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 avoidanceMotion 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 painStarT Generic Screening Tool

• Assessing sensory cortical reorganization:– Two point discrimination testing

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

Assessing central involvement: cortical

reorganization: SmudgingAltered Two Point

Discrimination Associated with Distorted Body Image

in Back Pain

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.