Hello and Welcome!

I am excited to present to you the second edition of the Practical Pain Science newsletter. If you would like to learn more about why I created this newsletter then check out the first issue HERE.

Dr. Orit Hickman, PT, DPT, TPS

I am so excited to continue to help you have practical information at your fingertips as you treat patients with persistent pain. I received wonderful feedback after the last newsletter so please keep it coming.

Learning about allodynia and hyperalgesia were so critical to my work with patients with persistent pain. In the last issue I outlined the three different types of pain that can be experienced by patients who have pain in the musculoskeletal system-- nociception, peripheral neuropathic and nociplastic. If you would like to check it out again then go HERE.

Once I understood that nociplastic pain (sometimes called central sensitization and sometimes called neuropathic pain as in the below cited article) was a real thing I needed to find a way to get buy in and understanding from my patients.

Before I decided to become a PT I had my sights set on law. So it must come naturally that I always think about mounting evidence when I am making a case about a diagnosis. In the case of nociplastic pain, it is usually very easy to make the diagnosis based on patient history, but this doesn't convince a patient. Being able to test and show a patient that something they are experiencing is outside the norm is really important. For movement patterning we can do this easily by using a mirror and having a patient demonstrate a movement on the unaffected then affected side. For strength the patient can usually feel the differences side to side. For nociplastic pain I am looking to test for hyperalgesia, hyperesthesia and allodynia.

Allodynia is when a person experiences pain from a sensory input that should not cause pain. For example, a patient might describe that a bed sheet against their foot is painful or they can not tolerate the waist band of their jeans against their back. OR they might say that they cannot lean against a surface in sitting or they feel the seams of the chair they are sitting on is bothering them and causing pain.

Hyperesthesia is when the CNS magnifies sensory information. Examples of this can be when testing vibration sensation and a patient lets me know they feel the vibration up their entire leg into their low back but the tuning fork is down on their shin.

Hyperalgesia is also magnification by the CNS but it is a magnification of the pain response or when the pain response seems magnified and is much louder than what you would expect. For example you test a patient's pain pressure threshold and at 2 pounds of pressure at their shin they experience significant pain that continues long after you remove the device.

One of the best resources I have found for terminology definitions is the International Association for the Study of Pain (IASP). There are free resources on the site to help define the different pain and sensory experiences that patients are having.

This article below tries to more clearly define the differences between allodynia and hyperalgesia. In the following sections I will try to give you more clear clinical testing and evidence to help you with the diagnosis of nociplastic pain.

• Article defining allodynia

In this video I outline how to test for hyperalgesia and allodynia with patients that you suspect might have nocicplastic pain. Please forgive me for it being backwards-- I totally forgot to flip it before uploading it to my YouTube channel!

Check out issue no. 1 HERE to read through the original case study.

During the evaluation of the patient outlined in Issue no. 1, assessment of hyperalgesia and allodynia were done. During the patient history the patient described having frequent flare-ups that did not link to any specific activity. They would comment that if they "did too much" they would flare up but were not able to clearly quantify "too much." In fact they had a really difficult time correlating activity to pain yet were highly afraid of most movement. Due to the history of having pain that didn't correlate with activity, flare ups and pain that moved around, nociplastic pain was suspected as the primary pain.

In order to build evidence that the diagnosis of nociplastic pain was correct, sensory testing was performed to assess for hyperalgesia and allodynia.

Findings were as follows

1. Pain Pressure thresholds around the low back were 2-3 lbs of pressure before the patient experienced pain
2. Light touch with the heaviest monofilament felt numb to the patient while light touch with the lightest monofilament felt sharp per patient report
3. The patient reported that when they drove and walk they had pain so vibration testing with a tuning fork was done on the heels, shins and patella without any significant increase in discomfort or pain. More aggressive vibration testing was done through the heels by taking my hand and gently smacking the heels on each leg. The patient reported feeling pain in their low back with this activity.

All findings were explained to the patient in depth.

In the next issue I will discuss some treatment approaches to nociplastic pain.

Pain Science Physical Therapy will be hosting Dr. Joe Tatta and Dr. Jeremy Fletcher for a 2 day course addressing mental flourishing in physical therapy (how to prevent burnout and continue to thrive as a clinician in this changing medical field!). This course will be a 2 day LIVE event April 27th-28th. This class will be limited to 20 participants since interaction is key to the learning process and objectives of the course. If you are interested in learning more and/or reserving your spot then go HERE. At the end of this course you will have earned 14 CEUs in Washington state.

Pain Science Physical Therapy is an outpatient community based woman-owned clinic located in Burien, WA. We treat patients 1:1 utilizing pain science to help diagnose and treat patients with persistent pain. Learn more about our clinic at www.painsciencept.com