Rehabilitation for the Sensitized Nervous
System: What Can PT and OT do for the pain
patient?
Nora Stern, PT, MSPT
Conflict of Interest Disclosure
Nora 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 neurogenic
presentation
• 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
Central: Beliefs about pain
StarT Generic Screening Tool
• Assessing sensory cortical reorganization:
– Two point discrimination testing
Assessing central
involvement: cortical
reorganization: Smudging
Altered Two Point
Discrimination Associated
with Distorted Body Image
in Back Pain
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
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.