NEW NEW Chr Chronic nic Pa Pain Solutions: Solutions: The The La Latest In Integrativ ive Re Research and and Appr Approaches oaches in in the the Success Successful ful Trea eatmen tment of of Chr Chronic nic Pa Pain Conditions Conditions Brian Trzaskos PT, LMT, CSCS, CMP, MI ‐ C 1
BodyMind Rehabilitation • The bodymind functions inseparably in all human activity. • Approaches clients as holistic beings. • 3 planes of existence • Body.Mind.Spirit • Biopsychosocial 2
The Impact of Chronic Pain • The NIH reports that 25.3 million Americans live with chronic pain • Chronic pain costs $635 billion dollars annually • 2 million people are addicted to opioids secondary to chronic pain • Opioid mis ‐ use costs $78.5 billion per year • 42,000 people died in 2019 from opioid overdose 3
The NEW Science of Pain 4
Sensory Pathway Cortex Thalamus/Limbic Spinal Cord Receptors 5
Peripheral Receptors • Mechanical • Temperature • Chemical • Nociceptive 6
“Nociception is clearly not sufficient for pain– if it were we would have no explanation for times when we sustain a clear injury that is pain free. Nociception is not necessary for pain – if it were we would have no explanation for those times when cognitive illusion evokes pain.” ‐ Butler, Moseley: Explain Pain Supercharged 7
The Spinal Cord Spinal Cord • Peripheral to Central NS. Bridge Nerve Roots • Structurally Sensitive • Monosynaptic Reflex Vertebra • System Redundancy Intervertebral disk 8
Spinal Cord Contribution • Central Sensitization • Wind ‐ Up • Hyperalgesia • Allodynia • Pathways • Monosynaptic Reflex (20x) • Ascending (input) • Descending (output) 9
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Brain Adaptations 14
CEO in the Dark • The brain creates a pain experience from a summary of incoming and stored information. • Pain is Out ‐ Put • Phantom limb • Parents/children • Violinist/Dancers • Anticipation/Fear 15
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NEW Pain Formula If sensations + beliefs + memories + emotions = “THREAT”, then output = PAIN 17
Neuromuscular Compensations • Mobilizers • Stabilizers • Fast twitch (type 2) • Slow twitch (type 1) • Anaerobic • Aerobic • Produce torque & power • Maintain joint balance • Concentric function • Eccentric/Isometric function • Fatigue easily • Fatigue resistant • Often superficial • Often deeply placed • Small proprioceptive role • Major proprioceptive role • Tighten & Shorten* • Weaken & lengthen* Chaitow. Muscle Energy Techniques 2006. 18
Autonomic N.S. Influence (perception) • Sympathetic • Parasympathetic • “Threat” based • “Safety” based • Increases sensitivity • Endorphins • Increases muscle tension • Descending inhibition • Depresses immune system • Decreases muscle tension • Cortical shut ‐ down • Improves circulation • Reactive states • Activates immune system • Protective movement • Higher cortical centers • Creative movements patterns 19
Integrative Approaches Foundation Breath Vision Body 20
Mindfulness in Rehabilitation • Elements • Maintain present moment to moment awareness • Disengage from strong attachments to beliefs, thoughts, and emotions • Non ‐ judgmental witnessing of self and habitual patterns of behavior The Role of Mindfulness in Healthcare Reform: A Policy Paper McCabe Ruff, Kelley et al. Explore: The Journal of Science and Healing , Volume 5 , Issue 6 , 313 – 323 21
Mindfulness research… • decreased perception of pain • increased ability to tolerate pain • reduced stress, anxiety, and depression • diminished use of medication (lessening adverse effects of drugs) • enhanced medical decision making • better adherence to medical treatments • increased motivation to make lifestyle changes • more social connection and enriched interpersonal • enhanced neuroendocrine and immune system function 22
Mindfulness for the clinician • Reduction of medical errors • Iatrogenic illness is 3 rd leading cause of death • Prevent burnout, stress management, increase empathy • 69% of health care professionals are significantly stressed • Improves patient outcomes when practitioners practice mindfulness** 23
Functional Abdominal Breathing • Energy Generation • Immune Function Exhaling • Lymph System • Nervous System 24
Breath Practices • Sigh of Relief • 2,3,4,5 ‐ part abdominal breath • Exhale initiation (slow, smooth, deep) • Postural efficiency • Paced breathing • Square breathing (4x4x4x4) • Rooted breathing • In/out through feet • Coordinated breathing • Slow, fluid movement 25
Vision • Research Results • Reflexive Muscle Activation • Vestibular • Proprioceptive • Balance 26
Visualization • Research Results • Skill Performance • Strength • Motor Recruitment • Balance • Skin Temperature • Immune Function 27
Effective Visualization • Vivid • Active • Kinesthetic • Symbolic • Desired Outcome 28
3 ‐ Step Integrative Graded Movement Process 1. Get Safe 3. Yellow Zone Movement • Reduces “Threat” • Opens Communication with the Brain/Builds trust • Re ‐ patterns movement 2. Abdominal Breath • Distal to Local • Parasympathetic shift • Asymmetrical • Decreases MM tension • Move further into “Ease” • Improve Immune Function • Returns volitional control • Endorphin Release • Vision/Visualization • Possibility Thinking • It always changes! 29
Graded Movement: Staying In the Yellow Zone Too Much Movement Work Here JUST RIGHT Too Little Movement 30
Integrative Graded Movement • Abdominal Breathing/Pelvic Tilts • Ankle/Wrist Circles • Hip/Shoulder Opening • 3 ‐ Way Rotation 31
Assessment & Screening • The Pattern Based Interview • Emotional & Psychosocial Considerations • Physical Assessment Tools 32
< 7 years old Belief Patterns SC B B B B Subconscious Mind ‐ Accepts Belief Patterns ‐ Wires Physiology Body 33
> 7 years old Subconscious Mind ‐ “Filters” Reality ‐ Maintains Programming C ‐ The SC Paradox SC B B X Conscious Mind ‐ Accept or Reject ‐ Thinking (conscious ‐ mind) ‐ Sensations (body ‐ mind ) X X Results Body X 34
The Pattern Based Interview • Location • Characteristics • Onset • Duration • Severity • Aggravating factors • Relieving factors • Associate symptoms/issues 35
Pattern Based Interview • Location (Where?) • Local vs. traveling • Characteristics (What?) • Specific “sensations” • Stinging, stabbing, tightness, etc… • Onset (When?) • Believed causation • Timely life circumstances • Duration (How Long?) • Constant vs. exacerbations 36
Pattern Based Interview • Severity • 1 ‐ 10 Scale of “Sensations” • Aggravating factors • What makes it worse? • Think Biopsychosocial • Relieving factors • What makes it better? • Think Biopsychosocial • Associate symptoms/issues • Concomitant dis ‐ eases • Life circumstances • Environmental factors • Health care history • 0 ‐ 7 years old conditioning 37
Emotional & Psychosocial Considerations • Fear ‐ Avoidance • Adverse Childhood Experiences • PTSD/Hyper ‐ vigilance • Catastrophizing 38
Emotional & Psychosocial Considerations • Social Support • Active Coping • Acceptance • Self Efficacy 39
Physical Assessment • Reference tests (MRI, x ‐ rays, ultrasounds, blood, etc…) • Comparative observation • Opposite / adjacent • Posture / Gait • Balance / Functional Movement • ROM • Passive, active ‐ assistive, active • Strength • Isometric, concentric, eccentric • Palpation • Temperature, quality, trigger points • Vertebral assessment • Sensation • Special Tests 40
Decode the Pattern! 41
Functional Re ‐ wiring of Neural Systems 42
Sensation ‐ Based Concept ACTIONS WORDS THOUGHTS SENSATIONS 43
Behavioral Pattern Construction THOUGHTS SENSATIONS 44
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Sensations + Thoughts = Emotions The subconscious mind tells the conscious mind “HOW” to think about what you are experiencing in your sensations 46
…the human brain is anatomically structured so that no decision or action can be free of interoception and affect… Your bodily feeling right now will project forward to influence what you will feel and do in the future. It is a self ‐ fulfilling prophecy, embodied within the architecture of your brain. ‐ how emotions are made , lisa feldman barrett 47
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Behavioral Pattern Construction WORDS THOUGHTS SENSATIONS 49
Behavioral Pattern Construction ACTIONS WORDS THOUGHTS SENSATIONS 50
Cross Education • Research Results • Contralateral limb training • Immobilization • Stroke Rehabilitation • Mirror Therapy 51
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