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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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Two-Point System of Patient Education
Patient education should be consistent across all touchpoints in the healthcare
system. The PMCS allows providers to offer this consistency via the use of
the following two-point system for patient education: (1) explain pain using a
mechanism-based language common to the patient and the provider and (2)
use an “activity traffic light,” which is a guide to movement-safe pain. PMCS
education may reduce the number of needed interventions such as surgical
procedures, drugs, and injections by improving the patient’s understanding of
pain and the dominant mechanism causing symptoms.
16,22
Explanation of Pain Mechanisms
The patient should be instructed that pain is an output of the brain, not an
input from the body. This is an important topic because all patients with acute
or chronic pain should understand the meaning of their symptoms and
whether the brain is causing pain by interpreting a symptom as an alert of
danger and the need to protect that area. Most symptomatic signals sent by
the body are related to some type of imbalance (ie, injury, directions,
positions, deconditioning, poor coping, and negative emotions and thoughts);
these signals are then interpreted by the brain. Based on a perceived threat to
the body, the brain may interpret the signal as an indication of harm and the
need for protection; this results in pain and nociceptive sensitivity. The actual
symptoms of pain may be referred to the areas of signal generation or other
areas based on past and current life experiences related to the interpretation of
these signals of impending harm. Spine pain occurs on a continuum and
involves mechanical influences signaling a state of imbalance. If allowed to
persist, the signals involve the nervous system and related pain mechanisms
that become neurologically influenced16 (Figure 1). Nociceptive mechanical
mechanisms of pain can include chemical or mechanical inflammation,
ischemia, and peripheral neurogenic pain. Nervous system influences that are
directly related to the central nervous system include central sensitization,
affective, and motor/autonomic pain mechanisms. Patients with LBP should
understand that their dominant pain mechanism lies somewhere on this
continuum. This understanding is vital to patient education, which can affect
therapeutic exercise selection and, ultimately, the patient’s movement.
Activity Traffic Light: A Guide to Movement-Safe Pain
The second aspect of the two-point system of patient education is explaining
what the signal means and whether it is indicating the need for protection or
indicating that the pain is safe.19 The best analytic tool is the activity traffic
light. Education about movement-safe pain is not about what the patient feels,
but more about how the pain behaves with respect to the patient’s movement.
Pain behavior may be a red light indicating harm is occurring and an activity
should stop; a yellow light indicating that an activity is too much and too fast,
but with the need to stay the course at an appropriate pace; or a green light
indicating the need to continue an activity and confidently increase and
intensify the activity. Interpretation of the activity traffic light involves
considering the behavior of the symptoms during and after movements and
the effect on range of motion (Table 1). This analytic skill will help a patient
understand when pain is safe (no harm is occurring) and avoid pain flare-ups
or reinjury as return to activity progresses. This understanding is key to
successful self-management of pain for patients with any dominating
mechanism and any recommended exercise intervention. It can prevent a
patient from misinterpreting his or her pain as harmful and can discourage
negative thoughts, which become an active trigger and cause
misinterpretation and sensitization of the body’s signals.
Table 1
Validating the PMCS as a Subgrouping Classification System
The PMCS is a patient-centered biopsychosocial subgrouping method and
language used to classify the dominant pain mechanism. The PMCS guides
the provider in understanding relevant subjective and objective characteristics
related to mechanical and neurologic pain mechanisms and focuses on the
mechanical, cognitive, emotional, social, and sensorimotor manifestations of
pain seen in clinical practice. In an analysis of data regarding clinical pain
characteristics using kappa and percentage of agreement values, 68% and
95% of items on the clinical criteria checklist demonstrated clinically
acceptable inter- and intra-examiner reliability, respectively, across multiple
disciplines.15 Inter- and intra-examiner agreement associated with clinicians’
identification of clinical criteria per pain mechanism involving low back and
leg pain was substantial and almost perfect, respectively. These findings
provided preliminary evidence supporting the reliability of clinical judgments
associated with pain mechanism classification in patients with LBP and leg
pain. A 2016 study reported good agreement between the PMCS category
determined by trained therapists and the PMCS category assigned based on a
computer-generated statistical model that used patients’ signs and
symptoms.7 Cluster analysis involving five assumed groups found that 97%
of patients could be classified by both models at the first visit. Sensitivity and
specificity results (95% confidence interval) were calculated for the five
categories using the PMCS categories assigned by the physical therapist as
the criterion standard for approximately 38,000 patients receiving therapy for
pain. The largest number of patients in the study were those with spine pain.
Sensitivity for four categories of pain (inflammatory, ischemia, peripheral
neurogenic, and central mechanisms) ranged from 72.4% (ischemia) to
98.8% (central mechanisms). This study provides empiric support that the
PMCS can be used to accurately diagnose dominant pain mechanisms in all
areas of the body at the first visit in an outpatient clinical pain practice.7 The
PMCS is a reliable and valid method for patient classification and can
provide better predictable outcomes.
Pain Mechanism Education and Prescriptive Therapeutic
Exercise
It is important to understand the involved pain mechanism, the type of
therapeutic exercise to prescribe, and the overall effect of the therapeutic
exercise. If an exercise is not effective, other pain mechanisms and exercise
approaches should be considered. An ineffective therapeutic exercise regimen
may result in greater patient dependency on the care provider and increase the
risk that spine pain will result in disability.27 Pain mechanism education and
prescriptive therapeutic exercise for LBP can be classified into five exercise
intervention subgroups that will ensure implementation of the correct type,
frequency, and intensity dosage needed for treatment of the dominant pain
mechanism.
Nociceptive Mechanical Inflammation Pain Mechanism and
Directional Preference Exercise Subgroup
In the nociceptive mechanical inflammation pain mechanism and directional
preference exercise subgroup, a nontraumatic mechanical mechanism is
related to a position or cumulative movement that occurs over time and
involves too much loading in the same direction without load reversal and
movement in the opposite direction. The needed treatment involves a certain
direction of movement. The clinician instructs the patient in an exercise that
highlights a preferred direction of movement. The pain response is rapid
because directional exercise restores the balance in movement and stops the
receptor from signaling.20 When the most prevalent nociceptive mechanical
inflammatory signals can be eased by movement in a certain direction, the
need for therapeutic exercise in a preferred direction is indicated to decrease
the risk of irritating or worsening the condition.
28-33
The directional exercise
will alleviate symptoms, and signs of centralization may occur with repeated
movements in that direction.
28,29,32,33
The primary goal of exercise in this
group is to abolish pain by using the directional preference.
Nociceptive Ischemia Pain Mechanism and Remodel Tight and
Weak Tissue Exercise Subgroup
In the nociceptive ischemia pain mechanism and remodel tight and weak
tissue exercise subgroup, there is not enough blood and oxygen to allow
complete healing or restoration of full function to the tissues. This condition
may occur during healing stages of repair and remodeling of connective
tissues. Remodeling exercise is indicated when nociceptive mechanical
ischemic signals indicate the need to increase mobility and strength in
specific tissues (ie, muscle, ligament, tendon, cartilage, or bone).
8,24,34
The
signals being sent are more related to a need to stretch tight or strengthen
weak connective tissue. This type of pain is safe and necessary to stimulate
further tissue healing and recovery.20 The remodeling exercise is intended to
produce and increase pain, but overall symptoms should be no worse after
exercise (green light, safe to keep performing). The adage of “no pain, no
gain” applies. The patient’s condition will slowly respond over time as the
tissue is remodeled, and improved health will be acheived.
8,24
Nociceptive Ischemia Pain Mechanism and Restore Function
Subgroup
Another type of nociceptive mechanical ischemic signal may indicate the
need for better quality movement.35 The pain signal means that a function or
a posture should be performed differently. The therapeutic exercise needs to
be specific and look like the patient’s function. Incorporating motor control
theories, developmental sequencing, and principles of applied physics into
the human kinetic chain is the focus of exercise to restore function. Often
symptoms may originate from a body part above or below the area of the
presenting symptoms. For example, back hinging (flexing) to perform
forward-directed movements will load a passive inert system. Teaching the
patient how to use hip hinging for forward-directed movement will load an
active muscular system. The patient’s condition will slowly improve as
performance of the movement pattern becomes more subconscious with
continued practice of the new motor strategy. The success of therapeutic
exercise in this subgroup depends on how well the patient integrates the new
motor strategy or posture into his or her daily habits and functions. In this
therapeutic exercise subgroup of ischemia, the function and quality of
performance are more important than targeting the remodeling of a specific
tissue. Subjective and objective characteristics and intervention guidelines
7,16
for the three most prevalent mechanical PMCS exercise subgroups can be
found in Table 2.
Central Sensitization or Affective Pain Mechanisms and Gradual
Exposure to Fearful and Pleasurable Activities Exercise
Subgroup
In patients requiring gradual exposure to fearful or pleasurable activities,
therapeutic exercise focuses on the dominant CNS pain mechanisms of
central sensitization and affective pain. Often, the pain is an indication of the
need for gradual exposure to either feared activities (when dominated by
central sensitivity) or the reintroduction of pleasurable activities (when
dominated by affective pain). Central sensitization occurs when the cognitive
processes in the spinal dorsal root ganglion and brain misinterpret the signal
from the body as harmful, causing ongoing sensitivity to the nociception and
persistent pain20 (Figure 2). Treatment for this pain mechanism includes
specific pain education regarding the brain’s role in pain as an interpretation
of the incoming signal for the purpose of protection and the effect of signal
misinterpretation on the sensitivity of the receptors in the tissues. The activity
traffic light guides movement-safe pain to retrain the cognitive interpretation
of the brain to incoming signals. In addition, patients are gradually exposed
to activities and movements or functions perceived as fearful or harmful, with
monitoring of their cognitive reframing of movement-safe pain that
desensitizes their pain alarm system. The affective pain mechanism occurs
when the emotional and social pressures of life reach a level that affects the
patient’s coping ability. This inability to cope is a result of negative emotions
and poor coping strategies. Negative impulses sensitize emotional centers of
the brain in attempts at protection and referral of pain and other symptoms to
certain areas of the body to distract focus from unpleasant circumstances.
20
The signals indicate an imbalance in emotional coping related to negative
thoughts and emotions that occur in an effort to deal with past, present, or
future circumstances that have caused or can result in pain.16 Treatment for
this pain mechanism involves gradual exposure to activities, movements, or
functions perceived as pleasurable, meaningful, and enjoyable. This gradual
process is geared toward a patient learning to think, cope, believe, and behave
differently about his or her pain. Patient education regarding this mechanism
involves understanding the brain’s role in pain as a protective mechanism
directly influenced by positive active coping. The brain causes pain in the
body in an effort to distract from life issues and their resolution. A patient’s
readiness to take a different approach and actively cope better will directly
affect outcomes.
Table 2
Motor/Autonomic Pain Mechanism and Sensorimotor Exercise
Subgroup
The motor/autonomic pain mechanism is dominant when representation is
lost in the area of the primary somatosensory cortex of the brain that
represents all body parts. Symptoms are related to cortical disinhibition, and
they present as a lack of awareness and decreased ability to recognize body
parts.20 Signs and symptoms involving the sympathetic and parasympathetic
nervous system are manifested. This pain mechanism has been well
recognized in complex regional pain syndrome affecting the extremities and
phantom pain; however, it also has been reported in spine-related pain. The
therapeutic exercise treatment is sensorimotor exercises directed at changing
brain recognition of body areas. Sensorimotor exercises involve exercise to
improve left-right discrimination, and the use of imagery and mirror
reflection therapy to encourage awareness of the affected body part. These
exercises involve a specific protocol of exercises and education regarding the
active mechanism occurring in the brain. After sensory and motor recognition
is perfected, traditional movement-based therapies can be directed at the
affected body part.
Classification System Terminology
The overarching PMCS covers all exercise subgroups previously discussed.
Other nociceptive mechanical classification systems that aid in therapeutic
exercise selection are the MDT and the TBC systems, which have limited
application to certain central nervous system pain mechanisms. Directional
preference has been recognized in all three classification systems; however,
different descriptive terms are used. The MDT system uses the term
derangement syndrome, the TBC system uses the term specific exercise
classification, and the PMCS uses the term inflammation-mechanical. As a
provider, it is helpful to determine the type of classification system used
when communicating with a patient. Using multiple classification systems
collaboratively for patients with LBP increases the strength of the therapeutic
exercise prescription.
Figure 2
Illustration depicting the central nervous system pain
mechanism and highlighting the input at the spinal cord
level that affects the fear and threat centers with perceived threats that
affect the descending inhibitory system and result in sensitization to
the nociceptors. (Reproduced with permission from O’Connor A,
Kolski MC: Central sensitization pain mechanism, in O’Connor A,
Kolski MC: A World of Hurt: A Guide to Classifying Pain. St. Louis,
MO, Thomas Land, 2015, pp 187-188.)
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