The document discusses a maladaptive perception model of chronic low back pain (CLBP). It summarizes evidence that CLBP is associated with changes in brain structure and function, sensory processing, motor control, and body perception. A plausible model is that maladaptive cognitive and sensory processes could influence tissue loading, sensitivity, fear and worry in a way that perpetuates pain. Experimental research supports the idea that correcting maladaptive body perception through sensory discrimination training and graded cortical retraining can reduce pain. Functional rehabilitation targeting both cognitive perception and self-perception may help normalize movement behaviors and integrate activities to mutually normalize perception and pain.
Cervicogenic Dizziness - identification and treatmentNVMT-symposium
Cervicogenic dizziness is a controversial diagnosis caused by dysfunction in the upper cervical spine that results in imbalance or disequilibrium. It is identified through a 5-step process including characteristics of imbalance-type dizziness, neck pain or stiffness exacerbating dizziness, and physical exam findings. Sustained natural apophyseal glides are an effective manual therapy treatment, shown to decrease dizziness and pain more than mobilizations or placebo. Multi-modal treatment including balance exercises is also recommended. Long-term follow up shows treatment effects are maintained for up to 12 months.
Presentatie Drs. Ronald Kan - Even wat rechtzetten NVMT-symposium
1) The document discusses evidence related to the effectiveness of manual therapy (MT) for various pain conditions like acute low back pain, chronic low back pain, and neck pain. It finds small but consistent effects for MT, though not more effective than other conservative treatments.
2) It explores how context, communication, and patient/therapist factors can influence pain through placebo and nocebo effects. Negative or threatening language can increase pain (nocebo), while positive expectations can decrease pain (placebo).
3) The language used by healthcare providers has enduring influence on patient beliefs and can potentially cause or increase disability if not carefully considered. Attention to communication is important to avoid iatrogenic outcomes.
Dr. Anton de Wijer is a specialist in special dental care, TMD and orofacial pain at the UMC St Radboud in the Netherlands. His practice focuses on treating temporomandibular disorders (TMD) using a multidisciplinary approach involving psychologists, manual therapists, dentists and other specialists. The document provides statistics on patients seen in his practice, describes the multidisciplinary treatment approach used at his clinic, and discusses the links between TMD and neck pain based on current research findings.
This document discusses central sensitization, a condition where the central nervous system amplifies sensory processing, resulting in hypersensitivity and chronic pain. It begins by explaining how acute pain becomes chronic pain due to central sensitization. It then describes the mechanisms of central sensitization, including wind-up in the spinal cord, impaired descending pain inhibition, and changes in the brain. It discusses how central sensitization can be assessed through measures like conditioned pain modulation, exercise-induced analgesia, and hypersensitivity questionnaires. The document provides criteria for identifying central sensitization in musculoskeletal pain patients and signs and symptoms of central sensitization. It concludes by discussing treatment implications when central sensitization is present.
‘Neurodynamics as a therapeutic intervention; the effectiveness and scientifi...NVMT-symposium
This document discusses the evidence for neural mobilization as a treatment for nerve disorders. It begins by reviewing animal studies showing that movement such as exercise prevents neuropathic pain development, aids nerve recovery after injury, and reduces neuropathic pain. However, the evidence for neural mobilization and nerve gliding exercises in humans is limited. A systematic review found limited evidence that neural mobilization is more effective than minimal interventions for pain and disability in carpal tunnel syndrome, but not more effective than other treatments. Another review found limited evidence for the effectiveness of nerve gliding exercises in carpal tunnel syndrome. The document concludes that while movement may be beneficial, the evidence does not clearly support neural mobilization over other conservative treatments, and more high-quality research is
This document discusses contemporary theories of motor adaptation related to neck pain. It proposes that motor adaptation: (1) involves diverse changes from subtle muscle activity changes to movement avoidance; (2) is specific to individuals; (3) aims to protect painful areas from further injury; (4) can precede or follow pain; and (5) has potential long-term consequences if maintained improperly. Studies show examples of adaptive changes in people with neck pain, such as altered muscle recruitment patterns and delayed responses to perturbations. Long-term motor adaptations can potentially cause further injury issues if excessive or inappropriate.
Presentatie Dr. Sue Shea - Providing Compassionate Healthcare NVMT-symposium
Getting to the ‘Heart’ of the Therapeutic Relationship – A Compassionate Approach discusses the importance of compassion in healthcare. It defines compassion as desiring to help relieve another's suffering through understanding, empathy, and action. The document explores how compassion benefits both patients and providers physically and mentally. It emphasizes the need for communication, individualized care, and seeing patients as more than their conditions to establish compassionate therapeutic relationships.
Cervicogenic Dizziness - identification and treatmentNVMT-symposium
Cervicogenic dizziness is a controversial diagnosis caused by dysfunction in the upper cervical spine that results in imbalance or disequilibrium. It is identified through a 5-step process including characteristics of imbalance-type dizziness, neck pain or stiffness exacerbating dizziness, and physical exam findings. Sustained natural apophyseal glides are an effective manual therapy treatment, shown to decrease dizziness and pain more than mobilizations or placebo. Multi-modal treatment including balance exercises is also recommended. Long-term follow up shows treatment effects are maintained for up to 12 months.
Presentatie Drs. Ronald Kan - Even wat rechtzetten NVMT-symposium
1) The document discusses evidence related to the effectiveness of manual therapy (MT) for various pain conditions like acute low back pain, chronic low back pain, and neck pain. It finds small but consistent effects for MT, though not more effective than other conservative treatments.
2) It explores how context, communication, and patient/therapist factors can influence pain through placebo and nocebo effects. Negative or threatening language can increase pain (nocebo), while positive expectations can decrease pain (placebo).
3) The language used by healthcare providers has enduring influence on patient beliefs and can potentially cause or increase disability if not carefully considered. Attention to communication is important to avoid iatrogenic outcomes.
Dr. Anton de Wijer is a specialist in special dental care, TMD and orofacial pain at the UMC St Radboud in the Netherlands. His practice focuses on treating temporomandibular disorders (TMD) using a multidisciplinary approach involving psychologists, manual therapists, dentists and other specialists. The document provides statistics on patients seen in his practice, describes the multidisciplinary treatment approach used at his clinic, and discusses the links between TMD and neck pain based on current research findings.
This document discusses central sensitization, a condition where the central nervous system amplifies sensory processing, resulting in hypersensitivity and chronic pain. It begins by explaining how acute pain becomes chronic pain due to central sensitization. It then describes the mechanisms of central sensitization, including wind-up in the spinal cord, impaired descending pain inhibition, and changes in the brain. It discusses how central sensitization can be assessed through measures like conditioned pain modulation, exercise-induced analgesia, and hypersensitivity questionnaires. The document provides criteria for identifying central sensitization in musculoskeletal pain patients and signs and symptoms of central sensitization. It concludes by discussing treatment implications when central sensitization is present.
‘Neurodynamics as a therapeutic intervention; the effectiveness and scientifi...NVMT-symposium
This document discusses the evidence for neural mobilization as a treatment for nerve disorders. It begins by reviewing animal studies showing that movement such as exercise prevents neuropathic pain development, aids nerve recovery after injury, and reduces neuropathic pain. However, the evidence for neural mobilization and nerve gliding exercises in humans is limited. A systematic review found limited evidence that neural mobilization is more effective than minimal interventions for pain and disability in carpal tunnel syndrome, but not more effective than other treatments. Another review found limited evidence for the effectiveness of nerve gliding exercises in carpal tunnel syndrome. The document concludes that while movement may be beneficial, the evidence does not clearly support neural mobilization over other conservative treatments, and more high-quality research is
This document discusses contemporary theories of motor adaptation related to neck pain. It proposes that motor adaptation: (1) involves diverse changes from subtle muscle activity changes to movement avoidance; (2) is specific to individuals; (3) aims to protect painful areas from further injury; (4) can precede or follow pain; and (5) has potential long-term consequences if maintained improperly. Studies show examples of adaptive changes in people with neck pain, such as altered muscle recruitment patterns and delayed responses to perturbations. Long-term motor adaptations can potentially cause further injury issues if excessive or inappropriate.
Presentatie Dr. Sue Shea - Providing Compassionate Healthcare NVMT-symposium
Getting to the ‘Heart’ of the Therapeutic Relationship – A Compassionate Approach discusses the importance of compassion in healthcare. It defines compassion as desiring to help relieve another's suffering through understanding, empathy, and action. The document explores how compassion benefits both patients and providers physically and mentally. It emphasizes the need for communication, individualized care, and seeing patients as more than their conditions to establish compassionate therapeutic relationships.
This document discusses chronic subjective dizziness (CSD), a condition characterized by non-vertiginous dizziness or imbalance that is exacerbated by motion and visual stimuli. CSD is thought to develop through classical and operant conditioning following acute vestibular disorders. Treatment involves diagnosis, education, pharmacology like SSRIs, psychotherapy, and vestibular rehabilitation therapy including habituation exercises and graded exposure. CSD is differentiated from other conditions through characteristic symptoms and normal exam findings despite a history of vestibular dysfunction.
Option of interventional pain therapy in multimodal treatment of chronic cancer and non-cancer pain
Established role when pharmacotherapy or surgery not suitable
Indications well accepted
Evidence for efficacy moderate to strong
The document discusses neonatal pain, including that babies can feel and react to pain, validated scales exist to measure neonatal pain, and developmental aspects of pain perception in newborns. It also outlines non-pharmacological and pharmacological approaches to treating pain in newborns, emphasizing the need for comprehensive pain management strategies that minimize unnecessary pain in neonates.
Awareness and assessment of the pain in
postoperative children is important
Remember the different pharmacology in
neonates, infants and children
Multi-modal approach to preventing and treating
pain to minimize adverse effects
Regional analgesia must be considered unless
contraindicated
Pain is common in elderly patients due to age-related changes in peripheral nerves and the central nervous system. Chronic pain is prevalent, with about 1 in 5 elderly patients experiencing pain for over 24 hours in the past month. Common causes of pain include arthritis, fractures, and neuropathies. Untreated pain can lead to depression, sleep disturbances, functional impairment, and reduced quality of life. Treatment involves both pharmacological and non-pharmacological approaches, with special considerations for age-related changes impacting drug metabolism and side effects.
Positive and negative thinking can affect pain and outcomes following total knee arthroplasty (TKA). Psychological factors like catastrophizing and fear of movement have been shown to correlate with increased post-surgical pain and decreased function. Cognitive and behavioral interventions can help address these factors. Guided imagery, distraction techniques, relaxation strategies, and therapeutic touch have all demonstrated benefits in reducing pain for TKA patients. Negative pre-surgical expectations can lead to higher reported pain levels after surgery, while positive thinking may improve outcomes.
Exercise Therapy in the Management of Low Back PainOlubusola Johnson
This document discusses exercise therapy for the management of low back pain. It provides background on low back pain, noting that most episodes are non-specific and occur with normal activities. It reviews the epidemiology of low back pain and classifications by duration and etiology. The document then discusses the anatomy of core muscles like the transversus abdominis and multifidus. It reviews evidence on exercises for flexibility, strengthening, core stabilization and their effectiveness in treating low back pain according to studies. Core stabilization exercises targeting the transversus abdominis and multifidus are emphasized as important for both treatment and prevention of recurrent low back pain.
- Pediatric pain management requires a multidisciplinary team approach to properly assess and treat a child's pain. This includes addressing physiological, sensory, cognitive, behavioral, and affective components of pain.
- It is important to believe the child's reports of pain, listen to parents and children, and consult other experts when needed. Treatment should be individualized and non-pharmacological options considered in addition to pharmacological interventions.
- Common opioid medications used for pediatric pain include morphine, hydromorphone, fentanyl, and methadone. Non-opioid options also have a role to play depending on the situation. Proper protocols and guidelines help ensure children's pain is well-managed
This document discusses emerging pharmacological and non-pharmacological aspects in pain management. It notes that multimodal analgesia using combinations of drugs targeting different pain pathways can provide improved pain relief with reduced side effects compared to single drugs. Newer drugs targeting specific receptor subtypes are emerging. Non-invasive options such as topical agents, exercise, and interventional techniques are increasingly utilized before more invasive options. Interventional pain management techniques discussed include injections, neurolysis, and spinal cord stimulation.
The document discusses the challenges of managing back pain in an aging population. It notes that medical factors like tolerances for pharmacotherapy and operative fitness limit management options for back dysfunction in older patients. It also discusses challenges from attitudes and perceptions about back pain in older adults, including myths and legends about opioid use and dependence. Finally, it covers how lifestyle factors and priorities around independence, future activity, finances, and environment affect back pain management priorities for retirees.
The document discusses neonatal pain, including outdated views, facts about neonatal pain perception, pain pathways and development, effects of untreated pain, common painful procedures in NICUs, and how neonates respond to pain physiologically and behaviorally. It also covers factors affecting pain response, the development of pain assessment and treatment, common pain assessment scales, prevention and management of neonatal pain including pharmacological and non-pharmacological approaches.
ISMST - 2014 Presentation Final PresentationKenneth Craig
This document summarizes a case series study on the use of extracorporeal shockwave therapy (ESWT) to treat complex/neuropathic pain syndromes. It describes 12 patients who underwent 4 treatments of ESWT at weekly intervals and experienced significant reductions in pain, physical impairment, and emotional distress that were maintained at 24-week follow up based on standardized questionnaires. The proposed mechanisms of action of ESWT for neuropathic pain and rationale for its application are discussed. The study concludes that ESWT shows promise for treating neuropathic pain and warrants further research.
Operative management for common back conditionsSpinePlus
This document discusses common lumbar spine conditions like disc herniations and spinal stenosis. It provides 5 facts about disc herniations including what causes them, typical symptoms, and treatment options like steroid injections or surgery. It also outlines 5 facts about spinal stenosis including what it is, typical symptoms, and potential surgical treatment. The document seeks to address 3 common misconceptions about spinal fusion surgery, noting risks are low, it is often successful when combined with decompression, and adjacent level degeneration is usually due to preexisting conditions, not the fusion itself.
Non-operative treatment for common back conditions SpinePlus
Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target areas like the lumbar spine, hips, and core to improve mobility and reduce recurrence, while avoiding movements that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription tailored to individual needs and abilities.
This document discusses PRN pain medication administration and management. It outlines objectives around offering PRN medications consistently based on evidence, using sedation and nonverbal pain scales, and properly documenting PRN medication administration in the Excellian system. Key recommendations include administering pain medications regularly to maintain therapeutic levels and using PRN medications for breakthrough pain. Proper documentation and timely administration of PRN medications can help effectively control pain.
Gingerich back pain presentation (sept. 2012)sepaincare
This document discusses common causes and treatments for chronic low back pain. It provides an overview of pain management as a specialty focused on finding and treating the source of pain. Common causes of chronic low back pain include herniated discs, spinal stenosis, and facet joint arthritis. Treatment approaches include conservative options like physical therapy and medications, as well as more advanced interventional techniques such as epidural steroid injections, radiofrequency ablation, and spinal cord stimulation. The goal of treatment is to control pain, improve function, and enhance quality of life.
The document discusses chronic pain and its treatment. It defines chronic pain as prolonged pain where the pain system is altered and no longer represents injury. Chronic pain is maintained by changes in the nervous system. Treatment of chronic pain focuses on understanding the biopsychosocial model of pain and using multidisciplinary treatments like exercise, CBT, and medication management of conditions like fibromyalgia, low back pain, and migraines. Mood disorders are also discussed as both causing and being caused by chronic pain conditions.
Dizziness and balance problems affect over 70% of people with multiple sclerosis. These issues are linked to reduced mobility and increased falls, and negatively impact quality of life. The vestibular system helps with gaze stability and postural control. In MS, vestibular deficits can cause impairments in these areas as well as dynamic balance and participation. Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo in MS and is treated with particle repositioning maneuvers. Vestibular rehabilitation aims to improve vestibular compensation through exercises targeting gaze stability, postural control, and motion tolerance.
Atraumatic/MDI - Physiotherapy Principles and ManagementThe Arm Clinic
Physiotherapy management of multidirectional instability (MDI) of the shoulder is complex due to various drivers of the condition. Research on MDI has been difficult to interpret due to inconsistent definitions, heterogeneous populations, lack of standardization, and insensitive outcome measures across studies. Physiotherapy aims to address drivers both local to the shoulder like atypical muscle activation patterns and scapular kinematics, as well as central nervous system drivers involving cortical reorganization. Rehabilitation focuses on normalizing range of motion, improving neuromuscular control, and training into positions of vulnerability using modalities that target specific muscles individually and create synergies between muscles.
The document discusses shoulder pain, specifically subacromial pain/non-specific shoulder pain. It notes that shoulder pain is prevalent, can impact daily activities, and for 40% of patients the pain is ongoing or recurrent after 12 months. Imaging and physical exams are not always reliable in diagnosing the source of pain. Exercise appears to be the most promising intervention for shoulder pain, though what type or amount of exercise is unclear. A proposed intervention focuses on teaching patients self-management skills and a home exercise program with 1-5 sessions from a physiotherapist and proactive follow-up.
This document discusses chronic subjective dizziness (CSD), a condition characterized by non-vertiginous dizziness or imbalance that is exacerbated by motion and visual stimuli. CSD is thought to develop through classical and operant conditioning following acute vestibular disorders. Treatment involves diagnosis, education, pharmacology like SSRIs, psychotherapy, and vestibular rehabilitation therapy including habituation exercises and graded exposure. CSD is differentiated from other conditions through characteristic symptoms and normal exam findings despite a history of vestibular dysfunction.
Option of interventional pain therapy in multimodal treatment of chronic cancer and non-cancer pain
Established role when pharmacotherapy or surgery not suitable
Indications well accepted
Evidence for efficacy moderate to strong
The document discusses neonatal pain, including that babies can feel and react to pain, validated scales exist to measure neonatal pain, and developmental aspects of pain perception in newborns. It also outlines non-pharmacological and pharmacological approaches to treating pain in newborns, emphasizing the need for comprehensive pain management strategies that minimize unnecessary pain in neonates.
Awareness and assessment of the pain in
postoperative children is important
Remember the different pharmacology in
neonates, infants and children
Multi-modal approach to preventing and treating
pain to minimize adverse effects
Regional analgesia must be considered unless
contraindicated
Pain is common in elderly patients due to age-related changes in peripheral nerves and the central nervous system. Chronic pain is prevalent, with about 1 in 5 elderly patients experiencing pain for over 24 hours in the past month. Common causes of pain include arthritis, fractures, and neuropathies. Untreated pain can lead to depression, sleep disturbances, functional impairment, and reduced quality of life. Treatment involves both pharmacological and non-pharmacological approaches, with special considerations for age-related changes impacting drug metabolism and side effects.
Positive and negative thinking can affect pain and outcomes following total knee arthroplasty (TKA). Psychological factors like catastrophizing and fear of movement have been shown to correlate with increased post-surgical pain and decreased function. Cognitive and behavioral interventions can help address these factors. Guided imagery, distraction techniques, relaxation strategies, and therapeutic touch have all demonstrated benefits in reducing pain for TKA patients. Negative pre-surgical expectations can lead to higher reported pain levels after surgery, while positive thinking may improve outcomes.
Exercise Therapy in the Management of Low Back PainOlubusola Johnson
This document discusses exercise therapy for the management of low back pain. It provides background on low back pain, noting that most episodes are non-specific and occur with normal activities. It reviews the epidemiology of low back pain and classifications by duration and etiology. The document then discusses the anatomy of core muscles like the transversus abdominis and multifidus. It reviews evidence on exercises for flexibility, strengthening, core stabilization and their effectiveness in treating low back pain according to studies. Core stabilization exercises targeting the transversus abdominis and multifidus are emphasized as important for both treatment and prevention of recurrent low back pain.
- Pediatric pain management requires a multidisciplinary team approach to properly assess and treat a child's pain. This includes addressing physiological, sensory, cognitive, behavioral, and affective components of pain.
- It is important to believe the child's reports of pain, listen to parents and children, and consult other experts when needed. Treatment should be individualized and non-pharmacological options considered in addition to pharmacological interventions.
- Common opioid medications used for pediatric pain include morphine, hydromorphone, fentanyl, and methadone. Non-opioid options also have a role to play depending on the situation. Proper protocols and guidelines help ensure children's pain is well-managed
This document discusses emerging pharmacological and non-pharmacological aspects in pain management. It notes that multimodal analgesia using combinations of drugs targeting different pain pathways can provide improved pain relief with reduced side effects compared to single drugs. Newer drugs targeting specific receptor subtypes are emerging. Non-invasive options such as topical agents, exercise, and interventional techniques are increasingly utilized before more invasive options. Interventional pain management techniques discussed include injections, neurolysis, and spinal cord stimulation.
The document discusses the challenges of managing back pain in an aging population. It notes that medical factors like tolerances for pharmacotherapy and operative fitness limit management options for back dysfunction in older patients. It also discusses challenges from attitudes and perceptions about back pain in older adults, including myths and legends about opioid use and dependence. Finally, it covers how lifestyle factors and priorities around independence, future activity, finances, and environment affect back pain management priorities for retirees.
The document discusses neonatal pain, including outdated views, facts about neonatal pain perception, pain pathways and development, effects of untreated pain, common painful procedures in NICUs, and how neonates respond to pain physiologically and behaviorally. It also covers factors affecting pain response, the development of pain assessment and treatment, common pain assessment scales, prevention and management of neonatal pain including pharmacological and non-pharmacological approaches.
ISMST - 2014 Presentation Final PresentationKenneth Craig
This document summarizes a case series study on the use of extracorporeal shockwave therapy (ESWT) to treat complex/neuropathic pain syndromes. It describes 12 patients who underwent 4 treatments of ESWT at weekly intervals and experienced significant reductions in pain, physical impairment, and emotional distress that were maintained at 24-week follow up based on standardized questionnaires. The proposed mechanisms of action of ESWT for neuropathic pain and rationale for its application are discussed. The study concludes that ESWT shows promise for treating neuropathic pain and warrants further research.
Operative management for common back conditionsSpinePlus
This document discusses common lumbar spine conditions like disc herniations and spinal stenosis. It provides 5 facts about disc herniations including what causes them, typical symptoms, and treatment options like steroid injections or surgery. It also outlines 5 facts about spinal stenosis including what it is, typical symptoms, and potential surgical treatment. The document seeks to address 3 common misconceptions about spinal fusion surgery, noting risks are low, it is often successful when combined with decompression, and adjacent level degeneration is usually due to preexisting conditions, not the fusion itself.
Non-operative treatment for common back conditions SpinePlus
Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target areas like the lumbar spine, hips, and core to improve mobility and reduce recurrence, while avoiding movements that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription tailored to individual needs and abilities.
This document discusses PRN pain medication administration and management. It outlines objectives around offering PRN medications consistently based on evidence, using sedation and nonverbal pain scales, and properly documenting PRN medication administration in the Excellian system. Key recommendations include administering pain medications regularly to maintain therapeutic levels and using PRN medications for breakthrough pain. Proper documentation and timely administration of PRN medications can help effectively control pain.
Gingerich back pain presentation (sept. 2012)sepaincare
This document discusses common causes and treatments for chronic low back pain. It provides an overview of pain management as a specialty focused on finding and treating the source of pain. Common causes of chronic low back pain include herniated discs, spinal stenosis, and facet joint arthritis. Treatment approaches include conservative options like physical therapy and medications, as well as more advanced interventional techniques such as epidural steroid injections, radiofrequency ablation, and spinal cord stimulation. The goal of treatment is to control pain, improve function, and enhance quality of life.
The document discusses chronic pain and its treatment. It defines chronic pain as prolonged pain where the pain system is altered and no longer represents injury. Chronic pain is maintained by changes in the nervous system. Treatment of chronic pain focuses on understanding the biopsychosocial model of pain and using multidisciplinary treatments like exercise, CBT, and medication management of conditions like fibromyalgia, low back pain, and migraines. Mood disorders are also discussed as both causing and being caused by chronic pain conditions.
Dizziness and balance problems affect over 70% of people with multiple sclerosis. These issues are linked to reduced mobility and increased falls, and negatively impact quality of life. The vestibular system helps with gaze stability and postural control. In MS, vestibular deficits can cause impairments in these areas as well as dynamic balance and participation. Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo in MS and is treated with particle repositioning maneuvers. Vestibular rehabilitation aims to improve vestibular compensation through exercises targeting gaze stability, postural control, and motion tolerance.
Atraumatic/MDI - Physiotherapy Principles and ManagementThe Arm Clinic
Physiotherapy management of multidirectional instability (MDI) of the shoulder is complex due to various drivers of the condition. Research on MDI has been difficult to interpret due to inconsistent definitions, heterogeneous populations, lack of standardization, and insensitive outcome measures across studies. Physiotherapy aims to address drivers both local to the shoulder like atypical muscle activation patterns and scapular kinematics, as well as central nervous system drivers involving cortical reorganization. Rehabilitation focuses on normalizing range of motion, improving neuromuscular control, and training into positions of vulnerability using modalities that target specific muscles individually and create synergies between muscles.
The document discusses shoulder pain, specifically subacromial pain/non-specific shoulder pain. It notes that shoulder pain is prevalent, can impact daily activities, and for 40% of patients the pain is ongoing or recurrent after 12 months. Imaging and physical exams are not always reliable in diagnosing the source of pain. Exercise appears to be the most promising intervention for shoulder pain, though what type or amount of exercise is unclear. A proposed intervention focuses on teaching patients self-management skills and a home exercise program with 1-5 sessions from a physiotherapist and proactive follow-up.
This document discusses a paradigm shift in spinal manual therapy from a biomechanical model to a neurophysiological model. It provides evidence that lower back pain is not caused by biomechanical factors like posture or spinal structure. While biomechanics was previously emphasized, evidence now shows biomechanics do not determine pain or pathology. The document advocates abandoning the postural-structural-biomechanical model and assessment of biomechanical factors in favor of a process-based approach focused on underlying neuromuscular processes rather than structure. Manual therapy should aim to facilitate changes in these processes rather than correct biomechanics, which are normal variations and cannot reliably be changed.
Physiotherapy plays an important role in mental health as part of a multidisciplinary team using a biopsychosocial model. Several evidence-based interventions are discussed including Norwegian psychomotor physiotherapy, basic body awareness therapy, cognitive behavioral therapy, physical activity, and progressive relaxation training. Effective communication and a strong therapeutic relationship are essential when working with mental health patients. Physiotherapists can help meet patient needs through management of physical comorbidities, a client-centered approach, and promotion of well-being.
This document summarizes a presentation on physiotherapy for non-cancer chronic pain. It discusses that physiotherapy aims to restore and promote optimal physical function and quality of life for those with persistent pain. It provides an overview of evaluation processes in physiotherapy and various treatment modalities. It also summarizes evidence on approaches for common persistent pain conditions like low back pain, whiplash associated disorder, and osteoarthritis. Screening tools for risk of long-term disability are also briefly covered.
This document summarizes a presentation on improving sleep for elders. It discusses the science of sleep, factors that can disrupt sleep for elders like pain, and non-pharmacological interventions to enhance sleep such as increasing physical activity, light exposure, and relaxing activities before bed. Screening tools are presented to assess sleep and pain levels in cognitively impaired residents. Organizational barriers to sleep in long-term care facilities are identified and addressing sleep quality is linked to improved health outcomes and quality measures.
This document describes a case study on using physiotherapy to treat severe tremor. The patient had multiple sclerosis with sensitive ataxia and severe left arm tremor. The physiotherapy treatment plan focused on teaching the patient about their condition, sensory stimulation like textures and movements, mirror therapy, and bilateral/unilateral coordination exercises with an emphasis on minimizing rocking movements. The conclusions were that the treatment improved movement quality but did not significantly improve activities of daily living or function, and more research is needed on physiotherapy for tremor patients.
This document summarizes the management of tremor and spasticity in multiple sclerosis. It discusses tremor, including types, assessment, and interventions like physiotherapy, oral medications, botulinum toxin injections, and deep brain stimulation. It also covers spasticity, defining it as part of the upper motor neuron syndrome and discussing its impact. Assessment of spasticity is highlighted as key to management. A multidisciplinary team approach is advocated to accurately assess issues, determine treatment goals, and provide non-pharmacological and pharmacological interventions.
Cerebral palsy (CP) is a group of disorders that affect movement and posture, caused by non-progressive damage to the developing brain. The motor disorders of CP are often accompanied by disturbances in other functions. CP affects 2-3 per 1000 live births and is a common cause of physical disability in children. Risk factors include problems during pregnancy, labor/delivery, or in the neonatal period. Symptoms include abnormal muscle tone, atypical posture, and delayed motor development. Treatment involves assessing motor skills, imaging, and developing individualized plans to address impairments and promote functional abilities.
The survey results show that patients with Ehlers-Danlos Syndrome (EDS) experience significant sleep issues, pain, and fatigue. Over 1,000 EDS patients completed questionnaires assessing sleep quality, pain, fatigue, and restless leg syndrome. The results showed poor overall sleep quality, frequent nighttime awakenings, less time spent sleeping, and daytime fatigue/sleepiness. Nearly all patients reported widespread chronic pain. High levels of pain and fatigue interfered with daily activities. While pain, fatigue, and sleep disturbances were correlated, pain may not be the sole cause of sleep issues in EDS patients. Restless leg syndrome was also common but had a modest effect on sleep. The study provides insight into how EDS
There research on the effectiveness of Physical Therapy for back pain is not compelling. This presentation overviews the current evidence base and discusses the potential for classification of back pain to demonstrate stronger support for Physical Therapy.
The Specific Treatment of Problems of the Spine (STOPS) trial protocol is then presented. This study was recently completed showing moderate to strong effect sizes favouring Physical Therapy over evidence-based advice.
Note that the clinical protocol details in the presentation are examples only. For the full clinical protocol visit Physical Therapy Reviews
This document discusses mood and sleep disorders that can occur after concussions. It notes that common sleep issues include insomnia, hypersomnia, and poor sleep quality. Poor sleep after concussions is associated with prolonged recovery times and worse outcomes. It also discusses the high rates of mood issues like anxiety and depression after concussions. Treatment options discussed include sleep hygiene, melatonin, CBT-I, and medications. The relationship between sleep, mood, and concussion recovery is bi-directional, so screening and treating both is important for optimal recovery.
The role of surgery in common lumbar conditionsSpinePlus
The document discusses common lumbar spine conditions including disc herniation, spinal stenosis, and chronic low back pain. It describes the causes, symptoms, treatments including surgery, and outcomes. For disc herniation, surgery in the form of discectomy is recommended for severe or unremitting leg pain and can provide relief in 90% of cases. Spinal stenosis is treated initially with physiotherapy or epidural injections, with surgery as an option for severe, unresolved symptoms. Fusion surgery is not usually indicated for chronic low back pain alone but may be used for instability or certain structural deformities.
Evidence-Based Practice in Vestibular RehabilitationBrenda Howard
Presented at the Indiana Occupational Therapy Association Fall Conference, October 26, 2013, at IUPUI. This presentation gives occupational therapists a few tools to recognize, begin treatment, and refer patients with vestibular dysfunction, for earlier identification and return to productive living.
The document discusses the classification and management of chronic low back pain. It notes that 95% of back pain cases do not require surgery or radiology, and most patients need multidisciplinary care. While patients experience back pain, investigations and treatments directed at the back are often ineffective, suggesting the cause may involve neurological reorganization in the brain. The document provides tools to assess patients and strategies for clinicians, including explaining to patients that the cause is often not well understood, recommending evidence-based treatments like exercise over passive therapies, and avoiding factors that could worsen the condition like prolonged opioid use.
Kimberley Haines is a senior ICU physiotherapist and the Allied Health Research Lead at Western Health. Her academic research focusses on the long term progress of ICU survivors. Here she discusses the developing puzzle of ICU outcomes.
This document discusses functional neurological symptoms in multiple sclerosis. It defines functional neurological disorder and lists common signs and symptoms. Research shows that approximately 10% of neurology patients have a functional disorder. While initially thought to be purely psychiatric, functional disorders are now understood to involve both neurological and psychological factors. The cerebellum and limbic system may play a role in converting emotions into physical sensations. Occupational therapy aims to comprehensively assess patients' functioning and identify treatment goals. Physiotherapy focuses on minimizing attention to symptoms and retraining normal movement patterns. Psychotherapies like CBT can help address emotional processing difficulties. Functional symptoms appear to exist on a continuum and may be more common in MS patients than previously recognized.
‘Clinical Neurodynamics: clinical application from an anatomical perspective’ NVMT-symposium
This document provides an overview of neurodynamics, including:
1. The history and key figures in the development of neurodynamics from the 1920s to present.
2. Anatomy of the peripheral nervous system, including gross anatomy of major nerves in the upper and lower limbs, microanatomy of nerves, and biomechanics of nerve movement.
3. Applications to clinical examination including common nerve pathoanatomies and how joint movement affects nerves.
4. Research on neurodynamic techniques and their effects on nerve displacement and strain.
Cervical Arterial Dysfunction – implications for clinical practice" NVMT-symposium
Cervical arterial dysfunction (CAD) is an area that requires a broader conceptual framework and updated clinical guidelines. CAD can initially manifest as neck and head pain and assessing blood pressure and performing cranial nerve and eye exams may help direct patient management. A new classification system categorizes CAD into 5 classes based on symptoms and risk level to better frame the condition. Evidence around CAD continues to emerge so re-evaluation of current practices is needed.
1. CHRONIC LOW BACK PAIN:
A MALADAPTIVE
PERCEPTION MODEL
“So when everything seems
to turn out for the better
and I am on track again, the
physiotherapist always finds
something new in my back
that is not OK and …….”
(Afrell 2007)
(Moseley 2008)
3. No Matter What We Do
(Schaafsma 2013)
(Henschke 2010)
(Ibrahim 2008)
4. Managing Nociception Is Not The Same As Managing Pain
END ORGAN DYSFUNCTION MODEL
•Focus on structure responsible for nociception
•Need to understand the back to understand LBP
•The back (& nociception) primary targets of treatment
CNS PROCESSING MODEL
•Focus on structure responsible constructing pain experience
•Need to understand the brain to understand LBP
•The brain (& pain experience) primary targets of treatment
9. Are The Data On Brain
Changes Compatible
With What Is Know
About CLBP
“It is necessary to evaluate claims of causality
within the context of the current state of knowledge
within a given field and in related fields”.
14. Altered Body Perception/Awareness
• Smaller than really is
• Midline shift
• Miss bits out (Moseley 2008)
• Neglect that side (Moseley 2012)
• Impaired visual recognition of actions
(de Lussanet 2012, 2013)
15. Altered Body Perception/Awareness
• Less precision with tracking
(Willigenburg 2013)
• Less able to detect postural drift
(Willigenburg 2012)
• Qualitative studies
(Smith & Osborn 2008, Crowe 2009)
–‘Not part of me’
– ‘Not controlled automatically’
– ‘Doesn’t belong
16. Self-Report Disturbances In Body
Perception (Wand 2014)
Never Rarely Occasionally Often Always
Not part of the rest of my body
49 26 20 4 2
Focus all my attention on my back to make it
move
22 22 29 18 10
Back moves involuntarily, without my control
55 22 14 10 0
I don’t know how my back is moving
39 26 20 12 4
Not exactly sure what position my back is in
51 29 12 4 4
I can’t perceive the exact outline of my back
39 29 22 8 2
My back feels like it is enlarged (swollen)
28 20 28 22 4
My back feels like it has shrunk
69 16 8 4 4
My back feels lopsided (asymmetrical)
12 16 26 29 18
17. Altered Body Perception Might Influence The
Clinical Condition In A Number Of Ways
Tissue loading
Reason for movement dysfunction
• Abnormal tissue loading
• Generate nociceptive input
• Motor control related to acuity
(Luomajoki 2011)
18. Altered Body Perception Might Influence The
Clinical Condition In A Number Of Ways
Tissue health
Disrupt homeostasis
• Cooling with disownership (Moseley 2008)
• Alters histamine response (Barnsley 2012)
• Goggles change swelling (Moseley 2008)
19. Altered Body Perception Might Influence The Clinical
Condition In A Number Of Ways
Enhanced Sensitivity
• Sensori-motor incongruence (Harris 1999)
• Expected ≠ Actual feedback
• Maybe information is more threatening
• Enhanced salience (Legrain 2011)
• Less safe
• Poor localisation
• Increase spatial summation (Defrin 2006)
20. Altered Body Perception Might Influence The
Clinical Condition In A Number Of Ways
Fear & Worry
• Poor localisation of inputs
• Unexpected inputs
• Unexplained inputs
• Wrong / strange / peculiar
• Loss of control /ownership
• Perceived vulnerability
21. Can We Build A Plausible
Model From That
Information?
22. We Really Need Some Longitudinal Data
Distress/Depression
Perceived persistence
Helplessness
Pessimism/Rumination
Activity is harmful
Something serious
Passive coping
Atrophy over time
Shift to emotional circuitry
Persistence predicted by
• Emotional pain score
• mPFC/NAcc connectivity
• mPFC over LPFC info sharing
• Avoid emotional pain stimuli
23. We Really Need Some Longitudinal Data
• Neutral reasoning
• Mediates analgesic effect of control
• Moderates catastrophisation and unpleasantness
• LPFC/NAcc - successful emotional reappraisal
• Emotional reasoning - Emotional persistence
• Mediates rel’ship clinical pain and depression
• Associated with spontaneous clinical pain
• mPFC/Nacc - related to anxiety
LPFC
mPFC
26. Looking At It Helps (Wand 2012)
• Cross-over experiment
• Standardised range, speed and reps – 60 reps
• Moving with visualisation v without visualisation
With visual feedback
mean (SD)
Without visual
feedback
mean (SD)
Mean difference
(95%CI)
p
Pain Intensity 7.75 (11.92) 17.00 (14.61) 9.25 (1.44-17.06) .022
Time To Ease 48.50 (56.09) 97.38 (80.17) 48.88 (19.53-78.22) .002
27. Sensory Discrimination Helps (Wand 2013)
• Cross-over experiment - acupuncture needles
• Control condition
– Relax and think of nothing
• Experimental condition
– Nominate which needle is being stimulated
• Pain intensity with ten active movements
Pain with training Pain without training Mean difference (95% CI) p
2.8 ± 2.5 3.6 ± 2.0 -0.8 (-1.4 to -0.3) p=0.011
30. And I know it isn't back pain but…Retraining the
working body schema might also
• Cross over experiment
• Chronic Achilles tendinopathy
• Pain on hopping
Feet training Hand training Mean difference (95% CI) p
50.33 ±19.107 63.5 ±25.018 13.17 (-20.4 to -0.7 ) p=0.04
32. And This One
(1) A cognitive component - vicious cycle of pain was outlined
(2) Specific exercises to normalize maladaptive movement behaviours
(3) Targeted functional integration of activities in their daily life
(4) A physical activity programme tailored to the movement classification
33. Functional Rehabilitation Which
Has Mutual Normalisation Of
Cognitive Perception And Self
Perception As Its Primary Focus
Stop reinforcing
• Fragility
• Hopelessness
• Vulnerability
Stop reinforcing
• Splinting
• Rigidity
• Lack of variability
34. In some more detail – cognitive perception
• Coherent explanation
– Neuroscience informed
– What they are feeling
– Reasons for treatment failure
– Controllable and reversible
– Pathway to resolution
• Though needs commitment
• Disavow pathoanatomy
– Robust
– Sore but safe
– Movement is helpful
– Movement is healthy
• Build confidence
• Restore hope
– Realistic timeframe
• Enhance self-efficacy
35. In some more detail – self perception
• Enhance self-perception
– Sensory awareness
– Spatial awareness
– Motor awareness
• Ownership and familiarity
– Sensory discrimination
– Motor empathy
– Laterality recognition
– Motor imagery
– Local muscle activation
• Delineation & Dissociation
– Independent movement
• Adequate local mobility
– Independent control
• Adequate remote mobility
• Awareness through range
• Functional integration
36. Questions?
Acknowledgements:
Dr Neil O’Connell
Prof. Lorimer Moseley
Dr James McAuley
Dr Anne Smith
Flavia Di Pietro
Verity Tulloch
Monique James
Jemma Keeves
Sam Abbaszadeh
Pam George
Claire Bourgoin
Pam Formby
Editor's Notes
WM volume, connectivity, hyperintensity
Diffusion tensor imaging or tractography anistrophy
Superior longitudinal fasciculus
Inferior longitudinal fasciculus
Anterior thalamic tract
Connect areas that share motor imagery, planning and execution – inability to integrate imaging the activity and its execution
Related to walking speed
Hohman post treatment diff -2.3 compared with wait list