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Assessing cortical changes in patients with pain
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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
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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
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Nervous System
- Predictor, creator of experiences (Bayes)- Dynamic, not static
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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
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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,
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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
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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
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Peripheral/central sensitization
WAD patientsFibromyalgia
Banic B. et al. Pain 2004
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Treatment
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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)
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Treatment
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Treatment
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Treatment
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Treatment
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Distraction
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Sensitization - Changes in RF
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Cortical Reorganization in CRPS
Marinus 2011
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Cortical Reorganization in Phantom Limb
Flor H 2002
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Changes in TPD in CLBP patiens
Moseley 2008
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Treatment sensitivity cortical changes
Moseley 2008
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Treatment sensitivity cortical changes
Short Term Long Term
Moseley, 2009
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Treatment sensitivity cortical changes
Moseley 2009
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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
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Treatment motor cortical changes•Graded Motor Imagery
• Laterality• Imagery• Mirror Therapy
•Correction of somatosensation?
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Treatment
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Treatment
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Graded Exposure
Motor:DistractionPacing
Somatosensory:GazeMirrorBrush
Motor:Confrontation
Somatosensory:Gaze
No mirrorBrush
Distraction
Atention needed!!!
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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
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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