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Manag ing the Chron i c Pa in Pa t i en t

Manag ing the Chron i c Pa in Pa t i en t

Dr Anthony Nicholson DACNB FIANM(aus)

CEO, Chiropractic Development International (CDI)

Adjunct Lecturer in Neuromusculoskeletal Diagnosis

Macquarie University

Chiropractor & Partner, Spine Partners Wahroonga

www.cdi.edu.au / www.spinepartners.com.au

Mary is 36 years old. She is referred by her General Practitioner for

assessment and management of chronic spinal pain. She was diagnosed

with fibromyalgia 10 years ago and has since been under the

management of a rheumatologist. Earlier this year she was also

diagnosed with seronegative rheumatoid arthritis. Whilst Mary

experiences widespread pain, her most troubling symptoms include lower

back and neck pain along with variable tingling sensations in both arms

from the shoulders down to the fingers. Mary has also had long standing

pain and stiffness in both knees. She has played netball for many years

and her knees seemed to be the start point of her broader pain syndrome.

Her medication list includes Lyrica, Micardis, Salazopyrin, Sinequan,

Solone and Trifeme. Mary also suffers anxiety, "brain fog" and frequent

headaches.

Adam is 26 years old. He has suffered from persistent lower back pain for the past

three years. This began during a basketball game and worsened a few weeks later as

he performed a side-step in a game of football. MRI demonstrated a bulging disc and

annular ‘tear’ and he was given rehab exercises. A further MRI was done a year later.

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O R I G I N A L I M A G I N G

O R I G I N A L I M A G I N G

I M A G I N G 1 Y E A R L A T E R

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I M A G I N G 1 Y E A R L A T E R

Currently Adam goes to the gym, although he can only manage to walk on the

treadmill and use an exercise bike, as resistance training seems to provoke back pain

almost immediately. Adam now feels constant stiffness and aching in the lower lumbar

region.

Adam has tried multiple treatment approaches from other musculoskeletal clinicians.

These have typically focussed upon mechanical explanations, such as ongoing ‘disc

injury’, ‘weak core muscles’ and ‘pelvic imbalance’.

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CNSA N A G I N G T H E C H R O N I C P A I N P A T I E N T

Understand the neurology of tissue protection

Gain a clear conceptual understanding of what pain represents

Identify the dominant pain mechanism

Identify faulty beliefs held by the patient

Appreciate the power of words & explanations

Use a brain-based treatment approach

Communicate using the latest concepts in pain science

CNS

Genetic tendency

It remembers…

It predicts…

It selects…

It decides…

The nociceptive system - the peripheral machinery for protection

Nociception is the detection of noxious stimuli – a high threshold system in its normal mode of operation

A noxious stimulus is one that is capable of producing tissue damage

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Withdrawal reflex for immediate protection

An intensely unpleasant experience linked to the stimulus to change future behaviour

Noxious stimulus

The second order neuron -

accessing the central pain

pathways

Reflex connections onto

lower motor neurons

Limbic system

Autonomic centres

Thalamus

Cortical areas

C E N T R A L P A I N N E U R O M A T R I X

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C E N T R A L P A I N N E U R O M A T R I X

Nociceptive inputs

Internal evaluation

This image cannot currently be displayed.

It is an output from the pain neuromatrix that alters the function of sensory, motor and autonomic systems.

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MEANING

Peripheral sensitisation

Central sensitisation

CNSD E S C E N D I N G I N H I B I T I O N

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Spinal cord

Midbrain

Pons

Medulla

Periaqueductal gray

Locus coeruleus

Nucleus raphe magnus

Dorsal horn

Inputs from hypothalamus, amygdala and cortex

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Loss of fine motor control

Tissue deconditioning

Activation of our protection system

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It is seen to represent

‘nothing’ – an inert

ingredient with no effect.

The skilful clinician recognises

and recruits the non-specific

effects of a clinical interaction.

Is this the same as placebo?

What does the term

‘Contextually Aided

Recovery’ actually mean?

Placebo is thought to

have emerged from

medieval Europe.

“The placebo pill or intervention is merely a trigger, wrapped in contextual meaning that

initiates an innate ability of the CNS to directly modulate ascending nociception.

Evidence is now incontrovertible that patient expectation of benefit as constructed by the use of

such contextual cues can also powerfully modulate motor and immune function. Some authors

have suggested alternative language to describe this phenomenon to decouple the historically

negative semantics of placebo from what are ostensibly desirable effects. For example,

Moerman suggested the ‘meaning effect’ while ‘contextual effect’ or ‘contextual healing’ have

also been suggested.”

“The contextual effect i.e., the analgesia, modulated immune or motor response - can be

triggered by a raft of contextual factors commonly present in therapeutic encounters. These may

include administration of a pill or treatment, powerful words as used by a clinician, the clinical

environment itself or the cultural signals engendered by the use of a white coat or the title of

‘doctor’ amongst many others.”

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“A recent review included general categories of known factors that support contextual

healing; patient-physician relationship (verbal communication, nonverbal communication),

treatment features (clear diagnosis, overt therapy and observational learning, patient centred

approach, global process of care, therapeutic touch), and healthcare setting features

(environment, architecture and interior design).

In short, how a patient understands and interprets the words and actions of a clinician and

the clinical environment within a clinical encounter, can switch on or off neurobiological

pathways that directly reduce or enhance pain.”

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Intermittent sharp, dull ache or throb at rest

Aggravating and easing factors

Proportionate painProportionate pain

N O C I C E P T I V E D O M I N A N T P A I N

No night pain, dysesthesia, burning,shooting or electric

Also consider how localised thepain is on the body chart

History of nerve pathology or compromise

Positive neurodynamic testsand palpation (mechanical tests)

Pain in dermatomal or cutaneous distributionPain in dermatomal or cutaneous distribution

P E R I P H E R A L N E U R O P A T H I C D O M I N A N T P A I N

Psychosocial issues – consider therisk rating from the intake forms

Diffuse palpation tenderness

Disproportionate aggravatingand easing factors

Disproportionate painDisproportionate pain

D O M I N A N T C E N T R A L P A I N M E C H A N I S M

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I D E N T I F Y F A U L T Y B E L I E F S

“Understanding the patient’s unique experience is essential to discovery of the patient-

specific beliefs and risk factors that will serve as the ‘target’ when educating a patient about the

biology and physiology of their pain experience in the therapeutic neuroscience education (TNE)

approach.”

“What do you think is causing your pain?”

“What have you been told is the reason for your pain?”

“What do you think is preventing you from getting past this?”

“When you bend over / lift your arm / and it hurts what do you think is happening to cause the pain at that moment?”

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T H E P O W E R O F W O R D S

“Explain Pain (EP) is an educational intervention aimed at reconceptualising pain itself. It’s a

conceptual change strategy.”

“Conceptual change learning is specifically shaped around challenging existing knowledge

and knowledge structures rather than simply learning new information.”

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“The core objective of EP approach to treatment is to shift one’s conceptualization of pain

from that of a marker of tissue damage or disease to that of a marker of perceived need to

protect body tissue.”

B R A I N - B A S E D A P P R O A C H

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Re-mapping the brain with novel and amplified sensory input

How could this relate to manual treatment?

S E N S O R Y D I S C R I M I N A T I O N T R A I N I N G

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CNSP R O F E S S I O N A L C O M M U N I C A T I O N

Working Diagnosis and Management:

Mary is neurologically intact at a gross level, with no signs ofuncontained disc pathology or focal insult to either the nerveroots or spinal cord.

While Mary does exhibit numerous areas of articular andmyofascial dysfunction that are viable targets for manualintervention, careful consideration is also given to the broadercontext of brain-amplified spinal pain mechanisms with whichher peripheral tissues interact.

CNSP R O F E S S I O N A L C O M M U N I C A T I O N

Research interest into Fibromyalgia as a prototypical central paindisorder continues to swell, and our clinical approach to patientslike Mary is constantly being refined accordingly. When thinkingperipherally, a worthwhile aim of manual treatment is to reduceobvious localised areas of tissue nociception that continue toactivate Mary’s peripheral pain pathways. Pain invariably leadsto the avoidance of movement and a shrinking physical capacity.Deconditioned tissues then become more potent paingenerators.

CNSP R O F E S S I O N A L C O M M U N I C A T I O N

From the perspective of Fibromyalgia being a centrally-augmented pain experience, manual treatment is beingconsidered in a different light. Patients with chronic pain areknown to exhibit distorted representations of body parts in thesensory and motor cortices, as well as impairments indescending pain inhibitory controls.

Gently applying passive joint movements as part of a moreglobal approach is seen as a way of amplifying theproprioceptive awareness of body movements again andrestoring a normal central representation – essentially breakinglearned associations between movement and pain. An effectivedose and blend of proprioceptive stimulation is also known tomodulate descending inhibitory control of spinal painprocessing.

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CNSP R O F E S S I O N A L C O M M U N I C A T I O N

Ensuring that Mary is actively engaged in her management asearly as possible is also considered highly important. A strongfocus on education to distinguish between ‘hurt’ and ‘harm’, aswell as exercises that gently challenge perceived movementlimitations are known to increase the chance of treatmentsuccess