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Physical Therapy, Pain, The Brain

Physical Therapy, Pain, The Brain. GOBHI May 17, 2012 Dr. Tom Watson PT MEd DAAPM Bend, Oregon. Conflict of Interest Financial Disclosure. Dr. Tom Watson DPT PT MEd Diplomate American Academy of Pain Management Rebound Physical Therapy 541-382-7875 Bend, Oregon

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Physical Therapy, Pain, The Brain

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  1. Physical Therapy, Pain, The Brain GOBHI May 17, 2012 Dr. Tom Watson PT MEd DAAPM Bend, Oregon

  2. Conflict of InterestFinancial Disclosure Dr. Tom Watson DPT PT MEd Diplomate American Academy of Pain Management Rebound Physical Therapy 541-382-7875 Bend, Oregon painfree@ix.netcom.com No conflicts of interest

  3. American Academy of Pain Management • The mission of the American Academy of Pain Management is to advance the field of pain management using an integrative model of patient-centered care by providing evidence-based education for pain practitioners, as well as credentialing and advocacy for its members. • http://www.aapainmanage.org/ • (209) 533-9744

  4. AAPM Annual Conference • The 2012 Annual Clinical Meeting will be held in Phoenix, Arizona, September 20-23, 2012 • Founded in 1988, the Academy is the largest pain management organization in the nation and the only one that embraces an integrative model of care, which is patient-centered, focuses on the “whole” person, is informed by evidence, and brings together, all appropriate therapeutic approaches to reduce pain and achieve optimal health and healing. The Academy offers continuing education, publications, and advocacy.

  5. Pain Anatomy

  6. PAIN • Pain, according to the IASP (International Association for the Study of Pain), is "an unpleasant sensory or emotional experience associated with actual or potential tissue damage and described in terms of such damage."

  7. PAIN (www.rosPAIN (www.ro PAIN (www.rosstoons.com)PAIN (www.rosstoons.com)m)stoons.com)

  8. PAIN • "Pain is a part of being alive, and we need to learn that. Pain does not last forever, nor is it necessarily unbeatable, and we need to be taught that."– Harold Kushner

  9. Freud on Pain • The pleasure-pain principle was originated by Sigmund Freud in modern psychoanalysis, although Aristotle noted the significance in his 'Rhetoric', more than 300 years BC. • 'We may lay it down that Pleasure is a movement, a movement by which the soul as a whole is consciously brought into its normal state of being; and that Pain is the opposite.” • http://changingminds.org/disciplines/psychoanalysis/concepts/pleasure_pain.htm

  10. Hippocrates on Pain • “Men ought to know that from the brain, and from the brain only, arise our pleasures, joys, laughter and jests, as well as our sorrows, pains, griefs and tears.” • The Sacred Disease, in Hippocrates, trans. W. H. S. Jones (1923), Vol. 2, 175

  11. Incidence of Pain • National Center for Health Statistics National Household Survey (Aug 2009): • Pain 100 million Americans (not including Vets and children – IOM 2011) • Diabetes 20.8 million • CAD 18.7 million • Cancer 1.4 million

  12. Cost of Pain

  13. PAIN • Pain is the primary reason for visits to a clinician • Pain always evokes a sensory or emotional response • When pain occurs, suffering and pain behaviors follow • A very complex perception- Albert Schweitzer- “may be worse then death”

  14. Classification • Pain is classified in three categories: • 1. Acute- lasting 4-6 weeks • 2. (Subacute-lasting 6-weeks to 6 months) • 3. Chronic pain- starting at six months or symptoms lasting longer than the anticipated time for recovery.

  15. Chronic Pain Syndrome • Mood • Memory- short and long term • Concentration • Sleep • Sex drive

  16. Types of Pain

  17. Neuropathic Pain • spontaneous burning pain with an intermittent sharp stabbing or lancinating character, an increased pain response to noxious stimuli (hyperalgesia), pain elicited by non-noxious stimuli (allodynia) • structural and/or functional nervous system adaptations secondary to injury • centrally or peripherally –large and small fiber • Diabetic neuropathy

  18. RSD, CRPS, SMP

  19. CRPS Treatment- ECT • ECT (electro convulsive therapy) • 1940s-chronic pain • 1957-CRPS I, Retrograde amnesia • RUL (Right Unilateral) ECT without persistent cognitive side effects • 6-12 sessions • Increase in thalamic blood flow, PET Scan changes in thalamus-parietal-frontal lobes - relief of CRPS symptoms

  20. CRPS Treatment • VIT D3, Red Krill Fish Oil • Microcurrent Stimulation, Cold Laser, • Neuro mobilization • Mirror Therapy • NMDR • Hypnosis • Acupuncture • Meds: Opioids, Psychotropic, Neuroleptics, steroids, non-steroidals

  21. Pain Combinations

  22. Central Pain • Central pain -IASP: "pain initiated or caused by a primary lesion or dysfunction in the central nervous system" (Merskey, Bogduk, 1994). • Caused by “wind-up” phenomena • Thalamic or other area in Brain • "Neuropathic" vs. "neurogenic", a term used to describe pain resulting from injury to a peripheral nerve but without necessarily implying any "neuropathy

  23. Psychogenic Pain • "Psychogenic" pain arises due to maladaptive thought processes • Somatization-bowel disorder, palpitations, fatigue, respiratory, all disproportionate • Hypochondriasis- fear of condition • Factitious Disorder-Munchausen syndrome

  24. Pain of Youth

  25. Nociception • Pain is transmitted to the brain through neurological process of nociception • Nociception is pain in which normal nerves transmit information to the central nervous system about trauma to tissues (nocere = to injure, Latin).

  26. Nociception • Nociceptionnormal nerves transmit information to the central nervous system about trauma to tissues (nocere = to injure). • A-beta fibers thickly myelinated mostly sensory, 10% transmit pain • A-delta fibers thinly myelinated, transmit sharp/lancinating pain • C-fibers non-myelinated fibers, dull or chronic pain

  27. Nociception • Special nerve endings or type IV mechanoreceptors, i.e. free nerve endings, absorb chemicals, transfer information to the spinal cord. • Noxious stimuli via peripheral A delta and C fibers: release of excitatory amino acid neurotransmitters (glutamate), neuro-peptides, substance P

  28. Nociceptive Agents • Nociception occurs with damage to tissue and chemical or endogenous agents are released • bradykinins, serotonin, cytokines, protons, sensory neuropeptides, and arachidonic acids: leukotrienes & prostaglandins, substance P, K+, ATP

  29. Site of Trauma

  30. Nociception • Type IV Mechanoreceptors: • Location: joint capsule, blood vessels, articular fat pads, anterior dura mater, Ant. Long. Lig., PLL, connective tissue • NOT in: muscle, Ligamentum flavum, nerve, articular cartilage • Non-adapting- keep firing until noxious stim (mechanical, chemical, thermal) removed. • Pain causes: tonic reflexogenic-guarding tonic muscles proximal to joint-ischemia, no guarding with phasic muscles

  31. Dorsal root ganglia • DRG: The free nerve ending in the tip of your finger that feels the paper cut, cell body in dorsal root ganglion.

  32. Response • Motor –protective • Perceptual- cross over, pain response can increase or decrease • Sympathetic- vasoconstriction, sweat, cool/moist increase output • Remove stimulus- type IV non-adapting, deformity 3%, thermal below 44.8 C • Emotional, memory, response

  33. Cancer Pain • 70% of all cancer patients have pain, 50% have severe to intractable pain • Somatic Cancer Pain neoplastic invasion of bone, joint, muscle, or connective tissue. • Bone Pain direct tumour invasion of bone. Not all bone metastases are painful • Visceral Cancer Pain. Solid organs - lung, liver, and kidney parenchyma are insensitive,. Harmful stimuli ie. burning or cutting of visceral tissue do not cause pain, whereas natural stimuli such as hollow organ distension readily produce pain • Neuropathic Cancer Pain- herpes zoster(Shingles)

  34. CIPA • Congenital Insensitivity to Pain with Anhidrosis, Hereditary Sensory and Autonomic Neuropathies (HSAN) (4) • impaired autonomic, sensory, motor functions • Insensitivity to superficial and deep pain, neuropathic joints, risk of unrecognized injury (burns, fractures), corneal ulceration • No cure exists, death

  35. Spinal Cord Transmitters • many neurotransmitters in dorsal horns • substance P has a prime role, may promote later release of EAA • NMDA (glutamate), aspartate, CGRP-facilitates pain • GABA-pain inhibition

  36. Central Assent • Pain information ascends via spinal thalamic tract or Lissaurs track, terminates in thalamus, somatosensory cortex, limbic system, midbrain, hypothalamus, or thalamic nuclei. • Facilitation-pathology, environment, emotional stress • Facilitation-sensory, motor, sympathetic

  37. Distribution of neurotransmitters

  38. Descending control • major descending modulation pathway originates: periaquaductal gray area, the locus ceruleus, the nucleus raphe magnus and the dorsal horn of the spinal cord terminating in laminae I, II, and IV. • Descending noradrenergic antinociceptive systems originating in the brainstem contribute to pain control, in the substantia gelatinosa of the dorsal horn

  39. Descending Control • Inhibitory- 36 different brain opiods (Korr) • Endorphins- 15-20 minutes of continuous activity to be produced, half life 6-8 hours • Takes another 15-20 minutes to reach target site: Axoplasmatic flow of nerves, blood, CSF via lymphatics

  40. Descending control • Pharmacological • Cannabis decreases pain-cortical reticular • Alcohol can increase or decrease pain cortical or rostral reticular • Caffeine-increases- rostral reticular • Barbiturates (Soma) increase cortical reticular - increase pain

  41. Descending Control • Periaquecductal of Gray: Releases Opiods receptors: enkephlins, endorphins • Opiods inhibit the neurons that suppress the activity of Bulbospinal tract • morphine and electrical stimulation produce potent anti-nociception • High Intensity afferent input: Manipulation, high frequency e-stim, sex, baroque music, pain (Grimsby)

  42. Women and Pain • Extra Nerve Fibers May Heighten Female Pain Perception By Jeff Minerd , MedPage Today Staff Writer, Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine. • average fiber density in female samples was 34 ± 19 fibers/cm2. • - average density in male samples was 17 ± 8 fibers/cm2 (P=0.038.) • favors physical (organic) not psychosocial explanation for more pronounced pain perception in female patients

  43. Men and Pain • Pain

  44. The 4 “A’s” of Pain Treatment Outcomes “A successful outcome in pain therapy involves more than the lowering of pain intensity scores” • Analgesia • Pain relief • Activities of daily living • Psychosocial functioning • Adverse effects • Side effects • Aberrant drug-taking • Addiction-related outcomes • Passik et al. J Support Oncol. 2005;3(1):83-86 .

  45. Pain Tolerance • Where’s Mommy??

  46. Psychology and Pain • Hypnosis- opiate/endorphin release • CBT • Meditation, prayer • Group therapy • midbrain and cortical structures • Personality, gender, age, culture, fear/avoidance, pre-existing conditions • Interdisciplinary approach-best

  47. Psychology and Pain • MPD/Dis-associative Identity Disorders(DID) • BPD, Bi-Polar • and • Chronic Pain • Symptomatic changes in 1 area may manifest or decrease other diagnosis

  48. Greeks, Egyptians, Chinese, Romans: Heat, sun, geodes, eels, massage, manipulation Modalities-Thermal, Sound ,Traction, Magnets Lasers, electrical stimulation Manual therapies Therapeutic exercise Ancient Times and Today

  49. Modalities

  50. Effectiveness of Evidence-Based Modalities Philadelphia Panel Evidence-Based Clinical Practice Guidelines (EBCPG) in Selected Rehabilitation Intervention for Low Back Pain Cochrane Collaboration, and literature review using meta-analysis and observational studies

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