Therapeutic Neuroscience Education OPTA June 2016
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Therapeutic Neuroscience
EductionKnow Pain; Know Gain
Kory Zimney, PT, DPT, CSMT, CAFS
Therapeutic Neuroscience Education OPTA June 2016
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10 Visits• 64 year old lady with
3 years of CLBP
• Numerous treatments
• Numerous clinicians
• Pain rating 9/10
(NRS)
• Oswestry 54%
(Severe disability)
• FABQ-W= 25/42,;
FABQ-PA = 20/24
• Zung depression
scale = 58
And more…Ultrasound
Spinal
Mobilization
Spinal
Manipulation
Aquatic
Therapy Soft Tissue
Treatment
Electrical
Stimulation
TENS
Posture
Ergonomics
Spinal
Stabilization
Traction
Myofacial
Release
Cranio
Sacral
Triggerpoint
Therapy
Name the treatment
Up to 2/3 of the 70+ million have been living with this pain for more than five years
(AAPM, 1999)
IOM Relieving Pain in America 2011
Report: “Chronic Pain affects about
100 million American adults.”
x 25
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Chronic Pain Numbers
• Epidemiological data suggest that chronic,widespread, nonspecific musculoskeletal pain is onthe rise, especially in the area of chronic low backpain(CLBP), adding to the ever increasing costs ofhealth care (Magni et al, 1993; McMahon andKoltzenburg, 2005).
• The prevalence of chronic pain was 35.5% (Raftery,Sarma et al. 2011)
We all practice a bio-psycho-social approach…right…? Example 1
• What is this?
• How long will it take?
• What do you want the patient to do?
• What should the patient NOT do?
• What will you as the clinician be doing for this?
Example 2
• What is this?
• How long will it take?
• What do you want the patient to do?
• What should the patient NOT do?
• What will you as the clinician be doing for this?
Underpinning
the bio-psycho-social
approach & held together with
reasoning “glue”
Representation
Pain mechanisms
Onion skins
Beliefs/fears/threats Biomechanics
Pathoanatomy
Evolutionary
Biology
Anatomy
Louw A, Butler DS. Chronic
Pain. In: S.B. B, Manske R,
eds. Clinical Orthopaedic
Rehabilitation. 3rd Edition ed.
Philadelphia, PA: Elsevier;
2011.
Therapeutic Neuroscience Education OPTA June 2016
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Underpinning
the bio-psycho-social
approach & held together with
reasoning “glue”
Representation
Pain mechanisms
Onion skins
Beliefs/fears/threats Biomechanics
Pathoanatomy
Evolutionary
Biology
Anatomy
Louw A, Butler DS. Chronic
Pain. In: S.B. B, Manske R,
eds. Clinical Orthopaedic
Rehabilitation. 3rd Edition ed.
Philadelphia, PA: Elsevier;
2011.
Underpinning
the bio-psycho-social
approach & held together with
reasoning “glue”
Representation
Pain mechanisms
Onion skins
Beliefs/fears/threats Biomechanics
Pathoanatomy
Evolutionary
Biology
Anatomy
Louw A, Butler DS. Chronic
Pain. In: S.B. B, Manske R,
eds. Clinical Orthopaedic
Rehabilitation. 3rd Edition ed.
Philadelphia, PA: Elsevier;
2011.
Biomechanical models
Underpinning
the bio-psycho-social
approach & held together with
reasoning “glue”
Representation
Pain mechanisms
Onion skins
Beliefs/fears/threats Biomechanics
Pathoanatomy
Evolutionary
Biology
Anatomy
Louw A, Butler DS. Chronic
Pain. In: S.B. B, Manske R,
eds. Clinical Orthopaedic
Rehabilitation. 3rd Edition ed.
Philadelphia, PA: Elsevier;
2011.
Tissue Pathology
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ihavewhiplash.com
myanklehurts.com These models are
very prevalent
• Prevailing biomedical models focus on tissues and tissueinjury.(Houben, Ostelo et al. 2005; Henrotin, Cedraschi et al.2006; Weiner 2008)
• Orthopedic-based professions such physical therapycommonly use anatomy and patho-anatomy based models toexplain pain to their patients. (Houben, Ostelo et al. 2005;Henrotin, Cedraschi et al. 2006; Spoto and Collins 2008;Weiner 2008)
1. Anatomy
2. Biomechanics
3. Pathoanatomy
Research into anatomy, biomechanical and
pathoanatomy models
• Not only have these models
shown limited efficacy in
decreasing pain and disability, but
they may increase fear in
patients, which in turn, may
increase their pain.(Greene,
Appel et al. 2005; Morr, Shanti et
al. 2010)
Degenerative terms
•“Wear and tear”
•“Deterioration”
•“Disc space loss”
•“Crumbling”
•“Collapsing”
Research into anatomy, biomechanical and
pathoanatomy models
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Underpinning
the bio-psycho-social
approach & held together with
reasoning “glue”
representation
Pain mechanisms
onion skins
Beliefs/fears/threats biomechanics
pathoanatomy
evolutionary
biology
anatomy
Louw A, Butler DS. Chronic
Pain. In: S.B. B, Manske R,
eds. Clinical Orthopaedic
Rehabilitation. 3rd Edition ed.
Philadelphia, PA: Elsevier;
2011.
Would this hurt?
Louw A. Why You Hurt: A
Neuroscience Approach to Pain.
Minneapolis: OPTP; 2012.
Would this hurt if….?
34
Louw A. Why You Hurt: A
Neuroscience Approach to Pain.
Minneapolis: OPTP; 2012.
How Dangerous is
this?
This is dangerous
More information
Facilitation
Neuronal adaption
How Dangerous is
this?
This is not
dangerous
Inhibition
Endogenous
Consider this….
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Perception can change based on
contextPain relies on context
Pain relies on context Pain relies on context
Simotas, A. C. Shen, T. Neck pain in demolition derby drivers. Arch Phys Med Rehabil.
2005. 86(4): 693-696
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Underpinning
the bio-psycho-social
approach & held together with
reasoning “glue”
Representation
Pain mechanisms
Onion skins
Beliefs/fears/threats Biomechanics
Pathoanatomy
Evolutionary
Biology
Anatomy
Louw A, Butler DS. Chronic
Pain. In: S.B. B, Manske R,
eds. Clinical Orthopaedic
Rehabilitation. 3rd Edition ed.
Philadelphia, PA: Elsevier;
2011.
Our view of pain processing is old
Wade, D., Why physical medicine, physical disability and physical rehabilitation?
We should abandon Cartesian dualism. Clin Rehab, 2006. 20: p. 85-90.
Pain is viewed as a Thing
It’s
Fasci
a
It’s a
Trigger
Point
It’s
Postur
e
It’s a
DiscIt’s
the
Face
t
It’s
the
Core
Fundamental Beliefs:
• Pain only occurs when you are injured.
• The amount of pain one feels is a
direct indication of the amount of
tissue damage one has incurred.
Fundamental Reality:
Pain ≠ Injury
An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage.
Therapeutic Neuroscience Education OPTA June 2016
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An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage.
An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage.
An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage.
Pain viewed as a
Personal Experience
THOUGHTS
DREAMS
HOPES
FEARS
ANXIETIES
BEHAVIORSBELIEFS
HABITS
STRESSORS
EMOTIONS
DISABILITY
DEPRESSION
FINANCES
IDENTITY
RESOND via
OUTPUTS: • Pain
• Action programs
• Stress regulation
Tissues
Environment
SCRUTINIZE via
BODY-SELF
NEUROMATRIX: • Sensory
• Cognitive
• Affective
Gifford, L.S., Pain, the tissues and the nervous
system. Physiotherapy, 1998. 84: p. 27-33.
Mature
Organism
Model
Underpinning
the bio-psycho-social
approach & held together with
reasoning “glue”
Representation
Pain mechanisms
Onion skins
Beliefs/fears/threats Biomechanics
Pathoanatomy
Evolutionary
Biology
Anatomy
Louw A, Butler DS. Chronic
Pain. In: S.B. B, Manske R,
eds. Clinical Orthopaedic
Rehabilitation. 3rd Edition ed.
Philadelphia, PA: Elsevier;
2011.
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Evolutionary Models
• Parents to offspring
• Survival
• Consider:
– Pain protects
– Inflammation protects
– Some dysfunctions protect
Underpinning
the bio-psycho-social
approach & held together with
reasoning “glue”
Representation
Pain mechanisms
Onion skins
Beliefs/fears/threats Biomechanics
Pathoanatomy
Evolutionary
Biology
Anatomy
Louw A, Butler DS. Chronic
Pain. In: S.B. B, Manske R,
eds. Clinical Orthopaedic
Rehabilitation. 3rd Edition ed.
Philadelphia, PA: Elsevier;
2011.
Butler D, Moseley G. Explain Pain.
Adelaide: Noigroup; 2003.
Underpinning
the bio-psycho-social
approach & held together with
reasoning “glue”
Representation
Pain mechanisms
Onion skins
Beliefs/fears/threats Biomechanics
Pathoanatomy
Evolutionary
Biology
Anatomy
Louw A, Butler DS. Chronic
Pain. In: S.B. B, Manske R,
eds. Clinical Orthopaedic
Rehabilitation. 3rd Edition ed.
Philadelphia, PA: Elsevier;
2011.
Vlaeyen JWS, Linton SJ. Fear-avoidance and its
consequences in chronic musculoskeletal pain: a
state of the art. Pain. 2000;85:317-322.
Could also be emotional
overload
Choice made
Importance of early
education?
Knowledge
Threatening and provocative words; Medical tests; Various
opinions; Internet information; Experiences
Irrational thoughts
Limited knowledge
Pull back
Do less
Increased fear
Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317-322.
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“I’m good”“No big deal”“I’ll be OK”“Lots I can do for this”“Keep moving”“No pain, no gain”“Couple of beers…I’ll be OK”
Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317-322.
May have never
experienced good pain
Remembers various pain experiences quite vividly
“I have a bulging disc”“I have arthritis”“No one agrees”“No one can find it”“ My dad had severe…”“Saw on the Internet…”“My neighbor…”
“This must be bad”“I will never be able to…”“I will be cripple at 65”“I will be in a wheelchair”
“Since this I have not gone out much”“No going to the movies”
Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317-322.
Pain is a %$#@ more complex than just
tissue…
A fundamental flaw:
The Predominant Model for Pain
If the main reason for pain is a
stiff joint…
Flynn T, Fritz J, Whitman
J, et al. A clinical
prediction rule for
classifying patients with
low back pain who
demonstrate short-term
improvement with spinal
manipulation. Spine. Dec
15 2002;27(24):2835-
2843.
If the main reason for pain is a
tight muscle…
Fernandez-de-Las-
Penas C, Alonso-
Blanco C, Cuadrado
ML, Miangolarra JC,
Barriga FJ, Pareja JA.
Are manual therapies
effective in reducing
pain from tension-type
headache?: a
systematic review.
Clin J Pain. Mar-Apr
2006;22(3):278-285.
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If the main reason for pain is
altered muscle recruitment…
Hodges PW. Core
stability exercises for
chronic low back pain.
Orthopedic Clinics of
North America.
2003;34:245-254.
But what if the
pain and
disability is due
to faulty
cognitions?
• My pain is due to the bulging disc
• I hurt because I have arthritis
• Movement will damage tissue and increase pain
• Pain means something is wrong
• I am not doing anything until all pain is gone
• I am afraid my pain will get worse
• I have a very rare case of…
It is well established that psychological and
socioeconomic factors are correlated to pain• Fear
• Catastrophization
• Knowledge
• Anticipation and consequence of pain1. Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic
low back pain and its relation to behavioural performance. Pain. 1995;62:363-372.
2. Kovacs FM, Seco J, Royuela A, Pena A, Muriel A. The correlation between pain, catastrophizing, and
disability in subacute and chronic low back pain: a study in the routine clinical practice of the Spanish
National Health Service. Spine. Feb 15 2011;36(4):339-345.
3. Moseley GL, Hodges PW, Nicholas MK. A randomized controlled trial of intensive neurophysiology
education in chronic low back pain. Clinical Journal of Pain. 2004;20:324-330.Moseley GL. A pain
neuromatrix approach to patients with chronic pain. Man Ther. Aug 2003;8(3):130-140.
Returning to our patient• “I have
bulging
discs”
• “I have
arthritis”
Louw A, Puentedura EL,
Mintken P. Use of an
abbreviated neuroscience
education approach in the
treatment of chronic low
back pain: A case report.
Physiotherapy theory and
practice. Jul 3 2011.
Cognitive Processing
• Afraid; poorly understood; movement = pain
due to tissues being damaged
High
Threat
PAIN
to
defend
Louw A, Puentedura EL, Mintken P. Use of an abbreviated neuroscience
education approach in the treatment of chronic low back pain: A case report.
Physiotherapy theory and practice. Jul 3 2011.
What about…
The Top Down Effect
Tissues
Environment Adapted from Gifford LS. Pain, the tissues and the
nervous system. Physiotherapy. 1998;84:27-33.
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That ultrasound thing works every time My pain story
So…
• Current clinical educational models
don’t really work
• We need to change beliefs
• Is there a “better way” to educate?
• Why educate patients in PAIN
about anatomy and biomechanics?
Why not just teach them more
about….PAIN?Image: Clinical Journal
of Genius 2013
Origins of Neuroscience Education
The origins of neuroscience education
Moseley L. Combined physiotherapy and
education is efficacious for chronic low back
pain. Aust J Physiother. 2002;48(4):297-302.
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Efficacy Neuroscience Education
Louw A, Zimney K, Puentedura EJ,
Diener I. The Efficacy of Pain
Neuroscience Education on
Musculoskeletal Pain – A Systematic
Review of the Literature. Physiotherapy
Theory and Practice. In Press
Conclusions: Current evidence supports the use of PNE
for chronic MSK disorders in reducing pain and improving
patient knowledge of pain, improving function and lowering
disability, reducing psychosocial factors, enhancing
movement and minimizing healthcare utilization.
Therapeutic Neuroscience Education
82
• Metaphors and examples
• Pictures
• One-on-one
• Therapist
Too many numbers?• 34 year-old female
• 4.5 years of pain
• Started as LBP, then spread to her buttocks and now into both legs
• Pain would flare up with stress at work
• First child 2.5 years ago – “horrible” labor, delivery and pain
• Now constant LBP
• Not able to return to work
• Now severe spasms in both legs
• CT, MRI and X-Ray WNL
• Meds: High doses of pain killers and narcotics
A brain that feels extremely threatened,
confused, hopeless…
85Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI
evaluation of a single patient with chronic low back pain. Aust J Physiother. 2005;51(1):49-52.
A brain that understands, is less
threatened and has hope…
86Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI
evaluation of a single patient with chronic low back pain. Aust J Physiother. 2005;51(1):49-52.
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Key message of this study…
• Every PT clinic should have an fMRI…
One last time…
• People in pain want to know
more about pain
• The more they know about
pain, the less pain they
experience!
The
Neuroscience of
Pain
RESOND via
OUTPUTS: • Pain
• Action programs
• Stress regulation
Tissues
Environment
SCRUTINIZE via
BODY-SELF
NEUROMATRIX: • Sensory
• Cognitive
• Affective
Mature
Organism
Model
Gifford, L.S., Pain, the tissues and the nervous system.
Physiotherapy, 1998. 84: p. 27-33.
91
Tissues
Environment
Transduction
92
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93 94
Receptor - Ion channels
Action/Generator Potential
95
Various kinds of channels…
Genetic Coding
DNA mRNA Proteins
DNA mRNA Proteins
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Name the ion channel… Name the channel…
Key point: Ion channels
101
Key point: Ion channels
102
Tissues
Environment
TransductionPain relies on context
104
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Pain relies on context
105
Tissues
Environment
106
First Pain – Aδ fiber
Second Pain – C fiber
107
There are NO pain fibers in the body Key Point: Damaged or Removed Myelin
• Mechanical
• Immune
• Chemical
108
Clinical Example
109
Modulation
110
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Melzack and Wall’s
Gate Control Theory
111
Central Modulation
A-Beta fibers
C fibers
Interneuron
Second Order
Wide Dynamic
Ranging Neuron
Second Order
Nociceptive
Specific
A-Beta fibers
C fibers
Interneuron
Second Order
Wide Dynamic
Ranging Neuron
Second Order
Nociceptive
Specific
Other Side
Other Levels
Sympathetic
Action Potential Wind-up
VS.
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How Dangerous
is this?
This is
dangerous
More information
Facilitation
Neuronal
adaption
117
How Dangerous
is this?
This is not
dangerous
Inhibition
Endogenous
118
Tissues
Environment
Perception
SCRUTINIZE via
BODY-SELF
NEUROMATRIX: • Sensory
• Cognitive
• Affective
119
GRANNY
The Brain’s Processing…Grandma
The Brain’s processing of LBP
• Common areas are frequently “ignited”
• Via connections, backfiring neurons, andneurotransmitters, pain is perceived – thepain neural signature
1. Flor, H. The image of pain. in Annual scientific meeting of The Pain Society (Britain). 2003. Glasgow, Scotland.
2. Flor, H., The functional organization of the brain in chronic pain, in Progress in Brain Research, Vol 129, J.
Sandkühler, B. Bromm, and G.F. Gebhart, Editors. 2000, Elsevier: Amsterdam.
3. Casey, K.L. and M.C. Bushnell, Pain imaging. Pain: Clinical Updates, 2000. 8: p. 1-4.
4. Petrovic, P. and M. Ingvar, Imaging cognitive modulation of pain processing. Pain, 2002. 95(1-2): p. 1-5.
5. Moseley, G.L., Widespread brain activity during an abdominal task markedly reduced after pain physiology
education: fMRI evaluation of a single patient with chronic low back pain. Aust J Physiother, 2005. 51(1): p. 49-
52.
Louw A, Butler DS, Diener I, Puentedura E and Peoples, R; 2013 Preoperative Neuroscience
Education for Lumbar Radiculopathy: A Single Case fMRI Study
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1. PREMOTOR/ MOTOR CORTEX
organize and prepare movements
2. CINGULATE CORTEX
concentration, focusing
3. PREFRONTAL CORTEX
problem solving, memory
4. AMYGDALA
fear, fear conditioning, addiction
5. SENSORY CORTEX
sensory discrimination
6. HYPOTHALAMUS/ THALAMUS
stress responses, autonomic regulation,
motivation
7. CEREBELLUM
movement and cognition
8. HIPPOCAMPUS
memory, spacial recognition, fear
conditioning
9. SPINAL CORD
gating from the periphery
A TYPICAL PAIN NEUROTAG
9
5
6
8
1
7
2
3
4
123
But…
• There’s more
complexity…
Denotes synaptic modulation
Beliefs
Denotes synaptic modulation
Beliefs
Knowledge, logic
Denotes synaptic modulation
Beliefs
Knowledge, logic
Social context
Denotes synaptic modulation
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Beliefs
Knowledge, logic
Social context
Anticipated
consequences
Denotes synaptic modulation
Beliefs
Knowledge, logic
Social context
Anticipated
consequences
Other sensory cues
Denotes synaptic modulation
Beliefs
Knowledge, logic
Social context
Anticipated
consequences
Other sensory cues
Physical therapy
Denotes synaptic modulation
Melzack’s Pain Neuromatrix
132
Modulation
133
Bulging Discs and Pain
• 40% of the general
population has a
significant bulging disc,
but no pain
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No Correlation Between LBP and DJD
20 30 4050
60
70
More info on imaging…
• 25-50% of general population:– Hypointense disc signal
– Annular tears
– High intensity zones
– Disc protrusions
– Endplate changes
– Zygapophyseal joint degeneration
– Asymmetry
– Foraminal stenosis.
Kjaer P, Leboeuf-Yde C,
Korsholm L, Sorensen JS,
Bendix T. Magnetic resonance
imaging and low back pain in
adults: a diagnostic imaging
study of 40-year-old men and
women. Spine. May 15
2005;30(10):1173-1180.
Shoulder…
After successful rotator cuff repairs and clinically sound examination:
• 90% abnormal signaling
• 16% partial tears
• 20% complete tears
• 33% sub-acromial effusion
• 16% joint effusion
• 20% bone marrow edema
(Spielmann, Forster et al. 1999)
Shoulder…
• The over-all prevalence of tears of the rotator cuff in allage-groups was 35% (Sher, Uribe et al. 1995)
• Over age 70: 2 out of 3 have asymptomatic RCtear(Milgrom, Schaffler et al. 1995)
• 40% of normal asymptomatic people have RC tears(Reilly, Macleod et al. 2006)
Knee…
• 15% of MRI‟s show meniscus degeneration (Munk,Lundorf et al. 2004)
• 50% correlation between knee pain and arthritis(Bedson and Croft 2008)
• 35% of collegiate basketball players with no knee pain– significant abnormalities on MRI (Major and Helms2002)
TISSUES HEAL…
Louw A, Puentedura EJ. Therapeutic Neuroscience Education. Vol 1.
Minneapolis, MN: OPTP; 2013.
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Output (Interpretation and Behavior)
• Pain
• Sympathetic
• Motor
• Immune
• Adrenaline
• Cortisol
• Respiration
• Language
• Etc
141 142
143 144
PERIPHERAL AND CENTRAL
SENSITIZATION
145
“Nerves that fire together…
wire together”-Hebbian Plasticity Theory
146
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Pain
Neurosignature
“Representation”
147
Long Term
Potentiation
(LTP)
• Memory
• Learning
148
Central and Peripheral
149
Sensor
y
Emotional
Shift /
Time
150
Central
SensitizationClinical Example:
Phantom Limb Pain
152
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Clinical Example:
Smudging
153
Definition of Pain: Update
Pain is produced by the brain after a person’s neural
signature has been activated and concluded the body
is in danger and action is required (Moseley 2003;
Moseley 2007).
OUTPUTS • Pain
• Action programs
• Stress regulation
Tissues
Environment
PROCESSING via
BODY-SELF
NEUROMATRIX: • Sensory
• Cognitive
• Affective
Gifford, L.S., Pain, the tissues and the nervous system.
Physiotherapy, 1998. 84: p. 27-33.
The Big Picture
So How Do You Do It? 1. The Brain is Key
Alter/Challenge Beliefs
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Taking it to patients…PART 1 Taking it to patients
• They want it…
• We underestimate their ability to take on the
information
• Metaphors and examples
• Pictures
We already have the script
• Neurophysiology of pain – how we view pain
• Nociception and nociceptive pathways
• Neurons
• Synapses
• Action potential
• Spinal inhibition and facilitation
• Peripheral sensitization
• Central sensitization
• Plasticity of the nervous system
Let’s Start: So Many Paths to Take
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2. We DO NOT manage pain!
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From Steve Schmidt
Focus on Function3. Don’t tell me you don’t know what to do
1. Skillful delivery of medication
2. Therapeutic Neuroscience Education
(make the threat smaller)
3. Aerobic exercise
4. General stabilization (versus specific)
5. Posture – likely self-correct and no
prolonged sessions
6. Relaxation
7. Meditation
8. Diet
9. Sleep hygiene
10. Journaling
11. Coping skills
12. Social interaction
13. Humor
14. Manual therapy
15. Modalities
16. Aquatic therapy
17. Welcoming, safe, healing
environment
18. Goal setting
19. Other…
4. Consider ALL treatment this way…
BOTH
5. Bottom Up has it’s place
6. Top Down: Change Beliefs 7. Make lions smaller
Therapeutic Neuroscience Education OPTA June 2016
Property of ISPI– not to be copied
without permission 37
8. Aerobic Exercise
• Incredible high-level
evidence
• Flush the system
That’s it?
Thank you & acknowledgements…
• Tina, Tyler, Ella, and Lanie Zimney
• Dr. Adriaan Louw
• Dr. Louie Puentedura
• ISPI/EIM staff and faculty
• University of South Dakota
• Nova Southeastern University