Wednesday, August 28, 2019

Key Takeaways from "Advances in Pain Science- Clinical Implications for Rehabilitation"

By Lori Parchman, DPT, OCS, FAAOMPT

Course Presented by Derrick Sueki PT, PhD, DPT, GCPT, OCS, FAAOMPT (Azusa Pacific University)

I recently attended Dr. Derrick Sueki’s course on Pain Science and Clinical Implications for Rehabilitation.  Among a long list of accomplishments, Dr. Sueki is an assistant professor at Azusa Pacific University, serves on the Board of the Pain Management Special Interest Group of the APTA, is a practicing clinician, an author, and a researcher.

“Is this person’s pain acute or chronic?”, a question posed at the beginning of the course to ask ourselves when conducting a subjective examination. The answer…Acute and chronic pain are like apples and oranges. Chronic pain out lasts the typical healing time frame for tissues and can exceed a 3 to 6 month window. If symptoms are chronic, we need a paradigm shift in our questioning and interventions. In our initial training as physical therapists, we become very skilled at asking about acute symptoms that fit a tissue healing timeline.  Although this line of questioning, assessment, and treatment has its place, how should we adapt when a patient’s symptoms are no longer acute and not responding with our usual tissue-based treatment methods?  

30% of people with acute injuries will have persistent or chronic pain. 50% of people who initially get better will have a re-occurrence of symptoms.
Bouhassira et al (2008), Johannes et al (2010)

Chronic pain is always associated with an emotion and feeling.

Used with kind permission from Derrick Sueki

With chronic pain, memory and emotion are always on alert to serve a protective function. Therefore, interventions need to reduce fear and change memory to calm down the nervous system.

Moseley and Vlaeyen (2015) proposed that with chronic pain, non-nociceptive cues become linked to the nociceptive input trigger and condition a response (eg. increased low back pain only while sitting riding in cars vs. no pain with sitting in regular chairs due to a past MVA; in this example the environment of the car becomes the trigger for danger and pain.) This theory is call associative learning. This is why asking more questions regarding the environment of the pain onset and patient’s belief system can be so important during subjective interviewing with chronic symptoms. The aggravating factor doesn’t necessarily have to be a mechanical event.

With that background, here are several intervention strategies to consider…

Key Intervention Takeaways:

Used with kind permission from Derrick Sueki

1. Autonomic Nervous System:
Calming the sympathetic nervous system (fight or flight) and enhancing the parasympathetic system. This helps retrain the associative learning.
Ø Manual therapy
·      Gentle joint mobilizations to thoracic spine to address the autonomic system. Incorporate deep breathing and cognitive cueing (onset of triggering event and ending with positive recollections). Clinicians should use discretion here regarding the circumstances around triggering event (e.g. abuse, trauma).
·      Massage to promote vagal nerve stimulation.

Ø Mindfulness Meditation
Shown to be effective with attention regulation, body awareness, change in perspective on self, emotion regulation.
Free Apps: HeadSpace, Smiling Mind

Image from Headspace
2. Cognition

Ø Therapeutic Neuroscience Education
·      Explaining the physiology and nature of pain.
Research has shown the therapeutic effect of education on chronic pain. Multiple resources and online videos are available for PTs and patients. (Ex. Explain Pain, Butler & Moseley).
Louw, A., Zimney, K. et all 2016
·      Nutrition: Reduce inflammatory causing foods (e.g. refined and artificial sugars, dairy products, processed foods) and promote anti-inflammatory diet (ex. vegetables, turmeric, ginger, etc).
Recommending patient consult with a dietician can be helpful for additional guidance.
·      Sleep is vitally important for tissue repair and reducing pain. See here and here for advice on sleep hygiene habits.

Ø Cognitive Behavioral Therapy
·      Motivational Interviewing: goal-oriented, non-judgmental, client-centered. Aim is to increase patient’s awareness of their behaviors
·      Positive Motivation
·      Empathy: Building a good therapeutic relationship with your patient/client can account for 30% of therapeutic factors for improvement. (i.e. It helps if your patients like you!)
Asay and Lambert, 1999

3. Motor Control
Ø Graded Exposure: mirror box training, laterality training, movement

Image from U.S. Navy 

Image from Recognise app

Ø Therapeutic Exercise
Teach people it’s OK to move!
Incorporating what we as PTs already practice but with additional layers…. Gradually exposing patients to fear inducing environment and have them function in it. Your patient s/p 1 year ankle sprain can maintain proper single limb squat mechanics on a bosu ball in clinic, but can they on grass or listening to the sound of a whistle that’s similar to the environment of injury? Address the associative learning aspect of their pain. Very important to know the patient’s experience and environmental triggers.

Closing clinical concept pearl…

It’s important to remember that memory pathways do not go away, but more positive ones can be built on top. A resonating analogy Dr. Sueki made was to think back to a time when you moved homes. Although you may have been driving to your new home for some time now, one day when very fatigued or distracted, you end up back at your old house thinking “how did I get here?” Pain pathways can be similar. Although never gone, thanks to neuroplasticity they can be positively replaced with some training and persistence!

Lori Parchman is a physical therapist with Kaiser Permanente Woodland Hills, California. She is a Certified Movement Links Clinician and a graduate from the Kaiser Orthopaedic Residency, Movement Science and Spine Fellowship Programs.

Asay, T. R., & Lambert, M. J. (1999). The empirical case of the common factors in psychotherapy: quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: what works in therapy (pp. 23-55). Washington DC: American Psychological Association. doi:10.1037/11132-001

Bouhassira, D., Lantéri-Minet, M., Attal, N., Laurent, B., & Touboul, C. (2008). Prevalence of chronic pain with neuropathic characteristics in the general population. Pain136(3), 380-387.

Butler, David S, and G L. Moseley. Explain Pain. Adelaide: Noigroup Publications, 2003. Print

Johannes, C. B., Le, T. K., Zhou, X., Johnston, J. A., & Dworkin, R. H. (2010). The prevalence of chronic pain in United States adults: results of an Internet-based survey. The Journal of Pain11(11), 1230-1239.

Louw, A., Zimney, K., Puentedura, E. J., & Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy theory and practice, 32(5), 332-355.

Moseley, G. L., & Vlaeyen, J. W. (2015). Beyond nociception: the imprecision hypothesis of chronic pain. Pain156(1), 35-38