Divine is

the task to
relieve pain.
-Hippocrates

Prevention of Chronic Pain: A

Human Systems Approach

The Body
The Risk and Protective Factors
in the Musculoskeletal System

Dr. James Fricton

Professor, University of Minnesota (umn.edu)
HealthPartners Ins;tute for Educa;on and Research (hpier.org)
Minnesota Head & Neck Pain Clinic (mhnpc.com)
President, Interna;onal Myopain Society (myopain.org)

This module has 6 parts

Musculoskeletal Pain Mechanisms
Repe;;ve Strain
Postural Strain
Exercise for Range of Mo;on, Strength and
Condi;oning
Preven;ng Injuries
Experien;al Learning: Do the exercises

By the end of this module

you will be able to:
Ar;culate some of the mechanisms of
musculoskeletal pain
Explain how posture and repe;;ve strain can play a
role in chronic pain
Review how exercise can build strength, condi;oning
and range of mo;on to prevent musculoskeletal pain
Review how injuries can play a role in chronic pain
Perform ve dierent types of exercise to protect
you from chronic pain.

Module: The Body

Musculoskeletal Pain
Mechanisms

So where is the pain

coming from?

Musculoskeletal Afferent
Sensory Nerves
Type I muscle spindle (movement)
Responds to muscle length and velocity when
muscle contracted (a if muscle, b if tendon)
Type II stretch receptor (posture)
Responds to position sense when muscle or
joint is at rest
Type III Nociceptor (pain)
Responds to strain/ injury with continuous
pain (dull ache)
Type IV Nocicepter (tenderness)
Responds to strain/ injury with tenderness
Mense, 2004"

Mechanisms of Musculoskeletal Pain"

Sensitization: Increased synaptic efficiency due to
repeated firing of synapse at the peripheral and
central nervous system level"
Allodynia: An enhanced pain report from normal
stimuli"
!

Primary
!! hyperalgesia: Decreased threshold for pain
in an injured tissue"
Secondary hyperalgesia: Decreased threshold for
pain in the surrounding tissues"

Sensi;za;on

Hyperalgesia

Hyperalgesia is hypersensitivity to
pain that occurs directly
as a result
sensitization due to damaged
peripheral tissues or dysregulation
of the central nervous system

Peripheral
Sensi;za;on

Hypersensi;vity of nocicep;ve primary aerent neurons (pain

nerves) in the ;ssues
Mediators include bradykinin, prostaglandins, neuropep;des,
and cytokines
Upregulated (promoted) during inamma;on, injury, and
repe;;ve strain

Central
Sensi;za;on

Hypersensi;vity of nocicep;ve neurons in the central nervous

system (spinal cord and brain)
Mediators include glutamate through N-methyl-d-aspartate
(NMDA), substance P and calcitonin gene-related pep;de (CGRP)
Upregulated (promoted) during sustained pain and threat to
body

Wind-Up
An increase in pain over
time when a painful stimulus
is delivered repeatedly
above a critical rate.

Expanding Pain Pattern

As stimulation of the pain receptors from
the strain continues, the tissues let you
know it by expanding the pain pattern
through convergence facilitation.

First, tenderness (X)

Then, localized pain
Finally, referred pain

Body Realm

Protective Factors
Balanced posture
Relaxation exercise
Stretching exercise
Strengthening exercise
Conditioning exercise
Genetics

Risk Factors
Sustained or eccentric postures
Repetitive strain
Loss of flexibility and range of
motion
Weak muscles
Poor conditioning
Injuries
Conditions such as obesity and
hypo- or hyper-mobile joints

Module: The Body

Repetitive Strain

Repe;;ve Strain Injury (RSI)

An injury due to strain of the muscles
and joints from:
repe;;ve tasks (e.g. bracing phone)
forceful exer;ons (e.g. liUing)
Vibra;ons (e.g. equipment)
mechanical compression (e.g.
shoulder bag)
sustained or awkward posi;ons (e.g.
computer work)
and many other types of sustained
tension

Jaw

Occupational
RSI

2%
10%

28%
Hands

38%

12%

7%

Also called repetitive stress

injury, repetitive motion injuries,
cumulative trauma disorder
(CTD), occupational overuse
injury, overuse syndrome,
myofascial pain, and regional
musculoskeletal disorder.

Feet
http://www.safework.sa.gov.au

First, understand the muscles

Red Type I fibers

for posture
White type II fibers
for strength

Type I and II fiber types are distributed throughout all skeletal

muscles !

Muscle Fiber Type I

(red, slow)!
l Postural

muscle tone

l High

endurance

l Slow

twitch (red)

l High

oxidative
phosphorylation with high
O2, ATP production,
mitochondria, and
increased vascularity

l Marathon

runner

Muscle Fiber Type II

(white, fast)!
l Large

forces over brief

period"

l Low

endurance"

l Fast

twitch (white)"

l Anaerobic

glycolysis
with low O2, low
mitochondria, high
lactic acid"

l Sprinter

"

Muscle fibers are like chameleons!

Increased demand from high forces

for short periods
Type I (slow) !

Type II (fast)!

Increased demand from postural strain

for longer periods

Who wins?
Type I
Slow
posture

Type II
Fast
strength

With repetitive strain, muscle fibers of

type I compensates but often loses
Type I (slow) !

Type II (fast)!

Increased conversion due to repetitive

postural strain
Abnormal Metabolic Activity in Type I Fibers
l Low Oxygen and ATP (fuel depleted)
l Increased and ragged Type I Posture Fibers
l Decreased Type II strength fibers with atrophy
l Abnormal mitochondrial changes on EM on Type I"
l

-Larsson, et al, 1988, Bengsston, et al, 1986, Dennett, Fry, 1988"

"

The Slippery Slope of Chronic Pain

Acute to Chronic Muscle Pain"

Acute Muscle
Injury!
Peripheral Factors (e.g.
(injury, posture, trauma,
repetitive strain)!

High muscle tone and

PNS ! low removal of pain
alogens!

Central Factors (e.g.

inactivity, anxiety,
depression, sleep)!

Sensitization of
muscle
nociceptors!

Sensitization, wind-up,
expansion of receptor fields,
and hyperalgesia!

Convergence facilitation,
CNS ! broadening of pain and
more muscle strain!

Sensitization of
central processing!

Muscle pain and

repe<<ve strain

An injury starts
the pain cycle

Tensing due to
pain, inactivity to
avoid pain

Muscle strain
and more pain

Poor posture,
protect muscles,
weakness

Jaw pain and headache results from

Patients Gen. Pop.

Daytime Clenching
72.2 42.1
Night Clenching
66.7 32.2
Biting tongue/cheek
61.0 23.7
Jaw sore in A.M.
59.3 42.3
Tongue thrust
52.8 41.2
Night Bruxism
50.0 25.1
Unilateral Chewing
50.0 42.0
Daytime Bruxism
47.2 27.3
Biting nails/objects
30.6 28.4
Chewing Gum
27.8 18.2
musical instruments/ scuba/ singing
Fricton, et al J Orofacial Pain. 1996

Neck pain results from

Awkward tense computer posture
Bend or twist neck repeatedly
Look up or down for hours
Tense neck and shoulders
Brace phone with shoulder
Forceful arm movements
Holding arm in tense posture
Long duration of sitting
Twisting or bending of the trunk,
hand-arm vibration
Ariens GA et al Physical risk factors for neck pain. Scan J Work Environ Health.. (2000)

Back pain results from

Rotation or bending of the trunk
Lifting repeatedly by bending at waist
Heavy physical workload
Lack of exercise
higher body mass index
Prolonged sitting or standing
Monotonous work
Frequent manual operations
whole body vibration
Bjrck-van Dijken C1 et al J Rehabil Med.(2008), Kelsey JL,
Golden AL. Occup Med. 1988, Yilmaz E, Health Science
Journal, (2012)

Occupa;onal RSI
risk factors

Poorly designed workstation

Cluttered workstation
Cold setting
Awkward posture to work
Vibrating equipment
No rest or stretch breaks
Tripping on equipment and
cables

Douglas, AY et al American J of Preventive

Medicine (2009)!

Short-term and

Long-term

Module: The Body

Postural Strain

Do we only
have five
senses?

Proprioception and pain is the sixth sense..

designed to
protect us from
repetitive strain

Gallace A et al The analgesic effect of crossing the arms. Pain. (2011)

What is good
posture?

Body posi;ons that balance the musculoskeletal system

against gravity to reduce sustained muscle tension and
strain

Good posture is
Ecient. Lets you rest pain free in a
posi;on with a minimum of muscle
strain and energy expenditure.
Eec<ve. Facilitates ongoing
ac;vi;es in si^ng, standing,
walking, running, and others
Eortless. Allows a quick and easy
transi;on into the next relevant
movement.

And.
It makes one attractive and
attentive
It feels natural and relaxed
It is not about holding your
body still and tense
It does not require any extra
effort or constant attention.

and, its not

how it looks but
how it feels that
counts

Good sitting body

mechanics can
prevent;

back pain
pelvic pain
knee pain
neck pain
arm pain
Headaches
hand pain!

Si^ng Posture
Head up and back
Shoulders down
and back

Sit with boFom to back

of chair

Jaw posture

Tongue up
Teeth apart
Jaw relaxed
Lips open or closed

The head is heavy

12 lbs

32 lbs

12 lbs

42 lbs

30 lbs

if its not balanced on the neck chin in, shoulders

back, and chest up

Walking Posture

Sleeping Posture

Somewhere, something went terribly wrong

Module: The Body

Exercise

Exercise is
the original
protector

Five types of
exercise
Musculoskeletal Goal

Exercise Strategy

Range of motion

Stretching and yoga

Strength

Weights and resistance

Endurance

Conditioning and aerobic

Balance

Maintaining posture

Reduce repetitive strain

Relaxation

Range of motion: we all try to maintain it

Yoga is dynamic stretching

Significantly improved;
pain
quality of life
disability
stress
depression
medication usage
in 8 of the 10 chronic
back pain clinical trials

Diaz AM, et al. American

Journal of Lifestyle
Medicine April 16, 2013

Principles of
Stretching

Do it slowly, gently and frequently (several times per day)

Stretch to pain but not beyond. Feel each of muscle being
stretched.
Push to full joint range of motion and hold it. Count to 20.
Breath slowly and deeply as you stretch.
Do not hurry or bounce with the stretch. Hold it steady

Strengthening: Use it or lose it

Strengthening to
prevent chronic back pain
More effective than no exercise.
Increasing intensity and motivation increases results.
Strengthening equal to conditioning and stretching
exercises.

Systematic Reviews. Bell J, et al J. of Occupational Medicine (2010) and Slade SC et al J.

Manipulative and Physiological Therapeutics (2006)

Condi;oning for chronic pain

Significantly improved;
Pain
Function
Quality of life
Disability
Psychosocial status
9 systema;c reviews,
comprising a total of 224 trials
and 24,059 pa;ents with
bromyalgia, osteoarthri;s,
rheumatoid arthri;s, back,
neck and shoulder pain
Hagen et al BMC Medicine 2012

High Intensity Interval Training

Module: The Body

Preventing Injury

Abuse it and
lose it

Delayed-onset muscle
soreness

Post-exercise muscle pain

Normal response to unusual
exer;on
Adapta;on process that leads
to greater stamina and strength
Muscles recover and build
strength and bulk

Distinguishing muscle injury

from post-exercise muscle soreness
Muscle or Joint Injury

Delayed Onset Muscle Soreness

From pulled, torn, strained or

sprained muscle or joint

From post-exercise, over-exer;on,

and over-use

Abrupt onset

Gradual pain aUer exercise

Sharp localized pain

Diuse soreness over most of

muscle or joint

Inability to con;nue the ac;vity

and cannot put force on it

Can con;nue if choose and can put

force on it

Weakness,, tenderness, and

No weakness, no swelling, no
bruising, can con;nue the ac;vity

swelling and bruising

No surface signs of injury

Preventing
Sports Injuries

Warm-up exercises cut knee injuries by 50%

among female college soccer players
Dynamic warm-up exercises with a gentle walk or
jog then static stretching to increase the range of
mo;on of various joint
www.aclprevent.com/pepprogram.html

Preventing injuries from becoming

chronic
Not R.I.C.E.
Rest, Ice, Compression and
Elevate


Use M.E.A.T.
Movement, Exercise,
Analgesics and Treatment

Identify co-morbid conditions can lead to

chronic pain

Obesity
Hyper-mobile joints
Osteoarthritis
Rheumatoid arthritis
Auto-immune disorders
Migraine
Diabetes
Depression and Anxiety
Addiction including tobacco
Many more

Trigger Point Massage

The Knobble

http://www.pressurepositive.com

Take Home:
Love the body you are in

1. Give yourself permission to love

your body.
2. Celebrate one thing you love
about your body.
3. Send love to your troubled
body parts.
4. Find the cosme;c balance.
5. Dont verbally cri;cize your body.
6. Accept what you cannot change,
then forget about it.

http://empoweredsustenance.com/love-your-body/!

The Body: Take Home

1. 90/10 rule. 90% protective factors, 10% risk factors.
2. Posture. Live balanced against gravity
3. Strain. Relax when using your muscles
4. Exercise. An hour per day, six days a week.
5. Cross train. Stretching, conditioning, and strengthening.
6. Massage. Identify and reduce trigger points
7. Track. Monitor pain, range of motion, steps, calories, blood
pressure, heart rate, workouts, and other health measures.
8. Be positive. Its all about your energy

Now, just do it
watch the videos
do the exercises