Brain Scans Fuel Efforts to Teach Patients How to Short-Circuit Hurtful Signals

How you think about pain can have a major impact on how it feels.

That’s the intriguing conclusion neuroscientists are reaching as scanning technologies let them see how the brain processes pain.

That’s also the principle behind many mind-body approaches to chronic pain that are proving surprisingly effective in clinical trials.

Some are as old as meditation, hypnosis and tai chi, while others are far more high tech. In studies at Stanford University’s Neuroscience and Pain Lab, subjects can watch their own brains react to pain in real-time and learn to control their response—much like building up a muscle. When subjects focused on something distracting instead of the pain, they had more activity in the higher-thinking parts of their brains. When they “re-evaluated” their pain emotionally—”Yes, my back hurts, but I won’t let that stop me”—they had more activity in the deep brain structures that process emotion. Either way, they were able to ease their own pain significantly, according to a study in the journal Anesthesiology last month.

While some of these therapies have been used successfully for years, “we are only now starting to understand the brain basis of how they work, and how they work differently from each other,” says Sean Mackey, chief of the division of pain management at Stanford.

He and his colleagues were just awarded a $9 million grant to study mind-based therapies for chronic low back pain from the government’s National Center for Complementary and Alternative Medicine (NCCAM).

Some 116 million American adults—one-third of the population—struggle with chronic pain, and many are inadequately treated, according to a report by the Institute of Medicine in July.

Yet abuse of pain medication is rampant. Annual deaths due to overdoses of painkillers quadrupled, to 14,800, between 1998 and 2008, according to the Centers for Disease Control and Prevention. The painkiller Vicodin is now the most prescribed drug in the U.S.

“There is a growing recognition that drugs are only part of the solution and that people who live with chronic pain have to develop a strategy that calls upon some inner resources,” says Josephine Briggs, director of NCCAM, which has funded much of the research into alternative approaches to pain relief.

Already, neuroscientists know that how people perceive pain is highly individual, involving heredity, stress, anxiety, fear, depression, previous experience and general health. Motivation also plays a huge role—and helps explain why a gravely wounded soldier can ignore his own pain to save his buddies while someone who is depressed may feel incapacitated by a minor sprain.

“We are all walking around carrying the baggage, both good and bad, from our past experience and we use that information to make projections about what we expect to happen in the future,” says Robert Coghill, a neuroscientist at Wake Forest Baptist Medical Center in Winston-Salem, N.C.

Dr. Coghill gives a personal example: “I’m periodically trying to get into shape—I go to the gym and work out way too much and my muscles are really sore, but I interpret that as a positive. I’m thinking, ‘I’ve really worked hard.’ ” A person with fibromyalgia might be getting similar pain signals, he says, but experience them very differently, particularly if she fears she will never get better.

Dr. Mackey says patients’ emotional states can even predict how they will respond to an illness. For example, people who are anxious are more likely to experience pain after surgery or develop lingering nerve pain after a case of shingles.

That doesn’t mean that the pain is imaginary, experts stress. In fact, brain scans show that chronic pain (defined as pain that lasts at least 12 weeks or a long time after the injury has healed) represents a malfunction in the brain’s pain processing systems. The pain signals take detours into areas of the brain involved with emotion, attention and perception of danger and can cause gray matter to atrophy. That may explain why some chronic pain sufferers lose some cognitive ability, which is often thought to be a side effect of pain medication.

The dysfunction “feeds on itself,” says Dr. Mackey. “You get into a vicious circle of more pain, more anxiety, more fear, more depression. We need to interrupt that cycle.”

One technique is attention distraction, simply directing your mind away from the pain. “It’s like having a flashlight in the dark—you choose what you want to focus on. We have that same power with our mind,” says Ravi Prasad, a pain psychologist at Stanford.

Guided imagery, in which a patient imagines, say, floating on a cloud, also works in part by diverting attention away from pain. So does mindfulness meditation. In a study in the Journal of Neuroscience in April, researchers at Wake Forest taught 15 adults how to meditate for 20 minutes a day for four days and subjected them to painful stimuli (a probe heated to 120 degrees Fahrenheit on the leg).

Brain scans before and after showed that while they were meditating, they had less activity in the primary somatosensory cortex, the part of the brain that registers where pain is coming from, and greater activity in the anterior cingulate cortex, which plays a role in handling unpleasant feelings. Subjects also reported feeling 40% less pain intensity and 57% less unpleasantness while meditating.

“Our subjects really looked at pain differently after meditating. Some said, ‘I didn’t need to say ouch,’ ” says Fadel Zeidan, the lead investigator.

Techniques that help patients “emotionally reappraise” their pain rather than ignore it are particularly helpful when patients are afraid they will suffer further injury and become sedentary, experts say.

Cognitive behavioral therapy, which is offered at many pain-management programs, teaches patients to challenge their negative thoughts about their pain and substitute more positive behaviors.

Even getting therapy by telephone for six months helped British patients with fibromyalgia, according to a study published online this week in the Archives of Internal Medicine. Nearly 30% of patients receiving the therapy reported less pain, compared with 8% of those getting conventional treatments. The study noted that in the U.K., no drugs are approved for use in fibromyalgia and access to therapy or exercise programs is limited, if available at all.

Anticipating relief also seems to make it happen, research into the placebo effect has shown. In another NCCAM-funded study, 48 subjects were given either real or simulated acupuncture and then exposed to heat stimuli.

Both groups reported similar levels of pain relief—but brain scans showed that actual acupuncture interrupted pain signals in the spinal cord while the sham version, which didn’t penetrate the skin, activated parts of the brain associated with mood and expectation, according to a 2009 study in the journal Neuroimage.

One of Dr. Mackey’s favorite pain-relieving techniques is love. He and colleagues recruited 15 Stanford undergraduates and had them bring in photos of their beloved and another friend. Then he scanned their brains while applying pain stimuli from a hot probe. On average, the subject reported feeling 44% less pain while focusing on their loved one than on their friend. Brain images showed they had strong activity in the nucleus accumbens, an area deep in the brain involved with dopamine and reward circuits.

Experts stress that much still isn’t known about pain and the brain, including whom these mind-body therapies are most appropriate for. They also say it’s important that anyone who is in pain get a thorough medical examination. “You can’t just say, ‘Go take a yoga class.’ That’s not a thoughtful approach to pain management,” says Dr. Briggs.

See original article at: The Wall Street Journal

People in the state of Vermont are fortunate to have DIRECT ACCESS TO PHYSICAL THERAPY.  That means unless your insurance company requires it, you may see any Physical Therapist of your choosing without a physician referral.  A new study published in the journal Health Services Research found that allowing direct access to physical therapy was a more efficient treatment delivery model as compared to a physician-referral model.  As the US population ages and physical therapy utilization continues to grow, implementing a direct access model across all states and all insurances, including Medicare, may significantly contribute to a reduction in health care costs.  Physical Therapists are health care providers specially-trained in the recognition and treatment of musculoskeletal injuries.  Here at the EDGE Physical Therapy, we encourage you to stop in and have a conversation with one of our PT’s to find out if physical therapy care can help you!  Call or click today to schedule an appointment.

http://www.apta.org/Media/Releases/Consumer/2011/10/13/

Check out this recent article from the Washington Post entitled “Physical Therapists can help injuries heal, even when the cause is unclear.”

http://www.washingtonpost.com/lifestyle/wellness/physical-therapists-can-help-injuries-heal-even-when-the-cause-is-unclear/2011/05/23/AGB5FRFH_story_1.html

The countdown is on to the 2011 Vermont City Marathon!  It’s a fantastic event that I would encourage anyone to check out.  I’ll be spectating from the “Fast Track” Medical Tent at the finish line, where I’ll be volunteering helping injured runners again this year.

Here’s my advice to all you runners dealing with an injury leading up to any race day:  It’s better to show up on race day feeling healthy than to show up feeling 100% trained. This is especially true for people running the entire marathon who began training +/- four months prior.  Many people get a decent amount training mileage under their belt and get at least a few long runs accomplished, but then get de-railed by injury.  The line I always hear is, “I need to keep running because I still have an 18 or 20-mile run in my training program.”  Truth is, if you’ve done much of the program, you’re probably more prepared than you think.  Plus, the adrenaline from the marathon environment provides a boost that will get you through (although you’ll still pay for it after!).  But, if you’re standing on the start line and you can feel that injury hurting, then 26.2 miles will likely be more than it can take, and your chances of finishing are in jeopardy.

Hopefully all you VCM runners are ready, whether you’re doing a relay or the whole thing!  If you’re not sure about an injury, an ache, or a pain and would like it checked before (or after) the race, give a call or send me an e-mail and request a FREE Injury Screening.  Twenty minutes of advice might help you achieve your VCM goals….or at least keep you out of my medical tent afterwards!

Good luck runners!

Dan Farnham, PT, DPT, ATC
danf@edgevt.com, 383-0676

KINESIOTAPE can be a huge addition to any Physical Therapy.  It can be used to help with swelling, support injured joints or relax tight muscles.  Some say it’s almost as good as taking your therapists hands home with you!  Come find out all the benefits at the Edge PT.

Tracy Benedict, PT, DPT, MTC, CKTP

Taped for Recovery – Exploring therapeutic taping for treatment of sports injuries

It is spring and runners and walkers are outside once again! Unfortunately running and walking on uneven surfaces can increase your risk for ankle and foot injuries. One of the most difficult, not necessarily confined to runners, is plantar fasciits, an inflammation of the connective tissue on the sole of the foot. The fascia originates at the heel, goes forward and attaches at the base of the toes. Pain is felt anywhere along the length of the tissue, most commonly in the front of the heel, the arch area, or the ball of the foot. A common complaint is severe pain in the sole of the foot on arising in the morning.

Regular and thorough stretching is the key to prevention, and the most effective single stretch is to press the heel down while standing at the edge of a step, which also stretches the calf muscles. Once the foot is painful and the inflammation is severe, physical therapy is effective in treatment, and might consist of icing, ultrasound, electrical stimulation, soft tissue mobilization, iontophoresis and exercises, leading to a safe return to the running or walking program. For more information, for a free injury screening, or to schedule treatment, call or email today!

Posted by Alice Grau, PT

Edge Physical Therapy
75 Eastwood Drive
South Burlington, VT
802-860-0209
aliceg@edgevt.com

Some of the confusion may be around how we define warming up. Many of us warm-up by doing a series of static stretches (ex: holding a hamstring stretch for 30 sec) before beginning our exercise routine (cardio and or strengthening). In general, static stretching provides little if any benefit as a warm-up to exercise BUT it is a good post exercise activity. Your warm-up should do just that! It should literally warm your muscles up. The good old 5 to 10 minutes of light cardio such as an easy jog is still a good warm-up.

Another way to warm-up and frequently done by athletes (and typically sport specific) is dynamic stretching. Dynamic (or active) stretching consists of a series of active movements that place a mild tension/stretch on the opposing muscle group. Because it is active and repetitive (typically 10 to 12 repetitions) it also serves to warm the muscle up. Dynamic stretches can be done as your warm-up or follow the 5 to 10 min of light cardio. Dynamic or active stretching should not be confused with ballistic stretching which is also active but can be dangerous because ballistic stretches are done quickly and push your muscles past their normal limits. Ballistic stretches when done appropriately (muscles being well warmed-up prior to) are an important training tool for some sports such as kick-boxing.

Static stretches are most beneficial when done as part of your cool-down. Muscle groups that you have specifically exercised during your work-out and muscle groups that are problematic/tight for you are best addressed during this phase of your workout. Static stretches should be done to the point where you feel a tolerable stretch in the muscle and held for 30 seconds gradually increasing the stretch as you feel it lessen. One to three repetitions are typically recommended (go by how it feels to you, sometimes a particular muscle needs a little longer to relax and lengthen where another muscle might feel good after just one repetition).

For more information on stretching (research, types of stretches, actual dynamic stretches) you may find the following links useful:

http://www.livestrong.com/article/354556-definition-of-dynamic-stretches

When to Stretch – Why Experts Recommend Athletes Stretch After Exercise http://sportsmedicine.about.com/cs/flexibility

Stretching: A Research Retrospective http://unm.edu/~lkravitz/Article%20folder/stretching2010UNM.html

The Edge Physical Therapy has teamed up with Essex Parks and Recreation. Tracy Benedict, DPT, will teach exercises and safety techniques to reduce falls and fall-related injuries. In this low-impact exercise class, you will learn strengthening, stretching, and balance activities at each class. Each participant will be assessed to see how well their balance has improved and to make further recommendations. Each participant should wear comfortable clothes and supportive shoes to each class. If a cane, walker or caregiver is needed, please be sure to bring them to class as well.

Instructor: Tracy Benedict
Class # 153181 A
Who: Ages 55 & Up
Dates: Fridays, January 28 – March 18
Time: 9:00 a.m. – 10:00 a.m.
Place: Essex Senior Center
Cost: $24.00 Essex Resident / $26.00 Non-resident

Click here for Registration Form (PDF – 86kb)

A 1/3/11 Boston Globe health article offers eleven suggestions for healthy 2011, featuring Physical Therapists’ advice on how to keep muscles working outside of your scheduled daily exercise.

Number 5. Keep Moving

“J. Alex McKinney of Marathon Physical Therapy and Sports Medicine goes further. Say you’ve gotten in the recommended 30 to 45 minutes of daily exercise. Don’t forget about your muscles once you settle into your desk at work. First, make sure your workstation is ergonomically correct so that you don’t get into painful bad habits that could result in muscle shortening. Second, engage those muscles when you can. “I tell patients when you sit, contract you abdominals,” he said. “Use the muscles that are the prime movers.” That means the abs and the glutes, the hip and the shoulder stabilizers. Set a timer at your desk and get up and walk every 30 minutes or so, to make sure those muscles don’t get tight from sitting all day.

The ten other health resolutions are:
1. Don’t Diet
2. Be Aware of Stress and How To Respond To It
3. Pick a Goal and Try To Get Closer To It
4. Get Going
6. Focus on Family
7. Be an Active Participant in Your Health Care
8. Pick Something Small to Adjust
9. Eat One Family Meal Together Every Day
10. Daydream
11. Choose Actively

In Recognition of National Physical Therapy Month, Physical Therapists Offer “Smart Moves for Families” to Prevent and Combat Obesity and its Consequences

Download in Adobe PDF

ALEXANDRIA, VA, October 1, 2010 — Making the commitment to be physically active is one of the best ways children and adults can prevent or combat obesity and its consequences, say physical therapists from the American Physical Therapy Association (APTA).

Physical therapist and APTA member Teresa Schuemann, PT, SCS, of Colorado Physical Therapy Specialists in Ft. Collins, CO, and a sports certified specialist, says families should be at the forefront of establishing good physical activity habits. “It’s much easier for children to adopt healthy lifestyles if they see their parents making physical activity a priority,” she says. “Parents should emphasize a healthy lifestyle instead of focusing solely on weight and support the family’s healthy choices rather than pounds lost,” she added. “Children and adults who participate in sustained daily physical activity and follow a balanced diet enjoy improved cardiovascular fitness, greater bone mass and strength, and are better able to manage their weight ― all of which help prevent the onset of obesity and type 2 diabetes.”

Children with physical disabilities have a strong desire to participate in physical activities and sports, yet opportunities and resources are often limited, explained physical therapist and APTA member Lisa Chiarello, PT, PhD, PCS, associate professor in the Department of Physical Therapy and Rehabilitation Sciences at Drexel University in Philadelphia, PA. “Children with physical disabilities are at risk of not participating in any form of physical activity,” she said. “Motor function and adaptive behavior, family activity, environmental modifications, activity accommodations, and assistive technology all play key roles in supporting physical activity in children with physical disabilities.” Physical therapists help families balance the many priorities they have for their children and help them find ways to incorporate physical activity into children’s play, leisure time, and daily family routines.

Physical therapists support the Department of Health and Human Services 2008 Physical Activity Guidelines for Americans, which describe the types and amounts of physical activity that offer substantial health benefits to Americans.

The following “Smart Moves for Families” are available from APTA.

A Personal Approach to Managing Obesity

For obese children and adults, promoting movement, reducing pain when it is present, maintaining or restoring function, and preventing disability are the goals of a physical therapist-designed exercise program. According to physical therapist and APTA member Susan Deusinger, PT, PhD, FAPTA, professor of physical therapy and neurology and director of the Program in Physical Therapy at the Washington University School of Medicine in St. Louis, Mo, preventing or combating obesity is a complex and long-term challenge. “Physical therapists address how obesity affects the way the body moves and functions. This is accomplished through individual and group exercises to restore flexibility, increase strength and cardiovascular endurance, reduce pain, and address postural stability and balance. These help the individual to better perform activities of daily living while decreasing disability associated with long term obesity.”

Physical therapists also incorporate behavior modification into weight loss programs. For instance, treatment may include identifying causes of unhealthy behaviors, learning how an individual’s readiness to begin or continue positive behaviors impacts progress, and recognizing any barriers that may compromise healthy habits. Physical therapists help the individual set goals and monitor his or her behavior. Frequent contact, feedback, and continuous motivation and support are all components of behavioral programs that physical therapists provide in individual and group settings.

Combating Type 2 Diabetes

Obesity is a risk factor for type 2 diabetes, a chronic disease marked by high levels of sugar in the blood that is associated with numerous health complications. Improving capacity for physical activity and increasing muscular strength are crucial to preventing loss of physical function and independence. An individualized program developed by a physical therapist can help reduce the need for medications, lower risk of heart disease and stroke, and help manage glucose levels. For people with complications associated with diabetes, physical therapists can help restore quality of life through the use of special tests to check foot sensation; decrease cramping pain during walking; evaluate and care for skin ulcers and sores that are slow to heal; improve walking ability by adapting shoes or orthotics; instruct on how to protect the feet if they have lost sensation, and recommend shoe wear or assistive devices. “Because of the health risks associated with obesity, physical therapists collaborate with physicians, nurse practitioners, physician assistants, dietitians, and other health professionals in managing a patient’s care,” said Deusinger.

Physical therapists often encounter children and adults who have experienced difficulties making physical activity a part of daily life. The guidance and encouragement of a physical therapist who understands individual needs, priorities, and challenges and who is able to closely support and monitor progress can be the determining factor in helping an individual to achieve his or her goals.

The American Physical Therapy Association (APTA) represents more than 78,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Learn more about conditions physical therapists can treat and find a physical therapist in your area at www.moveforwardpt.com. Consumers are encouraged to follow us on Twitter (@moveforwardpt) and Facebook.