Monthly Archives

July 2017

Explaining Chronic Pain

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Chronic pain involves changes in the peripheral nervous system (PNS) which conveys nociceptive information to the central nervous system (CNS).  Over time, changes occur in the CNS that can cause continuation of the nociceptive information – even if the original stimulus has been removed!  For instance, say someone has a very painful ulcer on their calf.  The doctor sees the infection is spreading and must amputate the leg to save the person’s life.  After the amputation, the patient continues to report pain in the calf from the ulcer.  This is called phantom limb pain.  Let’s work through the process of how phantom limb pain (and chronic pain) occurs.

A-delta and C fibers are nociceptor unencapsulated receptors (free nerve endings) that respond to noxious stimuli.  Noxious stimuli is an actual or potential tissue injury that is likely to cause pain.  Nociceptors convert mechanical, thermal, and chemical energy into electrical signals and carry this information to the CNS.  Mechanical energy can include compression or tension.  Thermal energy includes heat which is caused by inflammation.  While chemical energy is a response to the chemicals in the body.  The nociceptors are found in/around most tissue including skin, muscle, tendons, joint structures, periosteum, intervertebral disks, and within peripheral nerves.

Nociceptors can begin to have increased responsiveness, which is termed peripheral sensitization.  Sensitization of a neuron is characterized by increased spontaneous activity, a decrease in threshold of response to noxious stimuli, an increase in responsiveness to the same noxious stimuli, and/or an increase in receptive field size.  So, what a normal nerve might perceive as slightly painful a sensitized nerve may perceive as excruciatingly painful.

Nociceptors then send their information up to the CNS:

  • Creating a reflexive response that is coordinated within the spinal cord to withdraw the body from the painful stimulus (i.e. pulling your hand away from a hot stove)
  • Ascending nociceptive pathways which take the information up to the brain to be further processed and may trigger
  • Descending facilitatory pathways which increase the nociceptive response and can cause referred pain, secondary hyperalgesia, and contralateral hyperalgesia or
  • Descending inhibitory pathways which decrease the nociceptive response

More recently, researchers have found glial cells in the CNS which also play a critical role in the processing of nociceptive information.  Research indicates that glial cells can release anti-inflammatory factors that help to restore normal nociceptive processing.  However, they also release a variety of substances that facilitate nociceptive information.  Therefore, glial cells play an important role in both the facilitation and inhibition of nociceptive information in the CNS.

Are you completely confused with all of this and questioning how it applies to your chronic pain?  Hold tight – the next blog posts discuss this in further detail regarding specific diagnosis.  Or, if you would like to understand more about the pathways involved in chronic pain, please feel free to contact Amy at Physical Therapy for EveryBODY at (360)367-0970 or amykonvalinpt@gmail.com.  I am passionate about education and would be happy to have a phone conversation with you!

Acute versus Chronic Pain

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The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. By this definition, pain does not HAVE to be associated with observable tissue damage or have a detectable underlying cause.

Pain is subjective.

If described by the patient – pain IS real.

Now, before you shoot the messenger here, let me explain the point of this blog series I am starting. An updated version of “Mechanisms and Management of Pain for the Physical Therapist” was recently released. As I was reading it I thought to myself “Are we using the proper vocabulary to explain chronic pain to our patients?” Why is this important, you ask. Because chronic pain works through a different mechanism than acute pain. And, the pain cycle we describe in the clinic tends to focus on acute pain. Which confuses people because they assume pain MUST be associated with tissue damage and we know that is false. So, it’s time to clear up the confusion!

Acute pain is a direct result of tissue damage and IS a symptom. When you sprain you ankle and the ligaments are overstretched, acute pain tells you to take it easy on the ankle and give it a chance to heal. This is a useful function of pain! Acute pain usually responds well and quickly to treatment including pain free movement, ice, and nonsteroidal anti-inflammatory drugs.

On the other hand, chronic pain is not protective and does not serve a biological purpose. Pain is defined as chronic if: 1) it outlasts normal tissue healing time, 2) the impairment is greater than would be expected from the physical findings or injury, and/or 3) pain occurs in the absence of identifiable tissue damage. In VERY general terms, chronic pain is pain that has lasted more than 3-6 months. However, you must take into consideration if the initial injury was properly diagnosed/treated in the first place, if the condition has been given enough time to heal, or if an athlete is constantly reinjuring the same tissues.

If YOU need help understanding YOUR pain, please feel free to contact us here at Physical Therapy for everybody at (360)367-0970 or amykonvalinpt@gmail.com.

Hip Osteoarthritis – New Clinical Practice Guideline

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Physical Therapy utilizes art and science to create a specific program for restoration of each patient’s physical function.  Later blog articles will focus on the ART while this article is focusing on the SCIENCE.  Physical Therapists are passionate about finding, confirming, and using optimal treatment strategies for their patients.  We are greatly indebted to the researchers who dedicate their lives to helping us in that pursuit.

The Journal of Orthopaedic and Sports Physical Therapy (JOSPT) is one of my “go to” journals for good, sound research.  In June 2017 they published a new Clinical Practice Guideline for Hip Osteoarthritis.  What does that mean for you, the person living with hip osteoarthritis?  That means that a bunch of really smart people combed through all the research and made recommendations for people like me to use when helping the most important people involved – our patients!  And, here is what they said…

How do we diagnose Hip Osteoarthritis?  Adults over the age of 50 with moderate anterior or lateral hip pain during weight-bearing activities, morning stiffness less than 1 hour duration after waking, hip internal rotation (IR) range of motion less than 24 degrees or IR and flexion 15 degrees less than non-painful side, and/or increased hip pain associated with passive hip internal rotation.  What is hip internal rotation?  Lie on your back with one knee and same hip bent to 90 degrees.  While maintaining this hip and knee position, try to bring your foot out to the side.  Compare the motion to the other side.

What tests and measures should be included in the evaluation?  You should be assessed for physical function measures, balance performance/risk of falls assessment, active range of motion for the hip, and muscle strength.

How should we treat Hip Osteoarthritis?  Manual therapy should be used to improve hip mobility.  This should be followed up with flexibility, strengthening, and endurance exercises to address impairments in hip range of motion, specific muscle weakness, and limited muscle flexibility.  Patients should receive education on activity modification, exercise, weight reduction when overweight, and methods of unloading the arthritic joints.  Bracing should be used as a last resort if these forms of treatment are not effective.

If you have any questions regarding these recommendations, please feel free to contact us here at Physical Therapy for Everybody – amykonvalinpt@gmail.com or (360)367-0970.  If you would like to read the complete article:

http://www.jospt.org/doi/full/10.2519/jospt.2017.0301