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15 Articles in Volume 16, Issue #6
Osteoarthritis and Central Pain
Uncovering the Sources of Osteoarthritis Pain
The Synergistic Effects of Mood and Sleep on Arthritis Pain
Nonsurgical Rx of OA: Analyzing the Guidelines
Osteoarthritis Disability Is Often Underestimated By Rheumatologists
10 Pain Medication Myths
The Use of Medical Marijuana for Pain in Canada
6 Common Concerns Regarding Medical Marijuana
What Pain Specialists Need to Know About Medicinal Cannabis
Applying Kinesiology as a Multipronged Approach to Pain Management: Part 2
Practical Guide to Adding Recreation Therapy Into Pain Management
A Novel Treatment for Acute Complex Regional Pain Syndrome
Genetic Testing in High-Dose Opioid Patients
No More “Fifth Vital Sign”
Letters to the Editor: Disc Herniation, SCS, Arachnoiditis, Tapering Opioids

Applying Kinesiology as a Multipronged Approach to Pain Management: Part 2

Improving balance to prevent risk of falls and injury.

In the first installment of this article in the June issue of Practical Pain Management, the authors introduced the field of kinesiology as a key component of an effective biopsychosocial model for an interdisciplinary pain management program. In this installment, the role of kinesiology will be examined. In particular, the role of improving balance will be highlighted—an important area of research due to the ever-increasing population of Americans over 65 who have chronic pain and are at risk of falls and injury.

Exercise and Pain’s Effects on Balance

Under normal circumstances, the body uses 3 primary systems to maintain balance: the visual system, the vestibular system, and the proprioceptive system (Figure 1).

Kinesiologists have long studied these important areas of balance because:

  • The visual system provides information about the environment that can be seen with the eyes
  • The vestibular system provides information about motion, equilibrium, and spatial orientation
  • The proprioceptive system provides information about the position of the limbs and the amount of force being exerted during movement through sensors in the skeletal muscles, joints, and skin

All 3 of these systems provide information to the central nervous system, which then sends signals to the skeletal muscles with instructions on what movements are required to maintain posture, and therefore balance.

How Does Pain Impact Balance?

Understanding how the body works to maintain postural control is necessary to allow a clinician to piece together how pain might have a detrimental effect on balance. Postural control has been defined as the act of maintaining, achieving, or restoring a state of balance during any posture or activity. Unfortunately, the 3 systems that work together to maintain balance can become impaired for a variety of reasons. For example, removal of visual input (due to blindness, cataracts, etc) can increase reliance on the proprioceptive and vestibular systems.1 Impairments in the proprioceptive system (due to chronic musculoskeletal pain or neuropathy), for example, might limit range of motion, forcing an increased reliance on the visual and vestibular systems to maintain postural control.2

One way that pain impacts balance indirectly, especially in the elderly, is through self-imposed restriction on physical activity in order to avoid pain. The Fear-Avoidance Model3 suggests that people who suffer from chronic pain may avoid movements or activities for fear of inducing pain.

This self imposed restriction on physical activity contributes to deconditioning and skeletal muscle atrophy and stiffness, further decreasing the body’s ability to maintain core strength and good postural control (ie, increasing frailty).4  Patients who are deconditioned or have poor postural control are at an increased risk of falling, which increases their risk of sustaining a hip, wrist, or ankle fracture. Fractures account for 61% of the $19 billion spent annually to treat nonfatal falls in the US.5

Pain and the Visual System

Various types of chronic pain can impact vision. For example, fibromyalgia deteriorates the nervous system (central sensitization), which can include the nerves leading to the eyes. This can result in blurred vision, sensitivity to light, double vision, and loss of peripheral vision.6

A vast majority of individuals with multiple sclerosis (75%) can have a condition known as optic neuritis, which is characterized by an inflammation of the optic nerve.7 This can result in blurred vision or even blindness. Another condition associated with multiple sclerosis is nystagmus, which is uncontrolled eye movements. The severity of nystagmus typically dictates whether or not vision is impaired.4

Individuals diagnosed with rheumatoid arthritis can also have vision impairments. Twenty-five percent of patients with rheumatoid arthritis will have vision problems, including pain with sensitivity to light, blurred vision, and pain with eye movement.8 Dry eye, which is increasingly becoming a public health problem, is associated with multiple symptoms, including blurred vision, irritation, and pain.9

Pain and the Vestibular System

A number of chronic pain conditions can impact the vestibular system, which can lead to an increased risk of falling. These include patients with chronic, non-cancer related pain or underlying neurologic disorders such as spinal stenosis (usually secondary to degenerative disc disease and spondylosis), ruptured disc, spinal instability, spondylolisthesis, spinal cord injury or disorder (ie, multiple sclerosis, myelopathy, and syrinx), peripheral nerve injury or disorder, or brain injury or disorder (eg, stroke, multiple sclerosis, Chiari malformation).10

Cervical vertigo (dizziness) can be induced by neck pain or stiffness, arthritis, and other causes.11 Dizziness in the elderly can be a result of problems with the vestibular, central nervous system, and vision systems. However, approximately 50% of reported dizziness in the elderly is thought to be caused by vestibular disorders.12

Individuals with migraines often complain of vestibular problems, such as vertigo, unsteadiness, and head motion intolerance.13 According to the Vestibular Disorders Association, vestibular hyperacusis, which is the perception of an unusual auditory sensitivity to certain sounds, occurs when “the complex electrical signals generated by sound vibrations are misinterpreted, confused, or exaggerated. With cochlear hyperacusis, subjects feel ear pain, discomfort, annoyance, or some other emotional reaction when certain sounds are heard. In vestibular hyperacusis, exposure to sound can result in falling or a loss of balance.”12

Another interesting phenomenon is medication-induced vestibular dysfunction. A recent study found that 66.9% of subjects who were prescribed a chronic non-cancer pain medication or a medication for a neurological condition had vestibular dysfunction, which was significantly higher than the 35.4% incidence among the general population.10 The type and dosage of medications were not provided in the article. Physician-recommended therapy included neurologic examination and possible magnetic resonance imaging (MRI) or computed tomography (CT) of the brain, vestibular rehabilitation therapy, and related balance-
function rehabilitation therapy.

This warrants particular consideration in patients at higher risk for falls, and it may benefit clinicians to counsel patients on balance strategies to counteract any vestibular dysfunction that may be impacted by pain or pain medications.

Pain and the Proprioceptive System

As with the visual system and the vestibular system, pain can impact the proprioceptive system.14 In addition, patients with chronic low back pain tend to exhibit atrophy in key muscles that contribute to postural control, primarily in a muscle called the multifidus. The multifidus is attached directly to the spine, and not only plays a role in trunk extension and rotation, but also works to stabilize the vertebrae and provides valuable proprioceptive feedback.15 Decreased postural control has been seen in patients with low back pain,16 and patients with low back pain have decreased proprioception in muscles of the lower spine,17 altering the strategies (hip strategy, which entails lowering the center of gravity and activation of the hip musculature, versus ankle strategy, which is preferred and includes minor adjustments via the musculature surrounding the ankles) used to maintain postural control.18

Patients diagnosed with diabetic neuropathy (of which pain is a prominent symptom) tend to have decreased postural control, which can be influenced by increased pain or decreased sensitivity to touch. In a study by Cimbiz and Cakir, the researchers found that diabetic neuropathy disturbed the balance on the dominant leg and decreased physical fitness.19

Patients with fibromyalgia are more reliant on visual feedback to maintain postural control than on proprioceptive feedback,20 suggesting impairments in the proprioceptive system. Patients with chronic neck pain have been documented to have reduced proprioception awareness, resulting in a larger “sway area,” or peak-to-peak disturbance, and decreased ability to complete more challenging balance tasks.21 Additionally, patients with multiple sclerosis experience greater deficits in proprioception that have a detrimental effect on balance. Indeed, these proprioceptive deficits appear to impact patients with multiple sclerosis more than individuals with other conditions such as osteoarthritis.22

Kinesiology and Muscle Training

Kinesiology is often part of an interdisciplinary biopsychosocial model for treating chronic pain. Such programs include: physical training via physical therapy; ergonomic training via occupational therapy; psychosocial pain management; education on circumstances related to pain; and recreational activities such as playing games. (See related article).

One benefit to individuals participating in such programs is that because physical improvement is quantifiable, participants/therapists are able to monitor patients’ physical progress. The primary outcome goals are to increase physical functioning, improve pain-coping skills, promote the return to a productive and active lifestyle, and promote independence in pain management.

It should be noted that physical therapy/kinesiology are sometimes used as “stand-alone” modalities for the treatment of pain in general. These health care providers will take a variety of approaches to treat pain, depending on the location and cause.

Improving Balance

Fortunately, there are ways to improve balance that can have a direct influence on chronic pain. The benefits of exercise for improved balance and health in patients with chronic pain are well documented, including:

  • Increased muscular strength23
  • Flexibility
  • Muscular endurance24

These benefits can often extend to pain management. Studies have shown that activities such as yoga have a positive effect on pain levels in patients with chronic neck pain,25 and pool-based exercise can improve pain symptoms in fibromyalgia patients.26

Passive manual mobilization is another technique used to provide short-term pain relief and restore pain-free functional movements. This technique is geared toward improving joint mobility and pain relief. In patients with knee osteoarthritis, strength training alone has shown benefits for pain management, but this effect is amplified when combined with passive manual mobilization.27 This approach is effective in 2 ways: it increases strength of atrophied muscles that may be contributing to pain; and it improves joint mobility. Improved joint mobility is important in patients with knee osteoarthritis, as joint mobility can often be a determinant of disability in this population.28

Strength Training

Strength training plays a role in a pain management program, especially when that training is targeting muscles that have atrophied and are either contributing to, or are a result of, pain.29 Targeting muscle imbalances is frequently an effective strategy, as this is often thought to be a contributor to musculoskeletal pain, especially in the knees30 and lower back.31 For example, an outcome goal for patients with patellofemoral knee pain might be to restore patellar alignment through strengthening the quadriceps, stretching, or patellar taping.32

Given that chronic low back pain has a high rate of recurrence,33 and considering that atrophy of key muscles in the low back is thought to contribute to low back pain,15 strength training that focuses on the stabilization of these key muscles can be a powerful tool in treatment and prevention.

Indeed, muscle-strengthening exercises are commonly used to combat muscular atrophy and stabilize the trunk. In one study, an exercise approach that focused on retraining and strengthening the core muscles of the deep trunk—the transversus abdominis and lumbar multifidus—supported the use of independent transversus abdominis contractions for the treatment of low back pain and prevention of musculoskeletal injuries.34 In the study, equipment for progressive resistance strengthening of isolated muscle groups was used. The training program differs from the current concept of core strengthening in that it emphasizes nonfunctional isolation exercises over motor relearning.34

Compared to general exercise, core stability exercise is effective in decreasing pain and improves physical function in patients with chronic low back pain, but patients who engaged in core stability exercise versus those who engaged in general exercise had no significant long-term differences in pain severity.35 Also, research provides evidence to suggest that lumbar extension exercise is beneficial for strengthening the lumbar extensor, decreasing pain, and improving psychosocial functioning in low back pain patients.36

Lumbar stabilization is another active form of exercise used in kinesiology and physical therapy to modulate chronic back pain. It is designed to strengthen muscles to support the spine, and to help prevent low back pain. This exercise technique relies on proprioception, or the awareness of where one’s joints are positioned. Lumbar stabilization involves strength, flexibility, and endurance.37 This approach is aimed at improving the neuromuscular control, strength, and endurance of muscles central to maintaining dynamic spinal and trunk stability. Lumbar stabilization has been found to strengthen the lumbar extensors and reduce low back pain.37

It should also be noted that individuals interested in starting a strength- training program, especially as part of a pain management program, should always consult with their physician or other health care professional before beginning a program in order to avoid further injury or worsening their current pain.

Stretching

Muscular flexibility can be obtained through performing certain stretching exercises designed to elongate one’s muscles and prevent injury. The stretching of muscles improves circulation of blood to the muscles and joints and increases range of motion, thereby allowing the joints to remain flexible.38

Flexibility training has been shown to be an important component of an effective pain management strategy. In a study by Cunha et al, the researchers randomly divided 31 women with neck pain into 2 groups: the global posture re-education group (n=15) performed muscle chain stretching related to postural or flexibility imbalances, while the conventional stretching group (n=16) performed conventional static muscle stretching. Both groups also underwent manual therapy.38 Muscle chain stretching uses postural positions for global stretching, whereas static stretching is the stretching of muscles while the body is at rest, lengthening a muscle to an elongated position. In both groups, significant pain relief and range-of-motion improvement were observed after treatment was implemented. The researchers concluded that conventional stretching and muscle chain stretching are both effective in reducing pain, as well as improving the range of motion and quality of life of patients with chronic pain.38

The effectiveness of physical exercise or a yoga program on spinal flexibility in patients with chronic low back pain has also been evaluated. A study conducted by Tekur and colleagues assessed pain-related outcomes with the Oswestry Disability Index (ODI), and a goniometer used to measure spinal flexibility, at pre- and post-intervention, with 1 group receiving a yoga exercise program and the other receiving a general physical exercise program.39 The results of the study found that a yoga-based lifestyle program reduced pain and improved spinal flexibility in patients with chronic low back pain to a greater extent than general physical exercise.39

In addition, exercises that incorporate yoga and Pilates have been shown to improve balance and flexibility, and to decrease pain in individuals with low back pain.40 Yoga also has a mindfulness aspect, which may be just as powerful in pain management via improving pain acceptance and therefore improving physical functioning.41 Like yoga, Pilates incorporates physical and mental mindfulness training, but focuses more on “core” training. In this instance, the “core” refers to the abdominal, gluteal, and paraspinal muscles. As such, Pilates may be particularly conducive to the alleviation of chronic low back pain.42

Myofascial Release

Myofascial release techniques (MFRT) are a form of treatment in which relief of myofascial tension is accomplished by applying pressure (a massage-style technique) on myofascial trigger points, which are sensitive areas in discrete, tense bands of hardened muscle that produce symptoms such as pain and stiffness.43,44 MFRT has been demonstrated to be effective in alleviating chronic pain.

For example, a study by Castro-Sánchez and colleagues included 30 patients with fibromyalgia who received a weekly 90-minute session of massage-MFRT intervention (over a period of 20 weeks).45 The investigators found significant improvement in 18 assessed trigger points of myofascial tightness; significantly lower post-therapy self-report of pain on the McGill Pain Questionnaire; an increase in reported physical functioning on the Fibromyalgia Impact Questionnaire; and a decrease in self-reported clinical severity of their pain.45

Further research by Castro-Sánchez and colleagues found MFRT significantly improved pain assessed with a visual analog scale, anxiety scores on the State-Trait Anxiety Inventory, depression as scored by the Beck Depression Inventory, sleep quality determined by the Pittsburgh Quality of Sleep Index, and quality-of-life assessed by the Quality of Life Questionnaire.46 Put together, these results indicate that MFRT not only improves physical functioning in fibromyalgia patients, but it also improves psychosocial variables of patients suffering from chronic illnesses.46

MFRT has also been evaluated in patients suffering from chronic pelvic pain syndrome (CPPS) and chronic prostatitis (CP). Anderson and colleagues administered 3 months (8 sessions) of MFRT, in conjunction with paradoxical relaxation therapy (PRT), in 138 men suffering from CPPS and CP.47 The therapy was administered by a team of physiotherapists, psychologists, and urologists. Seventy-two percentof patients reported that the MFRT and PRT had a moderate or greater than moderate effect on relieving pain symptoms, providing evidence to suggest that MFRT, in conjunction with PRT, is efficacious in managing pain symptoms associated with CPPS and CP, relative to traditional therapies.47

Research also has demonstrated the effectiveness of MFRT in common shoulder disorders, although it has rarely been documented as a form of treatment in publications. Bron and colleagues suggested some shoulder pain symptoms may be associated with myofascial trigger points.48 A study conducted by Gam and colleagues evaluated MFRT on neck and shoulder pain.49 In that study, participants received 8 treatment sessions consisting of massage techniques on myofascial trigger points, and performed exercises designed to increase strength and flexibility in the neck and shoulder areas of the body. Results of the study found that participants receiving the massage and exercise treatment had significantly less tenderness in myofascial trigger point areas than control participants receiving no treatment; a 6-month follow-up after treatment found that 64% of participants still reported at least some positive effect of the treatment.49

Overall, the administration of MFRT for chronic pain disorders appears promising, given the limited amount of research conducted to date on it. As innovative techniques such as MFRT start to become more popularized in general physical therapy protocols, more evidence-based research will accumulate in evaluating the efficacy of MFRT in treating chronic pain disorders.

Nutrition

Another (often undervalued) component of comprehensive pain management is nutritional intervention. Pain is often caused by chronic inflammation, as seen in illnesses such as arthritis, multiple sclerosis, or other musculoskeletal pain disorders such as low back pain. For example, individuals with chronic low back pain tend to have a higher chronic low-level inflammation.50 Consequently, dietary interventions have been shown to markedly reduce circulating levels of the biomarkers that exacerbate inflammation and chronic pain.51

Dietary interventions (including control of caloric intake) also assist in weight loss, which can alleviate musculoskeletal pain, especially in overweight or obese individuals.52 With the developing world moving more toward a pro-inflammatory diet consisting more of processed foods than fruits and vegetables,51 it is becoming more important than ever for healt care providers to incorporate nutrition into pain management programs.

Summary

Historically, health issues have usually been addressed through individual health disciplines. When it comes to a health issue like pain, however, which significantly affects all facets of an individual’s functioning, an interdisciplinary approach is not only preferable, but also necessary. A pain management “team” can encompass a wide variety of disciplines. As discussed in this article, effective pain management involves more than pharmacology alone. An effective interdisciplinary pain management team, embracing the biopsychosocial model of pain, includes physicians, nurses, physical therapists/kinesiologists, pharmacists, recreational therapists, psychologists, psychiatrists, nutritionists, and others to provide appropriate care to the individual suffering pain. The important but often unappreciated field of kinesiology is a vital link in better understanding, treating, and developing treatment outcomes for this biopsychosocial model approach. Indeed, this approach follows the long-accepted Aristotelian dictum “The whole is greater than the sum of its parts.”

Last updated on: August 4, 2016
Continue Reading:
Practical Guide to Adding Recreation Therapy Into Pain Management

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