SC-Atlanta Quarter 4 Integrative Pain Sciences (IPS) Final Exam PDF

SC-Atlanta Quarter 4 -Integrative Pain Sciences (IPS) Final exam Question type (N=80) Number of question type T/F MC Fill in black 18 51 11 Likelihood of correct response by % 50% 25% 25% Exam content materials can be found in the following Recording Syn Lectures and or PowerPoint presentations. Syn...

SC-Atlanta Quarter 4 -Integrative Pain Sciences (IPS) Final exam Question type (N=80) Number of question type T/F MC Fill in black 18 51 11 Likelihood of correct response by % 50% 25% 25% Exam content materials can be found in the following Recording Syn Lectures and or PowerPoint presentations. Sync Session Week 2 (April10th) Dr Shaw Define DIMs and SIMS; how the relationship between DIMS &Sims produces pain. - DIM (danger in me) is anything you perceive to be dangerous to your body, well being or yourself as a person - A SIM (safety in me) is anything that evokes a sense of health happiness, comfort or confidence - DIMs > SIMs= potential pain What does “hurt doesn’t always mean harm” mean? - Perceived discomfort, soreness, “pain” is may not be correlated to tissue damage What is PNE? What percentage of patients need it? What metaphors are used? - Pain Neuroscience Education (PNE): is an educational approach use to increase a patient’s knowledge about pain (how it works biologically and physically) as a strategy to improve pain - - Metaphor The sensitive Alarm system metaphor When you step on the rusty nail, the alarm in the foot goes off. The alarm sends “danger” message to the brain The brain produces pain to grab your attention and get you to take care of the proble, Once you take the nail out the alarm should go down/back to a normal level. As a result you may feel discomfort or pain in the foot for a few days. This is normal once the alarm is back to its previous threshold it ready for another danger event 1 in 4 people will have alarm that doesn’t return to their normal (baseline) The threshold may be more elevated now Intervention historically used with PNE - PNS was first used in conjunction with manual therapy as mobilizations were used to treat the nervous system Candidates for PNE - Patient with: High pain catastrophizing High fear avoidance With chronic pain With central sensitization/nociplastic pain Those “ready for change: Contemplation or preparation phases of behavior change - It is not only for patient with chronic pain. It has been used with people with Preop- surgery post- surgical pain management Middle school to improve students pain knowledge fostered healthier belied about pain reducer fear avoidance around injury Acute pain Older pain Define yellow flags and know examples. Yellow flags: Are psychosocial factors that have been shown to correlated with the development of chronic pain - Yellow flags have led to the development of the FABQ, TSK and PCS outcome measures Examples of yellow flags: - Failed treatments - Family issues - Fear and anxiety - Chronic pain - Job issues - Contrasting expectation regarding treatments Sync Session Week 3 (April 15th) Dr Fondren Know beliefs and expectations related to chronic low back pain (Main et al article) The CB-CFT intervention has 4 main components. - The CB-CFT intervention 1. Cognitive component for each patient, their vicious cycle of pain was outlined in a diagram based on their finding from the examination and the OMPQ 2. Specific movement exercises designed to normalized maladaptice movement behaviors as directed by the movement classification 3. Targeted functional integration of activities in their daily life, reported to be avoided or provocative by patient and 4. A Physical activity program tailored to the movement classification Know physical exam elements associated with chronic pain (nociplastic/central sensitization symptoms): 7 physical exam elements. - Physical exam elements can identify Low pressure pain threshold Cold hyperalgesia Diffuse palpation tenderness Kinesiophobia Altered gross movement patterns. Altered 2-point discrimination Altered laterality Who needs PNE? EVERYONE basically - Pain neuroscicen education as a stand alone treatment generated clinical meaningful improvement in fear of movement and pain catastrophizing but not effective for relieving pain in patient with pain - Clinicians should focus on movement as the key element of managing persistent pain adjunct intervention may be used to facilitate movement - Pain education when applied to clinician may be beneficial to effect changes in belief and attidues about pain and improve delivery of evidence based interventions - Collaboration and teamwork both within the profession and with our patients will be key to tackling the current pain and opioid epidemics “Magic of exercise”- exercise induced analgesia: know those exercises intensities. - Exercise is the biggest pain killer on the planet! A 6 mile run stimulate endorphin release that is equivalent to 10 mg of morphine - Baseline threshold for aerobic prescription to elicit exercise-induced analgesia >50% of VO2 max Duration > 10 minutes Define Graded motor imagery and components of this intervention. What is the sequencing for implementing these components? - Graded motor imagery (GMI) treatment program that aim to sequenti ally activate the premotor and primary motor cortices through 3 steps 1. Left/right discrimation – People in pain often lose the ability to identify left or right images of their painful body part 2. Explicit motor imagery – Thinking about moving without actually moving 3. Mirror therapy- If you put left hand behind a mirror and right hand in front you can trick your brain into believing that the reflection of your right hand in the mirror is your left and you are now exercising your left hand in the brain Sync session week 3 (April 17th) Dr Fondren Wait “What signals go where”? know those 3 steps to ascending pathway pain perception processing. 1. Transduction 2. Transmission 3. Integration of nociceptive signaling and perception of pain Laterality: defined, intervention implementation rules, areas of brain activated - Laterality: The accuracy and speed of identifying if the body part is a left or right part therefore accomplishing left and right discrimination - Loss of laterality is often seen in amputees, CRPS population, chronic back pain, carpal tunnel, knee OA, post CVA and radiculopathies - Laterality activates the pre-motor cortex not the primary motor cortex Rules - Start with UE if LE injury and vise versa - If bilateral pain the worse side is the abnormal side - Most be achieved before performing mirror therapy - Achievement >80% accuracy and 1.6 second speed GMI/Explicit motor imagery: defined, intervention implementation rules, areas of brain activated, and progression of positions. Imagine a body part - Progression-> Static-> Dynamic-> Functional task - Activation of pre motor cortex and primary motor cortex Application - Ask/ identify top 10 task that need to be performed that are painful or being avoided - Find images - Patient will draw a card and imagine body parts - Progression to mirror therapy when motor imagery can be completed to mirror therapy when motor imagery can be completed without significant increase in pain, swelling and emotions Mirror Therapy defined criteria for appropriateness. - Using uninvoled side to “trick the brain” into thinking the involved side is moving - Laterality must be restored first to avoid increased confusion and pain - Remove jewerly, cover tattoos etc. - Graded exposure , Sync Session Week 4 (April 22) Dr Fondren Define smudging & relationship with the homunculus. - Smudging: Changes in brain area that are devoted to detecting the stimulation of body part and performing functions that being overlapping Two-point discrimination assessment Pressure sufficient to blanch skin Average of 5 ascending and 5 descending measurements Start at 0mm, increase until 2 points clearly felt graphesthesia defined and implementation process. - Graphesthesia- is the ability to recognize symbols written on the skin through tactile pressure PT randomly stimuted the 9- blocks asking for continuous verval feedback as to the location of the stimulus; this was done for 5 minutes in total With a correct identificagtion of the area the PT proceeded to the next block for identification In the event of an incorrect answer the area was re-stimulated and the therapist would develop a greater ability to identified the stimulated grid The stimulation of the grids was a random and decided upon per discretion of the clincian know what sleep hygiene is and recognize examples. benefits of gratitude and heuristic model components - Gratitude has a measurable benefits for just about every area of our lives. Gratitude appeared to contribute substantially to individual well- being and physical health - Benefits: Improved quality of sleep Decreased sensitivity to pain Improved pain tolerance An increased in self-esteem members of interprofessional team 38 different medical specialties define functional medicine. - The functional medicine model is an individualized, patient-centered, sciencebased approach that empowers patients and practitioners to work together to address the underlying causes of disease and promote optimal wellness. It requires a detailed understanding of each patient’s genetic, biochemical and lifestyle factor and leverage that data to direct personalized treatment plans that lead to improve patient outcomes. Sync Session Week 5 (April 29th) Dr Fondren SMART goal acronym and what it stands for Define motivational intervention and purpose. Readiness and change Be able to identify the “Commercial” drug examples on all levels of drug pyramid. Schedule 1: Substance that have no currently accepted medical use in the united states a lack of accepted safety for use under medical supervision and a high potential for abuse - Heroin - Lysergic acid diethylamide (LSD) - Peyote - Methaqualone - Escatsy Schedule 2: Substance in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence - Hydromorphone - Meperidine - Fentanyl - Opium - Amphetamine (Adderall) - Methylphenidate (Ritaline) - Methadone (Dolophine) - Oxycodone (Percocet) - Morphine - Codeine -Methamphetamine (Desoxyn) Schedule 3: Substances in this schedule have potential abuse less than substance 1 or 2 and abuse may lead to moderate or low physical dependence or high physical dependence or high psychological dependence - Combination product containing less than 15 mg of hydrocone per dosage unit (Vicodin) products containing not more than 90 mg of codein per dosage unit (Tylenol with codeine) and buprenorphine (suboxone) Schedule 4: Have low potential for abuse relative to substance in schedule III - Alprazolan ( Xanax) - Carisoprodol ( Soma) -Clonazepam (Klonopin) - Clorazepate ( Tranxene) - Diazepam (Valium) - Lorazepam (Ativan) - Midazolam (Versed) - Temazepam (Restoril) - Triazolam (Halcion) Schedule 5: Have low potential for abuse relative to substance listen in schedule IV and consist primarily of preparations containing limited quantities of certain narcotics - Cough preparation containing not more than 200 mg of codein per 100 milliliters or per 100 grams (Robitussin AC, Phenergan with codeine and ezogabine Identify commercial names of TCA, SSRI, membrane stabilizers, and opioids drugs. - TCA- Tricyclic Antidepressant - Selective Serotonin Reuptake Inhibitors (SSRIs) - Membrane Stabilizing Medication - Opioid medication Side effects of opioids and purpose of BRAVO B – Broaching the subject R – Risk-benefit calculator A – Addiction happens V – Validation happens O – Other treatments for pain Last Sync Week 5 (May 1st) Dr Shaw Know benefit exercise on chronic pain based on evidence from studies on slide #3 - Numerous clinical studies find substantial evidence to support the role of exercise in controlling chronic pain. These studies have focused on various chronic pain conditions, including low back pain, fibromyalgia, osteoarthritis and neuropathic pain - The journal of pain review of 36 studies found that exercise effectively reduced pain intensity and improve physical function for chronic msk pain - The result of trial published in “Arthritis care and research” demonstrated that exercise significantly reduce pain severity and improve physical function in patient with knee osteoarthritis - A study published in the “Annal of internal medicine” found that aeorib exercise and strength training effectively reduced pain and improved symptoms in individuals with fibromyalgia Characteristics of an exercise prescription - Patients goals? - Individualized plan and patient centered - Prescribe- How frequent and how it should be performed - Exercise has side effects- Discomfort, soreness, boredom, inconvenience, fatigue, etc. - Establish as baseline of function Benefits of exercise and reasons to stop exercise. Benefits of exercise Reason to stop exercise Helps manage chronic pain Nausea and vomiting Improves quality of life Not able to catch breath Help manage body weight Chest pain Help manage blood pressure Lightheadedness/dizziness Help manage mood/affect Feeling faint Help with fatigue and tiredness A new pain or injury Help with sleep define exercise: mode/type, intensity frequency duration & manipulating these variables to progress exercise. - Mode/type: Aerobic (endurance training), Resistance (strength training), Flexibility and balance - Intensity: The level of effort being exerted by the participant and can be measured in a variety ways - Duration and frequency: The length and number of exercise sessions performed within a given time (3 sets if 10 reps 3x wk for 4 weeks) - PROGRESSION--- Progressing aerobic exercise include increasing the duration of session 5 to 10 min every 1-2 weeks for first 4-6 weeks - Frequency and intensity can be preogress as tolerated. Overall volume should be monitor for adverse effects decreased if necessary - In the case of resistance exercise, increasing repetitions (endurance) is favored before increasing load (intensity). Once the maximum repetitions for a target range have been achieved load can increase by approximately 5% so that no more than the lower limit of repetitions (8-12 reps) can be performed Know ACSM and CDC exercise guidelines. - 150 Minutes of moderate-intensity aerobic activity every week - 2 X per week muscle strengthening activities on 2 or more days a week that work all major muscle groups Reasons for exercise prescription for chronic pain Aerobic ( water based): Up to 30 minutes/5 days a week, moderate intensity Strengthening: Start with 1 set of reps with goal of performing 3 sets Stretching: Hold 30 seconds (may need to start lower) and repeat 3 times Appropriate moderate intensity rating for client with chronic pain What is the neurophysiological basis using this moderate intensity? - - - Chronic pain is an syndrome that result in the dysregulation of the nervous system processing of the nociceptive or unpleasant stimuli. It causes our nervous system to become more sensitive routine activity We want to retrain the brain and nervous system to become less sensitive to nociceptive inputs. “Moderate” Exercise or physical activity taps into the neuroplastic properties of the nervous system to shift or change sensitivity back toward “before pain threshold” Additionally we could mindful awareness while performing exercises noticing bodily sensations/ discomfort as a cues for rest or change position or add use support (toward >7/10). The goal while doing activity is to minimize a pain flare up Sensations are associated with pain, discomfort, or possible flare with exercise. - Joint pain: Aching, burning, swelling and stiffness - Bone pain: Deep and dull - Muscle Pain: Cramps, aches and muscle seizures - Tendon pain: Sharp pain at the time of injury that worsens with tenson use - Tenson pain “ Pins and needles” sensations, tingling burning, soreness, weakness or uncontrolled twitching Body systems involved in the exercise induced analgesic and anti-inflammatory effect physical exercise. 1. Within the central nervous system: The opiod and endocannabinoid system (your body’s in-house pharmacies) are activated during physical exercise to provide most analgesic effect 2. Hormonal/endocrine (hormonal) system: during physical exercise progesterone is released and is known to produce an analgesic effect 3. Immune system: Physical exercise dec level of pro-inflammatory cytokines by activating macrophages to release anti- inflammatory cytokines These analgesic processes (shift of the alarm threshold) via physical exercise is dependent on the progression intensity (load/resistance) and volume (consistency/frequency). Start with low intensity activities with minimal discomfort Why paired breathing is important. - Breathing with movement is important because it activate the parasympathetic (rest and digest) Keep the nervous system calm Steps to construction exercise prescription 1. Evaluation/assessment: perform biopsychosocial assessment, MMT, goals, perform any psychological assessment, posture, identify impairments, NRS etc 2. Assess dynamic movement and pain/discomfort with movement. Identify modes of activities to performed 3. Provide therapeutic (pain) neuroscience education 4. Establish baseline activity tolerance for modes of exercise in your treatment session. This can begin the formation of the patients home exercise program (HEP). Model, coach and or perform activities or exercises with patient. This is especially important if they have high TSK, FABQ or PCS scores around movement 5. Establish endurance, intensity, frequency and duration for HEP with patient. Identify possible barriers to executing HEP. Give them about 2-3 exercises no more than 4. Don’t overwhelm them with HEP 6. Schedule follow up session and get feedback and modify HEP as needed Questions to ask for someone who “is feeling pain” during activity.