Pain Management

StrategiesAnd their effects on wellbeing

MS Therapy Centre, Bedford

Where I work

How I ‘got into pain’ !

When do OTs work with pain? Almost all your clients will potentially have pain Neuro – large percentage have pain Case management Running pain management programs People with chronic pain often face work related

issues Palliative care Many that I don’t know!!

Summary Definitions of pain Classification of pain Persistent pain The Pain Cycle Pain gate theory Common analgesic treatments & effects on

wellbeing Common non-pharmarceutical treatments &

effects Branching out Our experiences with APS Therapy

Pain ‘an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or described in terms of such damage’

-International Association for the Study of Pain 1979

‘Pain is whatever the experiencing person says it is, existing whenever the person says it does’

-McCaffery 1968

Nociceptive

Neuropathic Neuropathic pain may arise as a consequence of

a lesion or disease affecting the somatosensory system

Inflammatory

Functional

Acute Pain Short-lasting (up to 3 months) Associated with tissue damage eg

wound, surgery, injury Warning of potential damage Healing process Usually relieved by treatment

Chronic/Persistent Pain Long-lasting – more than 12 weeks May be ‘maladaptive’ or have no

biological usefulness May not respond to standard

treatments Impact on individual – physically,

emotionally, socially, financially, psychologically – Pain Cycle

‘adaptive & maladaptive’ pain

Causes of chronic painPain Proposal, Improving the current and future management of chronic pain.A European Consensus ReportBaker et al. 2010

Classifications of pain seen in pain clinic; National Pain audit, 2011

Cause of pain seen in pain clinics; National Pain Audit, 2011

Impact on work of pain

National Pain Audit 2011

Development of maladaptive/functional/ chronic/persistent pain

Usually, once healing has occurred, the pain signals fade and go away completely

Sometimes, the pain signal fails to decrease, even after an injury has healed

The nervous system has ‘learnt’ the pain, and the pain messages continue to travel to the brain

Mechanisms

Not well understood- IASP Factsheet – Mechanisms of Neuropathic pain

Pain Gate Theory Melzack and Wall 1965

‘Gate’ in the spinal cord which can be opened or closed – controls how much pain your brain is aware of

Designed to block pain if it will affect you badly eg in an attack

Pain gate theory

Pain Gate Theory The Gate can also cause increased awareness of

pain during healing process – eg inflammatory stage, encouraging protection of injured area

Regeneration stage – relies on gradual but steady return to normal activities

What opens the Gate? Physical factors: Extent of injury Inappropriate activity level Emotional factors: Fear, stress, anxiety, depression Mental factors: Concentrating on the pain Boredom

Gate is opened, increasing perception of pain

When the Gate is Open People commonly try to protect painful areas by

not using them – muscles de-condition, causing weakness and loss of stamina

This means eventually a usually non-painful sensation such as stretching, can be perceived as painful

What can Close the Gate?

Positive emotions – happiness, interest, excitement

Concentrating on something else / distraction

Analgesics / treatments

Relaxation techniques

Counter stimulation – eg heat, massage

Activity/exercise/stretching

‘The Persistent Pain cycle’

Important not to underestimate -

- Pain Proposal, Improving the current and future management of chronic pain. A European Consensus Report 2010

Recommendations for pain management

No one careplan – pain is individual Improved access to pain services with md team Improved physician training No current national clinical guidelines for

management of persistent pain Apart from Neuropathic - NICE Guidelines

Health Improvement Scotland – management chronic pain

Assisting self-management

Toolkit features Acceptance Engagement & building support team Pacing Planning & prioritising Goals & action plans Being patient with self Relaxation skills Stretching & Exercise Diary Set-back plan Keeping it up

Analgesia: WHO Ladder

Step One

Step Two

Step Three

Simple analgesia e.g. paracetamol +/- NSAID

Opioids suitable for mild/moderate pain (codeine, dihydrocodeine, tramadol)

+ simple analgesia

Opioids for use in severe pain (morphine, oxycodone, fentanyl)

+ simple analgesia

Step One

Step Two

Step Three

Simple analgesia e.g. paracetamol +/- NSAID

Opioids suitable for mild/moderate pain (codeine, dihydrocodeine, tramadol)

+ simple analgesia

Opioids for use in severe pain (morphine, oxycodone, fentanyl)

+ simple analgesia

Suggested update Relieving Persistent Pain, Improving Health Outcomes – UCL School of pharmacy

Dosage & method ‘by the clock’ vs ‘as & when’ Standard release – absorbed within 30min-1hr, lasts

for 4-6 hours (liquid acts faster than tablets) Slow release (SR, MR, PR) – slower acting, last usually

for 12 hours therefore twice daily dose. Sometimes XL or LA – last 24 hourso Smoother drug release / side-effect profileo Lasts through the nighto Less flexibility

Creams & gels Anti-inflammatory Heat rub Patches

Paracetamol Taken ‘as and when’ not very effective for chronic

pain Need to take regularly , 2 tablets x 4 times every day

for at least 7-14 days to see effect Provides a good foundation for other drugs if needed Effects on wellbeing: Side-effects very rare; safe (no damage to organs at

normal doses) Very toxic in overdose; higher doses do not give

better pain relief (check OTC meds) Realistic expectation – may reduce pain by 1-2 points

Anti-inflammatory drugs (NSAIDs) Ibuprofen, diclofenac, naproxen, others Short term for acute pain and for conditions

with inflammation they can work well For most people paracetamol will work just as

well Long term need to weigh up risk and benefit

(some are safer than others) Effects on wellbeing:

Side-effects of NSAIDs

Opioids Morphine type drugs Block pain receptors Effects on wellbeing: 30% of pain in 30% Increase feelings of pleasure

o Constipation (may need to modify diet/use laxative)o Drowsiness, dizziness, confusiono Nauseao Hallucinations (particularly with tramadol)o Long term effects on hormones and immune system

Addiction Addiction

o Opioids have the potential to be addictiveo Addiction is relatively uncommon during treatment for chronic paino Addiction is a behaviour – compulsive use of the drug for non-

medical reasons, craving its mood altering effect not pain reliefo Commonly mistaken for dependence and tolerance

Physical dependenceo Physiological adaptation of the body to the opioido Reason that people suffer withdrawal if they stop suddenlyo Withdrawal effects are unpleasant but not life threatening and

include anxiety, insomnia, pain, sweating, diarrhoea, abdominal cramp, nausea, vomiting (cold turkey)

Toleranceo Decrease in the effect of the drug over timeo Sometimes need a higher dose to get the same effect or may need

to switch to a different drug

Neuropathic pain meds• Pregabalin:up to 600mg• Gabapentin: up to

3,600mgAnticonvulsan

ts

• Amitryptilline – 10 – 150mg

• Duloxetine – 60mgAntidepressan

ts

• Localised pain, & cannot tolerate/wish to avoid drugs

Topical capsaicin

Side effects

Anticonvulsants: somnolence, weight gain, dizziness, peripheral oedema, headache, dry mouth, blurred vision, diploplia, dysarthria, abnormal co-ordination, parasthesia

Also:  sexual dysfunction, constipation, vomiting, flatulence, memory impairment, vertigo, increased creatine kinase level, memory impairment, increased risk of depression & suicidal thoughts and behaviours.

Side effects - TCAs

common : dry mouth, constipation, dizziness, blurred vision, urinary retention, drowsiness, palpitations, orthostatic hypertension, sweating.

Also linked to: cognitive disorders, confusion, gait disturbance, falls

Recent research shows causative link to dementia in long term use ( 2 years low dose)

Cumulative Use of Strong Anticholinergics and Incident Dementia A Prospective Cohort StudyShelly L. Gray,et al JAMA Intern Med. Published online January 26, 2015. doi:10.1001/jamainternmed.2014.7663

Electrotherapies

One of 3 main physiotherapy modalities; manual therapy, exercise therapy, electrotherapy. Electrical stimulation agents, including

Transcutaneous Electrical Nerve stimulation (TENS), Interferential Therapy (IFT), Functional Electrical Stimulation (FES), and Microcurrent therapy (MCT), Action Potential Simulation Therapy (APS Therapy)

Thermal modalities,  including Infra red Irradiation (IFR), Therapeutic Ultrasound and Laser Therapy, and

Non Thermal Modalities including Pulsed Ultrasound, Pulsed Electromagnetic Fields (PEMFs) and Microcurrent Therapy (MCT)

Effects on wellbeing Depend on therapy being used Mixed effectiveness Some (eg TENS) have poor carry-over and

adaptation Some (eg micro-current) possible initial detox

reactions, but more beneficial effect on general wellbeing

Prices vary, from TENS ( cheap) to SCENAR ( expensive)

Some can self-manage = empowering, others involve treatment by physio/practitioner

Generally extremely safe

Psychological/behavioural therapies

Counselling/Talking therapies Cognitive Behavioural Therapy Neuro-Linguistic Programming/ ‘The Journey’/

EMDR Hypnosis/self-hypnosis Mindfulness / EMG Biofeedback Effects on wellbeing Vary with skill of practitioner, receptiveness of

client And effectiveness of strategy… can go in circles Can be profound & lead to excellent self-

management And real reduction in pain Availability as free service/cost implications

Manual/bodywork Therapies Physiotherapy/hydrotherapy Massage Osteopathy/cranial osteopathy Chiropractic Bowen technique Kinesiology Acupuncture Myofascial release/trigger point therapy Shiatsu Reflexology

Effects on wellbeing Generally beneficial Generally safe Interaction with practitioner Human touch Assistance in manual lymph drainage,

intracellular communication Effectiveness varies depending on therapy,

condition & skill Price considerations and possibility of exploitation

Self-management techniques Massage balls/ self-massage Acupressure/reflexology stimulation points Home-use electrotherapies Exercise: Yoga, Pilates, core strengthening,

stretching, Wii fit, aquarobics, swimming, exercise equipment, senior movement/keep fit, Tai Chi

Supplements – vitamin D etc within safe limits Effects of wellbeing: Excellent – increases self-efficacy

3rd line/Invasive Interventions Lidocaine infusions ( local anaesthetic) Epidurals Nerve blocks – injections ( local anaesthetic and

steroid) Surgery eg spinal fusion Spinal cord stimulation Deep brain stimulation Patient controlled analgesia (PCA) pump –

palliative Wellbeing – waiting time, funding, rejections,

short term, unrealistic expectations, tolerance, and risks.

More out there….. Keep learning, keep an open mind Lots out there – one site I liked recently www.painscience.com https://

www.painscience.com/articles/pain-tips.php#sec_drs

There’s more out there..

Be aware: doctors may not know their aches & pains medicine 2.2 Trigger point massage: the best “secret” weapon, useful even when muscle pain is not the main problem 2.3 Learn your perfect spots for pressure: a few key points go a long way 2.4 The bath trick: give yourself a back rub with a ball in a bath 2.5 Prevention: important even after you’ve been hurt 2.6 Microbreaking: mobilizations at work 2.7 Endurance training: under-rated but vital therapeutic exercise 2.8 Strength training: better, easier than you thought 2.9 The scientific 7-minute workout 2.10 Stretching is most over-rated! But it may be useful for a few specific problems 2.11 Heating: the most basic comfort 2.12 Raw icing and power icing: for acute and chronic injuries 2.13 An important icing exception: please (almost) never ice low back pain! 2.14 Contrasting with heating and cooling: well worth a shot 2.15 Epsom salt baths: the bath is nice, but the salt is useless 2.16 Extra water intake? Don’t worry about it 2.17 Get more sleep! If you’ve got insomnia, start looking seriously for solutions 2.18 Tactical resting: the underestimated art of taking it easy 2.19 Nutrition for healing: possibly helpful for serious chronic pain 2.20 Vitamin D: the most likely of all supplements to be useful for pain 2.21 Avoid most nutraceuticals, especially chondroitin and glucosamine: they are a waste of your money 2.22 Try creatine & bromelain Minor update Jan 14 '15 Minor update (Jan 14 '15) — Made the tip more concise, and linked out to a

new short article about smoking and pain. 2.23 Quit smoking: it’s not just for your lungs 2.24 Postural correction: difficult and usually not very important, but still … 2.25 Tits up! Use “power poses” to reduce pain sensitivity 2.26 Reduce postural strain with ergonomics: not just about your keyboard height 2.27 Use a wobble cushion: an unstable recovery? 2.28 If you sit a lot, get a great chair, probably an Aeron

There’s more out there…

2.29 Crunch! Self “adjust” your spine 2.30 The confidence cure: rational, informed confidence can probably reduce pain 2.31 Be kind to your nervous system: create pleasant, safe sensory experiences 2.32 Orthotics: slip into something more comfortable 2.33 Do not get a joint lube job: avoid artificial synovial fluid injection 2.34 Heal by growing up: sometimes sweeping personal changes will also affect pain 2.35 Hyperventilate: an unusual and powerful tool for changing your state 2.36 General activity increase: do something, anything! 2.37 Blow off steam: breathe and shake stress away 2.38 Don’t be a pain drama queen! Tear up that one-way ticket to hell 2.39 Exercise classes: aerobics, yoga, Pilates, taijiquan, boot camp, etc … 2.40 Progressive training: break up the challenge into baby steps 2.41 Friction massage (for tendonitis only) 2.42 Pain-free ROM exercises after injury: use it (thoroughly) or lose it 2.43 Mobilizations: massaging yourself with movement 2.44 Don’t bother with hip strengthening: “weak hips” is a poor scapegoat for chronic leg injuries 2.45 Try Voltaren: anti-inflammatory medication only where you need it 2.46 The most popular of all “herbal” pain creams has precious little herb in it 2.47 Check your drugs! Pain can actually be a side effect — even of pain killers! New Jun 27 '15  +New (Jun 27 '15) — adjustments (Sep 10 '15) — Small but meaningful improvements regarding safety and efficacy. 2.48 Master over-the-counter pain medications 2.49 Get in the pool! Water is a really good place for rehab and pain 2.50 Relaxation massage: not just fluffy 2.51 Novel sensory input: change how it feels with taping, bracing, or other tricks 2.52 Don’t knock “masking” symptoms

Thankyou & contactsMiranda Olding  RGN MSCN MCMA

www.painfreepotential.co.uk www.mirandasmsblog.com

01908 799870

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miranda@painfreepotential.co.uk

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