Reconceptualizing Pain: Maximizing Patient Outcomes Through Pain - - PowerPoint PPT Presentation

AN D Y R OOF, M P T, OCS OCTOB ER 14 , 2 0 16

N u r s e P r a c t i t i o n e r s o f O r e g o n E d u c a t i o n Co n f e r e n c e

Reconceptualizing Pain: Maximizing Patient Outcomes Through Pain Neuroscience Education

Learning Objectives

 1. To gain an understanding of the current model of

chronic pain and how this differs from the standard "tissue lesion-based" model.

 2. To have an evidence-based understanding of the

need for pain neuroscience education in the treatment of chronic pain.

 3.To learn "talking points" regarding pain education

such that all practitioners are consistent with their message to patients.

What is Pain?

International Association of the

Study of Pain (IASP) definition: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

What Is Pain?

Alternative definition:

An unpleasant, but protective, sensory experience in response to what your brain judges to be a threatening situation.

Acute Pain Chronic Pain

 Experienced in response

to disease, inflammation

• r tissue injury

 Experienced in response

to tissue fatigue/ hypoxia

 Involves nociception  Pain is a symptom  Resolves with time and

healing

 Pain that persists beyond

the normal basic tissue healing times of 6-8 weeks

 Pain is related to

hypersensitivity in the nervous system rather than tissue damage or nociception

 Pain is the primary

disorder

Acute vs. Chronic Pain

Chronic Pain may have co-existing pain conditions:

 Chronic Fatigue Syndrome  Endometriosis  Fibromyalgia  Inflammatory bowel disease  Insterstitial cystitis  Temporomandibular joint disease  Vulvodynia

Chronic Pain Neurophysiology

 Central sensitization is characterized by widespread

hypersensitivity of the central nervous system

 This involves impaired functioning of brain-induced

descending anti-nociceptive mechanisms and

• veractivation of descending and ascending pain

facilitatory pathways… this leads to an augmentation

• f nociceptive transmission1

Changes in the Neuromatrix in Chronic Pain

 Increased activity in brain areas known to be

involved in acute pain sensation e.g. insula, anterior cingulate cortex and prefrontal cortex

 Brain activity in regions usually not involved in acute

pain sensations e.g. various brain stem nuclei, dorsolateral frontal cortex and parietal associated cortex

 “Cognitive emotional sensitization:” the capacity of

the forebrain centers to exert powerful influences on various brainstem nuclei involved in descending facilitatory pathways2

Peripheral influences

 Chronic pain can originate from a period of massive

peripheral (nociceptive) input in the acute and subacute stage (e.g. whiplash, multiple surgical procedures)

 In response, the central nervous system modulates

the sensitivity of the somatosensory system

 Any further peripheral injury or stress can further

sustain or aggravate the process of central sensitization

All Pain is Real Pain

 Each person’s pain is unique and needs to be acknowledged  All pain experiences are a normal response to what your

brain thinks is a threat

 Real pain can exist without any damage to the tissues  The construction of a pain experience in the brain relies on

many sensory cues

 The pain experience relies on a very complex electrical and

chemical response in the body

However…

 The degree of injury does not always correlate with

degree of pain

 Diagnostic imaging may not accurately indicate a

tissue “responsible” for the pain

 Psychological factors such as depression and anxiety

can make pain worse

 Social environment may influence perception of pain  Improving an individual’s understanding of pain

through education may reduce the need for care

Pain Neuroscience Education

 Defined as an educational session outlining the

neurobiology and neurophysiology of pain

 Does NOT focus on tissue injury and/ or nociception  Describes how the nervous system, via

up/ downregulation, has the capacity to modulate the pain experience.

 Explains peripheral nerve sensitization, central

sensitization, synaptic activity and brain processing in laymen’s terms.

This form of education is indicated when:

 The clinical picture is dominated by central

sensitization

 Maladaptive pain cognitions, illness

perceptions and/ or coping strategies are present

 Patient is ruminating about pain and is

hypervigilant to somatic signs

Underlying Theme of this Education:

The nervous system processes

MANY inputs including psychological and cognitive information in its construction of the pain experience.

It is not all about nociception!

Benefits of Pain Neuroscience Education

 Studies have shown that neuroscience education can:  1. Decrease fear and positively affect patient’s

perceptions of their pain3

 2. Make improvements in pain, cognition and

physical performance4

 3. Increase pain thresholds during physical tasks5  4. Improve outcomes of therapeutic exercises6

Goal of Pain Neuroscience Education

To change the patient’s concept of

pain so that they are more inclined to exercise, move, and physically function while accepting some level

• f discomfort as “normal” rather

than indicative of ongoing tissue injury.

The BRAIN controls pain: You can have no pain with extreme tissue damage

 Even if problems exist in your bones, joints,

muscles, ligaments, nerves or anywhere else, it won’t hurt unless your brain thinks you are in danger.

 Examples:

Professional athletes and injury Military personnel and GSW’s

The BRAIN creates pain based on its interpretation

• f what is happening to the body

 Pain is an output of the brain, not an input.  The information given to the brain by the

nervous system is: where the pain is, the amount of danger and the nature of the

• danger. The “stretching,” “ripping,”

“burning” sensations are produced by the brain’s construction of events.

Phantom Limb Pain

 70% of people who lose a limb experience a

“phantom limb” that can itch, tingle and hurt

 This relates to the “virtual limb” in our brain. There

is still a brain-constructed representation of that limb in our heads even though the actual limb is missing.

 This “virtual limb” representation is changed in

chronic pain states.

Degenerative Changes

 It is a normal process of aging for our tissues to

degenerate, or at least look a little different than they did at age 16.

 Disc degeneration, degenerative joint disease and

arthritic changes are all normal age-related processes.

 Since these processes occur slowly and over time, our

brains usually do not perceive them as threatening, therefore there is no pain.

Pain Relies on Context

We will experience more or less pain

based on sensory cues that we are receiving in conjunction with the pain

“Stubbing your toe hurts more on a

stressful day than at your birthday party.”

Neuroanatomy/ Neurophysiology Overview

 Group education format  Whiteboard cartoon

Sensors

 Millions of little sensors all throughout your body

that survey their area and convey information to the spinal cord

 When sensors respond to a stimulus (can be

mechanical pressure, changes in temperature, or chemical changes) they open so that positively charged particles from outside the neuron rush into the neuron; this sets up an electrical impulse in the neuron.

Action Potential

 When enough sensors open, and enough + charged

particles rush in, a rapid wave of electrical current travels up the neuron..this is called an Action Potential

 Action Potentials are the way that nerves carry a

single message. This message from the nerve to the spinal cord only says “danger,” not “pain.” The spinal cord and brain receive and process these inputs to create a pain sensation.

Synapse

 When AP reaches the other end of the neuron at the

spinal cord, it causes chemicals to be poured into the gap or “synapse” between the sensory neuron, its neighboring neurons, and the second order neuron that then goes up to the brain. If enough of the correct chemicals are released into the synapse and

• pen enough sensors on the second order neuron, an

AP is produced that carries a “danger” message to the brain.

Brain Processing

 Danger message is ultimately delivered to

the brain, which processes that message, along with all other information that is arriving at the brain.

 Brain uses memory, reasoning and

emotional processes and includes consideration of the potential consequences

• f a response.

Pain Ignition Nodes

 Rather than just one “pain center” in the brain, there are

multiple “ignition nodes.”

 These nodes include parts of the brain used for sensation,

movement, emotions and memory.

 These nodes are “ignited” during a pain experience and link

up to each other electrically and chemically.

 In chronic pain, these nodes become overactive and nearly

dedicated to creating the pain experience. ..like a skipping record… (“nerves that fire together, wire together”)

Descending input

 Neurons descend from the brain, down the spinal

cord, and terminate near the synapse between 1st and 2nd order neurons.

 These neurons provide a flood of “happy

hormones” (opioids and serotonin) that are 60x more powerful than any drug at dampening alarm signals.

Nervous system changes in chronic pain

 Sensors stay open longer  More sensors are manufactured  Danger messenger neuron increases its sensitivity

to incoming excitatory chemicals

 Other neurons that don’t carry danger messages

sprout close to the synapse and the chemicals they release activate the pain neuron

Altered spinal cord inputs

These changes in the spinal cord make

it so that the brain is not receiving accurate information about what is happening in the tissues.

“The spinal cord as a magnifier of tissue

reality”

Backfiring Nerves

Impulses can travel back down the

neuron and cause release of chemicals at the end of the neuron in the area of the originally damaged tissue. This can cause

• ngoing inflammation in the

tissues.

Nerve Pain and Zingers

Nerves, especially damaged ones, can

cause pins and needles, burning pain, “zingers” and pain at night (esp. hands and feet)

Nerves can become sensitive to

chemicals you produce when stressed…

The problem is now in the nervous system

 Chronic pain exists because of changes in

the brain, spinal cord and nerves. It is no longer a result of ongoing tissue d a m a ge.

 When we experience pain in a chronic state

it is important to remind ourselves that it is because our nervous system is “sensitive and

• ver active.”

Thoughts play into this pain…

Thoughts and beliefs are nerve

impulses too.

Imagining a movement or watching

someone else move can produce pain.

Imagining movement may cause

swelling of the painful part.

Your pain can be worse due to:

Negative thoughts: anger,

depression, fear, stress, painful memories, negative attitudes and beliefs

Physical state: fatigue (lack of sleep),

hunger, cold, heat, noise, illness

Chronic Pain Process

 Known tissue healing time has passed, yet pain

persists

 Diagnoses based on tissue processes are no longer

accurate

 Pain becomes related to CNS processes (brain,

spinal cord and nerves) as opposed to actual tissue damage (tendons, ligaments, muscles, discs)

Chronic Pain Process

Normal sensations produced by

movement or touch are translated by the nervous system into a pain message.

The pain becomes a false signal caused

by hypersensitive nerves.

And so now…

HURT ≠ HARM

Sympathetic Nervous System

Nerve network throughout the body Distributes adrenaline to all of your

tissues

In chronic pain states, there can be

increased adrenaline levels

Adrenaline increases the alarm system

sensitivity

Parasympathetic Nervous System

Slows and conserves energy, aids in

digestion, cellular replacement, tissue healing

Decreases adrenaline levels Meditation, quality sleep, deep

breathing and relaxation all facilitate this

Immune System

 Pro-inflammatory cytokines are active when

you have the flu… .this is desirable for healing response

 Long term stress and pain lead to chronic

inflammatory cytokine activity… movements are more sensitive, old pains can come back to revisit.

Buffer Your Immune System

 Optimal nutrition  Be in control of your life and your treatment

• ptions

 Have family and medical support  Have a strong belief system  Have and use a sense of humor  Exercise appropriately

Effects of Movement and Exercise

 Exercise:  1. improves blood flow to the brain, joints and

muscles

 2.regulates mood in a positive way  3. primes the brain for learning  4.results in a chemical release that helps decrease

pain perception.

Exercise boosts levels of beneficial neurotransmitters

 Dopam ine: vital for movement, attention,

cognition, motivation and pleasure.

 Serotonin: important for mood, learning, self-

esteem and decreased anxiety and impulsiveness

 Endorphins: act as natural morphine, blocking

pain and producing feelings of pleasure, satisfaction and bliss

Exercise helps with depression

 SMILE studies from Duke University⁷

compared exercise vs. Zoloft in the

treatment of depression over a 16 week period

Results: Exercise was as effective as

medication at causing a significant drop in depression

Key “coachable” components

 Understanding (Explain Pain class)  Support (family, friends, social groups)  Achievable goals  Knowledge  Exercise  Engagement in enjoyable activities  Relaxation and deep breathing

Instead of “No Pain, No Gain… ”

“Know Pain or No Gain”

Self-Treatment for Managing Chronic Pain

 Exercise: includes walking, hiking, dancing,

swimming, water aerobics, bicycling, working out at the gym… all of this promotes the release of “feel good” brain chemicals!

 Self-massage with a tennis ball, pokey ball,

vibrating massager, your fingers, etc… improves circulation to tight muscles which helps them to relax and leads to less pain and more movement.

Self-Treatment for Managing Chronic Pain

 Relaxation to stimulate the “feel good” brain

chemicals and decrease the “stress”

• chemicals. This includes deep breathing,

meditation, mindfulness, yoga, prayer…

 Proper nutrition: a whole foods or anti-

inflammatory diet to optimize the immune system’s functioning and to decrease painful inflammation in the body

Self-Treatment for Managing Chronic Pain

 Proper sleep: 6-9 hours of sleep per night to

allow your body time to heal.

 Only YOU can commit to following up on

these ideas. No one can give them to you, charge you money for them, etc… When it comes to treating your chronic pain, the best things in life really ARE free!

How to Start Exercising

 Start with something you enjoy. Walking, hiking, biking,

dancing, swimming and water aerobics are all good choices.

 Start slowly and time yourself so that you have an objective

measure of your exercise.

 If you have a pain flare, remember that it is your nervous

system “speaking up” as it gets used to a different level of

• activity. Decrease your time of exercise by 20% and get

back out there!

Education is a continuous process

 Pain neuroscience education is a continuous process

and needs to be applied across treatment sessions, during therapeutic exercise and during manual therapy.

 Pain neuroscience education should be utilized by all

healthcare professionals working with the patient. The message needs to be consistent across all disciplines for optimal reinforcement and deep learning by the patient.

Brainman Video

 Brainman Understanding Pain

https:/ / www.youtube.com/ watch?v=4b8oB757DKc

Persistent Pain Education Program

 The Persistent Pain Education Program (PPEP) is a

series of eight presentations that educates people in a comprehensive, pain management approach. Each 90-minute talk is led by a different healthcare professional including Physical Therapist, Clinical Psychologist, Clinical Pharmacist, Sleep Specialist, Dietician and Therapeutic Yoga Instructor. The classes help people dealing with chronic pain to address multiple areas of self-management that can ultimately lead to decreased pain and improved quality of life.

Explain Pain Class

 This class is taught by Andy Roof, Physical Therapist,

and covers the basic physiology of pain, what is happening in our brains and nerves when we feel pain, and how a “chronic” pain state develops in our nervous system. Research suggests that people who are able to change their pain cognitions following an educational intervention demonstrate an improvement in physical performance. (Moseley, 2004)

Living a Fulfilling Life with Pain

 This class is taught by Sandy Bushberg, PhD,

Psychologist, and builds on the Explain Pain class by covering the neurophysiological and psychobiological effects of the pain experience. Dr. Bushberg instructs participants in Acceptance and Commitment Therapy which involves living a values- driven and purposeful life despite experiencing pain.

Anti-Inflammatory Diet

 This class is taught by Tracy Dugick, Registered

Dietician, and covers the Anti-Inflammatory Diet. Chronic inflammation has been shown to be involved in multiple disease processes that are involved in creating a persistent pain condition. This chronic inflammation is influenced by diet and this class aims to educate people in eating properly to reduce inflammation in the body. This class will cover a week’s worth of meal ideas that are affordable and healthy.

Mindfulness Meditation

 This class is taught by Jill Kieffer, RN, Therapeutic

Yoga Instructor. Certain parts of the nervous system become “wound up” and dysfunctional in a persistent pain state. Yoga, meditation, deep breathing and relaxation can help to calm the nervous system and return it to a healthy state. This class covers simple breathing and relaxation techniques that can be performed daily as part of a self-treatment program.

Mindfulness Movement

 This class builds on the breathing and relaxation

techniques learned in Mindfulness Meditation. Persistent pain often involves dysfunctional habitual movements that include poor breathing patterns and excessive muscle tension being held in the torso, pelvis and neck/ shoulder. This class instructs students to pay attention to their breathing while performing fluid, relaxed motions during everyday activities such as working in the kitchen and garden.

Pharmacology Class

 This class is taught by Eric Holeman, Clinical

Pharmacist, and covers proper pain management with prescription drugs. Topics covered also include

• pioid tolerance, dependence, addiction and safe

tapering or weaning techniques.

Sleep and Pain

 This class is taught by Paul Cardosi, MD, a sleep

• specialist. Good sleep is beneficial for mind and

body, but pain can get in the way and poor sleep may make coping with pain more difficult. This class will explore this relationship and discuss options for treatment.

Outcome Measures

 Program participants will complete outcome

measures reflective of their pain levels, physical function, pain acceptance and health locus of control before and after completion of the program.

 -Brief Pain Inventory: reflects pain intensity and

physical functioning

-Multidimensional Health Locus of Control

(Form C)

-Chronic Pain Acceptance Questionnaire: reflects

acceptance of pain

 “In order for man to succeed in life, God

provided him with two means, education and physical activity. Not separately, one for the soul and the other for the body, but for the two together. With these two means, man can attain perfection.”

• ---Plato

References

 1. Nijs, et al. How to explain central sensitization to patients with

“unexplained” chronic musculoskeletal pain: Practice guidelines. Manual Therapy 16 (2011) 413-418.

 2. Brosschot JF. Cognitive-emotional sensitization and somatic health

• complaints. Scan J of Psych 2002; 43:113-21.

 3. Moseley GL. Joining forces---combining cognition-targeted motor

control training with group or individual pain physiology education: a successful treatment for low back pain. J Man Manip Therapy 2003;11:88- 94.

 4. Moseley GL. Evidence for a direct relationship between cognitive and

physical change during an education intervention in people with chronic low back pain. Eur J Pain 2004;8:39-45.

 5.Moseley GL, Hodges PW, Nicholas MK. A randomized controlled trial of

intensive neurophysiology education in chronic low back pain. Clin J Pain 2004;20:324-30.

 6.Moseley L. Combined physiotherapy and education is efficacious for

chronic low back pain. Aust J Physiother 2002;48:297-302.

References

 7. Blumenthal JA, et al. Exercise and pharmacotherapy in the treatment of

major depressive disorder. Psychosom Med. 2007 Sep-Oct; 69(7): 587-96.

 8. Butler, D., Moseley, L. Explain Pain. Noigroup Publications, Adelaide,

Australia, 2003.

 9. www.ninds.nih.gov/ disorders/ chronic_pain/ detail_chronic_pain.htm  10. Ratey, J. Spark: The Revolutionary New Science of Exercise and the Brain.

Little, Brown and Co., 2008.