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Persisting Shoulder PainRichmond Stace MCSP MSc (Pain) BSc (Hons)
Specialist Pain Physiotherapist
Saturday, 8 February 14
Where is the pain?
• Biomedical - “It’s in the shoulder”
• Neuroscience - “It’s in the space deemed in need of protection by the brain”.
Saturday, 8 February 14
Phantom limb painSaturday, 8 February 14
VS RamachandranSaturday, 8 February 14
Analgesic effect of crossing the arms
Saturday, 8 February 14
Pain in space
• Pain allocated a space
• What is in the space?
• Junk - chemicals
• Why does it hurt?
Space junk
Saturday, 8 February 14
Why does it hurt?
• Brain perceives danger
• Is there really danger?
• How dangerous?
• What is the context?
• Prior experience
Saturday, 8 February 14
Do you need tissues to hurt?
• In most cases, initially yes
• Need a sense of body
• Persisting pain?
• pain - tissue disconnect
Saturday, 8 February 14
Pain neurobiology
• Pain is a conscious, neuroimmunoendocrinological experience
• Multi-system - homeostatic mechanism? (Craig)
• Multi-dimensional -- pain & pain relief
• Physical
• Emotional
• Cognitive
Saturday, 8 February 14
Pain as an emotion
• How is the patient feeling about their pain?
• Emotional brain (Ledoux)
• Danger signals flow to the emotional centres
• Emotional state affects pain (Tracey)
• Any less important than pain with movement?
Saturday, 8 February 14
Pain & cognition
• The bidirectional body-brain
• Thoughts are played out via the body
• Body feelings are interpreted
• Attentional bias
• Stress - anxiety
Saturday, 8 February 14
Pain & stress
• Shoulder - the emotional joint?
• Stress
• Perception of a situation
• Automatic thoughts
• Body responses
• Autonomic NS -- on alert
Saturday, 8 February 14
Movement and pain
• Assumption: painful movement - movement is the problem due to structure
• Movement end result of a process
• Nothing in isolation
• Neuroimmune priming
• Prior experience, thoughts, mindset, beliefs, environment, who’s there.....
Saturday, 8 February 14
Influences on pain• What you are doing
• What you are thinking
• Where you are
• Who you are with
• What have you done there before
• How you are feeling
• Past experiences
• Culture
• Gender
• Genetics
• What your brain thinks you may do (prediction)
• What others are doing
Saturday, 8 February 14
A formula
• Pain biology + influences (biology) - level of resilience + emotional state = pain
• Where can we intervene?
Saturday, 8 February 14
Treatment
• Multidimensional
• Foundation - the basics
• Understanding the biology
• Understanding the influences
• Raise awareness to cultivate change
Saturday, 8 February 14
NeuroplasticitySaturday, 8 February 14
Create the conditions for change
• Neuroplasticity means we can learn & change
• Early messages - “you can’t”, “you won’t”
Saturday, 8 February 14
Pain is an output
• A protective output
• Emerges from the body
• End result of a process
• Target the processes
Saturday, 8 February 14
Training
• To re-programme
• Thoughts & mindset
• Specific sensorimotor training
• Central sensitisation - e.g./ planning stages of movement, medication
Saturday, 8 February 14
Healthy experiences
• Multi-sensory feedback from the painful area
• Movement and other input that does not hurt = happy brain
• Safe
• Knowing that ‘hurt does not equal harm’
Saturday, 8 February 14
Pain & mindsetSaturday, 8 February 14
Look for the clues in the narrativeCompassionate listening & communication
Saturday, 8 February 14
www.specialistpainphysio.com@painphysio t. 07932 689081
Saturday, 8 February 14