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% ����� ���&� ����������� Department of Rehabilitation & Movement Science College of Nursing and Health Sciences University of Vermont

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� PT in Motion (Sept., 2014). Treating Pain Head-on � Nijs et al. (2014). A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Physical Therapy, 94, 730-738. � Louw et al. (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation, 92, 2041-2056. � Hoeger Bement et al. (2014). An interprofessional consensus of core competencies for prelicensure education in pain management: curriculum application for physical therapy. Physical Therapy, 94, 451-465.

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� Disclosure # �&������ ������������������� � PhD in Psychology # Comp Exam on pain � Explosion in pain research last 2 decades � International Association for the Study of Pain

(IASP) member since 1997 � Attend IASP meetings / access resources � Advocacy and education to address pain myths

and improve pain assessment and management � Scholarly activity in pain

F8G',/#7'+%%%� Review pain definitions, concepts and

terminology � Discuss neuroplasticity and central

sensitization associated with chronic pain � Differentiate between the biomedical and

biopsychosocial models of pain � Summarize research examining the efficacy

of neuroscience education in managing pain � Identify pain neuroscience education

protocols and resources

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%� Domain 1: Multidimensional Nature of Pain: What Is Pain? � fundamental concepts of pain, including the

science, nomenclature, experience of pain, ���� ��&����� ��������������!�� �� ���������"

� Domain 2: Pain Assessment and

Measurement: How Is Pain Recognized?

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%� Domain 3: Management of Pain: How Is Pain Relieved? � $����� ���� � ����� ���������������-management

strategies that include education on the science of pain, exercise and exercise progression, pacing, and self-� � �������������� ��%

� Domain 4: - Clinical Conditions: How Does Context Influence Pain Management? � Lifespan; � Diverse patient populations, etc.

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An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

International Association for

the Study of Pain (IASP) Taxonomy

Pain is a disturbed sensation that may cause disability, suffering or distress

APTA Guide to Physical

Therapist Practice, 3rd Ed., 2014

8

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� Anatomical focus � CNS transmits

information passively about the onset, duration, intensity, location and quality of noxious stimuli in periphery to the brain

� ����� ��������������for chronic pain

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� 1965 Melzack & Wall, Gate Control theory � Showed the sensory relay system could be

modulated in spinal cord by inhibitory controls � 1970 -1980 � discovery of inhibitory circuits and

control mechanisms � endogenous inhibitory controls � enkephalins and endorphins � diffuse noxious inhibitory controls

� 1980s Clifford Woolf discovered central sensitization

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responsiveness of nociceptive neurons in the CNS to their normal or subthreshold ��������� �����

� Neuronal sensitivity altered by changes in: ! Threshold ! Gain ! Spatial input

Source: Woolf CJ. (2014). What to call the amplification of nociceptive signals in the central nervous system that contribute to widespread pain? Pain, 155, 1911-1912.

Figure 9 Multiple cellular processes lead to central sensitization. Central sensitization is not defined by activation of a single molecular pathway but rather represents the altered functional status of nociceptive neurons. During central sensitization, these neurons display 1 or all of the following: i, development of or an increase in spontaneous activity; ii, reduction in threshold for activation; and iii, enlargement of nociceptive neuron receptive ��������

Alban Latremoliere , Clifford J. Woolf . Central Sensitization: A Generator of Pain Hypersensitivity by Central Neural Plasticity, The Journal of Pain, Volume 10, Issue 9, 2009, 895 � 926, http://dx.doi.org/10.1016/j.jpain.2009.06.012

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824/=&!"#$%&,>*%?*@?,>&� �������������������������������������

uncoupling of the clear stimulus response ��������� ���� ��������������������������

� ���������������������-dependent synaptic plasticity, changes in microglia, astrocytes, gap junctions, membrane excitability and gene transcription all can contribute to the �����������������������������������

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Ascending (A) and descending (B) pain pathways in the human brain

(A) (B)

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� Nociception � neural process of encoding

noxious stimuli � Pain

� sensory perception of nociceptive stimulus

� Suffering � negative affective reaction to

pain � Pain Behavior

� What person does (or does not) say or do

� Social � environmental context

16

D24/&43&9"78#.X&� Biological

� � �������������������������ability to heal) � Central sensitization, pain and plasticity � Individual & genetic differences

� Psychological � Thoughts, feelings, beliefs, coping � Cognitive & communication skills

� Social � Beliefs, stereotypes, attitudes, and disparities

17

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http://www.ted.com/talks/elliot_krane_the_mystery_of_chronic_pain?language=en

Pain animations � Phases of Nociceptive Pain

� https://www.youtube.com/watch?v=PMZdkac4YLk

� Central Nervous System Mechanisms of Pain Modulation � https://www.youtube.com/watch?v=FbJF8gijf8E

� The Mechanisms of Musculoskeletal Pain

� https://www.youtube.com/watch?v=4LEy8B1D3QE

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!"#$%&'()*+,#'$,'%-.(,"/#*$%Terms � Pain physiology

education � Pain biology

education � Neurophysiology of

pain education � Therapeutic

neuroscience education

Goals � Provide education � Elicit pain beliefs and

address fears, myths, misunderstandings

� Desensitize the CNS � Increase movement

and function

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Premises: � Pain myths, fears, and

misunderstandings common � Most people (including �������� ��� ����� ��������have accurate and current knowledge of pain

� Accurate knowledge improves patient functioning

� Explaining pain is an effective intervention

� Understanding pain physiology changes the way people think, ��threat and perceived danger of pain

� Increases self management

Butler, David, S. & Moseley, G. Lorimer Noigroup Publications: Adelaide, Australia 1st Edition 2003 2nd Edition 2013 http://www.noigroup.com/en/Home

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� BodyinMind.org - Research into the role of the brain and mind in chronic pain � http://www.bodyinmind.org/

� Excellent website � TedTalk � Why Things Hurt

� https://www.youtube.com/watch?v=gwd-wLdIHjs � Understanding Pain: Brainman Chooses

(~2 minutes) � https://www.youtube.com/watch?v=jIwn9rC3rOI

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http://www.optp.com/Adriaan-Louw#.VGExvvnF-Sr

B*%&#C+%'/%"46%7$#8')+#/5%*9%D)(++'4+%%� Pain in Motion Website

� http://www.paininmotion.be/EN/index-E.html

� Tools for Clinical Practice � http://www.paininmotion.be/EN/sem-tools.html

� Pain Physiology Education Slides � http://www.paininmotion.be/EN/sem-

PainPhysiologyEducationEnglish.pdf

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%� Active area of research internationally � Major research contributors:

� Butler and Moseley � Louw and Puentedura � Nijs et al.

� Review selected studies � Discuss intervention protocols and potential

practice implications

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Background � MSK pain ��������� �������������������������findings � Patients may receive erroneous or inaccurate information � Erroneous information triggers maladaptive cognitions � Maladaptive beliefs reinforce fear of movement and

perceived threat � ����������������������������������maladaptive beliefs � Maladaptive beliefs may result in misguided decisions to

pursue risky or unproven treatments in search of a cure

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� Examples of how our language may reinforce maladaptive beliefs- e.g., pain = tissue damage � �������������������� � � ������������������������������������ � ���������������������������� � ������ ��������������������������� � My friend - hypermobility syndrome - �your

joints are slipping / sliding out ����������

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� 8 studies reviewed: � 6 high-quality RCTs � 1 pseudo-RCT � 1 comparative study

� 401 subjects � Most studies were of good quality � Narrative synthesis of results

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� Duration & frequency of NE Intervention � 30 minutes to 8 hours � Single to multiple

education sessions � Mean time � between

2 ! and 4 hours

� Educational tools � Prepared pictures � Examples � Metaphors � Hand drawings � Workbook with

reading/question-answer assignments

� Neurophysiology Pain Questionnaire

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� In patients with various types of chronic MSK pain NE was effective & resulted in: � reduced pain � increased function � reduced catastrophization � improved movement

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� Perspective article � Argues that CSP interventions should address

CNS as well as peripheral dysfunction � Suggest using pain neuroscience education

1st followed by cognition-targeted motor control training

� Provides a model for how this might be applied in physical therapist practice

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The modern neuroscience approach to chronic spinal pain.

Nijs J et al. PHYS THER 2014;94:730-738

© 2014 American Physical Therapy Association

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� Authors offer a 5-step evidence-based approach to care for patients with chronic MSK pain

� Self-reflection of therapists re: pain beliefs � Assessment of patients��pain attitudes /beliefs � Clinical reasoning process outlined � Tailor neuro education program to align with

beliefs of patient � Intervention

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Fig. 1. 5-����������� ����������������������� �� ���������������������������� beliefs and attitudes regarding chronic musculoskeletal pain in clinical practice.

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� Example - patient with moderate hip OA because cartilage ����������������������������� [biomedical]

� Consequence - patient unable to participate in PT/ physical activity; belief - movement will make hip worse

� Graded activity and exercise recommended � Gap between patient and provider perceptions of pain

and its management must be addressed � Role for patient education to address central

sensitization in OA in addition to traditional care

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� Pain physiology education is indicated when: � clinical picture indicates central sensitization � maladaptive illness perceptions exist

� Structure of education � Face-to-face educational sessions in addition to

providing written educational materials � Session 1: basic pain physiology; contrast acute

nociception versus chronic pain � Homework � Session 2: Address misunderstandings and promote

adaptive pain coping to daily functioning I2586&7%M("-%"-%:2'"2-%F&0$"'&%B%M("-%M,1$"2)2/1%N356('"2-%I)"3&$%%%%

Nijs et al. - Patient Education booklet

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91&(":(-&.*;3"$1((� Gallagher L, McAuley J, Moseley GL. (2013). A

randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain. Clinical Journal of Pain, 29, 20-25.

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(� Objective:

� Does the use of written metaphor and story increase knowledge of the biology of pain and reduce pain-related catastrophizing?

� Methods: � 79 people with chronic pain given either a/an: � Booklet of metaphors to convey pain biology

concepts or � Advise booklet on how to manage chronic pain

using cognitive-behavioral principles

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� Results: � Metaphor group showed larger changes in

both pain biology knowledge & catastrophizing � Gains were maintained for at least 3 months � There was no change in pain or self-reported

disability in either group

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� Pediatric Pain Letter � http://childpain.org/ppl/

� Coakley, R. & Schechter, N. (2013). Commentary: Chronic ����� ������The clinical use of analogy and metaphor in the treatment of chronic pain in children. Pediatric Pain Letter,15, No. 1 � http://childpain.org/ppl/issues/v15n1_2013/v15n1_

coakley.pdf

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� Dolphens et al. (2014). Efficacy of a modern neuroscience approach versus usual care evidence-based physiotherapy on pain, disability and brain characteristics in chronic spinal pain patients: protocol of a randomized clinical trial. BMC Musculoskeletal Disorders, 8,15:149. � http://www.biomedcentral.com/1471-2474/15/149

� Traeger et al. (2014). Pain education to prevent chronic low back pain: a study protocol for a randomised controlled trial. BMJ Open, 2, 4(6):e005505. � http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4054624/

1&746'<&7!!� Books

� Explain Pain and Graded Motor Imagery � Therapeutic Neuroscience Education � Why You Hurt

� Good websites � Check pain animations

� IASP website � Articles � many are open access � ���������

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� 2014 - Orofacial pain � 2015- Neuropathic Pain � 2016 - Pain in the Joints � 2017 - Postsurgical Pain

� Fact Sheets � Free - many topics

� 3 short educational videos � Global Year Against

Musculoskeletal Pain � Myths

F6::"'I((� Pain neuroscience education

� Evidence based � Replicated by different research groups with

different patient populations � Materials and protocols available to help

implement this intervention in clinical practice � Questions / comments

Thank you!!!