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What is the bottom up approach of addressing pain?

The approach where we change the tissues
- Put an orthotic in
- Unload it with a cane
- Put the patient in aquatic therapy to unload some joints
- Alter the environment


What is a top down approach of addressing pain?

Th approach where the brain alters the pain experience


What are some of the top down approaches in addressing pain/ to calm the nervous system down?

• Therapeutic Neuroscience Education
• Aerobic Exercise
• Manual Therapy
• Breathing, relaxation, mediation
• Modalities
• Etc.


What are some problems with the biomedical model on addressing pain?

- It induces fear
- It cannot explain complex pain states
- It doesn't work


What are the parameters of therapeutic neuroscience education: education delivery methods?

• Physical therapists
Duration and frequency
• High: 8 hours
• Low: 30 - 60 minutes
Educational format
• One-on-one verbal communication
• Two studies utilized group sessions.
Educational tools
• Prepared pictures
• Metaphors
• Hand drawings
• Workbook with reading/Q&A
• Neurophysiology questionnaire


What are the adjunct treatment used for therapeutic neuroscience education?

• Manual therapy including spinal mobilization and manipulation
• Soft tissue treatment/massage
• Neural tissue mobilisation
• Spinal stabilisation exercises
• Home exercises
• None (neuroscience education only)
• Circuit training
• Aerobic exercise


What should the content of therapeutic neuroscience education include?

Neurophysiology of pain
• No reference to anatomical or patho-anatomical models
• No discussion of emotional or behavioral aspects to pain
• Nociception and nociceptive pathways
• Neurones
• Synapses
• Action potential
• Spinal inhibition and facilitation
• Peripheral sensitization
• Central sensitization
• Plasticity of the nervous system


Why is therapeutic neuroscience education effective?

• Redefine pain and thus change cognitions regarding pain
• Pain and Tissue injury are two different things
• Reduces threat


Why do patients in pain get better?

1) Treatment specific effects
2) Factors unrelated to treatment
– Natural history
– Regression to the mean
– Repeated measuring
3) Preliminary elements
– Improvement after scheduling
– Providing diagnosis prior to treatment onset
4) Non- specific factors
– Patient provider relationship
– Expectations
– Practice ambience


What are the factors that determine how patients are going to respond to treatment?

- Patient related factors
- Therapist related factors
- Combined environmental factors


What are the patient contextual factors that influence treatment?

- Expectations
- Preference


What are the therapist contextual factors that influence treatment?

Clinical Equipoise


What is Clinical Equipoise?

Lack of preference or uncertainty for a treatment


What are the combined contextual factors that influence treatment?

Therapeutic Alliance


What is Therapeutic Alliance?

Collaboration, warmth, and
support between therapist and patient


What are some of the ways to get the most out of your time with your patients?

- Shared decision making
- Expectations
- Preventing nocebo
- Therapeutic alliance
- Consider The Meaning Of Pain


What are the characteristics of shared decision making?

1) Physician and patient share
2) Physician explores patient’s
values and preferences
3) Physician assists patient in
selecting the best option
4) Physician is guided by the
patient’s preferences regarding how much information to share and how much to involve the patient in the decision making process
5) Physician respects the patient’s right to make the decision


What are the characteristics of expectations?

• Include in your clinical decision making process
• Maximize expectation
- “This intervention is known to significantly reduce pain in
some patients”
• Be aware of unrealistic expectations
- Maximize realistic expectations


What are the characteristics of preventing nocebo?

Frame the instruction, be positive


What are the characteristics of Therapeutic Alliance?

• Warm, friendly manner
• Active listening
- Repeating patient’s words
- Asking for clarification
• Empathy: “I can understand how difficult this must be for you”
• Periods of thoughtful silence
• Communication of confidence and positive expectation


What are the important factors that influence our perception of pain?

- Memory
- Hyper-vigilance
- Catastrophization