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Slide 1
Pain Perception and Chronic Pain Perception and Chronic PainPain
Tara Jo Manal PT, OCS, SCSTara Jo Manal PT, OCS, SCS
Slide 2
EpidemiologyEpidemiology
97% causes are unknown97% causes are unknown 2% are disk2% are disk 1% Facet1% Facet ~30% require conservative management~30% require conservative management 1% surgery1% surgery All others recover spontaneously All others recover spontaneously
Slide 3
EpidemiologyEpidemiology
30% workers miss time due to back injury30% workers miss time due to back injury 2-4% change jobs as a result2-4% change jobs as a result Workers off work >6months have 50% Workers off work >6months have 50%
chance of returningchance of returning Decreases to 25% after 1 yearDecreases to 25% after 1 year 88% first time injury pain-free in 6 wks88% first time injury pain-free in 6 wks 98% in 24 weeks98% in 24 weeks 99% in 52 weeks99% in 52 weeks
Slide 4
Nonorganic SignsNonorganic Signs
3 or more are considered + test3 or more are considered + test
Regional Disturbance- Sensory or motor Regional Disturbance- Sensory or motor changes/weakness that is nonanatomicalchanges/weakness that is nonanatomical
Superficial/nonanatomic tendernessSuperficial/nonanatomic tenderness– Light touch or deep tenderness over a Light touch or deep tenderness over a
widespread area, nonanatomicwidespread area, nonanatomic
Slide 5
Nonorganic SignsNonorganic Signs
SimulationSimulation
Axial LoadingAxial Loading– Low back pain reported with pressure on the Low back pain reported with pressure on the
patient’s head while standingpatient’s head while standing
Slide 6
Nonorganic SignsNonorganic Signs
SimulationSimulation
RotationRotation– Pain in the low back when the shoulders and Pain in the low back when the shoulders and
pelvis are rotated in the same plane as the pelvis are rotated in the same plane as the patient standspatient stands
Slide 7
Nonorganic SignsNonorganic Signs
DistractionDistraction
Straight Leg RaisingStraight Leg Raising– Inconsistent limitation of straight leg raising in Inconsistent limitation of straight leg raising in
supine and seated positionssupine and seated positions
Slide 8
Nonorganic SignsNonorganic Signs
OverreactionOverreaction
Disporportinate verbalization, facial Disporportinate verbalization, facial expressions, muscle tension, collapsing, expressions, muscle tension, collapsing, sweating, during the examinationsweating, during the examination
Slide 9
Nonorganic Symptom Nonorganic Symptom DescriptorsDescriptors
Do you get pain in your Do you get pain in your tailbone?tailbone?
Do you have numbness Do you have numbness in your entire leg (front, in your entire leg (front, side, and back) at the side, and back) at the same time?same time?
Do you have pain in Do you have pain in your entire leg (front, your entire leg (front, side, and back) at the side, and back) at the same time?same time?
Does your whole leg Does your whole leg give way?give way?
Have you had any time Have you had any time during this episode during this episode when you have very when you have very little back pain?little back pain?
Have you had to go to Have you had to go to the ER due to back the ER due to back pain?pain?
Has all treatment for Has all treatment for your back pain made your back pain made you worse?you worse?
Slide 10
Abnormal Illness Abnormal Illness BehaviorBehavior
Maladaptive overt illness related behavior Maladaptive overt illness related behavior which is out of proportion to the underlying which is out of proportion to the underlying physical disease and more readily physical disease and more readily attributable to associated cognitive and attributable to associated cognitive and affective disturbancesaffective disturbances
Slide 11
Purpose of Nonorganic Purpose of Nonorganic TestingTesting
When the test is negative they can “rule out” When the test is negative they can “rule out” abnormal illness behaviorabnormal illness behavior
Not intended to “rule in” only identify those at Not intended to “rule in” only identify those at risk for an unsuccessful treatment outcomerisk for an unsuccessful treatment outcome
Fritz 2000 Acute LBPFritz 2000 Acute LBP– 2 or more signs2 or more signs– 3 or more symptoms3 or more symptoms– Increase likelihood of not returning to work by 6-Increase likelihood of not returning to work by 6-
10%10%
Slide 12
Psychosocial Variables Psychosocial Variables in LBPin LBP
Bigos et al 1986Bigos et al 1986 Boeing plant in WashingtonBoeing plant in Washington Analyzed 4645 injuries (900LB) over Analyzed 4645 injuries (900LB) over
15months15months Correlation between back injury and poor Correlation between back injury and poor
appraisal ratings (6 mo before injury)appraisal ratings (6 mo before injury) Designed prospective study to look at 3020 Designed prospective study to look at 3020
employees.. 279 developed back injuryemployees.. 279 developed back injury
Slide 13
Psychosocial Variables Psychosocial Variables in LBPin LBP
Psychosocial FactorsPsychosocial Factors Personality InventoriesPersonality Inventories Family SupportFamily Support Co-worker supportCo-worker support Job satisfactionJob satisfaction
Personal FactorsPersonal Factors Isometric strengthIsometric strength FlexibililtyFlexibililty Aerobic CapacityAerobic Capacity HeightHeight WeightWeight
Slide 14
Psychosocial Variables Psychosocial Variables in LBPin LBP
Psychosocial Factors (job employment) had Psychosocial Factors (job employment) had strongest influencestrongest influence
Poor satisfaction – 1.85 times more likely to Poor satisfaction – 1.85 times more likely to report a back injuryreport a back injury
15% variance explained by Job Satisfaction 15% variance explained by Job Satisfaction 85% unaccounted for (not job satisfaction)85% unaccounted for (not job satisfaction) Marras 1993- 400 repetitive lifting jobs in 48 Marras 1993- 400 repetitive lifting jobs in 48
industries (1.56 odds ratio for job industries (1.56 odds ratio for job satisfaction)satisfaction)
Slide 15
Psychosocial Variables Psychosocial Variables in LBPin LBP
Marras 1995Marras 1995 400 lifting jobs classified as low, medium, or 400 lifting jobs classified as low, medium, or
high risk jobshigh risk jobs 5 measures reflected the classification5 measures reflected the classification
– Maximum load moment, maximum lateral trunk Maximum load moment, maximum lateral trunk angular velocity, average trunk twisting velocity, angular velocity, average trunk twisting velocity, lifting frequency, maximum saggital trunk angle)lifting frequency, maximum saggital trunk angle)
Saw job satisfaction 1.32 – 1.48 but the Saw job satisfaction 1.32 – 1.48 but the measures above could predict 10times more measures above could predict 10times more likely to be injuredlikely to be injured
Slide 16
Psychosocial Variables Psychosocial Variables in LBPin LBP
Norman 1998Norman 1998 Auto plant- 104 cases and 130 random Auto plant- 104 cases and 130 random
controlscontrols Biomechanical data, psychosocial, and Biomechanical data, psychosocial, and
psychophysical (perceived stresses)psychophysical (perceived stresses) FactorsFactors
– Peak lumbar shear force 1.7Peak lumbar shear force 1.7– Lumbar disc compression over shift 2.0Lumbar disc compression over shift 2.0– Poor workplace social environment 2.6Poor workplace social environment 2.6– Higher job satisfaction 1.7Higher job satisfaction 1.7
Slide 17
Psychosocial Variables Psychosocial Variables in LBPin LBP
FactorsFactors– Higher coworker support 1.6Higher coworker support 1.6– Perception of being more educated 2.2Perception of being more educated 2.2– Perception of higher physical exertion 3.0Perception of higher physical exertion 3.0
• Capacity of worker relative to jobCapacity of worker relative to job– 45% of variance is explained by these factors45% of variance is explained by these factors
• 12% psychosocial factors12% psychosocial factors• 31% biomechanical31% biomechanical
– Body mass index 2.0Body mass index 2.0– Prior compensation claim 2.2Prior compensation claim 2.2
Slide 18
Chronic Pain and Chronic Pain and DisabilityDisability
Mendelson 1982 LBP persists after legal Mendelson 1982 LBP persists after legal settlement settlement
Hadler 1991 relationship between medical Hadler 1991 relationship between medical examiner determining reward and patient examiner determining reward and patient cases the patient to act disabled cases the patient to act disabled
Werneke and Hart 2001- pain patterns that Werneke and Hart 2001- pain patterns that centralize or not are more predictive of centralize or not are more predictive of chronicity than psychosocial factors chronicity than psychosocial factors
Slide 19
Chronic PainChronic Pain
White and Gordon 1982White and Gordon 1982 85% of disabling LBP cases have no 85% of disabling LBP cases have no
definitive pathoanatomical diagnosisdefinitive pathoanatomical diagnosis
– LBP patients have “nonorganic signs” suggesting LBP patients have “nonorganic signs” suggesting psychological disturbances psychological disturbances
– Poor diagnostic techniques make solid diagnosis Poor diagnostic techniques make solid diagnosis difficultdifficult
Slide 20
Biomechanical and Biomechanical and Psychosocial FactorsPsychosocial Factors
Psychological and Pain are linked Psychological and Pain are linked Marras 2000Marras 2000
– Personality and psychosocial factors increase Personality and psychosocial factors increase spinal loads by up to 27%spinal loads by up to 27%
– Muscular co-contractionMuscular co-contraction– Seen at moderate lifting loads, at heavy loads Seen at moderate lifting loads, at heavy loads
gonegone
Slide 21
First-time Injury Risk First-time Injury Risk FactorsFactors
Best indicator of back trouble is previous back Best indicator of back trouble is previous back trouble (~60%)trouble (~60%)
Police officersPolice officers– Body armor is increased riskBody armor is increased risk– Greater than 2hrs in car is increased riskGreater than 2hrs in car is increased risk
FallsFalls– Longer sick time and greater recurrence than other types Longer sick time and greater recurrence than other types
of first-time LBPof first-time LBP Age and GenderAge and Gender
– Females sustain 2/3 load malesFemales sustain 2/3 load males– 60year old sustain 2/3 of 20 year old60year old sustain 2/3 of 20 year old– 35%female in heavy loads and 19% males35%female in heavy loads and 19% males
Slide 22
First-time Injury Risk First-time Injury Risk FactorsFactors
Increased joint mobility and decreased lumbar Increased joint mobility and decreased lumbar endurance affected first time LBPendurance affected first time LBP
Vibration( esp. sitting)Vibration( esp. sitting) Remaining sedentaryRemaining sedentary
– 8% increase white collar8% increase white collar– 14% decrease for blue collar14% decrease for blue collar
Static work posturesStatic work postures– Esp. mild trunk flexion 20Esp. mild trunk flexion 20°°-45-45°°
Frequent bending and twistingFrequent bending and twisting– Spine motion not torsoSpine motion not torso
LiftingLifting Pulling Pulling PushingPushing
Slide 23
Chronic Changes After Chronic Changes After InjuryInjury
Muscular FunctionMuscular Function– Delayed onset of trunk muscles to sudden Delayed onset of trunk muscles to sudden
activityactivity Anatomical changesAnatomical changes
– Multifidus atrophyMultifidus atrophy Muscular ImbalanceMuscular Imbalance
– Increased BMIIncreased BMI– Flexor/Extensor RatioFlexor/Extensor Ratio– Lateral Bend EnduranceLateral Bend Endurance– Loss Flexion ROMLoss Flexion ROM
Slide 24
Biomechanics and Biomechanics and Psychosocial FactorsPsychosocial Factors
Biomechanical Factors are associated with Biomechanical Factors are associated with LBPLBP
Psychosocial Factors play role and may Psychosocial Factors play role and may related more to episodes after initialrelated more to episodes after initial
The 2 influence each otherThe 2 influence each other LB tissue damage can initiate a cascade of LB tissue damage can initiate a cascade of
changes that can cause pain and intolerance changes that can cause pain and intolerance for yearsfor years
Many times of damage are not detected and Many times of damage are not detected and others are over interpretedothers are over interpreted
Slide 25
Chronic PainChronic Pain
Emotional distressEmotional distress DepressionDepression Failed TreatmentFailed Treatment Adoption of a sick roleAdoption of a sick role Self-sustaining conditionSelf-sustaining condition
Slide 26
Pain ModelsPain Models
NociceptionNociception PainPain SufferingSuffering Pain BehaviorPain Behavior
Physical ProblemPhysical Problem DistressDistress Illness BehaviorIllness Behavior Sick RoleSick Role
Slide 27
Fear AvoidanceFear Avoidance
Pain perceptionPain perception– SensorySensory– EmotionalEmotional
Synchronous and ProportionalSynchronous and Proportional DisassociationDisassociation
– Pain is out of proportion to injuryPain is out of proportion to injury Patient fears pain and avoids itPatient fears pain and avoids it
Slide 28
Fear of PainFear of Pain
Stressful life eventsStressful life events PersonalityPersonality Previous pain historyPrevious pain history Normal pain coping strategyNormal pain coping strategy
– Confrontation resumes activity as toleratedConfrontation resumes activity as tolerated– Avoidance of activities that may cause painAvoidance of activities that may cause pain
Slide 29
Fear Avoidance Belief Fear Avoidance Belief QuestionnaireQuestionnaire
FABQFABQ 16 Items 0-6 (higher = avoidance)16 Items 0-6 (higher = avoidance) 7 Item work subscale7 Item work subscale
– My work might harm my backMy work might harm my back 4 Item physical activity subscale4 Item physical activity subscale
– I should not do physical activity that might make I should not do physical activity that might make my pain worsemy pain worse
Slide 30
Fear Avoidance Belief Fear Avoidance Belief QuestionnaireQuestionnaire
FABQFABQ No difference found between cervical and No difference found between cervical and
lumbarlumbar Patients with cervical spine disorder had Patients with cervical spine disorder had
weaker relationships with pain and disability weaker relationships with pain and disability than lumbarthan lumbar
Differences seen with gender, symptom Differences seen with gender, symptom onset and payer typeonset and payer type
Slide 31
Fear Avoidance Belief PTFear Avoidance Belief PT
Educate the patient LBP is a common Educate the patient LBP is a common condition not a serious diseasecondition not a serious disease
Back BookBack Book Graded ExerciseGraded Exercise
Those with higher Fear Avoidance Belief Those with higher Fear Avoidance Belief benefit from FABPTbenefit from FABPT
Slide 32
DepressionDepression Depressed mood most of the day, nearly every Depressed mood most of the day, nearly every
day day Markedly diminished interest or pleasure in Markedly diminished interest or pleasure in
almost all activities most of the day, nearly almost all activities most of the day, nearly every day (as indicated by either subjective every day (as indicated by either subjective account or observation by others of apathy account or observation by others of apathy most of the time) most of the time)
Significant weight loss or gain Significant weight loss or gain Insomnia or hypersomnia Insomnia or hypersomnia Psychomotor agitation or retardation Psychomotor agitation or retardation Fatigue (loss of energy) Fatigue (loss of energy) Feelings of worthlessness (guilt) Feelings of worthlessness (guilt) Impaired concentration (indecisiveness) Impaired concentration (indecisiveness) Recurrent thoughts of death or suicideRecurrent thoughts of death or suicide