Explaining Pain Science

What We Know and Who Can Help

Heather Robinson PT, DPT, LMT Tiffany Nguyen PT, DPT

Donna Bzdil OTR/L Ivan Sultan, PT

Organization Name: 2018 NW Opioid & Substance Use Summit
Course Title: Explaining Pain Science
Location: Seaside, OR
Date: 4/23/18-4/24/18

Disclosure:

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planning committee, applicable staff and faculty to disclose the existence of those commercial interests which produce, market, re-sell, or distribute health
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The members of the faculty and planning committee and applicable staff for this conference have indicated that they have no financial relationships to
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CME Credit:

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical
Education through the joint providership of the Oregon Medical Association and Columbia Pacific CCO. The Oregon Medical Association (OMA) is
accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Oregon Medical Association designates this live activity for a maximum of 8 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit
commensurate with the extent of their participation in the activity.
American Opioid Epidemic
- Chronic pain is an epidemic
- Pain prevalence 25.3 million adults (Nahin, 2015)

- Opioids are prescribed for pain

- Median time from 1st opioid prescription to death Capitalism at Its Worst: The Opioid Crisis, Newco Shift, 16 Oct. 2017,
=
shift.newco.co/capitalism-at-its-worst-the-opioid-crisis-443cb0da91f9.
2.6 yrs (Kaplovitch, 2015; Freiden, 2016)
- In 2016, more Americans died from opioid overdose (63,600) than homicide (17,250) and
motor vehicle accidents (37,461) (CDC, FBI, USDOT)

Do we have an alternative?
EDUCATION as a non-pharmacological treatment for chronic pain
What is Pain?
Pain is an “unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described
described in terms of such damage”
-www.iasp-pain.org

New Hope in the Fight against Pain. McGill Newsroom, 17 Feb. 2015,

Why do we need to know what pain is? www.mcgill.ca/newsroom/channels/news/new-hope-fight-against-pain-242448.

If you don’t know what you are treating, you don’t know how to treat it
(or you treat it incorrectly)
 Pain Questionnaire
What do you know about pain?

Which Minion Is Your Alter Ego?, Clevver, 1 July 2017, www.clevver.com/despicable-me-3-

minions-character-personality-match-quiz/.
Catley, MJ, O'Connell, NE, & Moseley, GL, How good is the Neurophysiology of Pain Questionnaire? A Rasch analysis of psychometric
properties. Journal of Pain, 2013; 14(8): 818-827

https://cdn.bodyinmind.org/wp-content/uploads/Revised-neurophysiology-of-Pain-Questionnaire-1.pdf
Old Models of Pain
● “Bottom up” approach

● Painful stimulus pain

● Amount of tissue damage intensity of pain

Illustration of the pain pathway in René Descartes'
Traite de l'homme (Treatise of Man) 1664.

● This model does not account for the effect of emotions and
cognitions on the pain experience (Butler, 2000)
Ok, then how do we explain these….
● Painless battle wounds
● Surfers felt a “bump” w/ loss of limb of
of limb from shark attack
(Butler, 2003; www.sharkattacksurvivors.com)

● Phantom limb pain

● Man with nail in his “foot”
(Fisher et al. Minerva. British Medical Journal. 1995)

Hard as Nails, Mind Hacks, 19 Jan. 2010, mindhacks.com/2010/01/19/hard-as-nails/.

Studies on Back pain and Imaging
Boden SD, et al. “Abnormal magnetic-resonance scans of the lumbar spine
in asymptomatic subjects.” J Bone Joint Surg Am. 1990;72a(3):403-408.

● Ages <60 20% had disc herniations, 1 had spinal stenosis

● Ages >60 36% had disc herniations, 21% had spinal stenosis
● Disc bulges and degeneration in 35% aged 20-39, in all but one of the 60-80
of the 60-80 yr olds

Powell, M. et al. “Prevalence Of Lumbar Disc Degeneration Observed By

Magnetic Resonance In Symptomless Women.” The Lancet. 1986. 328(8520),
Bulging Disc, PhysioWorks, 18 Jan. 2018,
328(8520), 1366-1367. doi:10.1016/s0140-6736(86)92008-8 physioworks.com.au/injuries-conditions-1/bulging_disc

● 1 or more degenerative discs in 34% of women age 21-30, 60% age 31-40, 95% by age 70
Modern Pain Biology
● Pain is normal
● Pain as a protective
mechanism

● Pain Output
● Hurt Harm

● Nociception is neither sufficient

sufficient nor necessary for pain Artemis, Angela. “Photo of Brain in Hands.” Powered by Intuition, 26 Feb. 2012, www.poweredbyintuition.com/wp-
content/uploads/2010/03/Photo-of-Brain-in-Hands.jpg.
(Butler, 2003)

Pain is 100% of the time in the brain!

The Development of Chronic Pain

***

Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl), S2–15.

● Sensitivity of nociceptors in an area can change as often as every few days

(Butler, 2003; Moseley, 2017)
Central Nervous System Sensitization
● Lowering of the resting potential of
primary nociceptors

● Increase in efficiency of ion channels

in spinal nociceptors

● Increase in density of ion channels

in spinal nociceptors
The Spine, the Brain, & the Central Nervous System, 22 Apr. 2014,
https://sinicropispine.com/spine-brain-central-nervous-system/.
(Moseley, 2017)
Cortical Sensitization
● Repeated activation of a neurotag -
increases synaptic efficacy (Woolf, 2011)

● Cells that fire together, wire together

(Löwel, 1992)

● Activation of a “pain” neurotag can occur occur

through synaptic connections from other from other
neurotags in the brain.

● Emotions, thoughts, beliefs Pain

(Moseley, 2017)
Butler, David S., and G. Lorimer Moseley. Explain Pain. Noigroup, 2003.
Cortical Sensitization

● Fears and beliefs may provide central input

strong enough to activate a “Back Pain”
neurotag (Moseley, 2017)

● Reversible

● Education on what modulates pain

Neuroplasticity

ANATOMY & PHYSIOLOGY, CONNEXIONS WEBSITE. HTTP://CNX.ORG/CONTENT/COL11496/1.6/ Tolpa, Tami. “The Scientist.” The Scientist, LabX Media Group, 1 May 2017, www.the-
scientist.com/?articles.view/articleNo/49280/title/Infographic--The-Rubber-Hand-Illusion/

● Decreased blood flow and increase histamine reactivity has been shown in the real arm during rubber
hand illusion experiments suggesting that cortical representation of the fake hand replaced that of the
real hand to some degree (Moseley, 2008; Barnsley, 2012)
 Pain Relies on Context
● Descending pathways can be
excitatory or inhibitory
(Moseley, 2012)

JHG

Boston Bodyworker, 4 May 2013, bostonbodyworker.com/2015/05/know-pain-no-pain/.

Health Line, 28 June 2017, www.healthline.com/health/wasp-sting .
Biopsychosocial Model

Gliedt, Jordan A., et al. “An Illustration of the Biopsychosocial Model Comprised of Biological, Psychological, and Sociological Influences .” The Biopsychosocial Model Andchiropractic: a Commentary Withrecommendations for the
Chiropracticprofession, Chiropractic and Manual Therapies, 7 June 2017, www.researchgate.net/publication/317415046_The_biopsychosocial_model_and_ch iropractic_A_commentary_with_recommendations_for_the_chiropractic_profession.
https://cdn.bodyinmind.org/wp-content/uploads/Revised-neurophysiology-of-Pain-Questionnaire-1.pdf
What is Physical Therapy
“Physical therapists teach patients how to
prevent or manage their condition so that
they will achieve long-term health benefits.
PTs examine each individual and develop
a plan, using treatment techniques to promote “Aspen Orthopedics.” Aspen Orthopedics, www.aspenors.com/physical-therapy/.

the ability to move, reduce pain, restore function, and prevent disability.” -APTA

-Reducing pain is a significant reason why people seek physical therapists

-Pt with chronic pain: primary goal is to improve their function vs. just decreasing
pain, as it is difficult to objectively see improvement with subjective reporting.
Conventional Physical Therapy Treatment
For patients who don’t fall in the category of having chronic pain the following
treatment options can be effective:

-Manual Therapy to improve soft tissue mobility, joint mobility and range of motion
(soft tissue mobilization, joint mobilization, myofascial release)

-Therapeutic Exercise to improve muscular flexibility and strength which can

address the muscular dysfunction contributing to the pain

-Modalities (Ultrasound, Electrical stimulation, iontophoresis etc.)

-Education: postural education, ergonomics, lifting mechanics etc.

Pain Science Education
-Use of pain science education, in adjunct to conventional physical therapy is
effective in improving function.

-Studies show that patients

who have better understanding
of pain science have decreased
pain experiences (Moseley GL 2002,
Ryan et al. 2010, Nijs J,
Van/ Oosterwijck J 2011,
Louw et al. 2011)

http://exercise.trekeducation.org/pain-science/
Implementation of Pain Science
-Build rapport with patients to get an idea of their belief system and knowledge of
pain, as that plays a role in their overall pain experience.

-Can give them questionnaires to fill out during the first session with the patient.

1) Physical Readiness Activity Questionnaire (PAR-Q) (Daly 2006)

2) Fear Avoidance Behavior Questionnaire (FABQ) (Waddell 1993)
3) Pain Science Knowledge Questionnaire (O’Connelly 2013).

-Identify patients with acute pain vs. chronic pain > 3 months (Rolf-Detlef T 2015),
as that will impact when and how you want to implement pain science education.
Implementation of Pain Science
-Validate their pain experience and build good rapport with the patient to gain the trust.

-Explained to patient when there is damage to tissues: e.g. tear in ligaments/muscles, fracture in bones,
or nerve damage will heal within 1-3 for bones and 3-6 months for soft tissue (Ruedi TP, 2007, Walter J
1987).

-Distinguishing nociception vs. pain. Reinforced that pain doesn’t always equal tissue damage (Nijs J/Van
Wilgen PC 2011; National 2009)

-Citing neuroscience research to patients to explain “Smudging effect” and “Central (or Peripheral)
Sensitization of Pain” (Moseley GL and Flor 2012; Tsao et al. 2011; Barnsley et al. 2012, National
Research 2009).
Implementation of Pain Science
-Give cited examples or stories that tissue damage isn’t a 1:1 correlation w/ pain
experience) (e.g. construction worker w/ nail in boot, phantom limb pain).

-Give patients metaphors and stories that relate to the individuals to explain
central and peripheral sensitization (e.g. wasp story) (Moseley 2012).

-Inform the patient that he/she has a sensitive nervous system, and that it is much
more excitable compared to others.
Pacing
-Implementation of pacing with activities/exercises
can be helpful for patients with chronic pain. Inactivity
contributes to the decline in function whereas
overactivity can flare-up symptoms, setting the
patient back (Andrews NE 2012, Andrews NE
2015).

“Raja Thatha's Blog.” Raja Thatha's Blog, 22 Oct. 2016, rajathathablog.blogspot.com/2016/10/the-rabbit-tortoise-running-race-story.html.

-Inform the patient that movement helps nourish the nervous system w/ increased blood flow and O2 to
the nervous system. This can make it less sensitive. (Butler 2000, Rozamaryn, Dovelle et al. 1998;
Coppieters and Butler 2007).
Pacing
-Have patient physically record a baseline of activities/exercises that are tolerable,
that don’t exacerbate their symptoms on a daily basis. Instruct the patient to pick
activities/exercises that the patient feels most comfortable to do first vs. an activity
that triggers great anxiety.

-Instruct the patient to slowly increase the intensity of the activities/exercises. E.g.
If it exasperates the symptoms to walk 1 block, cut it to ¼ block. Increase
intensity by no more than ~10% every week or 2 weeks. There is a trial an error
component.

-Inform Pt that there may be increased pain intensity with these

activities/exercises but that there is “NO DAMAGE” being imposed on the body.
No bone is being broken, no ligament or muscles are being torn.
Pacing
-The body is trying to acclimate to these activities/exercises, so the body may
send signals to the nervous system to “tense the muscles” as a protective
mechanism, resulting in the increased “pain experience.”

-Stay at a slow and steady pace. If the patient “works through the pain” at too
high of a pain level e.g. 10/10, the Pt would be flared up to do anything, resulting
in a setback in their functional mobility. Being in that high level of pain would
prevent proper muscular activation and strengthening needed for optimal motion
in the body.

-Can start w/ graded motor imagery if subtle movements are too aggravating. Can
use mirror to assist or watch videos of another person performing the task that
provokes anxiety/pain.
Interdisciplinary Approach
-Help find resources for financial resources, if
finances is a source of stress which can adversely
affect their pain experience.

-Refer to dietician and/or give patient

contacts/resources for food if there is scarcity
at home.

-Refer to social services if housing is a problem

or patient needs public assistance (welfare etc.). on:
“Glamrock Nails.” Glamrock Nails, www.glamrocknails.com/2017/03/02/teamwork/.

-Refer to mental health specialist but this can be a sensitive topic. Be sensitive to the patient.

-Refer to Occupational Therapy to help with energy conservation or management of their daily activities to
help minimize their pain experiences.
Further tools and education
-Can go over meditation with patient and relaxation techniques to help calm the
nervous system (use of music, dimmed lights and using calm voice to guide the
breathing/meditation).

-Can go over sleep hygiene at home. Having good

sleep helps decrease states of inflammation in the
body which can contribute to the pain experience.

-Nutrition. We can go over basic nutrition about

staying away from foods that cause inflammation.
“Bart MS Blog.” Bart MS Blog, 13 Aug. 2015, multiple-
Can refer to a dietician if they want a specific meal plan. sclerosis-research.blogspot.com/2015/08/yoga-is-form-of-
exercise-that-is-good.html.
Case example
-Pt is a 59 y/o female who chronic L upper trap/parascapular pain s/p mastectomy
after being diagnosed with breast cancer.

“Wilderman Physical Therapy.” Wilderman Physical Therapy, www.wildermanphysicaltherapy.com/.

OCCUPATIONAL THERAPY

Winder, Chuck. The Heavy Workshop. www.ourmansfieldandarea.org.uk/page_id__176.aspx.

 Occupational Therapy
● Occupation is central to human behavior. There is an intrinsic relationship
between occupations, health and wellbeing (Activities that “occupy” our lives).
● Gary Kielhofner (The Model of Human Occupation)
● Roles you have in your life: Husband, Mother, Sibling, Grandparent, Worker,
Professional, Leader, Coach, Daughter, Artist, Part of a Congregation, etc.

● Those Roles Make us who we are, all the tasks we do promote, improve,
strengthen our life and bring quality.

● When our purpose and ability to have meaningful lives are interrupted it
affects the core of who we are
OCCUPATIONAL THERAPY: CAN MAKE A DIFFERENCE FOR THOSE
IN PERSISTENT PAIN
Pain breaks those down. OT looks at those roles and how Pain interferes with a
quality life mind and body.

THE PAIN RESULTS: ANXIETY ANGER FRUSTRATION

DEPRESSION HOPELESS POOR MOTIVATION CONFUSION
TIRED
Jerry: k

● Years in a hard labor job

● Care Taker (wife/grandkids)
● Strong Figure as father/husband/brother
● Severe shoulder injury
● Pain for 2 years; off work
● Stopped activities of interest
● Depression
● Felt useless
● OT for FCE/Work Hardening
Kathy: Arthritis

● Married and Adult Children/Grandmother

● Ran her own business
● Loved to garden
● Hip and back pain for over 3 years.
● Standing only 1-2 minutes
● Stopped all activities she enjoyed
● Depression; hopelessness
● Unable to pick up or care for grandkids
 Treatment and Tools To Return To Activities
● Activity training
● Education: regarding their injury or issues as well as understanding the
pain;Communication Skills (regarding pain)-tracking forms
● Neuromuscular Retraining: relearning how to move your body, learning how
of relax muscles, use appropriate muscles, biofeedback, etc.
● Coping Skills:Breathing Techniques; stress management/spiritual practices
● Joint protection/Energy Conservation: to make it a good experience and
wanting to get back involved in their activities
● Nutrition and Sleep Hygiene: being in the right mind to handle the pain
● Sensory Processing Programs: Listening Programs, desensitization programs
● Modifications/Adaptive Equipment
● Endurance Training/Strengthening: years of not engaging in activities of
interest
 Jerry
● Jerry return to work (full time after 2+ years: pain and limitations)
● He started to travel again
● Felt strong at home
● Understood movement and body mechanics; helpful in management of pain
● Lost weight/sleeping better
● Able to help his family with home tasks
Kathy
● She had little to no pain 3 weeks with her basic self care and home tasks
● She started to go out to lunch with her husband because she could tolerate
being in the community for a longer period of time
● She instituted the journaling and pacing strategies initially and found success
● She was back working with her husband both on the home and in their
business
● She was enjoying her grandkids
Occupational Therapy:Summary
Using language that gives them hope

It is providing opportunity: AE, MODIFICATIONS

Giving Possibilities: ACTIVITY ANALYSIS

Empowering our Patients: EDUCATION

A collaborative multidisciplinary approach to help

our patients

Pain does not have to rule the patient’s life

IVAN - Personal Experience
Pain without evidence of injury

Onset - 3 days post MVA

Immediately relieved by review of

imagery
Words that Harm, Words that Heal
Language is not neutral

How a caregiver delivers education impacts the recovery process

Sometimes words are used to instill a sense of urgency

Language that heals simply explains what is happening

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Questions

“Centers for Disease Control and Prevention.” Centers for Disease Control and Prevention, US Department of
Health & Human Services, 6 Mar. 2018, www.cdc.gov/epilepsy/about/faq.htm