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Rehabilitation for the Sensitized Nervous System: What Can PT and OT do for the pain patient?
Nora Stern, PT, MSPT
Conflict of Interest DisclosureNora Stern, PT, MS, PT
Has no real or apparent
conflicts of interest to report.
Looking at what is sensitizing the systems:
• Nociceptive input
• Peripheral
• Central
• Output driven
Nocioceptive
• Active inflammatory process:
– Treatment: Explain Pain
Address fear avoidance
Motion is lotion: flushing inflammation
Peripheral neurogenicpresentation
• Follows nerve pathway or adjacent pathway, but in new areas along pathway
• Shooting up or down along pathway
Treatment for peripheral neurogenic
• Motion is lotion
• Address neurodynamics
• Health of container: taping, manual therapy
• Decrease in threat value: pain education, normalize experience
• What does pt need to hear?
Assessing central sensitization
• Pain searing, stabbing, like a knife, hot poker
• Diffuse
• Appearing on other side of body, pain in new area
• Not consistent w findings
• Does not follow anatomy
• Large or diffuse areas of pain
• Black body diagram
• Altered 2 point discrimination
• Delay in laterality recognition > 1.5 sec, < 90% accuracy
Fig. 1 Patient data: TPD threshold, normal distribution of pain, and body image. Two-point discrimination threshold (TPD) was
assessed bilaterally at 16 levels, shown here superimposed over line drawings of the sense of physical self, or body image, of six...
Moseley, GL, “I Cant’ find it! Distorted body image and tactile dysfunction in patients with chronic back pain.” Pain Vol 140, Issue 1,
2008, 239-243
Assessing central involvement: cortical
reorganization: SmudgingAltered Two Point
Discrimination Associated with Distorted Body Image
in Back Pain
Central: what aspects of the brain processing are
contributing to central sensitization?• Thinking
• Feeling
• Sensing
• Acting/moving
Disruption of output, mirror neurons and sensory and motor
homuncular representation
(smudging)
• Swelling
• Sweating
• Itching
• cold sensitivity
• Pain w thinking about movement, watching someone move
• Altered 2 point discrimination
• Altered body schema
• Poor motor planning
Treatment interventions:Central
• Pain education:
– Fear Avoidance and Graded Exposure: Moseley and Butler’s twin peaks
Treatment Interventions: Central
• Cortical Reorganization:
– Graded Motor Imagery
– Body scan
– General kinesthetic sensing with exercise
– Whole body movement to restore virtual body representation
Graded Motor Imagery
• Laterality recognition:
– Activates pre-motor but not primary motor cortex Norm of 90% accuracy and 1.5 sec reaction time
• Imagined movement
• Mirrors
Graded exposure
• Pacing: twin peaks
• Vary the task:
• Laterality recognition
• Imagine movement
• Change setting
• Do in pleasurable context
• Do parts of a task; eg knees to chest as component of bending over
Treatment Interventions:Central
• Stress response: physiological quieting
• www.meditationcenter.com: easy to follow meditations. • http://www.allaboutdepression.com/relax/ 8 free
breathing tapes, relaxation activities. •
•
• http://vcc.asu.edu/relaxaindex.shtml: free guided instruction in progressive muscle relaxation and guided imagery.