240 – Jo Nijs how sleep affects pain perception

Dr. Nijs holds a PhD in rehabilitation science and physiotherapy and also has a master of science in physiotherapy and rehabilitations sciences as well as in manual therapy.

He is currently a associate professor at the Vrije Universiteit Brussel (in Belgium), and a practicing physiotherapist at the University Hospital Brussels, and holder of the Chair ‘Exercise immunology and chronic fatigue in health and disease’ funded by the European College for Decongestive Lymphatic Therapy.

Dr. Jo Nijs, PhD also runs the “Pain in Motion” research team and a physiotherapy-based treatment program for patients with chronic pain at the University Hospital in Brussels. His research and clinical interests are patients with chronic ‘unexplained’ pain and fatigue and the interactions between pain and movement, with a special emphasis on the central nervous system. The primary aim of his research is improving physiotherapy based care for patients with chronic pain. He has co-authored more than 150 peer reviewed publications.

Without further ado, here are 20 quotes from physiotherapist Dr. Jo Nijs, PhD:

“It is well established that the biomedical model falls short in explaining chronic musculoskeletal pain. Although many musculoskeletal therapists have moved on in their thinking and apply a broad bio- psychosocial view with regard to chronic pain disorders, the majority of clinicians have received a biomedical-focused training/education. Such a biomedical training is likely to influence the therapists’ attitudes and core beliefs toward chronic musculoskeletal pain. Therapists should be aware of the impact of their own attitudes and beliefs on the patient’s attitudes and beliefs.” Dr. Jo Nijs, PhD

“Self-reflection is required for the musculoskeletal health care professionals, even for those who have moved on in their thinking. Indeed, it has been demonstrated that previous (biomedical oriented) treatment by physiotherapists is a risk factor for long- term sick leave in patients with low back pain” Dr. Jo Nijs, PhD

“Therapists should become aware that focusing on the biomedical model for chronic musculoskeletal pain is likely to result in poor compliance with evidence based treatment guidelines, less treatment adherence, and poorer treatment outcome” Dr. Jo Nijs, PhD

“Chronic musculoskeletal pain is a complex and challenging medical problem. Therefore, it is a challenging issue for researchers and clinicians, including manual therapists. Over the past decades, scientific understanding of chronic musculoskeletal pain has increased substantially.” Dr. Jo Nijs, PhD

“In contrast to the increasing evidence for the biopsychosocial model for chronic musculoskeletal pain, the majority of clinicians have received a biomedical-focused training/ education. The biomedical focus applies in part to the manual therapy profession as well, with a long history of biomechanical- focused treatments. Such a biomedical training is likely to shape the therapists’ attitudes and core beliefs toward chronic musculoskeletal pain, as evidenced by a randomized trial comparing biomedical versus biopsychosocial training about low back pain in physiotherapy students” Dr. Jo Nijs, PhD

“It is advocated to be cautious with stabilization exercises when patients have moderate or high fear of movement, as such therapy might trigger more (kinesio)phobic (“I have to keep my back always stable and I am therefore not allowed to move my back”) and catastrophic thoughts (e.g. “If I do not continuously activate my stabilization muscles, my back will be prone to severe injuries.”)” Dr. Jo Nijs, PhD

“Pain neuroscience has taught us that pain can be present without tissue damage, is often disproportionate to tissue damage, and that tissue damage (and nociception) does not necessarily result in the feeling of pain. Unfortunately patients are often not aware of these facts and stick more to a biomedical model in which they keep on searching for a structural cause of their pain and consequently the “magic bullet” to solve their problem. This may result in low self-efficacy, unrealistic or inappropriate therapy expectations and huge therapy barriers.” Dr. Jo Nijs, PhD

“Only patients dissatisfied with their current perceptions about pain are prone to reconceptualization of pain 16-18 This implies that therapist should question the patient’s pain perceptions thoroughly prior to commencing pain neuroscience education. Even though their pain perceptions lack medical and scientific validity, patients are often satisfied with them. In such cases, it is necessary to question whether the patient can think of other reasons / underlying mechanisms for their pain rather than lecturing about pain mechanisms. It makes no sense to impose concepts and certain behaviours if the patients does not comply with them or believe in it. “ Dr. Jo Nijs, PhD

“When healthy people start to exercise, the brain activates powerful descending analgesic systems (pain inhibitory actions). This leads to increased pain thresholds during exercise, making it less likely that we will feel pain during, or immediately following, exercise.  However, brain-orchestrated analgesia or pain inhibition is often impaired in people with chronic pain and central sensitization.” Dr. Jo Nijs, PhD

“The precise mechanism underlying the dysfunctional response of the central analgesic systems to exercise in some patients with chronic pain remain to be revealed, and are the subject of ongoing research. If we understand it better, we might be able to treat it, which in turn should lead to more effective exercise therapy for these patients.” Dr. Jo Nijs, PhD

“Aerobic exercises like bicycling do not activate brain-orchestrated analgesia in patients with fibromyalgia, chronic whiplash associated disorders, or chronic fatigue syndrome. Remarkably, chronic low back pain patients are able to activate their brain-orchestrated analgesic systems normally during exercise.” Dr. Jo Nijs, PhD

“Pain neuroscience education intends to transfer knowledge to chronic pain patients, thus allowing them to understand their pain and create adaptive perceptions and improving their ability to cope with their pain. Pain neuroscience education implies teaching people about the underlying mechanisms of pain, including how the brain produces pain. Much attention is paid to the fact that pain is not always the consequence of damage and that, definitely in the case of persistent pain, the pain is due to enhanced central pain processing rather than structural damage.” Dr. Jo Nijs, PhD

“Understanding pain this way, decreases its threat value, leading to more effective pain coping strategies1,2. We and others have shown that pain neuroscience education is effective in changing pain beliefs, improving health status and reducing health care expenditure in adult patients with various chronic pain disorders” Dr. Jo Nijs, PhD

“Central sensitization is frequently present in a variety of chronic disorders like fibromyalgia, chronic whiplash associated disorders, osteoarthritis, irritable bowel syndrome and some cases of chronic low back pain. In the late nineties, it was first hypothesized that chronic fatigue syndrome (CFS) is characterized by central sensitization as well.” Dr. Jo Nijs, PhD

“Many people with CFS feel most comfortable attributing their illness to a disorder of the central nervous system, and this seems to be rational given the cluster of symptoms that occur in the illness. Symptoms like fatigue, non-refreshing sleep, concentration difficulties, impairments in short-term memory, sensitivity to variable stimuli like bright light and chemicals, a decreased load tolerance and widespread pain are suggestive of central nervous system involvement.”  Dr. Jo Nijs, PhD

“Central sensitization in CFS corroborates with the presence of several psychological influences on the illness, the presence of infectious agents and immune dysfunctions, and the dysfunctional hypothalamus pituitary adrenal-axis as seen in these severely debilitated patients. This is important for an illness with a long history of disagreement between scientists.” Dr. Jo Nijs, PhD

“Even though the content of pain neuroscience education is backed-up by a body of scientific literature, it should apply to the patient’s situation/pain. For instance, if you include the mechanism of central sensitization in your pain neuroscience education for a particular patient, then you want to be 100% certain that this patient is having a clinical picture dominated by central sensitization” Dr. Jo Nijs, PhD

“To move on in the model of the “stages of change”, it is important that the concept is beneficial for the patient. This means that the patient will only be open to new ideas if they lead to opportunities. Therefore, the pain education should be offered as a physiological explanation for their complaints. As patients often search for a biomedical explanation and the people in a patient’s  environment tends to classify the pain more as psychosomatic, pain education builds the bridge in between. “ Dr. Jo Nijs, PhD

“Physiotherapists often see patients with fibromyalgia (FM) in primary care. However, guidelines for the treatment of FM are based primarily on outcome from multidisciplinary and tertiary care treatment studies. This leaves primary care physios wondering: can I actually help these patients or should I send them directly to a specialized centre for multidisciplinary care? The latter is not always possible due to the limited availability of such centres and the long waiting lists. “ Dr. Jo Nijs, PhD

“Primary care physical therapy for patients with FMS should include (pain physiology) education, aerobic exercise, and strengthening exercise. For other treatment components like passive treatments, activity management and relaxation, less evidence is currently available to advocate its use in primary care physical therapy. Superior results are to be expected when various treatment components are combined. “ Dr. Jo Nijs, PhD