Pain: It’s Not All In Your Head

Chronic Pain Syndromeand

Management

Jay Tracy, PA‐C, PsyD, LP

Courage Kenny Rehabilitation InstituteChronic Pain Program

CHRONIC PAIN SYNDROME

When chronic pain negatively affects almost every area of functioning.

• It’s Not All In Your Head

• The Tests Don’t Show Everything

• It’s All In Your Head

Fundamental Attribution Error

(Actor‐Observer Bias)

In attribution theory, the fundamental attribution error (sometimes referred to as the actor‐observer bias) is the tendency for people to over‐emphasize 

dispositional, or personality‐based, explanations for behaviors observed in others while under‐emphasizing the role and power of situational influences on the same behavior. In other words, people tend to have a default assumption that 

what a person does is based more on what "kind" of person he is, rather than the  social and environmental forces at work on that person.  

An example is attributing a friend's recent car accident to the fact that the friend is a poor driver rather than to the fact that another car just happened to pull out 

in front of her. The former would be a dispositional attribution; the latter a situational attribution.

Cognitive Stereotypes

•Lazy

•Weak

•Unable to tolerate pain

• Irresponsible

•Fraudulent

•Seeking secondary gains

•Malingering

•Factitious

Sympathetic and Central Nervous System Responses

• Fight, flight• Excessive anxiety, worry• Hyper‐alertness, hyper‐vigilance, restless, keyed up

• Muscle tightness, tension, irritability, on edge• Fatigue, poor sleep• Dilated pupils• Increased pulse rate, pounding heart, palpitations

• Increased blood pressure• Increased blood sugar• Decreased gastric acid production, but buildup

• Decreased gastric motility• Nausea and abdominal distress

• Increased adrenaline, epinephrine• Trembling or shaking• Sensations of shortness of breath or smothering

• Hyperventilation, feeling of choking• Feeling dizzy, unsteady, lightheaded, or faint• Paresthesias, numbness or tingling sensations• Sweating, chills or hot flashes • Difficulty concentrating, mind “going blank”• De‐realization and de‐personalization• Feeling of loss of control or sense of “going crazy”

• Fear of dying• Chest pain or discomfort• Hypersensitivity to various stimuli

Muscle Pain

Tight

Tired

Compartmentalization

SIMPLE (2+2=?)

VS

COMPLICATED (0.15625 +[(5/4+4/5)x 1.875]=?)

Compartmentalization

• Medical • Physical • Psychological • Vocational • Other

Compartmentalization

• Diagnosis

• Treatment

• Prognosis

Compartmentalization

Medical Treatment “Fix it” model

vs 

Rehabilitation model

Compartmentalization

Medical Treatment, “Fix it” model

What the medical providers can do:SurgeriesInjectionsPhysical TherapiesMedications

Compartmentalization

1.  Make pain go away2.  Lessen pain as much as possible3.  Live better with what remains

1     2     3     4     5     6     7     8     9     10Make pain Lessen it as  Live bettergo away much as  with what                  

possible  remains

Discordant Goals

010203040506070

Make paingo away

Lessen asmuch aspossible

Live betterwith whatremains

PatientsPhysicians

Sensitivity

• Normal

• Abnormal

• Changeable

PainDRG = dorsal root ganglionPAG = peri‐aqueductal grayVP = ventro‐posterior thalamus S1 = first somatosensory cortex

SufferingACC = anterior cingulate cortexAmyg = amygdalaHT = hypothalamusPF = prefrontal cortexPPC = posterior parietal complexSMA = supplementary motor areaInsula = social/emotional

Compartmentalization

Acute  _ Chronic____Protective Not protectiveTime  IndefiniteRest Activity

TIME

A C T I V I T Y

TIME

A C T I V I T Y

TIME

A C T I V I T Y

endurance

TIME

A C T I V I T Y

endurance

frustration

TIME

A C T I V I T Y

endurance

frustration

TIME

A C T I V I T Y

EnduranceFrustration

A C T I V I T Y

Endurance Frustration

TIME

PAIN(Lack ofcontrol)

PAIN(Lack ofcontrol)

Anger

PAIN(Lack ofcontrol)

Anger

Depression

PAIN(Lack ofcontrol)

Anger

Depression

Fatigue

PAIN(Lack ofcontrol)

Anger

Depression

Fatigue

AlternativeStates

(like drugs oralcohol)

PAIN(Lack ofcontrol)

Anger

Depression

Fatigue

AlternativeStates

(like drugs oralcohol)

Frustration, Blame,Worry, Inactivity,Guilt, Losses, Fear

Types of Pain Programs: (see handout)

“Fix it”  vs  “Rehab”Comprehensive, multidisciplinary, intensive, i.e. 3 weeks…

Syndrome oriented…i.e. Minnesota Head and Neck

Modality oriented…i.e. interventions

Medications mainly

Other (i.e. partial programs)

Management / Rehabilitation

Validation  (factual and emotional levels)Normalization  (other patients in group) Motivation  (understand patient goals) Education  (ongoing) Support  (ongoing) Structure  (ongoing) 

Two Prongs of Self‐Management: (see handout) 

• Lifestyle changes which, when done over time, reduce the sensitization of the dysregulated nervous system.

• Increase abilities to cope with the pain that remains.

Multidisciplinary

Team Approach

Active Co‐Management

Identify Strengths 

Build on Strengths

No pain, no gain……….If it hurts, don’t do it. 

STATISTICS / OUTCOMES (78 patients 2015 who accessed Allina Health facilities) (see handout)

Opioids:56% of the patients came into the program on narcotics. 83% of these reported elimination or decrease in narcotic use upon completion of program

Mood/Psych:91% reported better mood (BDI‐2) upon completion of program72% reported better mood (BDI‐2) upon completion of aftercare (4 months)

Medical utilization: (12 months post‐program compared to 12 months pre‐program)ED: 54% decrease in total visits to EDHospital: 77% reduction in hospital admissions

Work: (of those not working when they came into the program compared to 4 months post‐program)33% were working, volunteering, or in active job search33% remained on disability insurance7% were retired27% remained unemployed

Books:

• Pain: It’s Not All In Your Head; The Tests Don’t Show Everything, Tracy, CreateSpace Publishing, Amazon.com 2002, ISBN: 978-1467923439

• Pain: Nerves on Fire; Changing Neuropathic Pain, Tracy, CreateSpace Publishing, Amazon.com 2012, ISBN: 978-1466476073

Contact Information:

Matthew Monsein, MD, Medical Director Murray McAllister, PsyD, LP, Program DirectorJay Tracy, PA-C, PsyD, LP

Courage Kenny Rehabilitation InstituteChronic Pain Rehabilitation Program 3915 Golden Valley Road Minneapolis, Minnesota, 55422

Telephone: 612-775-2606 Fax: 612-262-6720