Persisting Shoulder PainRichmond Stace MCSP MSc (Pain) BSc (Hons)

Specialist Pain Physiotherapist

Saturday, 8 February 14

Where is the pain?

• Biomedical - “It’s in the shoulder”

• Neuroscience - “It’s in the space deemed in need of protection by the brain”.

Saturday, 8 February 14

Phantom limb painSaturday, 8 February 14

VS RamachandranSaturday, 8 February 14

Analgesic effect of crossing the arms

Saturday, 8 February 14

Pain in space

• Pain allocated a space

• What is in the space?

• Junk - chemicals

• Why does it hurt?

Space junk

Saturday, 8 February 14

Why does it hurt?

• Brain perceives danger

• Is there really danger?

• How dangerous?

• What is the context?

• Prior experience

Saturday, 8 February 14

Do you need tissues to hurt?

• In most cases, initially yes

• Need a sense of body

• Persisting pain?

• pain - tissue disconnect

Saturday, 8 February 14

Pain neurobiology

• Pain is a conscious, neuroimmunoendocrinological experience

• Multi-system - homeostatic mechanism? (Craig)

• Multi-dimensional -- pain & pain relief

• Physical

• Emotional

• Cognitive

Saturday, 8 February 14

Pain as an emotion

• How is the patient feeling about their pain?

• Emotional brain (Ledoux)

• Danger signals flow to the emotional centres

• Emotional state affects pain (Tracey)

• Any less important than pain with movement?

Saturday, 8 February 14

Pain & cognition

• The bidirectional body-brain

• Thoughts are played out via the body

• Body feelings are interpreted

• Attentional bias

• Stress - anxiety

Saturday, 8 February 14

Pain & stress

• Shoulder - the emotional joint?

• Stress

• Perception of a situation

• Automatic thoughts

• Body responses

• Autonomic NS -- on alert

Saturday, 8 February 14

Movement and pain

• Assumption: painful movement - movement is the problem due to structure

• Movement end result of a process

• Nothing in isolation

• Neuroimmune priming

• Prior experience, thoughts, mindset, beliefs, environment, who’s there.....

Saturday, 8 February 14

Influences on pain• What you are doing

• What you are thinking

• Where you are

• Who you are with

• What have you done there before

• How you are feeling

• Past experiences

• Culture

• Gender

• Genetics

• What your brain thinks you may do (prediction)

• What others are doing

Saturday, 8 February 14

A formula

• Pain biology + influences (biology) - level of resilience + emotional state = pain

• Where can we intervene?

Saturday, 8 February 14

Treatment

• Multidimensional

• Foundation - the basics

• Understanding the biology

• Understanding the influences

• Raise awareness to cultivate change

Saturday, 8 February 14

NeuroplasticitySaturday, 8 February 14

Create the conditions for change

• Neuroplasticity means we can learn & change

• Early messages - “you can’t”, “you won’t”

Saturday, 8 February 14

Pain is an output

• A protective output

• Emerges from the body

• End result of a process

• Target the processes

Saturday, 8 February 14

Training

• To re-programme

• Thoughts & mindset

• Specific sensorimotor training

• Central sensitisation - e.g./ planning stages of movement, medication

Saturday, 8 February 14

Healthy experiences

• Multi-sensory feedback from the painful area

• Movement and other input that does not hurt = happy brain

• Safe

• Knowing that ‘hurt does not equal harm’

Saturday, 8 February 14

Pain & mindsetSaturday, 8 February 14

Look for the clues in the narrativeCompassionate listening & communication

Saturday, 8 February 14

www.specialistpainphysio.com@painphysio t. 07932 689081

Saturday, 8 February 14