pain care doesn’t have to be torture · background information: 54 year old female, thoracic low...

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Pain Care Doesn’t Have Pain Care Doesn’t Have Pain Care Doesn’t Have Pain Care Doesn’t Have to Be Tortureto Be Tortureto Be Tortureto Be TortureHow explaining pain to your patient can change the How explaining pain to your patient can change the How explaining pain to your patient can change the How explaining pain to your patient can change the conversation and promote alliance and selfconversation and promote alliance and selfconversation and promote alliance and selfconversation and promote alliance and self----efficacyefficacyefficacyefficacy

PRESENTED BY NORA STERN, PT, MSPT

PROVIDENCE ST. JOSEPH HEALTH AND SERVICES

Session objectives:Session objectives:Session objectives:Session objectives:

�Understand biopsychosocial model for pain, skills and treatment planning based on this model

�Learn key phrasing to change conversation about pain

�Understand resources for further pain education and motivational interviewing

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PT First: $4793 less per episode of care than radiology first (Fritz 2011 n=406)

But we have to get this right!!!

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ChristinaBackground Information:

54 year old female, thoracic low back and right > left leg pain, knee arthritis “severe.” Pain increasing in area and intensity

Co-Morbidities: Type II diabetes, obesity, anxiety

Pain description:

◦ Spreading into lumbar bilateral and left lower thoracic area, R and L leg pain

◦ Hard to tell where it is sometimes

◦ Worse with cold weather.

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Christina continuedChristina continuedChristina continuedChristina continued

Function:

◦ “Physical therapy made me pain worse.”

◦ Walking limited because she hurts, uses a walker to get around the house

◦ Has no hobbies, in bed watching TV majority of day

Radiology:

◦ Knee findings: severe OA bilateral

◦ Lumbar: moderate degeneration at L3-5 bilateral facets

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Physical Therapy: Traditional Approach

2 times per week for 4 weeks

Aerobic conditioning

Core strengthening

Modalities

Home exercise program

Old Model

Pain

=

Tissue Damage

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Context and meaningChildbirth vs. Trauma

COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 10

Key Points

Pain ≠ Harm

Adapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010

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Louis Gifford, 1998

Complex pain is…… complex

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Acute Injury: Fewer brain processes involved in pain experience

Stress

Sensory

Motor

Memory

Problem

Solving

SNS

Input from

Tissues

Stress response activates autonomic

nervous system

Sensory cortex: identify body part

Memory: has this happened before?

Problem-solving: assess situation

Motor: acts to protect


Persistent Pain: Brain functions change

Stress

Sensory

Motor

Memory

Problem

Solving

SNS

Input from

Tissues?

Stress: chronic stress associated with

disability, other life issues

Sensory cortex: smudging

Memory: associates actions with history

of pain. “Every time I bend over my

back hurts.”

Problem-solving: focus on looking

for answers

Motor: decrease in physical activity

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Persistent Pain: More pain functions coupled with pain response

Input from

Tissues?

Fear & Fear Avoidance: associates

pain with harm, avoids movement

Balance and Visual Input

Attention: centrality of pain in one’s life

Premotor planning: expecting pain

with movement, preparing for

movement evokes pain

Depression, anxiety & trauma: strongly

associated with increase in persistent pain

SNS

Premotor

Planning

Balance

Visual Input

Problem

Solving

Attention

Motor

Memory

Depression

& Anxiety

Stress

SensoryFear & Fear

Avoidance

Input from

Tissues?

SNS

Premotor

Planning

Balance

Visual Input

Problem

Solving

Attention

Motor

Memory

Depression

& Anxiety

Stress

Sensory


Possible Changes Through Understanding Pain

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Input from

Tissues?

SNS

Premotor

Planning

Balance

Visual Input

Problem

Solving

Attention

Motor

Memory

Depression

& Anxiety

Stress

Sensory



Problem Solving: Understanding pain,

problems and solutions differently

Input from

Tissues?

SNS

Problem

Solving

Attention

Motor

Memory

Depression

& Anxiety

Stress

Sensory





Quieting stress response

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Input from

Tissues?

SNS

Problem

Solving

Attention

Motor

Memory

Depression

& Anxiety

Stress

Sensory





Possible Changes Through

Understanding Pain

Input from

Tissues?

SNS

Problem

Solving

Attention

Motor

Memory

Depression

& Anxiety

Stress

Sensory





Addressing depression, anxiety and

trauma and validating their role in the

pain experience


Understanding Pain

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Input from

Tissues?

SNS

Problem

Solving

Attention

Motor

Memory

Depression

& Anxiety

Stress

Sensory





Understanding fear avoidance and

beginning to return to physical activity



pain experience


Understanding Pain

Input from

Tissues?

SNS

Problem

Solving

Attention

Motor

Memory

Depression

& Anxiety

Stress

Sensory





Understanding fear avoidance and

beginning to return to physical activity



pain experience


Understanding Pain

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Central Sensitization

NMDA receptor proliferation at neuron

Sensory Cortical changes

Mirror neuron changes

Suffering

Pain catastrophizing

Social Contributions

Fear AvoidanceNeuropathicNociceptive


Key Points

Pain is a multi-dimensional experience

All pain is real pain

Nociception is neither necessary nor sufficient for pain

Pain occurs when credible evidence of danger outweighs the credible evidence of safety


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Key Points

Pain ≠ Harm


THREAT!

MRI and X-Ray

results

Fear of movement

Medication is the only thing

that can help meStruggles in living with pain

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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)

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

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Pain Assessment

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Identifying pain: A work in progressIdentifying pain: A work in progressIdentifying pain: A work in progressIdentifying pain: A work in progress

STarT Back Screening Tool

Fear Avoidance Behavior Questionnaire

Patient Activation Measure

PEG

Brief Pain Inventory

© Keele University Aug 1, 2007

Hill JC, et al. Arthritis Rheum. 2008;59:632-641.

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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

Patient Activation Measure

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PEG – validated 3 item tool to assess pain intensity, interference with enjoyment of life and

interference with general activity (Krebs, 2009)PEG score = average the 3 questions (30% improvement is clinically meaningful)

Interagency Guidelines on Prescribing Opioids for Pain 2015 & CDC Guidelines 2016 35

Brief Pain Inventory

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Pain Care

Pain Education

Behavioral Health

Rehab

38

Written and video material available online,

virtual classes currently trialed

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Providence Primary Care

Rehab Persistent Pain Pathway

PCP

Standard Pain Visit (Biopsychosocial)

Higher PAM/

Low STarT

BH Pain Protocol

Individual or group

(including pain class)

BH Brief Pain

Protocol

Persistent Pain Rehab

Low PAM/

High STarT

Providence Rehabilitation Caregiver Pain Care Skills

Graded Motor Imagery

Pacing &Graded Exposure

Physiological Quieting

Pain Education

Motivational Interviewing

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Return to activity

Teaching about pain versus harm

Pacing:

◦ Starting out very slow and giving positive reinforcement for any gains no matter how small

Graded exposure:

◦ Adding complexity

ChristinaBackground Information:54 year old female, thoracic low back and right > left leg pain, knee arthritis “severe.” Pain increasing in area and intensity

Co-Morbidities: Type II diabetes, obesity, anxiety

Brief Pain Interference Scale: 60/70

STarT score = 7/9

PAM = 2

Pain description: ◦ Spreading into lumbar bilateral and left lower thoracic area, R and L leg pain

◦ Hard to tell where it is sometimes

◦ Worse with cold weather.

Function: ◦ “Physical therapy made me pain worse.”

◦ Walking limited because she hurts


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Questions

ReferencesBrinjikji, W., et al "Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations," AJNR Am J Neuroradiol 36:811–16 Apr 2015 www.ajnr.org

Butler, David, and Lorimer Moseley, Explain Pain, NOIGroup Publishing, Adelaide, Australia

Creamer, P., and Hochber, M.C., “Why does osteoarthritis of the knee hurt sometimes,” British Journal of Rheumatology 0886 Vol 36 No 7, 1997 p 726-7

Fritz, Julie, et al, “ Implications of early and guideline adherent physical therapy for low back pain on utilization and costs,” BMC Health Services Research 2015

National Pain Strategy, 2016

Institute of Medicine, “Relieving Pain in America,” 2011.

Teraguchi M, et al. "Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study." Osteoarthritis Cart., 2014;22:104–10

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Ideas for future skill-building opportunities in complex pain care Pain education

Motivational interviewing

Shared decision making

Trauma informed care

Yoga/Feldenkrais

Mindfulness

Cognitive behavioral therapy/Acceptance Commitment Therapy

pain care doesn’t have to be torture · background information: 54 year old female, thoracic low...

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