By: Jonathan Noury SDPT

ChronicPAIN

DIFFERENTIALS

• Before treating any patient you must

RULE OUT THE WORST CASE SCENARIO• X-ray, MRI, Blood plasma, special test.• Red flags:– PMH, Unexpected Weight loss, Lumps, Saddle Anesthesia, Fever

Injury

PAINAltered Motor Pattern

THE VICIOUS CYCLE

WHY DOES IS HURT?• Bio-physiological Explanation Acute Phase

– Nociception: actual tissue damage response– Nociceptors- respond to stretch, tears, pinch, heat, noxious biochemical.

(Garland 2012)

- Inflammatory response ensues• Chronic pain

– Toxic levels of Glutamate found in Achilles tendonosis. (Maffulli, 2008)

• High intensity exercise may enhance the uptake of Glutamate. (Cunhaa, 2012)

• There is no inflammatory process in chronic pain

Insult to Injury

• FAST vs. SLOW

– Fast pain is the immediate sensation (sharp, prickling) that is felt due to an injury. (Aδ)

– Slow pain is the longer lasting, more intense, and throbbing pain. ACUTE

• If the cause of pain is not addressed immediately it may become chronic.

(Garland 2012)

The Stats…

• According to the APTA over 116 million people in the US have chronic pain each year.

• The cost in the United States is $560–$635 billion annually for medical treatment, lost work time, and lost wages.

What is IT?

• Chronic pain:– Pain lasting longer than three months– Hypersensitivity of the CNS/PNS

• May lead to:– Fearfulness – Poor circulation – Weight gain – Pharmacology use/abuse

DISABILITY

Capacity

• Reoccurring instances of tendon pain may be due to the patient attempting to use the muscle at a capacity that it is not suitable for.

It’s Not About Size• Research suggest, in regards to rotator cuff injuries, the tear size,

superior head migration, and rotator cuff muscle atrophy were not associated with pain level.

• What was associated?

1. Number of co-morbidities2. Education level 3. Race

• Relevance: – Surgery will not fix the associated factors or pain.– Look elsewhere to decrease pain (SFMA?)

(Matsen III, 2014)

Movement Analyst

• As PT’s, we are trained movement specialists– We examine for asymmetries and abnormalities of

movement and strength.

• SFMA (not voodoo) is a tool to incorporate into your examination. – It allows you to look for dysfunctions that may be

contributing to their chronic pain.

Tendinopathy

• Tendinitis (acute) Tendinosis (chronic)• Angiofibroblastic Hyperplasia• Plan of care: POLICE

• Enhance collagen layout through manual/instrumental techniques.– Breakdown scar tissue and promote linearly

oriented collagen.

• Start Optimal Loading at every stage of treatment.– Isometric Con/Eccentric

• HEP- reinforce what you did in the clinic at home.

A Continuum of Stages

• Reactive- cell proliferation phase where tendon thickens and tightens to reduce stress on tendon Acute, tendon swelling

• NSAIDS

• Disrepair- Collagen disorganization and possible neovascularisation.

• Degenerative- Increased scar tissue and microvasculature. May lead to RUPTURE

• NO NSAIDS

(Cook, 2009)

Alfredson Rehab Model

• Rest (active or full)• Orthotic/Corrective Treatment• Medication• Stretching• Strength Training (eccentric focused)

Eccentrically load (180 heel drops/ day) through pain in attempt to damage the AFH and nerve endings signaling pain

- Slight difference in mid vs insertional tendon

(Alfredson, 2007)

Fundamental Rules of Tissue• Length: if the tendon is pre-stretched,

its resting length is increased, and there will be less strain on that tendon during movement.

• Load: by progressively increasing the load exerted on the tendon, there should be a resultant increase in inherent strength of the tendon.

• Recruitment: by increasing the speed of contraction, a greater force will be developed.

(Maffulli,2008)

Pushing Through The Pain

• Patients should not be returning to activities that are causing pain. Altered motor Patterns

• However, in a controlled environment, incorporating some level of pain into the exercise program may affect nociception and decrease the magnitude of pain in the next flare up.

(Cook, 2003)

Effects of Manual Therapy• Chemical Changes: Increased blood levels of neurotensin, oxytocin, and

cortisol (cervical manipulation)

• Improvements in signs and symptoms when providing MT to a remote location. Such as treating cervical pain with MT directed to the thoracic spine.

• “bombard the central nervous system with sensory input from the muscle proprioceptors”

• Systemic changes: Positive change in skin conductance, respiratory rate, blood pressure, and heart rate.

• Higher Force (90N compared to 30N) yields greater decrease in chronic neck pain no indication of mechanical transformation

(Plaza-Manzano, 2014)

(Cleland et al., 2007)

(Pickar & Wheeler, 2001).

(Kingston, 2014)

(Snodgrass , 2014)

Tai Chi (not tea)

• Tai Chi Vs. Stretching for LBP– Imbalances between spinal erectors and trunk flexors

reducing flexibility.– Compilation of slow and smooth motions– More effective in pain reduction and decreased muscle

activity. (Cho, 2014)

• High Threshold strategy- Spurt take over Shunt • Rhythmic motion does not have to be strictly Tai

Chi.

Fear Avoidance Model• Psychological factor stronger than physical?• People adapt in response to pain• FAM suggests introducing the patient to situations they avoid

due to pain or anxiety in a controlled setting. • Combines tissue adaptations through exercises and

psychological changes through accomplishments of motions.

(George, 2009)

• Alfredson, Håkan. Cook, Jill. 2007. A treatment algorithm for managing Achilles tendinopathy: new treatment options. British Journal of Sports Medicine; 41(4): 211–216. • Bluma, E. Procaccib, P. Conteb, V. Hanania M. 2014. Systemic inflammation alters satellite glial cell function and structure. A possible contribution to pain. Neuroscience.

Volume 274; Pages 209–217

• Cho, YongHo. 2014. Effects of Tai Chi on Pain and Muscle Activity in Young Males with Acute Low Back Pain. Journal of Physical Therapy Science; 26(5): 679–681.

• Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. 2007. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual Therapy,10(2):127-35.

• Cook, Jill. Purdam, Craig. 2013. Rehabilitation of lower limb tendinopathies. Clinical Sports Med 22 (2003) 777 – 789

• Cunhaa, Maira J. Cunhaa, Aline A. 2012. Physical exercise reverses glutamate uptake and oxidative stress effects of chronic homocysteine administration in the rat International Journal of Developmental Neuroscience; Volume 30, Issue 2, Pages 69–74

• Garland, Eric L. 2012. Pain Processing in the Human Nervous System: A Selective Review of Nociceptive and Biobehavioral Pathways. National Institute of Health and Primary Care, Sep 2012; 39(3): 561–571.

• George, Steven Z. 2009 Physical Therapy Utilization of Graded Exposure for Patients With Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy; 39:7, 496-505.

• Kingston, Laura. Claydon, Leica. Tumilty, Steve. 2014. The effects of spinal mobilizations on the sympathetic nervous system: A systematic review Manual Therapy, Volume 19, Issue 4, Pages 281-287 • Matsen III, Frederick . 2014. Shoulder Pain Does Not Parallel Rotator Cuff Tear Size—What Does That Tell Us? Journal of Bone and Joint Surgery, 21;96(10):e86 • Maffulli, N. Longo, U. G. How do eccentric exercises work in tendinopathy? 2008. Oxford Journals Rheumatology; Volume 47, Issue 10Pp. 1444-1445 • Pickar JG, Wilder DG. Spinal manipulation alters electromyographic activity of paraspinal muscles: a descriptive study. J.Manipulative Physiol Ther. 2005;28:465–471. • Plaza-Manzano, Gustavo. Molina, Francisco. Lomas-Vega, Rafael. Et. Al. 2014. Biochemical Markers of Pain Perception and Stress Response After Spinal Manipulation.

Journal of Orthopaedic & Sports Physical Therapy, Volume: 44 Issue: 4 Pages: 231-239 • Snodgrass SJ, et al. 2014 Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in

patients with neck pain. Journal of Orthopedics and Sports Physical Therapy, (3):141-52.

• Wu, A. , Green, C.R. Rupenthal, I., Moalem-Taylor, G. 2012. Role of gap junctions in chronic pain. Journal of Neuroscience Research, Volume 90, Issue 2 Pages 337-345. • Zane, Mary Kay. 2012. Physical Therapist's Guide to Chronic Pain Syndromes. MoveForwardPT. • Cook JL, Purdam CR: Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009,

43(6):409-416.