TherMod Pain Exam

Define: Activity Pacing

component of CBT; patients are encouraged to decrease the speed of performing activities, take breaks as necessary, maintain a consistent pace, and to break tasks into manageable components.

A-delta fibers: Peripheral Nociceptors

myelinated - meaning they have faster conduction speed than the unmyelinated c- fibers. more protective resulting in "first pain" which is localized and often described as "sharp" or "pricking".

The Specificity Theory of Pain

nerve fibers are specific to a cutaneous sensation Pain intensity considered proportional to tissue damage *Lacking in* its ability to account for phantom limb pain and allodynia (non-painful stimuli are perceived as painful)

Central Sensitization is driven by ____ ?

• (seems to be) driven by peripheral nociceptive input and can be lessened or normalized with blocking of this input. ○ For example, the use of lidocaine to a peripheral trigger point in a person with fibromyalgia or the rectum in a person with irritable bowel syndrome results in a lessening of generalized sensitivity. ○ peripheral targets may drive central sensitization and effectively blocking these may result in decreased sensitivity.

Quantifiable measures of pain (5 scoring systems)

1. Fear Avoidance Beliefs Questionnaire (FABQ) 2. Tampa Scale of Kinesiophobia (measure of fear of movement and/or re injury) 3. Fear of Daily Activities Questionnaire (FDAQ) - developed to identify fear of specific actives in individuals with LBP 4. Pain Catastrophizing Scale 5. Depression Questionnaires (depression highly correlated w/ chronic pain) *Depression associated with chronic pain conditions differs from that associated with a mental health condition alone in that individuals with pain tend to not present with a negative self view.

Disorders associated with/suggestive of central sensitization (4)

1. Fibromyalgia 2. Chronic Whiplash 3. LBP 4. OA

The Variability in pain response

"Pain is a uniquely individual, subjective experience. Why one person suffers an injury and reports modest pain and another with a similar injury reports serious pain depends on many factors..."

C-fibers: Peripheral Nociceptors

"Second pain": the feeling you get when you touch something hot and then pull your hand away - the delayed onset of pain once your hand is removed from the hot surface and this is the c- fiber mediated second pain. pain is more diffuse and often described as "dull", "aching", and/or "burning".

Define "Wind-up"

(Animal studies) - Increased responsiveness of the *wide dynamic range neurons* in the dorsal horn of the spinal cord in response to temporal summation protocols when directly observed in animal studies, this phenomena is termed "wind- up" and considered direct evidence of central sensitization. UNABLE to directly observe the dorsal horn in humans Wind up (animals) = Temporal Summation (humans)

Easiest Pain Scales vs Most Difficult vs Most Responsive

*Easiest* • The verbal descriptor scales are the easiest to use and to comprehend * may be more appropriate for children and geriatric patients. *Most Difficult* • Visual analog scales are the most difficult to use and for patients to comprehend. *Most Responsive* • Numeric rating scales and visual analog scales are more responsive (than verbal descriptor scales). Only the visual analog scale has known ratio properties.

Types of Nociceptors: Mechanical vs Thermal vs Plymodal

*Mechanical* - Mechanical stimulus (sharp objects, squeezing, pinching) - Primarily A-delta fibers *Thermal* - Above 45 or below 5 degrees celsius = painful - primarily A- delta fibers. *Polymodal* - mechanical, thermal, and/or chemical irritant stimuli. - primarily c- fibers

How Physical Therapy interventions may inhibit pain (Peripherally vs Centrally)

*Peripheral* by removing irritants or activation of peripheral opioids receptors *Central* by increasing activation of the spinal and supraspinal pain inhibitory mechanisms and/or by decreasing activation of the spinal and supraspinal pain facilitatory mechanisms.

Peripheral Sensitization (definition, characteristics, results in___)

*defined as*: increased responsiveness and reduced threshold of nociceptive neurons in the periphery to the stimulation of their receptive fields. *characteristics*: ○ an increase in spontaneous activity of the nociceptors, ○ a decrease in response threshold ○ an increase in responsiveness to a noxious stimulus, ○ an increase in the size of the receptive field. *results in* primary hyperalgesia which is hyperalgesia at the site of the injury

Key components of Cognitive behavioral therapy approach (3)

1) a strong therapeutic alliance between the patient and practitioner with the development of a shared view of the problem; 2) a focus on the present; 3) personalized and time dependent goals which are continually monitored.

Three types of neurons that exist in Dorsal Horn of Spinal Cord

1. *High threshold neurons*: respond only to noxious stimuli. 2. *Low threshold neurons*: respond only to non- noxious stimuli. 3. *Wide dynamic range neurons*: respond to both noxious and non-noxious stimuli.

Steps of "Exposure Based Treatment of Chronic Pain"

1. Education and Preparation 2. Treatment goals (SMART) 3. Establish a fear hierarchy 4. Graded in vivo exposure with behavioral experiment

Placebo psychological responses are influenced by ____ (4 things)

1. Expectation *** (Primary mechanism)* 2. Conditioning and learning *** (Primary mechanism)* 3. Negative affect (anxiety or fear) 4. Positive affect (optimism)

Factors that Contribute to Pain Variability

1. Nervous system processing 2. Race/Ethnicity 3. Genetics 4. Age (chronic pain most prevalent in middle age) 5. Sex

Dorsal Horn Ascending Pathways

From the dorsal horn of the spinal cord, nociceptive input is transmitted through ascending pathways to the suparapinal structures. 1. The Spinothalamic tract 2. the Spinomesencephalic tract 3. the Spinoreticular tract tracts terminate in the regions of the cortex (emotion) and the midbrain and brainstem to trigger the endogenous pain modulatory systems.

Exercise Induced Hypoalgesia

Global Effect (highly variable responses) Moderate effect on pain for 15 minutes post exercise, and up to 30 minutes of smaller effects Possible hyperalgesic affect in working muscle w/ hypoalgesia in distant sites

Self Efficacy's effect on pain

May have a protective effect (low self efficacy may re- enforce overreaction and inactivity in response to chronic pain) Influences by choice of activities initiated, effort given towards a goal, the persistence applied toward accomplishing a gaol, and how an individual copes with pain "the belief in one's ability to perform a behavior capable of producing a desired outcome"

Can we identify Placebo Responders?

NO (not specifically) Everyone is believed to be a responder - but the type we respond to is highly individualized

A patient reports greater pain after being told, "This is going to really hurt" is an example of ____ ?

Nocebo

A noxious stimulus is transducer and transmitted from the periphery by a _______ ?

Nociceptor

You are treating a non-verbal older adult with dementia and wish to monitor this individual for pain. Your BEST option would be to ____ ?

Observe the individual and document non-verbal indicators suggesting pain

The most valid method to measure a patient's pain level is ____ ?

Obtain a rating through SELF REPORT

How have the theories of pain changed over time

Old thought --> pain = damage, more damage = more pain • dependent on periphery stimulus • nociception = pain New thought • nociception doesn't always equate to pain • pain modulation now believed ○ pain can be inhibited or facilitated by descending pathways

The Pattern Theory of Pain

Pain resulted from a patterned input (intensity over time and area from sensory organs in the skin) • Pain was considered a learning event not requiring a specific sensory channel. • *lacking in* its ability to account for specialized sensory endings which do respond to noxious stimuli as well as the central pain transmission pathways.

Psychologically informed practice include ____ ?

Physically therapy treatment is modified to include consideration of both physical and psychosocial factors

Placebo analgesia is dependent upon which area of the brain?

Pre-frontal cortex (reductions in brain activity)

The goal of secondary prevention is ____ ?

Prevent the progression of acute pain to chronic pain

Different Classifications of Prevention

Primary = attempt to prevent pain from occurring Secondary = prevent condition from progressing (acute to chronic) OR preventing recurrences of condition upon resolution *involves a more traditional physical therapy approach of determining the peripheral cause of acute pain and applying interventions to correct the related dysfunction. Tertiary = *management* of patients who have developed chronic pain (not realistic to attempt to relieve or lessen pain here)

The application of a standard stimuli to assess and quantify sensory nerve function is ____ ?

Quantitative sensory testing

How does Sensitization occur? (physiologically)

Release of non-neuronal activators and inflammatory mediators such as bradykinin, prostaglandins, cytokines resulting in sensitization of the A delta and c- fiber afferents.

A visual analog scale requires ____ ?

Requires the patient to place a mark on a line to indicate their level of pain

_____ is the belief in one's ability to perform a behavior capable of producing a desired outcome.

Self efficacy

Gold standard for measuring pain

Self report

2 Components of Pain Experience

Sensory & Emotional (all pain has emotional component)

Psychological factors regarding pain

Serve as prognostic factors (high levels of depression or catastrophizing are suggestive of a patient not as likely to respond to treatment) May be treatment effect modifiers May be treatment targets for interventions

Difference between Specific effects of an intervention vs Non-Specific Effects

Specific = mechanisms directly related to an individual intervention. Nonspecific effects = the contextual influences of an intervention such as improvements in outcomes related to the interaction between the healthcare provider and the patient during the application of a specific intervention or the patient's expectations for a specific intervention.

Acute vs Chronic Pain

Symptom vs Disease *Acute* 1. SYMPTOM in response to tissue damage or potential tissue damage 2. Well defined time of onset and clear pathology 3. Protective 4. Treat with interventions aimed at the peripheral tissue damage *Chronic* 1. DOES NOT serve a biological purpose 2. Outlasts normal tissue healing 3. Impairment greater than expected from physical findings or injury 4. Presenting the absence of identifiable tissue damage 5. Considered a DISEASE 6. May not respond to peripherally directed interventions

7 Methods of Assessing (scoring) Pain

1. Numeric Rating Scales: 0-10 (influenced by self perception of fraudulence, fatigue, mood) 2. Ratio Scale: 4/10 (have not been found to have ratio scale qualities) 3. Visual Analog Scales: pt. makes more along line (not appropriate for all pt.s and involved extra work to grade) 4. Verbal Descriptor Scales: choose the adjective best describing pain (less responsive than numeric and VAS and not a good option to measure small changes) 5. Faces of Pain Scale: specific type of verbal descriptor scale (useful for children above 3) 6. Global rating of change scale: a rating of perceived recovery (15 point scale indicating how symptoms have changed) 7. Pain diagrams: pt. asked to color area of pain on diagram (pain severity does not correspond to the size of the pain drawing area marked)

Contextual Influences on Pain (3 types)

1. Patient Contextual factors (patient expectation & preference) 2. Therapist Contextual Factors (clinical equipoise and provider expectation) 3. Interaction between therapist and patient (patient personality & therapeutic alliance)

5 Reasons why Patients consult with Healthcare Providers

1. Seeking cure/symptom relief 2. Seeking diagnostic clarification 3. Seeking reassurance 4. Seeking legitimization of symptoms 5. Wishing to express distress/frustration/anger

Variability in a pain experience can be explained by _____ ? (3 things)

1. Sex of the individual 2. Race of the individual 3. Psychological factors

Methods for Monitoring pain in non-verbal pt.s

1. The Behavioral Pain Scale: considers domains specific to facial expression, movement of the upper limbs, and compliance with ventilator. 2. The Critical Care Pain Observation Tool: considers 4 domains specific to facial expression, body movements, muscle tension, and compliance with a ventilator for intubated patients OR vocalization for extubated patients

Maintenance strategies for chronic pain (3)

1. advice for managing flare ups; 2. considering future problems; 3. education and home exercise for self management. problem solving strategies include consider alternative solutions should a problem arise.

Common Factors Conceptual Framework (4 factors)

1. confiding RELATIONSHIP with therapist 2. healing SETTING 3. RATIONALE, conceptual scheme or myth explaining procedure 4. PROCEDURE (or ritual)

Quantitative sensory testing measures (8)

1. threshold: the minimal stimulus intensity that is perceived as painful 2. tolerance: the maximum intensity of a pain producing stimulus a subject will accept in a given situation, 3. hyperalgesia: increased pain from a stimulus which normally provokes pain. 4. analgesia: the absence of pain in response to a normally painful stimulus, 5. hypoalgesia: the lessening of pain in response to a previously painful stimulus, 6. allodynia: pain due to a stimulus which is not normally pain provoking. 7. temporal summation: With repetition of the same noxious stimuli, the individual perceived the pulses as becoming more painful. 8. conditioned pain modulation: Pain inhibitory process - Pain is measured in one region, then pain is caused in another region in conjunction with the original stimulus resulting is a lower pain rating.

Define Graded activity

A goal is set for exercise based on time, # of reps, or # of sets and the patient is encouraged to complete the prescribed amount *without regard to changes in their pain*

Define Noxious Stimulus

A stimulus which is damaging or threatening damage to normal tissue (not "pain" until it is recognized by brain)

Define Motivational Interviewing

A technique with the goal of having the patient agree a targeted behavior is desirable and possible The clinician role in motivational interviewing is to: · Express empathy · Makes patient aware of discrepancies between current maladaptive coping and personal goals · Avoiding arguing with, criticizing, hurrying, or labeling the patient · Support self-efficacy by asking questions that will elicit statements that reflect positive self-efficacy beliefs (eg, "What do you think it will take to increase your confidence that you will be able to be more active despite pain?") and then reflecting back these statements to encourage more self-efficacy talk

_____ is defined as "an exaggerated negative orientation towards a noxious stimuli" and includes rumination, magnification, and helplessness.

Catastrophizing

Anxiety and Pain

Anxiety is a normal response to acute pain or change in the pain of an illness Anxiety is highly correlated with pain and disability individuals with higher pain related anxiety are more likely to interpret pain as dangerous and to be avoided

Does the descending pain modulatory system inhibit or facilitate pain?

BOTH - facilitates and inhibits pain

Hyperalgesia vs Allodynia

Both are inferences of sensitization *Allodynia*: pain due to a stimulus which is not normally pain provoking. (example; in individuals with severe chronic pain conditions, light touch or even the pressure from clothing may be perceived as painful) *Hyperalgesia*: increased pain from a stimulus which normally provokes pain.

Define: Graded Exposure

CBT Technique; Activity specific! Gradual, systematic progression of exercise from initial tolerable level Determining what a pt. is fearful of and then getting them to confront fears (return to function phase) - only needs to be done once or twice to get them "over the hump"

Define: Attention Diversion

CBT Technique; Distract from pain to reduce the perception of pain and associated stress, such as encouraged exposure to pleasant activities

Define: Cognitive Restructuring

CBT Technique; Identify and change maladaptive thoughts and emotions: Pain Neuroscience Education = Explain process of pain and what pain means Common cognitive errors; 1) overgeneralization such as concluding nothing will help due to the failure of one approach; 2) focusing on the worst possibility; 3) considering only the worst or best of a situation without considering the range of possibilities; 4) attending only to negative aspects without regard for positive aspects; 5) jumping to conclusions without rationally evaluating the situation.

Define: Graded Activity

CBT Technique; a goal is set for exercise based on time, number or repetitions, or number of sets and the patient is encouraged to complete the prescribed amount without regard to changes in their pain Individuals participating in a graded activity approach are educated the difference between "harm" and "hurt"

Central Sensitization (definition, characteristics)

CNS dysfunction in response to repetitive nociceptive input *defined as*: increased responsiveness of nociceptive (high threshold and wide dynamic range) neurons in the central nervous system to their normal or subthreshold afferent input. *Characterized by* • an increased receptive field size • generalized hyperalgesia and allodynia.

A patient with R shoulder pain is painful with light palpation to the R shoulder but also the L shoulder and both legs. This characterizes ______ ?

Central Sensitization

Lack of preference or uncertainty for a treatment is known as ____ ?

Clinical equipoise

Treatment approaches intended to improve a patient's ability to deal with their pain and improve participation

Cognitive behavioral therapy

Therapeutic alliance is defined as ____ ?

Collaboration, warmth, and support between the therapist and the patient

Sensitization

Definition = an increased responsiveness of nociceptive neurons to their normal input, and/or recruitment of a response to normally subthreshold inputs. *NORMAL* response to an acute injury Present in many chronic pain conditions long beyond normal tissue healing time

Where do A-delta and C-fiber nociceptors' periphery signals terminate?

Dorsal horn of the spinal cord (end of the 1st order neuron and beginning of 2nd order)

Placebo responses are produced through ____ and _____

Expectation and Conditioning

True or false, Central sensitization can be observed in humans

FALSE - can only be observed in animal studies in which direct visualization of the nervous system is possible

Shared Decision Making; the process by which ____ ?

The provider explores the patient's values and preferences and respects the patient's rights to make a decision Can lead to greater placebo analgesia in patients who desire control during treatment decision making process

Descending Pain Modulatory System

These supraspinal structures are involved with pain modulation and able to BOTH *inhibit and facilitate pain* 1. Anterior Cingulate Cortex 2. Amygdala 3. Periaqueductal Gray 4. Rostral Ventromedial Medulla (RVM) 5. Dorsal Lateral Pontine Tegmentum (DLPT)

Quantitative Sensory testing (define)

a psychophysical technique used to quantify pain sensitivity involving the application of a standard stimulus to assess and quantify sensory nerve function. • Approaches include mechanical stimulation such as the use of; • algometer - pressure • ischemic (such as the use of a blood pressure cuff) • chemical (such as the use of a chemical irritant such as capsaicin) • thermal cannot be assess with clinical pain studies - but can be used to provide a standardized noxious stimulus

Define Temporal Summation

an experimental pain protocol demonstrating a pain facility process • Occurs in response to repeated noxious stimuli: With repetition, the individual perceived the pulses (stimulus) as becoming more painful. Higher rates of temporal summation are seen in older individuals as well as individuals with some chronic pain conditions and may pre-dispose individuals to the development and maintenance of chronic pain conditions.

Definition of "Pain"

an unpleasant, sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

Movement Evoked Pain

commonly more severe than pain at rest. (postoperative movement evoked pain to have up to 226% greater intensity than resting pain) • related to function and is associated with functional ability following surgery as well as following a whiplash injury in a manner not captured by resting pain. • interventions (TENS, Opioids) may selectively target movement evoked pain.

Gate Control Theory of Pain

considers both the physiological and psychological constructs of pain. proposes specialized nerve endings or nociceptors who response is modulated in the dorsal horn of the spinal cord. Large (non- nociceptive) and small (nociceptive) fiber afferents converge in the dorsal horn onto Transmission Cells. balance exists between large and small fiber afferents and pain is inhibited. Increased activity from the large, non- nociceptive fibers results in closing of the gait and pain inhibition. *Lacking in* its ability to account for post synaptic mechanisms of inhibition as well as supraspinal facilitation and inhibition of pain at the spinal cord implying pain modulation without gating.

Conditioned Pain Modulation

example of a pain inhibitory process Protocol = a baseline pain sensitivity measure is assessed - Pain is then caused in another region in conjunction with the original stimulus resulting is a lower pain rating. Inefficient conditioned pain modulation is observed in *older adults* as well as those with *chronic pain conditions* (increased risk of both the progression of acute to chronic pain as well as the maintenance of a chronic pain condition)

Indirect Measures of Central Sensitization

heightened temporal summation and/or lessened conditioned pain modulation Central sensitization corresponds to maladaptive function of the descending inhibitory system and/or ascending and descending pain facilitatory systems.

Primary goal of Cognitive Behavioral Therapy Approach

not to reduce or control pain to "increase patients' psychological flexibility for dealing with unwanted experiences and improve their engagement in activities that are important to them." Ex) the goal of a CBT program may be to lessen fear of movement and improve self-efficacy in order to accomplish the goal of increasing participation in specific desired work or recreational activities.

The Common Factors Model proposes what?

proposes factors across interventions are more relevant to outcomes than the specific components of individual interventions. (interventions with vastly different theories result in similar effects - aka - individual treatment approaches fail to distinguish themselves from each other.) "Everybody has won, and all must have prizes."

Lamina Divisions of the Dorsal Horn of the Spinal Cord

• *Neurons in lamina I*: receive A delta and c- fiber input. • *Neurons in lamina II*: receive input from c- fibers and relay this information to other laminae. Subsequently, neurons in lamina I and II establish whether a stimulation is painful or not. • Wide dynamic range neurons are present in *lamina V* and receive A delta, c, and A beta fiber input. Lamina V cells provide details about the stimulus.

The Pain Neuromatrix Theory

• Gate Control theory + supraspinal influences on the pain experience. • Neural network within the brain integrates multiple sources to produce pain. The network results in a characteristic pattern termed the "neurosignature" for the awareness of pain. The neurosignature is modulated by sensory input and cognitive events.

The Biopsychosoical Model of Pain (Pain as an interaction between ____)

• Pain as an interaction between biological, psychological, and sociocultural variables. • Nociception = the neural process of encoding noxious stimuli Pain is recognized at the cortical level and influenced by psychological variables.

Biomedical Model of Pain

• The traditional *pathoanatomic* approach to pain. • Pain has a distinct, physiological, and generally peripheral cause. • Both clinical tests and imaging are important to determine the cause. Specialists such as Orthopaedists or Neurologists are often consulted to diagnose and recommend treatment and specific, peripheral diagnoses are sought.

Primary Nociceptive condition vs Centralized Condition

• nociceptive dominant = pain is in line with damage ○ clinical presentation matches pain condition • Centralized condition = driven by periphery ○ clinical presentation doesn't match pain presentation ○ treat periphery to allow CNS to "calm down" ○ pt.'s will often have increased sensitivity § tend to be more irritable § less exercise tolerance ○ cognitive behavioral approaches may be effective with this population

Individuals with greater overall sensitivity are thought to be at more risk to _____ (3 things)

○ develop a pain condition, ○ likely to have greater pain when a pain condition does develop, ○ more likely to develop a chronic pain condition in response to an acute pain episode.