Modern pain neuroscience in clinical practice: applied to post-cancer, paediatric and sports-related pain.

In the last decade, evidence regarding chronic pain has developed exponentially. Numerous studies show that many chronic pain populations show specific neuroplastic changes in the peripheral and central nervous system. These changes are reflected in clinical manifestations, like a generalized hypersensitivity of the somatosensory system. Besides a hypersensitivity of bottom-up nociceptive transmission, there is also evidence for top-down facilitation of pain due to malfunctioning of the endogenous descending nociceptive modulatory systems. These and other aspects of modern pain neuroscience are starting to be applied within daily clinical practice. However, currently the application of this knowledge is mostly limited to the general adult population with musculoskeletal problems, while evidence is getting stronger that also in other chronic pain populations these neuroplastic processes may contribute to the occurrence and persistence of the pain problem.

Therefore, this masterclass article aims at giving an overview of the current modern pain neuroscience knowledge and its potential application in post-cancer, paediatric and sports-related pain problems.

Woebot, a bridge to Artificially Intelligent Physiotherapy?

It is human nature to make tools to make our lives easier. In recent history the development of automation changed lives substantially. Now at first this makes you think of huge clunky machines which lift heavy things onto conveyor belts and performed physical tasks, and this is true. Now refine that concept, add smarter technology and make it smaller and you have a different beast. Now you have something which can learn new tasks and perform complex analysis faster and cheaper than a person.

As this recent article in Wired explains, chatbots are beginning to work in sensitive areas of society such advising refugees, something which you would think only a human would be able to do. Advising a person what to do from a strict list of commands is one thing and never has a chatbot treated a clinical condition before. This line has now been crossed and we are now on a precipice of a dramatic shift in the delivery healthcare.

Woebot was created by Stanford psychologists and AI experts acts as a mental health therapeutic assistant. It provides a therapeutic experience to the users via concepts similar to those used in CBT. Obviously Woebot is not a doctor and is unable to make diagnoses or prescribe medication and advises you to seek ‘real world’ help if it detects a crisis however evidence has shown it to be effective at reducing stress and anxiety.

The technology works through Facebook messenger and asks you questions about your mood. Depending on your answer Woebot follows your answers along a decision tree and offers personal responses. The conversations are tracked and this allows further personalised answers.

The project is based on a previous project called ‘Ellie’ which showed that computers actually make good therapists. Now it is important to say that I am an advocate of technology such as Woebot. It improve the mental health of those unable to access psychiatric healthcare or those who are unlikely to seek help in the first place.

Let’s be honest it is only a matter of time before this sort of tech is changing the landscape of physiotherapy.

Apply this concept to something like exercise prescription and this could alter the future of physiotherapy dramatically. We are already seeing novel telerehab ideas which reduce the need for face to face follow up sessions. Add virtual reality technology into the mix and suddenly a face-to-face consultation is (kind of-)replicated.

(Disclaimer – I’m oversimplifying what we do a physiotherapists in the next part to allow critical discussion)

In a crude sense (I really mean crude sense) some aspects of physiotherapy assessments are either pattern recognition or fitting a particular set of movement restrictions or pain into a diagnostic algorithm. We do this all the time as clinicians, a positive test with a restriction in a movement along with a history will normally tell you what the diagnosis is and therefore your treatment plan. Use the example of an ankle sprain, the assessment can be simple and the rehab can be very specific. Listen to Calibe Doherty and you’ll see what I mean. It is possible with the right combinations of technology could form an advanced form of a PhysioBot. Imagine a Woebot with movement sensors.

Obviously this isn’t happening now and there is a big chance it isn’t happening soon, I haven’t even begun to discuss the ethical implications and the complex clinical reasoning that goes into a physiotherapy assessment and treatment plan or the human contact. It is important we think ahead though.

As a profession we need to embrace this technology and have our say with how it should be used. It is important we don’t see this as a threat or we run the risk of being cast aside, we won’t win in a battle against technology. If we embrace it we will flourish alongside and work together to improve health around the world.

Comparison Between Chronic Migraine & Temporomandibular Disorders in Pain-Related Disability & Fear-Avoidance

The aim of this study was to compare patients with chronic migraine (CM) and chronic temporomandibular disorders (TMD) on disability, pain, and fear avoidance factors and to associate these variables within groups. A total of 50 patients with CM and 51 patients with chronic TMD, classified by international criteria classifications were included in the study. The variables evaluated included pain intensity (visual analog scale [VAS]), neck disability (NDI), craniofacial pain and disability (CF-PDI), headache impact (HIT-6), pain catastrophizing (PCS), and kinesiophobia (TSK-11).

Statistically significant differences were found between the CM group and the chronic TMD group in CF-PDI ( P  < 0.001), PCS ( P  = 0.03), and HIT-6 ( P  < 0.001); however, there were no differences between the CM group and the VAS, NDI, and TSK-11 groups ( P  > 0.05). For the chronic TMD group, the combination of NDI and TSK-11 was a significant covariate model of CF-PDI (adjusted R 2  = 0.34). In the CM group, the regression model showed that NDI was a significant predictive factor for HIT-6 (adjusted R 2  = 0.19).

Differences between the CM group and the chronic TMD group were found in craniofacial pain and disability, pain catastrophizing, and headache impact, but they were similar for pain intensity, neck disability, and kinesiophobia. Neck disability and kinesiophobia were covariates of craniofacial pain and disability (34% of variance) for chronic TMD. In the CM group, neck disability was a predictive factor for headache impact (19.3% of variance).

Individualised functional restoration plus guideline-based advice vs advice alone for non-reducible discogenic LBP

The aim of this study was to evaluate the effectiveness of individualised functional restoration plus guideline-based advice compared to advice alone in people with non-reducible discogenic pain (NRDP).

This was a subgroup analysis within a multicentre, parallel group randomised controlled trial involving ninety-six participants with clinical features indicative of NRDP (6 week to 6 month duration of injury). Over a 10 week period physiotherapists provided 10 sessions of individualised functional restoration plus guideline-based advice or two sessions of advice alone.

Between-group differences favoured individualised functional restoration over advice for back pain (1.1, 95% CI 0.1 to 2.1), leg pain (1.5, 95% CI 0.4 to 2.6) and Oswestry (6.3, 95% CI 1.3 to 11.4) at 10 weeks as well as Oswestry at 26 weeks (6.6, 95% CI 1.4 to 11.8). Secondary outcomes and responder analyses also favoured physiotherapy functional restoration suggesting the differences were clinically important.

In people with NRDP of ≥6 weeks and ≤6 months duration, individualised functional restoration was more effective than advice for all primary outcomes at 10 weeks and sustained at 26 weeks for activity limitation. The results suggest that for people with NRDP not recovering after 6 weeks, an individualised physiotherapy functional restoration program should be considered.

Developing minimum clinical standards for physiotherapy in South African ICUs: A qualitative study.

Physiotherapists are integral members of the intensive care unit (ICU) team. Clinicians working in ICU are dependent on their own experience when making decisions regarding individual patient management thus resulting in variation in clinical practice. No formalized clinical practice guidelines or standards exist for the educational profile or scope of practice requirements for ICU physiotherapy. This study explored perceptions of physiotherapists on minimum clinical standards that ICU physiotherapists should adhere to for delivering safe, effective physiotherapy services to critically ill patients.

Experienced physiotherapists offering a service to South African ICUs were purposively sampled. Three focus group sessions were held in different parts of the country to ensure national participation. Each was audio recorded. The stimulus question posed was “What is the minimum standard of clinical practice needed by physiotherapists to ensure safe and independent practice in South African ICUs?” Three categories were explored, namely, knowledge, skill, and attributes. Themes and subthemes were developed using the codes identified. An inductive approach to data analysis was used to perform conventional content analysis.

Twenty-five physiotherapists participated in 1 of 3 focus group sessions. Mean years of ICU experience was 10.8 years (±7.0; range, 3-33). Three themes emerged from the data namely, integrated medical knowledge, multidisciplinary teamwork, and physiotherapy practice. Integrated medical knowledge related to anatomy and physiology, conditions that patients present with in ICU, the ICU environment, pathology and pathophysiology, and pharmacology. Multidisciplinary teamwork encompassed elements related to communication, continuous professional development, cultural sensitivity, documentation, ethics, professionalism, safety in ICU, and technology. Components related to physiotherapy practice included clinical reasoning, handling skills, interventions, and patient care.

The information obtained will be used to inform the development of a list of standards to be presented to the wider national physiotherapy and ICU communities for further consensus-building activities.

Top 5 Fridays! 5 Things You Need to Start Your PT Career

Note, Dr. Ben Fung released this on Monday on UpDoc Media, but I thought it’s perfect material for a Top 5 Fridays! It’s like Taco Tuesday, but on a Friday!
Dr E….
It’s a Monday. Usually, Monday mornings are a drudge of things to do. Still, every once in a while, someone reaches out and we both leave with inspiration. Yet, all to often in the world of physical therapy, colleagues sail by each other like two ships passing in the night. It is TRAGIC, the amount of inspiration we are leaving behind, simply by not reaching out to our colleagues to exchange thoughts, ideas, and friendship.
So… it just happened that, today, a soon to be Doctor of Physical Therapy, Lisa Weiss, sent me a Facebook message asking for my thoughts on “3 important topics to hit home on for my classmates to take with them into careers” for the commencement speech she’ll be giving her colleagues.
As usual, I started typing the same way I would be speaking as if Lisa was sitting across from me at a coffee shop. Thanking her for the kind message, I opened my reply with:
“I’d definitely send them out there with inspiration, confidence, driven, purpose, and passion.”
This moment, immediately became an inspiration of my own with an entire speech segment flying through my fingers! I promised not to steal her thunder, but we thought it’d be cool to share just a snippet of our ideas.

Inspiration, Confidence, Drive, Purpose & Passion

As you venture out there, new grad, licensed, fresh professional… as you become seasoned and veteran in our field, never forget these five reasons of why you began this journey:
  1. Inspiration: Find daily inspirations in daily wins, for yourself and for your patients.
  2. Confidence: Stand strong in the foundations you’ve been taught, the training you’ve received, and the mission of lifelong learning. More importantly, GIVE confidence freely to those you serve.
  3. Drive: So much of healthcare is innately reactionary. As physical therapists, we can give people the inner fuel they need to pursue their health — their LIVES proactively.
  4. Purpose: Always remember the reasons of why you went through so much schooling, so many years, and, so much debt! In doing so, NEVER SETTLE FOR LESS in any way; in your practice, in your position, in your pay, career path, and never settle for the purpose of your patients.
  5. Passion:  To serve well & transform society, we must share our passions through the perspectives and lenses of those we serve. We must share the victory stories of our patients; we must share for them, with them, and through them. And, why is it so important to share passion? Because, passion inspires.

Nevertheless, I hope this encourages you, if anything, to do one thing: REACH OUT & CONNECT! You never know how things might end up. I mean, who knows… you may end up forming a company with someone you barely know and start a business together before physically meeting in person 😉
Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic…

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What is Pain?

“Society needs to understand pain ~ what is pain?

Last week I attended the SIP 2017 Conference in Malta where a meeting of stakeholders deeply considered the issue of pain in society. Pain is a societal problem and the way forward will emerge from considering pain in this light. Significant and exciting steps were taken, which will be covered in a forthcoming article on this site and the UP | understand pain site.
Chronic pain is the number one global health burden. The approaches used for pain are not working. We are seeing the figures increasing over the years as more and more people suffer ~ 100 million people in Europe. Why? The main reason is the misunderstanding of pain that results in unnecessary investigations, treatments that don’t work and low expectations. The predominant thinking remains ‘biomedical’ both in terms of healthcare delivered and society’s expectations. Pain is not a medical problem. It is a public health, or societal issue. We are in it together, all of us. Even clinicians are patients!

Where do we start?

The UP enterprise has a purpose, and that is to change the way that society thinks about pain, hence Understand Pain. From the point of understanding comes new belief and commitment to reach one’s potential. The vision is a world where people understand pain so that the focus is upon the practices that foster a healthy, meaningful existence within the context of the person’s unique life. This emerges from co-operation between the person and the care-giver, working together to achieve results. This is the essence of Pain Coach, grounded in pain sciences, modern philosophy and strengths based coaching, delivering results based on what works.
Pain Coach not only gives individuals unique knowledge and skills according to their needs, but also the all-important know how. I may have the best drill in the world, but without the know-how I will still make big holes in the wall as I try to hang a picture. The Pain Coach coaches the person to coach themselves to overcome pain. Conversely, interventions and medicines are ways to circumnavigate the problem. This is not to say that they do not have a role, however, the person learns nothing about facing it and transforming the experience and therefore will continue the loop of suffering. Only by learning about one’s existing patterns and creating new patterns in line with a vision of success, can the person overcome their pain.

“What do you focus on?

What do you focus on? What language do you use to yourself over and over? What story do you tell yourself? You can make the decision to change your story. What can you control? Your attitudes, your thoughts, your day to day decisions are all yours. What do you do consistently? What do you think and embody consistently? That becomes the story of you. You can choose another script. That is the role of a coach, to help you realise and actualise your choices. To help you make decisions but ultimately you make them and commit to doing positive work to move in a desired direction. You decide the direction.

What is pain?

Pain is part of the whole person state of protect. Pain is poorly related to any stage of injury, tissue damage or indeed tissue state. This is the common misunderstanding, that somehow pain and injury are the same or related. This is not the case and indeed Pat Wall, the father of pain science and medicine, stated this in his 1979 paper. Why then, is this not practiced as mainstream? This is one of the key messages for all.
What are we protecting against? Initially there may be some kind of actual threat such as an injury or disease state, which is rightly interpreted by body systems as dangerous or potentially dangerous.  That’s the whole point of pain in a sense, to be so unpleasant that it compels us to take action. It is a vital survival mechanism without which we have no way to detect actual or potential danger. But, the pain itself remains part of a protect state in light of a perceived threat.

“Pain is a feature of a state of protection

When pain persists, aka chronic pain (not everyone likes this term or wishes to be labelled as such), it means that a state of protect is persistently emerging as the prediction of threat frequents each day. The range of cues or patterns interpreted as potentially dangerous seems to widen and widen so that normally innocuous situations are deemed to be dangerous. This does not mean it has always to be at a conscious level as most of our biology operates in the dark, ie/ there are hidden causes. However, expectation does play a role in as much as when we expect something to hurt it does and often more as we prime, raise the threat level, predict to ourselves that it will hurt and guess what?
Pain is not a constant state. There is no constant state, instead we are continuously ‘updating’, dynamically exploring the environment with the aim of meeting our predicted needs. When a person suffers chronic pain, they will experience a number of episodes in a given day, with a more challenging day featuring more frequent or longer episodes, and a better day featuring less or shorter episodes.
We are changing by design. No moment is the same. Like a foot placed in a river, it is never the same water that passes by. So change is not the question, rather which direction will you go? Which direction will you choose? To coach yourself towards a vision of success? To decide to commit to the practices of well-being? When people realise that they do have a choice it is empowering, inspiring and enabling.  We can decide to reach our potential.

Who suffers chronic pain?

Work is being done to discover more about who would be vulnerable to a chronic state of protect. Players include genetics, past experience (e.g. prior pain, early life events) and gender. One way to think about this is that we are on a timeline, so nothing happens in isolation. When I stub my toe, my existing health and sense of well-being will influence how I react both ‘myself’ and my biology. In other words, if I am very tired and stressed, my experience will be very different to if I were relaxed and happy. Getting the person’s story is key to understanding the context.
You can think of life’s events as priming. From day dot we are shaping ourselves and being shaped, right up until this moment. Every experience and everything learned sculpts us, our body manifest of the sum of all the things we have done and felt. The body systems that protect us evolve and become highly efficient, predicting that the causes of the sensory information mean that danger exists. Actively changing the sensory information with new practices, new habits and patterns of thought and action take us on different path. A path onward in a chosen direction. Our attitude to change and belief in our own abilities are both key factors — and both can change in themselves!

“Pain is whole person — it’s not my back in pain, I am in pain. Me

The perception or experience of pain is coloured by many factors in that person’s life, including past experience, beliefs, context, environment, actions (current and predicted), emotional state, attentional bias (what I am focusing upon), other people and more. Pain undoubtedly emerges in the person. In other words, it is the person who suffers pain, not the body region where it is felt. Much like it is the person who is thirsty, not their mouth.

In summary

  • It is the whole person who feels pain
  • Pain is part of the way we protect ourselves in the light of a perceived threat
  • Pain can and does change
  • Understand pain to change pain
Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic…

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