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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

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NEW NEW Chr Chronic nic Pa Pain Solutions: Solutions:

The The La Latest In Integrativ ive Re Research and and Appr Approaches

  • aches in

in the the Success Successful ful Trea eatmen tment of

  • f Chr

Chronic nic Pa Pain Conditions Conditions

Brian Trzaskos PT, LMT, CSCS, CMP, MI‐C

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BodyMind Rehabilitation

  • The bodymind functions

inseparably in all human activity.

  • Approaches clients as holistic

beings.

  • 3 planes of existence
  • Body.Mind.Spirit
  • Biopsychosocial

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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

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The NEW Science of Pain

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Receptors Spinal Cord Thalamus/Limbic Cortex

Sensory Pathway

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Peripheral Receptors

  • Mechanical
  • Temperature
  • Chemical
  • Nociceptive

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“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

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The Spinal Cord

  • Peripheral to Central
  • NS. Bridge
  • Structurally Sensitive
  • Monosynaptic Reflex
  • System Redundancy

8 Spinal Cord Nerve Roots Vertebra Intervertebral disk

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Spinal Cord Contribution

  • Central Sensitization
  • Wind‐Up
  • Hyperalgesia
  • Allodynia
  • Pathways
  • Monosynaptic Reflex (20x)
  • Ascending (input)
  • Descending (output)

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Brain Adaptations

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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

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NEW Pain Formula

  • If sensations + beliefs + memories + emotions

= “THREAT”, then output = PAIN

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Neuromuscular Compensations

  • Mobilizers
  • Fast twitch (type 2)
  • Anaerobic
  • Produce torque & power
  • Concentric function
  • Fatigue easily
  • Often superficial
  • Small proprioceptive role
  • Tighten & Shorten*
  • Stabilizers
  • Slow twitch (type 1)
  • Aerobic
  • Maintain joint balance
  • Eccentric/Isometric function
  • Fatigue resistant
  • Often deeply placed
  • Major proprioceptive role
  • Weaken & lengthen*
  • Chaitow. Muscle Energy Techniques 2006.

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Autonomic N.S. Influence (perception)

  • Sympathetic
  • “Threat” based
  • Increases sensitivity
  • Increases muscle tension
  • Depresses immune system
  • Cortical shut‐down
  • Reactive states
  • Protective movement

patterns

  • Parasympathetic
  • “Safety” based
  • Endorphins
  • Descending inhibition
  • Decreases muscle tension
  • Improves circulation
  • Activates immune system
  • Higher cortical centers
  • Creative movements

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Integrative Approaches Foundation

Body Breath Vision

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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

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Mindfulness research…

  • decreased perception of pain
  • increased ability to tolerate pain
  • reduced stress, anxiety, and depression
  • diminished use of medication (lessening adverse effects
  • f 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

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Mindfulness for the clinician

  • Reduction of medical errors
  • Iatrogenic illness is 3rd 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**

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Functional Abdominal Breathing

  • Energy Generation
  • Immune Function
  • Lymph System
  • Nervous System

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Exhaling

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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

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Vision

  • Research Results
  • Reflexive Muscle

Activation

  • Vestibular
  • Proprioceptive
  • Balance

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Visualization

  • Research Results
  • Skill Performance
  • Strength
  • Motor Recruitment
  • Balance
  • Skin Temperature
  • Immune Function

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Effective Visualization

  • Vivid
  • Active
  • Kinesthetic
  • Symbolic
  • Desired Outcome

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3‐Step Integrative Graded Movement Process

  • 1. Get Safe
  • Reduces “Threat”
  • 2. Abdominal Breath
  • Parasympathetic shift
  • Decreases MM tension
  • Improve Immune Function
  • Endorphin Release
  • Possibility Thinking
  • 3. Yellow Zone Movement
  • Opens Communication with

the Brain/Builds trust

  • Re‐patterns movement
  • Distal to Local
  • Asymmetrical
  • Move further into “Ease”
  • Returns volitional control
  • Vision/Visualization
  • It always changes!

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Graded Movement: Staying In the Yellow Zone

Too Much Movement Too Little Movement JUST RIGHT Work Here

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Integrative Graded Movement

  • Abdominal Breathing/Pelvic Tilts
  • Ankle/Wrist Circles
  • Hip/Shoulder Opening
  • 3‐Way Rotation

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Assessment & Screening

  • The Pattern Based Interview
  • Emotional & Psychosocial

Considerations

  • Physical Assessment Tools

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SC Body

< 7 years old

B B B B

Subconscious Mind ‐Accepts Belief Patterns ‐Wires Physiology

Belief Patterns

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SC

Body

Subconscious Mind ‐ “Filters” Reality ‐Maintains Programming ‐ The SC Paradox Conscious Mind ‐Accept or Reject ‐Thinking (conscious‐mind) ‐Sensations (body‐mind)

> 7 years old

C B

X

B

X Results X X

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The Pattern Based Interview

  • Location
  • Characteristics
  • Onset
  • Duration
  • Severity
  • Aggravating factors
  • Relieving factors
  • Associate symptoms/issues

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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

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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

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Emotional & Psychosocial Considerations

  • Fear‐Avoidance
  • Adverse Childhood

Experiences

  • PTSD/Hyper‐vigilance
  • Catastrophizing

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Emotional & Psychosocial Considerations

  • Social Support
  • Active Coping
  • Acceptance
  • Self Efficacy

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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

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Decode the Pattern!

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Functional Re‐wiring of Neural Systems

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SENSATIONS THOUGHTS WORDS ACTIONS

Sensation‐Based Concept

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SENSATIONS THOUGHTS

Behavioral Pattern Construction

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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

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…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

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SENSATIONS THOUGHTS WORDS

Behavioral Pattern Construction

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SENSATIONS THOUGHTS WORDS ACTIONS

Behavioral Pattern Construction

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Cross Education

  • Research Results
  • Contralateral limb training
  • Immobilization
  • Stroke Rehabilitation
  • Mirror Therapy

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Contralateral Limb Training

  • Neuro‐physiological adaptations associated with cross‐education
  • f strength. Jonathan P. Farthing, Ron Borowsky, Philip D. Chilibeck,

Gord Binsted, Gordon E. Sarty. Brain Topogr. 2007 Winter; 20(2): 77– 88.

  • 23 females. Right ulnar deviation. 4x/6wks. Peak torque, muscle

thickness, EMG, fMRI.

  • Strength training was highly effective for increasing strength in

trained (45.3%; P < 0.01) and untrained (47.1%; P < 0.01) limbs.

  • After training, there was an enlarged region of activation in

contralateral sensorimotor cortex and left temporal lobe during muscle contractions with the untrained left arm (P < 0.001)

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Cast Immobilization Training

  • Changes in functional magnetic resonance imaging cortical

activation with cross education to an immobilized limb. Jonathan P. Farthing, Joel R. Krentz, Charlene R. A. Magnus, Trevor S. Barss, Joel L. Lanovaz, Jacqueline Cummine, Carrie Esopenko, Gordon E. Sarty, Ron

  • Borowsky. Med Sci Sports Exerc. 2011 August; 43(8): 1394–1405
  • 14 subjects. Left hand/wrist cast. Right isometric grip. Peak force,

muscle thickness, EMG, fMRI.

  • Handgrip strength of the immobilized arm of CAST‐TRAIN was

maintained, whereas the immobilized arm of CAST significantly decreased by 11% (P < 0.05)

  • Conclusion: Handgrip strength training of the free limb attenuated

strength loss during unilateral immobilization. The maintenance of strength in the immobilized limb via the cross‐education effect may be associated with increased motor cortex activation.

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Stoke Rehabilitation

  • Urbin MA, Harris‐Love ML, Carter AR, Lang CE. High‐Intensity,

Unilateral Resistance Training of a Non‐Paretic Muscle Group Increases Active Range of Motion in a Severely Paretic Upper Extremity Muscle Group after Stroke.Frontiers in Neurology.

  • 13 subjects. >4mos post stroke. 16 sessions. Dynamic contractions
  • f non‐paretic wrist.
  • Results of this study demonstrate that high‐intensity resistance

training of a non‐paretic upper extremity muscle group can enhance voluntary muscle activation and force‐generating capacity

  • f a severely paretic muscle group after stroke. There is also

preliminary evidence that corticospinal adaptations may accompany these gains.

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Mirror Therapy Analysis

  • Thieme H, Morkisch N, Mehrholz J, et al. Mirror therapy for

improving motor function after stroke. Cochrane Database Syst Rev. 2018;7(7):CD008449. Published 2018 Jul 11. doi:10.1002/14651858.CD008449.pub3

  • 62 studies with a total of 1982 participants that compared mirror

therapy with other interventions.

  • When compared with all other interventions, we found

moderate‐quality evidence that mirror therapy has a significant positive effect on motor function (SMD 0.47, 95% CI 0.27 to 0.67; 1173 participants; 36 studies) and motor impairment (SMD 0.49, 95% CI 0.32 to 0.66; 1292 participants; 39 studies).

  • Mirror therapy reduced pain after stroke, but mainly in people with a

complex regional pain syndrome.

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Cross Mapping for Physical Pain

  • Work both sides
  • mirror/alternate
  • Identify differences
  • Strengths vs. weaknesses
  • Desired vs. undesired sensations
  • Exaggerate strengths on “good” side
  • Focus on desired function
  • Cross Map
  • Vision + desired sensation

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What is Tai Chi?

Philosophy and Martial Art

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What is Qigong?

  • Qi = Universal Life Force Energy/

Breath

  • Gong= practice/cultivation
  • Rehabilitative Qigong & Tai Chi
  • Body Focus
  • Breath Focus
  • Vision (mind) Focus

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Qigong / Tai Chi Principles

  • Upright Spine (head–tail)
  • Coordinated Breathing
  • Weight shift
  • Pole
  • Slow
  • Fluid
  • Rounded
  • Balanced Center (Dantian)
  • Relaxed
  • Imagery/Symbolism
  • Smile!

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“Supreme Ultimate Balance”

  • Yang
  • Male
  • Light
  • Outward
  • Hot
  • Sky
  • Day
  • Active
  • Yin
  • Female
  • Dark
  • Inward
  • Cold
  • Earth
  • Night
  • Rest

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Tai Chi Physiology

  • Yang
  • Sympathetic NS
  • Contraction Phase
  • Red Blood Cells
  • Exhale
  • Intellectual
  • Systolic
  • Catabolic
  • Yin
  • Parasympathetic NS
  • Relaxation Phase
  • White Blood Cells
  • Inhale
  • Intuition (gut sense)
  • Diastolic
  • Anabolic

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Rehabilitative Qigong & Tai Chi

  • QTC Posture
  • Flowing Motion
  • Circling
  • Gathering Qi
  • Cloud Hands

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Qigong Tai Chi Posture

Connect Feet to Ground Relax Knees Settle Tail Lift Crown of Head

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Flowing Motion

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Flowing Motion (continued)

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Flowing Motion (continued)

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Flowing Motion (continued)

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Tai Chi Circling

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Tai Chi Circling (continued)

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Tai Chi Circling (continued)

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Tai Chi Circling (continued)

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Tai Chi Circling

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Tai Chi Circling (continued)

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Tai Chi Circling (continued)

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Tai Chi Circling (continued)

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Tai Chi Circling (continued)

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Tai Chi Circling (continued)

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Gathering Qi from Earth & Sky

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Gathering Qi from Earth & Sky

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Gathering Qi from Earth & Sky

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Cloud Hands

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Cloud Hands (continued)

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Cloud Hands (continued)

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Cloud Hands

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Cloud Hands (continued)

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Cloud Hands (continued)

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Cloud Hands (continued)

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Ta Tai Chi Chi fo for Chr Chronic nic Pa Pain Condi Conditions: tions: Met Meta‐Analy Analysis is

  • 18 RCTs
  • Immediate relief from chronic pain associated with:
  • Osteoarthritis
  • Low Back Pain
  • Osteoporosis
  • Kong LJ, Lauche R, Klose P, et al. Tai Chi for Chronic Pain

Conditions: A Systematic Review and Meta‐analysis of Randomized Controlled Trials. Scientific Reports. 2016;6:25325. doi:10.1038/srep25325.

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Tai Chi & Chronic Conditions

  • Chen Y‐W, Hunt MA, Campbell KL, et al. The effect of Tai Chi on

four chronic conditions‐cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease: a systematic review and meta‐analyses. Br J Sports Med. Published Online First: 2015 Sep 17

  • Meta‐Analysis. 33 Studies Reviewed.
  • Results: Meta‐analyses showed that Tai Chi improved or showed a

tendency to improve physical performance outcomes, including 6‐ min walking distance (6MWD) and knee extensor strength, in most

  • r all four chronic conditions. Tai Chi also improved disease‐specific

symptoms of pain and stiffness in OA.

  • Conclusion: The results demonstrated a favorable effect or

tendency of Tai Chi to improve physical performance and showed that this type of exercise could be performed by individuals with different chronic conditions, including COPD, HF and OA.

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Documentation & Coding for Reimbursement

  • 97112 Neuromuscular Re‐Education of Movement,

Balance, Coordination :The clinician and/or patient perform activities to one or more body areas that facilitate reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception.

  • 97110 Therapeutic Exercise: A manner of effecting

change through the application of clinical skills and/or services that attempt to improve function, develop strength, endurance, range of motion, and flexibility

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Key Practitioner Roles

  • Therapeutic Entrainment
  • Advanced Listening
  • Value‐Based Goal Setting

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Therapeutic Entrainment

(aka. “become the tuning fork”)

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Coherence & Entrainment

Just as oscillators provide the timing for computers, coordination of body function via rhythms such as heart beat and respiration are described by coherence and

  • entrainment. The term coherence is used to describe two or more waves (or systems)

that are either phase‐ or frequency‐locked. This is also called entrainment. In the coherent mode, respiration, heart rhythms, and blood pressure rhythms become entrained and oscillate at the same frequency. An exchange of electromagnetic energy produced by the heart occurs when people touch or are in proximity. Signal averaging techniques are used to show that one's electrocardiogram (ECG) signal is registered in another person's electroencephalogram (EEG) and elsewhere on the other person's body. While this signal is strongest when people are in contact, it is still detectable when subjects are in proximity without contact. Sustained positive emotions affect bodily functions. Thus, there are physiological correlates of positive emotion. This is called psychophysiological coherence. This mode, characterized by heart rhythm coherence, increased heart‐brain synchronization and entrainment of diverse physiological

  • scillatory systems, is associated with increased emotional stability, improved

cognitive performance, and a range of positive health‐related outcomes.

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Coherence & Entrainment

McCraty R., Clinical Applications of Bioelectromagnetic Medicine, 2005.

Additionally, individuals frequently report feelings of increased spiritual connectedness during psychophysiologically coherent states. Through the use of tools and technologies that foster positive emotions and psychophysiological coherence, individuals can effectively initiate a repatterning process, whereby habitual emotional patterns underlying stress are replaced with new, healthier patterns that establish increased emotional stability, mental acuity, and physiological efficiency.

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Advanced Listening

  • “Good listeners are no less rare or important than good

communicators… an unusual degree of confidence is the key – a capacity to not be thrown off course by, or buckle under the weight of, information that may challenge certain settled assumptions.” Alain de Botton

  • Listen for “flags”
  • Verbal – Listen for “how” rather than what
  • Movement – Observe repeated patterns of movement
  • Breathing – fast/slow, high/low, short/long, weak/strong,

rough/smooth

  • “You don’t need to know the right answers, just the right

questions.”

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Value Based Outcomes

  • “No one will ever do anything for your reasons...”
  • The 9‐Core Motivators
  • Spirit
  • Creator
  • Searcher
  • Expert
  • Builder
  • Director
  • Friend
  • Defender
  • Star
  • Connect their Purpose, Path, and Desired outcome

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Summit Blog Page

https://blog.summit‐education.com/trzaskos‐2/

  • Includes:
  • Manual
  • PowerPoint
  • References
  • Additional supplements
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SLIDE 98

For updated support materials visit:

www.NEWwayofhealth.com/PainCourse

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