Professional issueExercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories
Introduction
In acute musculoskeletal pain, the main focus for treatment is to reduce the nociceptive trigger. Such a focus on peripheral pain generators is often effective for treatment of (sub)acute musculoskeletal pain (Surenkok et al., 2009, Grunnesjo et al., 2011, Brantingham et al., 2013, Struyf et al., 2013). In patients with chronic musculoskeletal pain, ongoing nociception rarely dominates the clinical picture. Chronic musculoskeletal pain conditions including osteoarthritis (Lluch Girbes et al., 2013), rheumatoid arthritis (Meeus et al., 2012), whiplash (Curatolo et al., 2001, Banic et al., 2004, Sterling, 2010), fibromyalgia (Staud, 2002, Meeus and Nijs, 2007), low back pain (Roussel et al., 2013), pelvic pain (Kaya et al., 2013) and lateral epicondylitis (Fernandez-Carnero et al., 2009), are often characterized by brain plasticity that leads to hyperexcitability of the central nervous system (central sensitization). Growing evidence supports the clinical importance of central sensitization in patients with chronic musculoskeletal pain (Sterling et al., 2003, Jull et al., 2007, Coombes et al., 2012, Smart et al., 2012).
In such cases, musculoskeletal therapists need to think and treat beyond muscles and joints (Nijs et al., 2013). Within the context of the management of chronic pain, it is crucial to consider the concept of central pain mechanisms including central sensitization (Gifford and Butler, 1997). Modern pain neuroscience calls for treatment strategies aimed at decreasing the sensitivity of the central nervous system (i.e. desensitizing therapies).
Treatments capable of desensitizing the central nervous system in patients with chronic pain have been proposed, including exercise prescription (Mease et al., 2011, Woolf, 2011, Nijs et al., 2011a, Lluch Girbes et al., 2013), but up to now exercise therapy as a potential desensitizing treatment (Nijs et al., 2012) for chronic musculoskeletal pain has not been adequately addressed. Here it is explained how musculoskeletal therapists can integrate pain neuroscience education (Butler and Moseley, 2003, Nijs et al., 2011b) with exercise interventions, and how they can apply graded exposure in vivo principles (Vlaeyen et al., 2012) during exercise therapy for patients with chronic musculoskeletal pain. Together, the treatment proposed here aims at altering pain memories in patients with chronic musculoskeletal pain.
Section snippets
Prerequisites for the therapist to provide cognition-targeted exercise therapy
The therapist should have certain prerequisites for providing cognition-targeted exercise therapy. First, therapists require an in-depth understanding of pain mechanisms (Butler and Moseley, 2003) and the dysfunctional central nociceptive processing in those with chronic musculoskeletal pain (Woolf and Salter, 2000, Woolf, 2011). This includes a thorough understanding of the role of fear (of movement) in the development and sustainment of chronic pain (Vlaeyen and Crombez, 1999). Second,
The role of fear (of movement) in the pain neuromatrix
In those with central sensitization pain, the pain neuromatrix is likely to be overactive: increased activity is present in the insula, anterior cingulate cortex, prefrontal cortex, various brain stem nuclei, dorsolateral frontal cortex and the parietal associated cortex (Seifert and Maihofner, 2009). Long-term potentiation of neuronal synapses (Zhuo, 2007), as well as decreased gamma-aminobutyric acid-neurotransmission (Suarez-Roca et al., 2008) represent two mechanisms contributing to the
Step 2: Cognition-targeted exercise therapy for chronic musculoskeletal pain
Following pain neuroscience education, as soon as the patient with chronic pain understands that all pain is produced in the brain and has adopted less threatening perceptions about pain, one can proceed to the next level: cognition-targeted exercise therapy (Nijs et al., 2014). Here it is explained how therapists can use cognition-targeted exercise therapy for altering pain memories in patients with chronic musculoskeletal pain and central sensitization. Such exercise therapy can include
Conclusion
The goal of cognition-targeted exercise therapy is systematic desensitization, or graded, repeated exposure to generate a new memory of safety in the brain, replacing or bypassing the old and maladaptive movement-related pain memories. Hence, such an approach directly targets the brain circuitries orchestrated by the amygdala (the memory of fear centre in the brain).
Central sensitization or hyperexcitability of the central nervous system implies increased synaptic efficiency and development of
Acknowledgements
The first author is grateful to Luc Vanderweeën for alerting us to valuable scientific sources for understanding the theory behind pain memories. Anneleen Malfliet is a PhD research fellow of the Agency for Innovation by Science and Technology (Agentschap voor Innovatie door Wetenschap en Technologie)(IWTTBM130246) – Applied Biomedical Research Program (TBM), Belgium. Jo Nijs is holder of a Chair funded by the European College for Decongestive Lymphatic Therapy, The Netherlands. Michele
References (73)
- et al.
Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia
Pain
(2004) - et al.
Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review
J Manipulative Physiol Ther
(2013) - et al.
Reduction of pain-related fear and disability in post-traumatic neck pain: a replicated single-case experimental study of exposure in vivo
J Pain
(2008) - et al.
Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo
Pain
(2005) - et al.
Reduction of pain-related fear and increased function and participation in work-related upper extremity pain (WRUEP): effects of exposure in vivo
Pain
(2012) - et al.
The integration of pain sciences into clinical practice
J Hand Ther
(1997) - et al.
Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash?–A preliminary RCT
Pain
(2007) - et al.
Motor control problems in patients with spinal pain: a new direction for therapeutic exercise
J Manipulative Physiol Ther
(2000) - et al.
Increased power spectral density in resting-state pain-related brain networks in fibromyalgia
Pain
(2013) - et al.
Measuring perceived harmfulness of physical activities in patients with chronic low back pain: the photograph series of daily Activities–short electronic version
J Pain
(2007)
Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial
Pain
Central sensitization in patients with rheumatoid arthritis: a systematic literature review
Semin Arthritis Rheum
Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain
Eur J Pain (London, England)
How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines
Man Ther
Thinking beyond muscles and joints: therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment
Man Ther
A neuroscience approach to managing athletes with low back pain
Phys Ther Sport: Official J Assoc Chart Physiotherapists Sports Med
Stress-induced hyperalgesia is associated with a reduced and delayed GABA inhibitory control that enhances post-synaptic NMDA receptor activation in the spinal cord
Pain
Muscle control-pain control. What exercises would you prescribe?
Man Ther
Self-reported pain severity, quality of life, disability, anxiety and depression in patients classified with 'nociceptive', 'peripheral neuropathic' and 'central sensitisation' pain. The discriminant validity of mechanisms-based classifications of low back (+/-leg) pain
Man Ther
Differential development of sensory hypersensitivity and a measure of spinal cord hyperexcitability following whiplash injury
Pain
Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery
Pain
Reduced GABA neurotransmission underlies hyperalgesia induced by repeated forced swimming stress
Behav Brain Res
Stress and excitatory synapses: from health to disease
Neuroscience
Examination of the photograph series of daily activities (PHODA) scale in chronic low back pain patients with high and low kinesiophobia
Pain
Similar alteration of motor unit recruitment strategies during the anticipation and experience of pain
Pain
Assessing fear in patients with cervical pain: development and validation of the pictorial fear of activity scale-cervical (PFActS-C)
Pain
The sensitization model to explain how chronic pain exists without tissue damage
Pain Manag Nurs: Official J Am Soc Pain Manag Nurses
Fear of movement/(re)injury, avoidance and pain disability in chronic low back pain patients
Man Ther
Central sensitization: implications for the diagnosis and treatment of pain
Pain
A synaptic model for pain: long-term potentiation in the anterior cingulate cortex
Mol Cells
Explain pain
Thermal hyperalgesia distinguishes those with severe pain and disability in unilateral lateral epicondylalgia
Clin J Pain
Central hypersensitivity in chronic pain after whiplash injury
Clin J Pain
Widespread mechanical pain hypersensitivity as sign of central sensitization in unilateral epicondylalgia: a blinded, controlled study
Clin J Pain
The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain
Phys Ther
A randomized controlled trial of the effects of muscle stretching, manual therapy and steroid injections in addition to 'stay active' care on health-related quality of life in acute or subacute low back pain
Clin Rehabil
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