THE NEUROSCIENCE OF
ORTHOPEDICS
COMPLEX PROBLEMS WITH SIMPLE SOLUTIONS
RODERICK HENDERSON, PT, SCD, OCS, MA, CSCS
WHAT YOU’LL LEARN
• ORTHOPEDIC DIAGNOSES ARE OFTEN VERY STRAIGHTFORWARD
• THE PATIENT’S RESPONSE TO A DIAGNOSIS MAY VARY ACCORDING
TO:
• SENSORY PHYSIOLOGY
• CENTRAL PROCESSING (COGNITIVE / AFFECTIVE)
• AUTONOMIC DRIVE
THE NERVOUS SYSTEM
• DRIVES THE RESPONSE
• ADAPTS TO NEW INFORMATION
WHERE WE’RE GOING
• HOW DID WE PUT THE NEURO IN ORTHO?
• HOW DO WE TREAT COMPLEX PROBLEMS WITH STRAIGHTFORWARD
SOLUTIONS?
ORTHOPEDIC PT STEREOTYPE
• FORMULAIC
• PROTOCOL-DRIVEN
• BORING…
WHAT WE REALLY SEE
• TREMENDOUS VARIABILITY
• CHALLENGING PROBLEMS
• EXCITING OPPORTUNITIES
CHALLENGE #1
• ORTHOPEDIC PTS TRAINED AS CLINICAL BIOMECHANISTS
• BUT – LINES BETWEEN BIOMECHANICS AND PATHOLOGY ARE BLURRY!
CHALLENGE #2
• WE DON’T LIKE CHASING PAIN
• BUT - PAIN IS OFTEN THE PATIENT’S CHIEF COMPLAINT!
Symptoms
TRADITIONAL INJURY MODEL
Pathology
Halderman S. Presidential Address, North American Spine Society: Failure of
the pathology model to predict back pain. 1990; Spine 15:718-724.
Symptoms
IDEAL RECOVERY
Pathology
Halderman S. Presidential Address, North American Spine Society: Failure of
the pathology model to predict back pain. 1990; Spine 15:718-724.
EXPECTATIONS
• PATHOLOGY AND SYMPTOMS SHOULD IMPROVE WITH EFFECTIVE
TREATMENTS
• IDEALLY SHOULD ALSO SEE A REVERSAL OF ANY STRUCTURAL
ABNORMALITY
Symptoms
PERSISTENT PAIN
Pathology
Halderman S. Presidential Address, North American Spine Society: Failure of
the pathology model to predict back pain. 1990; Spine 15:718-724.
Symptoms
THE AGING BODY
Pathology
Halderman S. Presidential Address, North American Spine Society: Failure of
the pathology model to predict back pain. 1990; Spine 15:718-724.
A GROWING TREND
• PATHOLOGICAL SIGNS PRESENT WITHOUT SYMPTOMS (FALSE
POSITIVES)
• SEEN WITH INCREASING REGULARITY
• LUMBAR SPINE
• SHOULDER
• FOOT AND ANKLE
CONSEQUENCES
• DISABILITY, FEAR, FRUSTRATION
• HIGHER COSTS, OVERUTILIZATION, DEPENDENCE UPON PASSIVE
INTERVENTION
STILL BORED??
• THOUSANDS OF NEW ARTICLES PUBLISHED
• EVOLVING CLINICAL GUIDELINES
• MORE WAYS TO HELP OUR PATIENTS
ANSWERS
• FULLY UNDERSTANDING RESPONSE TO INJURY
• SEE WHERE THINGS GO WRONG
• TREAT THE PATIENT USING A BIOPSYCHOSOCIAL MODEL
EVOLUTION OF PAIN THEORY
• SPECIFICITY
• GATE
• PAIN MATRIX
SPECIFICITY
PRINCIPLES
• TISSUES HAVE “PAIN” RECEPTORS
• PAIN SIGNALS TRANSMITTED TO THE BRAIN
KEY ASSUMPTIONS
• PAIN IS AN INPUT TO THE CNS
• PATHOLOGY = PAIN
• PINEAL GLAND IS THE PAIN CENTER
IMPLICATIONS
• PATHOLOGY = PAIN
• ERADICATE PATHOLOGY = ERADICATE PAIN
UPSIDE OF SPECIFICITY
• UPGRADE FROM THE MYSTICAL MODEL!
• ACKNOWLEDGED THE NERVOUS SYSTEM
LIMITATIONS OF SPECIFICITY
• PAIN CAN BE PRESENT WITHOUT TISSUE DAMAGE
• TISSUE DAMAGE CAN BE PRESENT WITHOUT PAIN
KEY NOTE: NOCICEPTION IS NEITHER NECESSARY NOR SUFFICIENT
FOR THE PRODUCTION OF PAIN
OTHER PROBLEMS
• PHANTOM LIMB PAIN
• CHRONIC REGIONAL PAIN SYNDROME
BODY PARTS ARE REPRESENTED IN THE CNS THROUGH MAPS
THE SECOND EVOLUTION
GATE THEORY (1965)
• DESCENDING CONTROL FROM BRAIN AND SPINAL CORD
• FORMED THE BASIS FOR TENS
• MOST PTS ARE AWARE OF THIS MODEL
WHAT CHANGED?
• CHALLENGES THE CONCEPT OF “PAIN GENERATOR”
• NOXIOUS STIMULI MODULATED BY DORSAL HORN AND CNS
• OUTPUT IS THE “PAIN EXPERIENCE”
LIMITATIONS OF THE GATE
• WIDESPREAD OR CHRONIC PAIN SYNDROMES?
• PAIN FOLLOWING SPINAL CORD INJURY
• STILL NO ACCOUNTING FOR CRPS!
Melzack R. From the Gate to the Neuromatrix. Pain Supplement. 1999;
6:S121-S126.
ENTER THE MATRIX
• ALSO KNOWN AS THE “PAIN MATRIX” OR “NEUROMATRIX”
• FRAMEWORK FOR MULTI-SYSTEM RESPONSE TO INJURY
• THE MOST CURRENT MODEL OF INJURY RESPONSE TO DATE
Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education.
2001;65(12):1378-1382
GETTING ORGANIZED
Inputs
Outputs
Processing
Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education.
2001;65(12):1378-1382
WHAT IS AN INPUT?
• BRAIN CONSTANTLY SAMPLING INFORMATION
• INTERNAL INFORMATION FROM BODILY TISSUES
• EXTERNAL INFORMATION FROM THE ENVIRONMENT
INPUTS
• SENSORY
• COGNITIVE
• AFFECTIVE
SENSORY INPUTS
Mechanical
Chemical
Thermal
• Movement
• Touch
• Inflammation
• Neurotransmitters
• Warmth produced by metabolic activity
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
RELEVANCE OF SENSORY INPUTS
• WE ARE HIGHLY SELECTIVE
• PRIORITY OF INPUTS IS VARIABLE
• ALTERED BY ATTENTION
NOT A ONE-WAY STREET
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
CLINICAL RELEVANCE
• COMMUNICATION BETWEEN TISSUE AND CNS IS BIDIRECTIONAL
• LONG-STANDING MSK PROBLEMS SHOW SIGNS OF NEUROGENIC
INFLAMMATION
• IMPLICATIONS FOR NEURODYNAMICS
THE VALUE OF GOOD INPUT
• STIMULUS-DETECTION SYSTEM OF THE BODY
• TISSUE DAMAGE WILL INCREASE SIGNAL INTENSITY FROM THAT
REGION
• PURPOSE IS TO GET YOUR ATTENTION!
• SENSORY FIBERS ARE NOT PURELY SENSORY
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
COGNITIVE INPUTS
• KNOWLEDGE
• EXPERIENCE
• EXPECTATION
COGNITIVE INPUTS
• WHAT DOES THE PATIENT BELIEVE IS HAPPENING?
• HAVE THEY DEALT WITH SIMILAR PROBLEMS?
COGNITIVE INPUTS
• HOW DID THEY HANDLE IT?
• WHAT DO THEY THINK IS GOING TO HAPPEN?
RELEVANCE OF COGNITIVE INPUTS
• BELIEF INFLUENCE OUTCOMES
• EXPERIENCE SHAPES COPING
• EXPECTATION INFLUENCES RESPONSE
AFFECTIVE INPUTS
• BASELINE IMMUNE / ENDOCRINE FUNCTION
• AUTONOMIC NERVOUS SYSTEM FUNCTION
• LIMBIC SYSTEM – EMOTIONAL REGULATION
RELEVANCE OF AFFECTIVE INPUT
• INTERACTION BETWEEN NERVOUS AND IMMUNE
• AUTONOMIC FUNCTION INFLUENCES PROCESSING
THERAPEUTIC INPUTS
• PATIENT EDUCATION
• MANUAL THERAPY
• ACTIVE MOVEMENT
IMPLICATIONS
• MULTIPLE AVENUES TO PAIN RELIEF
• OR EXACERBATION
• MAYBE WHY “EVERYTHING” SEEMS TO WORK?
Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education.
2001;65(12):1378-1382
DYNAMIC PROCESSING
• INPUTS CONSTANTLY EVALUATED
• INJURY
• MOVEMENT
• TOUCH
• OUTPUT IS PRODUCED AND EVALUATED
• THINK OF STEPPING ON A STICKER BURR!
• CHANGES MAY OCCUR THROUGHOUT THE CNS
DYNAMIC PROCESSING
• DISTRIBUTED PROCESSING WITH NO
“PAIN CENTER”
• CORRESPONDS WITH
CHARACTERISTIC PAIN BEHAVIORS
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
CENTRAL INFLUENCES
• COGNITION AND CONTEXT
• EMOTIONS AND MOOD
• ATTENTION AND VIGILANCE
DORSAL HORN
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
IMPLICATIONS OF DORSAL HORN
• SPINAL CORD ACTS AS AN
AMPLIFIER OR INHIBITOR OF
SOMATOSENSORY INPUT
• PERSISTENT NOCICEPTION CREATES AN EXPANSION OF RECEPTIVE
FIELDS
• PAIN WITH A-BETA STIMULATION
• INCREASING PATTERNS OF REFERRAL WITH CHRONICITY
MANUAL CARE AND THE DORSAL HORN
• ALTERATIONS IN MOTOR NEURON POOL RECRUITMENT
• MODIFIED C-FIBER ACTIVITY FOLLOWING MANIPULATION
• RECEPTIVE FIELDS ALTERED BY OPIOID AND B-ENDORPHIN RESPONSE
CEREBRAL PLASTICITY
• PAIN AND INJURY ALTER CEREBRAL PHYSIOLOGY AND ARCHITECTURE
• NEURONS THAT “FIRE TOGETHER, WIRE TOGETHER”
• NEURAL PLASTICITY UNDERAPPRECIATED IN ORTHOPEDIC PT!
May A. Chronic pain may change the structure of the brain.
Pain. 2008;137:7-15.
EVIDENCE FOR CENTRAL CEREBRAL
CHANGES
• REDUCTION IN GREY MATTER
SHOWN IN YELLOW COMPARED
TO HEALTHY CONTROLS
• STILL UNCLEAR IF A CAUSE OR
CONSEQUENCE
May A. Chronic pain may change the structure of the brain. Pain.
2008; 137:7-15.
CEREBRAL CHANGES – ACL
• CASE CONTROL STUDY OF 17 ACL-DEFICIENT KNEES AND 18 HEALTHY CONTROLS
• BRAIN ACTIVITY MEASURED USING FMRI
• CONCLUSIONS
• ACL INJURY CAUSED FUNCTIONAL REORGANIZATION OF CNS
• SHOULD BE CONSIDERED A NEUROPHYSIOLOGIC DYSFUNCTION, NOT A SIMPLE
MUSCULOSKELETAL INJURY
• FINDINGS COULD LEAD TO NEW STANDARDS OF REHABILITATION AND MOTOR CONTROL
APPLICATION
Kaprieli E, Athanasopoulous S, et al. Anterior Cruciate Ligament injury causes
brain plasticity: A functional MRI study. Am J Sports Med. 2009;37:2419-2426.
CORTICAL CHANGES - LBP
• CLBP INDUCES SIGNIFICANT CORTICAL CHANGES
• MAY EXPLAIN PERSISTENT SYMPTOMS IN THE ABSENCE OF STRONG
MECHANICAL FINDINGS
Flor H, Braun C, Elbert T, Birbaumer N. Extensive reorganization of primary
somatosensory cortex in chronic back pain patients. Neurosci. Lett. 1997;224(1):5-8.
CORTICAL CHANGES - CTS
Napadow V, Kettner N, Ryan A, et al. Somatosensory cortical plasticity in carpal tunnel
syndrome--a cross-sectional fMRI evaluation. Neuroimage. 2006;31(2):520-530.
CORTICAL CHANGES - CTS
• ALTERED AFFERENT PROCESSING PRODUCED CORTICAL CHANGES IN
SYMPTOMATIC SUBJECTS
• TAKE HOME – INJURY CHANGES THE BRAIN!
Napadow V, Kettner N, Ryan A, et al. Somatosensory cortical plasticity in carpal tunnel
syndrome--a cross-sectional fMRI evaluation. Neuroimage. 2006;31(2):520-530.
Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education.
2001;65(12):1378-1382
OUTPUTS
• INPUTS AND PROCESSING PRODUCE OUTPUTS
• PRIMARY REASON FOR OUTPUTS IS TO MAINTAIN HOMEOSTASIS
• OUTPUTS GET US OUT OF TROUBLE!
IMMUNE / ENDOCRINE RESPONSE
• THE CHEMICAL “MUSCLES” OF THE CNS
• INTEGRAL TO RESPONSE OR OUTPUT
• STRONG INFLUENCES ON AROUSAL, ATTENTION, AND FEAR
IMMUNE / ENDOCRINE RESPONSE
• BOTH SYSTEMS RESPOND TO STRESS AND TISSUE INJURY
• INFLUENCE NEURAL RESPONSE
• STRONG INFLUENCE ON TISSUE HEALING
• TWO PRIMARY RESPONSE AXES
• HYPOTHALAMUS-PITUITARY-ADRENAL AXIS
• SYMPATHOADRENAL AXIS
HPA AXIS
• PAIN ELICITS A CORTISOL
RESPONSE
• CHRONIC PAIN RESULTS IN
ALTERATIONS OF CORTISOL
VARIABILITY
• ASSOCIATED WITH HIGH FEAR,
DISABILITY, AND
CATASTROPHIZING
Johannson et al. Pain, disability and coping reflected in the diurnal
cortisol variability in patients scheduled for lumbar disc surgery. Eur J
Pain. 2008;12:633-640
SA AXIS
• SNS CAN CONTRIBUTE TO
SENSITIVITY OF A-DELTA AND C
AFFERENTS
• PERSISTENT PAIN CAN LEAD TO
ADRENORECEPTOR
UPREGULATION AT DRG
Chapman CR, Tuckett RP, Song CW. Pain and Stress in a Systems Perspective:
Reciprocal Neural, Endocrine, and Immune Interactions. Journal of Pain. 2008;9(2):
122-145
IMMUNE RESPONSE: CYTOKINES
• CHEMICAL MESSENGERS PRODUCED DURING TISSUE INJURY AND STRESS
Pro-Inflammatory
Anti-Inflammatory
TNF – Alpha
IL-4
IL-1
IL-10
IL-6
IL-13
Powerful contributors to inflammation and pain!
Chapman CR, Tuckett RP, Song CW. Pain and Stress in a Systems
Perspective: Reciprocal Neural, Endocrine, and Immune Interactions.
Journal of Pain. 2008;9(2): 122-145
CYTOKINES IN DIAGNOSIS
• DIAGNOSTIC UTILITY OF CYTOKINE BIOMARKERS IN ACUTE KNEE PAIN
• PROSPECTIVE COHORT OF 70 KNEES
• 32 PATIENTS
• 15 CONTROLS
• SEVENTEEN INFLAMMATORY CYTOKINES EVALUATED
• STUDY EXAMINED:
• PREOPERATIVE MRI
• CYTOKINE PROFILE
• OPERATIVE FINDINGS
Cuellar JM, Scuderi GJ, Cuellar VG, et al. Diagnostic Utility of Cytokine
Biomarkers in the Evaluation of Acute Knee Pain. Journal of Bone and
Joint Surgery. 2009;91:2313-20.
RESULTS
• SIGNIFICANTLY HIGHER CYTOKINE CONCENTRATION IN
SYMPTOMATIC KNEES
• PRESENCE OF FOUR INFLAMMATORY CYTOKINES PERFORMED AS
WELL AS MRI IN PREDICTING INTRAOPERATIVE FINDINGS
Cuellar JM, Scuderi GJ, Cuellar VG, et al. Diagnostic Utility of Cytokine
Biomarkers in the Evaluation of Acute Knee Pain. Journal of Bone and
Joint Surgery. 2009;91:2313-20.
CONCLUSIONS
“INTRA ARTICULAR CONCENTRATIONS OF FOUR INFLAMMATORY
CYTOKINES….WERE MARKEDLY LOWER IN ASYMPTOMATIC NORMAL
KNEES AND IN ASYMPTOMATIC KNEES WITH MENISCAL TEARS.”
Cuellar JM, Scuderi GJ, Cuellar VG, et al. Diagnostic Utility of Cytokine
Biomarkers in the Evaluation of Acute Knee Pain. Journal of Bone and
Joint Surgery. 2009;91:2313-20.
MORE ON CYTOKINES
• CYTOKINES PLAY A ROLE IN OA PATHOGENESIS
• NOT PURELY A MECHANICAL PHENOMENON
Orita S, Koshi T, Mitsuka T, et al. Associations between proinflammatory cytokines in the
synovial fluid and radiographic grading and pain-related scores in 47 consecutive
patients with osteoarthritis of the knee. BMC Musculoskelet Disord. 2011;12:144.
CYTOKINES IN OA
• Inflammatory cytokines produced by synovial
tissue
• Injection of inhibiting agents slowed
progression in animal models
FERNANDES JC, MARTEL-PELLETIER J, PELLETIER J-P. THE ROLE OF CYTOKINES IN
OSTEOARTHRITIS PATHOPHYSIOLOGY. BIORHEOLOGY. 2002;39(1-2):237-246.
CYTOKINES AND MUSCLE TIISSUE
• Potential anti-inflammatory role of muscle tissue
in cartilage degeneration
• Another avenue for the benefits of physical
activity?
CAIRNS DM, UCHIMURA T, KWON H, ET AL. MUSCLE CELLS ENHANCE RESISTANCE TO
PRO-INFLAMMATORY CYTOKINE-INDUCED CARTILAGE DESTRUCTION. BIOCHEM.
BIOPHYS. RES. COMMUN. 2010;392(1):22-28.
OUTPUTS: WHAT WE SEE
Pain
Behavior
Stress
Response
Movement
Alterations
Severity
Fear /
Anxiety
Postural
Irritability
Helpless /
Hopeless
Nature
Autonomic
changes
Dynamic
THE MATRIX UPGRADE
• MULTIPLE INPUTS
• DYNAMIC PROCESSING
• PAIN IS THE OUTPUT
WHY IS THIS A BIG DEAL?
• CONSIDER CLINICAL PHENOMENON LIKE ANTALGIC GAITS AND
POSTURES
• ARE THEY DEFECTS OR DEFENSE?
• WOULD IT CHANGE OUR MANAGEMENT?
IMPLICATIONS
• EFFECTS OF INJURY DISTRIBUTED ACROSS SEVERAL SYSTEMS
• CHANGES IN PAIN REFLECTS A CHANGES TO ONE OR MORE OF
THESE SYSTEMS
Tracey I, Mantyh PW. The Cerebral Signature for Pain and its modulation.
J Neuron. 2007;55:377-391
IMPLICATIONS
• NERVOUS SYSTEM ACUTELY ADAPTS TO INJURY AND TREATMENT
• REHABILITATION INFLUENCES CEREBRAL AND DORSAL HORN PLASTICITY
Boudreau SA, Farino D, Falla D. The role of neuroplasticity in designing
rehabilitation approaches for musculoskeletal pain disorders. Manual Therapy
(2010), doi:10:1016/j.math.2010.05.008
Traditional Model
Contemporary Model
EXERCISE – IT’S WHAT WE DO
• ALMOST SYNONYMOUS WITH OUR PROFESSION
• FOUNDATIONAL COMPONENT OF OUR PRACTICE
• WE SHOULD HAVE THIS DOWN RIGHT?
TRADITIONAL FOCUS
Physical
• Stronger muscles
• Improved flexibility
• More endurance
EMERGING EVIDENCE
Psychological
• Reduced fear
• Improved efficacy
• Stress tolerance
CONTEMPORARY MODEL
Physical
• Stronger
muscles
• Improved
flexibility
• More
endurance
Psychological
• Reduced fear
• Improved
efficacy
• Stress tolerant
OUR CHALLENGES
• GROWING EVIDENCE-BASE OF EXERCISE SCIENCE
• NOT A LOT OF ENTRY-LEVEL TRAINING
• LIMITED POST-GRADUATE TRAINING
NO EASY ANSWERS
• WE KNOW MOVEMENT IS BENEFICIAL
• NO CLEAR CONSENSUS EXIST REGARDING
• TYPE
• DOSE
• SUB-GROUPING MAY GUIDE DECISIONS BUT STILL NOT CLEAR
Kent P, Mjøsund HL, Petersen DHD. Does targeting manual therapy and/or exercise
improve patient outcomes in nonspecific low back pain? A systematic review. BMC
Med. 2010;8:22.
WHERE’S THE EVIDENCE?
MOST OF IT’S HERE…
EXERCISE AND LOW BACK PAIN
• HIGHEST FORMS OF EVIDENCE SUGGEST MINIMAL BENEFIT
• LOWER FORMS OF EVIDENCE SUGGEST MODERATE BENEFIT
van Middelkoop M, Rubinstein S, Kuijpers T, et al. A systematic review on the
effectiveness of physical and rehabilitation interventions for chronic non-specific
low back pain. European Spine Journal. 2011;20(1):19–39.
Choi BK, Verbeek JH, Tam WW-S, Jiang JY. Exercises for prevention of recurrences
of low-back pain. In: The Cochrane Collaboration, Choi BK, eds. Cochrane
Database of Systematic Reviews.
POSSIBLE EXPLANATIONS?
“THE PROBLEM WITH THE EVIDENCE PYRAMID IS THAT IT'S SORTED BY RIGOR,
NOT BY RELEVANCE."
-PHIL SIZER PT, PHD, FAAOMPT
POSSIBLE EXPLANATIONS
If you let systematic reviews dictate your practice this is what
you'll do for low back pain: "stay active, it's not serious, no you
don't need MRI, get regular exercise, avoid surgery, have a
nice day. NEXT!“
-Jason Silvernail, DPT, DSc, FAAOMPT
CURRENT CLINICAL GUIDELINES
• EXERCISE RECOMMENDED FOLLOWING SELF-CARE
• ALSO RECOMMENDED
• YOGA
• COGNITIVE-BEHAVIORAL THERAPY
• SPINAL MANIPULATION
Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint
clinical practice guideline from the American College of Physicians and the American
Pain Society. Ann Intern Med. 2007;147:478–491.
IASP GUIDELINES
• EXERCISE IS BENEFICIAL FOR MAJORITY OF MSK CONDITIONS
• NO OPTIMAL TYPE OR DOSE OF ACTIVITY IS ESTABLISHED
IASP Global Year Against Musculoskeletal Pain http://www.iasp-pain.org
IASP GUIDELINES
• LOWER INTENSITY PROGRAMS RECOMMENDED BASED ON TOLERANCE
• HIGHER INTENSITY MAY BE INDICATED AS TOLERANCE IMPROVES
• ACUTE TOLERANCE MAY NOT PREDICT LONG-TERM RESPONSE
IASP Global Year Against Musculoskeletal Pain http://www.iasp-pain.org
IASP GUIDELINES
• SUPERVISED PROGRAMS PREFERABLE
• COMPLIANCE IMPROVED BY COMBINING
• EXERCISE
• MOTIVATIONAL PROGRAMS
IASP Global Year Against Musculoskeletal Pain http://www.iasp-pain.org
POSSIBLE TAKE HOME
• EXERCISE A BENEFICIAL COMPONENT OF MUSCULOSKELETAL
MANAGEMENT
• EDUCATION
• MANUAL CARE
• NO MAGIC BULLET “SYSTEMS” OR “EXERCISES”
IN SHORT…
• MOVEMENT CERTAINLY HELPS
• SPECIFICS ARE VERY FUZZY
• USE CLINICAL JUDGMENT
• BIOMECHANICS+
• NEUROSCIENCE+
GREAT…SO NOW WHAT?
• MOVEMENT-BASED PROGRAMS THAT
• OPTIMIZE STRESSES ON RECOVERING TISSUE
• MINIMIZE NOCICEPTIVE DRIVE
• FACILITATE CENTRAL INHIBITION OF PAIN
• LOT’S OF WAYS TO ACCOMPLISH THIS!
OUR APPROACH
• GRADED ACTIVITY / EXPOSURE
• AEROBIC EXERCISE
• AWARENESS THROUGH MOVEMENT (ATM) LESSONS
• RESISTANCE EXERCISE
GRADED ACTIVITY
• IDENTIFY DIRECTIONAL PREFERENCES
• MINIMIZES NOCICEPTIVE DRIVE
• STRONG EMPHASIS ON LOW-THRESHOLD INPUTS
• BENEFICIAL FOR PATIENT AND THERAPIST
• DIAGNOSTIC
• THERAPEUTIC
• HIGHLY BENEFICIAL FOR NOCICEPTIVE AND PERIPHERAL NEUROGENIC PAIN STATES
EXAMPLE
• LUMBAR AND CERVICAL ROTATION
• PASSIVE AND AA SHOULDER ELEVATION
• ACTIVE NEURODYNAMIC “SLIDERS”
EMPHASIS
• PAIN-FREE MOTION
• WORKING ALONG THE “EDGES”
• DISCOURAGE UNHELPFUL BELIEFS
• “NO PAIN. NO GAIN”
• “AVOID PAIN AT ALL COSTS”
BENEFITS
• PATIENT ABLE TO EVALUATE THEIR OWN PROGRESSION
• THERAPIST CAN GUIDE THE PATIENT WITH
• EDUCATION
• REASSURANCE
• GOAL SETTING
GRADED PROGRESSION
WHAT IF “EVERYTHING” HURTS?
• NOT UNCOMMON IN PATIENTS WITH CENTRAL SENSITIZATION
• CLINICAL EXAMS MAY NOT EFFECTIVELY GUIDE INTERVENTION
• BUT WE STILL DO THEM!
• CONSIDER ACTIVITIES THAT WILL ENHANCE CENTRAL INHIBITION
WHAT IF EVERYTHING HURTS?
• CONSIDER GRADED MOTOR IMAGERY
• EVIDENCE IS ENCOURAGING BUT STILL DEVELOPING
Moseley GL, Zalucki N, Birklein F, et al. Thinking about movement hurts: the effect of
motor imagery on pain and swelling in people with chronic arm pain. Arthritis
Rheum. 2008;59(5):623–631.
Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled
trial. Neurology. 2006;67(12):2129–2134.
MOTOR IMAGERY
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
MOTOR IMAGERY
NeuroOrthopedic Institute: www.noigroup.com
MENTAL VS PHYSICAL PRACTICE
Lederman E. Neuromuscular Rehabilitation in Manual and Physical Therapies:
Principles to Practice, 1e. 1 Har/DVD. Churchill Livingstone; 2010.
VIRTUAL MOVEMENT
• IMAGINING MOVEMENTS
• ALTER CONTEXT
• PLAY WITH BALANCE
• CHANGE VISUAL OR AUDITORY INPUTS
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
VIRTUAL MOVEMENT
• CHANGE THE MOVEMENT ENVIRONMENT
• MOVE UNDER DIFFERENT EMOTIONAL STATES
• EXERCISE WHILE DISTRACTED
• PLAN CHALLENGING ACTIVITY
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
PACING AND GRADED EXPOSURE
Lederman, E. Neuromuscular Rehabilitation in Manual and Physical Therapies:
Principles to Practice, 1e. 1 Har/DVD. Churchill Livingstone; 2010.
PACING AND GRADED EXPOSURE
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
Butler D, Moseley P and DL. Explain Pain. 1st ed. Orthopedic Physical Therapy
Products; 2003.
IS THIS REALLY ANY DIFFERENT?
TRADITIONAL APPROACH
• STRENGTHEN WEAK MUSCLES
• STRETCH TIGHT MUSCLES
• TRAIN “THE CORE”
• DISCOURAGE HARMFUL MOVEMENT
IS THIS REALLY ANY DIFFERENT?
CONTEMPORARY APPROACH
• EMPHASIS ON MOVEMENT – NOT MUSCLE
• MOTOR CONTROL VERSUS “CORE TRAINING”
• POSTURE IS CONTEXT DEPENDENT
• ENCOURAGE GRADED EXPOSURE TO MOVEMENT
GET SYMPATHETIC
• MORE SPECIFICALLY – PARASYMPATHETIC
• STRONG SYMPATHETIC DRIVE LINKED TO HIGHER PAIN LEVELS
• MOVEMENT AND MANUAL CARE INFLUENCES IT!
Kregel KC, Seals DR, Callister R. Sympathetic Nervous System Activity During Skin
Cooling in Humans: Relationship to Stimulus Intensity and Pain Sensation. J Physiol.
1992;454(1):359–371.
Perry J, Green A, Singh S, Watson P. A preliminary investigation into the magnitude
of effect of lumbar extension exercises and a segmental rotatory manipulation on
sympathetic nervous system activity. Manual Therapy. 2011;16(2):190–195.
GETTING PARA-SYMPATHETIC
• EXPLICITLY ENCOURAGE REGULAR AEROBIC EXERCISE
• PROGRESSION TOWARD ACSM GUIDELINES
Glass JM, Lyden AK, Petzke F, et al. The effect of brief exercise cessation on pain,
fatigue, and mood symptom development in healthy, fit individuals. Journal of
Psychosomatic Research. 2004;57(4):391–398.
Koltyn K.F. Exercise-Induced Hypoalgesia and Intensity of Exercise. Sports Medicine.
2002;32(8):477–487.
Mueller PJ. Exercise training and sympathetic nervous system activity: evidence for
physical activity dependent neural plasticity. Clin. Exp. Pharmacol. Physiol.
2007;34(4):377–384.
ACSM GUIDELINES
• AT LEAST 150 MINUTE OF MODERATE INTENSITY EXERCISE EACH WEEK
• BETWEEN 3.0 AND 5.9 METS
• MORE VIGOROUS EXERCISE 20-60 MINUTES THREE TIMES A WEEK ALSO
ACCEPTABLE
• OVER 6 METS
Garber CE, Blissmer B, Deschenes MR, et al. Quantity and Quality of Exercise for
Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor
Fitness in Apparently Healthy Adults. Medicine & Science in Sports & Exercise.
2011;43(7):1334–1359.
OTHER WAYS
Satyapriya M, Nagendra HR, Nagarathna R, Padmalatha V. Effect of integrated
yoga on stress and heart rate variability in pregnant women. Int J Gynaecol Obstet.
2009;104(3):218–222.
Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration following
two yoga relaxation techniques. Appl Psychophysiol Biofeedback. 2000;25(4):221–
227.
Veerabhadrappa SG, Baljoshi VS, Khanapure S, et al. Effect of yogic bellows on
cardiovascular autonomic reactivity. J Cardiovasc Dis Res. 2011;2(4):223–227.
SUMMARY OF RECOMMENDATIONS
• GRADED PROGRESSION OF PHYSICAL ACTIVITY
• PACING AND GRADED EXPOSURE
• DAILY AEROBIC EXERCISE
REMEMBER
THANK YOU