Prevention of Chronic Pain: A Human Systems Approach

“Divine is the task to relieve pain.” -Hippocrates

Dr.  James  Fricton      Professor,  University  of  Minnesota  (umn.edu)    HealthPartners  Ins;tute  for  Educa;on  and  Research  (hpier.org)  Minnesota  Head  &  Neck  Pain  Clinic  (mhnpc.com)  President,  Interna;onal  Myopain  Society  (myopain.org)    

The Body The Risk and Protective Factors in the Musculoskeletal System

This  module  has  6  parts  

•  Musculoskeletal  Pain  Mechanisms  •  Repe;;ve  Strain  •  Postural  Strain    •  Exercise  for  Range  of  Mo;on,  Strength  and  Condi;oning      

•  Preven;ng  Injuries    •  Experien;al  Learning:  Do  the  exercises  

By  the  end  of  this  module…  

 you  will  be  able  to:  •  Ar;culate  some  of  the  mechanisms  of  musculoskeletal  pain  

•  Explain  how  posture  and  repe;;ve  strain  can  play  a  role  in  chronic  pain  

•  Review  how  exercise  can  build  strength,  condi;oning  and  range  of  mo;on  to  prevent  musculoskeletal  pain  

•  Review  how  injuries  can  play  a  role  in  chronic  pain  •  Perform  five  different  types  of  exercise  to  protect  you  from  chronic  pain.  

Musculoskeletal Pain Mechanisms

Module: The Body

So where is the pain coming from?

Musculoskeletal Afferent Sensory Nerves

Mense, 2004"

Type I muscle spindle (movement) •  Responds to muscle length and velocity when

muscle contracted (a if muscle, b if tendon) Type II stretch receptor (posture) •  Responds to position sense when muscle or

joint is at rest Type III Nociceptor (pain) •  Responds to strain/ injury with continuous

pain (dull ache) Type IV Nocicepter (tenderness) •  Responds to strain/ injury with tenderness

Mechanisms of Musculoskeletal Pain"

!!!

Sensitization: Increased synaptic efficiency due to repeated firing of synapse at the peripheral and central nervous system level"

Allodynia: An enhanced pain report from normal stimuli"

Primary hyperalgesia: Decreased threshold for pain in an injured tissue"

Secondary hyperalgesia: Decreased threshold for pain in the surrounding tissues"

""

Sensi;za;on  

Hyperalgesia        

Hyperalgesia is hypersensitivity to pain that occurs directly as a result sensitization due to damaged peripheral tissues or dysregulation of the central nervous system

Peripheral  Sensi;za;on  

•  Hypersensi;vity  of  nocicep;ve  primary  afferent  neurons  (pain  nerves)  in  the  ;ssues  

•  Mediators  include  bradykinin,  prostaglandins,  neuropep;des,  and  cytokines  

•  Upregulated  (promoted)  during  inflamma;on,  injury,  and  repe;;ve  strain    

Central  Sensi;za;on  

•  Hypersensi;vity  of  nocicep;ve  neurons  in  the  central  nervous  system  (spinal  cord  and  brain)  

•  Mediators  include  glutamate  through  N-­‐methyl-­‐d-­‐aspartate  (NMDA),  substance  P  and  calcitonin  gene-­‐related  pep;de  (CGRP)  

•  Upregulated  (promoted)  during  sustained  pain  and  threat  to  body  

Wind-Up An increase in pain over

time when a painful stimulus is delivered repeatedly above a critical rate.

Expanding Pain Pattern

As stimulation of the pain receptors from the strain continues, the tissues let you know it by expanding the pain pattern through convergence facilitation.

•  First, tenderness (X) •  Then, localized pain •  Finally, referred pain

Body  Realm    

Protective Factors Balanced posture Relaxation exercise Stretching exercise Strengthening exercise Conditioning exercise Genetics

Risk Factors Sustained or eccentric postures Repetitive strain Loss of flexibility and range of motion Weak muscles Poor conditioning Injuries Conditions such as obesity and hypo- or hyper-mobile joints

Repetitive Strain

Module: The Body

Repe;;ve  Strain  Injury  (RSI)  

An  injury  due  to  strain  of  the  muscles  and  joints  from:  •  repe;;ve  tasks  (e.g.  bracing  phone)  •  forceful  exer;ons  (e.g.  liUing)  •  Vibra;ons  (e.g.  equipment)  •  mechanical  compression  (e.g.  

shoulder  bag)  •  sustained  or  awkward  posi;ons  (e.g.  

computer  work)  •  and  many  other  types  of  sustained  

tension

http://www.safework.sa.gov.au

10%

38%

12%

28%

2%

7%

Occupational RSI

Also called repetitive stress injury, repetitive motion injuries, cumulative trauma disorder (CTD), occupational overuse injury, overuse syndrome, myofascial pain, and regional musculoskeletal disorder.

Jaw

Feet

Hands

First, understand the muscles

Red Type I fibers for posture

White type II fibers for strength

Type I and II fiber types are distributed throughout all skeletal muscles !

Muscle Fiber Type I (red, slow)!

l Postural muscle tone

l High endurance

l Slow twitch (red)

l High oxidative phosphorylation with high O2, ATP production, mitochondria, and increased vascularity

l Marathon runner

Muscle Fiber Type II (white, fast)!

l Large forces over brief period"

l Low endurance"l Fast twitch (white)"

l Anaerobic glycolysis with low O2, low mitochondria, high lactic acid"

l Sprinter "

Muscle fibers are like chameleons !

Type I (slow) ! Type II (fast)!

Increased demand from high forces for short periods

Increased demand from postural strain for longer periods

Who  wins?  

Type I Slow

posture

Type II Fast

strength

With repetitive strain, muscle fibers of type I compensates but often loses

-Larsson, et al, 1988, Bengsston, et al, 1986, Dennett, Fry, 1988""

l  Abnormal Metabolic Activity in Type I Fibers l  Low Oxygen and ATP (fuel depleted) l  Increased and ragged Type I Posture Fibers l  Decreased Type II strength fibers with atrophy l  Abnormal mitochondrial changes on EM on Type I"

Type I (slow) ! Type II (fast)!

Increased conversion due to repetitive postural strain

The  Slippery  Slope  of  Chronic  Pain  

Acute to Chronic Muscle Pain"Acute Muscle

Injury!Peripheral Factors (e.g.

(injury, posture, trauma, repetitive strain)!

Central Factors (e.g. inactivity, anxiety, depression, sleep)!

Convergence facilitation, broadening of pain and

more muscle strain!

High muscle tone and low removal of pain

alogens!

Sensitization of muscle

nociceptors!

Sensitization of central processing!

PNS !

CNS !

Sensitization, wind-up, expansion of receptor fields,

and hyperalgesia!

An injury starts the pain cycle…

Tensing due to pain, inactivity to

avoid pain

Muscle  pain  and  repe<<ve  strain    

Muscle strain and more pain

Poor posture, protect muscles,

weakness

Jaw pain and headache results from…

Daytime Clenching 72.2 42.1 Night Clenching 66.7 32.2 Biting tongue/cheek 61.0 23.7 Jaw sore in A.M. 59.3 42.3 Tongue thrust 52.8 41.2 Night Bruxism 50.0 25.1 Unilateral Chewing 50.0 42.0 Daytime Bruxism 47.2 27.3 Biting nails/objects 30.6 28.4 Chewing Gum 27.8 18.2 musical instruments/ scuba/ singing

Patients Gen. Pop.

Fricton, et al J Orofacial Pain. 1996

Neck pain results from…

Ariens GA et al Physical risk factors for neck pain. Scan J Work Environ Health.. (2000)

•  Awkward tense computer posture

•  Bend or twist neck repeatedly

•  Look up or down for hours

•  Tense neck and shoulders

•  Brace phone with shoulder

•  Forceful arm movements

•  Holding arm in tense posture

•  Long duration of sitting

•  Twisting or bending of the trunk,

•  hand-arm vibration

Back  pain  results  from…  

Björck-van Dijken C1 et al J Rehabil Med.(2008), Kelsey JL, Golden AL. Occup Med. 1988, Yilmaz E, Health Science Journal, (2012)

•  Rotation or bending of the trunk

•  Lifting repeatedly by bending at waist

•  Heavy physical workload

•  Lack of exercise

•  higher body mass index

•  Prolonged sitting or standing

•  Monotonous work

•  Frequent manual operations

•  whole body vibration

Occupa;onal    RSI  risk  factors  

•  Poorly designed workstation •  Cluttered workstation •  Cold setting •  Awkward posture to work •  Vibrating equipment •  No rest or stretch breaks •  Tripping on equipment and

cables

Douglas, AY et al American J of Preventive Medicine (2009)!

Short-term and… Long-term

Postural Strain

Module: The Body

Do we only have five senses?

Proprioception and pain is the sixth sense..

Gallace A et al The analgesic effect of crossing the arms. Pain. (2011)

…designed to protect us from repetitive strain

What  is  good  posture?  

Body  posi;ons  that  balance  the  musculoskeletal  system  against  gravity  to  reduce  sustained  muscle  tension  and  strain  

Good  posture  is…  

•  Efficient.    Lets  you  rest  pain  free  in  a  posi;on  with  a  minimum  of  muscle  strain  and  energy  expenditure.    

•  Effec<ve.  Facilitates  ongoing  ac;vi;es  in  si^ng,  standing,  walking,  running,  and  others  

•  Effortless.  Allows  a  quick  and  easy    transi;on  into  the  next  relevant  movement.  

And….  

•  It makes one attractive and attentive

•  It feels natural and relaxed •  It is not about holding your

body still and tense

•  It does not require any extra effort or constant attention.

…and, it’s not how it looks but how it feels that

counts

Good sitting body mechanics can prevent; •  back pain •  pelvic pain •  knee pain •  neck pain •  arm pain •  Headaches •  hand pain!

Si^ng  Posture  Head  up  and  back  Shoulders  down  and  back  

Sit  with  boFom  to  back  of  chair  

Jaw  posture  •  Tongue  up  •  Teeth  apart  •  Jaw  relaxed  •  Lips  open  or  closed  

The head is heavy…

…if  it’s  not  balanced  on  the  neck  chin  in,  shoulders  back,  and  chest  up  

12 lbs 30 lbs

12 lbs 32 lbs 42 lbs

Walking  Posture  

Sleeping  Posture  

Somewhere, something went terribly wrong

Exercise

Module: The Body

Exercise is the original protector

Five  types  of  exercise  

Musculoskeletal Goal Exercise Strategy Range of motion Stretching and yoga Strength Weights and resistance Endurance Conditioning and aerobic Balance Maintaining posture Reduce repetitive strain Relaxation

Range of motion: we all try to maintain it…

Yoga  is  dynamic  stretching  Significantly improved; •  pain •  quality of life •  disability •  stress •  depression •  medication usage in 8 of the 10 chronic back pain clinical trials

Diaz AM, et al. American Journal of Lifestyle Medicine April 16, 2013

Principles of Stretching

•  Do it slowly, gently and frequently (several times per day) •  Stretch to pain but not beyond. Feel each of muscle being

stretched. •  Push to full joint range of motion and hold it. Count to 20. •  Breath slowly and deeply as you stretch. •  Do not hurry or bounce with the stretch. Hold it steady

Strengthening: Use it or lose it

Strengthening  to    prevent  chronic  back  pain  

•  More effective than no exercise. •  Increasing intensity and motivation increases results. •  Strengthening equal to conditioning and stretching

exercises.

Systematic Reviews. Bell J, et al J. of Occupational Medicine (2010) and Slade SC et al J. Manipulative and Physiological Therapeutics (2006)

Condi;oning  for  chronic  pain  Significantly improved; •  Pain •  Function •  Quality of life •  Disability •  Psychosocial status 9  systema;c  reviews,  comprising  a  total  of  224  trials  and  24,059  pa;ents  with  fibromyalgia,  osteoarthri;s,  rheumatoid  arthri;s,  back,  neck  and  shoulder  pain  

Hagen et al BMC Medicine 2012

High Intensity Interval Training

Preventing Injury

Module: The Body

Abuse  it  and  lose  it  

Delayed-­‐onset  muscle  soreness  

•  Post-­‐exercise  muscle  pain  •  Normal  response  to  unusual  exer;on  

•  Adapta;on  process  that  leads  to  greater  stamina  and  strength  

•  Muscles  recover  and  build  strength  and  bulk  

Distinguishing muscle injury from post-exercise muscle soreness

Muscle  or  Joint  Injury   Delayed  Onset  Muscle  Soreness  

From  pulled,  torn,  strained  or  sprained  muscle  or  joint    

From  post-­‐exercise,  over-­‐exer;on,  and  over-­‐use  

Abrupt  onset   Gradual  pain  aUer  exercise  Sharp  localized  pain   Diffuse  soreness  over  most  of  

muscle  or  joint    Inability  to  con;nue  the  ac;vity  and  cannot  put  force  on  it  

Can  con;nue  if  choose  and  can  put  force  on  it  

Weakness,,  tenderness,  and   No  weakness,  no  swelling,  no  bruising,  can  con;nue  the  ac;vity  

swelling  and  bruising   No  surface  signs  of  injury  

Preventing Sports Injuries

•  Warm-up exercises cut knee injuries by 50% among female college soccer players

•  Dynamic warm-up exercises with  a  gentle  walk  or  jog   then static stretching to  increase  the  range  of  mo;on  of  various  joint  

www.aclprevent.com/pepprogram.html

Preventing injuries from becoming chronic

Not  R.I.C.E.    Rest,  Ice,  Compression  and  Elevate      Use  M.E.A.T.    Movement,  Exercise,  Analgesics  and  Treatment  

Identify co-morbid conditions can lead to chronic pain

•  Obesity •  Hyper-mobile joints •  Osteoarthritis •  Rheumatoid arthritis •  Auto-immune disorders •  Migraine •  Diabetes •  Depression and Anxiety •  Addiction including tobacco •  Many more…

Trigger Point Massage

http://www.pressurepositive.com

The Knobble

Take  Home:    Love  the  body  you  are  in    

 1.  Give  yourself  permission  to  love  your  body.  2.  Celebrate  one  thing  you  love  about  your  body.  3.  Send  love  to  your  “troubled”  body  parts.  4.  Find  the  cosme;c  balance.  5.  Don’t  verbally  cri;cize  your  body.  6.  Accept  what  you  cannot  change,  then  forget  about  it.    

http://empoweredsustenance.com/love-your-body/!

1.  90/10 rule. 90% protective factors, 10% risk factors.

2.  Posture. Live balanced against gravity

3.  Strain. Relax when using your muscles

4.  Exercise. An hour per day, six days a week.

5.  Cross train. Stretching, conditioning, and strengthening.

6.  Massage. Identify and reduce trigger points

7.  Track. Monitor pain, range of motion, steps, calories, blood pressure, heart rate, workouts, and other health measures.

8.  Be positive. It’s all about your energy

The Body: Take Home

Now, just do it… watch the videos do the exercises