Joanne Smithson and Philippa Bolton

Objectives for today

1. Increase knowledge and skills of front line providers in managing patients with persistent physical symptoms

2. Improve the health outcomes for patients with persistent physical symptoms: More confident to self manage their symptoms

Better quality of life

Better knowledge and skills with own access to resources/ tools to supportthese outcomes

Reduction in ineffective unsafe use of medication / tests/ referrals

Who are these patients? In the next 60 seconds, write down the presentations

of all the patients with persistent physical symptoms in your clinics that you have seen in the last 3 days.

What proportion of outpatients present with all or mostly functional symptoms?

Gastro – 50%

Neuro – 30%

Gynae – 60%

Respiratory – 30%

Cardiac – 30%

GP – 20%

The patient:

Patient

GP

Gynae

Gastro

A and E

Pain clinic

Mental health

Gen surgery

The Science Patients want and need a non judgemental

physiological explanation of symptoms – ie some science to explain their symptoms and the rationale for treatment.

Key concepts:

Symptoms are produced all, or mostly, centrally.

Disease management and symptom management are not synonymous.

Pain matrix

Brain plasticity

What does this translate to?Brain area Clinical implications

Emotion

Positive reinforcers

Negative reinforcers

Prediction

Memory

Ask about impact of symptom on mood

How might we reinforce helpful and unhelpful symptom behaviours

Ask – what do you think will happen?

Ask – have you or your family had symptoms or illness like this before?

What things do we do that positively and negatively reinforce pain and pain behaviour? Write down ideas in the next 60 seconds – you can

discuss with the person next to you!

First. Do no harm. We can harm patients by reinforcing unhelpful

symptom behaviours:

1) reliance on medical profession to provide short term relief – tests/ referrals/ appointments / drugs/ operations are potent positive reinforcers and reduce pain temporarily leading patients to seek more of these things.

Did you know that in acute back pain, requesting MRI’s means patients are more likely to develop chronic pain than if an MRI is not requested.

2) providing sick notes with no concurrent consideration about preserving function / rehabilitation/ supporting patients to maintain employment increasing focus and attention on symptoms and reinforcing that the patient is sick and unable to cope.

3) providing opiates – they don’t work in chronic pain, kill people, and recent work suggests that in chronic pain they are treating affect, not pain, leading to pain being produced to procure opiates when patient feels distress (backward conditioning)

Reinforcing the positives Good psychoeducation – explores salience of

symptoms and can reduce catastrophizing cognitions and predictions.

Treat anxiety and depression – duloxetine for chronic pain often works better than opiates.

Find ways to reinforce that the patient can cope with and manage the symptoms without relying on you as the doctor ie how can we help you get the best quality of life with these symptoms?

The role of focus and attention (using FND as an example)

Focus and attention (it is not all about stress):

Consciousness split into 2 systems – actions you consciously think about (eg walking backwards) and actions you do without thinking and are in muscle memory (walking forwards).

If thinking interferes with the muscle memory, the you can lose the ability to access the muscle memory and things go wrong. So often an illness/ accident can precipitate a functional presentation.

The more focus and attention you give a symptom, the worse this process gets.

In NEAD, EEG findings have demonstrated that attention goes massively inwards just prior to a seizure. Which is why grounding techniques,

which pull attention outwards, work.

Physiotherapy can resolve two thirds of fixed functional neurological symptoms (tremor, gait disturbance, spasm) by

tricking the mind into stopping the ‘thinking interference’ (pulling the attention onto something else to stop the interference by using

music, mirror image work, speeding up an action etc)

Using social prescribing to pull attention away from symptoms and towards quality of life works in a

powerful way to reduce symptoms. Use diary cards with patients to prove it to you and them.

In speech disorders you can overcome the thinking

interference by using a different mode of sound –singing, reading, talking

in a foreign language

The impact on the body

Sympathetic vs Parasympathetic Nervous System

Muscle Tension

Hormone changes

Immune system changes.

We can now use biofeedback kits to test HRV and help patients recognise when their bodies are in a state of ‘wellness’. We can do this to train patients in relaxations etc, but also to target interventions – eg one person may have good HRV will

choir, another with pilates.

Exercises such as T’ai Chi, Yoga and pilates are good for getting the

body to get the vagal nerve working – body feedback to the mind and muscles back where they should be, and improved core strength

You can explain to patients that the vagal nerve can be

controlled by how people think and feel, so by doing things

that make people feel calm and good, the vagal nerve will work

better, and symptoms will reduce.

Fabulous Resource Moment A series of three short films featuring ‘Brainman’ have

been developed by an Australian partnership (GP Access and the Hunter Integrated Pain Service) supported by Professor Lorimer Mosely.

Understanding Pain in less than 5 minutes

https://www.youtube.com/watch?v=5KrUL8tOaQs

This video introduces people with chronic pain to aself-management tool that will help them manage the impacts of chronic pain on their functioning, emotions and interpersonal relationships.

Effective explanations are: Tangible, credible and linked to mechanisms in the body:

“I think these symptoms are occurring because your balance system isn’t working properly. Would it help if I tried to show you how the balance system works – how it communicates with your brain?”

Blame free reinforcing symptoms are real and not inadvertently blaming the patient: “your brain has lost trust in your balance system” or “your balance system is no longer accurately telling your brain what is happening” rather than “you have become more sensitive to movement.”

Involving - moving from symptoms to action: “how about downloading the vestibular rehabilitation leaflet from the Ménière’s Society website and working to retrain your brain, so that it trusts your balance system again.”

Difficult to get diagnosis, prognosis and validation

Cause can be someone else’s fault

Misconceptions about symptoms and pain

Accepting there is often no cure or complete relief

Impacts on every aspect of life

Co-morbidity

Why are PPS so difficult to live with for patients?

Why are PPS so difficult for practitioners?

Medical model does not work well

Drugs don’t work well

We worry we still might miss something ‘treatable’

Patients can feel hard work

We are not sure what else we can do

We actively take on responsibility for fixing…

Key elements of new approach

Name emerging persistent physical symptoms <6months onset and manage expectations from the start

Shift focus from biomedical to biopsychosocial; person centredapproach with shared responsibility

Explain symptom and Explore symptom impact

Move from HOW IS SYMPTOM? to HOW IS YOUR LIFE?

Use of tools + guides to help understanding and self management

Less drugs/ always framed as a trial

More effective, timely, and successful referrals to wider support services

Three proactive consultations

The basic modelRecognise PPS, tentatively name it, secure buy in to new approach

Hear the story, and start exploring broader IMPACTUse the 2 questions if necessary: activity and mood

AGREE A NO TEST APPROACH

Start trying to SHIFT the conversation - from search and fix towards

– acceptance/ understanding/ and living well with

Explanation of symptom Exploration of impact

Introduce Self management: identify a task

Consultation 3 Follow upToolkits/ Exercises/ Techniques and referral - Less meds/ more patient responsibility

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Introducing the model/intervention/doing things differently piece I think your symptom may not be as simple as we first thought We would hope this type of symptom, in this situation, would be

getting less/ better controlled with the meds/ starting to fade….so it is not straightforward. We need to change tack

Could we move forward … as this symptom is tricky ... And can we look at it in a different way?

I think you have something called a persistent physical symptom / a persistent pain problem....

We know that at this stage that there is no longer any tissue damage and yet you are still experiencing lots of pain – I think your pain problem is changing…

We need to work together and differently... Are you up for that?

Two helpful/probing questions

During the past month have your symptoms prevented you from doing your day to day activities?

During the past month have your symptoms made you feel worried or low in mood?

The basic modelRecognise PPS, tentatively name it, secure buy in to new approach

Hear the story, and start exploring broader IMPACTUse the 2 questions if necessary: activity and mood

AGREE A NO TEST APPROACH

Start trying to SHIFT the conversation - from search and fix towards

– acceptance/ understanding/ and living well with

Explanation of symptom Exploration of impact

Introduce Self management: identify a task

Consultation 3 Follow upToolkits/ Exercises/ Techniques and referral - Less meds/ more patient responsibility

Co

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Biopsychosocial historyQuestions that link bodies and minds:

So tell me a bit about how life was like for you a few months before your symptoms started?

Questions that link symptom to circumstance:

When you first had the symptom what was happening? Who was around? What did they say or do?

Questions that situate the patient and symptoms:

It would really help me to know a little more about you. Have you picked up any patterns in the symptom and what is happening in your life?

Exploring symptom and impact Predisposing factors – what’s in the past that is

relevant?

Precipitating factors – what happened in the few months before the symptoms started?

Perpetuating factors – what’s making the symptoms worse?

Protective factors – what makes symptoms better?

The basic modelRecognise PPS, tentatively name it, secure buy in to new approach

Hear the story, and start exploring broader IMPACTUse the 2 questions if necessary: activity and mood

AGREE A NO TEST APPROACH

Start trying to SHIFT the conversation - from search and fix towards

– acceptance/ understanding/ and living well with

Explanation of symptom Exploration of impact

Introduce Self management: identify a task

Consultation 3 Follow upToolkits/ Exercises/ Techniques and referral - Less meds/ more patient responsibility

Co

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Five areas, person centred model

Life Situation/Practical Problem etc. Memory; boss bullying me,

stress with neighbours, gas bill due this week

Altered thinking

Altered physical sensations Altered mood (emotions)

Altered behaviour / actions

Neck pain, stiff shoulder, I sleep badly, tired all day

Worried, low

Stopped work & my daily dog walks, Just watching daytime TV. And rest whenever I can. Don’t

go out much now

I can’t cope anymore, nothing helps no money coming in, lost my future now. I worry something

worse will go wrong with my neck

Provided by Sally Wood, North Tyneside.

Here’s a couple we prepared earlier…

The basic modelRecognise PPS, tentatively name it, secure buy in to new approach

Hear the story, and start exploring broader IMPACTUse the 2 questions if necessary: activity and mood

AGREE A NO TEST APPROACH

Start trying to SHIFT the conversation - from search and fix towards

– acceptance/ understanding/ and living well with

Explanation of symptom Exploration of impact

Introduce Self management: identify a task

Consultation 3 Follow up – did the patient succeed in the task?Toolkits/ Exercises/ Techniques and referral - Less meds/ more patient responsibility

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acceptance,improved symptom relief

theself care

cycle

activity planning,goal setting

self help + support options

plan, prioritisepace activities

getting fitterprogramme

relaxation skills

ways toimprove sleep

skills to manageunhelpful moods

challengenegative thoughts,positive self-talk

sustain change,manage setbacks

assertiveness,problem solving

healthy eating

Changing the impact of persistent physical symptoms: Self care cycle

The ‘how’ – knowledge, skills, tools and resources

Adapted from resources on the Live Well with Pain website

Self management – next steps ‘What’s causing my symptoms?’ leaflet

Self help cycle

Pain toolkit

Live well with pain website www.livewellwithpain.co.uk

www.neurosymptoms.org website for functional neurology

Social prescribing, walking groups, art groups

Identify what’s available in your local area and how best to refer

Yellow flags from BMJ article on back pain

BMJ2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7388.535 (Published 08 March 2003) Cite this as: BMJ 2003;326:53

A negative attitude that back pain is harmful or potentially severely disabling

Fear avoidance behaviour and reduced activity levels

An expectation that passive, rather than active, treatment will be beneficial

A tendency to depression, low morale, and social withdrawal

Social or financial problems

How will we know if we are making a difference?

Brief illness perception questionnaire (B-IPQ)

Explores cognition and emotion

Cognition: identity, consequences, cause, timeline, cure or control

Emotional: fear, anger, distress

Patients with a better understanding of what’s causing their symptoms utilise more proactive coping strategies

Negative illness perceptions are associated with poorer recovery

Key messages

Increase knowledge + skills of front line providers managing patients with persistent physical symptoms:

Name emerging persistent physical symptoms <6months onset

Shift focus from biomedical to biopsychosocial; person centred approach with shared responsibility

Explain symptom and Explore symptom impact

Move from HOW IS SYMPTOM? to HOW IS YOUR LIFE?

Use of tools + guides to help understanding and self management

Less drugs/ always framed as a trial

More effective, timely, and successful referrals to wider support services

2-3 consultations