session 3_lisbon_may_2010.ppt

8/17/2019 session 3_lisbon_may_2010.ppt

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Tissues – Nociception – Brain - PainTissues – Nociception – Brain - Pain

Tissue Damage

Inflammatory

Cascade

V en u le

A N

B -a ff e re nt

BradyikininProstaglandins

Substance PSubstance P

atec!ola"inesatec!ola"ines

A -a ff er e nt

! " AfferentBarrage

E # # e

r e n t

a c t i o

n

E # # e

r e n t

a c t i o

n

Pain

egmental fortification


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T#e #omeostatic $pain% systemT#e #omeostatic $pain% system

Pain

The NociceptiveSystem

T#e Body Tissues

Descending$Pain% Pat!&ays

'scending$Pain% Pat!&ays

Brain

(nput #ro" t!e

(nternal Environ"ent

(nput #ro" t!eE)ternal Environ"ent

BrainBrain*utput*utput


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' tissue insult (though not necessary)

Descending$pain%

pat!&ays

&

T#e analysis of t#reatT#e analysis of t#reat

PainMulti+syste"brain output

,eo+corte) neuro+c!e"icalbe!avioural plat#or":

conte)t co!esion control

'lo+corte) plat#or":e"otion - "e"ory

.!e brain plat#or" #orbase survival drives

'nalysiso# $t!reat%

'scending $pain% pat!&ays

So"atosensory corte)

/sed as a re#erence#or t!e $re#erred pain%


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,eural 'sse"blies #or t!e onscious,eural 'sse"blies #or t!e onsciousortical '&areness o# Painortical '&areness o# Pain

(nput t!at is nociceptive or &arning(nput t!at is nociceptive or &arningcan be seen as being analogous to acan be seen as being analogous to apebblepebble,eural asse"blies take and last #or,eural asse"blies take and last #or

"illiseconds and can be seen as"illiseconds and can be seen asbeing analogous to a ripplebeing analogous to a ripple

' standing ripple can be #or"ed ' standing ripple can be #or"eduser dependant plasticityuser dependant plasticity

.!e ripple spread is dependant on.!e ripple spread is dependant ont!e #luid neuro+a"ine activityt!e #luid neuro+a"ine activity

o"peting ripples can disrupt itso"peting ripples can disrupt itssi e and s!ape in!ibitory inputssi e and s!ape in!ibitory inputs.!e level o# conscious a&areness.!e level o# conscious a&areness#or a pain is related to t!e neural#or a pain is related to t!e neuralasse"bly si easse"bly si e

.!e “throw a pebble intoa pond”, ripple analogy


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Degree o# $nociceptive% andot!er sensory sti"ulation

'vailability o# neuro+a"ines#acilitating enlarged #ield o#

association

E)tent o# usual

neuronal association

4or"ation o# a

co"peting asse"bly

'vailability o#ot!er "odulators

irculating peptides

,euronal

asse"bly si e

Consciousa'areness of pain

Action onrest of (ody

Neuronal Assem(lies for t#e Neural Correlate of Consciousness )for pain*+

Adapted from: Susan Greenfield (Oxford University) theory of consciousness


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Case scenario !Case scenario !Mary &as returning alone #ro" t!e sc!ool run and stoppedMary &as returning alone #ro" t!e sc!ool run and stopped!er car at tra##ic lig!ts only to be !it in t!e rear by a lorry5!er car at tra##ic lig!ts only to be !it in t!e rear by a lorry5#iercely breaking in t!e !eavy rain#iercely breaking in t!e !eavy rain

S!e describes t!e sounds o# screec!ing and breaking glass5S!e describes t!e sounds o# screec!ing and breaking glass5t!en silence &it! an overpo&ering s"ell o# rubber5 petrol andt!en silence &it! an overpo&ering s"ell o# rubber5 petrol and

spilt #res! co##ee5 t!e darkness as a cloud o# dust engul#edspilt #res! co##ee5 t!e darkness as a cloud o# dust engul#ed!er only penetrated by a single !eadlig!t and t!e!er only penetrated by a single !eadlig!t and t!eclaustrop!obic #eeling o# being trapped by curiously &ar" airclaustrop!obic #eeling o# being trapped by curiously &ar" airbags in t!e gloo"bags in t!e gloo"

Mary &as taken by a"bulance to !ospital #or neck )+rays andMary &as taken by a"bulance to !ospital #or neck )+rays andassess"ent5 s!e &as soon disc!arged &it! $neck sprain% andassess"ent5 s!e &as soon disc!arged &it! $neck sprain% anda supply o# pain "edication .!e #a"ily car un+repairable5a supply o# pain "edication .!e #a"ily car un+repairable5ta)i !o"e to try and arrange #or #riends to collect t!e c!ildrenta)i !o"e to try and arrange #or #riends to collect t!e c!ildren#ro" t!eir di##erent sc!ools and !er !usband #ro" t!e station#ro" t!eir di##erent sc!ools and !er !usband #ro" t!e station


8/41

Case scenario !Case scenario !.!e accident &as si) "ont!s ago.!e accident &as si) "ont!s ago

Mary still !as neck and sternu" pain5 s!e !asMary still !as neck and sternu" pain5 s!e !asdeveloped !eadac!es and nausea5 and #inds itdeveloped !eadac!es and nausea5 and #inds itdi##icult to sleep and concentrate on t!ingsdi##icult to sleep and concentrate on t!ings

S!e reports t!at !er neck and c!est #eel tig!t everyS!e reports t!at !er neck and c!est #eel tig!t everyti"e s!e passes t!e sa"e accident site and tries toti"e s!e passes t!e sa"e accident site and tries toavoid it5 also &!enever s!e s"ells rubber5 petrol oravoid it5 also &!enever s!e s"ells rubber5 petrol or

even co##ee5 and even i# !er #ace roles ne)t to aeven co##ee5 and even i# !er #ace roles ne)t to a&ar" pillo& or !er son s!ines a torc! at !er&ar" pillo& or !er son s!ines a torc! at !er


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66Mary and t!e lorry7Mary and t!e lorry7Mary !it in t!e rear by a lorryMary !it in t!e rear by a lorrySounds o# screec!ing and breakingSounds o# screec!ing and breakingglassglassS"ell o# rubber5 petrol and spilt #res!S"ell o# rubber5 petrol and spilt #res!co##eeco##ee

Darkness5 dust5 a single !eadlig!tDarkness5 dust5 a single !eadlig!t4eeling o# being trapped4eeling o# being trappedMary5!ospital5 )+rays5 neck sprain%Mary5!ospital5 )+rays5 neck sprain%.!is &as si) "ont!s ago.!is &as si) "ont!s agoS!e still !as neck5 sternu" pain5S!e still !as neck5 sternu" pain5!eadac!es5 nausea5 sleep 8!eadac!es5 nausea5 sleep 8concentration proble"sconcentration proble"sS!e reports t!at !er neck and c!estS!e reports t!at !er neck and c!est

#eel tig!t every ti"e s!e 9#eel tig!t every ti"e s!e 9


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66Mary and t!e lorry7 + 'DMary and t!e lorry7 + 'D

PromotionPromotion

In#i(itionIn#i(ition

(n#or"ation regarding

p!ysical surroundings5 s"all5sounds5 so"atic and visceralpain and e"otions relating to

a trau"atic e)perience

'"ygdala o# t!e non+do"inant !e"isp!ere rig!t

Stored as i"plicit non+declarative "e"ory +Situationally 'ccessibleMe"ory A, +cannot

be recalled in anintegrated "eaning#ul

&ay

;ippoca"pus o# Do"inant!e"isp!ere le#t associatesand integrates as e)plicit

declarative +


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Case scenario Case scenario Mike !as &orked #or a !ig! street bank #or nearly t&entyMike !as &orked #or a !ig! street bank #or nearly t&enty

years over &!ic! ti"e !is >ob !as beco"e less varied andyears over &!ic! ti"e !is >ob !as beco"e less varied and"ore stress#ul"ore stress#ul

' year ago !e consulted occupational !ealt! as !e &as ' year ago !e consulted occupational !ealt! as !e &ase)periencing an increasing #re?uency o# pain#ul s&elling ande)periencing an increasing #re?uency o# pain#ul s&elling and

sti##ness in !is rig!t !and5 &rist and #orear"sti##ness in !is rig!t !and5 &rist and #orear"

Mike &as in#or"ed t!at !e !ad developed repetitive strainMike &as in#or"ed t!at !e !ad developed repetitive strainin>ury @S( a##ecting t!e tendons in !is &ristin>ury @S( a##ecting t!e tendons in !is &rist

Mike e)plains t!at t!e pain is o#ten spontaneous #or noMike e)plains t!at t!e pain is o#ten spontaneous #or noobvious reason5 t!e &rist and !and #eel sti## andobvious reason5 t!e &rist and !and #eel sti## and!ypersensitive i# t!ey touc! so"et!ing5 and is o#ten ac!ing5!ypersensitive i# t!ey touc! so"et!ing5 and is o#ten ac!ing5burning5 !as a prickling sensation along &it! s!ock+like >erksburning5 !as a prickling sensation along &it! s!ock+like >erksand #eel &eak ;e drops t!ings5 so tends not to use itand #eel &eak ;e drops t!ings5 so tends not to use it


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Case scenario Case scenario (n spite o# receiving various treat"ents5 electrot!erapy5(n spite o# receiving various treat"ents5 electrot!erapy5

e)ercises5 !ydrocortisone in>ections and prolonged use o# ae)ercises5 !ydrocortisone in>ections and prolonged use o# a&rist splint5 Mike is #inding it increasingly di##icult to stay at&rist splint5 Mike is #inding it increasingly di##icult to stay at&ork and #ears #or !is >ob5 as &ell as consu"ing a large&ork and #ears #or !is >ob5 as &ell as consu"ing a largenu"ber o# pain relieving tabletsnu"ber o# pain relieving tablets


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Mike5 a strain in t!e brainAMike5 a strain in t!e brainAMike5 !ig! street bank &orker 1 yrMike5 !ig! street bank &orker 1 yre)periencing an increasinge)periencing an increasing#re?uency o# pain#ul s&elling and#re?uency o# pain#ul s&elling andsti##ness in !is rig!t !and5 &riststi##ness in !is rig!t !and5 &ristand #orear"and #orear"(n#or"ed t!at !e !ad @S( a##ecting(n#or"ed t!at !e !ad @S( a##ectingar" tendonsar" tendonspain o#ten spontaneous5 t!ey #eelpain o#ten spontaneous5 t!ey #eelsti##5 !ypersensitive5 ac!ing5sti##5 !ypersensitive5 ac!ing5burning5 prickling5 s!ock+like >erks5burning5 prickling5 s!ock+like >erks5

&eak5 drops t!ings5 not using it&eak5 drops t!ings5 not using itvarious treat"ents5 increasinglyvarious treat"ents5 increasinglydi##icult &ork5 >ob #ears5 "anydi##icult &ork5 >ob #ears5 "anytabletstablets


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Case scenario .Case scenario .May !ad a teenage le#t knee in>ury and at C yearsMay !ad a teenage le#t knee in>ury and at C years

under&ent a total replace"ent o# !er le#t kneeunder&ent a total replace"ent o# !er le#t knee

een to start playing tennis again s!e !ad !ydrot!erapyeen to start playing tennis again s!e !ad !ydrot!erapybe#ore leaving !ospital t!at caused considerable pain5 t!isbe#ore leaving !ospital t!at caused considerable pain5 t!issee"ed to subside and May &as sent !o"e &it! ansee"ed to subside and May &as sent !o"e &it! an

e)ercise plan and analgesicse)ercise plan and analgesics

.!oug! s!e &as "eticulous in doing !er e)ercises t!e knee.!oug! s!e &as "eticulous in doing !er e)ercises t!e kneebeca"e "ore pain#ul and sti##erbeca"e "ore pain#ul and sti##er

;er doctor e)cluded in#ection and prescribed a co"bination;er doctor e)cluded in#ection and prescribed a co"binationo# analgesics and anti+in#la""atory drugs ,S'(Dso# analgesics and anti+in#la""atory drugs ,S'(Ds


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Case scenario .Case scenario . 't !er si)+&eek revie& &it! t!e surgeon t!e server pain and 't !er si)+&eek revie& &it! t!e surgeon t!e server pain and!ypersensitivity &as li"iting !er recovery5 t!e le#t knee!ypersensitivity &as li"iting !er recovery5 t!e le#t kneelooked s&ollen and generally &ar"er t!an t!e rig!tlooked s&ollen and generally &ar"er t!an t!e rig!t

's May appeared depressed s!e agreed &it! t!e surgeon to 's May appeared depressed s!e agreed &it! t!e surgeon toalso take antidepressants and use an ice cu## over t!e kneealso take antidepressants and use an ice cu## over t!e knee

By eig!t &eeks t!e le#t knee and &!ole leg &ere veryBy eig!t &eeks t!e le#t knee and &!ole leg &ere verypain#ul5 constantly ac!ed5 #elt &eak along &it! touc! andpain#ul5 constantly ac!ed5 #elt &eak along &it! touc! and"ove"ent related !yperalgesia - allodynia"ove"ent related !yperalgesia - allodynia

;er doctor o##ered !er "orp!ine patc!es to keep !er going;er doctor o##ered !er "orp!ine patc!es to keep !er goinguntil s!e consulted !er surgeon #or #urt!er adviseuntil s!e consulted !er surgeon #or #urt!er advise


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May5 post+op persistent painMay5 post+op persistent pain

May5 C 5 !ad a total le#t kneeMay5 C 5 !ad a total le#t kneereplace"ent op5 initial bad start5replace"ent op5 initial bad start5knee beca"e "ore pain#ul andknee beca"e "ore pain#ul andsti##er5 "ore analgesics 8 ,S'(Dssti##er5 "ore analgesics 8 ,S'(Ds

't C &eeks post+op server pain5 't C &eeks post+op server pain5!ypersensitivity5 li"ited recovery5!ypersensitivity5 li"ited recovery5s&ollen5 &ar"er5 May depressed5s&ollen5 &ar"er5 May depressed5also on antidepressants 8 ice cu##also on antidepressants 8 ice cu##By F &eeks t!e le#t knee - leg veryBy F &eeks t!e le#t knee - leg verypain#ul5 constantly ac!ed5 #eltpain#ul5 constantly ac!ed5 #elt&eak5 !yperalgesia - allodynia5&eak5 !yperalgesia - allodynia5"orp!ine patc!es to keep !er"orp!ine patc!es to keep !ergoinggoing


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19/41

Case scenario 1Case scenario 1Sara! su##ered #ro" acute onset o# lo& back pain a#ter aSara! su##ered #ro" acute onset o# lo& back pain a#ter ali#ting in>ury at &ork &!en s!e &as GHli#ting in>ury at &ork &!en s!e &as GH

S!e continued in t!e sa"e >ob and over t!e ne)t si) "ont!sS!e continued in t!e sa"e >ob and over t!e ne)t si) "ont!s!ad recurrent bouts o# back pain along &it! so"e neck!ad recurrent bouts o# back pain along &it! so"e neckac!eac!e

By !er #i#tiet! birt!day s!e !as to take days o## &orkBy !er #i#tiet! birt!day s!e !as to take days o## &orkbecause o# back5 neck or !eadac!es and "uscle painsbecause o# back5 neck or !eadac!es and "uscle pains

Sara! is #inding it di##icult to keep !er attention #ocused onSara! is #inding it di##icult to keep !er attention #ocused on!er &ork5 #inds !er sleep pattern is disturbed5 and is a&are!er &ork5 #inds !er sleep pattern is disturbed5 and is a&are

t!at !er co+&orkers are tending to isolate !er and aret!at !er co+&orkers are tending to isolate !er and are"aking co""ents about !aving to cover #or !er &!en s!e"aking co""ents about !aving to cover #or !er &!en s!e!as ti"e o##!as ti"e o##


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Case scenario 1Case scenario 1Just a#ter !er #i#tiet! birt!day Sara! consults !er doctor &it!Just a#ter !er #i#tiet! birt!day Sara! consults !er doctor &it!a greater t!an t!ree "ont! !istory o# "ultiple areas o#a greater t!an t!ree "ont! !istory o# "ultiple areas o#asy""etrical "uscle pain and sti##ness in !er li"bs5 neckasy""etrical "uscle pain and sti##ness in !er li"bs5 neckand back along &it! c!ronic !eadac!es5 a sleep disorder5and back along &it! c!ronic !eadac!es5 a sleep disorder5#atigue and poor attention5 and t!e beginnings o# a #unctional#atigue and poor attention5 and t!e beginnings o# a #unctionalbo&el disturbancebo&el disturbance

;er doctor carries out a series o# tests t!e results o# &!ic!;er doctor carries out a series o# tests t!e results o# &!ic!are nor"al 5 prescribes antidepressants and suggests t!atare nor"al 5 prescribes antidepressants and suggests t!ats!e consider early retire"ents!e consider early retire"ent


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Sara!5 &idespread pain a#ter back strainSara!5 &idespread pain a#ter back strain 't GH5 &ork IB in>ury5 over ne)t C 't GH5 &ork IB in>ury5 over ne)t C

"ont!s recurrent IBP5 so"e neck ac!e"ont!s recurrent IBP5 so"e neck ac!eBy 0By 0 t!t! birt!day5 days o## &ork5 back5birt!day5 days o## &ork5 back5neck5 !eadac!es5 "uscle pains5neck5 !eadac!es5 "uscle pains5attention di##iculties5 sleep patternattention di##iculties5 sleep patterndisturbed o+&orkers5 isolate !er5disturbed o+&orkers5 isolate !er5"aking co""ents about ti"e o##"aking co""ents about ti"e o##

'#ter 0 '#ter 0 t!t! birt!day consults doctor &it! abirt!day consults doctor &it! agreater t!an t!ree "ont! !istory o#:greater t!an t!ree "ont! !istory o#: "ultiple areas o# asy""etrical "uscle pain"ultiple areas o# asy""etrical "uscle pain

and sti##ness in !er li"bs5 neck and backand sti##ness in !er li"bs5 neck and back c!ronic !eadac!es5 a sleep disorder5 #atiguec!ronic !eadac!es5 a sleep disorder5 #atigue

and poor attention5 and t!e beginnings o# aand poor attention5 and t!e beginnings o# a#unctional bo&el disturbance#unctional bo&el disturbance

Doctor5 all nor"al5 antidepressants 8Doctor5 all nor"al5 antidepressants 8early retire"entearly retire"ent


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Sara!5 &idespread pain a#ter back strainSara!5 &idespread pain a#ter back strain

4ibro"yalgia4ibro"yalgiaMuscle tenderness5 &idespread "uscle pain5 allodynia5Muscle tenderness5 &idespread "uscle pain5 allodynia5a)ial pain "ust be presenta)ial pain "ust be present

'lso t&o o#: ;'5 (BS5 4atigue5 Sti##ness5 Sleep 8 attention 'lso t&o o#: ;'5 (BS5 4atigue5 Sti##ness5 Sleep 8 attentiondisordersdisorders


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Case scenario 2Case scenario 2.!e story o# ;enry is given by !is &i#e.!e story o# ;enry is given by !is &i#e

;enry !as su##ered a nu"ber o# in>uries and seen "any;enry !as su##ered a nu"ber o# in>uries and seen "any#riends in>ured and die#riends in>ured and die

My !usband !as beco"e &it!dra&n5 restless5 "elanc!olic5My !usband !as beco"e &it!dra&n5 restless5 "elanc!olic5no eye contact5 !as very disturbed sleep &it! dark drea"s5no eye contact5 !as very disturbed sleep &it! dark drea"s5tossing5 talking and s&eating in !is sleep5 !e !as lost !is se)tossing5 talking and s&eating in !is sleep5 !e !as lost !is se)drive5 appetite #or #ood and appears dra&n and paledrive5 appetite #or #ood and appears dra&n and pale

ased on “the ailments o! "enry "otspur”, as described by #ha$espeare in% "enryased on “the ailments o! "enry "otspur”, as described by #ha$espeare in% "enryI& 'art I% ct II #cene *. +his is a classic description o! 'ost +raumatic #tressI& 'art I% ct II #cene *. +his is a classic description o! 'ost +raumatic #tress

isorder.isorder.


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.!e ail"ents o# ;enry ;otspur.!e ail"ents o# ;enry ;otspur

.!e story o# ;enry is given.!e story o# ;enry is givenby !is &i#eby !is &i#e;enry !as su##ered a nu"ber;enry !as su##ered a nu"bero# in>uries and seen "anyo# in>uries and seen "any#riends in>ured and die#riends in>ured and dieMy !usband !as beco"eMy !usband !as beco"e&it!dra&n5 restless5&it!dra&n5 restless5"elanc!olic5 no eye contact5"elanc!olic5 no eye contact5!as very disturbed sleep &it!!as very disturbed sleep &it!

dark drea"s5 tossing5 talkingdark drea"s5 tossing5 talkingand s&eating in !is sleep5 !eand s&eating in !is sleep5 !e!as lost !is se) drive5!as lost !is se) drive5appetite #or #ood andappetite #or #ood andappears dra&n and paleappears dra&n and pale


25/41

@evie& o# Pain#ul onditions@evie& o# Pain#ul onditions

Sensory 8Sy"pat!etically

"aintainedpain

@e ta in ed S 'M

'l lo s ta tic an d E " o tio n a l I o a d

onte ) t5 o! es ion5 ontr ol

P las ticity o #t! e n e ur o+" a tri)S o" a to s e ns or y orte )

!ronic

idespread Pain4ibro"yalgia

(BS

!ronic ;''DP.SD

!ronic IBP

!ronic neck pain4ro en s!oulder

@PS@S( and 4;D

,erve in>ury painP!anto" pain


26/41

Part 2:Part 2:-sing our understanding o! pain to-sing our understanding o! pain to

in!orm our osteopathic models o! patientin!orm our osteopathic models o! patientmanagementmanagement


27/41

.!e proble" &it! Descartes.!e proble" &it! Descartes

Dualistic "ind body divideDualistic "ind body divide*ne+to+one relations!ip*ne+to+one relations!ip

D

!"

=ate ontrol .!eory=ate ontrol .!eory,euro"atri) .!eory,euro"atri) .!eory

Biological issuesBiological issuesPsyc!ological issuesPsyc!ological issuesSocial issuesSocial issues

ork issuesork issues


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Pain Mec!anis"s to Models o# (llnessPain Mec!anis"s to Models o# (llness=lasgo& (llness Model=lasgo& (llness Model

,ociception,ociceptionPainPainSu##eringSu##eringPain be!aviourPain be!aviour

PainPainDisabilityDisability

("pair"ents("pair"ents

Body structure 8 #unctionsBody structure 8 #unctions 'ctivity li"itations 'ctivity li"itationsPersonal #actorsPersonal #actorsParticipation restrictionsParticipation restrictions

;* - ( 4 classi#ications;* - ( 4 classi#ications

,europ!ysiologyP!ysiologic dys#unction

.issue da"ageA

(llness be!aviour Belie#s5 coping strategies

E"otion5 distress

ultureSocial interactions

.!e sick roleSocialSocial

Psyc!o+Psyc!o+

Bio+Bio+


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Models o# Pain and DisabilityModels o# Pain and Disability

PainPainDisabilityDisability

@isk #actors #or poor@isk #actors #or pooroutco"e 8outco"e 8obstacles to recoveryobstacles to recovery@isk o# acute@isk o# acutebeco"ing a c!ronicbeco"ing a c!ronicpain syndro"epain syndro"e.!e 4lag (nitiative.!e 4lag (nitiative*steopat!ic relevance*steopat!ic relevance0ed

3lags

Blue3lags

4ello'3lags

5range3lags

Black 4lags


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.!e ,euro+"atri) available #or intervention.!e ,euro+"atri) available #or intervention

SpinalSpinalordord

Seg"entSeg"ent

B+a##erent nerve #ibre nociceptive input

@educed anti+nociceptive in!ibition5aberrant activity in t!e inter neurone

pool su""ates to be a nociceptiveoutput Ioss o# sensory discreetness t!e $#u y seg"ent%

P!ysiological or pat!ological lo&ering

o# depolarisation potentials 4ro"Do&n+strea" "odulation or un"asking*# prior nociceptive event


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Brain Ste"Brain Ste"8 @eptilian8 @eptilianBrainBrainPlat#or"Plat#or"

'ltered biological patterns: altered5sleep 'ltered biological patterns: altered5sleeppattern5 breat!ing patterns5 !or"onalpattern5 breat!ing patterns5 !or"onalreleasesreleases

;eig!tened state o# arousal 8 stress;eig!tened state o# arousal 8 stress

Di"inis!ed pleasure #ro" altruistic acts5Di"inis!ed pleasure #ro" altruistic acts5#eeding5 etc#eeding5 etc

Ii"bicIi"bicSyste" andSyste" and

'lo+corte) 'lo+corte)BrainBrainPlat#or"Plat#or"

Depression and ot!er psyc!o+e"otionalDepression and ot!er psyc!o+e"otional

StatesStates 'n)iety states and undue #ear responses 'n)iety states and undue #ear responses

(nappropriate retained "e"ory o# trau"atic(nappropriate retained "e"ory o# trau"aticli#e eventsli#e events



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,eo+corte),eo+corte)BrainBrainPlat#or"Plat#or"

Belie# constructs suc! as $!urt "eansBelie# constructs suc! as $!urt "eans!ar"%5 etc Iack o# conte)t #or pain!ar"%5 etc Iack o# conte)t #or pain

e)perience and its e)planation5e)perience and its e)planation5di"inis!ed sense o# co!esion anddi"inis!ed sense o# co!esion andcontrol5 etccontrol5 etc@educed in!ibition@educed in!ibition


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.o&ards *steopat!ic .reat"ent (ntent.o&ards *steopat!ic .reat"ent (ntent'eripheral 'eripheral

3actor 3actor Treatment IntentTreatment Intent

(n#la""ation and(n#la""ation andinappropriate c!e"icalinappropriate c!e"ical

build+up in tissuesbuild+up in tissues

4luid "ove"ent to potentate rapid 84luid "ove"ent to potentate rapid 8resolving o# t!e in#la""atoryresolving o# t!e in#la""atory

cascade5 pro"ote scaring 8 !ealingcascade5 pro"ote scaring 8 !ealing(nappropriate or(nappropriate orunanticipatedunanticipated"ec!anical response"ec!anical response

o# tissueso# tissues

@estore "ec!anical relations!ips@estore "ec!anical relations!ipsbet&een tissues #ocus on $glidingbet&een tissues #ocus on $glidinginter#aces% in "yo+#ascial5 articularinter#aces% in "yo+#ascial5 articular

and neural structuresand neural structuresEctopic depolarisationEctopic depolarisationo# nociceptive a)onso# nociceptive a)ons

@e"oval o# "ec!anical or c!e"ical@e"oval o# "ec!anical or c!e"icalirritation o# nerve #ibre5 considerationirritation o# nerve #ibre5 considerationo# traction induced radial co"pressiono# traction induced radial co"pression


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.o&ards *steopat!ic .reat"ent (ntent.o&ards *steopat!ic .reat"ent (ntent#egmental #egmental

3actor 3actor Treatment IntentTreatment IntentB+a##erent input intoB+a##erent input intot!e spinal seg"entt!e spinal seg"ent

Enlarge t!e non+nociceptive '+Enlarge t!e non+nociceptive '+a##erent input t!at is a po&er#ula##erent input t!at is a po&er#ulin!ibitor o# B+a##erent trans"issionin!ibitor o# B+a##erent trans"issionPressure5 "uscle and >oint tensionPressure5 "uscle and >oint tensionand "ove"ent sti"uliand "ove"ent sti"uli

B+a##erent input intoB+a##erent input intot!e spinal seg"entt!e spinal seg"ent

Providing varied "ulti+"odalProviding varied "ulti+"odal"ove"ent 8 tension c!aracteristics"ove"ent 8 tension c!aracteristics

#ro" a &ide region o# t!e body#ro" a &ide region o# t!e bodyi"puting into t!at region o# cord andi"puting into t!at region o# cord andits connections Possibly passive atits connections Possibly passive at#irst5 rein#orced actively5 t!en as part#irst5 rein#orced actively5 t!en as part

o# a purpose#ul activityo# a purpose#ul activity


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3actor 3actor Treatment IntentTreatment Intent

.!e $#u y.!e $#u y

!o"unculus%!o"unculus%

Encourage discri"inative sensoryEncourage discri"inative sensory

in#or"ation and sense o# body in#or"ation and sense o# body re#res! t!e sensory !o"unculusre#res! t!e sensory !o"unculus

.o&ards *steopat!ic .reat"ent (ntent.o&ards *steopat!ic .reat"ent (ntentortex ortex


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K 'ssess #or @ed and Black 4lags5 and Biological (ssues

K@ecognise &!at are pain issues and &!at are disability issues

K4urt!er 'ction-re#erral-no treat"ent 8 Prevention o# #urt!er in>ury

K 'n e)planation t!at is conte)t based5 including your evaluation5any di##erential diagnosis and reassurance

K(nitial relie# o# sy"pto"s and Ensure ade?uate pain control and#irst+aid% advice in case t!ey get a reoccurrence

KEncourage staying active and "aintain a sense o##a"ily-social-&ork co!esion

K ' clear and concise "anage"ent strategy5 &!en to revie& and&!o to !o& to in#or" i# &orse o# ne& sy"pto"s develop and

Ensure t!at e)pectations are si"ilar

Su""ary o# *steopat!ic Manage"ent 'pproac!Su""ary o# *steopat!ic Manage"ent 'pproac!

(""ediate or S!ort+ter" action:(""ediate or S!ort+ter" action:


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K Supporting t!e restoration o# local tissue !ealt!

K onsider in#or"ally #or"ally a#ter si) &eeks Lello&5k*range5 Blue 4lags

K 'ddressing t!e diverse Biopsyc!osocial BPSsu""ative distant #actors5 or blocks to recovery

K @e#ine"ent o# your evaluation

K Developing &it! t!e patient interventions t!at &ill supportc!ange

K ,egotiating &it! t!e patient your plan5 revisitinge)pectations and &!en to revie&

K @estoration o# $capacity%

Su""ary o# *steopat!ic Manage"ent 'pproac!Su""ary o# *steopat!ic Manage"ent 'pproac!Mediu" ter" intervention:Mediu" ter" intervention:


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K Discussion o# any appropriate li#e+style issues

K Education and advise re#er to guidelines #or education

and discussion issues suc! as prevention o# lo& back pain5etc

K onsider i# t!ere is a need "ulti+pro#essional support

K onsideration &it! patient o# longer+ter" e)pectations orcoping &it! t!e end disability

K @estoration o# $agency%

Su""ary o# *steopat!ic Manage"ent 'pproac!Su""ary o# *steopat!ic Manage"ent 'pproac!

Ionger ter" ai"s:Ionger ter" ai"s:


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@evie& o# our "odel@evie& o# our "odel


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TheNociceptive

System

BrainBrain

DescendingDescending$$Pain% Pat!&aysPain% Pat!&ays

'scending 'scending$$Pain% Pat!&aysPain% Pat!&ays

(nput #ro" t!e(nput #ro" t!e(nternal Environ"ent(nternal Environ"ent

(nput #ro" t!e(nput #ro" t!eE)ternal Environ"entE)ternal Environ"ent

BrainBrain*utput*utput

PainPain

B+a##erent #ibre receptor #ield

,euro+secretions Mec!anical or !e"ical sti"ulus

B+a##erent neurons in perip!eral nerve 8 spinal nerve root

Spinal ord $seg"ent% Dorsal ;orn D@+cells

'scending Pat!&aysMedial Iateral

Spino+reticular Spino+t!ala"ic

Descending Pat!&ays@eticulo+spinal

ortico+spinal

,eo+corte) neuro+c!e"ical Be!avioural Plat#or"onte)t o!esion ontrol

'lo+corte) E"otion - Me"ory Plat#or"

.!e brain Survival Plat#or"Sleeping Breat!ing 4eeding Se)

'nalysiso# $.!reat%

Multi+syste"Brain *utput

ConsciousConscious PainPain

session 3_lisbon_may_2010.ppt

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