MSK 3 Unit 2: Psychosocial aspects of care: LBP with cognitive and affective tendencies and LBP with generalized pain

what plays a larger role in back pain, psychosocial factors or physical factors

psychosocial

what are examples of psychosocial factors that impact LBP (8)

fear

distress

fear avoidance

fear of re-injury

low expectations of recovery

high pain

work related parameters

passive coping style

what are the dimensions of pain (6)

sensory

affective

sociocultural-ethnocultural

behavioral

cognitive

physiological

what are orange flags

psychiatric symptoms

what are yellow flags

beliefs, appraisals, judgements, emotional responses, and pain behaviors such as coping skills, fear, and anxiety

what are blue flags

related to work beliefs

what are black flags

system or contextual issues such as insurance

how should yellow and orange flags be screened

using a multidimensional screening tool such as the OSPRO, Orebro, Keele STarT Back, or central sensitization inventory followed by a unidimensional screening tool for a specific domain

what tools can be used for assessing negative mood

pain catastrophizing scale or the PHQ-2 for depression symptoms

what can be used to assess movement related fear

fear avoidance questionnaire or Tampa scale of kinesiophobia

what can be used to assess positive effect

pain self efficacy or chronic pain acceptance scale

how often should orange and yellow flags be screened

every two weeks

what are functional outcomes used for the low back (2)

Oswestry LBP disability scale

Roland-Morris Disability questionnaire

what outcome measure assessed knee function

knee injury and OA outcome scale

what outcome measure assesses hip and knee function

Western Ontario and McMaster universities arthritis index (WOMAC)

what outcome measure assesses foot and ankle function

foot and ankle disability index (FADI)

what is the acceptance and commitment model

when pts have rigid beliefs in pain management it can lead to problems with acceptance and QOL which can further lead to disability behaviors

what is the purpose of acceptance and commitment therapy

attempts to increase psychological flexibility and mindfulness for helping manage the chronic pain condition

what is the misdirected problem solving model

involved normal worrying about pain, determining pain relief strategies with biomedical approaches such as rest, analgesics, or modifying activity which is not successful in chronic pain leading to a cycle of worry and problem solving resulting in chronic pain and more worry about pain

what is the self efficacy model

addresses ones personal belief and ability to cope with pain

what is the stress diastasis model

those who already have high levels of psychological distress are more likely to generate higher levels of emotional distress and unhelpful pain behaviors when experiencing pain

how may nociceptive input be categorized (5)

mechanical

temperature

chemical from tissue inflammation

chemical from neurogenic inflammation

chemical from the immune system

what are type A nerve fibers

myelinated thick fibers with fast conduction that carry efferent motor and afferent input from skin

what are type B nerve fibers

myelinated medium thick and fast seen in preganglionic autonomic efferent fibers

what are type C nerve fibers

non myelinated thin and slow fibers that are seen in postganglionic autonomic efferent fibers and afferent fibers from skin

where are ion channels located on a nerve fiber

within areas without myelin such as nodes of Ranvier, dorsal root ganglion, or areas of injured nerves where the myelin is damaged

hoe often do ion channels change in an axon

every 48 hours in response to changes in the body

what occurs as ion channel numbers increase

ease of depolarization increase

what can occur if axon depolarization increases in frequency carrying nociception

it could signal the start of peripheral sensitization or nociplastic pain

what occurs when the PNS starts to generate its own impulses or become sensitized

the SC, dorsal horn, and second order neurons receive more input which can alter conductivity

what do C fibers detect

danger information

what do A beta fibers detect

light touch

what is action potential windup

where repeated and progressive increases in action potential generated by neurons and interneurons causes on impulse from the periphery to cause multiple impulses to travel to the brain which amplifies the signal creating nociplastic pain condition

what occurs if C fibers are more active

the inhibitory neurons die

what are the clinical consequences of processing mechanisms (9)

decreased inhibition of peripheral nociception

increased firing to the brain

spreading pain

sympathetic, immune, and motor contributions

opening of spinal cord blood barrier

allodynia and hyperalgesia

functional shift in brain pain neuromatrix

bilateral mirror pain

structural shift in brain (homuncular smudging)

how is pain addressed in the acute stage

turning on the brain with pain neuroscience education with a top-down approach

what is a bottom up approach of pain modulation

using modalities like cryotherapy, tens, manual therapy, etc to modulate C fiber activity

what manual therapy is beneficial for chronic LBP (3)

thrust and non thrust joint mobilization

neural mobilization

soft tissue mobilization with other treatments

what occurs as pain becomes more persistent

the pain moves from a nociceptive circuit to emotional circuits so the areas of the brain associated with pain become captivated contributing to issues with focus, concentration, body temp, sleep, memory, etc

what is the Hebbian theory

states that neurons that fire together, wire together which sustains the pain condition

what are the structural changes in the brain from chronic pain (3)

cortical smudging

changes in perceived size of affected body part

difficulty with speed and accuracy in left right judgement (laterality

what occurs of the brain senses danger with nociception

descending facilitatory pathways activate to gain more information about the situation and prepare for action

what occurs if there is nociception without a sense of threat in the brain

the descending inhibitory pathways activate to dampen the nociceptive input and return the system to normal

what is the normal response to pain

stress response to prepare the body for action

what occurs in the body with the stress response (10)

increased adrenaline

increased HR

increased vessel diameter

increased air passage

increased metabolic capability

larger muscle groups are activated

smaller postural muscles deactivated

loud and abrupt language

increased RR

suppressed and immune function suppression

what occurs in the stress response once the sense of threat is dispersed

the stress response reverses through the parasympathetic nervous system and homeostasis returns

what occurs to the stress reaction in pain with psychosocial factors

the stress response may already be elevated and no return to baseline on a regular basis and adrenaline gets replaced by cortisol

why does adrenaline get replaced by cortisol in a long term stress response

long term stress activates the hypothalamic pituitary adrenal system and cortisol is released by the adrenal gland working to increase glucose, and suppress the immune system

what is the impact of of cortisol production with the stress response (6)

learning and memory is impacted

increased rate of cytokines promoting the inflammatory response long term

increased BP

impaired reproductive system

weight gait, obesity, appetite changes

what is nociceptive pain

pain localized to the area of injury or dysfunction which can be somatic referral, clear, proportionate mechanical aches and eases

what is neuropathic pain

pain referred in a dermatomal or cutaneous nerve distribution

what is nociplastic pain

disproportionate, non mechanical, unpredictable patterns of pain provocation in response to multiple or nonspecific aggs and eases

what causes pain in LBP with cognitive and affective tendencies

the impairments occur due to to presence and influence of yellow flags with concurrent diagnoses or symptoms of depression or anxiety

when does LBP with cognitive and affective tendencies occur

in the acute or subacute phase of LBP

what may occur if cognitive and affective tendencies are not addressed in LBP

the pain may progress to LBP with generalized pain

what is seen in LBP with generalized pain

LBP and/or low back related LE symptoms of more than three months with psychosocial factors with the presence of depression, fear avoidance beliefs, and/or pain catastrophizing

what is seen in movement related to fear avoidance behaviors in the low back

hypermobility in the surrounding areas such as the thoracic, lumbopelvic, and hip joints

what systems are impacted in LBP with cognitive and affective tendencies (2)

MSK

psychosocial

what systems are impacted in LBP with generalized pain (3)

MSK

psychosocial

neurologic

how can neurologic pain be associated with LBP with generalized pain

in chronic LBP the prolonged elevated stress response can create nociplastic changes in the CNS and PNS leading to allodynia, cold hyperalgesia, widespread pain, etc

what is the focus of rehab in LBP with cognitive and affective tendencies

tissue specific healing and psychosocial paramters

what is the focus of rehab in LBP with generalized pain

more emphasis on psychosocial parameters

when does cognitive and affective tendency LBP present

in the earlier phases of tissue healing such as acute and subacute phases

when does LBP with generalized pain occur

in the later chronic stages of healing

what may be seen in addition to LBP with cognitive and affective tendencies

other conditions such as mobility deficits or movement coordination impairments

what is commonly reported in the subjective exam with LBP with cognitive and affective tendencies (5)

history of acute or subacute trauma or injury

back pain with or without somatic referred pain in LE

high pain and disability scores

concurrent symptoms or dx of anxiety or depression

variable agg/ease factors and 24 hr behavior based in pain mechanism and yellow flags

what is reported in the subjective exam of LBP with generalized pain (5)

history of chronic trauma or injury

back pain with or without LE referred pain

constant and unremitting pain with night pain and disturbed sleep

history of depression, anxiety, fear avoidance, pain catastrophizing

variable agg/ease and widespread distribution and disproportionate pain experience

what are common subjective reports in LBP with cognitive and affective tendencies and generalized pain (6)

pain is harmful and disabling leading to fear of movement

pain must completely resolve before returning to activity

work or activity increases pain

pain is uncontrollable

worst will always happen

rehab will likely not help

what behaviors are seen in LBP with cognitive and affective tendencies or generalized pain (6)

extended rest

reduced or avoiding daily activity

extremely high pain intensity

rely on braces, aids, etc

poor sleep

increased alcohol, substance, or tobacco use

what is first screened in an exam with LBP with cognitive and affective tendencies or generalized pain (3)

psychosocial outcome measures

CVP

neuromusculoskeletal

what are examples of advanced sensory examinations (7)

pressure algometry

ice pain test

SLR neurodynamic testing

temporal summation

2 pt discrimination

localization

brush evoked sensitivity for allodynia

what does a positive test in the advanced sensory exam suggest

the pt has progressed towards LBP with generalized pain with nociplastic changes

what may be seen in palpation during an exam of LBP with cognitive and affective tendencies or generalized pain (2)

tenderness with myofascial TP

increased resting tone of superficial C/S muscles

what may be seen in ROM in an exam for LBP with cognitive and affective tendencies or generalized pain (4)

limited ROM and symptom provocation

guarding

altered movement recruitment

aberrant motion

what may be seen in SIJ provocation testing with SIJ pain in LBP with cognitive and affective tendencies or generalized pain (2)

positive hip thrust, SIJ compression and distraction

negative ASLR

manual compression or SI belts make symptoms worse

what is seen in posture with SIJ pain with cognitive and affective or generalized pain

increased global and local muscle activation and habitual erect postures which may be due to SIJ displacement

what is the most effective use of pain neuroscience education

in combination with movement and activity

what are the 4 questions every pt wants to know

what is wrong with me?

what can I do for it?

what can you do for it?

how long will it take?

what is cognitive behavioral therapy

a treatment approach based on the idea that thoughts influence their feelings and behaviors

what are situations and what are they influenced by

situations are anything that happens outside the control of the person which can be influenced by behaviors

what is the approach of cognitive behavioral therapy

a goal oriented systematic approach of identifying maladaptive thoughts and behaviors and replacing them with adaptable thoughts and behaviors

what is motivational interviewing

using the transtheoretical model of change and skilled conversation to determine where in the states of change a person is and how to help them move to the next stage

what is the precontemplation stage

the pt is not ready to take action in the foreseeable future

what may be seen in the precontemplation stage

the pt may be uninformed, unmotivated, or unready for help

the pt may view the cons of change outweight the pros

what can the PT do for a pt in the precontemplative stage (3)

focus on understanding the pt

express empathy and acceptance

ask to reassess readiness at a later time

what is the contemplative stage

when the pt intends to change in the next 6 months

what can the PT do in the contemplative stage (2)

they can connect to internal motivators, values, and strengths for the desired change

set small goals for change

what is the preparation stage

the pt intends to take action in the near future saying things like I will change and they have taken small related actions in the last year

what can the PT do for a pt in the preparation stage

set SMART goals for behavioral change and explore challenged to identify solutions

what is the action stage

the pt has made specific changes in the last 6 months and says things like I am changing

what can the PT do for a pt in the action stage (2)

keep motivators, strengths, and values

identify appropriate rewards to reinforce behavior and develop contingency plans for situations

what is the maintenance stage

when the pt has made changes in lifestyle and is working to prevent relapse for a least 6 months

what can the PT do for a pt in the maintenance stage

help the pt reconnect with motivators, values, and strengths and assess for stages of relapse by keeping the behavior fresh

what is OARS in motivational interviewing

open ended questions

affirmations

reflective listening

summarizing

what should the pt be asked before starting treatment with LBP with cognitive and affective tendencies or generalized pain

if the pt wants to know more about the pain before physical treatments

how can aerobic exercise relax the nervous system

it pumps blood around and soothes the nerves and the brain

what should be told to pts rather than no pain no gain

tease it, touch it, nudge it to ger the pt to do activity to the point of discomfort but not past the threshold

what is graded exposure

gradually increasing tolerance and ability to do an activity

what is pacing

cycles of activity and rest

what intensity should aerobic exercise be performed for sensitized pain

a HR of 100-110 BPM with activities like a brisk walk

>50% of VO2 max for more than 10 minutes