chronic and interventions

do McKenzie and TBC work with chronic LBP?

no, best with acute/subacute

what do traditional models for LBP focus on

• anatomy, biomechanics

how do clinicians aim to explain pain to patients

from a tissue perspective:
• contrasting healthy and injured tissues (pathoanatomy)
• highlighting a mechanical deviance from normal expected patterns of movement (biomechanics)
• a disease state such as degenerative changes (pathoanatomy)

bottom up approach

• Painful stimulus = pain

• Amount of tissue damage = intensity of pain

• Yes = Clinical value in more acute phases of injury, surgical, or disease states

what is the problem with bottom up approach

Lacks the ability to explain complex pain issues:
• peripheral and central sensitization,
• neuroplasticity,
• facilitation and inhibition,
• immune and endocrine changes
All of these have been implicated in more complex and persistent pain states

Limited Efficacy of Biomedical Models with treatment for chronic

1. Limited efficacy in alleviating pain and disability
2. May even increase patient fears, anxiety, and stress, thus negatively impacted their intended outcomes

Persistent or Chronic pain

• Leads to significant changes in brain, alters processing of pain and activation of catastrophization
  • Sensory homonculus
  • Motor homonculus

• Many areas of the brain are involved in the pain experience

Smudging

brain areas normally devoted to different body parts/functions start to overlap → limits movement in motor area, or makes more areas sensitive on sensory area
• Key Point - IT CAN BE REVERSED WITH TRAINING

Central Sensitization

● Peripheral noxious inputs into CNS lead to increased excitability where the
response to normal inputs is enhanced
● CNS has become hyper-excitable to input received from periphery
● Hypersensitivity of CNS

how to identify if a patient fall into chronic pain

• Subjective cues - Flags

• Functional outcome scores

• Pain Catastrophizing questionnaires

• Depression screens

• Fear Avoidance behaviors

Behavior related factors and LBP

1. Inactivity
2. Current or former smokers
3. Current or former alcohol drinkers
4. Extreme sleep duration habits
5. Obesity

types of flags

• red

• yellow

• blue

• black

yellow

• emotional distress

• hypervigilance

• pain catasstrophizing

• elevated fear-avoidance beliefs

• low self-efficacy

• misunderstanding anout the nature and likely impact of pain

• misunderstanding about the best strategies for long-term success

blue flags

• Employee
  ◦ Fear of re-injury
  ◦ High physical job demand
  ◦ Low expectation of resuming work
  ◦ Low job satisfaction
  ◦ Low social support or social dysfunction in workplace
  ◦ Perception of high job demand/‘stress’

• Workplace
  ◦ Lack of job accommodations/modified work
  ◦ Lack of employer communication with employees

black flags

• Misunderstandings and disagreements between key players (e.g. employee and employer, or with healthcare).

• Financial and compensation problems

• Process delays (e.g. due to mistakes, waiting lists, or claim acceptance).

• Overreactions to sensationalist media reports.

• Spouse or family member with negative expectations, fears or beliefs.

• Social isolation, social dysfunction.

• Unhelpful policies/procedures used by company

The goal of identifying Flags is to find factors that can be

• used positively to facilitate recovery and prevent or reduce long-term disability and work loss

• identifying
  • unintentional learning or emotional barriers (such as fear ofpain)
  • less common intentional barriers (malingering)

Considerations During Objective Evaluation if you are getting positives for yellow

• Rule out serious pathology

• Low tech exam

• Asterisk or comparable sign??

• Acknowledge nice movement / good muscle contraction

• Encouragement

• Questions associated with patient’s beliefs

Waddell’s Signs

1. Tenderness (widespread, non-anatomic)
2. Simulation tests (axial loading, rotation)
3. Distraction test (SLR supine vs sit)
4. Regional Disturbances
• weakness (non-anatomic, cogwheeling)
• sensory (stocking rather than dermatomal)
5. Overreaction (disproportionate expressions

what are Waddell signs assoicated with?

Poorer outcome (surg and non-surg), increased freq of visits, greater impairments, higher % psych problems
Increased with Chronic LBP, compensation

Two ways to effectively manage patients with chronic LBP

1. Key into how you talk to them about what is going on – our language matters
2. Interventions – how to approach activity, exercises and overall treatment

Pain Self-Efficacy

The belief in one’s ability to manage and complete a task despite their pain

increased self efficacy leads to

• Decreased disability
•Decreased disease activity
•Decreased depressive symptoms
•Decreased fatigue
•Decreased emotional distress
Adherence to physical activity and participation

Effective Interventions

1. Pain Neuroscience Education of Body response
2. Facilitating Mastery of Experience
3. Vicarious Experience
4. Verbal Persuasion
5. Graded Exercise
6. Graded Exposure
7. Group Exercise (Aerobic exercise)

Pain Neuroscience Education (PNE)

Explains biological and physiological processes involved
in pain experience
Defocus issues associated with anatomical structures
Teaches patients to re-think their pain.

How to implement a PNE

• Build rapport with patients to get an idea of their belief system and
  knowledge of pain, as that plays a role in their overall pain experience.

• Use questionnaires to fill out during the first session with the patient.
  1) Physical Readiness Activity Questionnaire (PAR-Q) (Daly 2006)
  2) Fear Avoidance Behavior Questionnaire (FABQ) (Waddell 1993)
  3) Pain Science Knowledge Questionnaire (O’Connelly 2013).

• Identify patients with acute pain vs. chronic pain > 3 months (Rolf-
  Detlef T 2015), as that will impact when and how you want to implement pain science education.

how does PNE improve MSK disorders

• Pain ratings

• Pain knowledge

• Disability

• Pain catastrophization

• Fear-avoidance

• Attitudes and behaviors regarding pain

• Physical movement

• Healthcare utilization

who is PNE appropriate for

• Chronic low back pain

• CRPS Type 1

• Phantom Limb Pain

• Brachial Plexus Injury

• Chronic pain s/p stroke

• Chronic neck pain

• Frozen shoulder

Intervention Guidelines for PNE

Encourage the use of a confrontation approach in those that normally wouldn’t
◦ Addressing the way the patient thinks about low back pain itself and the consequences of low back pain
◦ Addressing the way the patient participates in rehabilitation protocols
Turn “avoiders” into “confronters”

dosing for PNE

• 30 minutes - 4 hours

• 1 session - multiple sessions

• 1-on-1 > group

• Used pictures, PPT presentations, metaphors, drawings, examples, books

what works best for chronic LBP

PNE and exercise

Graded Exercise

• based on operant principles

• Reward patient for meeting activity goals

• No reward for activity limitation due to pain

• This is a quota based system
  ◦ Exercise progression based on meeting quota
  ◦ Pain does not normally figure in exercise progression

graded exposure

• Gradual exposure to specific activities that produce fear (George
  2009, JOSPT)

• Fear of Daily Activities Questionnaire

group therapy

• Set time each week

• Social

• Outside of home

• Support

• YMCA, senior centers

self help

Aerobic exercise
● increases Blood flow and oxygenation of muscles & nerves
● Regulates stress chemicals
● Boosts immune system
● Improves memory
● Decreases sleep disturbance
● Diaphragmatic breathing - 5 minutes

how common is LBP

• affects 80% of us some time in our lives

• one of the most frequent reasons that patients visit PCP and is 2nd most common reason for time taken off from work

• in the US, estimates of direct medical costs attributable to back pain are as high as 25 billion annually

• can occur at any age but is most prevalent during the third to sixth decades of life

muscles

• strain

• myofascial pain

• spasms

bone

vertebrae

• fractures

  • trauma

  • osteoprorsis

  • tumors/cancer

facet joints

• arthritis

• bone spurs

SI joint

discs

cushions or shock absorbers between vertebral

• herniation

• tear/rupture

spinal canal

the chamber that holds the spinal cord and nerves

• stenosis

what can cause back pain

• advanced age leading to arthritis

• falls

• auto accidents

• poor body mechanics or posture

• high impact sports (football)

• poor nutrition, obesity, and pregnancy

• smoking

• inflammation

• spasms

• nerve pain

• plain old pain

pain

• ultram

• vicodon

• percocet

• MS contin

• duragesic

side effects/problems

tolerance, addiction, abuse potential, street value

meds for nerve pain

• neurontin

• lyrica

• cymbalta

• tricyclic

side effects of nerve pain

drowsiness, swelling in the legs, dry mouth

• look art PMH, age and other meds

spasms

muscles will spasm aroud the spine

meds for spasms

0 flexaril

soma

skelaxin

robaxin

norflex

zanaflex

side effects of spasm meds

drowsiness

how does smoking impact LBP

smoking accleerates the thinning of vessels in vertebrae

meds for inflammation

• motirn

• aleve

• mobic

• celebrex

• modrol dosepak

side effects of inflammatory meds

upset stomach, risk for patients w/ ulcers or kindey problems

narcotics

• aren’t all bad; however they must be used cautionsly and responsibly

comprehensive pain program

• pain med contract

• urine testing

• PT

• acupuncture

• massage therapy

• mind-body therapies

• integrative psychotherapy and psychiatry

• nutritional support

• natural medicines

• trigger point therapy w/ homeopathic meds

are there limitations to treatment

yes

determining cause of pain

• history

• physical exam

• imaging

  • X-ray

  • MRI

  • CT scan

• nerve conduction studies/EMG

how to treat muscle strain, spasms, and myofascial pain

• medications

  • anti-inflammatories

  • muscle relaxants

• PT

  • education

  • ice, heat, massage

  • strength, ednurance and flexibility lead to improved stabilization and efficiancy

• trigger poin injections

trigger point injection

injection anaesthetic solution sometimes w/ steroid into muscle

how to treat compression fractures

• will usually cause pain only in the back

  • medication: narcotics

• bracing and PT with extension-based exercises

• vertebroplasty

• kyphoplasty

vertebroplasty and kyphoplasty

takin introducer and inserting into the bone, then inject a cement

• thoracic are more difficult to treat

how to treat facet joint straina nd arthritis

• usually cause pain only in the back

• meds: ant-inflammatories

• PT

• more pain in extension

facet joint injection

• injection of local anesthetic and steroid into the facet joint capsule to reduce inflammation

• procedure is one under X-ray guidance as an outpatient in a surgical center

• success and duration of relief is variable and depends on extent of inflammation, as well as post-injection habits

injection technique

• c-arm: takes live X-ray

facet medial branch blocks

• injection of local anesthetic only on the nerve fibers that transmit pain signals from the joint

• procedure is done under X-ray guidance as an outpatient in a surgical center

• a successful injection is measured by the amount of temporary relief of back pain

• it is usually done twice on 2 separate visits for confirmation purposes

• injection on to the bone instead of joint

• after 2 confirmatory blocks, the nerve fiber is destroyed w/ specialized radiofrequency needle

success of medial nerve block

variable; in theory it should be permeant; however, these nerve fibers can grow back; this procedure can be repeated in as soon as 6 months

SI joint strain and arthritis

• will usually cause pain only in the low back and buttocks

• meds: anti-inflammatories

• PT

SI joint injection

• injection of local anesthetic and striod into SI joint to reduce inflammation and pain

• done under X-ray guidance

• success and duration of relief is variale and depends on extent of inflammation as well as post-injection habits

hwo to treat disc herniation and spinal stenosis

will usually cause pain in the back w/ radiation into the leg because of irritation of the nerve root

• meds

• PT: including traction

• epidural steroird injection

• referrals for surgery

meds for disc hernation and spinal stenosis

• anti-inflammatories

• nerve meds

• pain med

epidural steroid injection

• injection of local anesthesic and steirod inot epidural space or along the nerve roots to reduce inflammation and pain

• under X-ray guidance

• success and duration depnds on extent of inflammation and post-injection habits

appraches to epidural steriod

• interlaminar approach: between lamia

• transforaminal approach: through the foramen

• caudal approach: through tailbone region through sacral hiatus

how many injection can i have

there is no consensus on the number of injection given in a year, 3 injections in a 6-12 month period

what are the benefits to an injection

• concentration of steroid delivered to the site of pathology is presumed to be proportional to its effectiveness

• injected steroid is not dependent on local blood flow, which has shown to be compromised w/ compressive lesions