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.
---
References
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. Pain, 136(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 Pain, 11(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. Pain, 156(1), 35-38
