Week 4 - Clinical Assessment and Chronic Pain.pdf

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright u...

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice  EHR520 – Week 4 Clinical Assessment and Chronic Pain Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Clinical Assessment and Chronic Pain POSTURE AND BODY MECHANICS Definition of Posture “Posture is usually defined as the relative arrangement of the parts of the body. Good posture is the state of muscular and skeletal balance that protects the supporting structures of the body against injury or progressive deformity irrespective of the attitude (e.g. erect, lying, squatting and stooping) in which these structures are working or resting. Under such conditions, the muscles function most efficiently, and the optimum positions are afforded for the thoracic and abdominal organs. Poor posture is a faulty relationship of the various parts of the body, which produces increased strain on the supporting structures and in which there is less efficient balance of the body over its base of support.” Posture Committee of the American Academy of Orthopaedic Surgeons Week 4 - Clinical Assessment and Chronic Pain 4 Good Posture Alignment of body segments in relation to one another Standing & sitting & functional movements Anterior, posterior, lateral views to examine alignment Good posture = balanced alignment of body segments = equal distribution of stresses throughout body = prevention of excessive strain Good posture important for both injury prevention & rehabilitation Week 4 - Clinical Assessment and Chronic Pain 5 Standing Alignment Week 4 - Clinical Assessment and Chronic Pain 6 Correct Sitting Posture Poor sitting posture can aggravate an existing injury or increase injury risk Feet should be flat on floor, 90° knee & hip flexion Lx & Tx spine supported by the chair (may need lumbar roll) Elbows should be flexed to 90° Shoulders in vertical alignment with Cx (check shoulder & head position) Week 4 - Clinical Assessment and Chronic Pain 7 Pathological Alignment Develops over time – some structures shorten, opposing structures lengthen resulting in poor movement efficiency & weakness Abnormal joint loading – increases injury risk, wear & tear Impact on organ systems e.g. restricted respiratory function due to hyperkyphosis Causes of postural impairment: Cumulative microtrauma – overuse, repetitive submaximal stress that exceeds tissue’s ability to adapt & repair Repetitive movements – ADL’s with incorrect biomechanics e.g. lifting, pushing, pulling Identify causes & eliminate or modify Grading of misalignment: mild, moderate or severe Six common postural types: normal/balanced; military posture; flat back; sway back; lordotic & kyphotic Week 4 - Clinical Assessment and Chronic Pain 8 Posture Types Week 4 - Clinical Assessment and Chronic Pain 9 Posture Types Week 4 - Clinical Assessment and Chronic Pain 10 Posture Types Week 4 - Clinical Assessment and Chronic Pain 11 Pelvis and Lumbar Spine Week 4 - Clinical Assessment and Chronic Pain 12 Pelvis and Lumbar Spine Week 4 - Clinical Assessment and Chronic Pain 13 Thoracic Spine Thoracic kyphosis: Usually caused by cervical or lumbar lordosis Tight chest muscles, weak erector spinae & scapular retractors Flat thoracic spine (military posture): tight thoracic erector spinae, rhomboids & trapezius muscles Scoliosis: Either ‘C’ or ‘S’ curve Caused by congenital deformities, leg-length differences or repetitive one-sided actions Week 4 - Clinical Assessment and Chronic Pain 14 Cervical Spine Cervical lordosis: Excessive computer work/sitting – tight upper cervical muscles & weak lower cervical muscles Forward head posture – Flattens lower cervical spine & hyperextends upper cervical spine Increased disc, facet joint & nerve root pressure Dowager’s hump Week 4 - Clinical Assessment and Chronic Pain 15 Lower Extremities Genu valgus Genu recurvatum Genu varus Squinting patella Week 4 - Clinical Assessment and Chronic Pain 16 Muscle Imbalances Muscle imbalances can cause postural faults & exacerbate poor posture Identify tight, long, weak & strong muscles Causes: Sustained shortening or lengthening of muscles Overuse through work or sport Aging – Decline in strength & flexibility Injuries to joints or soft tissue Hyper- or hypomobile joints – greater work for surrounding muscles Treatment: Lengthen shortened muscles; strengthen weak muscles Posture education Encourage bilateral activities & training Week 4 - Clinical Assessment and Chronic Pain 17 Muscle Imbalances Lower-extremity injury: ITB syndrome Caused by weak lateral hip stabilisers, weak hip extensors & lateral hip rotators; often tight hip flexors Results in excessive knee adduction during stance phase of running = increased ITB tension Upper-extremity injury: Shoulder impingement Caused by tight pecs, ant. deltoids & lat dorsi, creating round-shouldered posture Results in excessive strain on rotator cuff tendons Week 4 - Clinical Assessment and Chronic Pain 18 Body Mechanics The way the body is positioned & used during activity (e.g. lifting, functional activities, sports skills) Keep a straight spine in neutral alignment, lower C.O.G & maintain a broad base of support, face direction of force, strong core & hips When lifting: Flex hips & knees, push hips backwards, hold chest up Keep equal distribution of weight between feet, apply force from legs, alignment of spine & upper limbs relaxed Week 4 - Clinical Assessment and Chronic Pain 19 Body Awareness Programs Strong body-mind interaction determines a person’s movement patterns & abilities Feldenkrais Method: Motor skills influenced by unconscious sensorimotor relationship e.g. perception of balance, space, gravity, self-image & kinaesthetic awareness Slow movements avoiding pain, simple to complex, use imagery & visualisation to enhance awareness & improve movement quality Alexander Technique: Daily stresses increase muscle tension that affects posture & movement Self-examine posture, breathing, balance & coordination to increase awareness & reduce tension Re-educate new ways of performing tasks & handling stress Become aware of proper technique through touch & cueing, correcting motions & repeating Week 4 - Clinical Assessment and Chronic Pain 20 Body Awareness Programs Pilates: Movement starts at the core “foundation” One exercise flows into the next while building strength & balancing the body Involves: Relaxation, concentration, control, breathing, being centred, postural alignment, fluidity of movement and stamina Week 4 - Clinical Assessment and Chronic Pain 21 Clinical Assessment and Chronic Pain AMBULATION AND AMBULATION AIDS Normal Gait Cycle Week 4 - Clinical Assessment and Chronic Pain 23 Normal Gait - Required Joint ROM Week 4 - Clinical Assessment and Chronic Pain 24 Normal Gait - Required Joint ROM Week 4 - Clinical Assessment and Chronic Pain 25 Normal Gait – Muscle Activity Week 4 - Clinical Assessment and Chronic Pain 26 Clinical Gait Analysis Areas of tightness, pain or weakness Shod and barefoot, preferably over‐ground vs. treadmill Anterior, posterior and lateral views Overall picture: stride rate, step length L vs. R, limping, favouring one side, even trunk rotation, symmetrical arm swing, vertical trunk Joint & segment movements/actions: Shoulders level, head in neutral alignment, trunk vertical, hip and knee flexion/extension, ankle plantar/dorsiflexion, feet straight Week 4 - Clinical Assessment and Chronic Pain 27 Pathological Gait Trendelenburg Gait: Contralateral pelvic drop due to weak hip abductors (gluteus medius) – Fig. B Pt. may shift upper body towards side of stance leg to compensate for the weakness – Fig. C Week 4 - Clinical Assessment and Chronic Pain 28 Pathological Gait Quadriceps Gait: Pt. keeps knee extended during weight‐bearing phase of gait cycle Quadriceps too weak following knee surgery/injury Restricted Knee Motion Decreased knee ROM – swelling, jt. damage, scar tissue Knee remains flexed during gait cycle (see figure) Week 4 - Clinical Assessment and Chronic Pain 29 Pathological Gait Ankle Lurch Gait Ankle injury restricting ankle dorsi & plantar flexion & WB Hip hike, increased hip & knee flexion to bring leg through Shortened Step Length Pain, lack of confidence in WB, fear of falling, muscle weakness, loss of knee or ankle ROM Antalgic Gait Pain avoidance, reduce time spent in WB on injured side, shorter step length Week 4 - Clinical Assessment and Chronic Pain 30 Mechanics of Ambulation with Assistive Devices Provide external support for mobility Pt. can move freely & more efficiently Reduce or eliminate WB Prevent compensatory movement patterns & bad habits Indications: Structural deformity Fracture Amputation Injury Disease Poor balance Muscle weakness / paralysis Week 4 - Clinical Assessment and Chronic Pain 31 Mechanics of Ambulation with Assistive Devices Week 4 - Clinical Assessment and Chronic Pain 32 Types of Assistive Devices and WB Limitations Week 4 - Clinical Assessment and Chronic Pain 33 Types of Assistive Devices and WB Limitations Other Considerations: Age/confidence & general physical condition Level of balance/coordination Strength & ROM in UL & LL Level of independence Environmental conditions Ease of transportability Presence/absence of pain One or both hands required for ADLs Cost Week 4 - Clinical Assessment and Chronic Pain 34 Gait Patterns with Assistive Devices Two‐Point Gait: Partial WB allowed Some assistance required for balance/pain Crutch moves simultaneously with affected limb Three‐Point Gait: Non‐WB Swing‐to or swing‐through gait Four‐Point Gait: Slowest ambulation Both limbs injured Left crutch, right leg, right crutch, left leg, repeat Week 4 - Clinical Assessment and Chronic Pain 35 Gait Patterns with Assistive Devices Single Support: One crutch or cane in hand opposite to injured side Stability & support Stairs: Going up stairs: Uninjured leg steps up first Going down stairs: Injured leg down first Assistive device always moves with injured side Week 4 - Clinical Assessment and Chronic Pain 36 Clinical Assessment and Chronic Pain CHRONIC PAIN Pain and Nociception Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage Chronic Pain: Pain that lasts for more than three months, typically beyond the normal healing time of the tissue Nociception: Potentially tissue-damaging thermal or mechanical energy that impinges upon specialised nerve endings. These nerve endings, predominantly the A-delta and C fibres are high threshold fibres Week 4 - Clinical Assessment and Chronic Pain 38 Chronic Pain Pain is our brain’s interpretation of nociceptive input – we do not have specific “pain” receptors or fibres When compared with acute pain, chronic pain is characterised as follows: It is maladaptive, not adaptive It is dominated by cognitive and emotional, rather than physical dimensions There is little evidence that structural or anatomical “damage” contributes to, or correlates with, the degree of reported pain Week 4 - Clinical Assessment and Chronic Pain 39 Localisation Theory and Neuroplasticity Week 4 - Clinical Assessment and Chronic Pain 40 Peripheral Sensitisation Peripheral sensitisation can occur at two different points: 1. First order afferent and axon terminal – An increase in the resting membrane activity – More neurotransmitter release for the same stimulus – Increased number of receptor sites at axon terminal 2. Second order afferent – Decreased membrane threshold – Action potentials now sent for a stimuli that would not previously reach the required threshold Week 4 - Clinical Assessment and Chronic Pain 41 Central Sensitisation The brain is plastic and dedicates a greater area to nociceptive information from an injured area Chronic pain is characterised by over-activation of the sympathetic nervous system and under-activation of the parasympathetic nervous system Neurotags are also excitatory for pain Past experience Mood, including depression, anxiety and stress Attention Knowledge Cues: – Physiological – Social – Sensory Week 4 - Clinical Assessment and Chronic Pain 42 Behavioural Components Week 4 - Clinical Assessment and Chronic Pain 43 Red vs. Yellow Flags Red Flag: Signs and symptoms found in either the patient history or clinical examination that indicate a potentially serious pathology Yellow Flag: Psychosocial indicators or risk factors suggesting an increased risk of progression to long-term pain and disability Week 4 - Clinical Assessment and Chronic Pain 44 Treatment There is evidence that exercise intervention can help facilitate neuroplasticity, and subsequently a reduction in pain, through the release of BDNF Reverse deconditioning often associated with chronic pain Evidence suggests that discussing the neurophysiology of pain with patients is more productive than discussing anatomy and structure (eg. IVD protrusion) Utilise techniques of cognitive behavioural therapy (CBT) Week 4 - Clinical Assessment and Chronic Pain 45 Treatment – Techniques of CBT Reformulate The Patient’s Problem Tissue damage is no longer the primary cause of pain Desensitise Fear-Avoidance Behaviour Address the idea that more pain does not equate to more damage Through small progression, provide patient’s the confidence to move without fear of their pain Contingencies For Reinforcement Make movement a part of the patient’s normal routine Shaping Modify exercises to create a version that the patient can achieve Pacing Be slow and progressive – avoid under- or over-doing Work towards reactivation, or a resumption of normal daily activities Week 4 - Clinical Assessment and Chronic Pain 46