1. PERSISTENT PAIN & Physical Therapy
Melanie Mailand PT, DPT

2. Review from previous class:
Persistent Pain comes from a sensitized nervous system
Hyper-excitable
Structural and functional changes
Pain thresholds in the whole body are lowered
Cortical disorganization

3. The issue is NOT the tissue There is no pain input to the brain
light/sound waves
Processing occurs in many parts of the brain
Thalamus
Amygdala
Primary motor & sensory cortex
Cerebellum
Hypothalamus
Cingulate gyrus
Pain is an output and perfectly normal
Pain is an indication that the brain believes there is danger, a call to action.
It is not a damage meter.

4. Neurophysiology of pain

5. Acute vs. chronic pain Acute pain Chronic pain Short lived
Lasts longer than 6 months
Area of pain becomes bigger and more diffuse
Pain may intensify
Things that didn’t cause pain before now cause you pain
Acute pain
Short lived
Related to injury
Area of pain is the injured anatomy
**And the more persistent the pain is, the less the pain has to do with any tissues or anatomy

6. 5 Signs of Central Sensitization
Pain spreads out
Hyperalgesia
Allodynia
Spontaneous pain
Twitching in pain
Decrease activation thresholds of spinal neuron
International Association for the Study of Pain

7. Other Clinical Signs Loss of L/R discrimination
Altered limb perception (neglect)
Pull away from attempts to touch painful part of body
Latent pain response
Treatment response varies

8. Sensitizers Diabetes Depression PTSD Decreased blood flow Medications
Caffeine
Poor Diet
Poor Sleep
Inactivity
Stress
Alcohol
Smoking/Tobacco

9. De-Sensitizers Exercise Routine Active Lifestyle Body Awareness Pacing
Self-management
TENS
Social Support
Intimacy
Quit Smoking
Medications
Reduce Stress
Improve Sleep
Improve Diet
Humor

10. Only you can change your pain
Because when you know pain… you know gain

11. If you had a choice…. What would you choose?
…nervous system dysfunction or orthopedic dysfunction
Stroke or a broken Leg
Parkinson’s disease or a sprained ankle

12. Neuro Plasticity
The brain’s ability to re-organize itself by forming new neural connections.
The Brain can Change
Repetition, intensity, duration are key

13. Neuro Tag Brain’s network of cells that produce pain
The nervous system is plastic and can be changed
Pain that is NOT bio-mechanical, but IS chronic, is the result of the sensitized nervous system.

14. Imaging and Pain
Degenerative changes that are seen on imaging is normal
Degenerative changes are NOT pathological
You should show signs of
degenerative changes after
the age of 19

15. Pain with function is expected
that doesn’t mean that there is tissue harm.
It means that the brain is sensitive
25% of Total Knee Arthroplasty’s still have pain after surgery
Anatomy does not dictate pain
Imaging is not recommended unless there is evidence of progressive neurologic deficits.
Images do not reveal beliefs, feelings, or context and persistent pain involves all of these.
“It appears you are not 19 years old anymore”
Use healing language

16. So, What do we do about persistent pain?
Knowledge is power
Education is therapy
It has to occur before any reconceptualization occurs.
Education WITH exercise is superior to education alone
Focus on desensitizing strategies

17. What does Physical Therapy Have to offer
Remember the issue is NOT with the tissue
PT will look at:
Strength
ROM
Balance
Activity tolerance

18. There will be deficits due to hypo-mobility and sedentary life style
These deficits do not cause back pain, but physical therapy will address them
Posture
Body mechanics
Heat and Ice
Dry needling
TENS
Restores central descending inhibition
Neuroscience education

19. Exercise is medicine http://exerciseismedicine.org/
Exercise induced analgesia
Aerobic
Isometric
Isotonic
Pain is not the limiting factor
Goal will be quota based

20. Sitting decreases the effectiveness of exercise
Be gentle…your brain is in training
Hurt does not equal harm
How much exercise do you do now?

21. Motion is Lotion
If you keep cells moving and functioning, it decreases, cancer risk, systemic disease risk and a host of other chronic diseases.
Motion promotes healthy nerves and gets the spinal cord and brain headed in the right direction.

22. Smudging
Pain spreads out as a result of the brain’s changes and disorganized cortical representation.
Smudging makes movement
without pain difficult.

23. Graded motor imagery & movement dysfunction therapy
Training the brain promotes neuro plasticity and desensitization
Laterality cards (disengages the motor cortex)
Organize first
Community limb identification
Training load
Motor imagery
Mirror therapy
Graded Exposure
Function

24. Relaxation
Coloring
Chill drills
Explain Pain video - hB93rvI

25. Goal:
To create an accurate cortical representation of the body by remapping the brain

26. Summary
Activity
Self management
Self efficacy
**Goal Resuming Life