Dor: avaliacao e intervencao

em osteopatia
Parte 3:
Dor: diagnostico e
intervencao osteopatica
Jorge Esteves Maio 2010

Tissues – Nociception – Brain - Pain
Tissue Damage

Venule

Pain

A-afferent
Catecholamines
1º Afferent
Barrage

ANS

Bradyikinin

Ef
fe
re
nt
ac
tio
n

Prostaglandins

B-afferent
Substance P
Inflammatory
Cascade

Segmental fortification

The homeostatic ‘pain’ system
Pain
Brain
Brain
Output

Descending
‘Pain’ Pathways

Input from the
External Environment

Input from the
Internal Environment

Ascending
‘Pain’ Pathways

The Body Tissues

The Nociceptive
System

The analysis of threat

?

Multi-system
brain output

Neo-cortex neuro-chemical
behavioural platform:
context cohesion control

Pain
Used as a reference
for the ‘referred pain’
Analysis
of ‘threat’

Alo-cortex platform:
emotion / memory
The brain platform for
base survival drives
Descending
‘pain’
pathways

Somatosensory cortex

Ascending ‘pain’ pathways
A tissue insult (though not necessary)

Neural Assemblies for the Conscious
Cortical Awareness of Pain
The “throw a pebble into
a pond”, ripple analogy




Input that is nociceptive or warning
can be seen as being analogous to a
pebble.
Neural assemblies take and last for
milliseconds and can be seen as
being analogous to a ripple.
A standing ripple can be formed
(user dependant plasticity).
The ripple spread is dependant on
the fluid (neuro-amine activity).
Competing ripples can disrupt its
size and shape (inhibitory inputs).
The level of conscious awareness
for a pain is related to the neural
assembly size.

Neuronal Assemblies for the Neural Correlate of Consciousness (for pain).
Neuronal
assembly size

Availability of
other modulators

Extent of usual
neuronal association

Circulating peptides

Action on
rest of body

Conscious
awareness of pain
Degree of ‘nociceptive’ and
other sensory stimulation

Formation of a
competing assembly

Availability of neuro-amines
facilitating enlarged field of
association

Adapted from: Susan Greenfield (Oxford University) theory of consciousness.

Case scenario 1

Mary was returning alone from the school run and stopped
her car at traffic lights only to be hit in the rear by a lorry,
fiercely breaking in the heavy rain.

She describes the sounds of screeching and breaking glass,
then silence with an overpowering smell of rubber, petrol and
spilt fresh coffee, the darkness as a cloud of dust engulfed
her only penetrated by a single headlight and the
claustrophobic feeling of being trapped by curiously warm air
bags in the gloom.

Mary was taken by ambulance to hospital for neck x-rays and
assessment, she was soon discharged with ‘neck sprain’ and
a supply of pain medication. The family car un-repairable,
taxi home to try and arrange for friends to collect the children
from their different schools and her husband from the station.

Case scenario 1

The accident was six months ago.

Mary still has neck and sternum pain, she has
developed headaches and nausea, and finds it
difficult to sleep and concentrate on things.

She reports that her neck and chest feel tight every
time she passes the same accident site and tries to
avoid it, also whenever she smells rubber, petrol or
even coffee, and even if her face roles next to a
warm pillow or her son shines a torch at her.

“Mary and the lorry”







Mary hit in the rear by a lorry
Sounds of screeching and breaking
glass
Smell of rubber, petrol and spilt fresh
coffee
Darkness, dust, a single headlight
Feeling of being trapped.
Mary,hospital, x-rays, neck sprain’
This was six months ago.
She still has neck, sternum pain,
headaches, nausea, sleep &
concentration problems.
She reports that her neck and chest
feel tight every time she …

“Mary and the lorry” - WAD
Information regarding
physical surroundings, small,
sounds, somatic and visceral
pain and emotions relating to
a traumatic experience.

Hippocampus of Dominant
hemisphere (left) associates
and integrates as explicit
(declarative) - Verbally
Accessible Memory (VAM)memory that can be verbally
and logically recalled.

Amygdala of the nondominant hemisphere (right).
If extreme stress the same
chemicals bring negative
biological changes. Inhibiting
certain memory functions.
Traumatic memories stored that
lack a spatio-temporal
framework.
Inhibition
Promotion
If manageable stress it brings
positive biological changes.
Greater endurance, awareness,
strength, determination and
immunity. Traumatic memories
consolidated in the neocortex
and the limbic system as explicit
memory.

Stored as implicit (nondeclarative) memory Situationally Accessible
Memory (SAM) -cannot
be recalled in an
integrated meaningful
way.

Case scenario 2

Mike has worked for a high street bank for nearly twenty
years over which time his job has become less varied and
more stressful.

A year ago he consulted occupational health as he was
experiencing an increasing frequency of painful swelling and
stiffness in his right hand, wrist and forearm.

Mike was informed that he had developed repetitive strain
injury (RSI) affecting the tendons in his wrist.

Mike explains that the pain is often spontaneous for no
obvious reason, the wrist and hand feel stiff and
hypersensitive if they touch something, and is often aching,
burning, has a prickling sensation along with shock-like jerks
and feel weak. He drops things, so tends not to use it.

Case scenario 2

In spite of receiving various treatments, electrotherapy,
exercises, hydrocortisone injections and prolonged use of a
wrist splint, Mike is finding it increasingly difficult to stay at
work and fears for his job, as well as consuming a large
number of pain relieving tablets.

Mike, a strain in the brain?


Mike, high street bank worker. 1 yr
experiencing an increasing
frequency of painful swelling and
stiffness in his right hand, wrist
and forearm.
Informed that he had RSI affecting
arm tendons.
pain often spontaneous, they feel
stiff, hypersensitive, aching,
burning, prickling, shock-like jerks,
weak, drops things, not using it.
various treatments, increasingly
difficult work, job fears, many
tablets.

Mike, a strain in the brain? – RSI / FHD

Normal

RSI

Fuzzy Homunculus
Organises inappropriate sensory – motor response
Pain Perception
Repetitive Strain Injury / Focal Hand Dystonia

Case scenario 3

May had a teenage left knee injury and at 65 years
underwent a total replacement of her left knee.

Keen to start playing tennis again she had hydrotherapy
before leaving hospital that caused considerable pain, this
seemed to subside and May was sent home with an
exercise plan and analgesics.

Though she was meticulous in doing her exercises the knee
became more painful and stiffer.

Her doctor excluded infection and prescribed a combination
of analgesics and anti-inflammatory drugs (NSAIDs).

Case scenario 3

At her six-week review with the surgeon the server pain and
hypersensitivity was limiting her recovery, the left knee
looked swollen and generally warmer than the right.

As May appeared depressed she agreed with the surgeon to
also take antidepressants and use an ice cuff over the knee.

By eight weeks the left knee and whole leg were very
painful, constantly ached, felt weak along with touch and
movement related hyperalgesia / allodynia.

Her doctor offered her morphine patches to keep her going
until she consulted her surgeon for further advise.

May, post-op persistent pain.

May, 65, had a total left knee
replacement op, initial bad start,
knee became more painful and
stiffer, more analgesics & NSAIDs.

At 6 weeks post-op server pain,
hypersensitivity, limited recovery,
swollen, warmer, May depressed,
also on antidepressants & ice cuff.
By 8 weeks the left knee / leg very
painful, constantly ached, felt
weak, hyperalgesia / allodynia,
morphine patches to keep her
going.

May, post-op persistent pain.
Complex Regional Pain Syndromes (CRPS).
 They are conditions that typify the somatic and autonomic
efferent outputs from the neural pain assemblies in an
altered brain neuromatrix. Two subgroups are recognised.
 CRPS Type I (RSD). (Follows an initiating noxious event)
– Spontaneous pain and allodynia disproportionate to the
inciting event.
– Oedema, skin blood flow changes, sudomotor and motor
abnormalities.
– Distal predominance of temperature and abnormal sensory
findings.
 CRPS Type II (Causalgia). (Follows nerve injury. It is
similar in all other respects to type I).
 CRPS Type III, (Has been recognised and is a mixed RDS
and causalgia form)

Case scenario 4

Sarah suffered from acute onset of low back pain after a
lifting injury at work when she was 49.

She continued in the same job and over the next six months
had recurrent bouts of back pain along with some neck
ache.
By her fiftieth birthday she has to take days off work
because of back, neck or headaches and muscle pains.

Sarah is finding it difficult to keep her attention focused on
her work, finds her sleep pattern is disturbed, and is aware
that her co-workers are tending to isolate her and are
making comments about having to cover for her when she
has time off.

Case scenario 4

Just after her fiftieth birthday Sarah consults her doctor with
a greater than three month history of multiple areas of
asymmetrical muscle pain and stiffness in her limbs, neck
and back along with chronic headaches, a sleep disorder,
fatigue and poor attention, and the beginnings of a functional
bowel disturbance.

Her doctor carries out a series of tests (the results of which
are normal), prescribes antidepressants and suggests that
she consider early retirement.

Sarah, widespread pain after back strain.

At 49, work LB injury, over next 6
months recurrent LBP, some neck ache.
By 50th birthday, days off work, back,
neck, headaches, muscle pains,
attention difficulties, sleep pattern
disturbed. Co-workers, isolate her,
making comments about time off.
After 50th birthday consults doctor with a
greater than three month history of:
– multiple areas of asymmetrical muscle pain
and stiffness in her limbs, neck and back
– chronic headaches, a sleep disorder, fatigue
and poor attention, and the beginnings of a
functional bowel disturbance.

Doctor, all normal, antidepressants &
early retirement.

Sarah, widespread pain after back strain.

Fibromyalgia

Muscle tenderness, widespread muscle pain, allodynia,
axial pain – must be present.
Also two of: HA, IBS, Fatigue, Stiffness, Sleep & attention
disorders.

Case scenario 5

The story of Henry is given by his wife.

Henry has suffered a number of injuries and seen many
friends injured and die.

My husband has become withdrawn, restless, melancholic,
no eye contact, has very disturbed sleep with dark dreams,
tossing, talking and sweating in his sleep, he has lost his sex
drive, appetite for food and appears drawn and pale.
Based on “the ailments of Henry Hotspur”, as described by Shakespeare in: Henry
IV Part I: Act II; Scene 3. This is a classic description of Post Traumatic Stress
Disorder.

The ailments of Henry Hotspur.

The story of Henry is given
by his wife.
Henry has suffered a number
of injuries and seen many
friends injured and die.
My husband has become
withdrawn, restless,
melancholic, no eye contact,
has very disturbed sleep with
dark dreams, tossing, talking
and sweating in his sleep, he
has lost his sex drive,
appetite for food and
appears drawn and pale.

Review of Painful Conditions.
Context, Cohesion, Control
Plasticity of the neuro-matrix
Somato sensory Cortex

CRPS
Chronic LBP
RSI and FHD
Chronic neck pain
Sensory
&
Nerve injury pain
Frozen shoulder
Phantom pain Sympathetically
maintained
Chronic
pain
Chronic HA
Widespread Pain
WAD
Fibromyalgia
PTSD
IBS
Retained SAM
Allostatic and Emotional Load

Part 2:
Using our understanding of pain to
inform our osteopathic models of patient
management

The problem with Descartes

D

C
A



B

Dualistic mind body divide.
One-to-one relationship.
Gate Control Theory.
Neuromatrix Theory.
Biological issues.
Psychological issues.
Social issues.
Work issues.

Pain Mechanisms to Models of Illness
Social

Culture
Social interactions
The sick role

Psycho-

Illness behaviour
Beliefs, coping strategies
Emotion, distress

Glasgow Illness Model
 Nociception.
 Pain.
 Suffering.
 Pain behaviour.

Pain.
Disability.

Bio-

Neurophysiology
Physiologic dysfunction
Tissue damage?





Impairments
Body structure & functions
Activity (limitations)
Personal factors
Participation (restrictions)
WHO / ICF classifications

Models of Pain and Disability
Black Flags

Blue
Flags


Orange
Flags

Yellow
Flags

Red
Flags

Pain.
Disability.
Risk factors for poor
outcome &
obstacles to recovery.
Risk of acute
becoming a chronic
pain syndrome.
The Flag Initiative.
Osteopathic relevance.

The Neuro-matrix available for intervention
Build up of pro-inflammatory chemicals in
the tissues, the result of tissue damage
Peripheral or a neurogenic effect.
Tissues
Active immune response chemical
accumulation in tissues.
Local build up of metabolic waste products
In tissues.
Inappropriate mechanical response from
the sliding interfaces between tissues or
within a tissue.
Direct irritation of a nerve (nociceptive)
fibre resulting in ectopic depolarisation.

The Neuro-matrix available for intervention
Spinal
Cord
Segment

B-afferent nerve fibre nociceptive input.
Reduced anti-nociceptive inhibition,
aberrant activity in the inter neurone
pool summates to be a nociceptive
output. (Loss of sensory discreetness –
the ‘fuzzy segment’.)
Physiological or pathological lowering
of depolarisation potentials. (From
Down-stream modulation or unmasking
Of prior nociceptive event.)

The Neuro-matrix available for intervention
Brain Stem
& Reptilian
Brain
Platform

Altered biological patterns: altered,sleep
pattern, breathing patterns, hormonal
releases.
Heightened state of arousal & stress.
Diminished pleasure from altruistic acts,
feeding, etc.
Depression and other psycho-emotional
States.

Limbic
System and
Alo-cortex
Anxiety states and undue fear responses.
Brain
Inappropriate retained memory of traumatic
Platform
life events.

The Neuro-matrix available for intervention

Neo-cortex
Brain
Platform

Belief constructs such as ‘hurt means
harm’, etc. Lack of context for pain
experience and its explanation,
diminished sense of cohesion and
control, etc.
Reduced inhibition

Towards Osteopathic Treatment Intent
Peripheral
Factor
Inflammation and
inappropriate chemical
build-up in tissues.

Treatment Intent
Fluid movement to potentate rapid &
resolving of the inflammatory
cascade, promote scaring & healing.

Inappropriate or
unanticipated
mechanical response
of tissues.
Ectopic depolarisation
of nociceptive axons.

Restore mechanical relationships
between tissues; focus on ‘gliding
interfaces’ in myo-fascial, articular
and neural structures.
Removal of mechanical or chemical
irritation of nerve fibre, consideration
of traction induced radial compression

Towards Osteopathic Treatment Intent
Segmental
Factor
B-afferent input into
the spinal segment

B-afferent input into
the spinal segment

Treatment Intent
Enlarge the non-nociceptive Aafferent input that is a powerful
inhibitor of B-afferent transmission.
Pressure, muscle and joint tension
and movement stimuli.
Providing varied multi-modal
movement & tension characteristics
from a wide region of the body
imputing into that region of cord and
its connections. Possibly passive at
first, reinforced actively, then as part
of a purposeful activity.

Towards Osteopathic Treatment Intent
Cortex

Factor
The ‘fuzzy
homunculus’.

Treatment Intent
Encourage discriminative sensory
information and sense of body –
refresh the sensory homunculus.

Summary of Osteopathic Management Approach
Immediate or Short-term action:
•Assess for Red and Black Flags, and Biological Issues.
•Recognise what are pain issues and what are disability issues.
•Further Action/referral/no treatment & Prevention of further injury.
•An explanation that is context based, including your evaluation,
any differential diagnosis and reassurance.
•Initial relief of symptoms and Ensure adequate pain control and
;first-aid’ advice in case they get a reoccurrence.
•Encourage staying active and maintain a sense of
family/social/work cohesion.
•A clear and concise management strategy, when to review and
who to (how to) inform if worse of new symptoms develop and
Ensure that expectations are similar.

Summary of Osteopathic Management Approach
Medium term intervention:
• Supporting the restoration of local tissue health
• Consider informally (formally after six weeks) Yellow,k
Orange, Blue Flags.
• Addressing the diverse Biopsychosocial (BPS)
summative distant factors, or blocks to recovery.
• Refinement of your evaluation.
• Developing with the patient interventions that will support
change.
• Negotiating with the patient your plan, revisiting
expectations and when to review.
• Restoration of ‘capacity’.

Summary of Osteopathic Management Approach
Longer term aims:
• Discussion of any appropriate life-style issues.
• Education and advise. (refer to guidelines for education
and discussion issues such as prevention of low back pain,
etc.).
• Consider if there is a need multi-professional support.
• Consideration with patient of longer-term expectations or
coping with the end disability.
• Restoration of ‘agency’.

Review of our model

Neo-cortex neuro-chemical Behavioural
Input from
Platform
the
Brain
Context Cohesion External
Control Environment

Conscious
Pain

Pain
Pain
Pain

Alo-cortex Emotion / Memory Platform

Analysis
Brain
of ‘Threat’
Output

TheInput
brainfrom
Survival
the Platform
Sleeping
InternalBreathing
Environment
Feeding Sex

Multi-system
Brain Output

Descending Pathways
Reticulo-spinal
Descending
‘Cortico-spinal
Pain’ Pathways

Ascending Pathways
Ascending
Medial
Lateral
‘Pain’
Spino-reticular
PathwaysSpino-thalamic

The
Nociceptive
Spinal Cord ‘segment’ Dorsal Horn WDR-cells
System

B-afferent neurons in peripheral nerve & spinal nerve root
Neuro-secretions

Mechanical or Chemical stimulus

B-afferent fibre receptor field
The Body Tissues