Week 4 Summary IPS PDF

4.1 unpacking perception 5 steps nociception- unpacking perception 1. transduction 2. conduction 3. transmission 4. modulation 5. perception definition of unpacking perception : process of converting nociceptive input to an unpleasant sensation that can be localized to 1 area of body 1987 pain and d...

4.1 unpacking perception 5 steps nociception- unpacking perception 1. transduction 2. conduction 3. transmission 4. modulation 5. perception definition of unpacking perception : process of converting nociceptive input to an unpleasant sensation that can be localized to 1 area of body 1987 pain and disability, clinical behavioral and public policy perspective Perception: subjective awareness produced by sensory signals * involves integration of many sensory messages into a coherent and meaningful whole perception processes: 1. attention 2. expectations 3. interpretation of info * true to biopsychosocial model * involve biological processes: thalamus, primary cortex, limbic systems * produced by sensory messages that are influenced by social and environmental conditions -includes our past experiences w pain pathways primary anatomical structures associated with perception of pain Eric garland 2013-pain processing in human nervous system -pain is a complex biopsychosocial phenomenon that arises from the interaction of multiple neuroanatomic and neurochemical systems w a # of cognitive and affective processes.” extensions from spinothalamic tract: A delta & C fibers (neospinothalamic) 1 &2 1. immediate discriminating touch and pain VPL of thalamus (A delta) > prim somatosensory cortex 1 & 2 2. delayed, aching and non discriminating pain PF-CM (C fibers) > prim somatosensory cortex 1 & 2 ↓ Periesiculus and central medial aspects of thalamus aka intralaminar nuclei extension from reticular formation; C fibers (paleo and archi) mesencephalic reticular formation in the PAG & fibers from tectum (part of spinotectal and spinomedullar tract) branches of spinothalamic tract (incorporate C fibers) that go into RF >>modulates nociceptive input to body 1. emotion of pain PF-CM (IL) > limbic system (sensory) PF-CM (IL) > frontal cortex > limbic system (cognitive) - gives us our experience of emotions associated w painful stimulus 2. visceral & autonomic pain PF-CM (IL) > limbic system > hypothalamus basics unpacking perception 3 categories (represent intrinsic and extrinsic influences at level of CNS) factors of pain are not siloed joe loser- neurologist and director of multidisciplinary pain center 1982-1997 UoW our experiences of pain are an organic construct w many layers that include: environment, pain escape behavior, suffering, attitude, beliefs and nociception all are interrelated & add to experience of pain Neuromatrix theory Malzaks neuromatrix theory of pain -accounts for biological and psychological but not social constructs of pain says pain emerges once a particular set of brain cells are activated in a very particular manner inputs to CNS include: cognitive, sensory and affective neuromodules-activate a series of brain cells > result in outputs like pain perception and defensive pain behaviors inputs are factors of our biology, psychology, & post fact (sociology) take-aways 1. nociceptive perception is the process of converting nociceptive input to an unpleasant sensation that can be localized to one area of the body. 2. “pain is a complex, biopsychosocial phenomenon that arises from the interaction of multiple neuroanatomic and neurochemical systems with a number of cognitive and affective processes.” Garland, E. 2013 3. this course will be using Melzak’s Neuromatrix Theory to conceptually illustrate how pain is perceived. 4.2 Nociception Perception: The Neuromatrix Pain Neuromatrix Conceptual Theory - Melzek proposed CNS responsible for eliciting painful sensations rather than PNS - Many areas contribute to perception of pain - Info from PNS processed by CNS forms neurosignature - Neurosignature is product of competition & collaboration b/w neural structures - Interplay of systems & structures affect perception of what we experience or do in response to nociception - Predicated by type & quality of neurosignature - PNS not capable of producing neurosignature - Theory fails to account for social constructs of pain - Moseley & Butler - Modulation of social factors of CNS will result in similar neurosignatures - Overall - Theory aims to describe outputs from brain as complex & pattern neural impulses or neural signatures - Acts as both machine & ecosystem Machine - Interplay b/w different regions of brain that allows us to modulate incoming info - Idea is that pain emerges once particular set of brain cells are activated in set manner - Groups of brain cells called modules, cohorts, or neurotags - Collective brain cells create neurosignatures - Neurosignatures are conceived to be something like executive commands that influence exertion both Inside & outside brain - Brain responsible for regulating every system in body & neural inputs predicate the function of these systems Example of Pain Neuromatrix - Neuromatrix functions as environment for data processing & formation of neural commands - Example: Hand is burned - Neural Modules - Visually Encoded Data - Visually where pain is coming from w/ eyes - Proprioception - Joints telling us position of the hand at moment in time - Thermal Nociception - Info regarding noxious info - Chemical Nociception - Recognizes inflammation associated with/ injury - (Modules can create neural signatures) - Neural Signatures - Visual Encoded & Proprioception - Gives us concept/neurosignature of the hand - Thermal & Chemical Nocicpetion - Give us neural signature of burning pain - Experienced Output - Collection of numerous info collected & organized into modules Ecosystem - Neuromatrix evolves - Changes based on info it receives from different systems, but also outputs - Outputs actually change neuromatrix - Interplay responsible for unique presentations of pain each person experiences - 2 distinct functions - Operations - Distribution Coding - Ability to delegate task to set of neurons - Single Cell Insufficiency - Take 1 neuron from module to do a task, it would not be able to - Mulit-Tasking - Each cell is functionally insufficient, thought to be able to multitask - Each neuron can contribute to task at any number of modules depending on environment - Influence - Neuronal Strength - The higher the mass of the module, the more influence it will have - Neuronal Precision - Has to do with/ the efficiency of the individual neuron - Reflects the likelihood of 1 brain cell being activated relative to likelihood of its neighboring cell being activated - If 1 cell activated by input but not neighboring, precision is 100% - The fewer neighboring cells activated, more precise - (Both strength & precision can change over time) - Any neural module can be influenced by other neural modules Clinical Application - Types of pain related neural signatures - Memory of Pain - Feelings of Social Support - Learned Protective Behavior - Knowledge of Pain Neuroscience - Patient may have fluctuating experience of pain depending on external or internal environment - Due to location, intensity, quality - In the moment, experience of pain for each individual can change - Case Example - Robin, 40 yr old, minor burn at home - (Reported having similar burn yrs ago, in debt, has medical bills) - Previous experiences will impact his current experience w/ pain - Collective experiences and stimulus exposed to will change our neuromatrix & how it functions Take Aways - Neuromatrix proposes neuronal processes that act as both machine & organic ecosystem - Conscious & unconscious functions of brain are product of complex cooperation & competition b/w series of brain cells, called neuromatrix - Physiological outputs from neuromatrix are modulated by both internal/external stimulus predicted by cognitive, sensory, affective, & social factors 4.3 Protecto Meter What are DIMS and SIMS What they are to the Neuromatric Theory and clinical manifestation of pain Apply concepts to two clinical cases while emphasizing positive comm and education What is PROTECTOMETER Conceptual Theory developed by Lorimer Moselet and David Butler Increased intensity of pain, duration, and quality can be altered by the perception, anxiety levels, and depression Reverse is true as well. Feeling of safety , decreases intensity of pain and more positive outlook on the current physical state DIMS and SIMS help us identify contributing factors to recovery Thoughts can alter perceived dangers in the body. Either increase or decrease CASE: Fred Red negative thoughts I need meds I have no money This can alter their perception for pain, lower threshold for pain, and increase fear of avoidance behavior CASE: Jean Green broken bones heal i guess gentle exercise can help Its just old age there’s light at the end of the tunnel These beliefs are optimistic views and can alter a patients perception on their recovery. She will see a relative decrease in the intensity of her pain. Clinical Application: Identify and Modify Transformative Metaphors Recovery Positive Communication Distraction and Education Patient Readiness self management and responsibility understanding more likely to complete treatment when patients understand that self management is also their responsibility 4.4 Classification of Pain Pain Classification: Background no validated means to classify pain “pain categories are variably defined based on the etiology or primarily affected anatomical system or structure. Some diagnoses of pain defy these classification principles…” Treede classifying pain aka source general specific everyone needs a framework for conditions - enables order of own data - identify dif diseases/syndromes - compare experience & observations w/ others ICD 11 = international standard in diagnostic medicine common language about health plans/stats - classify injuries, diseases, causes of death Dr. J, Pain Classifications location quality duration intensity ex: acute,chronic pain differentiate physiological processes nociceptive neuropathic neoplastic process of disease/ condition that leads to pain ex: burn pain from a burn = thermal mode, etiology classification pain classification: characteristic temporal (duration of time the person experiences symptoms) - acute (specific injury/tissue trauma indicating threat to body, self limiting = pain resolved once damage healed) - chronic (more than 3-6 months, beyond normal healing) - mainly neck, back - primary pain = chronic conditions identified as disease - secondary pain= from another disease process location - somatic - visceral intensity - magnitude of pain - numeric rating scale/ visual analog scale pain classification: neurophysiological (complexity makes it difficult for management of msk conditions bc of varying presentations) nociceptive pain = pain from actual or threatened damage to tissues bc of activation of nociceptors] acute neuropathic pain = pain caused by injury/disruption of the somatic neural system acute nociplastic pain = pain that arises from altered nociception despite NO clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain chronic 3 categories of pain by International Association for the Study of Pain (IASP) study shows that its difficult to use classification scheme bc progression of disease, temporal changes, and subjective nature of pain experience pain classification: etiology cancer related non cancer - post surgery - post traumatic limits all uniaxial classifications - diabetic neuropathy - tension type headache - arthritis pain classification: Visceral pain pain presentation coming from visceral structures diffuse referred persistent deep Sleissenger & Fortran’s GI & Liver disease 4 anatomic factors that contribute to poor localization of visceral pain spinal splanic - spread across a lot of DRG (unlike somatic nociceptors that go to one) - causes poor anatomic discrimination somatic nociceptors organized/direct correspondence to body part & CNS aka somatotopic enter Bilaterally = localization of visceral pain in midline ratio of afferent fibers to cell bodies in DRG = low somatic nociceptors = high spinal afferent - generalized overlapping visceral distribution & enter spin bilaterally convergence/crosstalks b/w visceral afferents & somatic pain neurons in dorsal horn of SC visceral broad topological area visceral pain diagrams vary determines our tests have to base on pt expression of pain -what internal organ? chronic state/acute? OVERALL: need multi axial classification of pain to acknowledge subjective nature of perceived pain in pts IASP 5 point taxonomy region system acuity intensity etiology too comprehensive! exists as ICD 11 APTA = no one method to classify pain characteristics of pain can help guide documentation pathophysiological classification in documentation outpatient ortho etiological classification in documentation acute summary pain categories vary based on etiology or primarily affected anatomical system or structure, some diagnoses of pain defy these classification principles such as visceral pain differentiate b/w four primary methods of pain classification including, characteristics, pathophysiology, etiology, multi axial nature of pain PT traditionally use the characteristics of pain to guide classification of pain bc we cant diagnose the mechanism of pain 4.5 Chronic Pain Define Knows the constructs- biological, psychological, social Affects- mental, physical 3 months of longer is CHRONIC PAIN Treed 20% of people worldwide, common Does not require peripheral nociception 635$ billion dollars spend on chronic pain management a year 1.9 billion are affected by tension type headaches Physiological, cognitive, behavioral, environmental. (CONSTRUCTS) chronic pain: “When pain persists for three months or longer, it is considered chronic and, while not necessarily maladaptive, often leads to physical decline, limited functional ability and emotional distress.” Griensven, H. et al. 2014.