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Merging Pain Science and Movement
in a Biopsychosocial Treatment
Chris Joyce PT, DPT, SCS
Assistant Professor
Doctoral Student
Objectives For Today
• To understand the general processes of nociception, peripheral and central
sensitization
• To be able to beneficially apply this understanding to comprehensible education for
patients
• To merge pain neurophysiology, movement into a biopsychosocial treatment of a
patient in pain
• To apply learned concepts to patient cases
Objectives 1 and 2
• To understand the general processes of nociception, peripheral and central
sensitization
• To be able to beneficially apply this understanding to comprehensible
education for patients
Your Body
Your Shoulder/Back/Knee
Nociceptors
Pain Neuromatrix
(Brain)
Your Shoulder/Back/Knee
If You Broke Your Toe, Would It Hurt?
If You Broke Your Toe, Would It Hurt?
Results:
Significant differences were observed between the control
and intervention groups in external rotation and posterior
tilt after 6 weeks of training and in external rotation,
posterior tilt, and upward rotation after 12 weeks of
training
Results (cont.):
All groups showed improvement in self-
reported pain and disability scores; however,
there were no significant differences between
the groups.Conclusion: Hip and knee strengthening is effective and superior to
knee strengthening alone for decreasing pain and
improving activity in persons with patellofemoral pain,
Conclusion(cont.):
…however these outcomes were achieved
without a concurrent change in strength.
Results:
Moderate evidence of relationship in cross-
sectional studies, Moderate evidence of no
relationship in prospective studies Results:
Minimal relationship between changes in pain and
changes in: mobility, trunk extension strength,
trunk flexion strength and back muscle mobility
Imaging and Pain
Lesniak et. al (Am. J Sports Med 2013)-MRI of 21 Asymptomatic Shoulders
• 50% Rotator Cuff tears
• 47% SLAP tears
Navarro-Ledesma et. al (Musculoskelet Sci Pract 2017)-Ultrasonography of 97 patients with chronic shoulder pain
• No correlation between acromio-humeral distance and shoulder pain function and ROM
Schwartzeberg et. al (Orthop J Sports Med 2016)-MRI of 53 Asymptomatic Shoulders
• 55% and 72% had SLAP tears
49 Distinct Findings
0 Findings consistent in all 10 reports
37% Findings appeared only once
Fleiss kappa statistics = .20 (poor overall agreement)
The Pain System becomes the problem
Nociceptors
Pain Neuromatrix
(Brain)
Decreased ROM
Decreased Strength
Increase Swelling
Nociceptors
Pain Neuromatrix
(Brain)
Peripheral and Central Sensitizationhttps://www.youtube.com/watch?time_continue=287&v=YwDMmSwUOOU
Conclusion
For chronic MSK pain disorders, there is compelling evidence that an
educational strategy addressing neurophysiology and neurobiology of pain
can have a positive effect on pain, disability, catastrophization, and physical
performance.
Objectives 3 and 4
• To merge pain neurophysiology, movement into a biopsychosocial treatment of a
patient in pain
• To apply learned concepts to patient cases
Movement Based Interventions
• Task-Specific Training
• Graded Exposure
Task-Specific
BACKGROUND: Recent evidence suggests that traditional impairment-based rehabilitation
approaches for patients with knee pain may not result in improved function or reduced disability.
Bove et. al 2017, JOSPT
Task Specific Training
1. Identify tasks that are commonly difficult or painful
a. Patient-reported
b. Evidence-informed
2. Prescribe task-specific interventions
a. Utilize neuromotor learning principles
b. Neuroplasticity?
• Example: Pain with ascending/descending stairs
• Part Practice: Weight shifting, weight bearing, contralateral push-ing
• Blocked Practice: Repeating the same part over and over again without interruption i.e. step ups on small step using only one leg, then switching
• Random Order: Interspersing variability in practice i.e. switching legs, going up/down, changing foot position, changing weight bearing support or amount, change technique
• Open Environment Practice: Real staircase, with people, with distractions, carrying things, talking on phone
• Maximize Repetitions
Task Specific Training
Bove et. al 2017, JOSPT
Bove et. al 2017, JOSPT
Case Example-Task Specific Training
Your patient states when they raise their arm overhead they have anterior
shoulder pain. They’ve been told that they have “impingement” and that their
rotator cuff is fraying like a rope when it gets jammed in between the acromion
and head of humerus. They’ve heard that impingement is a precursor to rotator
cuff surgery, which they do not want, but they feel like they can’t lift their arm
above their shoulder without having any pain. This pain has been going on for
2 months despite rest, ice, NSAIDs, and activity modification to avoid OH
activities.
Task Specific Training
1. Identify tasks that are commonly difficult or painful
a. Patient-reported
b. Evidence-informed
2. Prescribe task-specific interventions
a. Utilize neuromotor learning principles
b. Neuroplasticity?
Task Specific Training
1. Identify tasks that are commonly difficult or painful-Shoulder Elevation
a. Patient-reported
b. Evidence-informed
2. Prescribe task-specific interventions
a. Utilize neuromotor learning principles
b. Neuroplasticity?
• Example: Shoulder Elevation
• Part Practice: Isometrics, Modified ROM exercises, Mirror therapy
• Blocked Practice: Repeating the same part over and over again without interruption
• Random Order: CKC shoulder elevation, sidelying elevation, prone PROM, OKC into CKC elevation
• Open Environment Practice: Reaching while on the phone, sitting and reaching, throwing a ball, waving,
• Maximize Repetitions
Task Specific Training
Bove et. al 2017, JOSPT
Graded Exposure
Graded Exposure to Fear vs. Graded Exposure to Painful Movements
1. Identify the movement or activity that patient is fearful of
• Fear of Daily Activities Questionnaire17 – VAS Scoring System
• Fear Avoidance Belief Questionnaires18 – Likert Scale Questionnaire
2. Involve the movement or activity in your treatment
3. Reassess fear
4. Increase the intensity of the activity or movement
• Can increase duration, load, volume or any other progressive variable
July, 2009
40
50
60
20
4020
40
10
2030
60
60
Folding laundry
Walking up incline George et. al
2009, JOSPT
George et. al
2009, JOSPT
Initial Session:• Identify most fearful activities (FDAQ)
• Patient reports level of activity he/she is willing to perform with increase in fear
Subsequent Sessions:• Patient performs fearful activities (level of determined based on previous session)
• PT monitors session
• FDAQ reassessment
Does patient have less fear of activities?
YES NO
+ Reinforcement
Increase activity level ≥10%
(duration, frequency, intensity)
Reinforcement of Importance
No change in activity level
(duration, frequency, intensity)
Repeat Process Repeat Process George et. al
2009, JOSPT
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