Untamed memories - the role of past trauma in the development of chronic pain

Derrick Sueki  PT, DPT, PhD(c), GCPT, OCS, FAAOMPT
Kim Dunleavy  PT, PhD, OCS
 Emilio “Louie” Puentedura  PT, DPT, PhD, OCS, FAAOMPT
Reviewed by Beth Shelly

Input - Sensations, nocieception, memories, emotions are all acting together on the brain

Out put  - motor, ANS, immune, pain

Pain requires cognitive process and engages the memory.

No pain is the same in two different people

Sensations - injury always occurs with other events - smell, sight, sound, feel

Memories - pain is designed to protect us from initial exposure and repeat exposure

Chronic pain changes the brain

Change in activity - chronic pain = increase activity and duration of activity
Change of structure
·         atrophy - hippocampus (initiator of ANS response) , thalamus (somatosensory info) , anterior cingulate cortex (emotion), medial prefrontal cortex (memories) due to the influence of cortisol
·         hypertrophy - amygdala (fear and threat)

 Hippocampus is critical in associative learning and is not fully developed till 2 years old

Associative learning - Pavlov's dog = pairing of two stimuli (pain and smell, sight, taste)
Can be unconscious - lab coat = increased BP

PTSD

PTSD is associated with chronic pain and visa versa - esp fibro, CRPS, pelvic pain, back pain, HA, face pain
Leads to increased disability, increased perception of pain, increased use of health care
Women are 2 times more likely to have PTSD and there seems to be a genetic predisposition
30% of women surviving rape develop PTSD
32% of people in ICU develop PTSD
23% of women with breast cancer develop PTSD

 Memory formation is not related to the amount of physical damage but is associated with the amount of fear

Avoidance of stimuli and activities that remind the individual of trauma is highly related to PTSD
When pain is linked to fear it is more likely to become chronic
 

Amygdala - is responsible for fear processing and is fully functional at birth

Fear = pain then the key to pain extinction is to change expectation - demolition derby

PT treatment in PTSD

Multidisciplinary approach - refer if needed

Focused on managing physical symptoms and changing maladaptive beliefs.
Cognitive behavioral therapy
·         explain reasons for exam and rx
·         provide clear instructions
·         set achievable specific goals
·         reinforce positive behavior
·         point out avoidance with rationale and explanations
·         Identify triggers and response to triggers
·         decrease high intensity stimulation and distractions
·         pain modulating modalities
·         relaxation, breathing
·         graded exercise and activities