Dr Julie ZarifehSenior Clinical Psychologist

Professional Practise Fellow

CDHB

University of Otago

Dr Chris HoffmanOrthopaedic Surgeon

Auckland

14:00 - 16:00 WS #12: Pain Symposium

16:30 - 18:30 WS #17: Pain Symposium (Repeated)

Mr Chris GreggPhysiotherapist

TBI Health

Wellington

Chronic Pain = Reassurance

Chris Hoffman

Spine Surgeon

The Problem..

• Chronic Musculoskeletal Pain▪ One of the most common reasons to visit the GP

▪ Untreated => depression, poor quality of life and loss of independence

• Often begins with an acute nociceptive event▪ Majority of episodes are short and self limiting

• Why do some persist?▪ Causes are multi-factorial

▪ An individuals genetics and neurophysiology have a role

Most patients with pain see their health care professional because:

• they are in pain and they want it to stop.

• they will be worried and they need reassurance.

• they want information about the source of the pain and the prognosis.

RCT - UCLA Back Pain Study

• GP vs Chiropractor treatment

• Clinically equal outcome

• But more satisfied with Chiro

• 2 reasons

- Receipt of self care advice

- Explanation of treatment

Hurwitz EL et al, Spine 2006 Mar 15;31(6):611-21

BioPsychoSocial Model

• Hurt vs Harm

• Illness vs Disease

• Activity vs Rest

Classification of Chronic Pain

Can be based on major pain features or body region

• Musculoskeletal (mechanical)

• Myofascial

• Neuropathic

• Fibromyalgia

• Chronic headache syndromes

• BMJ Best Practice – Chronic Pain

Classification of Chronic Pain

Can be based on major pain features or body region

• Musculoskeletal (mechanical)

• Myofascial

• Neuropathic

• Fibromyalgia

• Chronic headache syndromes

• BMJ Best Practice – Chronic Pain

Acute vs Chronic Pain

Chronic Pain Disorders

Chronic Pain Disorders

Chronic Pain Disorders

New Term = “Nociplastic” pain

• International Association for the Study of Pain

• Pain arises from altered nociception

• Can follow on from acute nociceptive pain

• Impact on patient

• Impaired physical function / Disability

• Person / Social setting / Work setting

Pain or Disability?

• Pain is not disability.

• The focus is resolving the disability not resolving the pain.

• Disability resolution needs both behavior and cognitive therapies.

• Determine the underlying mechanical triggers

Regions affected

• Back pain (53%)

• Headache (48% - ?cervical / muscular)

• Joint pain (46%)

• When re-evaluated in 12 months 46% persist

Focus on 4 common areas

• Cervical Spine pain

• Lumbar Back pain

• Shoulder joint pain or instability

• Knee pain

Trauma?

• Often a triggering event

• Particularly in NZ = ACC

• Needs to be a history of application of external force

• Problem is age related degenerative changes

Degenerative?

• Age-related change

• Normal range of aging

• Life-style / genetics

Cervical / Lumbar

• Patterns of pain

▪ Neck/Back Dominant• Consider Red Flags

▪ Arm/Leg Dominant• Radicular pain

• Radiculopathy?

• Most resolve quickly

• Most can be treated without imaging

• Red Flags

▪ Constant Pain

▪ Significant Trauma

▪ Myelopathy

▪ Cauda Equina Syndrome

▪ History of Cancer – wt loss

▪ Fever

Pattern 1 – Flexion Pattern 2 - Extension

History = Back Dominant

• Back or Buttock

• Worse with flexion

• Constant or Intermittent

Back Pain

History = Back Dominant

• Back or Buttock

• Worse with Extension

• Always Intermittent

• Never worse with flexion

Pattern 4 - Stenosis

History = Leg Dominant

• Below the Gluteal Fold

• Pain affected by back movement

• Previously/currently constant

History = Leg Dominant

• Leg pain worse with activity

• Leg pain better with position

• Intermittent

Pattern 3 - Sciatica

Pain Pacifying Strategies

Learn how to

do the Sloppy

Push-Up.

Learn how to

do the Knees-

to-Chest

Stretch and the

Pelvic Tilt.

Proper

positioning to

minimize your

leg pain during

the first few

days.

Embark on a

long-term

strengthening

program,

focusing on the

abdominal

muscles.

Pattern 1 Pattern 2 Pattern 3 Pattern 4

Shoulder Pain

• History of Trauma

• Episodes of instability

▪ Yes – Xrays

▪ Fracture/instability =>refer

• Cuff injury

▪ Yes – Ultrasound

▪ Massive tear =>refer

• Red Flags

▪ Unexplained swellings

▪ Significant weakness

▪ History of Cancer

▪ Fever

▪ Any Pulmonary or Vascular compromise

Shoulder Pain

• Rotator Cuff Tear

▪ Minor <5cm or single tendon

• Sub-acromial Bursitis

• Osteoarthritis

• Frozen Shoulder

• Initial referral for rehab

Knee Pain

• History of Trauma

▪ Meniscal / ligament injury

• Anterior Pain

▪ Tendinopathy Bursitis• Ultrasound

• Osteoarthritis

▪ Xray ?severity

▪ Pain vs degree of OA ?

• Red Flags

▪ Unexplained mass / swellings

▪ Erythema / Fever

▪ New deformity

Knee Pain and Degree of OA

• High Pain / Low Pain Pain Stimulated =

• Mild OA / Severe OA Measure Sensitization

• High Pain / Mild OA = Central sensitization

• High Pain / Severe OA = ?inflammatory

• Low Pain / Mild OA = Appropriate response

• Low Pain / Severe OA = Resilient ?how

• Finan P et al Arthritis Rheum 2013 Feb 65(2) 10

Why am I still in pain?

• Resolution of the nociceptive pain • “Mal-adaptation” to ongoing pain • Nociplastic pain becomes the problem

• Analogy – Priming of immune response▪ Stimulus has triggered response▪ System changes – now responds to normal stimulus▪ Treatment? – “re-train the guard dog”

• Ensure no further mechanical stimulus• Normalize Activity /Exercise • Focus on reducing disability

Pain self management

Aim

Try to explain the nebulous concept of pain self management

Reception calls: Unscheduled appointment for 4:30pm.

Ongoing pain.

“Right! I will send you to the pain clinic, they will help you”

Dear doctor,

Thank you for your referral. We have triaged your patient for a comprehensive pain assessment.

Our waiting list is currently 1 year.

While you wait you raid the cupboards.

Put out fires, one at a time.

Dear doctor,

I saw your patient in pain clinic…. He has chronic pain….Please reduce his medication.I have not made further follow-up plans.

Yours Sincerely

Reception calls: Unscheduled appointment for 4:30pm.Ongoing pain.

What do they do in pain clinic?

New Zealand Health Survey 2011/12, 16% of adults reported chronic pain (defined as pain that occurs every day, for

at least 6 months)

That is about 600,000 adults

1 year

12 months

52 weeks

365 days

8760 hours

People with long term health conditions spend about 3 hours a year with their health professional

The remaining 8757 hours they are on their own

600,000 people X 8757h = a lot of hours alone

Solution = patient takes care of themselves

Pain Self Management

What is pain self management?

• What it is NOT▪ It is not medication▪ It is not physiotherapy▪ It is not psychological

support▪ It is not a surgical procedure▪ It is not something done to

the patient▪ It is not coping – your

patients are already doing it

Manage pain by choosing

ACTIVE

and sustainable strategies to

target the areas affected by pain.

What is pain self management?

Active pain management skills

1. Good sleep hygiene to improve sleep

2. Limiting rest

3. Establish regular physical activity

Educational component

• Education around why pain persists

• Collaborative goal setting

• Coping skill acquisition▪ Physical – activity pacing, graded

exposure▪ Psychological – relaxation, attention

regulation, communication, problem solving, cognitive restructuring

Learning to self manageIt is like driving a car

Where does the instructor sit?Where does the learner sit?

That’s so hard!Are you sure there are no medication

or injection to try?

High dose opioids – No high quality evidence Methadone – No conclusion can be madeTapentadol – further studies neededPregabalin – note effective in chronic conditions which nerve damage is not the prime source of painGabapentin and pregabalin in preventing migraine attacks – not effectiveAntidepressives for NSLBP – No evidenceMuscle relaxants for NSLBP – short term relief, adverse effects require cautionNSAIDS for NSLBP – Short term relief, effect size is smallNSAIDS for low back pain and sciatica – not more effective than placebo in reducing sciatica. Overall improvement but results should be used interpreted with cautionProlotherapy for chronic low back pain – conflicting evidenceBotox for lower back pain and sciatica – low or very low qualityInjection therapy for subacute and chronic low back pain – insufficient evidence to support use of injection therapyNSAIDs – low quality evidence in osteoarthritis. No evidence for other chronic painful condition.Paracetamol – No evidence to support or refute provide pain reliefVitamin D – No consistent pattern Vit D better than placebo. More research is needed.Gabapentin for fibromyalgia – No good evidencePregabalin for fibromyalgia –Provided pain relief 10% more than placeboMilnacipran for fibromyalgia – Provided pain relief to 10% more than placebo, it will not work for most people.Duloxetine for fibromyalgia – low quality evidence duloxetine is effectiveBotox for myofascial pain – inconclusive evidencePregabalin for chronic prostatitis. Chronic pelvic pain – one RCT showing that pregabalin does not improve CP/CPPSCannabinoids – FPM PM10

Pharmacology often fails

Multiple dimensions of health affected

Let me give you a metaphor to put self management into context.

Choice

Engagement

Change

Shift in focus

Partnership

Time

Independance

Ideal situation for pain managementPatient:- Early chronic pain- Job attached- Surgically/ medically cleared- Motivated or willing to look at a different approach

Treatment team:- Multidisciplinary team- Rehabilitation approach- Strong emphasis on self management not passive therapy- Flexible and accommodating

What do they do in pain clinic?

Comprehensive assessment- Medical clearance for rehabilitation- Medication review and optimisation- Organise appropriate on referral, imaging or intervention - Assess impact of pain: biopsychosocial approach- Assess readiness to change- Assess barriers to change

Provide pain management education and experiential guidance.

If patients are not ready?

• Patience and compassion• Upskill your and patients knowledge around neurophysiology of

persistent pain• Encourage exploration of pain management as an alternative• Reinforce current evidence• Explore and identify area of life impacted by pain• Adhoc supports – psychology only, physiotherapy only,

medication trial• Harm minimisation

Retrainpain.org

Thank You

Thank you