Chronic MSK Pain pt 1 and 2

What is the definition of nociception?

The neuronal response to intense stimuli, specifically action potentials in nociceptive neurons.

True or False: Pain is simply the sensation resulting from the stimulation of nociceptors.

False; pain is an experience influenced by physiological and psychosocial factors.

List the five separate processes involved in the perception of pain.

Transduction
Conduction
Transmission
Perception
Modulation

At which stage of the five pain perception processes does neuroplasticity occur?

Neuroplasticity occurs at each of the five stages.

What is the functional role of neuroplasticity during the stages of pain perception?

It can either facilitate or inhibit neural responses.

To which three main brain regions does the Thalamus distribute pain information?

Somatosensory Cortex (S1)
Limbic System
Cingulate Cortex

Which peripheral and spinal sensory receptor is the most numerous in the human body?

C fibers

What is the primary stimulus that causes C fibers to depolarize?

Chemical stimulation (they are chemosensitive nociceptors).

Describe the physical characteristics of C fibers regarding size, speed, and insulation.

They are small, slow, and un-myelinated fibers.

In the dorsal horn, C fibers synapse with which type of neurons to produce motor effects?

Polysynaptic inter-neurons (PSIN).

What is the consequence of PSINs synapsing with anterior horn cells due to C fiber activity?

Hypertonicity of intrinsic spinal muscles and decreased inter-segmental spinal movement
Cause immobilization degeneration which may effect other segments above and below

How does the anterior motor rootlet connect to the sympathetic chain ganglion?

Via white rami communicans (WRC).

Which structures are innervated by the grey rami communicans exiting the sympathetic ganglion?

Blood vessels
Sweat glands
Hair follicles
Mast cells

Which sympathetic pathway leads to the 'fight or flight' response via the adrenal medulla?

White rami communicans (WRC) passing to chromaffin cells

Chronic activity of C fibers is most strongly associated with what type of sensitization?

Central Nervous System (CNS) sensitization
Nocioplastic pain

What happens with chronic C fiber activity (that results in CNS sensitization

Increased substance P production
Stimulates KINASE production in the dorsal horn

What is the effect of increased substance P production on peripheral nociceptors?

It lowers their threshold, making them fire more easily.

In the dorsal horn, the stimulation of KINASE production leads to:

Increased NMDA receptors
Increased glutamate production
Sprouting

What primary neurotransmitter do C fibers use to transmit messages to NMDA receptors?

Glutamate.

Which metabolic receptor acts to lower the firing threshold during sensitization?

Prostaglandin receptors.

Which receptor responds to Nerve Growth Factor (NGF) and is considered the 'main mechanism' of neuroplasticity?

Tyrosine kinase receptor.

Describe the clinical phenomenon of 'Wind-up'.

An increased receptor field and more sensitive nociceptors resulting from repeated stimulation
Dorsal horns that can more readily process nociceptor activity

What does The Pain Matrix consist of

All the parts of the brain whose activity fluctuates when an individual is experiencing pain

What does the pain matrix consist of

Primary (S1) and Secondary (S2) somatosensory cortices
The insula
The Anterior cingulate cortex (ACC)

What is the insula connected to and what is its role

It is connected to the limbic system
Its major role is perception of pain

True or False: The pain matrix can respond to salient or behaviorally relevant stimulation regardless of whether it is nociceptive in nature

True

What term did Melzack use to describe the unique brain activity pattern of an event in the neuromatrix?

Neurosignature.

What term do Butler and Moseley use as a 'trendy' alternative to neurosignature?

Neurotag.

What does referred pain confuse and what is the result of this confusion

The signal in the pain matrix and reinforce inappropriate neurotags

True or False: Once a peripheral noxious stimulus is gone, so is the ingrained neurotag

False

True or False: neurotags can be retrained using imagery

True

Typical physical examination for chronic pain

Perform MS examination
Look for mechanical pattern
Watch for overt pain behavior - also for consistency
Quantify activity intolerance
Functional tests > MMT and ROM

Which two psychological assessment tools are used to measure pain-related fear?

FABQ and TSK.

What are some considerations for treatment of CPS

Language
Treat myofascial trigger points
Consider thoracic (autonomic) dysfunction
Motor imagery
Target cognitive-emotional sensitization (CBT)

What are specific considerations when it comes to language in treating CPS

Use positive language
Reassure the patient and be kind
Keep it simple and don’t use to much jargon

Cognitive-behavioral therpay

Use time-contingent or pain contingent exercise therapy - graded exposure
Traditionally advocated goal-setting in a time contingent fashion - graded exposure
Patient education

What should you have a patient do when they are going through progression graded exposure

Use a diary to track activity and how they felt

When utilizing grade exposure how should your progress

Conservative but continual
Small, frequent increments in training load

Why is it important to treat myofascial trigger points in Chronic Pain Syndrome?

Untreated trigger points fuel the CNS with nociceptive input, sustaining central sensitization.

Why is limb laterally chosen as an intervention

Patients with chronic pain often have a distorted view of their involved limb secondary to prolonged period of pain stimuli

When utilizing imagined movement what should the patient do

Imagine that they are actually performing the motion rather than looking at themselves performing the motion through a mirror

Mirror therapy

The patient can visualize pain free motion without activating the musculature of the involved limb

What type of communication do patients with central sensitization need

Nonthreatening explanations

How would you suggest to a patient to relax and try to wind down the CNS

Listen to relaxing music or a watch a movie
Take a hot bath
Talk to a friend
Perform breathing techniques

Pain Self-Efficacy

One's confidence regarding one's ability to function effectively while in pain.

What is considered the best practice for CLBP

Multidisciplinary Rx (including psych) is superior to other active treatments alone