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- 2. DIFFERENTIALS • Before treatingany patient you must RULE OUT THE WORST CASE SCENARIO • X-ray, MRI, Blood plasma, special test. • Red flags: – PMH, Unexpected Weight loss, Lumps, Saddle Anesthesia, Fever
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- 5. WHY DOES ISHURT? • Bio-physiological Explanation Acute Phase – Nociception: actual tissue damage response – Nociceptors- respond to stretch, tears, pinch, heat, noxious biochemical. (Garland 2012) - Inflammatory response ensues • Chronic pain – Toxic levels of Glutamate found in Achilles tendonosis. (Maffulli, 2008) • High intensity exercise may enhance the uptake of Glutamate. (Cunhaa, 2012) • There is no inflammatory process in chronic pain
- 7. Insult to Injury •FAST vs. SLOW – Fast pain is the immediate sensation (sharp, prickling) that is felt due to an injury. (Aδ) – Slow pain is the longer lasting, more intense, and throbbing pain. ACUTE • If the cause of pain is not addressed immediately it may become chronic. (Garland 2012)
- 8. The Stats… • Accordingto the APTA over 116 million people in the US have chronic pain each year. • The cost in the United States is $560–$635 billion annually for medical treatment, lost work time, and lost wages.
- 9. What is IT? •Chronic pain: – Pain lasting longer than three months – Hypersensitivity of the CNS/PNS • May lead to: – Fearfulness – Poor circulation – Weight gain – Pharmacology use/abuse
- 10. Capacity • Reoccurring instancesof tendon pain may be due to the patient attempting to use the muscle at a capacity that it is not suitable for.
- 11. It’s Not AboutSize • Research suggest, in regards to rotator cuff injuries, the tear size, superior head migration, and rotator cuff muscle atrophy were not associated with pain level. • What was associated? 1. Number of co-morbidities 2. Education level 3. Race • Relevance: – Surgery will not fix the associated factors or pain. – Look elsewhere to decrease pain (SFMA?) (Matsen III, 2014)
- 12. Movement Analyst • AsPT’s, we are trained movement specialists – We examine for asymmetries and abnormalities of movement and strength. • SFMA (not voodoo) is a tool to incorporate into your examination. – It allows you to look for dysfunctions that may be contributing to their chronic pain.
- 13. Tendinopathy • Tendinitis (acute)Tendinosis (chronic) • Angiofibroblastic Hyperplasia • Plan of care: POLICE • Enhance collagen layout through manual/instrumental techniques. – Breakdown scar tissue and promote linearly oriented collagen. • Start Optimal Loading at every stage of treatment. – Isometric Con/Eccentric • HEP- reinforce what you did in the clinic at home.
- 14. A Continuum ofStages • Reactive- cell proliferation phase where tendon thickens and tightens to reduce stress on tendon Acute, tendon swelling • NSAIDS • Disrepair- Collagen disorganization and possible neovascularisation. • Degenerative- Increased scar tissue and microvasculature. May lead to RUPTURE • NO NSAIDS (Cook, 2009)
- 15. Alfredson Rehab Model •Rest (active or full) • Orthotic/Corrective Treatment • Medication • Stretching • Strength Training (eccentric focused) Eccentrically load (180 heel drops/ day) through pain in attempt to damage the AFH and nerve endings signaling pain - Slight difference in mid vs insertional tendon (Alfredson, 2007)
- 16. Fundamental Rules ofTissue • Length: if the tendon is pre- stretched, its resting length is increased, and there will be less strain on that tendon during movement. • Load: by progressively increasing the load exerted on the tendon, there should be a resultant increase in inherent strength of the tendon. • Recruitment: by increasing the speed of contraction, a greater force will be developed. (Maffulli,2008)
- 17. Pushing Through ThePain • Patients should not be returning to activities that are causing pain. Altered motor Patterns • However, in a controlled environment, incorporating some level of pain into the exercise program may affect nociception and decrease the magnitude of pain in the next flare up. (Cook, 2003)
- 18. Effects of ManualTherapy • Chemical Changes: Increased blood levels of neurotensin, oxytocin, and cortisol (cervical manipulation) • Improvements in signs and symptoms when providing MT to a remote location. Such as treating cervical pain with MT directed to the thoracic spine. • “bombard the central nervous system with sensory input from the muscle proprioceptors” • Systemic changes: Positive change in skin conductance, respiratory rate, blood pressure, and heart rate. • Higher Force (90N compared to 30N) yields greater decrease in chronic neck pain no indication of mechanical transformation (Plaza-Manzano, 2014) (Cleland et al., 2007) (Pickar & Wheeler, 2001). (Kingston, 2014) (Snodgrass , 2014)
- 19. Tai Chi (nottea) • Tai Chi Vs. Stretching for LBP – Imbalances between spinal erectors and trunk flexors reducing flexibility. – Compilation of slow and smooth motions – More effective in pain reduction and decreased muscle activity. (Cho, 2014) • High Threshold strategy- Spurt take over Shunt • Rhythmic motion does not have to be strictly Tai Chi.
- 20. Fear Avoidance Model •Psychological factor stronger than physical? • People adapt in response to pain • FAM suggests introducing the patient to situations they avoid due to pain or anxiety in a controlled setting. • Combines tissue adaptations through exercises and psychological changes through accomplishments of motions. (George, 2009)
- 21. • Alfredson, Håkan.Cook, Jill. 2007. A treatment algorithm for managing Achilles tendinopathy: new treatment options. British Journal of Sports Medicine; 41(4): 211–216. • Bluma, E. Procaccib, P. Conteb, V. Hanania M. 2014. Systemic inflammation alters satellite glial cell function and structure. A possible contribution to pain. Neuroscience. Volume 274; Pages 209–217 • Cho, YongHo. 2014. Effects of Tai Chi on Pain and Muscle Activity in Young Males with Acute Low Back Pain. Journal of Physical Therapy Science; 26(5): 679–681. • Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. 2007. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual Therapy,10(2):127-35. • Cook, Jill. Purdam, Craig. 2013. Rehabilitation of lower limb tendinopathies. Clinical Sports Med 22 (2003) 777 – 789 • Cunhaa, Maira J. Cunhaa, Aline A. 2012. Physical exercise reverses glutamate uptake and oxidative stress effects of chronic homocysteine administration in the rat International Journal of Developmental Neuroscience; Volume 30, Issue 2, Pages 69–74 • Garland, Eric L. 2012. Pain Processing in the Human Nervous System: A Selective Review of Nociceptive and Biobehavioral Pathways. National Institute of Health and Primary Care, Sep 2012; 39(3): 561–571. • George, Steven Z. 2009 Physical Therapy Utilization of Graded Exposure for Patients With Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy; 39:7, 496-505. • Kingston, Laura. Claydon, Leica. Tumilty, Steve. 2014. The effects of spinal mobilizations on the sympathetic nervous system: A systematic review Manual Therapy, Volume 19, Issue 4, Pages 281-287 • Matsen III, Frederick . 2014. Shoulder Pain Does Not Parallel Rotator Cuff Tear Size—What Does That Tell Us? Journal of Bone and Joint Surgery, 21;96(10):e86 • Maffulli, N. Longo, U. G. How do eccentric exercises work in tendinopathy? 2008. Oxford Journals Rheumatology; Volume 47, Issue 10Pp. 1444-1445 • Pickar JG, Wilder DG. Spinal manipulation alters electromyographic activity of paraspinal muscles: a descriptive study. J.Manipulative Physiol Ther. 2005;28:465–471. • Plaza-Manzano, Gustavo. Molina, Francisco. Lomas-Vega, Rafael. Et. Al. 2014. Biochemical Markers of Pain Perception and Stress Response After Spinal Manipulation. Journal of Orthopaedic & Sports Physical Therapy, Volume: 44 Issue: 4 Pages: 231-239 • Snodgrass SJ, et al. 2014 Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. Journal of Orthopedics and Sports Physical Therapy, (3):141-52. • Wu, A. , Green, C.R. Rupenthal, I., Moalem-Taylor, G. 2012. Role of gap junctions in chronic pain. Journal of Neuroscience Research, Volume 90, Issue 2 Pages 337-345. • Zane, Mary Kay. 2012. Physical Therapist's Guide to Chronic Pain Syndromes. MoveForwardPT. • Cook JL, Purdam CR: Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009, 43(6):409-416.
Editor's Notes
- #19 Neurotensin- It induces a variety of effects, including: analgesia, hypothermia and increased locomotor activity Oxytosin- also known as the “bonding hormone” enhances relaxation and trust. Corticol- increase blood glucose, decrease immune response, aide in metabolism