1. Rehabilitation for the Sensitized Nervous System: What Can PT and OT do for the pain patient? Nora Stern, PT, MSPT

2. Conflict of Interest Disclosure Nora Stern, PT, MS, PT Has no real or apparent conflicts of interest to report.

4. Looking at what is sensitizing the systems: Nociceptive input Peripheral Central Output driven

5. Nocioceptive Active inflammatory process: – Treatment: Explain Pain Address fear avoidance Motion is lotion: flushing inflammation

6. Peripheral neurogenic presentation Follows nerve pathway or adjacent pathway, but in new areas along pathway Shooting up or down along pathway

7. Treatment for peripheral neurogenic Motion is lotion Address neurodynamics Health of container: taping, manual therapy Decrease in threat value: pain education, normalize experience What does pt need to hear?

8. Assessing central sensitization Pain searing, stabbing, like a knife, hot poker Diffuse Appearing on other side of body, pain in new area Not consistent w findings Does not follow anatomy Large or diffuse areas of pain Black body diagram Altered 2 point discrimination Delay in laterality recognition > 1.5 sec, < 90% accuracy

9. Central: Beliefs about pain StarT Generic Screening Tool

10. Assessing sensory cortical reorganization: – Two point discrimination testing

11. Fig. 1 Patient data: TPD threshold, normal distribution of pain, and body image. Two-point discrimination threshold (TPD) was assessed bilaterally at 16 levels, shown here superimposed over line drawings of the sense of physical self, or body image, of six... Moseley, GL, “I Cant’ find it! Distorted body image and tactile dysfunction in patients with chronic back pain.” Pain Vol 140, Issue 1, 2008, 239-243 Assessing central involvement: cortical reorganization: Smudging Altered Two Point Discrimination Associated with Distorted Body Image in Back Pain

12. Central: what aspects of the brain processing are contributing to central sensitization? Thinking Feeling Sensing Acting/moving

13. Disruption of output, mirror neurons and sensory and motor homuncular representation (smudging ) Swelling Sweating Itching cold sensitivity Pain w thinking about movement, watching someone move Altered 2 point discrimination Altered body schema Poor motor planning

14. Treatment interventions: Central Pain education: – Fear Avoidance and Graded Exposure: Moseley and Butler’s twin peaks

15. Treatment Interventions: Central Cortical Reorganization: – Graded Motor Imagery – Body scan – General kinesthetic sensing with exercise – Whole body movement to restore virtual body representation

16. Graded Motor Imagery Laterality recognition: – Activates pre-motor but not primary motor cortex Norm of 90% accuracy and 1.5 sec reaction time Imagined movement Mirrors

17. Graded exposure Pacing: twin peaks Vary the task: Laterality recognition Imagine movement Change setting Do in pleasurable context Do parts of a task; eg knees to chest as component of bending over

18. Treatment Interventions: Central Stress response: physiological quieting www.meditationcenter.com: easy to follow meditations. www.meditationcenter.com http://www.allaboutdepression.com/relax/ 8 free breathing tapes, relaxation activities. http://www.allaboutdepression.com/relax/ http://vcc.asu.edu/relaxaindex.shtml: free guided instruction in progressive muscle relaxation and guided imagery. http://vcc.asu.edu/relaxaindex.shtml