12/1/2017

1

Copyright © 2016 Providence Health & Services

Moving on with it: Rehab (PT/OT/ST) for the Patient with Persistent Pain

Presented by TJ Melville, MPT

Providence Rehab Northeast

Objectives:

1. To learn how rehab can play a vital role in treating patients with

persistent pain

2. To understand what resources Providence Rehab offers for

patients with persistent pain

3. To learn how to set patients up for success in rehab

12/1/2017

2

Where we’ve been

Copyright (C) 2016 Providence Health & Services

3

Pain

Specialist/

MD

InjectionsImaging

Imaging

Imaging

Narcotic RX

Narcotic RX

Unidentified Persistent Pain Patient

MD/PC

PT/OT

IC/ED

PT/OT

Narcotic RX

Narcotic RX

Inpatient stay for

intractable pain

Surgical consult and

surgery

Narcotic RX

Physical Therapy: Traditional Approach

•2 times per week for 4 weeks

•Aerobic conditioning

•Core strengthening

•Modalities

•Home exercise program

12/1/2017

3

Old Model

Pain

=

Tissue Damage

Louis Gifford, 1998

12/1/2017

4

7

Reprinted with permission from Kevin Cuccaro, D.O., Straight Shot Health LLC

Pain = threat

New Model

12/1/2017

5

6 4

Score of ≥4/9 total or ≥ 4 on psychosocial subscore= High risk, pain care indicated

Providence Oregon Rehab Services Pain Care

STarT= Low Risk

All Pain Treated as Biopsychosocial

Potential referral to Persistent Pain Care

Specialists , BH in Medical Home

Orthopedic Pain-Informed PT

Best Practice;Basic Pain Care as

indicated

STarT = High Risk Psychosocial Involvement

STarT = Medium Risk

Monitor

12/1/2017

6

Hill, et al, “Comparison of stratified primary care management for low back pain with current best practice (StarT back): a randomized controlled trial, Lancet, Vol 378, No 9802, p 1560-71

Providence Oregon Rehab Services Pain Care

Providence Rehabilitation Caregiver Pain Care Skills

Graded Motor Imagery

Return to Activity

Physiological Quieting

Pain Education

Motivational Interviewing

12/1/2017

7

Pain Education As A Treatment Intervention

Decrease in pain rating (Van Oosterwijck et al 2011, Meeus et al, 2010, Ryan et al, 2010, Moseley, 2002, 2003, 2004)

Decrease in fear of re-injury (Van Oosterwijck et al 2011, Moseley, 2002, 2003)

Decrease in pain catastrophizing (Meeus et al, Moseley 2004, Louw et al 2011, Arch Phys Med Reh Systematic review)

Decrease in postoperative utilization of services (Adriaan Louw, PhD, PT, et SPINE Volume 39, #18)

Increase in function (Van Oosterwijck et al 2011, Moseley, 2002, 2003,Louw et al 2011 Arch Phys Med Reh Systematic review)

Increase in mobility (Moseley and Hodges, Clin J Pain. 2004 Louw et al Physiotherapy J, 2011)

12/1/2017 Creamer et al , British Journal of Rheumatology 0886 Vol 36 No 7, 1997 p 726-7 14

10% with no arthritis on xray have severe pain!!

Half of people with severe arthritis in the knee have no symptoms

12/1/2017

8

15

Written and video material available online, in-person and virtual class options

Providence Rehabilitation Caregiver Pain Care Skills

Graded Motor Imagery

Return to Activity

Physiological Quieting

Pain Education

Motivational Interviewing

12/1/2017

9

Copyright © 2016 Providence Health & Services

Providence Rehabilitation Caregiver Pain Care Skills

Graded Motor Imagery

Return to Activity

Physiological Quieting

Pain Education

Motivational Interviewing

12/1/2017

10

Copyright © 2016 Providence Health & Services

Kinesthetic Sense

•Awareness of muscular movement and position which helps us control and coordinate movement

•Yoga , Pilates, Tai Chi

•Breathing, body scan, progressive muscle relaxation

Copyright (C) 2016 Providence Health & Services 20

12/1/2017

11

Providence Rehabilitation Caregiver Pain Care Skills

Graded Motor Imagery

Pacing &Graded Exposure

Physiological Quieting

Pain Education

Motivational Interviewing

Stress response creates chemical changes that cause pain

Providence Oregon Rehab Services Pain Care

12/1/2017

12

Healthy balance in your day creates better sleep

Active

Restful

Easier sleep due to healthy balance over the day

Copyright (C) 2016 Providence Health & Services

23

Day Night

Day Night

Lack of balance during the day creates poor sleep

Active

Restful

Why can’t I get to sleep??!?

Copyright (C) 2016 Providence Health & Services 24

12/1/2017

13

Providence Rehabilitation Caregiver Pain Care Skills

Graded Motor Imagery

Pacing &Graded Exposure

Physiological Quieting

Pain Education

Motivational Interviewing

Graded Motor Imagery (GMI)

• A treatment progression which involves gradual exposure to the mental representation of movement, without body movement.

• Uncouples the link between the movement neurotag and pain neurotag

• 3 components: R vs L discrimination, mental imagery, mirror therapy

12/1/2017

14

7.57.8

6.66.3

7.8

6.7

8.79.1

8.79.0 9.0

9.3

6.0

6.5

7.0

7.5

8.0

8.5

9.0

9.5

May June July Aug Sept Oct

VIS

ITS

Pain Rehab Treatment Efficacy with Complex Patients

Labeled Pain n = 689 Labeled Ortho n = 14,256

Linear (Labeled Pain n = 689) Linear (Labeled Ortho n = 14,256)

12/1/2017

15

Setting patients up for success

•Warm hand-off

•Reinforce the treatment plan

•Focus on function

•Acknowledge effort and accomplishments

•Emphasize a sense of Safety and Hope

Providence Oregon Rehab Services Pain Care

Safety and

Hope

“Kisses of time”Up to half the people with knee arthritis have no symptoms

Understand painSore, but safe

Bring some fun back in your life

Quiet your worry