Pijnrevalidatie- een nieuw concept -

15 november 2013, Utrecht

Ernst van der WijkErasmusMC

‘

Sensitisatie

(Gemodificeerd uit van Wilgen, Nijs 2010)

Train the brain to lessen chronic pain – Moseley, 2012

Affaitati G, Costantini R, Fabrizio A, Lapenna D, Tafuri E, Giamberardino MA. Effects of treatment of peripheral pain generators in fibromyalgia patients. Eur J Pain. 2011 Jan;15(1):61-9. Aguilera FJ, Martin DP, Masanet RA, Botella AC, Soler LB, Morell FB. Immediate effect of ultrasound and ischemic compression techniques for the treatment of trapezius latent myofascial trigger points in healthy subjects: a randomized controlled study. Journal of manipulative and physiological therapeutics. 2009 Sep;32(7):515-20. PubMed PMID: 19748402. Ajimsha MS. Effectiveness of direct vs indirect technique myofascial release in the management of tension-type headache. J Bodyw Mov Ther. 2011 Oct;15(4):431-5. doi: 10.1016/j.jbmt.2011.01.021. Epub 2011 Feb 11 Ajimsha MS, Chithra S, Thulasyammal RP. Effectiveness of Myofascial Release in the Management ofLateral Epicondylitis in Computer Professionals. Arch Phys Med Rehabil Vol 93, April 2012 Alonso-Blanco C, Fernandez-de-las-Penas C, Morales-Cabezas M, Zarco-Moreno P, Ge HY, Florez-Garcia M. Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. The Clinical journal of pain. 2011 Jun;27(5):405-13. PubMed PMID: 21368661. Anderson RJ, McCrae CS, Staud R, Berry RB, Robinson ME. Predictors of clinical pain in fibromyalgia: examining the role of sleep. J Pain. 2012 Apr;13(4):350-8. Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005 Jul;174(1):155-60 Apkarian AV, Hashmi JA, Baliki MN. Pain and the brain: specificity and plasticity of the brain in clinical chronic pain. Pain. 2011 Mar;152(3 Suppl):S49-64. Apkarian AV,*, M. Catherine Bushnell b, Rolf-Detlef Treede c, Jon-Kar Zubieta.Human brain mechanisms of pain perception and regulation in health and disease Eur J Pain. 2005 Aug;9(4):463-84. Epub 2005 Jan 21. Arendt-Nielsen L. From basic science to management of chronic musculoskeletal pain. In: Mogil J, red. Pain 2010, an updated review. Seattle IASP: Press, 2010: 73-86.

Fernandez-Carnero -2009 - Widespread Mechanical Pain Hypersensitivity as Sign of Central Sensitization in Unilateral Epicondylalgia

Shah JP – 2008 - Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: An application of muscle pain concepts to myofascial pain syndrome

Ge H-Y – 2011 - Reproduction of overall spontaneous pain pattern by manual stimulation of active myofascial trigger points in fibromyalgia patients

Davis KD – 2012 - Central Mechanisms of Pain Revealed Through Functional and Structural MRI

This revealed a widespread mechanical hypersensitivity in patients with lateral epicondylalgia, which suggest that central sensitization mechanisms are involved in patients with unilateral lateral epicondylalgia.

The generalized decrease in Pressure Pain Threshold levels was associated with elbow pain intensity, supporting a role of peripheral sensitization mechanisms in the initiation or maintenance of central sensitization mechanisms.

In addition, females may be more prone to the development of generalized mechanical hypersensitivity.

Shah JP – 2008 - Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: An application of muscle pain concepts to myofascial pain syndromeVerlaagde zuurstofspanning:

Verstoord biochemisch milieu: hoge concentraties: protonen (lage pH), bradykinine, kaliumionen, substance P, etc.

Expanded integrated trigger point hypothesis

Oorzaak: Overbelasting (bio-psycho-sociaal)

- Verhoogde spanning thv motorische eindplaat- Energiecrisis – ‘minikramp’- Aanhoudende nocisensoriek

- Perifere sensitisatie

(Bron 2012, Dommerhold 2011, Gerwin 2004, Gold 2010, Simons 2008)

- Centrale sensitisatie

Ge H-Y – 2011 - Reproduction of overall spontaneous pain pattern by manual stimulation of active myofascial trigger points in fibromyalgia patients

- The overall spontaneous FM pain pattern can be reproduced by mechanical stimulation of active MTPs located in different muscles

- These results suggest that active MTPs are the major peripheral pain generators in FM

- Injections of anesthetic into multiple MTPs reverse mechanical hyperalgesia and decrease overall pain intensity in patients with whiplash and FM

- Active MTPs can serve as potent ongoing peripheral nociceptive inputs initiating and maintaining central sensitization in FM

SensitisatieNocisensoriek

(Affaitati 2011, Alonso-Blanco 2011, Ahrendt-Nielsen 2010, Baron 2013, Borg-Stein 2002, Coronado 2012, Farmer 2012, Fernandez-Carnero 2009, Fernandez-de-las-Penas 2009, Freeman 2009, Ge 2011, Gerwin 2013, Gold 2010, Jespersen 2013, Lim 2012, Price 2009, van Rooijen 2013, Skou 2013, Staud 2009 2011, Verne 2003, Vierck 2006, Woolf 2007, Xu 2010)

Peripheral changes seem critical to both induce and maintain central sensitisation. (Bron, 2013)

m.u.v. fantoompijn en somatoforme stoornis

Davis KD – 2012 - Central Mechanisms of Pain Revealed Through Functional and Structural MRI

neuroimaging has shown that the brain not only undergoes plasticity associated with chronic pain but also has the capacity to normalize after effective therapies.

(Apkarian 2004 ,2011, Baliki 2011, Burgmer 2009, Ceko 2012, Davis 2012, Farmer 2011, Gwilym 2010, May 2008, Moayedi 2013, Mordasini 2012, Obermann 2009, Puretic 2012, Robinson 2011, Rodriguez-Raeke 2009, 2013, Schmidt-Wilcke 2010, Seminovicz 2011, Stankewitz 2013, Teutsch 2008)

Bij chronische pijn speelt centrale sensitisatie een belangrijke rol

Welke perifere bronnen van nocisensoriek zijn er?

Nocisensoriek is nodig voor sensitisatie

Fascia

The missing link?

Fascia is the largest sensory organ

“This suggests that fascia rather than muscle tissue is important in Delayed Onset Muscle Soreness (DOMS) associated sensitisation.”

• (Gibson, 2009)

“These findings show that the thoracolumbar fascia is the deep tissue of the back that is most sensitive to chemical stimulation, making it a prime candidate to contribute to nonspecific LBP.”

(Schilder, 2013)

(Corey 2011, Deising 2012, Gibson 2009, Hoheisel 2009, 2013, Lindsay 2008, Schilder 2013, Schleip 2012, Stecco 2007, 2010, 2013, Tesarz 2011, van der Wal 2011, Willard 2012)

Langevin HM, Stevens-Tuttle D, Fox JR, Badger GJ, Bouffard NA, et al. (2009) Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Musculoskelet Disord 10: 151.

• Ultrasound imaging has revealed that altered thoracolumbar connective tissue thickness and echogenicity are associated with chronic low back pain, suggesting the presence of inflammation or fibrosis

(Bednar 1995, Corey 2012, Langevin 2009, Schoots 2013, Stecco 2010)

Habituatie of Sensitisatie?

(Mense 2008, Roussel 2013, Staud 2010, 2012)

Behandelmodel

Pijnintensiteit afhankelijk van:

1) Conditie van het weefsel

2) Gevoeligheid van het zenuwstelsel op dat moment

3) Mate van belasting

Onbegrepen klachten

Somatisch onvoldoende verklaarde lichamelijke klachten (S.O.L.K.)

Vage klachten

(Anderson 2005, Bakker 2011, Chaitow 2002, Chaleye 2009, Edmonson 2008, Jones 2010, Litchfield 2003, McLaughlin 2011, Mehling 2005, Perri 2004, Zautra 2009)

Ademhaling

Autonome zenuwstelsel

EmotiesImmuunsysteem

BloeddrukStabiliteit

Gasuitwisseling

Houding

Energie

SpijsverteringPijn

(ont)spanning

Trigger points

Trigger point behandeling

- Manuele behandeling- Instrument assisted trigger point treatment- Dry needling- Wet needling

- Oorzaken wegnemen

(Bron 2011, Cagnie 2013, Dommerholt 2011, Gautschi 2011, Giamberardino 2011, Maher 2013, Mense 2008, Tekin 2013 etc.)

Fasciatechnieken

Fasciatechnieken

"Approaching the fascia requires a different eye,a different touch and

tissue-specific techniques" (Thomas Myers)

Fuzz speech

Verschillende op fascia gerichte therapieën en technieken:

Myofascial release (MFR)Active Release Therapie (ART)Positional releaseFascial manipulationTotal motion releaseFascial distortion modelMyoskeletal Treatmentthe MELT methodNeuromuscular TechniqueInstrument assisted soft tissue mobilization (IASTM) / Graston technique

(te combineren met andere technieken als P.N.F. en Musle Energy Techniques)

(Abelson 2012, Chaitow 2006, 2007, 2011, Dalton 2005, Day 2009, Earls 2010, Ferguson 2005, Findley 2011, Gautschi 2011, Gehlsen 1999, Hammer 2007, Hitzmann 2013., Loghmani 2009, Looney 2011, Luchau 2012, Myers 2010, Pedrelli 2008, Riggs 2012, Rolf 1989, Schleip 2011, Simmonds 2012, Smith 2005, Stanborough 2004, Stecco 2009, 2013, Tozzi 2011 etc.)

Ernst van der Wijk - 2013 28

dp = dysfunctional + paindn = dysfunctional – no painfp = functional + painfn = functional – no pain

(Gemodificeerd van Cook 20011)

Ernst van der Wijk - 2013 29

dp = dysfunctional + paindn = dysfunctional – no painfp = functional + painfn = functional – no pain

(Gemodificeerd van Cook 20011)

Unlike muscle, fascia – once it is successfully lengthened –

does not ‘snap back’ into place.

Ernst van der Wijk - 2013 31

Doelen myofasciale behandeling:

– normaliseren afferente input (coördinatie, sensitisatie)

– herstellen mobiliteit– herstel glijvlakken– maximale veerkracht– bewegen met minder energie– normaliseren spierspanning– verbeteren autonome balans

study of anatomy - study of symptomsstudy of function - study of causes

There is a growing body of evidence to support the relationship between uncontrolled movement and symptoms (Dankaerts 2006, Luomajoki 2008, van Dillen 2009)

Contemporary research clearly demonstrates that individuals with pain present with aberrant movement patterns (Dankaerts 2006, 2009, Falla 2004, Ludewig & Cook 2000, O’Sullivan 1998)

(Comerford, 2013)

( Comerford 2013, Falla 2012, Hodges 2011, Jull 2008, Langevin 2007, Le Perra 2001, Nijs 2012, O’Sullivan 2003, Panjabi 2006)

Verstoorde coördinatie door:

- nocisensoriek (bv van trigger points)

- verstoorde proprioceptie (gewrichten, fascia)

- mobiliteitsbeperkingen (gewrichten, fascia)

- verhoogde sympaticotonus

- bewegingsangst

The clinical consequence of the shift in thinking is to stop trying to restore normal motor control in case of chronic nociception.

(Nijs 2012)

How do we best train to prevent damage and build elasticity and resilience into the system?

(Müller 2011, Myers 2011, Schleip 2012)

Veerkracht is vitaliteit!

When body tissues are restored to their ideal level of tone and balance, they are able to withstand tremendous forces and resist the tendency

to become seriously injured in the first place. (George Roth, 2005)

Praktijkopleiding fasciatherapieFasciaweb.nl