Pain:

More than a

4-Letter WordKEMERY J. SIGMUND, MS, ATC, LAT

CCE, ASSISTANT PROFESSOR,

CONCORDIA UNIVERSITY WISCONSIN

PHD CANDIDATE, KINESIOLOGY

UNIVERSITY OF WISCONSIN-MILWAUKEE

KEMERY.SIGMUND@CUW.EDU

Disclosures

Conflicts of Interest: None

No financial disclosures or conflicts

Viewpoints are my own

Patient information contained is not an

actual patient case or based on a real

person

Acknowledgements

Dr. Marie Hoeger Bement at Marquette University for photos and patient resources, support, & advising

Mary Beth Geiser, PT, DPT at Marquette University & Aurora Hospital Systems for photos and patient resources & support

Dr. Jennifer Earl-Boehm at UW-M for support & advising

Co-workers & students: Photos

What is Pain?

Pain is an unpleasant sensory & emotional experience

associated with actual or potential tissue damage. International Association for the Study of Pain (www.IASP-pain.org)

Pain is the 5th vital sign (The Joint Comission, 2001)

Pain is the number one reason people

seek medical care.

Effective pain management is a moral

imperative

Professional responsibility & Duty of

HCPs

Veterinarians receive 3X as much pain

education as doctors, therapists, and

human providers (all from IOM Report, 2011)

Pain is what the patient says it is (McCaffery,

1968)

Myths Surrounding Pain Assessment

I can only measure pain with Numeric Scales/ VAS

VAS/Numeric scales are not very accurate

If I assess pain, patients will focus on pain instead of function

My patient doesn’t have very high pain tolerance

I know what to expect w/ a given diagnosis

I don’t need to assess it- I can tell when my patient is “really in pain”

What do we know about pain?

A Case To Consider

Molly: HS track athlete with MTSS

Yesterday, pain was 6/10 and they had a meet –

successfully ran 3200m, 1600m; placed 2nd and 3rd,

respectively

Today: 8/10 pain; no visible signs of antalgic gait; walking

under own power; smiling & happy

Palp causes Molly to wince and pull leg away up the

medial tibial border

Pushes your hand away with sharp vs dull but you barely

touched her with the monofilament

Why might she be reporting 8/10

pain today and what do we do?

Biopsychosocial

Model

Biomedical

Model

Find the underlying

cause!

The issue is in the

tissue!

If it doesn’t work…

What is factors are

influencing her

pain? Our

assessment?

Consider 2 scenarios…

Is pain always indicative of tissue

damage?

NO.

When tissue damage does occur, do

you always feel pain?

NO.

Pain with no known tissue damage

Can cause increased nervous

system response

(AMPLIFICATION OF THE SIGNAL)

if persistent or continual

(Peripheral or Central):

Pain sensitization

Why does sensitization occur?

(The short version) Peripheral

Reduced nociceptor firing threshold

Increased nociceptor firing rate

Increased excitatory NT release

Increased receptive fields

Central (called Nociplasty)

Increased neuronal responsiveness

Reduced central/ Wide dynamic range neuron threshold

Communication between pain info (nociceptors) and touch receptors due to overload

Signs of pain sensitization:

Peripheral Nervous System Allodynia

Pain with a non-noxious

stimulus

Did we see this with

Molly?

Signs of Sensitization Hyperalgesia (Local or Remote)

Increased pain response to a noxious stimulus

Did we see this with

Molly?

Signs of Sensitization:

Central Nervous System Hyperalgesia (Remote)

Conditioned Pain

Modulation

Pain should inhibit pain

Impaired CPM Response=

when pain no longer inhibits

pain

Signs of Sensitization: Central

Temporal Summation

Increased pain with a constant

stimulus OR a repeated stimulus of

same intensity

Accentuated in those with

sensitization

Time (s)

0 20 40 60 80 100 120

Pa

in R

atin

gs

0

2

4

6

8

10Chronic

Pain

Healthy

Photos from the lab of Dr. Marie Hoeger

Bement, Marquette University

Clinical Assessment

Allodynia

Hyperalgesia

Temporal Summation

Conditioned Pain Modulation

Heat/Cold Sensation

So What?: Clinical Significance

1) Symptoms may not match behaviors

(they may not “look” like they’re in pain)

2) May appear to be overreactive: it’s a nervous

system issue

3) The “underlying cause” isn’t always malposition,

poor movement, etc.

Pain-movement Relationships

4) You can assess this and include it in notes!

5) You can treat this!

Pain Modulation: 4 M’s…

Medications

Doesn’t have to be all NSAIDs and Opioids

Modalities (affecting sensitization)

Options

Manual Therapy

Jt Mobs, Manips, Massage

Movement

Movement is therapy

…& 1 Big E

Patient Education

In chronic musculoskeletal conditions,

exercise + education can be more effective

than exercise alone

Patellofemoral Pain

Chronic LBP

Knee OA

One More Soapbox:

Opioid Epidemic & AT•“Playgrounds to Pills”:

•Every day (US,) 2500 youth (ages 12-17) abuse a Rx pain reliever for the 1st time.

•Avg age of first time drug use= 12

•2017: death by OD became the leading cause of death among teens in Waukesha County, surpassing traffic accidents

•OD deaths in WI have risen 72% since 2017

What’s your role? What can you do?

Pain in 5-minutes

Pain Specialists, Australia

https://www.youtube.com/watch?v=C_3phB93rvI

Other GREAT Resources

Spoon Theory: https://butyoudontlooksick.com/articles/written-

by-christine/the-spoon-theory/

Patient Education: Adriaan Louw- Why You Hurt

Flyers, This Year in Pain: www.IASP.org

References

International Association for the Study of Pain. Terminology. https://www.iasp-pain.org/terminology?navItemNumber=576

Baker DW. The Joint Commission’s Pain Standards: Origins and Evolution. Oakbrook Terrace, IL: The Joint Commission. 2001-2017.

Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education, and research.http://www.nap.edu/catalog.php?record_id=13172.

Clauw DJ. Diagnosing and treating chronic musculoskeletal pain based on the underlying mechanism(s) Best Pract Res ClinRheumatol. 2015; 29(1):6-19

Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011, 152 (3S) S2-15.

Resources

Fillingim RB, Loeser JD, Baron R, Edwards RR. Assessment of chronic

pain: Domains, methods, and mechanisms. J Pain. 2016; 17(9S): T10-

20.

Kennedy DL, Kemp HI, Ridout D, Yarnitsky D, Rice AS. Reliability of

conditioned pain modulation: a systematic review. Pain. 2016;

157(11): 184-192

Merkle SL, Sluka KA, Frey-Law LA. The interaction between pain and

movement. J Hand Ther. 2018; In Press.