1kinesiophobia
fear of movement
2patients were significantly more likely to transition to chronic LBP as their risk on the prognostic tool increased as they were exposed to more __________ ______________
nonconcordent recommendations
bad language
3patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were more likely to
develop chronic LBP
4contributors to persistent pain
biological, psychological, and social factors
5In the biopsychosocial model, you treat the ______, not just the tissue
Pain is _______, and a ___________ experience
there is a strong association with _________
person
multidimensional
subjective
expectations
6need to change the clinician’s stance from ________ ____________ to __________ _____________
objective detachment
reflective participation
7sleep _______ impacts pain experience
directly
8Why classify pain?
by defining the mechanism contributing to a patient’s pain, you can prioritize and target specific interventions to that specific pain mechanism
9Biological pain classifications
Nociceptive - nociceptors/peripheral sensitization
Nociplastic - central processing
Neuropathic - nerves
10Psychosocial pain classification
negative emotional factors may ________ other pain mechanisms and contribute to their pain
Critical in the transition from ______ to ______ pain
Predictive for development of _______ pain
augment
acute, chronic
chronic
11Movement systems Pain
relationship between movement and pain is _______ and highly _________
Increased ______ ______, _____, and _______ ______
Muscle ________
Provokes fear ________-> results in _______ and _________
complex
variable
muscle contraction, tone, trigger point
inhibition
avoidance
disuse, disability
12treatment for nociceptive pain
Exercise - decrease nociceptor excitability, increase peripheral inhibition, promote healing of injured tissues
massage - increases peripheral inhibition, promotes healing of injured/inflamed tissues, reduce mechanical activation of a nociceptor
TENS - useful for those with ehanced sympathetic activity and nociceptor sensitization, passive treatment
13treament for nociplastic pain
education - change how we think about pain, increased understanding on pain corresponds to an increase in pain threshold
exercise - modulation of pain sensitvity by altering central nociceptive processing and increasing central inhibition (global exercise)
massage - activation of central inhibitory mechanisms and reduce central exciteability producing analgesia (less autonomy for pt)
manipulation - reduces central excitability in the region of primary hyperalgesia, reduced secondary hyperalgesia in those with chronic pain
TENS - increasing central inhibition and reducing central exciteability
14treatment for neuropathic pain
exercise - increases anti-inflammatory cytokines, effect cytokines and macrophages allowing form increased nerve healing, considered disease modifying intervention
manual therapy - increase myelin sheath thickness in peripheral nerves, ameliorate nerve compression, be careful in glides
15treatment for psychological factors
education - CBT, reduce catastrophizing
exercise - reduces depressive symptoms, improves cognitive function, reduces pain catastrophizing
massage - decreases cortisol, power of positive touch
16treatment for motor
education
exercise
manipulation - decrease/increase motor neuron excitability
17Key pain education points
pain protects us and promotes healing
persistent pain over protects us and prevents recovery
many factors influence pain
there are many ways to reduce pain and promote recovery
18although each pain mechanism can be addressed individually, the efficacy of an interventino can be maximized when considering
multiple pain mechanisms might be addressed simultaneously
19Bio vs Psych vs Social
Bio - tissue changes, plastic nervous tissue changes
Psych - stress, anxiety, depression
Social - stress, support, life roles
20exercise goals
decrease pain
decrease catastrophizing thoughts
decreased kinesiophobia
increased ROM
increased tissue endurance
increased activity tolerance
improved strength
improved movement patterns
21principles of graded exercise therapy
must understand your patient
dosage
Sequence of exercise: global, semi global, local
restoration of optimal pain-free movement
return to function
22global exercise targets
endorphin response, whole body
increase tolerance of the individual to physical activity
23semi-global exercise
targets body regions
beneficial for kinesiophobia
prepare for local exercise
24Local exercise
specific to tissue
local tissue response
addresses tissues stress tolerance - healing and loading
25patient education and experience
set the expectations
addresses motivation, adaptation, and tolerance to movement
26encourage a tolerable amount of _____ with controlled and acceptable guidelines
symptoms or discomfort does not mean _____ ______
patients with high kinesiophobia need to _____ _____ and experience a _____ dosage of exercise and see how it feels during the movement and after
discomfort
tissue damage
start slow
small
27Mindfulness
intentional awareness of the present moment, non judgementally
28the influence of mindfulness is mostly at the ___________ and ______ stage of pain experience
Disrupting ______ to distressing thoughts, feelings, sensations
Uncoupling of ______ and ______ factors
Developing ______ to improve coping mechanisms
Using your mind to turn down ________ of nervous system
interpretation, appraisal
reactivity
sensory, affective
clarity
sensitivity
29McCracken - the role of mindfulness in a contextual cognitive behavioral analysis of chronic pain related suffering and disability
Increased mindfulness significantly correlated to:
less pain and less pain related distress
less depression, less pain-related anxiety, and fewer problems with cognitive functioning
less disability
fewer medications related to pain
30Fear avoidance
Schutze - low mindfulness predicts _____ ________ in fear avoidance model of chronic pain
________ correlated with variable in each stage of FA model
Moderated the relationship between pain _______ and pain _________
pain catastrophizing
negative
intensity, catastrophizing
31Effects of mindfulness training
Zeidan - the effects of brief mindfulness meditation training on experimentally induced pain
Compared to baseline:
Math Distraction
-decreased …
-no significant effect for …
Relaxation
-effect?
Mindfulness
-decreased … and …
pain ratings for high intensity stimulus
low intensity stimuli
no significant effect
pain ratings for high intensity stimuli and low intensity stimuli
32Mindfulness, CBT, or Usual?
Cherkin 2016
Mindfulness had significant ad clinically meaningful ________
Improvement maintained at ______ follow up
improvement
52 weeks
33low mindfulness -> (McCracken)
predicts physical and psychological functioning, pain related anxiety
34Analgesic effects
decreased pain intensity ratings following 3 wks mindfulness (Kingston et al)
35Brain Changes
increased activation in positive affect regions, decreased activation in negative affect regions at baseline, during positive and negative emotions
36Clinically significant improvement in
physical functioning, pain intensity, pain bothersomeness, and psychological functioning (cherkin et al)
37Greater home practice correlated to
greater reduction in pain and fucnional limitations (rosenzweig et al)
38Significant reduction in health care __________
utilization (McCubbin et al)
39CBT
time limited psychotherapeutic approach
structured approach that focuses on the relationships between thoughts, emotions, and behaviors
40CBT successfully appllied to the management of
chronic pain
Delivered alone
Component of an integrated, multimodal, and interdisciplinary pain management program
41Evidence suggests that CBT-CP improves ________ and _____ for a variety of chronic pain conditions
functioning
QOL
42What to pair with CBT
Exercise - engage with valued activities
Pacing - thoughtful and sensible way
Relaxation Training - decrease stress and muscle tension
Cognitive Restructuring - unhelpful thoughts, increase balanced thinking
Behavioral Activation - increase engagement in rewarding and meaningful activities
43Poor sleep is a ______ ______ issue
public health
44Why is sleep important?
Immune function
Tissue Healing
Pain modulation and perception
Cognitive function
Learning and Memory
Cardiovascular Health
Mental Health
Safety
45Without adequate sleep, people can experience
Increased pain perception
depression
anxiety
attention deficits
information processing disruption
impaired memory
reduced ability to learn new motor skills
increased risk for accidents, injuries, and fall
46People with pain:
Feel _____ control over their sleep
_______ _____ about lack of sleep affecting their health
More likely than others to say … to get a good night’s sleep
This suggests that taking greater care of the _______ _______ may be particularly helpful for those experiencing pain
less
worry more
environmental factors make it more difficult for them
bedroom environment
47Better sleep quality ->
improvement in neck pain
48sleep issues ->
drive pain
49better pain relief ->
restorative sleep
50sleep disturbance ->
pain intensity
51A decrease in slow wave sleep increases sensitivity to pain via
descending inhibitory pathways
52pain disrupts sleep by inducing
neurobiological sequelae of stress
53sleep enhanes ________ _______ learning
motor task
54Too long/short sleep time and fragmented sleep are significantly correlated with
poor performance of ADLs and IADLs
55Loss of REM sleep is important with respect to the formation of __________
memories
56the immune system is synchronized to our
sleep-work cycle
57During sleep, our bodies
form our immune cells
Down regulate our stress systems
58Sleep deprivation decreases our ability to …. and alters …
fight off illnesses
the body’s tissue healing mechanisms
59Patients with chronic pain: diet stuff
C reactive proteins
Elevated cytokines
Changes in TNF and Inter-leukins
All elevate sensitivity in the nervous system
60Nervous system sensitivity in relation to nutrition
release of neuropeptides such as Substance P
Decrease in serotonin, dopamine, glutamate endorphin, gamma-aminobutyric acid
Deficiencies of micronutrients - magnesium
61Benefit of an anti-inflammatory diet
can act on vascular system by reducing inflammatory markers, reducing oxidative stress or forming active metabolites
nutrients from anti-inflammatory foods reduce nervous system sensitization by reducing the inflammatory response in the body
62Pro inflammatory foods
preserved food, salted or sugary nuts, salted meats, cheeses, bread
63Anti inflammatory foods
veggies
fruits
whole grains
nuts. dry fruits
eggs, meat, poultry, fish