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ISSUE 5 | MAY 2015

Can my Brain have Pain?

Dave Reese PT, COMT, CSMTISPI Faculty Assistant

I hope you have been following this yearly article on concussions. It can be overwhelming trying to keep up with all the new information that is being published. Hopefully, I can pass on some new and different information to keep you up to speed and interested! Ok, so what does everyone think-can the brain have pain? I was listening to one of my colleague’s evaluations the other day and his patient kept telling him his brain hurts! Hmm…well, there are no pain receptors on the surface of the brain. Therefore, any pain is coming from pain sensitive structures around the brain. This can include muscles, nerves, arteries, veins, sinus, dural pain fibers, periosteum of the skull, subcutaneous tissue, mucous membrane, etc. Good news! You guys remember my woodpecker story? In the March 2014 issue of JOSPT they referenced the little guy stating that they can alter their jugular outflow. What this does is make his brain fit tighter in the cranium to reduce the impact. Pretty cool! Better yet…they even did a CT scan to prove it. Would you believe it happens in humans also? In the same issue, there is a study done by Myer, et al. titled: “Rates of concussions are lower in NFL

games played in higher altitudes.” What they found was concussions were 30% lower when played in altitude. They talk about “Brain slosh” how our brains move in the cranium with blood, spinal fluid, and the skull each having different densities. So in elevation the increase in intracranial volume induces a tighter fit of the brain in the cranium decreasing the brain slosh therefore, not as many concussions. There was a previous study done on high school athletes with the same results noted. Did you know that the brain impact of 2 head ramming sheep is 500g of force! Compare that with a MVA of 50-100g, and high school level impacts of 20-50g. Let’s talk about football helmets. A study presented by the American Academy of Neurology in May 2014, and sponsored by BRAINS, inc. (a research and development company focused on biomechanics of TBI) tested 10 of the more popular helmets. They used crash test dummy head and necks to simulate impact. The helmets included:

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Research:

Early imaging for back pain in older adults

Dry-needling and exercise for chronic whiplash

How does pain lead to disability?

CRPS progress in understanding

Hypoalgesia after exercise

Bullying, abuse and family con-flict as risk factors for pain

Relationship of pain and ancestry

Clinically derived postoperative pain trajectories differ

Effect of environment on long-term chronic pain

In This Issue:

Editorial: Can my Brain have Pain?

A Balanced View of TNE

TNE: When Things Go Wrong

Clinical Tools from OPTP

Clinical Conference 2015

Course Schedule 2015

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Adams a2000, Rawlings Quantum, Riddell 360, Riddell revolution, Riddell revolution speed, Riddell VSR4, Schutt Air advantage, Schutt DNA pro+, and the Zenith x1 and x2. What they found was that the more popular helmets were the least protected! The Schutt Air Advantage was the worst. The best overall was the Adams a2000, however; the Riddell 360 provided the most protection against a closed head injury. What they found was helmets only provide a 20% reduction in risk compared to not wearing a helmet. Biomechanically, linear and rotational forces cause the more serious head injuries. Helmets do provide protection from linear forces. These impacts include skull fractures with reduced risk of 60-70% and 70-80% for brain tissue bruising. Unfortunately, it is the rotational forces that cause the more serious brain damage. Remember, a helmet that doesn’t fit right or the straps not fastened or snug enough isn’t going to help much! Stay protected at all times!! I feel one area that really needs to be addressed are “subconcussions” These are cranial impacts that do not result in any known symptoms or tests. The concern is the repetitive hits someone may receive. Evidence is evolving. Neuropsychological tests have identified athletes with no symptoms, but are having functional impairments. Coaches need to limit the number of days of contact. California has a law limiting the number of tackling/contact to 3 hours per week! Texas has jumped in, limiting tackling to 90 minutes per week. Cool! Someone gets a concussion. Simple enough – you test them with the SCAT3 and they show signs/symptoms consistent with a concussion. But is that enough?? Let’s be more specific. We can break it down as to what type of concussion it is. There are currently 6 types we can categorize: 1. Cognitive/Fatigue- for someone who has decreased concentration, problems learning or retraining, can’t stay focused on a task, can’t multi-

task. May have some fatigue issues. 2. Vestibular- has difficulty with balance or coordinating head and eye movements. Vision issues with head movements. 3. Ocular- may have problems coordinating eye movements or tracking. 4. Post-Traumatic Migraine symptoms consistent with a head ache, sensitivity to light/noise, or being nauseous. 5. Cervical- affects the neck, cranial areas, or even spinal cord. Prolonged headaches. 6. Anxiety/mood- may worry, have mood swings, difficulty managing their thoughts and attitude. By further categorizing their symptoms, this may help with preventing post concussive syndrome. The focus on their treatment is more specific and appropriate for that individual. We need to get them back to school and then back to their sport! How fast can we do this?? A recent study in Pediatrics (Jan. 5, 2015) ‘Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial’ by Danny George Thomas et al may give us some answers. In summary, 88 patients aged 11-22 years old presented to emergency within 24hrs of their concussion. They went through a normal battery of tests, and were then randomized to either strict rest for 5 days versus usual care (1-2 days rest followed by step wise return to activity). They completed a diary to record physical, mental activity, energy exertion, and post concussive symptoms. Results: both groups recorded 20% decreased energy levels, the intervention group had less school and after school attendance, and there were no clinically significant difference in neurocognitive or balance outcomes. The intervention group reported more daily symptoms and slower symptom resolution. Conclusion: Recommending strict rest for adolescents post injury offered no added benefit over the usual care. Symptom reporting was influenced by recommending strict rest.

I would encourage you to respect days 1 and 2 post injury of “Cognitive Rest” and then proceed appropriately with return to school and sports with our current guidelines. Some may argue that “Return to Play” and a parallel concept of “Return to Learn” are consensus based and have not been validated by evidence based studies. More and more studies are coming our way so hopefully this will be addressed. On a final note…I know most of you know that pickle juice has been used to help with muscle cramping. Have you ever tried “Mustard”? Yep! Mustard has acetic acid which helps the body produce acetylcholine. This is a neurotransmitter that stimulates your muscles to work. The best part is they come in nice little packets and they are free at any hamburger place!

Can my Brain have Paincontinued from page 1

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Many therapists are very excited about pain education. We obvious-ly believe from Gifford’s inception of teaching people about pain, through the evidence based medicine period that pain education has come a long way and evidence supports its use. There is, however, a common trend we see in ALL therapeutic treatments – jump to the “new toy” at the cost of any and all treatments. We strong-ly believe pain education to be a tool that can be used for some people. Not everyone needs it. Not everyone is ready for it. Yes, we need to hone our skills and become better at it.

Our current research is interested in just that – who needs pain edu-cation, what characteristics makes a person do well with pain education, and so forth. Pain education has to

be merged with movement, pacing, graded exposure, the odd modal-ity to alter nociception, hands-on treatment, goal setting and so forth. Recently Gail Swoden posted such insight on the Charted Society of Physiotherapy (UK) website (March 6), passed onto us from Phillipa, Lou-is Gifford’s wife. We thought we’d post this for our readers, since we strongly agree with this:

I think a good neuroscience explanation can decrease the threat value of pain for some people but much of the effect is prob-ably due to non-specific effects and may also only be short term. I worry that the effectiveness of NE has been overstated and that it is sometimes done automati-cally with every chronic pain patient and is not used judiciously. Some clinicians spend a great deal of time and effort do-

ing it and I’m not sure this is warranted and I worry that some think it is THE treatment, rather than a possible part of treatment. I think we risk getting clev-erer and more complicated in our expla-nations and metaphors and sometimes simple is better. We can end up doing it just because we can and this becomes a knowledge demonstration that is not individualized and has no clear purpose (function). If something can have an ef-fect, it can do that in both directions, i.e. a positive or negative effect.

What is the function of our behavior when we give explanations? If your pur-pose is threat reduction, there is litera-ture to support the idea that attempt at reassurance generally only reassure in the short term, can increase anxiety, and are least likely to work with people with high levels of anxiety. For me, it’s got to be about behavior change. If it’s behavior change, cognitive or emotional change is not necessary first or at all. What about those highly anxious patients who have already been given explanations by you or others in the past. How likely is anoth-er explanation on the same point likely to be successful? Might we be keeping the patient stuck by reinforcing the idea that they need an explanation before behav-ior change can occur? Could we instead help them to increase meaningful living, with confusion, uncertainty and fear? Would we be willing to be alongside them on this journey and sit with our own sense of unease at not having given them an explanation?

A BALANCED VIEW OF THERAPEUTIC PAIN NEUROSCIENCE

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Therapeutic Neuroscience Education: When Things Go Wrong…I was recently contacted by a physical therapist that had a “bad” experience teaching her patient about pain. Al-though the patient seemed to “get it”, the patient upon return to a follow-up visit, was not happy. The proverbial “you think it’s in my head” conversa-tion ensued and the patient was not happy. Needless to say, I got an S-O-S e-mail (one of many) not knowing what to do next. I wish everyone could see my inbox – this is not un-common. (By the way – thanks to those who send us positive feedback). In this month’s newsletter, I thought I’d repost the e-mail reply I sent to the therapist, with the idea of helping many of you who have had “bad expe-riences” teaching people about pain and second-guessing the approach: 1. I am proud of you – keep going. If we had to stop after any/all failures in therapy with any/all ap-proaches, the average lifespan of a PT would be 1 week! 2. There are many unknowns about TNE. Many people ask me if this could work for people with per-sonality disorders, strokes, etc., and the answer is….we don’t know (yet) 3. Don’t kid yourself: If I had a penny for every failure with TNE I’d be rich. I have been fortunate enough to be around many of the “names” as-sociated with TNE and guess what: We all have failures! Should I quote Edison who failed a zillion times in making the light bulb? 4. TNE is not unique – for exam-ple, I perform spinal manipulation in the clinic and have had failures with it – someone coming back and being sore or worse. Why worse? I chose the wrong technique, did it on the wrong patient, did it too aggressively, etc. TNE does the same thing…Also think of a knee replacement patient you bend too much/hard and they come back the next time all flared up and angry. 5. If not TNE, then what? More

ultrasound? Have enough gel? More heat? The problem is not TNE, but the application – maybe too much; may-be the wrong patient; maybe the right patient but at the wrong time….Don’t be so hard on yourself and TNE…. 6. David Butler’s quote: The art explaining pain to a patient is to tell them it’s in their head without telling them it’s in their head! 7. Timing is everything. We have not studied this aspect yet – like-ly a huge factor 8. Is my delivery of TNE now as good as 15 years ago? No – much better. As with any other therapeutic skill, it takes practice. I know my de-livery is now easier, more relaxed, etc. 9. The current area we need to investigate in TNE is what makes it successful. Lorimer Moseley at CSM commented on “connecting” with a patient. One of our instructors is do-ing his PhD work on this exact topic and developing “trust” may be a huge part of the success. Now the question begs – what makes a patient trust a PT…time, honesty, thorough examina-tion, being treated as a human being, understanding their suffering, empa-thy, etc. Can a patient with person-ality disorder, or schizophrenia trust? Good question for the psychologists. 10. How much TNE do I provide at a session - it’s patient and scenario specific 11. I think you should be careful looking at this as a nega-tive experience. David Butler talks about, and we just got a paper accepted discussing this, called: Explain pain. If a patient e x p e r i e n c e s

more pain after TNE or it created some emotions (crying, depression, anger), it may be a good thing. This tells you he/she listened and it made an im-pact. These patients (per our paper) have shown to make the biggest shifts in the end. You have likely planted a seed. Don’t be surprised if the patient comes back at some point….because they know what you said was right. The opposite is not good – a patient who comes back and says they under-stand and know everything…we call this superficial learning 12. Education, just like exercise needs to be paced…you cannot start running by going out and running 20 miles. Most therapists want to tell patients everything they know about pain and give them the proverbial drink from a fire-hydrant. There is likely a lot more to add, but TNE is not unique. In contrast, the success of TNE is truly remark-able and likely a major factor in ther-apists falling in love with their pro-fession again. Have you fallen in love with your choice of profession after discovering pain science? Let us know – we’d love to share your story!

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Correlating pages

Section topic Card number

Teaching cues

Scientifi c support

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ort

Neuroscience Education Books for Patients Adriaan Louw’s neuroscience books use simple language to help patients understand and lessen their pain. Patient books and clinical resources from Adriaan Louw are available exclusively from OPTP.

Call 800.367.7393 or visit OPTP.com

Therapeutic Neuroscience Education: Teaching Patients About Pain; A Guide for Clinicians Evidence shows patients who understand how pain works experience less pain, are less fearful, move better and exercise more. Adriaan Louw and Emilio Puentedura deliver an evidence-based perspective on how the body and brain collaborate to create pain, how to convey this view of pain to patients and how to integrate therapeutic neuroscience education into a practice.

Why You Hurt: Therapeutic Neuroscience Education System Teach your patients about pain with Adriaan Louw’s comprehensive, integrated education system. With over a dozen versatile sessions, each with reproducible homework, you can deliver precise messages to a variety of pain patients and provide immediate application of therapeutic neuroscience. Why You Hurt includes 120+ illustrated education cards with teaching cues, 50 homework cards, 6 pain questionnaire cards, detailed instructions and an easy-to-use teaching index.

Understanding pain doesn’t have to hurt.USER-FRIENDLY NEUROSCIENCE EDUCATION TOOLS FOR CLINICIANS AND PATIENTS

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Save The Date

ISPI Clinical Conference 2015: Every Joint has a Brain

June 19, 20 & 21, 2015, Hilton Minneapolis/Bloomington, MN

PRE-CONFERENCE CRPS COURSESOLD OUT! Too Hot to Handle: Desensitizing the Hypersensitive Patient-Adriaan Louw/Kory Zimney

SATURDAY 2 HOUR BREAKOUT SESSIONS:Analysis of Lower Extremity Biomechanics-Chris Powers (AM Only)

SOLD OUT! The Neck Turns the Head…or Does it?-Ina Diener (PM Only)

75% FULL Trigger Points for the Lower Quarter-César Fernández

75% FULL Arms, Tunnels, Pain and Therapy-Steve Schmidt

3 AM SPOTS LEFT / PM SOLD OUT! The Frozen Shoulder Has A Brain-Paul Mintken

The Foot—Use it or Lose it-Steve Forbush/Colleen Louw

SUNDAY 4 HOUR BREAKOUT SESSIONS:90% FULL Trigger Points for the Upper Quarter-César Fernández

1 SPOT LEFT! The Triad: Shoulder, Neck and Thoracic Spine-Paul Mintken

Treating the Low Back via The Brain-Louie Puentedura

Pelvic Pain: What Every Therapist Needs to Know-Sandy Hilton

Therapeutic Neuroscience Education and the Brain-Adriaan Louw

Some of the more popular courses at the conference are selling out so we encourage you to get registered now if there is a speaker or topic that you are interested in. You will be placed on a waiting list for any courses that are full.

Click here to register or for more information

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Education is Therapy…

2015 Course Schedule

Sat/Sun May 2 & 3 Therapeutic Neuroscience Education: Educating Patients About Pain Houghton, MITue May 5 Why Do I Hurt? (2 hours) Davenport, IASat/Sun May 16 & 17 The Cervical Spine: A Manual Therapy & Pain Science Approach Roseburg, ORSat/Sun May 30 & 31 Therapeutic Neuroscience Education: Educating Patients About Pain Denver, COFri Jun 19 Too Hot to Handle: Desensitizing the Hypersensitive Patient Bloomington, MNFri/Sat/Sun Jun 19-22 The Clinical Conference: Every Joint Has a Brain Bloomington, MNSat/Sun Jun 27 & 28 Spinal Manipulation I: A Physical Therapy Approach Flower Mound, TXSat/Sun Aug 15 & 16 The Thoracic Spine: A Manual Therapy and Pain Science Approach Tulsa, OKFri/Sat/Sun Aug 21-23 Therapeutic Neuroscience Education: Educating Patients About Pain Santiago, ChileSat/Sun Sep 26 & 27 The Lumbar Spine: A Manual Therapy and Pain Science Approach Des Moines, IASat/Sun Sep 26 & 27 Therapeutic Neuroscience Education: Educating Patients About Pain Spartanburg, SCSat October 3 Too Hot to Handle: Desensitizing the Hypersensitive Patient Kansas City, MOSun October 4 Perioperative Therapeutic Neuroscience Education Kansas City, MOSat/Sun Oct 10 & 11 The Upper Quadrant: A Differential Diagnosis Approach to Manual Therapy Liberty, MOSat/Sun Oct 10 & 11 A Study of Neurodynamics: The Body’s Living Alarm Philadelphia, PA Sat/Sun Oct 24 & 25 Elbow, Wrist and Hand, Differential Diagnosis & Management Flower Mound, TXSat/Sun Oct 31 & Nov 1 Therapeutic Neuroscience Education: Educating Patients About Pain Fountain Valley, CASat/Sun Nov 7 & 8 Spinal Manipulation I: A Physical Therapy Approach Ashburn, VASat/Sun Nov 7 & 8 Focus on Function: Changing Pain Related Behavior Minneapolis, MNSat/Sun Nov 14 & 15 The Lower Quadrant: A Differential Diagnosis Approach to Manual Therapy Carroll, IASat/Sun Dec 5 & 6 Spinal Manipulation I: A Physical Therapy Approach Story City, IASat/Sun Dec 12 & 13 The Cervical Spine: A Manual Therapy and Pain Science Approach Story City, IA

We’re scheduling into 2016 right now If you are interested in hosting a one or two-day class at your facility, contact us.www.ispinstitute.com | info@ispinstitute.com | 1-866-235-4289