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Athletic development specialists dedicated to the art and science of excellence in movement

Lecture Notes: Dr. Phil Sizer on Pain Science

A few weeks ago, our school had the privilege of hosting Dr. Phil Sizer of Texas Tech University.  The main tenor of Dr. Sizer’s talk was focused on pain science.  Along with his duties as head of the physical therapy school and biomechanics lab, he is a highly versatile clinician and educator who maintains a patient load in addition to his teaching and research activities.  (for related discussion, see notes from Dr. Lorimer Moseley lecture)  Dr. Sizer was described as a “guy who reads journal articles on a Friday night,” so hopefully I can do him justice by posting this summary on a Friday night. 

Three take home points

  • Pain lives in the mind, but is the product of discrete processes often explainable through neuroscience.  Despite our growing understanding of pain as real phenomenon (as distinct from nociception), treating chronic pain is one of the most difficult challenges to us as clinicians.  
  • Structure, function, and sensation all have their place within a clinical approach.
  • The written evidence must not be treated as gospel and should never entirely usurp clinical judgment.  This was an extremely powerful message coming from someone with a prolific publication record and who continues to publish in several areas within the physical rehabilitation field. 

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*Clinician w/ terminal (academic) degree…Not in ivory tower: still sees patients!

*People in pain suffer longer than those who are dead!  Pain is the most insidious, least understood, most consequential phenomena

*Pain creates interpretation of sensory event: sometimes acted on in good way (protect body from further harm); other times is maladaptive (pain felt when no threat is present)

*Environmental factors: 40% of diseases treated by internal medicine docs did not exist 40 years ago

*Every pain experience is neurophysiological – people aren’t “crazy”!

*Different pathways exist for acute pain vs chronic pain

*Sensitization – peripheral mechanisms: what was once non-noxious becomes noxious

*Allodynia – non “pain fibers” begin producing pain w/ light touch

*The tissue is not THE issue but it is AN issue.  Main problem is the nervous system.  Check and balance system can go awry

*Antidepressants can work on pain pathways even if patient not depressed.  Can help “turn the corner’ on out of control systems. 

*Seratonin may change pain but mess w/ tissues all over body

*Chronic pain not classified by time: noted by out of control processes.  A disease in its own right.  Pain that lasts longer than reparative process and the curative agent. Characterized by sensitization. 

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*Acute pain

  1. Event
  2. Sensation
  3. Interpretation
  4. Response
  5. Experience

*Biopsychosocial factors

  1. Emotion
  2. Context               
  3. Social
  4. Psychological
  5. Affective/motivational
  6. Cognitive

*Neural adaptation

  •                 Hyperanalgesic – hurts more than it should
  •                 Allodynic – Hurts when it shouldn’t
  •                 Neuropathic – Keeps on hurtin

*Disc – creates thumbprint of pain; Facet creates pawprint of pain

*Manual therapy only as good as the exercise that augments it (10 days of exercise for every 10 minutes of manual therapy)

*Room for creativity/individualization  - manual therapy police won’t come after you if your techniques are not textbook (clinical reasoning process more important than technique)

*Descending inhibition

  •                 Acute – increasing effect of descending inhibition during 1st hours post-noxious event
  •                 Chronic – not clear; system goes into withdrawal.  Widespread, vague perception, emotional, conceptual aspects of pain perception -> pain is enduring, unpredictable, and mysterious

*How does nervous system change when exposed to persistent nociceptive input??

*Stop fighting about structure vs function, tissue vs brain…it all matters!!!

*Progression

  1. Symptom response
  2. Motor dysfunction
  3. Neuromotor control
  4. Somatosensory control
  5. Fundamental performance
  6. Advanced performance
  7. Functional advancement

*Sensitization               

  • Action potentials occur easier
  • Spontaneous neuron firing
  • Prolonged discharges
  • Expansion of receptor fields
  • Reduction of irritability influences

*Trust information from your locations distally more than locally

  •                 Wrist and hand – prime real estate
  •                 Elbow – starter home
  •                 Shoulder – bad neighborhood…don’t trust it!!

*Sometimes we don’t need permanent change – sometimes OK to to stuff to just prime the system (why we can prep the skin with hot packs, ice, US, etc)

*Clinical thought process – organize arrows in the quiver – no golden arrow!  Let people help you build your scaffolding

*Direct relation of the function of neck with the ocular behavior – motion drives somatosensory

*Chronic pain = “low fog over San Francisco bay” – sometimes treating one key brings you below threshold

*Movement desentitization = information for mind and body

*Strength and endurance are necessary but not sufficient for recovery – must address the sensory

*Build a model – martial arts: learn one practice but then integrate form multiple fields

*Different runways patients can land on – our job is to figure out which one they are on

  •                 Cognitive
  •                 Affective
  •                 Motivational
  •                 Emotional
  •                 Context
  •                 Afferent

*Each person’s response is different – chronic pain sufferers lose sense of self – body is distinction of awareness around it

*One solution – modeling painful elbow with pictures of other elbows

*When there is trauma, everyone sensitizes but people react differently long term

*Chemical mediators and tissue pH induce sensitization

*Patients are expecting you to dismiss them because they have been dealt with this way by other clinicians

*Relationship with clinician is crucial for chronic pain patient

*Manual therapy gets the boat back on course, movement is the wind and the sails (in other words, manual therapy is not the endgame…just an adjunct to facilitate progress with movement)

*Some clients aren’t in pain but come in just to learn how to move better

*FMS – PTs are the toughest to teach…they want to break everything down into minutiae…Just score it and move on!!!

*Biopsychosocial redirection – Shift from pain language to recovery language

*Traction has gotten bad press because researchers have done poor job classifying patients - Research must exploit differences among patients.  Case studies are not highest level of evidence but can be good to appreciate diversity of patients

*Position and movement management – mange the way patients move themselves in space

*Movement heals…fear of movement destroys

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*Manual therapy for pain

  1. Inform the body about movement
  2. Reduce excitability
  3. Do something (change/novelty…new information for someone who only knows pain)
  4. Activation

*..........But if you don’t move well these don’t work!  They only become temporary fixes

*Timing of manual therapy ---WHEN also matters, not only what and how

*Need BELIEF in what you are doing with chronic pain patients

  •                 Therapist must believe in self
  •                 Patient’s belief in the therapist

*Scientist used to be the explorer – Now clinician is the explorer

*Scientific conclusions are now based on consensus – When a good paper comes out it often gets shot down…that’s how the game works!

*Clinician’s judgment should not be bottom of evidence hierarchy in practice

*Patient centered…not research centered!

*Sound clinical reasoning comes from the model we are attached to; use the evidence to guide what we do

*Your creativity doesn’t stop when you graduate

*Two things are yours and yours alone

  •                 Ability to travel and see the world
  •                 Education

*Formerly we had an expert based system…then evidence based practice took over…we are now drowning in evidence!

*Most evidence doesn’t work with chronic pain patients…need a clinical framework

*Rigor vs relevance…Statistical vs clinical significance