I DO ALL OF THIS?
➤ Does not have to be a formal “skill acquisition" session with your client ➤ Intermittent throughout session, discussions and course of treatment - it
will come up naturally ➤ Example:
➤ Your client tells you there is nothing they can do to lessen their pain ➤ You decide to teach them diaphragmatic breathing ➤ They report some decreased pain or increased feeling of calmness ➤ You tell them that they were able to help themselves relax/feel less
anxious/decrease their pain ➤ Empower the client to do this on their own and remind them they do
have control of their pain and emotions ➤ You will need to do this frequently depending on the clients’ self-
efficacy and empowerment/disempowerment
WHAT ABOUT THE REIKI PART?
➤ Reiki is physiological relaxation, and as a Reiki practitioner you are already promoting parasympathetic nervous system activity by both the hands-on approach of Reiki which activates endogenous inhibitory mechanisms to decrease pain, and by teaching patients Hara breathing or the meditations such as Joshin Kokyu-ho and Seishin Toitsu
➤ In practicing the Reiki Precepts and Hara breathing, we recognize that we and are clients are complex beings who can hold both the troubling thoughts, feelings and sensations inside of us, while also cultivating our strong and stable parts of ourselves
➤ The new knowledge you have today will improve your practice by further empowering your clients to practice pain control skills on their own, and by enhancing the therapeutic relationship with your clients
PRACTICE AND CHALLENGES
➤ There is no cookbook and no perfect answer
➤ Just as your clients will need to practice pain coping skills, you will need to practice communication skills and teaching pain coping skills
➤ It’s okay to be uncertain
➤ It’s okay to get things wrong
➤ If you offend a client, acknowledge it, apologize and correct your mistake
➤ Find your own style
➤ “Don’t let perfect be the enemy of good”
ALL PEOPLE WANT TO BE UNDERSTOOD AND
ACCEPTED FOR WHO THEY ARE
QUESTIONS
