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3/10/2017
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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.
5
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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COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 13
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
COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 14
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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COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 15
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
COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 16
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
COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 17
Possible Changes Through Understanding Pain
Problem Solving: Understanding pain,
problems and solutions differently
Input from
Tissues?
SNS
Problem
Solving
Attention
Motor
Memory
Depression
& Anxiety
Stress
Sensory
COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 18
Possible Changes Through Understanding Pain
Problem Solving: Understanding pain,
problems and solutions differently
Quieting stress response
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Input from
Tissues?
SNS
Problem
Solving
Attention
Motor
Memory
Depression
& Anxiety
Stress
Sensory
COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 19
Problem Solving: Understanding pain,
problems and solutions differently
Quieting stress response
Possible Changes Through
Understanding Pain
Input from
Tissues?
SNS
Problem
Solving
Attention
Motor
Memory
Depression
& Anxiety
Stress
Sensory
COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 20
Problem Solving: Understanding pain,
problems and solutions differently
Quieting stress response
Addressing depression, anxiety and
trauma and validating their role in the
pain experience
Possible Changes Through
Understanding Pain
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Input from
Tissues?
SNS
Problem
Solving
Attention
Motor
Memory
Depression
& Anxiety
Stress
Sensory
COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 21
Problem Solving: Understanding pain,
problems and solutions differently
Quieting stress response
Understanding fear avoidance and
beginning to return to physical activity
Addressing depression, anxiety and
trauma and validating their role in the
pain experience
Possible Changes Through
Understanding Pain
Input from
Tissues?
SNS
Problem
Solving
Attention
Motor
Memory
Depression
& Anxiety
Stress
Sensory
COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 22
Problem Solving: Understanding pain,
problems and solutions differently
Quieting stress response
Understanding fear avoidance and
beginning to return to physical activity
Addressing depression, anxiety and
trauma and validating their role in the
pain experience
Possible Changes Through
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
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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
Adapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010
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COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 25
Key Points
Pain ≠ Harm
Adapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010
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
COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 42
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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
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