Articles Of The Week May 23, 2021

As it becomes legal in more places and consumption goes up, so does much of the hype around what cannabis can do. Specifically, people are looking to see if its use can help with chronic pain. Well, fortunately, our buddy Paul Ingraham tackled the issue for this article.

Marijuana for Pain – Paul Ingraham

We should always (when appropriate) encourage exercise and activity with our patients. Especially when people have been dealing with lockdowns, working from home, and any other thing that may have them in a position where they aren’t exercising as much we may want to look for some tips to pass on to them to get exercising again. This article has some great tips to just get people moving again.

Lockdown muscle loss: Five ways to get back in shape – David Brown

We all know how important mental health is, but do we talk about this very much amongst colleagues in our workplace? This article has some great advice around developing culture at work that places importance on this.

How to Talk About Mental Health in the Workplace – Haeli Harris

I don’t know about you, but I’m usually pretty good about starting an exercise program but have a tough time sticking with it. Here’s some great advice that we could use personally, but also use to give advice to patients.

How to Start Working Out (Consistently) – Jim Bathurst

Ever considered starting a blog for your massage practice? It can be a great way to get new patients to come in and also build your reputation. Here’s a lesson on how to start blogging and using appropriate science research to build around a blog post.

Science Blogging For Beginners – Nicolas Ng

 

 

An Attempt At Simplifying Central Sensitization

 

Have you ever had one of those appointments where you’re not sure of the outcome or the patient interaction?

I remember having a patient back in college who would come in for treatment of back pain. The person was in their early 20’s and told me they were dealing with chronic pain in the area. 

During the first treatment, as soon as I put my hands on them and pressed down, they quickly informed me that was too much pressure! So, of course, I backed off and used a much gentler touch. 

I felt like I was barely touching them. 

So, I treated the person a few times; then, they booked in with one of my classmates. 

However, during their treatment, the patient said “your treatment was okay, but you don’t use as much pressure as Jamie”!

We were both perplexed as my classmate said they were using very light touch (I think I had put something in the treatment notes about pressure). 

Neither of us could figure out what was the correct approach. There is a chance this was just therapist preference, but there’s also the possibility of something called Central Sensitization. 

Understanding Pain

It’s probably important to start by talking about Nociception. 

Nociception itself is not pain; it is the detection of noxious stimuli, which is a protective response that generates a reflex withdrawal to get us to stop doing whatever thing we are doing that could cause tissue damage. (1) Another result of this is it helps us avoid doing those things again (think the first time you put your hand on a hot stove, and will likely never do that again). 

When sensitization of this nociceptive system is repeated or more intense than usual, then the amount of stimulus needed to create pain decreases and becomes amplified. (1)

So, for Central Sensitization to occur, an intense stimulus has to happen repeatedly over an extended period. (1) Think of something like jabbing your forearm with a sharp pen for a couple of minutes (don’t actually do it, I’m just giving examples!). Doing the same thing with the pen for 5 seconds won’t have the same result. 

When this happens, it leads to Nociception no longer being a protection, and pain can arise out of nowhere. 

This can result in allodynia and hyperalgesia, and it is necessary to recognize the difference between the two. 

Hyperalgesia is where an increased response at a normal threshold or increased threshold creates an enhanced pain sensitivity. This is common for things like neuropathy. 

Allodynia is pain from something that shouldn’t be painful. Like the touch of a feather, as you can see in the image below.(2) 

 

Image from: Tsagareli, Merab. (2013). Pain and memory: Do they share similar mechanisms?. World Journal of Neuroscience. 3. 39-48. 10.4236/wjns.2013.31005.  

 

As well, pain can be exaggerated and prolonged because of its response to noxious stimuli and can spread to other parts of the body, which is called secondary hyperalgesia

The research papers cited show a whole host of molecular changes and activities in the spinal cord that lead to CS, but I’m not sure we have to know those specifics. It is important to know that these changes are happening in the dorsal horn of the spinal cord which is sending signals to the brain. 

Another essential takeaway is how there is no single defining mechanism; it’s a general phenomenon that changes how a stimulus is interpreted. 

So, how often have you had a patient come in where maybe their pain experience didn’t make sense? Perhaps their arm hit the door as they walked in, and it was excruciating? Maybe their description of what they are going through didn’t make sense? 

Well, this may be in part because of some CS occurring with them. Because tissue injury is not necessary, and pain can be maintained even though there isn’t any injury that has happened (recently), these may be signs that something more is going on. 

However, we aren’t able to diagnose this, but it may be vital for us to recognize it. So, let’s look at some conditions where this is common for people to experience this. 

What About Clinically? 

So, part of the issue with CS is that the CNS can change, distort, and amplify pain all without an actual noxious input. When we look at the lack of an injury, it may seem as though the pain isn’t real, but it most definitely is.(3)

So, imagine what this is like for the patient sitting in front of you. Especially when there could be things like work-related compensation etc. involved. (3) 

Another aspect regarding this condition is that it is complicated to diagnose because we cannot measure sensory input. So, pain hypersensitivity alone isn’t enough to say someone has CS. Some of the things they look at to determine if it is CS are (and remember how I said ‘a whole host of molecular changes and activities in the spinal cord that lead to CS, but I’m not sure we have to know those specifics’): (3)

  • pain mediated by low threshold fibres (but they have to use nerve blockers and electrical stimulation to figure that out)
  • spread of pain sensitivity to other areas without any injury
  • aftersensations (prolonged sensation after stimuli has been removed)
  • something called ‘temporal summation’ (basically things happening at the action potentials of nerve conduction)
  • pain continuing on from a small stimulus that usually wouldn’t cause pain

So, clearly, for us as Massage Therapists we wouldn’t be able to develop an accurate diagnosis for one of our patients, as much of this would have to be seen under MRI. 

However, we can look at some conditions where we are more likely to see this as CS can influence the following:(3)

Rheumatoid Arthritis

  • during flare ups more pain in the joints and remote areas could set up a state of CS

Osteoarthritis

  • degree of pain does not always correlate to extent of joint damage or active inflammation

Temporomandibular Issues

  •  associated with increase in generalized pain sensitivity after isometrics of orofacial muscles
  •  widespread bilateral mechanical and thermal pain sensitivity in women
  •  greater referred pain from trigger points
  •  mechanical allodynia with inflamed teeth, don’t become a dentist

Fibromyalgia 

  •  several studies showed increased sensitivity to pressure, thermal stimuli, and electrical stimulation of muscle and skin support CS
  •  they use medications in this case to treat the CNS

Musculoskeletal conditions

  •  Whiplash
  •  shoulder impingement syndrome
  •  tennis elbow (widespread bilateral mechanical pain)
  •  deep tissue hyperalgesia in chronic radiating low back pain, with intervertebral disc herniation
  •  characterized by spread of pain and sensitivity to deep uninjured tissue

Headache

  •  spontaneous body pain and allodynia preceeding migraine attacks
  •  chronic tension headaches referring to hyperalgesia of neck muscles
  •  CS may contribute to to chronification of tension headaches

Neuropathic Pain

  •  studies have looked at things like carpal tunnel that had enhanced bilateral sensitivity and spread of symptoms with nerve entrapment which supports CS

Complex Regional Pain Syndrome

  •  presents with increase in tactile and pressure invoked pain, presence of contralateral hypersensitivity in the absence of any inflammatory process

Post Surgical Pain

  •  depends on anasthesia and very important during recovery

Visceral pain

  •  IBS/referred pain – use local rectal anasthesia to help
  •  Non-cardiac chest pain have esophogeal  hypersensitivity   
  •  chronic pancreatitis – generalized deep pressure hyperalgesia
  •  urological tract hypersensitivity associated with: 
  •  interstitial cystitis
  •  chronic prostatitis
  •  endometriosis
  •  vulvodynia

Comorbidities

  •  fibromyalgia, tension headache, tmj, IBS
  •  no inflammation or cause which suggest CS
  •  good chance of genetic factors
  •  can contribute to depression, fatigue, joint pain

Okay I get it, that’s a LONG list. This post was intended to be a way to simplify what CS is, but there really are no ‘simple’ answers, especially for what we do to help patients. So there may not be a lot we can do treatment-wise, but what’s really important is to recognize what the person is going through. They may not get a CS diagnosis; they may not get any kind of diagnosis at all. 

And we know that patients (and insurance companies) really want to get a diagnosis to understand what is going on. So, our role may be to simply VALIDATE, VALIDATE, VALIDATE, the person sitting in front of us. You may be the first person who believes this person is in pain. Take the time to listen to them, let them talk, and support them! While you will likely have to adjust the pressure you use during treatment, those treatments may become supported self-management, and you may become their biggest ally for their journey. I don’t know to this day if that person I saw while I was a student had CS, I just hope I did a good enough job of minimizing their pain and feeling good, even for just an hour at a time. 

If you’d like to get more in-depth with the topic of Central Sensitization, Dr. Melissa Farmer has a great four-part series on the topic which you can read HERE

References

  1. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. The journal of pain. 2009 Sep 1;10(9):895-926.
  2. Tsagareli, Merab. (2013). Pain and memory: Do they share similar mechanisms?. World Journal of Neuroscience. 3. 39-48. 10.4236/wjns.2013.31005.  
  3. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011 Mar 1;152(3):S2-15

 

Articles Of The Week May 9, 2021

Sometimes getting some focus is difficult, especially if you’ve been working on a project for an extended period. While these brain breaks are intended for kids, us adults could probably use one or two of them as well.

20 Energizing Brain Breaks For Kids – Lee Douglas

There are several courses out there professing how they can screen or predict injuries in athletes. So, what does the research say on predicting injuries in runners? Well, you’ll have to read this article to find out.

The Elusive Art of Predicting Running InjuriesAlex Hutchinson

Some really interesting stuff on helping people with pain. New research showing how interactions with a persons environment can influence a persons pain experience.

How Enactive Philosophy Can Transform the Treatment of Chronic Pain – Jenny Logan

We’re big fans of this podcast and big fans of Bronnie, so naturally we had to share this. They cover the clinical encounter and how it relates to a BPS framework.

The Massage Collective Podcast With – Bronnie Lennox Thompson

“As the body of knowledge to support the use of massage therapy continues to grow, understanding the basic science behind what we do and the guiding principles of adaptability enable us to apply this work to a number of pathologies.” Great to see this kind of information being developed.

Massage Therapy For The Postoperative Population; Shoulder, Hip, Knee, and Ankle – Richard Lebert

Trigger Points With Paul Ingraham


 

This week we have our second guest on the podcast the one and only Paul Ingraham.

Paul Ingraham is a Vancouver science journalist and publishing entrepreneur and a former Registered Massage Therapist.  He left that profession over concerns about pseudoscientific beliefs and practices, and went on to create PainScience.com, a website about the science of pain, injury, treatment, and rehab. He has written hundreds of articles and ten books on these themes (and about half of those are about repetitive strain injuries).  He’s also a reluctant runner and an avid ultimate player with a long list of his own sports injuries and pain problems. He is currently sheltering in place with his wife, still hiding from SARS-CoV-2, working on his next book and an endless supply of science updates to PainScience.com.

Trigger point doubts article:
https://www.painscience.com/articles/trigger-point-doubts.php

Trigger points book:
https://www.painscience.com/tutorials/trigger-points.php

General article about massage science (an excellent place for MTs to start on PainScience.com):
https://www.painscience.com/articles/does-massage-work.php

 

Paul Ingraham

Does Exercise ‘Work’ For Pain? – Scrutinizing The Question!

Exercise has become a popular treatment for many musculoskeletal issues over the past few years but surprisingly little is actually understood, even after tons of research, about how to use it in clinical practice and maybe even if it’s worth using?

In this blog, we will look at the actual question of “does exercise ‘work’ for pain” as ‘works’ tends to be a phrase that gets bandied about a lot without much clarity. Similar to “the research shows” when often the deeper you dive into the research the LESS clear it often becomes, especially around pain.

I will write a few more posts on the “everything works/nothing works” perspective, how it might work and how specific we may need to be in future posts.

Well Does It Work?

 

Well, it depends on what you mean by work? Which condition? What are you comparing it against? Do you mean pain? Do you mean disability? Did it have an effect on physical function or some biomotor variable? All of these things are quite different questions that often get lumped into the catch-all term ‘works’.

We need to think as well about WHY we might come to a conclusion on if it ‘works’ or does not. Is it because I have read widely in this area? Is it because who I follow on Twitter tells me it does or doesn’t or am I simply following my biases? A little bit of epistemology perhaps.

Like ANY intervention, exercise should be thoroughly scrutinized and the basic reality is we have to be prepared that exercise will not work for everybody, it is not a magic bullet or panacea and a lot of what we do is a bunch of informed trial and error really, but we will come back to that later in another post. We have to remember we are dealing with HUMANS who tend to be wonderfully variable in their responses as most biological organisms are.

We now discuss pain as being a complex, multifactorial experience (blah blah blah) so why do we expect one thing to come along and solve it all for everybody? For some it will be revelatory, for some, it will do very little and for others, even flair them up, so we need a bit of perspective but as a standalone treatment I think there is a lot to like here especially with the benefits for our health and well-being.

Just Hurry Up And Tell Me…..

 

The whole idea of “it works” could stem from how we have traditionally looked at the research. To show a difference between two interventions or ‘usual care’ it has been common to use a significance level of p = 0.05 to indicate something ‘works’, so the observed difference in effect between two groups is likely to be at least as big as reported and this then is used to reject or accept the hypothesis of a study. Generally, something like “treatment A WORKS better than treatment B” or something along those lines. Is exercise better than manual therapy? Is it better than usual care? You get the picture. I am no statistician or researcher, only a humble clinician so bear with me here.

So we might say exercise is better than usual care or whatever else, but the real question should be HOW MUCH better or the actual magnitude/size of the difference. The p-value is a statistical tool and not a measure of the actual average size of the effect. Something can be statistically significant without really making a difference to our patients and this is where minimal clinical important difference comes in (MCID).

A clinically meaningful change for pain has been discussed as being somewhere between 1-2 points on an 11 point VAS/NPRS dependent on what it is being tested against such as ‘usual care’ or another specific intervention. Other magnitudes of clinical significance have pointed a 20% or 30% change from the baseline and this makes sense as a 2 point change for a baseline of 4 is far more significant than a 2 point change on a baseline of 8 for example.

We have to be aware that these cut-off values such as 0.05 are also a bit arbitrary. If we critique the significance of p = 0.05 then we probably have to do the same for MCID too. The real value of any effect may only really be possible via subjective evaluation by the person experiencing them and their expectations of what that change should be.

We may also have to consider how we view the ‘mean effect’ as this may not actually reflect THE effect that MY patient gets (for a whole load of potential reasons). The mean represents the average response and is sensitive to those that respond very highly and also people who respond lowly or even negatively. In trials with small sample sizes, as much of exercise & pain-related research is these more extreme values can significantly alter the mean.

We should also take into account the standard deviation of the mean response and this is a measure of the variation within the group of participants being studied. This could mean (get it…) that the variation in response when applying the treatment in the clinic could also be pretty wide too. A confidence interval (CI) is another measure of uncertainty/variability around the potential treatment effect on a wider population. The CI reflects the inherent variability/error in the process of sampling taking into account the size and variation within the sample.

The last question here is does exercise research always reflect clinical practice? Personally, I tinker with the type of exercise, intensity, frequency, volume etc to ‘optimise’ for the person whether that’s in relation to their response or ability to achieve the program. If I am not getting the desired response then I feel quite at home playing with the variables. Is this right or wrong? I have no idea but standardized programs used to study exercise often don’t do this.

You Really Didn’t Answer The Question…

 

So what was the point of all this, well we can start to see that “it works” is a pretty nebulous term really. It’s the classic clinical conundrum of applying the world of research to our patients and how we should expect them to respond. Predicting the future is always tough and worlds of research and clinical practice is definitely not a game of certainties.

We have to consider the actual size of what ‘works’ and how likely is my patient to actually respond in this way and I see it as a bit of a “probability wrapped up in a probability”. This often makes clinicians feel uncomfortable as we tend to like certainties and sometimes research can be portrayed as more certain than it really is IMO.  But we really have to look at the trials, who they are studying, how many people, what exercise/dosage and what’s the spread of responses amongst other things to even get close to answering the question.

Next time we might actually answer the question ; )