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Kasey Miller DPT, COMT  - Foot and Ankle Differential Diagnosis - Short Case Studies
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Sawyer EE, McDevitt AW, Louw A, Puentedura EJ, Mintken PE. (2018). Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor Imagery in an Individual with Frozen Shoulder. Journal of Orthopaedic & Sports Physical Therapy; 48(3): 174–184. 

Summarized by: Megan Barnes SPT, Missouri State University, Springfield, Missouri

The purpose of this case report was to demonstrate how pain neuroscience appeared to assist in the recovery of a 54-year-old woman in the freezing phase of frozen shoulder. This patient had previously been performing intensive physical therapy for four weeks with no improvement in her pain. Her previous therapy consisted of aggressive manual therapy and stretching of the capsule performed daily with no significant differences in her ROM. Her initial pain level was 7/10 and her Shoulder Pain and Disability Index (SPADI) was 64%. Along with increased pain and decreased ROM, she was also exhibiting signs of fear-avoidance behaviors.

 Pain neuroscience education in addition to therapeutic exercise was administered for twelve weeks, in which the first six weeks, the primary purpose of therapy was to address the central nervous system and pain sensitization. The patient was educated on how pain originates from the brain, how increased pain does not necessarily mean increased tissue damage, and how the environment can influence pain. The patient then initiated a graded motor imagery (GMI) training program initially emphasizing laterality training differentiating between left and right body parts in different positions, later concluding with mirror therapy training. For mirror therapy, she would actively flex the unaffected arm and observe this movement through a mirror. This creates the illusion that the affected limb is moving through all ranges of motion. After one week of mirror therapy, she was able to actively move her affected arm through all ranges, and her resting pain level was a 3/10. By the end of six weeks, the patient was much less sensitized, and she was now ready to proceed into the manual therapy and therapeutic exercise portion of treatment program. The final four weeks of physical therapy consisted of additional stretching and neuromuscular re-education. At the end f her 12 week treatment plan, this patient’s AROM increased in flexion from 61 degrees to 154 degrees, abduction from 32 degrees to 104 degrees, and external rotation from 3 degrees to 52 degrees. SPADI improved to 22%, and her resting pain was 0/10.

This case report suggests pain neuroscience education principles including a GMI program may also possibly be helpful as an adjunctive intervention with adhesive capsulitis.

Personal Commentary: 

Pain neuroscience is something I have definitely been intrigued in throughout physical therapy school, and I believe treating the whole patient is important to being a successful physical therapist. As humans, our brain is a very powerful organ that should definitely be utilized in various sections of physical therapy. Also, it is very exciting to see how pain neuroscience can also be utilized with specific musculoskeletal diagnoses, like frozen shoulder. There is not much definitive evidence for the treatment of frozen shoulder. For example, treatment with corticosteroid injection, NSAIDS, manipulation under anesthesia, and/or open or arthroscopic surgical release have shown that there is really no conclusive evidence that any of these treatments have been truly effective. There is also not a standard treatment that seems to be highly more effective than the other (Sharma et al., 2016). Also, just as this case report demonstrated, aggressive physical therapy and mobilizations does not always seem to promote recovery in patients with frozen shoulder. A partial explanation could be frozen shoulder is also primarily driven by pain. Since the shoulder is painful, the patient tends not move his or her shoulder, and he or she will start to associate movement with pain. Consequently, the patient’s ROM decreases, fear-avoidance cycle begins, and he or she is potentially diagnosed with frozen shoulder. This fear-avoidance behavior seems to be a frequent common denominator behind many limitations of motion in many musculoskeletal diagnoses. Patients who present with decreased ROM will oftentimes score high on the fear-avoidance belief questionnaire (FABQ). However, those same patients will also have a lower FABQ score once they have been received education on pain, and they tend to have improved ROM after just one pain educational session. (Nagarajan & Nair, 2010). Pain neuroscience is beginning to be utilized frequently in musculoskeletal injuries, and it is even beginning to be utilized before orthopedic surgeries. In fact, patients who received pain neuroscience before and after musculoskeletal surgical interventions tend to require less medical intervention and medication one-year post op and utilized less pain medication. (Louw, 2018). I hope the use of pain neuroscience is something more patients receive in their therapy sessions in order to address patient’s pain from a top-down approach, decrease the use and reliance on medication, and, most importantly, promote movement and return to optimal function in their lives. 

References

  1. Nagarajan, M. & Nair, M.R. (2010). Importance of fear-avoidance behavior in chronic  non-specific low back pain. Journal of Back and Musculoskeletal Rehabilitation, 23, 87–95. 
  2. Louw, A., Puentedura, E., Schmidt, S., & Zimney, K. (2018). Pain neuroscience education: Teaching people about pain. International Spine & Pain Institute. Retrieved from: https://www.ispinstitute.com/wp-content/uploads/sites/4/2017/08/Pain-Neuroscience-Education.pdf
  3. Sharma, S. P., Bærheim, A., Moe-Nilssen, R., & Kvåle, A. (2016). Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care. BMC Musculoskeletal Disorders17, 1–10.