PTE 742: midterm and final exams

chronic pain

pain that lasts beyond (persists) the normal tissue healing time of 3-6 months

what is chronic pain according to G. Lorimer Moseley?

“pain is a multiple system output activated by an individual-specific pain neuromatrix. the pain neuromatrix is activated whenever the brain concludes that body tissue is in danger and action is required.”

pain is considered an ____ and is very _____ with an “n= 1”

1. output

2. individualized

list the groups of individuals persistent pain is highest amongst.

• women

• older adults

• unemployed

• rural adults

• those in poverty or on public health insurance

describe the Cartesian Model of pain.

• “it hurts…ouch”; fire burns —> signal travels to brain—> realizes that hurts

• tissue damage = pain

• doesn’t explain complexities of pain

• may induce fear/anxiety

what pain paradigm is described in this picture?

Cartesian Model

what pain paradigm is described in this picture?

Mature Organism Model (MOM)

describe the Mature Organism Model of pain.

• “I think… it hurts… ouch”

• multi-dimensional input

• explains complexities; de-mystifies pain experience

• biopsychosoical model

what are nociceptors stimulated by?

potentially harmful stimuli, including extreme temperatures (heat or cold), intense mechanical pressure, and chemical signals indicating tissue damage

what are the three types of pain?

1. nociceptive pain

2. neuropathic pain

3. nociplastic pain

nociceptive pain

pain that arises from actual or threatened damage to non-neural tissue (obvious tissue issue) and is due to the activation of nociceptors

neuropathic pain

pain caused by a lesion or disease of the somatosensory nervous system (actual nerve issue within the peripheral or central systems)

nociplastic pain

pain that arises from altered nociception despite NO clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system

what populations might be susceptible to neuropathic pain?

individuals with MS, spinal cord injury, diabetes, or nerve root compression/irritation

what population might be more susceptible to nociplastic pain?

individuals with phantom limb syndrome

what is sensitization?

increased responsiveness of nociceptive neurons to their normal input, and/or recruitment of a response to normally subthreshold inputs

what are the two types of sensitization?

1. hyperalgesia

2. allodynia

hyperalgesia

increased pain from a stimulus that normally provokes pain

• longer a tissue issue occurs —> leads to sensitization —> heightens reaction

allodynia

pain due to a stimulus that does not normally provoke pain

what is the general rule when performing a skilled exam?

the more sensitized a person is, the more general the exam should be

• exclude red flags, identify urgent issues, and assess functional limitations

list some examples of red flags.

• cauda equina

• severe and worsening pain

• history of significant trauma

• weight changes (cancer or other)

• fevers

• use of IV drugs or steroids

what is a yellow flag?

any psychosocial barriers to recovery

list some examples of yellow flags.

• belief that all pain is harmful

• catastrophizing

• social withdrawal- negative moods

• work or relationship problems

• overprotective relationships or lack of support system

what are the three main characteristics of those who may benefit from Pain Neuroscience Education (PNE)?

1. high fear avoidance

2. high pain catastrophization

3. presence of central sensitization

what are the “3 Ps” patients want to know?

1. problem

2. prognosis

3. plan

what are the four pillars for dealing with persistent pain?

1. pain education

2. aerobic exercise

3. sleep hygiene

4. goal setting

what are some ways to calm the nervous system?

• alter nocicpetion via medical, modalities, movement, or relaxation techniques

• alter faulty cognitions and beliefs via PNE or coping strategies

• decrease fear/anxiety

PNE can help normalize pain experiences associated with:

• misbeliefs and faulty thought patterns associated with pain experience

• fear-avoidance and pain catastrophizing behaviors

what is phase 1 of intervention with PNE?

education patients about pain using simple content with graphics that is personalized to the patient’s situation; avoid causing fear and anxiety

what is phase 2 of intervention with PNE?

focus on function with persistent pain

• smart goal setting

• graded exposure

• patient empowerment

we should approach patients with persistent pain with a ______ approach.

biopsychosocial

T or F: it is possible to have pain and not know about it.

F

T or F: when part of your body is injured, special pain receptors convey the pain message to your brain.

F

T or F: pain only occurs when you are injured or at risk of being injured.

F

T or F: when you are injured, special receptors convey the danger message to your spinal cord.

T

T or F: special nerves in your spinal cord convey danger messages to your brain.

T

T or F: nerves adapt by increasing their resting level of excitement.

T

T or F: chronic pain means that an injury hasn’t healed properly.

F

T or F: worse injuries always result in worse pain.

F

T or F: descending neurons are always inhibitory.

F

T or F: pain occurs whenever you are injured.

F

T or F: when you injure yourself, the environment that you are in will not affect the amount of pain you experience, as long as the injury is exactly the same.

F

T or F: the brain decides when you will experience pain.

T

what is the gate control theory of pain?

pain signals can be modulated at the spinal cord, where a metaphorical "gate" can open or close to allow or restrict the transmission of pain signals to the brain, meaning that non-painful sensations can effectively "close the gate" and reduce the perception of pain

according to the gate control theory of pain, stimulus (input) from a small fiber ____ the gate.

opens

according to the gate control theory of pain, stimulus (input) from a large fiber ____ the gate.

closes

describe the nociceptive nerve fibers.

• A: thick, fast, myelinated fibers; motor and cutaneous

• B: medium, myelinated fibers; preganglionic ANS efferent

• C: thin, unmyelinated, slow fibers; postganglionic ANS efferent

what are the two input mechanisms for the Mature Organism Model?

1. environment

2. peripheral neurogenic

what are the gatekeepers of the central nervous system?

interneurons

what are the two processing mechanisms of the Mature Organism Model?

1. spinal cord

2. brain

interneurons control what type of messages?

danger messages (via C fibers)

with persistent input from the periphery, changes to the spinal cord second-order neurons and brain pathways, lead to _____ ____.

heightened sensitivity

what happens if the interneurons die?

decreased ability to modulate incoming info, thresholds are easily met for nociceptive specific second-order neurons, increasing the firing to the brain

• “action potential windup”

what are endogenous chemcials?

naturally occurring substances produced within the body, primarily "endorphins," which act as the body's natural painkillers

what does CRPS stand for?

complex regional pain syndrome

what are some symptoms of CRPS?

• pain and increased pain sensitivity

• changes in skin temp

• decreased function

• changes in skin color and texture

• swelling

• rapid or no hair and nail growth

describe the two types of CRPS.

1. no identifiable nerve injury

2. known nerve injury

why is determining the types of CRPS important?

they determine treatment plans

know these!

what are some techniques to not “lead a patient to pain”?

• use softer language

• ask what they are experiencing

• ache vs. pain, tenderness vs. pain

T or F: persistent pain patients usually lack control over various aspects of their lives.

T

know this chart!

how do you know where your patient falls within the previous chart?

look for subjective exam clues: patient’s attitude, responses, and complaints (follow the M.O.M.)

T or F: we want patients to progress through the previous chart from nociceptive pain to central sensitization.

F; we want them to improve to nociceptive pain or no pain at all

if a patient presents with nociceptive pain, where should the therapist start?

looking for/addressing the pain generators, tissue issues, or any possible dysfunctions

what are the general treatment options for patients experiencing peripheral neurogenic symptoms?

avoid stretching, perform nerve glides, and proceed with “gentle work”

what are the general treatment options for patients experiencing central sensitization?

do laterality testing, fill out fear avoidance questionnaire, and educate via PNE

what are some other objective measures?

• pressure pain threshold testing

• thermal, vibration, and neural tension testing

• joint end feel

• two-point discrimination

• graphesthesia testing

• laterality and mirror testing

T or F: it is okay to start PNE education on the initial evaluation.

T; also good to build a rapport with patient beforehand

when is it appropriate to schedule persistent pain patients?

mid morning to early afternoon appointments

what are three main types of treatment for persistent pain patients?

1. PNE- education and knowledge are powerful

2. aerobic exercise (aka any movement is good)

3. medication

why is it a good idea to give patients pre-visit paperwork to fill out?

patients might be more honest when filling out before session in the comfort of their home

what are the percentages associated with PNE and behavioral changes?

• 20%: no way

• 35%: I get it

• 45%: yes, yes I get it

what should therapists do with the 20% (no way) patients?

focus on planting seeds about change

describe the 45% (yes, yes I get it) patients.

chronic patients; they keep coming back but not getting any better

• they talk the talk but can’t walk the walk with PNE and behavioral changes

describe the 35% (I get it) patients.

life-long patients who progress but have episodes that keeps them coming back occasionally

• good to their words and actions