Pain Management

Agenda

• Explain Pain: “All pain is neurogenic.”

• Origins of Pain

• Neuromatrix Theory

• Neurodynamics: Pain and Movement

• Movement & Manual Therapy

• Exercise & Pain

• Pain is not an input to the body, but an output from the brain.

• Nociception is neither required nor sufficient for pain.

Lorimer Moseley, Physiotherapist

• Pain is a disordered affective state brought into being by chemical or mechanical changes in various tissues.

Barry Wyke, Neurologist

Vitals

• Origin – chemical or mechanical – Do your symptoms alter withposition or use?

• Is there any relevant disease process?

• What is your autonomic state / breathing pattern? Are youcommonly cool, especially your hands and feet?

• Which way do you want to move and how does it make youfeel?

• What position do your legs rest in supine?

• Essential Dx: what’s wrong and what to do

• It’s history that reveals the origin of the problem:– Mechanical deformation beyond tolerance

– Chemical irritation

• When the origin is mechanical the solution to the problem lies in movement.

Tautness in the

system where

slackness

should be –

natural shape of

the neural tissue

is undulate

Understand the mechanics and physiology of the nervous system

Requires mobility and blood flow

Nervous system is 2% of body mass and uses 20% of oxygen supply

“Nerves and Nerve Injuries”Sir Sidney Sunderland

Perversion of function – tingling, numbness, spreading pain, spontaneous pain, muscle twitching – without loss of conduction

Millions of people are suffering from this problem and

NO ONE IS TREATING THEM

Adaptive potential is the ability of the system to tolerate a repetitive movement, a forceful blow, or a prolonged position.

3 main challenges that contribute to mechanical pain: sustained positions, repetitive movements, and force.

Louis Gifford: “Any threat to the nervous system is a potential disaster for the future efficiency of the those afflicted. Far better, and more efficient to, whenever possible, adapt to a new posture that protects the nervous system, than to injure the nerve and suffer the consequences of neuropathy.”

REINTERPRET THE MUSCULATURE

• Brain concludes that the tissues are under threat … and that action is required…

• What action?• Patrick Wall – Pain: The Science of Suffering

– “What are the appropriate motor responses to the arrival of injury signals?”

– Pain as need state requiring consummatory act

HUNGRY FOR MOVEMENT

• Withdrawal

• Protection

• Resolution

INSTINCTIVE MOVEMENT

• Those interventions which allow a movement to be performed in a non-threatening context will be successful.

• For handling to be successful, it must be done in a way that reduces threat and/or fulfills expectation.

• Ideally, it will be a novel stimulus that is also non-threatening.

Cory Blickenstaff, PT

• Neurodynamic Mobilization = edgework

• Simple Contact = ideomotion (involuntary motor)

• Dermoneuromodulation = skin stretch (non-nociceptive sensory stimulation)

• Pain Reflex Release = down-regulate protective response

• Joint Mobilization / Manipulation = biomechanical and neurophysiological

• Somatics = sensorimotor integration

• Other?

• Neurofacilitation = muscle recruitment

• Motor Control = perfect practice

• Stabilization = control through range

• High Intensity, Low Force = productive exercise

• Conditioning = perfect practice