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Building-up a unique story for every patient, based on the highest quality evidence

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Building-up a unique story for every patient, based on the highest quality evidence

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Question to the group. How do you tend to discuss pain with individuals who may have a cognitive impairment or learning disability?

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Protective system Pain metaphor - parking alarm

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Painful metaphors: enactivism and art in qualitative research

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The tequila vaccine -  as a metaphor to help understand pain

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The tequila vaccine -  as a metaphor to help understand pain

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Harriët Wittink trained as a physiotherapist in the Netherlands. She then moved to the United States to pursue a master's degree in Orthopedic and Sports Physical Therapy. Following this she became an Orthopedic Clinical Specialist and gained her PhD at Boston University in 1998 with a thesis on "Chronic back pain, aerobic fitness, physical functioning and disability". From 1989 to 2001 she worked in large academic hospitals in Boston as a member of interdisciplinary pain management teams. She is professor and chair of the Lifestyle and Health Research Group of the Utrecht University of Applied Sciences since 2007.

Janke Oosterhaven received her master's degree in Movement Sciences in 2001 and she concluded her bachelor studies in Physiotherapy in 2004. She worked for several years as a physical therapist and started teaching physical therapists at bachelor and master level at the Utrecht University of applied Sciences in 2007. She joined the Research group Lifestyle and Health of the Utrecht University of applied Science in 2011 and is about to finish her PHD: a mixed methods study on patient dropout in chronic pain management programmes. Health literacy is one of the most important topics in this PHD study.

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Harriët Wittink trained as a physiotherapist in the Netherlands. She then moved to the United States to pursue a master's degree in Orthopedic and Sports Physical Therapy. Following this she became an Orthopedic Clinical Specialist and gained her PhD at Boston University in 1998 with a thesis on "Chronic back pain, aerobic fitness, physical functioning and disability".

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Theoretical considerations for chronic pain rehabilitation

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Theoretical considerations for chronic pain rehabilitation

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Theoretical Considerations for Chronic Pain Rehabilitation

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Affiliations

1 Department of Anesthesiology, Section Pain Therapy and Pain Psychology, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

2 Department of Pain Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, USA.

3 Department of Anesthesiology/Psychiatry, School of Medicine, University of Maryland, Baltimore, MD, USA.

4 Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, USA.

Free PMC article

Free PMC article

Affiliations

1 Department of Anesthesiology, Section Pain Therapy and Pain Psychology, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

2 Department of Pain Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, USA.

3 Department of Anesthesiology/Psychiatry, School of Medicine, University of Maryland, Baltimore, MD, USA.

4 Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, USA.

Abstract

Introduction: Nocebo-induced algesic responses occurring within clinical contexts present a challenge for health care practitioners working in the field of pain medicine.

Objectives: Following the recent research on algesic nocebo effects, the scope of this review is to develop ethically acceptable strategies to help avoid, or at least reduce, nocebo responses within clinical settings.

Methods: We reviewed relevant clinical studies that depict how patient-practitioner interactions may contribute to the reduction of nocebo responses.

Results: A strong algesic nocebo effect may adversely impact a patient's condition by causing decreases in both the efficacy and effectiveness of interventions, as well as by promoting treatment nonadherence and discontinuation. These effects may be triggered through multiple channels and can lead to significant alterations in a patient's perception of pain, consequently producing a weakening of the specific positive effects of pharmacological, psychological, or physical pain-management interventions.

Conclusion: To minimize nocebo effects in clinical settings, we identified and discussed five contextual aspects relevant to the treatment of patients with chronic pain: (1) negative patient-clinician communication and interaction during treatment; (2) emotional burden of patients during treatment with analgesic medication; (3) negative information provided via informational leaflets; (4) cued and contextual conditioning nocebo effects; and (5) patient's lack of positive information. Through an understanding of these elements, many preventive and ethically acceptable clinical actions can be taken to improve multidisciplinary pain treatment outcomes.

Keywords: Hyperalgesia; Nocebo algesia; Nocebo effects; Pain modulation; Pain treatment; clinical implications.

Conflict of interest statement

Disclosures The authors have no conflicts of interest to declare.

References

Ader R, Mercurio MG, Walton J, James D, Davis M, Ojha V, Kimball AB, Fiorentino D. Conditioned pharmacotherapeutic effects: a preliminary study. Psychosom Med 2010;72:192-7. - PMC - PubMed

Amanzio M, Corazzini LL, Vase L, Benedetti F. A systematic review of adverse events in placebo groups of anti-migraine clinical trials. PAIN 2009;146:261-9. - PubMed

Axford J, Butt A, Heron C, Hammond J, Morgan J, Alavi A, Bolton J, Bland M. Prevalence of anxiety and depression in osteoarthritis: use of the Hospital Anxiety and Depression Scale as a screening tool. Clin Rheumatol 2010;29:1277-83. - PubMed

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national center for biotechnology information

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Nocebo effects in clinical studies: hints for pain therapy - PubMed

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To minimize nocebo effects in clinical settings, we identified and discussed five contextual aspects relevant to the treatment of patients with chronic pain: (1) negative patient-clinician communication and interaction during treatment; (2) emotional burden of patients during treatment with analgesi ...

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The Effect of Treatment Expectation on Drug Efficacy: Imaging the Analgesic Benefit of the Opioid Remifentanil

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The Effect of Treatment Expectation on Drug Efficacy: Imaging the Analgesic Benefit of the Opioid Remifentanil

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The Effect of Treatment Expectation on Drug Efficacy: Imaging the Analgesic Benefit of the Opioid Remifentanil

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Affiliation

1 Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences (Division of Anaesthetics), University of Oxford, OX3 9DU Oxford, UK. bingel@uke.de

Free article

Abstract

Evidence from behavioral and self-reported data suggests that the patients' beliefs and expectations can shape both therapeutic and adverse effects of any given drug. We investigated how divergent expectancies alter the analgesic efficacy of a potent opioid in healthy volunteers by using brain imaging. The effect of a fixed concentration of the μ-opioid agonist remifentanil on constant heat pain was assessed under three experimental conditions using a within-subject design: with no expectation of analgesia, with expectancy of a positive analgesic effect, and with negative expectancy of analgesia (that is, expectation of hyperalgesia or exacerbation of pain). We used functional magnetic resonance imaging to record brain activity to corroborate the effects of expectations on the analgesic efficacy of the opioid and to elucidate the underlying neural mechanisms. Positive treatment expectancy substantially enhanced (doubled) the analgesic benefit of remifentanil. In contrast, negative treatment expectancy abolished remifentanil analgesia. These subjective effects were substantiated by significant changes in the neural activity in brain regions involved with the coding of pain intensity. The positive expectancy effects were associated with activity in the endogenous pain modulatory system, and the negative expectancy effects with activity in the hippocampus. On the basis of subjective and objective evidence, we contend that an individual's expectation of a drug's effect critically influences its therapeutic efficacy and that regulatory brain mechanisms differ as a function of expectancy. We propose that it may be necessary to integrate patients' beliefs and expectations into drug treatment regimes alongside traditional considerations in order to optimize treatment outcomes.

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Pergolizzi J, Böger RH, Budd K, Dahan A, Erdine S, Hans G, Kress HG, Langford R, Likar R, Raffa RB, Sacerdote P. Pergolizzi J, et al. Pain Pract. 2008 Jul-Aug;8(4):287-313. doi: 10.1111/j.1533-2500.2008.00204.x. Epub 2008 May 23. Pain Pract. 2008. PMID: 18503626

Manipulating placebo analgesia and nocebo hyperalgesia by changing brain excitability.

Tu Y, Wilson G, Camprodon J, Dougherty DD, Vangel M, Benedetti F, Kaptchuk TJ, Gollub RL, Kong J. Tu Y, et al. Proc Natl Acad Sci U S A. 2021 May 11;118(19):e2101273118. doi: 10.1073/pnas.2101273118. Proc Natl Acad Sci U S A. 2021. PMID: 33941677

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national center for biotechnology information

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The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil - PubMed

# data[].attributes.attachment_link.description
Evidence from behavioral and self-reported data suggests that the patients' beliefs and expectations can shape both therapeutic and adverse effects of any given drug. We investigated how divergent expectancies alter the analgesic efficacy of a potent opioid in healthy volunteers by using brain imagi ...

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Nocebo and pain: an overview of the psychoneurobiological mechanisms

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Nocebo and pain: an overview of the psychoneurobiological mechanisms

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Nocebo and pain- an overview of the psychoneurobiological mechanisms

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doi: 10.1186/s40945-020-00082-y.

Affiliations

1 Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genova, Campus Universitario di Savona, via Magliotto 2, 17100 Savona, Italy.

2 Department of Neuroscience, University of Turin Medical School, Turin, Italy.

3 Plateau Rosà Laboratories, Plateau Rosà Laboratories, Zermatt, Switzerland.

Free PMC article

Free PMC article

doi: 10.1186/s40945-020-00082-y.

Affiliations

1 Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genova, Campus Universitario di Savona, via Magliotto 2, 17100 Savona, Italy.

2 Department of Neuroscience, University of Turin Medical School, Turin, Italy.

3 Plateau Rosà Laboratories, Plateau Rosà Laboratories, Zermatt, Switzerland.

Abstract

Background: Placebo and nocebo effects embody psychoneurobiological phenomena where behavioural, neurophysiological, perceptive and cognitive changes occur during the therapeutic encounter in the healthcare context. Placebo effects are produced by a positive healthcare context; while nocebo effects are consequences of negative healthcare context. Historically, placebo, nocebo and context-related effects were considered as confounding elements for clinicians and researchers. In the last two decades this attitude started to change, and the understanding of the value of these effects has increased. Despite the growing interest, the knowledge and the awareness of using the healthcare context to trigger placebo and nocebo effects is currently limited and heterogeneous among physiotherapists, reducing their translational value in the physiotherapy field.

Objectives: To introduce the placebo, nocebo and context-related effects by: (1) presenting their psychological models; (2) describing their neurophysiological mechanisms; (3) underlining their impact for the physiotherapy profession; and (4) tracing lines for future researches.

Conclusion: Several psychological mechanisms are involved in placebo, nocebo and context-related effects; including expectation, learning processes (classical conditioning and observational learning), reinforced expectations, mindset and personality traits. The neurophysiological mechanisms mainly include the endogenous opioid, the endocannabinoid and the dopaminergic systems. Neuroimaging studies have identified different brain regions involved such as the dorsolateral prefrontal cortex, the rostral anterior cingulate cortex, the periaqueductal gray and the dorsal horn of spine. From a clinical perspective, the manipulation of the healthcare context with the best evidence-based therapy represents an opportunity to trigger placebo effects and to avoid nocebo effects respecting the ethical code of conduct. From a managerial perspective, stakeholders, organizations and governments should encourage the assessment of the healthcare context aimed to improve the quality of physiotherapy services. From an educational perspective, placebo and nocebo effects are professional topics that should be integrated in the university program of health and medical professions. From a research perspective, the control of placebo, nocebo and context-related effects offers to the scientific community the chance to better measure the impact of physiotherapy on different outcomes and in different conditions through primary studies.

Keywords: Conditioning; Contextual factors; Expectation; Learning; Nocebo effect; Pain; Physical therapy modalities; Placebo effect; Rehabilitation; Therapeutic outcome.

Conflict of interest statement

Competing interestsThe authors declare that they have no competing interests.

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Benedetti F. Placebo and the new physiology of the doctor-patient relationship. Physiol Rev. 2013;93:1207-1246. - PMC - PubMed

Colloca L, Barsky AJ. Placebo and Nocebo effects. N Engl J Med. 2020;382:554-561. - PubMed

Colloca L. The placebo effect in pain therapies. Annu Rev Pharmacol Toxicol. 2019;59:191-211. - PMC - PubMed

Blasini M, Corsi N, Klinger R, Colloca L. Nocebo and pain: an overview of the psychoneurobiological mechanisms. Pain Rep. 2017;2:e585. - PMC - PubMed

Klinger R, Blasini M, Schmitz J, Colloca L. Nocebo effects in clinical studies: hints for pain therapy. Pain Rep. 2017;2:e586. - PMC - PubMed

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national center for biotechnology information

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Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy - PubMed

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doi: 10.1186/s40945-020-00082-y. 1 Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genova, Campus Universitario di Savona, via Magliotto 2, 17100 Savona, Italy. 2 Department of Neuroscience, University of Turin Medical School, Turin, Italy. 3 Plateau Rosà Laboratories, Plateau Rosà Laboratories, Zermatt, Switzerland. Free PMC article Free PMC article doi: 10.1186/s40945-020-00082-y.

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national center for biotechnology information

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Placebo and the new physiology of the doctor-patient relationship - PubMed

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Modern medicine has progressed in parallel with the advancement of biochemistry, anatomy, and physiology. By using the tools of modern medicine, the physician today can treat and prevent a number of diseases through pharmacology, genetics, and physical interventions. Besides this materia medica, the ...

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doi: 10.1097/SPC.0000000000000419.

Affiliation

1 Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.

doi: 10.1097/SPC.0000000000000419.

Affiliation

1 Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.

Abstract

Purpose of review: The purpose of this review is to summarize recent findings on conditioned pain modulation (CPM) in humans with a focus on methodology, factors modulating CPM, and the potential for CPM as a clinical marker for pain progression.

Recent findings: CPM can be evoked by combining different stimulus modalities with good reliability; sequential CPM effects are stable over time with limited carryover effects. Optimism and pain catastrophizing might influence pain inhibition. Further, studies suggest that the CPM effect can be improved by gabapentinoids, transcranial direct current stimulation to cortical structures, and exercise and that long-term opioid use might impair CPM in patients with chronic pain. Clinical evidence suggests that preoperative impaired CPM may predict more severe chronic postoperative pain. The effect of pain duration on CPM impairment has been challenged by recent studies.

Summary: As CPM methodology is optimized, studies are revealing factors that can modulate descending pain inhibitory pathways. Understanding underlying mechanisms of CPM will improve the utility of CPM in a clinical setting and potentially lead to personalized treatments for chronic pain patients.

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transcranial direct current stimulation / methods

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As CPM methodology is optimized, studies are revealing factors that can modulate descending pain inhibitory pathways. Understanding underlying mechanisms of CPM will improve the utility of CPM in a clinical setting and potentially lead to personalized treatments for chronic pain patients.

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Your brain hallucinates your conscious reality | Anil Seth

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Your brain hallucinates your conscious reality | Anil Seth

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Your Brain Hallucinates Your Conscious Reality | Anil Seth | TED

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Predictive processing as a theory to understand pain | Mick Thacker 

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Predictive processing as a theory to understand pain | Mick Thacker 

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Predictive processing as a theory to understand pain | Mick Thacker | TEDxKingstonUponThames

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The plasticity of descending controls in pain: translational probing - PubMed

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Descending controls, comprising pathways that originate in midbrain and brainstem regions and project onto the spinal cord, have long been recognised as key links in the multiple neural networks that interact to produce the overall pain experience. There is clear evidence from preclinical and clinic…

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To live with chronic pain is to live with daily challenges around simple tasks that others take for granted. It often means being disbelieved, stigmatised for not getting better, or judged as not coping. It might mean living with poor mental health and self-esteem, absenteeism from school or work, the breakdown of relationships, and socioeconomic disadvantage. For society, the costs are staggering: low back pain is the leading cause of years lost to disability and chronic pain costs billions of dollars through health system expenditures, productivity losses, reduced quality of life, and informal care.

To read this article in full you will need to make a payment

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To live with chronic pain is to live with daily challenges around simple tasks that others take for granted. It often means being disbelieved, stigmatised for not getting better, or judged as not coping. It might mean living with poor mental health and self-esteem, absenteeism from school or work, the breakdown of relationships, and socioeconomic disadvantage.

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Neuropathic Pain: A Maladaptive Response of the Nervous System to Damage

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Neuropathic Pain: A Maladaptive Response of the Nervous System to Damage

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Neuropathic Pain: A Maladaptive Response of the Nervous System to Damage

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Self-care of chronic musculoskeletal pain

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Self-care of chronic musculoskeletal pain

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Self-care of chronic musculoskeletal pain – experiences and attitudes of patients and health care providers

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Sensory and pain perception changes with unilateral neuropathy

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Sensory and pain perception changes with unilateral neuropathy

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Contralateral Sensory and Pain Perception Changes in Patients With Unilateral Neuropathy

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Objective: To test whether contralateral sensory abnormalities in the clinically unaffected area of patients with unilateral neuropathic pain are due to the neuropathy or pain mechanisms. Methods: We analyzed the contralateral clinically unaffected side of patients with unilateral painful or painless neuropathy (peripheral nerve injury, PNI; postherpetic neuropathy, PHN; radiculopathy) by standardized quantitative sensory testing following a validated protocol.

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Self-management at the core of back pain care

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Self-management at the core of back pain care

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Highlights

*

Self-management support is person-centred care reinforcing patient autonomy.

*

Avoid strong clinician control and help patients developing self-efficacy.

*

Let patients' value-based goals and shared decisions guide management.

*

Help patients make sense of symptoms and reframe unhelpful perspectives.

Use supervised exercises as a tool to practice problem-solving skills

Abstract

Background

A paradigm shift away from clinician-led management of people with chronic disorders to people playing a key role in their own care has been advocated. At the same time, good health is recognised as the ability to adapt to changing life circumstances and to self-manage. Under this paradigm, successful management of persistent back pain is not mainly about clinicians diagnosing and curing patients, but rather about a partnership where clinicians help individuals live good lives despite back pain.

Objective

In this paper, we discuss why there is a need for clinicians to engage in supporting self-management for people with persistent back pain and which actions clinicians can take to integrate self-management support in their care for people with back pain.

Discussion

People with low back pain (LBP) self-manage their pain most of the time. Therefore, clinicians and health systems should empower them to do it well and provide knowledge and skills to make good decisions related to LBP and general health. Self-management does not mean that people are alone and without health care, rather it empowers people to know when to consult for diagnostic assessment, symptom relief, or advice. A shift in health care paradigm and clinicians' roles is not only challenging for individual clinicians, it requires organisational support in clinical settings and health systems. Currently, there is no clear evidence showing how exactly LBP self-management is most effectively supported in clinical practice, but core elements have been identified that involve working with cognitions related to pain, behaviour change, and patient autonomy.

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Self-management at the core of back pain care: 10 key points for clinicians

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Self-management support is person-centred care reinforcing patient autonomy. * Avoid strong clinician control and help patients developing self-efficacy. * Let patients' value-based goals and shared decisions guide management. * Help patients make sense of symptoms and reframe unhelpful perspectives.

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How would you like to change your practice following our time together?

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How would you like to change your practice following our time together?

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Central sensitization is not enough to explain chronic pain.

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Central sensitization is not enough to explain chronic pain.

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Non-painful exercises activate descending modulatory system in people with chronic pain

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Non-painful exercises activate descending modulatory system in people with chronic pain

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Musculoskeletal pain and exercise— challenging existing paradigms and introducing new

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. 2020 Aug 1;41(4):594-609.

doi: 10.1210/endrev/bnaa016.

Affiliation

1 Centre of Inflammation and Metabolism/Centre for Physical Activity Research (CIM/CFAS), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.

Free PMC article

Mai Charlotte Krogh Severinsen et al. Endocr Rev.

Free PMC article

. 2020 Aug 1;41(4):594-609.

doi: 10.1210/endrev/bnaa016.

Affiliation

1 Centre of Inflammation and Metabolism/Centre for Physical Activity Research (CIM/CFAS), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.

Abstract

Physical activity decreases the risk of a network of diseases, and exercise may be prescribed as medicine for lifestyle-related disorders such as type 2 diabetes, dementia, cardiovascular diseases, and cancer. During the past couple of decades, it has been apparent that skeletal muscle works as an endocrine organ, which can produce and secrete hundreds of myokines that exert their effects in either autocrine, paracrine, or endocrine manners. Recent advances show that skeletal muscle produces myokines in response to exercise, which allow for crosstalk between the muscle and other organs, including brain, adipose tissue, bone, liver, gut, pancreas, vascular bed, and skin, as well as communication within the muscle itself. Although only few myokines have been allocated to a specific function in humans, it has been identified that the biological roles of myokines include effects on, for example, cognition, lipid and glucose metabolism, browning of white fat, bone formation, endothelial cell function, hypertrophy, skin structure, and tumor growth. This suggests that myokines may be useful biomarkers for monitoring exercise prescription for people with, for example, cancer, diabetes, or neurodegenerative diseases.

Keywords: cancer; cytokines; diabetes; exercise; metabolism; physical activity.

Figures

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Pedersen BK. Pedersen BK. J Exp Biol. 2011 Jan 15;214(Pt 2):337-46. doi: 10.1242/jeb.048074. J Exp Biol. 2011. PMID: 21177953

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national center for biotechnology information

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Muscle-Organ Crosstalk: The Emerging Roles of Myokines - PubMed

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Physical activity decreases the risk of a network of diseases, and exercise may be prescribed as medicine for lifestyle-related disorders such as type 2 diabetes, dementia, cardiovascular diseases, and cancer. During the past couple of decades, it has been apparent that skeletal muscle works as an e ...

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Does exercise increase or decrease pain?

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?agency, identity and shift in sense of self

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Listen to the patients and empower them on what they feel they can do.

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Listen to the patients and empower them on what they feel they can do.

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IASP Classification of Chronic Primary Pain

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IASP Classification of Chronic Primary Pain

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The IASP classification of chronic pain for ICD-11: chronic primary pain

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We don't always have to know the exact explanation of what's working on our patient. It just works. Let's simply try not to harm.

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One of many Morten's golden quotes!

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national center for biotechnology information

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Plasticity in a monosynaptic cortical pathway - PubMed

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Plasticity in a monosynaptic cortical pathway

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national center for biotechnology information

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Heterosynaptic facilitation in neurones of the abdominal ganglion of Aplysia depilans - PubMed

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Heterosynaptic facilitation in neurones of the abdominal ganglion of Aplysia depilans

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Central sensitization: Implications for the diagnosis and treatment of pain

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Central sensitization: Implications for the diagnosis and treatment of pain

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Central sensitization: Implications for the diagnosis and treatment of pain

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Central sensitization 3rd phase could explain experiencing pain without having damage in the periphery

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Central sensitization 3rd phase could explain experiencing pain without having damage in the periphery

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doi: 10.1016/j.coph.2011.10.018.

Affiliation

1 Medical University of Vienna, Center for Brain Research, Department of Neurophysiology, Spitalgasse 4, A-1090 Vienna, Austria. juergen.sandkuehler@meduniwien.ac.at

Free PMC article

Free PMC article

doi: 10.1016/j.coph.2011.10.018.

Affiliation

1 Medical University of Vienna, Center for Brain Research, Department of Neurophysiology, Spitalgasse 4, A-1090 Vienna, Austria. juergen.sandkuehler@meduniwien.ac.at

Abstract

Long-term potentiation of synaptic strength (LTP) in nociceptive pathways shares principle features with hyperalgesia including induction protocols, pharmacological profile, neuronal and glial cell types involved and means for prevention. LTP at synapses of nociceptive nerve fibres constitutes a contemporary cellular model for pain amplification following trauma, inflammation, nerve injury or withdrawal from opioids. It provides a novel target for pain therapy. This review summarizes recent progress which has been made in unravelling the properties and functions of LTP in the nociceptive system and in identifying means for its prevention and reversal.

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Long-term potentiation in spinal nociceptive pathways as a novel target for pain therapy.

Ruscheweyh R, Wilder-Smith O, Drdla R, Liu XG, Sandkühler J. Ruscheweyh R, et al. Mol Pain. 2011 Mar 28;7:20. doi: 10.1186/1744-8069-7-20. Mol Pain. 2011. PMID: 21443797 Free PMC article. Review.

Understanding LTP in pain pathways.

Sandkühler J. Sandkühler J. Mol Pain. 2007 Apr 3;3:9. doi: 10.1186/1744-8069-3-9. Mol Pain. 2007. PMID: 17407590 Free PMC article. Review.

References

Basbaum A.I., Bautista D.M., Scherrer G., Julius D. Cellular and molecular mechanisms of pain. Cell. 2009;139:267-284. - PMC - PubMed

Mogil J.S. Animal models of pain: progress and challenges. Nat Rev Neurosci. 2009;10:283-294. - PubMed

Sandkühler J. Models and mechanisms of hyperalgesia and allodynia. Physiol Rev. 2009;89:707-758. - PubMed

Schmelz M. Translating nociceptive processing into human pain models. Exp Brain Res. 2009;196:173-178. - PubMed

Baron R. Handb Exp Pharmacol. 2009. Neuropathic pain: a clinical perspective. 3-30. - PubMed

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national center for biotechnology information

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Hyperalgesia by synaptic long-term potentiation (LTP): an update - PubMed

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Long-term potentiation of synaptic strength (LTP) in nociceptive pathways shares principle features with hyperalgesia including induction protocols, pharmacological profile, neuronal and glial cell types involved and means for prevention. LTP at synapses of nociceptive nerve fibres constitutes a con ...

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Central sensitization and LTP: do pain and memory share similar mechanisms?

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See Louis Gifford explanation for sensitization in his Aches and Pains. Cool!

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Can pain be best explained by acute injury or inflammation. If not we need a different explanation

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Can pain be best explained by acute injury or inflammation. If not we need a different explanation

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Neuropathic pain: an updated grading system for research and clinical practice

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Check out the reports to thermal stimulation!

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Inflammation and the intervertebral disc herniation

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Inflammation and the intervertebral disc herniation

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Inflammation in the intervertebral disc herniation

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Welcome to another episode of The Words Matter Podcast.

Following my commitment to explore the theoretical aspects and philosophical underpinnings of clinical practice, I'm diving in with both feet in this episode. As today I'm speaking with Dr Sabrina Coninx and Dr Peter Stilwell.

Sabrina is a philosopher currently located at the Institute for Philosophy at the Ruhr University Bochum in Germany. She is a postdoctoral researcher and scientific coordinator of the Research Training Group Situated Cognition. She has a Bachelor in Psychology and Philosophy, and a Master and PhD in Philosophy with a focus on Philosophy of Mind and Science. Her philosophical work is empirically informed and aims to contribute to debates across disciplines, including clinical practice. Her research focus is on pain, emotions, suffering, and affective disorders. For more information on her work see here. For more information on the RTG 'Situated Cognition' see here.

Peter is currently a Postdoctoral Researcher at McGill University and his research interests include utilising qualitative methodologies and involve theoretical/conceptual approaches to explore pain, suffering, and patient-clinician communication. Peter spoke with me on the podcast last year, and many of you will be familiar with his excellent paper from 2019 with Katherine Hartman introducing enactivism as a theoretical framework to move us beyond the biopsychosocial model. He's been very busy since then, and he published a number of related papers including his most recent one with Sabrina which we speak about in this episode. Find our more about Peter and his work here.

So in this episode we speak about:

Phenomenology as a philosophical framework

Enactivism and the value of this theoretical perspective for understanding pain and practice.

We also speak about enactivism in relation to dispostionalism (see CauseHealth Series here) and try to tease out some the differences and similarities between these two theories.

How enactive approaches can help us address the 'integration problem' (which is focus of their new paper), and how enactive approaches can causally integrate different phenomena such as neuropeptides with knees with cognitions with spines and with social relationships.

We speak about affordances as potential opportunities to better care for, treat and manage people living with pain.

How the concept of affordances can help us understand differences (beside mere temporality) between acute and chronic pain.

This was just a thrilling conversation. The combination of Sabrina's perspective as a philosopher and Peter's ability to bridge and translate these ideas with his clinical background was a complete joy. Their passion, curiosity and willingness to explore all sorts of different topics related to their paper was such fun.

Find Peter and Sabrina on Twitter and @Peter_Stilwell @sconinxphil
Support the show and contribute via Patreon If you liked the podcast, you'll love The Words Matter Follow Words Matter on: Instagram @Wordsmatter_education @TheWordsMatterPodcast Twitter @WordsClinical Facebook Words Matter - Improving Clinical Communication online course and mentoring to develop your clinical expertise - ideal for all MSK therapists. here

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Podcast 41: Phenomenology and Enactivism

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Welcome to another episode of The Words Matter Podcast. Following my commitment to explore the theoretical aspects and philosophical underpinnings of clinical practice, I'm diving in with both feet in this episode. As today I'm speaking with Dr Sabrina Coninx and Dr Peter Stilwell.

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I wrote the first version of this over 3 years ago and I still get contacted by health professionals who want to discuss their similar rollercoaster journeys. Here's an update on my ever-evolving roller coaster.

The first wave

When I emerged proudly with my degree in the late 70s, all packed with Maitland style manual therapy, I was convinced I could fix all and sundry and I often opened a clinical conversation with "what can I fix today?" (I feel ill saying it now!) Anyway, it all worked well for a few years but then I noticed that "it" was not delivering the goods so well. Unbelievably some patients dared not get better. Things were feeling professionally grim, career changes were pondered, but then, proud and erect, fresh from New Zealand, Robin McKenzie rode into town, maybe even on a white horse!

The second wave

Wow - this was it! How silly was I to miss the disc and the novel notion of actually getting people to treat themselves and to give your thumbs a good rest. People started getting better again, my practice was full of lumbar rolls, the "Treat your Own" books and models of discs and I was on a roll too. This McKenzie approach worked wonders for a few years, but then the outcomes began to taper off, some patients wouldn't improve, some wanted the old fashioned hands on that I had almost given away and a now familiar professional grimness emerged again. What next?

The third wave

I heard about a year-long Maitland post graduate course in South Australia and I reasoned that there must be more to it than I'd first thought, so I signed up for the year. I made it through a bit wounded, but the old "I can fix anything" returned and I went into the outer suburbs of Adelaide to ply my trade, wriggling and cracking joints and doing the new teasing nerves stuff. People got better and complex problems seemed to dissolve. But would you believe it - it happened again - the clinical outcomes tailed off with what I now recognise as centrally sensitised states, overuse syndrome and complex regional pain syndrome. I pondered a career change. Perhaps professional surfing?

The fourth wave

By now (late 80s, early 90s) I was becoming a bit older and wiser and trying to think more deeply about things - so I thought -"stuff the others - I'll try and work it out myself". And so I went off on the "neural tension" bandwagon - the idea of the physical health of the nervous system and mobilising nerves. I did some reading, had a few thoughts, stood on the shoulders of a few others and even wrote a couple of books. This was it I thought! Life will be easy from now on as we wriggled and glided and teased nerves from head to toe. Patients flocked in ... but the old diminishing outcomes emerged again, even for something I had helped to invent. Grim days - coffee was coming into fashion I pondered becoming a barista and investigated what it would take to become a marriage celebrant.

The fifth mini-wave

I was getting very wary now - the early work of Vladamir Janda was being updated and researched, particularly at the University of Queensland and once obscure bits of anatomy such as transversus abdominis, obturator internus and short neck flexors were now the new targets and the "with it" practitioners had ultrasound machine to view muscles. I went to the courses and gave it a go but my heart wasn't in it. Waves can be exhausting, and the outcomes were eluding me again, just like my transversus abdominis. I tried the taping stuff too, but like a focus on a single muscle, it just didn't make enough sense.

I drifted off into the world of pain and neuroscience and am still happily here. No magic, just a lot of hard work using neuroscience to fuel educational and imagery therapy and the good parts of the historic waves I've ridden. I thought I may have reached nirvana with the brain, but now I realise that neurones are only 10% of the brain and as the rest is immune cells, so there is long way to go.

I am still on this fifth mini-wave - trying to keep up with the world of brain plasticity, neuroimmunological balances and recent research and concepts of DAMPS (danger associated molecular patterns) and BAMPS (behaviour associated molecular patterns) and even CAMPS (cognitive associate molecular patterns) among others, all identified by Toll Like Receptors which can ratchet up their behaviour and keep enhances immune responses bubbling. It's infectious science. But ...

Uh oh - a sixth mini-wave beckons

I never thought this would happen, but I peering back at the tissues where I started all those years ago. The brain is so trendy that the scientific and some of the clinical world seemed to forget the rest of the body. I have been trimming my nails in anticipation of a return to the flesh! Not giving up the neuroimmunology of course but things like how can we dance with the different receptors in tissues, deal with the immunocompetence of the meninges, or indeed most tissues, and the simple and undervalued licence to touch is sacrosanct - even if just touching a hand while sharing knowledge. I notice and try and understand the trend towards predictive processing and Bayesian thinking, and find it fascinating but I am a wary old bugger. After all - all the talk was about phenomenology a year or so back but it seems to have gone out of favour. Are some of our colleagues onto their next mini waves

Three thoughts

1. I look around now at the course advertisements in the back of the journals and it seems the new roller coaster is still driven by dry needling, loading joints and lifting weights, someone called Pilates, and now mindfulness has become trendy - even yoga is on the up. No doubt some people are flying with it, and good on them, but not me - I am too war weary to get on the roller coaster again but I am sure there is something in it like there is in everything and if your professional paradigms are wide enough and trending towards biopsychosocial then there is a rational place for everything. The waves are not a loss if you can absorb them.

2. What bugs me is that it took so long to realise that it was I myself who was probably the main variable in outcomes - not the techniques. I am not saying that massaging patients with a wet salmon will help. However the interactional power needs better analysis and understanding and as Pat Wall would say "in the end, if the majority of the outcomes are based on placebo, do not fear, but work out what it was in the placebo which gave the outcome".

3. But what saddens me is that I now see a rapid and enforced rollercoaster in young therapists just out of college - youngsters with that precious, must be captured mindset of wanting to change the world. Yet increasingly employment is all about the dollar, the speed, the getting patients back and thus treatment processes inevitably based on singular biomedial paradigms. There is no time to work out for themselves what this professional rollercoaster of life is all about. We all need to work it out ourselves in some way. If not - we face professional burnout. I am looking forward to wave 7 soon!

- David Butler

HAVE YOU DOWNLOADED OUR NEW PROTECTOMETER APP YET?
Just search the App Store from your iPad for 'Protectometer'

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The Rollercoaster of Professional Life - still evolving - NOI Group

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I wrote the first version of this over 3 years ago and I still get contacted by health professionals who want to discuss their similar rollercoaster journeys. Here's an update on my ever-evolving roller coaster.

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Red Flags for Low Back Pain Are Not Always Really Red

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Context may sometimes be more important than biology

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Context may sometimes be more important than biology

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https://www.nature.com/articles/s41572-020-00234-1

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Arendt-Nielsen - assessing sensitisation in pain conditions

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Arendt-Nielsen - assessing sensitisation in pain conditions

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Peripheral, central & descending modulation

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shift in membrane potential due to changes brought about through transduction, inducing transmission of action potential

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ionotropic & metabotropic receptors
ligand gated & G-coupled receptors
stimuli are transduced through the action of these receptors expressed in the terminals of the sensory nerves

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Moving on With Pain - The Podcast is presented by the Danish Society for Pain and Physiotherapy. Visit our website here: www.smof.dk. - Listen to Moving on With Pain - MOWP instantly on your tablet, phone or browser - no downloads needed.

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Gate control (pain mechanisms) - Melzack & Wall
Onion skin model - Loeser
Mature Organism Model - Gifford
Fear-avoidance model - Vlaeyen & Linton
Sensitisation theory - ?Moseley & Butler
Brain - pain interactions?

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Important names in pain - Bonica, Wall, Melzack, Loeser, Beecher....

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Important names in pain - Bonica, Wall, Melzack, Loeser, Beecher....

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Painting a picture/portrait of my patient - aimed towards Rembrandt rather than Picasso when you demonstrate what you've heard when listening to your patients

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Painting a picture/portrait of my patient - aimed towards Rembrandt rather than Picasso when you demonstrate what you've heard when listening to your patients

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Next week we will look briefly into some of the theories of pain. This webinar from PainBC is a good introduction / supplement.

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Is the biopsychosocial model of pain adequate? Conceptual and therapeutic challenges

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Build 5 minutes to reflect into your day e.g. use of diagnoses to explain pain or treatment

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Have we over-egged the pudding

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Affiliations

1 Institute for Musculoskeletal Health, Sydney, NSW, Australia.

2 School of Public Health, The University of Sydney, Sydney, NSW, Australia.

3 Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Vic., Australia.

4 Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Vic., Australia.

5 South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.

Free PMC article

Free PMC article

Affiliations

1 Institute for Musculoskeletal Health, Sydney, NSW, Australia.

2 School of Public Health, The University of Sydney, Sydney, NSW, Australia.

3 Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Vic., Australia.

4 Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Vic., Australia.

5 South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.

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References

Elshaug AG, Rosenthal MB, Lavis JN, et al. Levers for addressing medical underuse and overuse: achieving high‐value health care. Lancet. 2017;390:191‐202. - PubMed

Moynihan R, Barratt AL, Buchbinder R, et al. Australia is responding to the complex challenge of overdiagnosis. Med J Aust. 2018;209:332‐334. - PubMed

Pathirana T, Clark J, Moynihan R. Mapping the drivers of overdiagnosis to potential solutions. BMJ. 2017;358:j3879. - PubMed

Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009;60:3072‐3080. - PubMed

Boyages SC. Vitamin D testing: new targeted guidelines stem the overtesting tide. Med J Aust. 2016;204:18. - PubMed

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health services misuse / statistics & numerical data

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medical overuse / statistics & numerical data*

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national center for biotechnology information

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Musculoskeletal healthcare: Have we over-egged the pudding? - PubMed

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Musculoskeletal healthcare: Have we over-egged the pudding?

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A prognosis - how long will it take for me to know I am wrong?

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A prognosis - how long will it take for me to know I am wrong?

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Pain mechanisms: a commentary on concepts and issues - PubMed

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This commentary on ideas about neural mechanisms underlying pain is aimed at providing perspective for a reader who does not work in the field of mammalian somatic sensation. It is not a comprehensive review of the literature. The organization is historical to chronicle the evolution of ideas. The a…

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Treatment as a taxi or a driving school?

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Treatment as a taxi or a driving school?

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Observations on the Seats and Causes of Diseases, Illustrated by the Dissections of the Late Professor Morgagni

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How does nociception relate to pain? Or does it?

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How does nociception relate to pain? Or does it?

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1. Watch the tutorial (important information on how to get your pdf-password included)

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