Kory Zimney, PT, DPT

IOM 2011
1. Pain is a public health challenge
2. Care of people with pain challenges
3. Educational challenges
4. Research challenges
Educational challenges
Finding 4-1. Education is a central part of
the necessary cultural transformation of the approach to pain.
 Recommendation 4-1. Expand and redesign education
programs to transform the understanding of pain.
 Recommendation 4-2. Improve curriculum and education for
health care professionals.
 Recommendation 4-3. Increase the number of health
professionals with advanced expertise in pain care.
“When the primary complaint is pain,
the treatment of pain should be primary.”
-Barrett L. Dorko, PT
Amazing Pain Stories
 The amount of pain you experience does not
necessarily relate to the amount of tissue damage
you have sustained.
Amazing Pain Stories
NO BRAIN, NO PAIN
 The brain decides whether something
hurts or not 100% of the time.
Melzack R. Pain and the neuromatrix in the brain
(J Dent Educ. 2001. 65(12): 1378-1382 )
Definition of Pain
 An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.
 SOURCE: IASP, 1994.
Complexity of Pain
Melzack and Wall (1996):
 The relationship between injury and pain varies
(that is, a minor injury may produce great pain,
or a significant injury may produce minor pain),
as does the relationship between the extent of
injury and the resulting disability.
 Non-noxious stimuli can sometimes produce pain
(allodynia), and minor amounts of noxious
stimuli can produce large amounts of pain
(hyperalgesia).
 The locations of pain and tissue damage are
sometimes different (referred pain).
Complexity of Pain
Melzack and Wall (1996):
 Pain can persist long after tissue healing.
 The nature of the pain and sometimes its location
can change over time.
 Pain is a multidimensional experience, with
strong psychosocial influences and impacts.
 Responses to a given therapy vary among
individuals.
 Earlier theories have not led to adequate pain
treatments.
Simple Side of the Complexity of Pain
 All pain experiences are normal, real and a response to
what your brain judges to be threatening. It is not just a
stimulus.
 This can be due to actual or potential tissue damage.
 Nociception is neither necessary nor sufficient to produce pain.
 Most people, including many health professionals, do not
have a modern understanding of pain.
 Much of the current understanding of pain has occurred in the last 10 years with
advances in imaging of the brain and pain studies.
 When pain persists it is difficult to understand why this is
useful. But the brain, often times subconsciously, has came
to the conclusion that the body is in danger.
 Pain is a category of complex experiences not a single sensation produced by a
single stimulus.
Single Idea
 Pain is an output of the brain, not an input.
Current Neuroscience and
Pain Discoveries
The virtual body
Pain relies on context
Pain relies on context
Pain relies on context
Pain relies on context
Pain can be anticipated
Pain can be anticipated and movement changed
(When your patient is in pain everything changes)
Pain is like Thirst
Pain is like Vision
Pain is like Vision
Mirror neurons
The brain’s automatic abilities
 The phaonmneal pweor of the hmuan mnid. Can you
blveiee that you can aulaclty uesdnatnrd what you are
rdanieg? It deosn’t mttaer in what oreder the ltteers in a
word are, the olny iprmoatnt tihng is that the frsit and
lsat ltter be in the rghit pclae. This is bcuseae the huamn
mnid does not raed ervey lteter by istlef, but the wrod as
a wlhoe.

 Waht we pecvriee is not aywlas atrccuae.

 History of Pain
Melzack and Wall: Gate Theory
René Descartes: Specificity of Pain

Traite de l'homme (Treatise of Man) 1664 Gate theory of pain. SG = substantia gelatinosa cell; V = central trigger cell of lamina V; + = excitatory
effects; - = inhibitory effects. From Wilson ME: Anaesthesia 1974; 29:407-421. Data from Melzack R, Wall
PD: Science 1965; 150:971-979.
Alarm
System

Bingel U, Tracey I, Imaging CNS Modulation of

Pain in Humans. Physiology. 2008; 23: 371-380,
Moseley GL. Pain, Brain, Illusions, Delusions: One Neuroscientist’s approach
to Pain. Course Notes. August 25, 2010; Lincoln, NE.
Where in the Brain is Pain?
 Premotor/Motor Cortex
 Sensory Cortex
 Prefrontal Cortex
 Insula
 Thalamus/Hypothalamus
 Limbic System
 Cingulate Cortex
 Amygdala
 Hippocampus
 Cerebellum
 Spinal Cord
Chronic Persistent Pain
 Central Sensitization or  Is not prolonged
Pain Memories Acute Pain.

 It is itself a disease, a
disease of the nervous
system, not a symptom.
Pain and the Brain’s effect on the body
 Nervous System
 Sympathetic Nervous System
 Parasympathetic System
 Motor System
 Endocrine System
 Immune System
 Respiratory System
 Mood/Cognition
 Language
 Pain Production System
Dark Side of Neuroplasticity –
Central and Peripheral Sensitization
 Peripheral Nerve
 Ion channels
 Myelin
 Spinal cord
 DRG
 Brain changes (neuroplasticity)
 Smudging of the motor and sensory areas (homuncular
arrangement)
 Decrease in gray matter
Nociception input vs. Pain output
Injury (harm) Pain (hurt)
 All injured tissues go  Pain is useful in
through a healing assisting proper healing.
process. Three stages of pain.
 Inflammation  Withdrawal
 Proliferation  Protection
 Remodeling  Resolution
Treating pain
Biomedical
Approach Biopsychosocial Approach
 Tools for Management
 Education and Understanding  Use your PT interventions
 Hurt does not always equal harm within context of current
 Ideomotor expression neuroscience
 Accessing the virtual body  Inside-out
 Graded Motor Imagery Neuromodulation
 Breathing/Relaxation/  Placebo/Expectations
Meditation Techniques  Outside-in
 Novel Movements Neuromodulation
 Graded Exposure
 Manual Therapy
 Explore “triggers” of pain -
CBT
Resources
Thanks