Therapeutic Neuroscience Eduction · Therapeutic Neuroscience Education OPTA June 2016 Property of ISPI–not to be copied without permission 3 Chronic Pain Numbers •Epidemiological

Therapeutic Neuroscience Education OPTA June 2016

Property of ISPI– not to be copied

without permission 1

Therapeutic Neuroscience

EductionKnow Pain; Know Gain

Kory Zimney, PT, DPT, CSMT, CAFS




10 Visits• 64 year old lady with

3 years of CLBP

• Numerous treatments

• Numerous clinicians

• Pain rating 9/10

(NRS)

• Oswestry 54%

(Severe disability)

• FABQ-W= 25/42,;

FABQ-PA = 20/24

• Zung depression

scale = 58

And more…Ultrasound

Spinal

Mobilization

Spinal

Manipulation

Aquatic

Therapy Soft Tissue

Treatment

Electrical

Stimulation

TENS

Posture

Ergonomics

Spinal

Stabilization

Traction

Myofacial

Release

Cranio

Sacral

Triggerpoint

Therapy

Name the treatment

Up to 2/3 of the 70+ million have been living with this pain for more than five years

(AAPM, 1999)

IOM Relieving Pain in America 2011

Report: “Chronic Pain affects about

100 million American adults.”

x 25




Chronic Pain Numbers

• Epidemiological data suggest that chronic,widespread, nonspecific musculoskeletal pain is onthe rise, especially in the area of chronic low backpain(CLBP), adding to the ever increasing costs ofhealth care (Magni et al, 1993; McMahon andKoltzenburg, 2005).

• The prevalence of chronic pain was 35.5% (Raftery,Sarma et al. 2011)

We all practice a bio-psycho-social approach…right…? Example 1

• What is this?

• How long will it take?

• What do you want the patient to do?

• What should the patient NOT do?

• What will you as the clinician be doing for this?

Example 2

• What is this?

• How long will it take?

• What do you want the patient to do?

• What should the patient NOT do?

• What will you as the clinician be doing for this?

Underpinning

the bio-psycho-social

approach & held together with

reasoning “glue”

Representation

Pain mechanisms

Onion skins

Beliefs/fears/threats Biomechanics

Pathoanatomy

Evolutionary

Biology

Anatomy

Louw A, Butler DS. Chronic

Pain. In: S.B. B, Manske R,

eds. Clinical Orthopaedic

Rehabilitation. 3rd Edition ed.

Philadelphia, PA: Elsevier;

2011.




Underpinning




Representation

Pain mechanisms

Onion skins


Pathoanatomy

Evolutionary

Biology

Anatomy






2011.

Underpinning




Representation

Pain mechanisms

Onion skins


Pathoanatomy

Evolutionary

Biology

Anatomy






2011.

Biomechanical models

Underpinning




Representation

Pain mechanisms

Onion skins


Pathoanatomy

Evolutionary

Biology

Anatomy






2011.

Tissue Pathology




ihavewhiplash.com

myanklehurts.com These models are

very prevalent

• Prevailing biomedical models focus on tissues and tissueinjury.(Houben, Ostelo et al. 2005; Henrotin, Cedraschi et al.2006; Weiner 2008)

• Orthopedic-based professions such physical therapycommonly use anatomy and patho-anatomy based models toexplain pain to their patients. (Houben, Ostelo et al. 2005;Henrotin, Cedraschi et al. 2006; Spoto and Collins 2008;Weiner 2008)

1. Anatomy

2. Biomechanics

3. Pathoanatomy

Research into anatomy, biomechanical and

pathoanatomy models

• Not only have these models

shown limited efficacy in

decreasing pain and disability, but

they may increase fear in

patients, which in turn, may

increase their pain.(Greene,

Appel et al. 2005; Morr, Shanti et

al. 2010)

Degenerative terms

•“Wear and tear”

•“Deterioration”

•“Disc space loss”

•“Crumbling”

•“Collapsing”

Research into anatomy, biomechanical and

pathoanatomy models




Underpinning




representation

Pain mechanisms

onion skins

Beliefs/fears/threats biomechanics

pathoanatomy

evolutionary

biology

anatomy






2011.

Would this hurt?

Louw A. Why You Hurt: A

Neuroscience Approach to Pain.

Minneapolis: OPTP; 2012.

Would this hurt if….?

34

Louw A. Why You Hurt: A

Neuroscience Approach to Pain.

Minneapolis: OPTP; 2012.

How Dangerous is

this?

This is dangerous

More information

Facilitation

Neuronal adaption

How Dangerous is

this?

This is not

dangerous

Inhibition

Endogenous

Consider this….




Perception can change based on

contextPain relies on context

Pain relies on context Pain relies on context

Simotas, A. C. Shen, T. Neck pain in demolition derby drivers. Arch Phys Med Rehabil.

2005. 86(4): 693-696




Underpinning




Representation

Pain mechanisms

Onion skins


Pathoanatomy

Evolutionary

Biology

Anatomy






2011.

Our view of pain processing is old

Wade, D., Why physical medicine, physical disability and physical rehabilitation?

We should abandon Cartesian dualism. Clin Rehab, 2006. 20: p. 85-90.

Pain is viewed as a Thing

It’s

Fasci

a

It’s a

Trigger

Point

It’s

Postur

e

It’s a

DiscIt’s

the

Face

t

It’s

the

Core

Fundamental Beliefs:

• Pain only occurs when you are injured.

• The amount of pain one feels is a

direct indication of the amount of

tissue damage one has incurred.

Fundamental Reality:

Pain ≠ Injury

An unpleasant sensory and

emotional experience associated

with actual or potential tissue

damage, or described in terms of

such damage.








such damage.





such damage.





such damage.

Pain viewed as a

Personal Experience

THOUGHTS

DREAMS

HOPES

FEARS

ANXIETIES

BEHAVIORSBELIEFS

HABITS

STRESSORS

EMOTIONS

DISABILITY

DEPRESSION

FINANCES

IDENTITY

RESOND via

OUTPUTS: • Pain

• Action programs

• Stress regulation

Tissues

Environment

SCRUTINIZE via

BODY-SELF

NEUROMATRIX: • Sensory

• Cognitive

• Affective

Gifford, L.S., Pain, the tissues and the nervous

system. Physiotherapy, 1998. 84: p. 27-33.

Mature

Organism

Model

Underpinning




Representation

Pain mechanisms

Onion skins


Pathoanatomy

Evolutionary

Biology

Anatomy






2011.




Evolutionary Models

• Parents to offspring

• Survival

• Consider:

– Pain protects

– Inflammation protects

– Some dysfunctions protect

Underpinning




Representation

Pain mechanisms

Onion skins


Pathoanatomy

Evolutionary

Biology

Anatomy






2011.

Butler D, Moseley G. Explain Pain.

Adelaide: Noigroup; 2003.

Underpinning




Representation

Pain mechanisms

Onion skins


Pathoanatomy

Evolutionary

Biology

Anatomy






2011.

Vlaeyen JWS, Linton SJ. Fear-avoidance and its

consequences in chronic musculoskeletal pain: a

state of the art. Pain. 2000;85:317-322.

Could also be emotional

overload

Choice made

Importance of early

education?

Knowledge

Threatening and provocative words; Medical tests; Various

opinions; Internet information; Experiences

Irrational thoughts

Limited knowledge

Pull back

Do less

Increased fear

Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317-322.




“I’m good”“No big deal”“I’ll be OK”“Lots I can do for this”“Keep moving”“No pain, no gain”“Couple of beers…I’ll be OK”


May have never

experienced good pain

Remembers various pain experiences quite vividly

“I have a bulging disc”“I have arthritis”“No one agrees”“No one can find it”“ My dad had severe…”“Saw on the Internet…”“My neighbor…”

“This must be bad”“I will never be able to…”“I will be cripple at 65”“I will be in a wheelchair”

“Since this I have not gone out much”“No going to the movies”


Pain is a %$#@ more complex than just

tissue…

A fundamental flaw:

The Predominant Model for Pain

If the main reason for pain is a

stiff joint…

Flynn T, Fritz J, Whitman

J, et al. A clinical

prediction rule for

classifying patients with

low back pain who

demonstrate short-term

improvement with spinal

manipulation. Spine. Dec

15 2002;27(24):2835-

2843.

If the main reason for pain is a

tight muscle…

Fernandez-de-Las-

Penas C, Alonso-

Blanco C, Cuadrado

ML, Miangolarra JC,

Barriga FJ, Pareja JA.

Are manual therapies

effective in reducing

pain from tension-type

headache?: a

systematic review.

Clin J Pain. Mar-Apr

2006;22(3):278-285.




If the main reason for pain is

altered muscle recruitment…

Hodges PW. Core

stability exercises for

chronic low back pain.

Orthopedic Clinics of

North America.

2003;34:245-254.

But what if the

pain and

disability is due

to faulty

cognitions?

• My pain is due to the bulging disc

• I hurt because I have arthritis

• Movement will damage tissue and increase pain

• Pain means something is wrong

• I am not doing anything until all pain is gone

• I am afraid my pain will get worse

• I have a very rare case of…

It is well established that psychological and

socioeconomic factors are correlated to pain• Fear

• Catastrophization

• Knowledge

• Anticipation and consequence of pain1. Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic

low back pain and its relation to behavioural performance. Pain. 1995;62:363-372.

2. Kovacs FM, Seco J, Royuela A, Pena A, Muriel A. The correlation between pain, catastrophizing, and

disability in subacute and chronic low back pain: a study in the routine clinical practice of the Spanish

National Health Service. Spine. Feb 15 2011;36(4):339-345.

3. Moseley GL, Hodges PW, Nicholas MK. A randomized controlled trial of intensive neurophysiology

education in chronic low back pain. Clinical Journal of Pain. 2004;20:324-330.Moseley GL. A pain

neuromatrix approach to patients with chronic pain. Man Ther. Aug 2003;8(3):130-140.

Returning to our patient• “I have

bulging

discs”

• “I have

arthritis”

Louw A, Puentedura EL,

Mintken P. Use of an

abbreviated neuroscience

education approach in the

treatment of chronic low

back pain: A case report.

Physiotherapy theory and

practice. Jul 3 2011.

Cognitive Processing

• Afraid; poorly understood; movement = pain

due to tissues being damaged

High

Threat

PAIN

to

defend

Louw A, Puentedura EL, Mintken P. Use of an abbreviated neuroscience

education approach in the treatment of chronic low back pain: A case report.

Physiotherapy theory and practice. Jul 3 2011.

What about…

The Top Down Effect

Tissues

Environment Adapted from Gifford LS. Pain, the tissues and the

nervous system. Physiotherapy. 1998;84:27-33.




That ultrasound thing works every time My pain story

So…

• Current clinical educational models

don’t really work

• We need to change beliefs

• Is there a “better way” to educate?

• Why educate patients in PAIN

about anatomy and biomechanics?

Why not just teach them more

about….PAIN?Image: Clinical Journal

of Genius 2013

Origins of Neuroscience Education

The origins of neuroscience education

Moseley L. Combined physiotherapy and

education is efficacious for chronic low back

pain. Aust J Physiother. 2002;48(4):297-302.




Efficacy Neuroscience Education

Louw A, Zimney K, Puentedura EJ,

Diener I. The Efficacy of Pain

Neuroscience Education on

Musculoskeletal Pain – A Systematic

Review of the Literature. Physiotherapy

Theory and Practice. In Press

Conclusions: Current evidence supports the use of PNE

for chronic MSK disorders in reducing pain and improving

patient knowledge of pain, improving function and lowering

disability, reducing psychosocial factors, enhancing

movement and minimizing healthcare utilization.

Therapeutic Neuroscience Education

82

• Metaphors and examples

• Pictures

• One-on-one

• Therapist

Too many numbers?• 34 year-old female

• 4.5 years of pain

• Started as LBP, then spread to her buttocks and now into both legs

• Pain would flare up with stress at work

• First child 2.5 years ago – “horrible” labor, delivery and pain

• Now constant LBP

• Not able to return to work

• Now severe spasms in both legs

• CT, MRI and X-Ray WNL

• Meds: High doses of pain killers and narcotics

A brain that feels extremely threatened,

confused, hopeless…

85Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI

evaluation of a single patient with chronic low back pain. Aust J Physiother. 2005;51(1):49-52.

A brain that understands, is less

threatened and has hope…

86Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI

evaluation of a single patient with chronic low back pain. Aust J Physiother. 2005;51(1):49-52.




Key message of this study…

• Every PT clinic should have an fMRI…

One last time…

• People in pain want to know

more about pain

• The more they know about

pain, the less pain they

experience!

The

Neuroscience of

Pain

RESOND via

OUTPUTS: • Pain

• Action programs


Tissues

Environment

SCRUTINIZE via

BODY-SELF


• Cognitive

• Affective

Mature

Organism

Model

Gifford, L.S., Pain, the tissues and the nervous system.

Physiotherapy, 1998. 84: p. 27-33.

91

Tissues

Environment

Transduction

92




93 94

Receptor - Ion channels

Action/Generator Potential

95

Various kinds of channels…

Genetic Coding

DNA mRNA Proteins

DNA mRNA Proteins




Name the ion channel… Name the channel…

Key point: Ion channels

101

Key point: Ion channels

102

Tissues

Environment

TransductionPain relies on context

104




Pain relies on context

105

Tissues

Environment

106

First Pain – Aδ fiber

Second Pain – C fiber

107

There are NO pain fibers in the body Key Point: Damaged or Removed Myelin

• Mechanical

• Immune

• Chemical

108

Clinical Example

109

Modulation

110




Melzack and Wall’s

Gate Control Theory

111

Central Modulation

A-Beta fibers

C fibers

Interneuron

Second Order

Wide Dynamic

Ranging Neuron

Second Order

Nociceptive

Specific

A-Beta fibers

C fibers

Interneuron

Second Order

Wide Dynamic

Ranging Neuron

Second Order

Nociceptive

Specific

Other Side

Other Levels

Sympathetic

Action Potential Wind-up

VS.




How Dangerous

is this?

This is

dangerous

More information

Facilitation

Neuronal

adaption

117

How Dangerous

is this?

This is not

dangerous

Inhibition

Endogenous

118

Tissues

Environment

Perception

SCRUTINIZE via

BODY-SELF


• Cognitive

• Affective

119

GRANNY

The Brain’s Processing…Grandma

The Brain’s processing of LBP

• Common areas are frequently “ignited”

• Via connections, backfiring neurons, andneurotransmitters, pain is perceived – thepain neural signature

1. Flor, H. The image of pain. in Annual scientific meeting of The Pain Society (Britain). 2003. Glasgow, Scotland.

2. Flor, H., The functional organization of the brain in chronic pain, in Progress in Brain Research, Vol 129, J.

Sandkühler, B. Bromm, and G.F. Gebhart, Editors. 2000, Elsevier: Amsterdam.

3. Casey, K.L. and M.C. Bushnell, Pain imaging. Pain: Clinical Updates, 2000. 8: p. 1-4.

4. Petrovic, P. and M. Ingvar, Imaging cognitive modulation of pain processing. Pain, 2002. 95(1-2): p. 1-5.

5. Moseley, G.L., Widespread brain activity during an abdominal task markedly reduced after pain physiology

education: fMRI evaluation of a single patient with chronic low back pain. Aust J Physiother, 2005. 51(1): p. 49-

52.

Louw A, Butler DS, Diener I, Puentedura E and Peoples, R; 2013 Preoperative Neuroscience

Education for Lumbar Radiculopathy: A Single Case fMRI Study




1. PREMOTOR/ MOTOR CORTEX

organize and prepare movements

2. CINGULATE CORTEX

concentration, focusing

3. PREFRONTAL CORTEX

problem solving, memory

4. AMYGDALA

fear, fear conditioning, addiction

5. SENSORY CORTEX

sensory discrimination

6. HYPOTHALAMUS/ THALAMUS

stress responses, autonomic regulation,

motivation

7. CEREBELLUM

movement and cognition

8. HIPPOCAMPUS

memory, spacial recognition, fear

conditioning

9. SPINAL CORD

gating from the periphery

A TYPICAL PAIN NEUROTAG

9

5

6

8

1

7

2

3

4

123

But…

• There’s more

complexity…

Denotes synaptic modulation

Beliefs


Beliefs

Knowledge, logic


Beliefs

Knowledge, logic

Social context





Beliefs

Knowledge, logic

Social context

Anticipated

consequences


Beliefs

Knowledge, logic

Social context

Anticipated

consequences

Other sensory cues


Beliefs

Knowledge, logic

Social context

Anticipated

consequences

Other sensory cues

Physical therapy


Melzack’s Pain Neuromatrix

132

Modulation

133

Bulging Discs and Pain

• 40% of the general

population has a

significant bulging disc,

but no pain




No Correlation Between LBP and DJD

20 30 4050

60

70

More info on imaging…

• 25-50% of general population:– Hypointense disc signal

– Annular tears

– High intensity zones

– Disc protrusions

– Endplate changes

– Zygapophyseal joint degeneration

– Asymmetry

– Foraminal stenosis.

Kjaer P, Leboeuf-Yde C,

Korsholm L, Sorensen JS,

Bendix T. Magnetic resonance

imaging and low back pain in

adults: a diagnostic imaging

study of 40-year-old men and

women. Spine. May 15

2005;30(10):1173-1180.

Shoulder…

After successful rotator cuff repairs and clinically sound examination:

• 90% abnormal signaling

• 16% partial tears

• 20% complete tears

• 33% sub-acromial effusion

• 16% joint effusion

• 20% bone marrow edema

(Spielmann, Forster et al. 1999)

Shoulder…

• The over-all prevalence of tears of the rotator cuff in allage-groups was 35% (Sher, Uribe et al. 1995)

• Over age 70: 2 out of 3 have asymptomatic RCtear(Milgrom, Schaffler et al. 1995)

• 40% of normal asymptomatic people have RC tears(Reilly, Macleod et al. 2006)

Knee…

• 15% of MRI‟s show meniscus degeneration (Munk,Lundorf et al. 2004)

• 50% correlation between knee pain and arthritis(Bedson and Croft 2008)

• 35% of collegiate basketball players with no knee pain– significant abnormalities on MRI (Major and Helms2002)

TISSUES HEAL…

Louw A, Puentedura EJ. Therapeutic Neuroscience Education. Vol 1.

Minneapolis, MN: OPTP; 2013.




Output (Interpretation and Behavior)

• Pain

• Sympathetic

• Motor

• Immune

• Adrenaline

• Cortisol

• Respiration

• Language

• Etc

141 142

143 144

PERIPHERAL AND CENTRAL

SENSITIZATION

145

“Nerves that fire together…

wire together”-Hebbian Plasticity Theory

146




Pain

Neurosignature

“Representation”

147

Long Term

Potentiation

(LTP)

• Memory

• Learning

148

Central and Peripheral

149

Sensor

y

Emotional

Shift /

Time

150

Central

SensitizationClinical Example:

Phantom Limb Pain

152




Clinical Example:

Smudging

153

Definition of Pain: Update

Pain is produced by the brain after a person’s neural

signature has been activated and concluded the body

is in danger and action is required (Moseley 2003;

Moseley 2007).

OUTPUTS • Pain

• Action programs


Tissues

Environment

PROCESSING via

BODY-SELF


• Cognitive

• Affective

Gifford, L.S., Pain, the tissues and the nervous system.

Physiotherapy, 1998. 84: p. 27-33.

The Big Picture

So How Do You Do It? 1. The Brain is Key

Alter/Challenge Beliefs




Taking it to patients…PART 1 Taking it to patients

• They want it…

• We underestimate their ability to take on the

information

• Metaphors and examples

• Pictures

We already have the script

• Neurophysiology of pain – how we view pain

• Nociception and nociceptive pathways

• Neurons

• Synapses

• Action potential

• Spinal inhibition and facilitation

• Peripheral sensitization

• Central sensitization

• Plasticity of the nervous system

Let’s Start: So Many Paths to Take

























2. We DO NOT manage pain!




From Steve Schmidt

Focus on Function3. Don’t tell me you don’t know what to do

1. Skillful delivery of medication

2. Therapeutic Neuroscience Education

(make the threat smaller)

3. Aerobic exercise

4. General stabilization (versus specific)

5. Posture – likely self-correct and no

prolonged sessions

6. Relaxation

7. Meditation

8. Diet

9. Sleep hygiene

10. Journaling

11. Coping skills

12. Social interaction

13. Humor

14. Manual therapy

15. Modalities

16. Aquatic therapy

17. Welcoming, safe, healing

environment

18. Goal setting

19. Other…

4. Consider ALL treatment this way…

BOTH

5. Bottom Up has it’s place

6. Top Down: Change Beliefs 7. Make lions smaller




8. Aerobic Exercise

• Incredible high-level

evidence

• Flush the system

That’s it?

Thank you & acknowledgements…

• Tina, Tyler, Ella, and Lanie Zimney

• Dr. Adriaan Louw

• Dr. Louie Puentedura

• ISPI/EIM staff and faculty

• University of South Dakota

• Nova Southeastern University

[email protected]

Documents

Therapeutic Neuroscience Eduction · Therapeutic Neuroscience Education OPTA June 2016 Property of ISPI–not to be copied without permission 3 Chronic Pain Numbers •Epidemiological