NOVITA' 2019Manipulating the brain or spine? Applying modern pain neuroscience to orthopaedic manual physical therapy practice
14-15 dicembre 20192 giornivia Pracchiuso 19, 33100 Udine
DOCENTI: Kelly Ickmans & Jo
(Pain in Motion International Research Group, www.paininmotion.be ,Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Belgium; Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Belgium)
Learning objectives: At the completion of this course, learners will be able to: - Apply evidence-based guidelines for chronic pain management to orthopaedic manual physical therapy practice; - Classify pain patients as having nociceptive, neuropathic or central sensitization pain; - Implement a thorough biopsychosocial assessment of a patient with chronic pain; - Devise an effective orthopaedic manual physical therapy program that balances hands-on with hand-off interventions; - Devise an effective orthopaedic manual physical therapy program to remediate pain that engages the patient and considers cognitive/affective/emotive aspects of the pain experience.
Content: Traditional understanding of musculoskeletal pain from a biomedical perspective has been challenged in light of increasing evidence supporting a key role of central sensitization in some patients. This fact may erroneously lead orthopaedic manual physical therapists to conclude that hands-on interventions have no place in the management of chronic musculoskeletal pain, and that hands-off interventions must be applied exclusively. Therefore the aim of this course is to encourage orthopaedic manual physical therapists in finding an equilibrium between hands-on and hands-off interventions capable of desensitizing the central nervous system in patients with chronic musculoskeletal pain dominated by central sensitization. The theoretical rationale1 for simultaneous application (2) of manual therapy and pain neuroscience education is presented together with skills training sessions. Practical problems orthopaedic manual physical therapists will have to deal with when combining these interventions are addressed (1,3). Increasing evidence supports a cardinal role for conservative treatment of chronic pain. Orthopaedic manual physical therapists combine the unique skills for targeting the chronic pain patient’s mind, body and brain concomitantly (4-8). Yet orthopaedic manual physical therapists are often unaware of their ability to treat complex patients with chronic pain. Therefore, the course aims at learning orthopaedic manual physical therapists to apply evidence-based guidelines for chronic pain management. Chronic pain represents a biopsychosocial problem, with maladaptive changes in the mind, body and brain. Education (9), exercise therapy (10) and physical activity interventions are effective treatments for various chronic pain disorders, including fibromyalgia, neck pain (11), osteoarthritis (4,12), rheumatoid arthritis and chronic low back pain (5). Although the clinical benefits of orthopaedic manual physical therapy in these populations are well established (i.e. evidence based), clinicians struggle applying science in daily practice.
One of the reasons why clinicians experience difficulties in applying evidence in practice, is that they are unaware of their capacity to differentiate between various pain types. Indeed, a prerequisite for providing appropriate treatment is classifying pain patients as having either nociceptive, neuropathic or central sensitization pain. Course participants will learn how orthopaedic manual physical therapists can classify their pain patients without relying on expensive or complex examinations. They will learn using a clinical algorithm for differentiating nociceptive from neuropathic and central sensitization pain in daily practice (13,14). Furthermore course participants will learn how to perform a thorough biopsychosocial assessment of patients with chronic pain so that they can assess the provoking and contributing factors of the pain problem. This will allow them to provide individually-tailored orthopaedic manual physical therapy, targeting mind, body and brain.
Once the chronic pain patients are correctly classified and the biopsychosocial aspects involved in the contribution of the problem are known, orthopaedic manual physical therapy can include interventions like counselling, activity self-management, and graded exercise therapy (including graded exposure in vivo) tailored to the patient’s preferences, needs, pain cognitions, musculoskeletal and central nervous system dysfunctions.
The course content will be delivered through a mixture of methods, including:
- interactive lectures
- practical skills training
- case studies
Key references 1. Lluch Girbes E, Meeus M, Baert I, Nijs J. Balancing "hands-on" with "hands-off" physical therapy interventions for the treatment of central sensitization pain in osteoarthritis. Manual therapy. 2014. 2. Lluch ED, L.; Falla, D.; Baert, I.; Meeus, M.; Sánchez-Frutos, J.; Nijs, J. . Preoperative pain neuroscience education combined with knee joint mobilization for knee osteoarthritis: a randomized controlled trial. Submitted. 2017. 3. Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. Journal of Manual & Manipulative Therapy. 2017;25(3):160-168. 4. Lluch Girbes E, Nijs J, Torres-Cueco R, Lopez Cubas C. Pain treatment for patients with osteoarthritis and central sensitization. Physical therapy. 2013;93(6):842-851. 5. Nijs J, Meeus M, Cagnie B, et al. A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Physical therapy. 2014;94(5):730-738. 6. Zusman M. Forebrain-mediated sensitization of central pain pathways: 'non-specific' pain and a new image for MT. Manual therapy. 2002;7(2):80-88. 7. Zusman M. Mechanisms of musculoskeletal physiotherapy. Physical Therapy Reviews. 2004;9:39-49. 8. Zusman M. Associative memory for movement-evoked chronic back pain and its extinction with musculoskeletal physiotherapy. Physical Therapy Reviews. 2008;13(1):57-68. 9. Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines. Manual therapy. 2011;16(5):413-418. 10. Nijs J, Lluch Girbes E, Lundberg M, Malfliet A, Sterling M. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual therapy. 2015;20(1):216-220. 11. Nijs J, Ickmans K. Chronic whiplash-associated disorders: to exercise or not? Lancet (London, England). 2014;384(9938):109-111. 12. Baert IA, Lluch E, Mulder T, Nijs J, Noten S, Meeus M. Does pre-surgical central modulation of pain influence outcome after total knee replacement? A systematic review. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2015. 13. Nijs J, Apeldoorn A, Hallegraeff H, et al. Low back pain: guidelines for the clinical classification of predominant neuropathic, nociceptive, or central sensitization pain. Pain physician. 2015;18(3):E333-346. 14. Nijs J, Torres-Cueco R, van Wilgen CP, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain physician. 2014;17(5):447-457.