hand fun assessing cortical changes

Assessing cortical changes in patients with pain

Pain

Pain is the cortical output of highest priority.

1- Pain is an output of the brain that is produced whenever the brain concludes that body tissues is in danger and action is required.

2- Pain is a multisystem output that is produced when an individual-specific cortical pain neuromatrix is activated.

Pain the defender, not the ofender

Moseley, 2003

Moseley, 2003

Sicuteri, 1992

Pain

1. Pain does not provide a measure of the state of the tissues

2. Pain is modulated by many factors: somatic, psychological and social

3. Relationship between pain and the state of the tissues is less predictable as pain persist

4. Conscious correlate of the implicit perception that tissue is in danger. Moseley, 2007

Nervous System

- Predictor, creator of experiences (Bayes)- Dynamic, not static

Changes in the Nervous System

· Peripheral and central changes

· Sensitization: Nonassociative learning. Repeated or extended application of a stimulus leads to an increase response. LTP (memory mechanisms)

·Disinhibition (impresicion) - Increase in RF

· Adaptative or maladaptative

Flor, 2012

Ji, 2003

Woolf CJ, 2004

Assessment

Subjective examinationSensory examinationMotor examination

Autonomic examination

MAKE THE FEATURES FIT

“Without identification of the mechanisms, the optimum treatment strategy for the patient´s pain cannot be selected”

Woolf & Mannion, 1999,

Clinical Assessment

Sensory Examination

Skin sensation: Light touchSuperficial painHot and coldDeep sensation:PainPropioceptionVibration

Motor Examination

Observation: Muscle wastingStrength testsFunctional testsReflexes:Stretch reflexesSkin reflexesCNS reflexes

Autonomic Exam

Observation: SkinHorner´s syndrome

Butler 2000

Sensory Examination

• Light touch:• Light touch (Semmes-Weinstein filament) - Fibres Aβ - Aα• Superficial pain: Aδ - C• Hot and Cold: Aδ - C

• Profound sensation:• Pain• Propioception• Vibration

• Cortical changes: Movement dystonia• Graphoesthesia• Finger identification• Stereognosia• TPD

Peripheral/central sensitization

WAD patientsFibromyalgia

Banic B. et al. Pain 2004

Treatment

Subjective examination: yellow flags

Beliefs that pain equals injuryFear avoidance-behaviorChanges in social interaccion. Mood changesExpectations on passive treatments

Affective component:

Suffering, description as negation of

live...

Treatment: Explain pain:

biologic explanationGraded exposure (activation)

Treatment

Treatment

Treatment

Treatment

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Distraction

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Sensitization - Changes in RF

Cortical Reorganization in CRPS

Marinus 2011

Cortical Reorganization in Phantom Limb

Flor H 2002

Changes in TPD in CLBP patiens

Moseley 2008

Treatment sensitivity cortical changes

Moseley 2008

Treatment sensitivity cortical changes

Short Term Long Term

Moseley, 2009

Treatment sensitivity cortical changes

Moseley 2009

Changes in peripersonal space

• Peripersonal space in CRPS

• Peripersonal space in Knee Osteoarthrosis Pain

• Assessment: recognise, TOJ

Stanton, 2012

Moseley 2009

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Motor Control

Treatment motor cortical changes•Graded Motor Imagery

• Laterality• Imagery• Mirror Therapy

•Correction of somatosensation?

Treatment

Treatment

Graded Exposure

Motor:DistractionPacing

Somatosensory:GazeMirrorBrush

Motor:Confrontation

Somatosensory:Gaze

No mirrorBrush

Distraction

Atention needed!!!

Is it possible that the physical examination, with its exhaustive and often repetitive provocation of specific joints, with specific mobilisations, which require the patient to carefully attend to and discriminate the location, quality and intensity of the percept works via similar mechanisms to discrimination training?

Is it possible that learning precise and sometimes subtle motor skills, which require the patient to attend carefully to specific body parts and to discrimi- nate the contraction of one muscle from the contraction of its immediate neighbour, has a similar effect?

Moseley 2008

Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther.

Moseley GL. Reconceptualising Pain. Physical Therapy Reviews. 2007 Aug 25;3(12):169-78.

Flor H. New developments in the understanding and management of persistent pain. Current opinion in psychiatry. 2012 Jan 6.

Ji R-R, Kohno T, Moore KA, Woolf CJ. Central sensitization and LTP: do pain and memory share similar mechanisms? Trends Neurosci. 2003 Dec 1;26(12):696-705.

Woolf CJ. Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management. 2004 Mar 16:1-11.

Banic B, Petersen-Felix S, Andersen OK, Radanov BP, Villiger PM, Arendt-Nielsen L, et al. Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia. Pain. 2004 Jan 1;107(1-2):7-15.

Marinus J, Moseley GL, Birklein F, Baron R, Maihöfner C, Kingery WS, et al. Clinical features and pathophysiology of complex regional pain syndrome. Lancet Neurol. 2011 Jul 1;10(7):637-48.

Moseley GL. I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008 Nov 15;140(1):239-43.

Moseley GL, Wiech K. The effect of tactile discrimination training is enhanced when patients watch the reflected image of their unaffected limb during training. Pain. 2009 Aug 1;144(3):314-9.

Moseley GL, Zalucki NM, Wiech K. Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain. Pain. 2008 Jul 31;137(3):600-8.

Maihöfner C, Handwerker HO, Neundörfer B, Birklein F. Patterns of cortical reorganization in complex regional pain syndrome. Neurology. 2003 Dec 23;61(12):1707-15.

Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol. 2002 Jul 1;1(3):182-9

Koelbaek Johansen M, Graven-Nielsen T, Schou Olesen A, Arendt-Nielsen L. Generalised muscular hyperalgesia in chronic whiplash syndrome. Pain. 1999 Nov 1;83(2):229-34.

Moseley GL, Gallace A, Spence C. Space-based, but not arm-based, shift in tactile processing in complex regional pain syndrome and its relationship to cooling of the affected limb. Brain. 2009 Nov 1;132(Pt 11):3142-51.

Stanton TR, Lin C-WC, Smeets RJEM, Taylor D, Law R, Lorimer Moseley G. Spatially defined disruption of motor imagery performance in people with osteoarthritis. Rheumatology (Oxford). 2012 Aug 1;51(8):1455-64

Moseley GL. Pain, brain imaging and physiotherapy--opportunity is knocking. Man Ther. 2008 Dec 1;13(6):475-7