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THE NEUROSCIENCE OF ORTHOPEDICS COMPLEX PROBLEMS WITH SIMPLE SOLUTIONS RODERICK HENDERSON, PT, SCD, OCS, MA, CSCS.

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Presentation on theme: "THE NEUROSCIENCE OF ORTHOPEDICS COMPLEX PROBLEMS WITH SIMPLE SOLUTIONS RODERICK HENDERSON, PT, SCD, OCS, MA, CSCS."— Presentation transcript:

1 THE NEUROSCIENCE OF ORTHOPEDICS COMPLEX PROBLEMS WITH SIMPLE SOLUTIONS RODERICK HENDERSON, PT, SCD, OCS, MA, CSCS

2 WHAT YOU’LL LEARN ORTHOPEDIC DIAGNOSES ARE OFTEN VERY STRAIGHTFORWARD THE PATIENT’S RESPONSE TO A DIAGNOSIS MAY VARY ACCORDING TO: SENSORY PHYSIOLOGY CENTRAL PROCESSING (COGNITIVE / AFFECTIVE) AUTONOMIC DRIVE

3 THE NERVOUS SYSTEM DRIVES THE RESPONSE ADAPTS TO NEW INFORMATION

4 WHERE WE’RE GOING HOW DID WE PUT THE NEURO IN ORTHO? HOW DO WE TREAT COMPLEX PROBLEMS WITH STRAIGHTFORWARD SOLUTIONS?

5 ORTHOPEDIC PT STEREOTYPE FORMULAIC PROTOCOL-DRIVEN BORING…

6 WHAT WE REALLY SEE TREMENDOUS VARIABILITY CHALLENGING PROBLEMS EXCITING OPPORTUNITIES

7 CHALLENGE #1 ORTHOPEDIC PTS TRAINED AS CLINICAL BIOMECHANISTS BUT – LINES BETWEEN BIOMECHANICS AND PATHOLOGY ARE BLURRY!

8 CHALLENGE #2 WE DON’T LIKE CHASING PAIN BUT - PAIN IS OFTEN THE PATIENT’S CHIEF COMPLAINT!

9

10 TRADITIONAL INJURY MODEL Pathology Symptoms Halderman S. Presidential Address, North American Spine Society: Failure of the pathology model to predict back pain. 1990; Spine 15:

11 IDEAL RECOVERY Pathology Symptoms Halderman S. Presidential Address, North American Spine Society: Failure of the pathology model to predict back pain. 1990; Spine 15:

12 EXPECTATIONS PATHOLOGY AND SYMPTOMS SHOULD IMPROVE WITH EFFECTIVE TREATMENTS IDEALLY SHOULD ALSO SEE A REVERSAL OF ANY STRUCTURAL ABNORMALITY

13 PERSISTENT PAIN Pathology Symptoms Halderman S. Presidential Address, North American Spine Society: Failure of the pathology model to predict back pain. 1990; Spine 15:

14 THE AGING BODY Pathology Symptoms Halderman S. Presidential Address, North American Spine Society: Failure of the pathology model to predict back pain. 1990; Spine 15:

15 A GROWING TREND PATHOLOGICAL SIGNS PRESENT WITHOUT SYMPTOMS (FALSE POSITIVES) SEEN WITH INCREASING REGULARITY LUMBAR SPINE SHOULDER FOOT AND ANKLE

16 CONSEQUENCES DISABILITY, FEAR, FRUSTRATION HIGHER COSTS, OVERUTILIZATION, DEPENDENCE UPON PASSIVE INTERVENTION

17 STILL BORED?? THOUSANDS OF NEW ARTICLES PUBLISHED EVOLVING CLINICAL GUIDELINES MORE WAYS TO HELP OUR PATIENTS

18 ANSWERS FULLY UNDERSTANDING RESPONSE TO INJURY SEE WHERE THINGS GO WRONG TREAT THE PATIENT USING A BIOPSYCHOSOCIAL MODEL

19 EVOLUTION OF PAIN THEORY SPECIFICITY GATE PAIN MATRIX

20 SPECIFICITY

21

22 PRINCIPLES TISSUES HAVE “PAIN” RECEPTORS PAIN SIGNALS TRANSMITTED TO THE BRAIN

23 KEY ASSUMPTIONS PAIN IS AN INPUT TO THE CNS PATHOLOGY = PAIN PINEAL GLAND IS THE PAIN CENTER

24 IMPLICATIONS PATHOLOGY = PAIN ERADICATE PATHOLOGY = ERADICATE PAIN

25 UPSIDE OF SPECIFICITY UPGRADE FROM THE MYSTICAL MODEL! ACKNOWLEDGED THE NERVOUS SYSTEM

26 LIMITATIONS OF SPECIFICITY PAIN CAN BE PRESENT WITHOUT TISSUE DAMAGE TISSUE DAMAGE CAN BE PRESENT WITHOUT PAIN KEY NOTE: NOCICEPTION IS NEITHER NECESSARY NOR SUFFICIENT FOR THE PRODUCTION OF PAIN

27 OTHER PROBLEMS PHANTOM LIMB PAIN CHRONIC REGIONAL PAIN SYNDROME BODY PARTS ARE REPRESENTED IN THE CNS THROUGH MAPS

28 THE SECOND EVOLUTION

29 GATE THEORY (1965) DESCENDING CONTROL FROM BRAIN AND SPINAL CORD FORMED THE BASIS FOR TENS MOST PTS ARE AWARE OF THIS MODEL

30 WHAT CHANGED? CHALLENGES THE CONCEPT OF “PAIN GENERATOR” NOXIOUS STIMULI MODULATED BY DORSAL HORN AND CNS OUTPUT IS THE “PAIN EXPERIENCE”

31 LIMITATIONS OF THE GATE WIDESPREAD OR CHRONIC PAIN SYNDROMES? PAIN FOLLOWING SPINAL CORD INJURY STILL NO ACCOUNTING FOR CRPS! Melzack R. From the Gate to the Neuromatrix. Pain Supplement. 1999; 6:S121-S126.

32 ENTER THE MATRIX ALSO KNOWN AS THE “PAIN MATRIX” OR “NEUROMATRIX” FRAMEWORK FOR MULTI-SYSTEM RESPONSE TO INJURY THE MOST CURRENT MODEL OF INJURY RESPONSE TO DATE

33 Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education. 2001;65(12):

34 GETTING ORGANIZED InputsProcessingOutputs

35 Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education. 2001;65(12):

36 WHAT IS AN INPUT? BRAIN CONSTANTLY SAMPLING INFORMATION INTERNAL INFORMATION FROM BODILY TISSUES EXTERNAL INFORMATION FROM THE ENVIRONMENT

37 INPUTS SENSORY COGNITIVE AFFECTIVE

38 SENSORY INPUTS Movement Touch Mechanical Inflammation Neurotransmitters Chemical Warmth produced by metabolic activity Thermal

39 Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy Products; 2003.

40 RELEVANCE OF SENSORY INPUTS WE ARE HIGHLY SELECTIVE PRIORITY OF INPUTS IS VARIABLE ALTERED BY ATTENTION

41 NOT A ONE-WAY STREET Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy Products; 2003.

42 CLINICAL RELEVANCE COMMUNICATION BETWEEN TISSUE AND CNS IS BIDIRECTIONAL LONG-STANDING MSK PROBLEMS SHOW SIGNS OF NEUROGENIC INFLAMMATION IMPLICATIONS FOR NEURODYNAMICS

43 THE VALUE OF GOOD INPUT STIMULUS-DETECTION SYSTEM OF THE BODY TISSUE DAMAGE WILL INCREASE SIGNAL INTENSITY FROM THAT REGION PURPOSE IS TO GET YOUR ATTENTION! SENSORY FIBERS ARE NOT PURELY SENSORY

44 Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy Products; 2003.

45 COGNITIVE INPUTS KNOWLEDGE EXPERIENCE EXPECTATION

46 COGNITIVE INPUTS WHAT DOES THE PATIENT BELIEVE IS HAPPENING? HAVE THEY DEALT WITH SIMILAR PROBLEMS?

47 COGNITIVE INPUTS HOW DID THEY HANDLE IT? WHAT DO THEY THINK IS GOING TO HAPPEN?

48 RELEVANCE OF COGNITIVE INPUTS BELIEF INFLUENCE OUTCOMES EXPERIENCE SHAPES COPING EXPECTATION INFLUENCES RESPONSE

49 AFFECTIVE INPUTS BASELINE IMMUNE / ENDOCRINE FUNCTION AUTONOMIC NERVOUS SYSTEM FUNCTION LIMBIC SYSTEM – EMOTIONAL REGULATION

50 RELEVANCE OF AFFECTIVE INPUT INTERACTION BETWEEN NERVOUS AND IMMUNE AUTONOMIC FUNCTION INFLUENCES PROCESSING

51 THERAPEUTIC INPUTS PATIENT EDUCATION MANUAL THERAPY ACTIVE MOVEMENT

52

53

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55 IMPLICATIONS MULTIPLE AVENUES TO PAIN RELIEF OR EXACERBATION MAYBE WHY “EVERYTHING” SEEMS TO WORK?

56 Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education. 2001;65(12):

57 DYNAMIC PROCESSING INPUTS CONSTANTLY EVALUATED INJURY MOVEMENT TOUCH OUTPUT IS PRODUCED AND EVALUATED THINK OF STEPPING ON A STICKER BURR! CHANGES MAY OCCUR THROUGHOUT THE CNS

58 DYNAMIC PROCESSING DISTRIBUTED PROCESSING WITH NO “PAIN CENTER” CORRESPONDS WITH CHARACTERISTIC PAIN BEHAVIORS

59 Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy Products; 2003.

60 CENTRAL INFLUENCES COGNITION AND CONTEXT EMOTIONS AND MOOD ATTENTION AND VIGILANCE

61 DORSAL HORN Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy Products; 2003.

62 IMPLICATIONS OF DORSAL HORN SPINAL CORD ACTS AS AN AMPLIFIER OR INHIBITOR OF SOMATOSENSORY INPUT PERSISTENT NOCICEPTION CREATES AN EXPANSION OF RECEPTIVE FIELDS PAIN WITH A-BETA STIMULATION INCREASING PATTERNS OF REFERRAL WITH CHRONICITY

63 MANUAL CARE AND THE DORSAL HORN ALTERATIONS IN MOTOR NEURON POOL RECRUITMENT MODIFIED C-FIBER ACTIVITY FOLLOWING MANIPULATION RECEPTIVE FIELDS ALTERED BY OPIOID AND B-ENDORPHIN RESPONSE

64 CEREBRAL PLASTICITY PAIN AND INJURY ALTER CEREBRAL PHYSIOLOGY AND ARCHITECTURE NEURONS THAT “FIRE TOGETHER, WIRE TOGETHER” NEURAL PLASTICITY UNDERAPPRECIATED IN ORTHOPEDIC PT! May A. Chronic pain may change the structure of the brain. Pain. 2008;137:7-15.

65 EVIDENCE FOR CENTRAL CEREBRAL CHANGES REDUCTION IN GREY MATTER SHOWN IN YELLOW COMPARED TO HEALTHY CONTROLS STILL UNCLEAR IF A CAUSE OR CONSEQUENCE May A. Chronic pain may change the structure of the brain. Pain. 2008; 137:7-15.

66 CEREBRAL CHANGES – ACL CASE CONTROL STUDY OF 17 ACL-DEFICIENT KNEES AND 18 HEALTHY CONTROLS BRAIN ACTIVITY MEASURED USING FMRI CONCLUSIONS ACL INJURY CAUSED FUNCTIONAL REORGANIZATION OF CNS SHOULD BE CONSIDERED A NEUROPHYSIOLOGIC DYSFUNCTION, NOT A SIMPLE MUSCULOSKELETAL INJURY FINDINGS COULD LEAD TO NEW STANDARDS OF REHABILITATION AND MOTOR CONTROL APPLICATION Kaprieli E, Athanasopoulous S, et al. Anterior Cruciate Ligament injury causes brain plasticity: A functional MRI study. Am J Sports Med. 2009;37:

67 CORTICAL CHANGES - LBP CLBP INDUCES SIGNIFICANT CORTICAL CHANGES MAY EXPLAIN PERSISTENT SYMPTOMS IN THE ABSENCE OF STRONG MECHANICAL FINDINGS Flor H, Braun C, Elbert T, Birbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neurosci. Lett. 1997;224(1):5-8.

68 CORTICAL CHANGES - CTS Napadow V, Kettner N, Ryan A, et al. Somatosensory cortical plasticity in carpal tunnel syndrome--a cross-sectional fMRI evaluation. Neuroimage. 2006;31(2):

69 CORTICAL CHANGES - CTS ALTERED AFFERENT PROCESSING PRODUCED CORTICAL CHANGES IN SYMPTOMATIC SUBJECTS TAKE HOME – INJURY CHANGES THE BRAIN! Napadow V, Kettner N, Ryan A, et al. Somatosensory cortical plasticity in carpal tunnel syndrome--a cross-sectional fMRI evaluation. Neuroimage. 2006;31(2):

70 Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education. 2001;65(12):

71 OUTPUTS INPUTS AND PROCESSING PRODUCE OUTPUTS PRIMARY REASON FOR OUTPUTS IS TO MAINTAIN HOMEOSTASIS OUTPUTS GET US OUT OF TROUBLE!

72

73 IMMUNE / ENDOCRINE RESPONSE THE CHEMICAL “MUSCLES” OF THE CNS INTEGRAL TO RESPONSE OR OUTPUT STRONG INFLUENCES ON AROUSAL, ATTENTION, AND FEAR

74 IMMUNE / ENDOCRINE RESPONSE BOTH SYSTEMS RESPOND TO STRESS AND TISSUE INJURY INFLUENCE NEURAL RESPONSE STRONG INFLUENCE ON TISSUE HEALING TWO PRIMARY RESPONSE AXES HYPOTHALAMUS-PITUITARY-ADRENAL AXIS SYMPATHOADRENAL AXIS

75 HPA AXIS PAIN ELICITS A CORTISOL RESPONSE CHRONIC PAIN RESULTS IN ALTERATIONS OF CORTISOL VARIABILITY ASSOCIATED WITH HIGH FEAR, DISABILITY, AND CATASTROPHIZING Johannson et al. Pain, disability and coping reflected in the diurnal cortisol variability in patients scheduled for lumbar disc surgery. Eur J Pain. 2008;12:

76 SA AXIS SNS CAN CONTRIBUTE TO SENSITIVITY OF A-DELTA AND C AFFERENTS PERSISTENT PAIN CAN LEAD TO ADRENORECEPTOR UPREGULATION AT DRG Chapman CR, Tuckett RP, Song CW. Pain and Stress in a Systems Perspective: Reciprocal Neural, Endocrine, and Immune Interactions. Journal of Pain. 2008;9(2):

77 IMMUNE RESPONSE: CYTOKINES CHEMICAL MESSENGERS PRODUCED DURING TISSUE INJURY AND STRESS Pro-InflammatoryAnti-Inflammatory TNF – AlphaIL-4 IL-1IL-10 IL-6IL-13 Powerful contributors to inflammation and pain! Chapman CR, Tuckett RP, Song CW. Pain and Stress in a Systems Perspective: Reciprocal Neural, Endocrine, and Immune Interactions. Journal of Pain. 2008;9(2):

78 CYTOKINES IN DIAGNOSIS DIAGNOSTIC UTILITY OF CYTOKINE BIOMARKERS IN ACUTE KNEE PAIN PROSPECTIVE COHORT OF 70 KNEES 32 PATIENTS 15 CONTROLS SEVENTEEN INFLAMMATORY CYTOKINES EVALUATED STUDY EXAMINED: PREOPERATIVE MRI CYTOKINE PROFILE OPERATIVE FINDINGS Cuellar JM, Scuderi GJ, Cuellar VG, et al. Diagnostic Utility of Cytokine Biomarkers in the Evaluation of Acute Knee Pain. Journal of Bone and Joint Surgery. 2009;91:

79 RESULTS SIGNIFICANTLY HIGHER CYTOKINE CONCENTRATION IN SYMPTOMATIC KNEES PRESENCE OF FOUR INFLAMMATORY CYTOKINES PERFORMED AS WELL AS MRI IN PREDICTING INTRAOPERATIVE FINDINGS Cuellar JM, Scuderi GJ, Cuellar VG, et al. Diagnostic Utility of Cytokine Biomarkers in the Evaluation of Acute Knee Pain. Journal of Bone and Joint Surgery. 2009;91:

80 CONCLUSIONS “INTRA ARTICULAR CONCENTRATIONS OF FOUR INFLAMMATORY CYTOKINES….WERE MARKEDLY LOWER IN ASYMPTOMATIC NORMAL KNEES AND IN ASYMPTOMATIC KNEES WITH MENISCAL TEARS.” Cuellar JM, Scuderi GJ, Cuellar VG, et al. Diagnostic Utility of Cytokine Biomarkers in the Evaluation of Acute Knee Pain. Journal of Bone and Joint Surgery. 2009;91:

81 MORE ON CYTOKINES CYTOKINES PLAY A ROLE IN OA PATHOGENESIS NOT PURELY A MECHANICAL PHENOMENON Orita S, Koshi T, Mitsuka T, et al. Associations between proinflammatory cytokines in the synovial fluid and radiographic grading and pain-related scores in 47 consecutive patients with osteoarthritis of the knee. BMC Musculoskelet Disord. 2011;12:144.

82 CYTOKINES IN OA FERNANDES JC, MARTEL-PELLETIER J, PELLETIER J-P. THE ROLE OF CYTOKINES IN OSTEOARTHRITIS PATHOPHYSIOLOGY. BIORHEOLOGY. 2002;39(1-2): Inflammatory cytokines produced by synovial tissue Injection of inhibiting agents slowed progression in animal models

83 CYTOKINES AND MUSCLE TIISSUE CAIRNS DM, UCHIMURA T, KWON H, ET AL. MUSCLE CELLS ENHANCE RESISTANCE TO PRO-INFLAMMATORY CYTOKINE-INDUCED CARTILAGE DESTRUCTION. BIOCHEM. BIOPHYS. RES. COMMUN. 2010;392(1): Potential anti-inflammatory role of muscle tissue in cartilage degeneration Another avenue for the benefits of physical activity?

84 OUTPUTS: WHAT WE SEE Pain Behavior SeverityIrritabilityNature Stress Response Fear / Anxiety Helpless / Hopeless Autonomic changes Movement Alterations PosturalDynamic

85 THE MATRIX UPGRADE MULTIPLE INPUTS DYNAMIC PROCESSING PAIN IS THE OUTPUT

86 WHY IS THIS A BIG DEAL? CONSIDER CLINICAL PHENOMENON LIKE ANTALGIC GAITS AND POSTURES ARE THEY DEFECTS OR DEFENSE? WOULD IT CHANGE OUR MANAGEMENT?

87 IMPLICATIONS EFFECTS OF INJURY DISTRIBUTED ACROSS SEVERAL SYSTEMS CHANGES IN PAIN REFLECTS A CHANGES TO ONE OR MORE OF THESE SYSTEMS Tracey I, Mantyh PW. The Cerebral Signature for Pain and its modulation. J Neuron. 2007;55:

88 IMPLICATIONS NERVOUS SYSTEM ACUTELY ADAPTS TO INJURY AND TREATMENT REHABILITATION INFLUENCES CEREBRAL AND DORSAL HORN PLASTICITY Boudreau SA, Farino D, Falla D. The role of neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Manual Therapy (2010), doi:10:1016/j.math

89 Traditional Model

90 Contemporary Model

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93 EXERCISE – IT’S WHAT WE DO ALMOST SYNONYMOUS WITH OUR PROFESSION FOUNDATIONAL COMPONENT OF OUR PRACTICE WE SHOULD HAVE THIS DOWN RIGHT?

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100 TRADITIONAL FOCUS Physical Stronger muscles Improved flexibility More endurance

101 EMERGING EVIDENCE Psychological Reduced fear Improved efficacy Stress tolerance

102 CONTEMPORARY MODEL Physical Stronger muscles Improved flexibility More endurance Psychological Reduced fear Improved efficacy Stress tolerant

103 OUR CHALLENGES GROWING EVIDENCE-BASE OF EXERCISE SCIENCE NOT A LOT OF ENTRY-LEVEL TRAINING LIMITED POST-GRADUATE TRAINING

104 NO EASY ANSWERS WE KNOW MOVEMENT IS BENEFICIAL NO CLEAR CONSENSUS EXIST REGARDING TYPE DOSE SUB-GROUPING MAY GUIDE DECISIONS BUT STILL NOT CLEAR Kent P, Mjøsund HL, Petersen DHD. Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review. BMC Med. 2010;8:22.

105 WHERE’S THE EVIDENCE?

106 MOST OF IT’S HERE…

107 EXERCISE AND LOW BACK PAIN HIGHEST FORMS OF EVIDENCE SUGGEST MINIMAL BENEFIT LOWER FORMS OF EVIDENCE SUGGEST MODERATE BENEFIT van Middelkoop M, Rubinstein S, Kuijpers T, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal. 2011;20(1):19–39. Choi BK, Verbeek JH, Tam WW-S, Jiang JY. Exercises for prevention of recurrences of low-back pain. In: The Cochrane Collaboration, Choi BK, eds. Cochrane Database of Systematic Reviews.

108 POSSIBLE EXPLANATIONS? “THE PROBLEM WITH THE EVIDENCE PYRAMID IS THAT IT'S SORTED BY RIGOR, NOT BY RELEVANCE." -PHIL SIZER PT, PHD, FAAOMPT

109 POSSIBLE EXPLANATIONS If you let systematic reviews dictate your practice this is what you'll do for low back pain: "stay active, it's not serious, no you don't need MRI, get regular exercise, avoid surgery, have a nice day. NEXT!“ -Jason Silvernail, DPT, DSc, FAAOMPT

110 CURRENT CLINICAL GUIDELINES EXERCISE RECOMMENDED FOLLOWING SELF-CARE ALSO RECOMMENDED YOGA COGNITIVE-BEHAVIORAL THERAPY SPINAL MANIPULATION Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–491.

111 IASP GUIDELINES EXERCISE IS BENEFICIAL FOR MAJORITY OF MSK CONDITIONS NO OPTIMAL TYPE OR DOSE OF ACTIVITY IS ESTABLISHED IASP Global Year Against Musculoskeletal Pain

112 IASP GUIDELINES LOWER INTENSITY PROGRAMS RECOMMENDED BASED ON TOLERANCE HIGHER INTENSITY MAY BE INDICATED AS TOLERANCE IMPROVES ACUTE TOLERANCE MAY NOT PREDICT LONG-TERM RESPONSE IASP Global Year Against Musculoskeletal Pain

113 IASP GUIDELINES SUPERVISED PROGRAMS PREFERABLE COMPLIANCE IMPROVED BY COMBINING EXERCISE MOTIVATIONAL PROGRAMS IASP Global Year Against Musculoskeletal Pain

114 POSSIBLE TAKE HOME EXERCISE A BENEFICIAL COMPONENT OF MUSCULOSKELETAL MANAGEMENT EDUCATION MANUAL CARE NO MAGIC BULLET “SYSTEMS” OR “EXERCISES”

115 IN SHORT… MOVEMENT CERTAINLY HELPS SPECIFICS ARE VERY FUZZY USE CLINICAL JUDGMENT BIOMECHANICS+ NEUROSCIENCE+

116 GREAT…SO NOW WHAT? MOVEMENT-BASED PROGRAMS THAT OPTIMIZE STRESSES ON RECOVERING TISSUE MINIMIZE NOCICEPTIVE DRIVE FACILITATE CENTRAL INHIBITION OF PAIN LOT’S OF WAYS TO ACCOMPLISH THIS!

117 OUR APPROACH GRADED ACTIVITY / EXPOSURE AEROBIC EXERCISE AWARENESS THROUGH MOVEMENT (ATM) LESSONS RESISTANCE EXERCISE

118 GRADED ACTIVITY IDENTIFY DIRECTIONAL PREFERENCES MINIMIZES NOCICEPTIVE DRIVE STRONG EMPHASIS ON LOW-THRESHOLD INPUTS BENEFICIAL FOR PATIENT AND THERAPIST DIAGNOSTIC THERAPEUTIC HIGHLY BENEFICIAL FOR NOCICEPTIVE AND PERIPHERAL NEUROGENIC PAIN STATES

119 EXAMPLE LUMBAR AND CERVICAL ROTATION PASSIVE AND AA SHOULDER ELEVATION ACTIVE NEURODYNAMIC “SLIDERS”

120 EMPHASIS PAIN-FREE MOTION WORKING ALONG THE “EDGES” DISCOURAGE UNHELPFUL BELIEFS “NO PAIN. NO GAIN” “AVOID PAIN AT ALL COSTS”

121 BENEFITS PATIENT ABLE TO EVALUATE THEIR OWN PROGRESSION THERAPIST CAN GUIDE THE PATIENT WITH EDUCATION REASSURANCE GOAL SETTING

122 GRADED PROGRESSION

123 WHAT IF “EVERYTHING” HURTS? NOT UNCOMMON IN PATIENTS WITH CENTRAL SENSITIZATION CLINICAL EXAMS MAY NOT EFFECTIVELY GUIDE INTERVENTION BUT WE STILL DO THEM! CONSIDER ACTIVITIES THAT WILL ENHANCE CENTRAL INHIBITION

124 WHAT IF EVERYTHING HURTS? CONSIDER GRADED MOTOR IMAGERY EVIDENCE IS ENCOURAGING BUT STILL DEVELOPING Moseley GL, Zalucki N, Birklein F, et al. Thinking about movement hurts: the effect of motor imagery on pain and swelling in people with chronic arm pain. Arthritis Rheum. 2008;59(5):623–631. Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology. 2006;67(12):2129–2134.

125 MOTOR IMAGERY Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy Products; 2003.

126 MOTOR IMAGERY NeuroOrthopedic Institute:

127 MENTAL VS PHYSICAL PRACTICE Lederman E. Neuromuscular Rehabilitation in Manual and Physical Therapies: Principles to Practice, 1e. 1 Har/DVD. Churchill Livingstone; 2010.

128 VIRTUAL MOVEMENT IMAGINING MOVEMENTS ALTER CONTEXT PLAY WITH BALANCE CHANGE VISUAL OR AUDITORY INPUTS Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy Products; 2003.

129 VIRTUAL MOVEMENT CHANGE THE MOVEMENT ENVIRONMENT MOVE UNDER DIFFERENT EMOTIONAL STATES EXERCISE WHILE DISTRACTED PLAN CHALLENGING ACTIVITY Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy Products; 2003.

130 PACING AND GRADED EXPOSURE Lederman, E. Neuromuscular Rehabilitation in Manual and Physical Therapies: Principles to Practice, 1e. 1 Har/DVD. Churchill Livingstone; 2010.

131 PACING AND GRADED EXPOSURE Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy Products; 2003.

132

133 IS THIS REALLY ANY DIFFERENT? TRADITIONAL APPROACH STRENGTHEN WEAK MUSCLES STRETCH TIGHT MUSCLES TRAIN “THE CORE” DISCOURAGE HARMFUL MOVEMENT

134 IS THIS REALLY ANY DIFFERENT? CONTEMPORARY APPROACH EMPHASIS ON MOVEMENT – NOT MUSCLE MOTOR CONTROL VERSUS “CORE TRAINING” POSTURE IS CONTEXT DEPENDENT ENCOURAGE GRADED EXPOSURE TO MOVEMENT

135 GET SYMPATHETIC MORE SPECIFICALLY – PARASYMPATHETIC STRONG SYMPATHETIC DRIVE LINKED TO HIGHER PAIN LEVELS MOVEMENT AND MANUAL CARE INFLUENCES IT! Kregel KC, Seals DR, Callister R. Sympathetic Nervous System Activity During Skin Cooling in Humans: Relationship to Stimulus Intensity and Pain Sensation. J Physiol. 1992;454(1):359–371. Perry J, Green A, Singh S, Watson P. A preliminary investigation into the magnitude of effect of lumbar extension exercises and a segmental rotatory manipulation on sympathetic nervous system activity. Manual Therapy. 2011;16(2):190–195.

136 GETTING PARA-SYMPATHETIC EXPLICITLY ENCOURAGE REGULAR AEROBIC EXERCISE PROGRESSION TOWARD ACSM GUIDELINES Glass JM, Lyden AK, Petzke F, et al. The effect of brief exercise cessation on pain, fatigue, and mood symptom development in healthy, fit individuals. Journal of Psychosomatic Research. 2004;57(4):391–398. Koltyn K.F. Exercise-Induced Hypoalgesia and Intensity of Exercise. Sports Medicine. 2002;32(8):477–487. Mueller PJ. Exercise training and sympathetic nervous system activity: evidence for physical activity dependent neural plasticity. Clin. Exp. Pharmacol. Physiol. 2007;34(4):377–384.

137 ACSM GUIDELINES AT LEAST 150 MINUTE OF MODERATE INTENSITY EXERCISE EACH WEEK BETWEEN 3.0 AND 5.9 METS MORE VIGOROUS EXERCISE MINUTES THREE TIMES A WEEK ALSO ACCEPTABLE OVER 6 METS Garber CE, Blissmer B, Deschenes MR, et al. Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults. Medicine & Science in Sports & Exercise. 2011;43(7):1334–1359.

138 OTHER WAYS Satyapriya M, Nagendra HR, Nagarathna R, Padmalatha V. Effect of integrated yoga on stress and heart rate variability in pregnant women. Int J Gynaecol Obstet. 2009;104(3):218–222. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration following two yoga relaxation techniques. Appl Psychophysiol Biofeedback. 2000;25(4):221– 227. Veerabhadrappa SG, Baljoshi VS, Khanapure S, et al. Effect of yogic bellows on cardiovascular autonomic reactivity. J Cardiovasc Dis Res. 2011;2(4):223–227.

139 SUMMARY OF RECOMMENDATIONS GRADED PROGRESSION OF PHYSICAL ACTIVITY PACING AND GRADED EXPOSURE DAILY AEROBIC EXERCISE

140 REMEMBER

141 THANK YOU


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