New York Physical Therapy Ebook Continuing Education

Summary headache red flags: Pain pattern ● Sudden onset of headache with maximal intensity reached within minutes or seconds. ● First or worst headache of a patient’s life.

● Headache triggered by cough, exertion, or strenuous exercise. ● Worsening pattern of headaches.

Central sensitization in the differential diagnosis of headaches The pathogenesis and perpetuation of chronic pain, including chronic headache pain, is complex and involves contributions from neurophysiological, neurobiological, cognitive, and sociological systems. Pain neuroscience education (PNE) involves addressing a patient’s misconceptions about the physiological phenomena of pain and providing education on the biological, psychological, and social processes that contribute to experiencing pain (Robins et al., 2016).

three years after involvement in serious accidents (Adams et al., 2015). ● Substance misuse and dependence —the relationship between substance misuse and chronic pain is seen often in clinical practice (Adams et al., 2015). ● Anger —people with central sensitization often report feelings of frustration and anger related to their situation, the intensity of their symptoms, the lack of a cause or cure, and challenges within the healthcare system. One possible explanation for the relationship between pain and anger is the finding that people who have high levels of anger expression may have deficits in their endogenous opioid function, resulting in increased pain sensitivity (Adams et al., 2015). ● Symptom appraisal and symptom belief —how a person looks at and interprets a situation can have a profound influence on their experience. The following specific beliefs have been identified as particularly maladaptive in managing chronic pain: pain is a signal of damage; activity should be avoided when pain is present; pain leads to disability; pain is uncontrollable; and pain is a permanent condition (Adams et al., 2015). ● Hypervigilance is an attentional bias for pain that might lead to increased fear-avoidance behavior. ● Perceived control versus helplessness —when individuals believe they can influence the duration, frequency, intensity, or unpleasantness of symptoms, they are often more motivated to pursue solutions to managing these symptoms. By contrast, persons with low perceived control report worse outcomes, including greater pain intensity and poorer physical and psychological adjustment to illness. As expected, patients with higher perceived control function better (Adams et al., 2015). ● Self-efficacy refers to the extent to which a person believes they can successfully complete the tasks necessary to achieve the desired outcome in each situation. Patients with higher self-efficacy have better outcomes with pain (Adams et al., 2015). ● Psychological inflexibility refers to an inability to act in accordance with one’s own values in the midst of interfering thoughts, feelings, or bodily sensations. High levels of psychological inflexibility (i.e., low levels of psychological flexibility) are associated with avoidant coping methods such as denial, behavioral disengagement, and self-blame (Adams et al., 2015). ● Social learning provides a framework for how a patient’s symptom behaviors develop and are maintained. Ideas about symptoms are learned from parents, culture, and environment. For example, people whose pain behavior is reinforced are more likely to continue to display those behaviors. ● Social stigma and skepticism —individuals with central sensitization often report that the stigma arising from other people’s response to their illness is a relevant issue for them. According to Adams et al. (2015), social stigma has negative implications for psychological well-being, quality of life, and health maintenance, with the potential to result in decreased self- esteem and higher rates of depression. This can result in lower rates of engagement with the healthcare system. Chronic pain patients often feel stigmatized by healthcare professionals (Adams et al., 2015). ● Social support —there is very strong evidence to support the idea that social ties and feeling cared for by others is positively associated with mental health, physical health, and life span (Adams et al., 2015).

The biopsychosocial model has emerged as the predominant explanation for the pain experience, especially chronic pain. This perspective considers the psychological, social, and contextual factors that combine with biological influences to contribute to the experience, maintenance, and exacerbation of pain symptoms (Adams et al., 2015). This model is an advancement on the previous one, which is often how our patients understand their pain, believing that the experience of pain is in direct proportion to the degree of tissue strain/stress and that alleviation of symptoms should center on addressing that tissue damage. Psychological factors that have been shown to influence the experience of pain include depression, anxiety, posttraumatic stress disorder, and substance misuse and dependence (Adams et al., 2015). Cognitive and affective features that have been shown to contribute to the experience of pain include anger, the patient’s interpretation of their situation (“This pain means something is terribly wrong”), catastrophic thinking and fear avoidance, hypervigilance, perceived helplessness, self-efficacy, and psychological inflexibility. Social factors associated with the experience of pain include social learning, social stigma and skepticism, and social support (Adams et al., 2015). A critical part of the biopsychosocial pain model and of pain neuroscience education is the concept of central sensitization. Central sensitization involves changes in the central nervous system that lead to pain hypersensitivity and the potentiation of chronic pain (Latremoliere et al., 2009). Central sensitization enhances the sensory response to normal inputs, including those sensations that would usually not cause pain (Latremoliere et al., 2009). Several explanations have been offered for the development of central sensitization. These include dysregulation in both ascending and descending central nervous system pathways due to physical trauma and sustained pain impulses, and the chronic release of pro-inflammatory cytokines by the immune system as a result of physical trauma or viral infection (Mayer et al., 2012). Another possible explanation is dysfunction of the stress system, including the hypothalamic– pituitary–adrenal axis (Mayer et al., 2012). Biopsychosocial factors associated with headaches ● Depression —the prevalence of chronic pain is higher among those with a diagnosis of depression. Conversely, the prevalence of depression among individuals with chronic pain is also higher (Adams et al., 2015). According to Adams et al. (2015), depression seems to exacerbate the experience of pain and is a strong determinant of pain-related disability. ● Anxiety —individuals with chronic pain often report being anxious and worried about their pain. In addition, there is strong evidence to support the influence of anxiety on pain perception. ● Posttraumatic stress disorder (PTSD) —when a formal diagnosis of posttraumatic stress disorder is present, the prevalence of chronic pain is 50%. The diagnosis of PTSD means a person has been exposed to a traumatic event that can in and of itself can cause pain. PTSD can also prolong the pain experience, with one study finding that PTSD symptoms were the only baseline factor that predicted persistent pain Physical-Therapy

Book Code: PTNY1024

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