Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Hand fun assessing cortical changes


Published on

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

  • Be the first to comment

  • Be the first to like this

Hand fun assessing cortical changes

  1. 1. Assessing cortical changes in patients with pain
  2. 2. PainPain is the cortical output of highest priority. Moseley, 20031- Pain is an output of the brain that is produced whenever the brain concludes thatbody tissues is in danger and action is required.2- Pain is a multisystem output that is produced when an individual-specific corticalpain neuromatrix is activated. Moseley, 2003Pain the defender, not the ofender Sicuteri, 1992
  3. 3. Pain1. Pain does not provide a measure of the state of the tissues2. Pain is modulated by many factors: somatic, psychological and social3. Relationship between pain and the state of the tissues is less predictableas pain persist4. Conscious correlate of the implicit perception that tissue is in danger. Moseley, 2007
  4. 4. Nervous System- Predictor, creator of experiences (Bayes)- Dynamic, not static
  5. 5. Changes in the Nervous System· Peripheral and central changes· Sensitization:Nonassociative learning. Repeated or extended application of a stimulus leadsto an increase response. Flor, 2012LTP (memory mechanisms) Ji, 2003·Disinhibition (impresicion) - Increase in RF· Adaptative or maladaptative Woolf CJ, 2004
  6. 6. AssessmentSubjective examinationSensory examinationMotor examinationAutonomic examinationMAKE THE FEATURES FIT“Without identification of the mechanisms, the optimum treatment strategyfor the patient´s pain cannot be selected” Woolf & Mannion, 1999,
  7. 7. Clinical AssessmentSensory 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. 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
  9. 9. Peripheral/central sensitizationFibromyalgia WAD patients Banic B. et al. Pain 2004
  10. 10. Treatment
  11. 11. Subjective examination: yellow flags Beliefs that pain equals injury Fear avoidance-behavior Changes in social interaccion. Mood changes Expectations on passive treatmentsAffective component: Suffering, description as negation of live...Treatment: Explain pain: biologic explanation Graded exposure (activation)
  12. 12. Treatment
  13. 13. Treatment
  14. 14. Treatment
  15. 15. Treatment
  16. 16. DistractionPara ver e sta pelícu la, d ebedisponer de QuickTime™ y de un descompresor mpeg4.
  17. 17. Sensitization - Changes in RF Para ver e sta pelícu la, d ebe disponer de QuickTime™ y de un descompresor mpeg4.
  18. 18. Cortical Reorganization in CRPS Marinus 2011
  19. 19. Cortical Reorganization in Phantom Limb Flor H 2002
  20. 20. Changes in TPD in CLBP patiens Moseley 2008
  21. 21. Treatment sensitivity cortical changes Moseley 2008
  22. 22. Treatment sensitivity cortical changes Short Term Long Term Moseley, 2009
  23. 23. Treatment sensitivity cortical changes Moseley 2009
  24. 24. Changes in peripersonal space• Peripersonal space in CRPS Moseley 2009• Peripersonal space in Knee Osteoarthrosis Pain Stanton, 2012• Assessment: recognise, TOJ
  25. 25. Motor Control Para ver e sta pelícu la, d ebe disponer de QuickTime™ y de un descompresor mpeg4.
  26. 26. Treatment motor cortical changes• Graded Motor Imagery • Laterality • Imagery • Mirror Therapy• Correction of somatosensation?
  27. 27. Treatment
  28. 28. Treatment
  29. 29. Graded ExposureMotor: Motor:Distraction ConfrontationPacing Somatosensory:Somatosensory: GazeGaze No mirrorMirror BrushBrush Distraction Atention needed!!!
  30. 30. Is it possible that the physical examination, with its exhaustive and oftenrepetitive provocation of specific joints, with specific mobilisations, whichrequire the patient to carefully attend to and discriminate the location, qualityand intensity of the percept works via similar mechanisms to discriminationtraining?Is it possible that learning precise and sometimes subtle motor skills, whichrequire the patient to attend carefully to specific body parts and to discrimi-nate the contraction of one muscle from the contraction of its immediateneighbour, has a similar effect? Moseley 2008
  31. 31. 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 Dec1;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 afterwhiplash 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 cant 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 duringtraining. 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 Dec23;61(12):1707-15.Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol. 2002 Jul 1;1(3):182-9Koelbaek 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 tocooling 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 withosteoarthritis. Rheumatology (Oxford). 2012 Aug 1;51(8):1455-64Moseley GL. Pain, brain imaging and physiotherapy--opportunity is knocking. Man Ther. 2008 Dec 1;13(6):475-7