Are You Sure It’s 10 Out of 10? What To Do When Pain is ... · When Pain is Paradoxical •Recall a time when… –Someone’s pain made no sense to you –OR when you doubted

@zachrstearns 9/15/2019

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Are You Sure It’s 10 Out of 10?What To Do When Pain is Paradoxical

Presented by:

Zachary Stearns, PT, DPT

Board-Certified Orthopaedic Clinical Specialist

PhD student (Health Sciences):

Rocky Mountain University of Health

ProfessionsTwitter: @zachrstearns

Who Is Here?

• Clinicians?

– Outpatient vs. Inpatient vs. Home health

• Students?

• Academic?

• Managerial/administrative?

• Patients/Patient advocates?

• Other?

When Pain is Paradoxical

• Recall a time when…– Someone’s pain made

no sense to you

– OR when you doubted the reality of pain

– OR when you thought someone was exaggerating pain

• For this presentation, that person is your person in pain

My “Person In Pain”: The First Patient On My Schedule

• MVA 2 weeks prior to evaluation

• Two small children in the car (uninjured)

• Other vehicle rolled over, totaled

• Unremarkable radiographs in ED

• Pain “jumped” from entire leg to leg, at rest

• Aggravated by bending, prolonged

positioning

Your Person In Pain:

What is their story?

What sticks with you about that story?

What confused you?

“To have great pain is to have certainty;

to hear that another person has pain is to have doubt.”

–Elaine Scarry,

The Body In Pain

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Objectives

• Attendees will be able to:

– Identify the domains of the pain experience that may serve as primary drivers of pain.

– Describe a clinical model that promotes pattern recognition to aid the diagnosis and treatment of pain.

– Discuss strategies of narrative-based medicine that improve the understanding of the pain experience and strengthen the therapeutic alliance.

– Compare the benefits of evidence-based pain management with the benefits of narrative-based practice.

Objectives






Pain Mechanisms

Chimenti et al. 2018; Smart et al.

2012a-c

Pain #2

Pain #3Pain #1

Pain Mechanisms


2012a-c

Pain #2

Pain #3

Photo by Jesper Aggergaard on Unsplash

Nociceptive

Due to activation of

nociceptors

• Inflammation

• Mechanical

irritant

• Injury

• Ex. Ankle sprain

Nociceptive pain

• Cluster found to have high levels of

classification accuracy (Sn 90.9%, Sp 91.0%)

– Pain localized to the area of dysfunction

– Proportionate mechanical nature to aggravating

and alleviating factors

– Intermittent and sharp with mechanical

provocation; may be a dull ache or throb at rest

– Absence of pain described as burning, shooting,

sharp or electric-shock-like

Smart et al. 2012

Nociceptive Nociceptive pain Nociceptive

7 8

9 10

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https://unsplash.com/@aggergakker?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

https://unsplash.com/search/photos/pain?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText


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Nociceptive

Nociceptive pain

Chimenti et al. 2018; Smart et al. 2012a-c


nociceptors

• Inflammation

• Mechanical

irritant

• Injury


Photo by Mitchell Hollander on Unsplash

Persistent pain

can be

nociceptive

Nociceptive


nociceptors

• Inflammation

• Mechanical

irritant

• Injury


“Nociception is neither

sufficient nor necessary for

pain.”

Moseley & Vlaeyen, 2015



– Pain localized to the area of dysfunction

– Proportionate mechanical nature to aggravating

and alleviating factors

– Intermittent and sharp with mechanical

provocation; may be a dull ache or throb at rest

– Absence of pain described as burning, shooting,

sharp or electric-shock-like

Smart et al. 2012

Nociceptive

Nociceptive

Pain Mechanisms


2012a-c

Pain #3


nociceptors

• Inflammation

• Mechanical

irritant

• Injury


Flame Photo by Yaoqi LAI on UnsplashLightning Photo by Brandon Morgan on Unsplash Icicle Photo by Robert Zunikoff on Unsplash

Neuropathic

Due to lesion or

disease of

somatosensory

system

• Ex. Complex

regional pain

syndrome

Neuropathic pain assessment

• Observation and touch to assess color

changes, allodynia, or hyperalgesia

• Neural tension testing

• PainDETECT Questionnaire

– https://tinyurl.com/y5hd4y4p

Neuropathic



– Pain referred in a dermatomal or cutaneous nerve

distribution

– History of nerve injury, pathology, or mechanical

compromise

– Pain/symptom provocation with

mechanical/movement tests (e.g. Active/passive,

Neurodynamic) that move/load/compress neural

tissue

Smart et al. 2012

Neuropathic

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https://unsplash.com/search/photos/pain?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

https://unsplash.com/@yaoqiqiqilai?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

https://unsplash.com/search/photos/burning?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

https://unsplash.com/@littleppl85?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

https://unsplash.com/search/photos/lightning?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

https://unsplash.com/@rzunikoff?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

https://unsplash.com/search/photos/icicle?utm_source=unsplash&utm_medium=referral&utm_content=creditCopyText

https://tinyurl.com/y5hd4y4p


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Two mechanisms of neuropathic pain

Lundy-Ekman 2013

Neuropathic

Unlike nociceptive pain, neuropathic pain does not require transduction (i.e., the conversion of noxious stimulus to nociceptive impulse)

Cohen & Mao, 2014

Neuropathic

Example: Complex Regional Pain Syndrome

Current IASP Clinical Diagnostic Criteria

1. Continuing pain, disproportionate to any inciting event

2. One symptom in 3 out of 4 categories:• (Sensory): hyperalgesia or allodynia or both

• (Vasomotor): temperature asymmetry or skin color changes/asymmetry

• (Sudomotor/edema): edema or sweating changes/asymmetry

• (Motor/trophic): decreased range of motion ormotor dysfunction or trophic changes (hair, nails, skin)

Bruehl, 2015


Current IASP Clinical Diagnostic Criteria

3. One sign at evaluation in 2 or more

categories:

• (Sensory): Evidence of hyperalgesia or allodynia

• (Vasomotor): Evidence of temperature asymmetry

or skin color changes/asymmetry

• (Sudomotor/edema): Evidence of edema or

sweating changes/asymmetry

• (Motor/trophic): Evidence of decreased range of

motion or motor dysfunction or trophic changes

4. No other diagnosis explains these better

Bruehl, 2015

A treatment: Graded Motor Imagery


Laterality

Training

Explicit

Imagery

Mirror

Therapy

Noigroup, 2016; Moseley 2004

Neuropathic

Neuropathic pain does not require discrete

large nerve injury

23% of those with hip/knee osteoarthritis

have neuropathic pain (95% CI: 10%-39%)

(French et al., 2017)

Neuropathic

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Pain Mechanisms

Nociceptive

NeuropathicDue to activation of

nociceptors

• Inflammation

• Mechanical

irritant

• Injury


Due to lesion or

disease of

somatosensory

system

• Ex. Complex

regional pain

syndrome

Due to

disturbance in

central pain

processing.

• Ex.

Fibromyalgia


2012a-c

Nociplastic

NociplasticIASP Definition:

Pain that arises from altered

nociception despite no clear evidence

of actual or threatened tissue damage

causing the activation of peripheral

nociceptors or evidence for disease or

lesion of the somatosensory system

causing the pain.

IASP Definition, paraphrased:

Pain that arises from altered nociception despite

no clear evidence of noxious stimulus causing

nociceptive pain or evidence for neuropathic

pain.IASP 2018; Aydede & Shriver, 2018

Nociplastic

IASP 2018; Aydede & Shriver, 2018

IASP Definition:

Pain that arises from altered

nociception despite no clear evidence

of actual or threatened tissue damage

causing the activation of peripheral

nociceptors or evidence for disease or

lesion of the somatosensory system

causing the pain.

A proposed revision of the definition:

Pain that arises from altered nociceptive function

Chimenti et al. 2018

Nociplastic

No pain

Peripheral

sensitization

Central

sensitization

Peripheral and

Central sensitization

Central Sensitization

• Symptoms and Signs Cluster (Sn 91.8%, Sp97.7%– Pain disproportionate to nature and extent of

injury and pathology

– Non-mechanical, unpredictable, disproportionate patterns of pain provocation in response to non-specific aggravating/easing factors

– Diffuse areas of pain/tenderness on palpation

– Strong association with maladaptive psychosocial factors (negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviors, altered family/work/social life, medical conflict)

Smart et al. 2012

Nociplastic Nociplastic


Conditioned Pain

Modulation is

impaired in people

with fibromyalgia and

widespread pain

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Boissoneault et al. 2019

NociplasticCortical Differences

Boissoneault et al. 2019

NociplasticCortical Differences

Objectives






Objectives






Clinical Model of Triangulation Elliott & Walton,

2018Socioenvironmental

Cognitive/Belief

Emotional/

Affective

Central Nociplastic Peripheral Neuropathic

Nociceptive /

Physiological

Sensorimotor

Dys-integration

Very

Low

Low

Moderate

High

Very High

Clinical Model of Triangulation

• Nociceptive / Physiological

• Peripheral Neuropathic

• Central Nociplastic

Elliott & Walton,

2018

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• Emotional/Affective

– Diagnosable psychopathology or affective

dysregulation as per DSM V

– Examples: depression, anxiety, schizophrenia,

or other mood disorder or personality disorder

Elliott & Walton,

2018 Clinical Model of Triangulation


– Depression and anxiety disorders are the

most common health conditions that co-occur

with pain

– The relationship is bi-directional

– Having a mental health condition increases

the likelihood of future chronic pain

– 40-60% of people with chronic pain have

depression

Elliott & Walton,

2018

Darnall 2019



– The Patient Health Questionnaire (PHQ-2)

– A screen for major depression

Over the past 2 weeks, how often have you

been bother by the following problems:

Elliott & Walton,

2018

Not at allSeveral

days

More

than half

the days

Nearly

every day

Little interest or pleasure

in doing things0 1 2 3

Feeling down, depressed,

or hopeless0 1 2 3

(Kroenke et al., 2009)






• Maladaptive Cognitions

– Unhelpful thoughts or beliefs related to pain

(yellow flags)

– Examples: fear avoidance, pain

catastrophizing, low self-efficacy

Elliott & Walton,

2018



– Pain catastrophizing: “a pattern of negative

cognitive and emotional responses to pain

and includes rumination on pain, the

magnification of pain, and feelings of

helplessness about pain” (Darnall, 2019)

– Catastrophizing increases pain and leads to

brain changes (Hubbard et al., 2014)

– High catastrophizing leads to six times

greater likelihood of adverse outcome for

knee replacements (Riddle et al., 2010)

Elliott & Walton,



– Pain-related fear

• Fear of pain predicts new-onset back pain 1 year

after pain-free baseline (Linton et al., 2000)

– Measures:

• Pain Catastrophizing Scale

• Fear Avoidance Beliefs Questionnaire

• Fear of Daily Activities Questionnaire

– Treatment consideration:

• Graded exposure (Darnall, 2019; Zeppieri & George, 2009)

Elliott & Walton,

2018

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• Socioenvironmental Context

– Wide-ranging contextual factors

– Examples: poor access to care; relationships

with family, friends, employer; cultural beliefs

Elliott & Walton,



– Those with low educational attainment are

three times more likely to develop chronic

post-surgical pain after knee replacement

(95% CI: 1.09-9.93) (Nunez-Cortes et al., 2019)

– Low education and low job position predicted

low back pain six months later (Fliesser et al., 2017)

Elliott & Walton,

2018








• Sensorimotor Dys-Integration

– Discordance between perceived self and

actual self. A problem of interoception.

Elliott & Walton,



– Those with neck pain are more likely than

those without pain to show “Joint Position

Sense Error” (de Vries et al., 2015)

– Caution: mechanisms and directionality still

unclear

Elliott & Walton,

2018









Elliott & Walton,

2018 Clinical Model of TriangulationSocioenvironmental

Cognitive/Belief

Emotional/

Affective


Nociceptive /

Physiological

Sensorimotor

Dys-integration

Very

Low

Low

Moderate

High

Very High

Elliott & Walton, 2018

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45 46

47 48


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Purely NociceptiveSocioenvironmental

Cognitive/Belief

Emotional/

Affective


Nociceptive /

Physiological

Sensorimotor

Dys-integration

Very

Low

Low

Moderate

High

Very High

Elliott & Walton, 2018A More “Common” Pattern

Socioenvironmental

Cognitive/Belief

Emotional/

Affective


Nociceptive /

Physiological

Sensorimotor

Dys-integration

Very

Low

Low

Moderate

High

Very High


My Person In PainSocioenvironmental

Cognitive/Belief

Emotional/

Affective


Nociceptive /

Physiological

Sensorimotor

Dys-integration

Very

Low

Low

Moderate

High

Very High

Elliott & Walton, 2018Your Person In Pain?


Socioenvironmental

Cognitive/Belief

Emotional/

Affective


Nociceptive /

Physiological

Sensorimotor

Dys-integration

Very

Low

Low

Moderate

High

Very High

Objectives






Objectives






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Why we need the narrative Why we need the narrative:

“Pain narrative is the most conceptually

aligned with the definition of pain.

“Pain narrative best supports ethical

principles when applied to practice.

“Pain narrative is commonly regarded as a

root source of validity in research and

practice.”

Wideman et al., 2019, p. 215

The Multimodal Assessment Model of Pain

Wideman et al., 2019

The Multimodal Assessment Model of Pain

Wideman et al., 2019

Narrative-based medicine

Definition:

Narrative medicine is medicine practiced with

the competence to recognize, absorb, interpret,

and be moved by the stories of illness.

Charon et al., 2016; Zaharias 2018

Narrative medicine

Attention

Representation

Affiliation

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Narrative medicine

Attention Representation Affiliation

“Absorbing what can be learned about [a]

person’s situation”

“Embracing patients as teachers”

“Becoming a recognizing vessel”

Charon, 2007

Narrative medicine


Making “audible and visible that which

otherwise would pass without notice.”

Telling, writing, drawing, sculpting, singing…

Charon, 2007

Narrative medicine


Charon, 2007

“The authentic and muscular connections

between doctor and patient…”

“To creatively ‘think with stories’ toward

personal and public meaning.”

Strive for therapeutic alliance

Narrative medicine: Close Reading

1. Observation

2. Perspective

3. Form

4. Voice

5. Mood

6. Motion

Charon et al., 2016


1. Observation

– Perceiving the concrete details.

– Seeing, hearing, touching.

– Descriptions, sensations.

Charon et al., 2016


1. Observation

2. Perspective

– Are there multiple perspectives?

– What are the assumptions, beliefs of the

perspective?

Charon et al., 2016

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1. Observation

2. Perspective

3. Form

– What is the genre (e.g., story, cautionary tale,

poem, film)

– Notice metaphor or imagery

– Note the order (e.g., chronological, random)

Charon et al., 2016


1. Observation

2. Perspective

3. Form

4. Voice

– First-person, third-person

– Self-aware or not

– Intimate or remote

Charon et al., 2016


1. Observation

2. Perspective

3. Form

4. Voice

5. Mood

– Emotions of the teller

– Intended emotions of the reader

Charon et al., 2016


1. Observation

2. Perspective

3. Form

4. Voice

5. Mood

6. Motion

– Where does the story move?

– Where does it end?

– Where does it want to go? Charon et al., 2016

Close Reading

1. Observation

2. Perspective

3. Form

4. Voice

5. Mood

6. Motion

Charon et al., 2016

1. Observation

2. Perspective

3. Form

4. Voice

5. Mood

6. Motion

Charon et al., 2016

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What is

happening in

this painting?

How is your

“person in pain”

like this person?

The Old Guitarist, Pablo Picasso, 1903-04

Photo: Christopher Rose, https://www.flickr.com/photos/khowaga/6377179033/in/photostream/, license (CC BY-NC 2.0)

Narrative Medicine Exercises

• Practice close reading of…

– Fiction

– Poetry

– Art

– Music

– Film

• Write, using prompts:

– “What happened during that encounter?”

– “What is that person’s story?”

– “What letter would you write to the person in pain?”

Objectives






Objectives






Evidence for Narrative Medicine

• Narrative medicine practices lead to...

– Increased knowledge of patients in settings

such as genetics counseling, fetal cardiology,

surgical training, and primary care

– Increased patient-centered communication

– Increases in empathy

– Increases in reflection on practice

Charon et al., 2016

Explore mechanisms based on narrative


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https://www.flickr.com/photos/khowaga/6377179033/in/photostream/


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Plan treatment based on mechanisms


When Narratives Collide

You A Story,

Text, or

Art Form

Stilwell & Harman, 2019

When Narratives Collide

You Your

Person In

Pain

Stilwell & Harman, 2019

When pain is paradoxical…

The sciences teach us about the

mechanisms of pain.

The humanities teach us about the

narrative of pain.

Combined, they teach us about progress

despite the paradox of pain.

When pain is paradoxical… When all else fails…

“The secret of the care of the patient is in

caring for the patient.”

-Francis Peabody, MD

March 19, 1927

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When all else fails…

May persons in pain… attain happiness

May persons in pain… be free from suffering

May persons in pain… never be separated

from joy

May persons in pain… abide in peacefulness

Resources

• Free Articles

– Chimenti 2018, Charon 2007, Charon 2016

• Books

– Principles and Practice of Narrative Medicine

– The Body in Pain Elaine Scarry

– Kitchen Table Wisdom Rachel Naomi Remen

– Explain Pain David Butler / Lorimer Moseley

– Mechanisms and Management of Pain for the

Physical Therapist Kathleen Sluka

Resources

• Podcasts

– Pain Reframed

– Pain Science and Sensibility

– Stories: Moth

– Stories: On Being

• Blogs

– MyCuppaJo.com

– Healthskills by Bronnie Thompson

Resources

• Clinical Tools

– Nocifacts by Melissa Farmer

• (FREE pain education)

– ISPI Free Information

– Matt Dancigers’s Pain Science Binder

– Joe Tatta’s 5 pillars of pain care

• Facebook Groups

– Exploring Pain Science

– Painful Stories (and How to Hear Them)

Thank you!!!

Twitter: @zachrstearns

Email: [email protected]

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Rheum, 47(1), 1-8. doi:10.1016/j.semarthrit.2017.02.008

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• Johnson, M. I. (2019). The Landscape of Chronic Pain: Broader Perspectives. Medicina (Kaunas), 55(5). doi:10.3390/medicina55050182

• Karos, K., Williams, A. C. C., Meulders, A., & Vlaeyen, J. W. S. (2018). Pain as a threat to the social self: a motivational account. Pain, 159(9), 1690-1695. doi:10.1097/j.pain.0000000000001257

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6256939/



https://www.amazon.com/Principles-Practice-Narrative-Medicine/dp/0199360197

https://www.amazon.com/Body-Pain-Making-Unmaking-World/dp/0195049969

https://www.amazon.com/Kitchen-Table-Wisdom-Stories-Anniversary/dp/1594482098

https://www.amazon.com/Explain-David-Butler-Lorimer-Moseley/dp/0987342665

https://www.amazon.com/Mechanisms-Management-Pain-Physical-Therapist/dp/1496343239/ref=dp_ob_image_bk

https://www.ispinstitute.com/pain-reframed-podcast/

https://ptpodcast.com/podcasts/pain-science-and-sensibility/

https://themoth.org/podcast

https://onbeing.org/

http://mycuppajo.com/

https://healthskills.wordpress.com/

https://visceralmind.science/nocifacts/

https://www.ispinstitute.com/free-information/

https://www.themanualtherapist.com/2016/05/patient-education-binder.html

https://www.integrativepainscienceinstitute.com/

https://www.facebook.com/groups/ExplainingPainScience/

https://www.facebook.com/groups/narrativemed/


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• Nguyen, R. H., Turner, R. M., Rydell, S. A., Maclehose, R. F., & Harlow, B. L. (2013). Perceived stereotyping and seeking care for chronic vulvar pain. Pain Med, 14(10),

1461-1467. doi:10.1111/pme.12151

• Nunez-Cortes, R., Chamorro, C., Ortega-Palavecinos, M., Mattar, G., Paredes, O., Besoain-Saldana, A., & Cruz-Montecinos, C. (2019). Social determinants associated to chronic pain after total knee arthroplasty. Int Orthop. doi:10.1007/s00264-019-04370-6

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