Ponencia de Arturo Such para el #HandFun celebrado en Begues el 23 de septiembre de 2012. Titulada: Assessing cortical changes in patients with pain

1. Assessing cortical changes in patients with pain

2. Pain
Pain is the cortical output of highest priority.
Moseley, 2003
1- Pain is an output of the brain that is produced whenever the brain concludes that
body tissues is in danger and action is required.
2- Pain is a multisystem output that is produced when an individual-specific cortical
pain neuromatrix is activated.
Moseley, 2003
Pain the defender, not the ofender Sicuteri, 1992

3. Pain
1. Pain does not provide a measure of the state of the tissues
2. Pain is modulated by many factors: somatic, psychological and social
3. Relationship between pain and the state of the tissues is less predictable
as pain persist
4. Conscious correlate of the implicit perception that tissue is in danger.
Moseley, 2007

4. Nervous System
- Predictor, creator of experiences (Bayes)
- Dynamic, not static

5. Changes in the Nervous System
· Peripheral and central changes
· Sensitization:
Nonassociative learning. Repeated or extended application of a stimulus leads
to an increase response. Flor, 2012
LTP (memory mechanisms) Ji, 2003
·Disinhibition (impresicion) - Increase in RF
· Adaptative or maladaptative Woolf CJ, 2004

6. Assessment
Subjective examination
Sensory examination
Motor examination
Autonomic examination
MAKE THE FEATURES FIT
“Without identification of the mechanisms, the optimum treatment strategy
for the patient´s pain cannot be selected”
Woolf & Mannion, 1999,

7. Clinical Assessment
Sensory Examination Motor Examination Autonomic Exam
Skin sensation: Observation: Observation:
Light touch Muscle wasting Skin
Superficial pain Strength tests Horner´s syndrome
Hot and cold Functional tests
Deep sensation: Reflexes:
Pain Stretch reflexes
Propioception Skin reflexes
Vibration CNS reflexes
Butler 2000

8. Sensory Examination
• Light touch:
• Light touch (Semmes-Weinstein filament) - Fibres Aβ - Aα
• Superficial pain: Aδ - C
• Hot and Cold: Aδ - C
• Profound sensation:
• Pain
• Propioception
• Vibration
• Cortical changes: Movement dystonia
• Graphoesthesia
• Finger identification
• Stereognosia
• TPD

10. Peripheral/central sensitization
Fibromyalgia WAD patients
Banic B. et al. Pain 2004

11. Treatment

12. Subjective examination: yellow flags
Beliefs that pain equals injury
Fear avoidance-behavior
Changes in social interaccion. Mood changes
Expectations on passive treatments
Affective component:
Suffering, description as negation of live...
Treatment: Explain pain:
biologic explanation
Graded exposure (activation)

13. Treatment

14. Treatment

15. Treatment

16. Treatment

17. Distraction
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un descompresor mpeg4.

18. Sensitization - Changes in RF
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19. Cortical Reorganization in CRPS
Marinus 2011

20. Cortical Reorganization in Phantom Limb
Flor H 2002

22. Changes in TPD in CLBP patiens
Moseley 2008

23. Treatment sensitivity cortical changes
Moseley 2008

24. Treatment sensitivity cortical changes
Short Term Long Term
Moseley, 2009

25. Treatment sensitivity cortical changes
Moseley 2009

26. Changes in peripersonal space
• Peripersonal space in CRPS
Moseley 2009
• Peripersonal space in Knee
Osteoarthrosis Pain
Stanton, 2012
• Assessment: recognise, TOJ

27. Motor Control
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28. Treatment motor cortical changes
• Graded Motor Imagery
• Laterality
• Imagery
• Mirror Therapy
• Correction of somatosensation?

29. Treatment

30. Treatment

31. Graded Exposure
Motor: Motor:
Distraction Confrontation
Pacing
Somatosensory:
Somatosensory: Gaze
Gaze No mirror
Mirror Brush
Brush Distraction
Atention needed!!!

32. Is it possible that the physical examination, with its exhaustive and often
repetitive provocation of specific joints, with specific mobilisations, which
require the patient to carefully attend to and discriminate the location, quality
and intensity of the percept works via similar mechanisms to discrimination
training?
Is it possible that learning precise and sometimes subtle motor skills, which
require the patient to attend carefully to specific body parts and to discrimi-
nate the contraction of one muscle from the contraction of its immediate
neighbour, has a similar effect?
Moseley 2008

33. Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther.
Moseley GL. Reconceptualising Pain. Physical Therapy Reviews. 2007 Aug 25;3(12):169-78.
Flor H. New developments in the understanding and management of persistent pain. Current opinion in psychiatry. 2012 Jan 6.
Ji R-R, Kohno T, Moore KA, Woolf CJ. Central sensitization and LTP: do pain and memory share similar mechanisms? Trends Neurosci. 2003 Dec
1;26(12):696-705.
Woolf CJ. Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management. 2004 Mar 16:1-11.
Banic B, Petersen-Felix S, Andersen OK, Radanov BP, Villiger PM, Arendt-Nielsen L, et al. Evidence for spinal cord hypersensitivity in chronic pain after
whiplash injury and in fibromyalgia. Pain. 2004 Jan 1;107(1-2):7-15.
Marinus J, Moseley GL, Birklein F, Baron R, Maihöfner C, Kingery WS, et al. Clinical features and pathophysiology of complex regional pain syndrome.
Lancet Neurol. 2011 Jul 1;10(7):637-48.
Moseley GL. I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008 Nov 15;140(1):239-43.
Moseley GL, Wiech K. The effect of tactile discrimination training is enhanced when patients watch the reflected image of their unaffected limb during
training. Pain. 2009 Aug 1;144(3):314-9.
Moseley GL, Zalucki NM, Wiech K. Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain. Pain. 2008 Jul 31;137(3):600-8.
Maihöfner C, Handwerker HO, Neundörfer B, Birklein F. Patterns of cortical reorganization in complex regional pain syndrome. Neurology. 2003 Dec
23;61(12):1707-15.
Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol. 2002 Jul 1;1(3):182-9
Koelbaek Johansen M, Graven-Nielsen T, Schou Olesen A, Arendt-Nielsen L. Generalised muscular hyperalgesia in chronic whiplash syndrome. Pain.
1999 Nov 1;83(2):229-34.
Moseley GL, Gallace A, Spence C. Space-based, but not arm-based, shift in tactile processing in complex regional pain syndrome and its relationship to
cooling of the affected limb. Brain. 2009 Nov 1;132(Pt 11):3142-51.
Stanton TR, Lin C-WC, Smeets RJEM, Taylor D, Law R, Lorimer Moseley G. Spatially defined disruption of motor imagery performance in people with
osteoarthritis. Rheumatology (Oxford). 2012 Aug 1;51(8):1455-64
Moseley GL. Pain, brain imaging and physiotherapy--opportunity is knocking. Man Ther. 2008 Dec 1;13(6):475-7