PERSISTENT PAIN: KNOWLEDGE AND TOOLS FOR OT/OTAS TREATING PATIENTS WITH PAIN

Transcription

1 PERSISTENT PAIN: KNOWLEDGE AND TOOLS FOR OT/OTAS TREATING PATIENTS WITH PAIN P R E S E N T E D B Y L I N D S AY M AR T H, M A, O T R / L, B C P R, T P S F O R M O T A C O N F E R E N C E O C T O B E R A D A P T E D F R O M P R E S E N T A T I O N S C R E A T E D B Y L I N D S A Y M A R T H, M A, O T R / L, B C P R, T P S & B E C K Y V O G S L A N D, D P T, O C S, C S M T, T P S HOUSTON: WE HAVE A PAIN PROBLEM Rates of Chronic Pain 1990 s 1:7 Pain Medication Prescription 2000 s 1:4 PEOPLE DON T DIE FROM PAIN, RIGHT? How many Americans die each day from opioids?

2 BUT WE RE WORKING SO HARD (DEYO AND MIRZA 2006; BRUMMETT C.M., URQUHART A.G., ET AL 2015) % Increase Approximate Changes in Surgery Prevalence 13% Increase 400% Increase 99% Increase 59% Increase Spinal Fusions Total Hip Spinal Stenosis Total Knee TKA Revisions Arthroplasty Surgeries Involving a Arthroplasty Among Among Medicare Fusion Medicare Beneficiaries Beneficiaries DO WE NEED MORE FANCY TESTS? What do we know about bulging discs?? If 100 people without pain are given an MRI, how many of them would have a bulging disc? 10% 20% 30% 40% Arthritis and LBP Arthritis Low Back Pain COMORBIDITIES Chronic pain is rarely the only issue clients face. Common comorbidities include: Anxiety, PTSD, depression, trauma, insomnia TBI, CVA, amputation Diabetes, cancer, autoimmune diseases, IBS 2

3 WORDS THAT HARM VS WORDS THAT HEAL Words That Harm What does this look like? Metaphors to explain complex concepts Medical jargon What are the results? Influencing therapeutic bias Fear Ambiguity and confusion Words That Heal What does this look like? Adaptive Empathetic Silence Attention to non-verbal cues What are the results? Encourages questions Builds therapeutic alliance HAVE YOUR CLIENTS BEEN TOLD? I reviewed the MRI and you have some degenerative changes in the lumbar spine, particularly at the L4-5 level where you have a disc bulge which may be contacting a nerve root. You have a really severe case of scoliosis, the worst I have ever seen. What you really need is a neck replacement, but we don t do those so you just have to learn to live with it. HAVE YOU EVER TOLD A CLIENT? The arthritis in your hands is bone on bone, you need to be really careful with everything you do or this will continue to get worse and worse. You need to be really careful with your walker, if you fall and end up in a wheelchair things will be worse for you. Listen to your body. If it hurts, don t do it. 3

4 DO YOUR CLIENTS EVER SAY TO THEMSELVES? When my pain gets better I will get on with my life. If only they can find out what s wrong, they can fix my pain problem. Physical therapy never works. I do everything I can. WHY IS THIS IMPORTANT? Adapted from Vlaeyen and Linton, 2000 OT SCHOOL DAY 1 Social Context Behavior Distress Biological Attitudes & Beliefs PAIN Psychological Social 4

5 BIOPSYCHOSOCIAL INDICATORS The power of the pain story Fear/ anxiety Catastrophizing Stressors Different Explanations/ Failed Treatments BIOPSYCHOSOCIAL INDICATORS- MEASURES Self-report measures Attitudes & Beliefs: E.g. Fear Avoidance Beliefs Questionnaire (FABQ) Function & Symptoms: Keele STarT Back PROMIS tools Behavioral observations Physical exam WHAT S THE HISTORY? 1600 s Decartes Cartesian Model 2000 s Melzack Neuromatrix Model 1965 Melzack & Wall Gate Theory 5

6 PAIN NEUROSCIENCE EDUCATION Explaining pain with a focus on biology & physiology instead of anatomy & pathology, using non-threatening concepts & language. Early 1990s Pain science & manual therapy Gifford, Butler 2005-present Secondary studies of PNE with other conditions Meeus, Nijs, Ryan, Louw & Puentedura Current & future states PNE as preemptive to prevent chronicity RCT s on PNE & CLBP Moseley Systematic reviews on PNE Clark, Louw Adapted from Louw, Puentedura, 2013 WHAT S IN A NAME? (LOUW 2016) Therapeutic Neuroscience Education Explain Pain Pain Science Education Pain Neuroscience Education (PNE) 6

7 CLINICIAN KNOWLEDGE OCCUPATIONAL THERAPY: UNTAPPED POTENTIAL FOR CHRONIC PAIN MANAGEMENT BY JAMES CHOO, MD PAIN MEDICINE NEWS SEPT 2017 Understanding the profession was our first challenge OT practitioners we encountered had little to no formal training (pain conditions, psychological considerations, treatments) They, in turn, taught us how neatly they fit into nearly all interdisciplinary spaces, as they are a conduit for the biopsychosocial treatment for many chronic conditions. Occupational therapy s distinct value is the ability to assess how the psychosocial and physical implications of pain affect a person s ability to participate in (life) 7

8 NEUROPHYSIOLOGY OF PAIN QUESTIONNAIRE (NPQ) (MOSELEY, 2003) 1. Receptors on nerves work by opening ion channels (gates) in the wall of the nerve. 2. When part of your body is injured, special pain receptors convey the pain message to your brain. 3. Pain only occurs when you are injured. 4. The timing and intensity of pain matches the timing and number of signals in nociceptors (danger receptors). 5. Nerves have to connect a body part to your brain in order for that body part to be in pain. 6. In chronic pain, the central nervous system becomes more sensitive to nociception (danger messages). 7. The body tells the brain when it is in pain. 8. The brain sends messages down your spinal cord that can increase the nociception (danger message) going up the spinal cord. 9. The brain decides when you will experience pain. 10. Nerves adapt by increasing their resting level of excitement. NEUROPHYSIOLOGY OF PAIN QUESTIONNAIRE (NPQ) (MOSELEY, 2003) 11. Chronic pain means that an injury hasn t healed properly. 12. Nerves can adapt by making more ion channels (gates). 13. Worse injuries always result in worse pain. 14. Nerves adapt by making ion channels (gates) stay open longer. 15. Second-order nociceptor (messenger nerve) post-synaptic membrane potential is dependent on descending modulation. 16. When you are injured, the environment that you are in will not have an effect on the amount of pain you experience. 17. It is possible to have pain and not know about it. 18. When you are injured, chemicals in your tissue can make nerves more sensitive. 19. In chronic pain, chemicals associated with stress can directly activate nociception pathways (danger message nerves). PAIN PROCESSING 7. The body tells the brain when it is in pain. Answer: False 8

9 NOCICEPTORS (LOUW, 2013; LOUW & PUENTEDURA, 2013; BUTLER & MOSELEY 2003) 2. When part of your body is injured, special pain receptors convey the pain message to your brain. Answer: False The school bus and the sprained ankle Sound receptors, light receptors, & nociceptors PAIN AND INJURY 3. Pain only occurs when you are injured. Answer: False 4. The timing and intensity of pain matches the timing and number of signals in nociceptors (danger receptors). Answer: False Amplification of signaling or action potential windup INJURY LEVEL AND HEALING 11. Chronic pain means that an injury hasn t healed properly. Answer: False 13. Worse injuries always result in worse pain. Answer: False 9

10 PERCEPTION OF THREAT Is this dangerous?? YES! No Pain is produced; pathways adapt to provide more information about the threat Pain is not produced; inhibitory activity modulates the danger messages PERCEPTION 9. The brain decides when you will experience pain. Answer: True PNE directly impacts the patient s perception of threat and therefore impacts their pain experience CENTRAL SENSITIZATION (LOUW, 2013; LOUW & PUENTEDURA, 2013; BUTLER & MOSELEY 2003) 6. In chronic pain, the central nervous system becomes more sensitive to nociception (danger messages). Answer: True Wet brain vs. dry brain release of chemicals such as opioids, endorphins, and serotonin are reduced DANGER DANGER 10

11 Initial Response Higher Level Processing Pain Neurotag 10/23/2018 ION CHANNELS (LOUW, 2013; LOUW & PUENTEDURA, 2013; BUTLER & MOSELEY 2003) 10. Nerves adapt by increasing their resting level of excitement. Answer: True Peripheral sensitivity Types of ion channels: movement, stress, temperature, pressure, immune Plasticity Ion channels continually change based on what your brain feels it needs to protect you PAIN NEUROTAG (LOUW, 2013; LOUW & PUENTEDURA, 2013; BUTLER & MOSELEY 2003) The danger response is processed in the lower centers of the brain The higher levels of the brain process feelings, thoughts, planning, memory, etc. A specific neural signature of the pain experience is developed where the basic danger signal and higher level processing are connected Nerves that fire together wire together The pain map is also impacted by beliefs, knowledge/ logic, social context, anticipated consequences, and other sensory cues ENVIRONMENT & STRESS 16. When you are injured, the environment that you are in will not have an effect on the amount of pain you experience. Answer: False 19. In chronic pain, chemicals associated with stress can directly activate nociception pathways (danger message nerves). Answer: True 11

12 ENVIRONMENT & STRESS CONT D (LOUW, 2013; LOUW & PUENTEDURA, 2013; BUTLER & MOSELEY 2003) Environmental issues (work, stress, anxiety, financial concerns, beliefs and fears) can lessen or increase the pain experience. Injuries in high-stress environment 7-8X more likely to develop chronic pain. Positive Effect: demolition derby drivers PAIN IS NOT THE NERVOUS SYSTEM S ONLY TOOL. Immune System Nervous System Endocrine System PNE BASICS (LOUW, 2013; LOUW & PUENTEDURA, 2013; BUTLER & MOSELEY 2003) Impact of stress, environment, cognitions, and past experiences on the processing lens. Anything that affects the nervous system affects the whole nervous system. pain, sleep, mood, cognition, digestion, etc. 12

13 THE MATURE ORGANISM MODEL (ADAPTED FROM SWANSON, 2014; GIFFORD, 1998) Behaviors, choices, movement, social interactions, health management Experiences, beliefs, knowledge, culture, motor pattern, fear, perception of threat Nociception, stressors, social supports, tissue health HOW DO YOU DO PNE? Visual: Paper &/or whiteboard, Pre-made pictures, wall posters Pre-planned stories/analogies/facts Homework Create an environment that is consistent with the message Get the team on board Learning theory NERVES AS ALARMS Alarm 13

14 NERVES AS ALARMS Alarm PNE SPRINKLES Language like "setting off the pain alarm "danger messages nerves making "noise This Photo by Unknown Author is licensed under CC BY-NC-SA Pain problem vs tissue issue as validating rather than invalidating PNE SPRINKLES CONT D Find common ground and build upon using information about pain processing 14

15 SCRIPTED EXAMPLES "it sounds like the nerves in your back are making a lot of noise down there and that is triggering off your pain alarm" starts to set the stage that the pain is not being sent by the back but rather is in response to the information (and potentially other things) "your tissues aren't perfect but the really high levels of pain you are experiencing indicates we need to look at this from a broader perspective" "you told me that your feet feel like they are burning, but we know your feet are not actually on fire- when those nerves are making a lot of noise, they don t give your system accurate information about what is happening in your body and that can trigger off your pain alarm You said your leg hurts more when it's cold outside. I can help explain why that happens. Is your leg in any more danger when it's cold? No, then why does the danger alarm-pain- go off louder? There are gates in our nerves that open in response to different things, temperature is one of them. If enough of those gates open, the nerve sends the danger message. When it's cold your nerve makes extra noise and because your system is on higher alert it is setting off the pain alarm louder, even though you are not in any more danger. "---- > "There are other gates that open when you move, that is why sometimes when you move your nerves make more noise and you experience more pain even though you aren't in any more danger" EDUCATION KEY POINTS Your nerves act like an alarm system. Pain is a normal mechanism designed to keep you safe. The sensitivity of that alarm can increase or decrease based on a number of factors. There are things that you can do to influence this process. Treatments are geared toward decreasing the sensitivity of the system and increasing tolerance for activities. TRADITIONAL PAIN TREATMENT Traditional pain treatment tools have been targeted at body tissues- find it and fix it. Procedures: MBB, RFA, injections, Botox, etc. Surgery Medication Exercise Manual therapy What does it mean when these don t work?? What happens next?? 15

16 NEW GAME; NEW RULES Retraining the CNS/PNS vs find it fix it All hands on, movement, and self-management interventions viewed through this lens and adapted Biopsychosocial paradigm for patient and clinician Education, retraining maladaptive thought and behavior patterns, & active rehab/ lifestyle tools INTEGRATING SELF-MANAGEMENT V E M A Validate Take time and energy to build rapport Listen to the patient's story Empathize Acknowledge the road to your door Employ therapeutic use of self and the therapeutic alliance Thorough physical evaluation VEMA Model created by Anthony J. Mariano, PhD Clinical Psychologist, Pain Service VA Puget Sound Health Care System EVALUATION PROCESS Self-report: typical daily functioning and routines, ADL/IADL, health management, pain factors, psychosocial Objective evaluation: myofascial, UE/ hand function, sensory, cognition Focus on rapport building; set stage for selfmanagement and biopsychosocial treatment approach Identify functional goals and get the patient focused on these as the treatment aims. 16

17 MI & OPEN ENDED QUESTIONS What do you think is wrong? What do you think could make it better? What do you think could make this worse? What are your fears? Is there anything about this plan that you don t think applies to you? Is there anything you want more information about? INTEGRATING SELF-MANAGEMENT V E M A Educate Empower patient with knowledge about PAIN Increase insight into what they re experiencing and the treatment plan Instruct on what the provider will do and what the patient needs to do Provide guidance on expected timeline for progress PAIN NEUROSCIENCE EDUCATION 17

18 INTEGRATING SELF-MANAGEMENT V E M A Motivate Assist in developing clear, functional goals Use SMART goal format to make goals effective and relevant to the patient s life Nurture internal investment in long-term commitment to the plan FUNCTION TIME PAIN INTEGRATING SELF-MANAGEMENT V E M A Activate Implement various bottom up and top down tools based on clinical decision making & patient preference Routine development & structure to increase consistent carryover 18

19 PAIN TREATMENTS Bottom Up *Surgery *Procedures *Medication *Rule Out Red Flags *CBT *Graded Motor Imagery *Pain Science Education *Relaxation/ Mind-Body Skills *Biofeedback *Social/ Leisure *Pacing/ Task Modification * Sleep Top Down *AE *Exercise *Modalities *Manual Therapy * Nutrition TREATMENT PROCESS: BEHAVIORAL ACTIVATION (HOFFMAN ET AL 2016; O CONNOR ET AL 2015) Pacing, task modification, activity & movement as therapy Adaptive equipment prn, structure and routine development PACING: USING EXERCISE AND ACTIVITY TO FACILITATE SUCCESS, REDUCE FEAR, AND CALM THE SYSTEM 19

20 AVOIDANCE TREATMENT PROCESS: SPECIALIZED INTERVENTIONS Myofascial work, sensory retraining, modalities (e.g. TENS) Neurodynamic testing, HEP/ functional movement Mind-body skills, mindful movement & other integrative tools BIOFEEDBACK Heart rate variability (HRV): activating the ANS EMG (muscle tension): movement and tension patterns in various body regions and with headaches Thermal: general relaxation, primary used with headaches Full physiological stress profile 20

21 Marth_MOTA 2018_PNE GRADED MOTOR IMAGERY Visualization Sensory Discrimination Mirror Therapy Laterality PNE 21

22 POTENTIAL BARRIERS THE BIG PICTURE Reducing perceived threat and increasing sense of safety Treatment of complex pain takes consistent implementation of a multi-faceted, holistic plan and time. TIPS & TRICKS Include Reinforce proactive strategies & manage expectations Sore but safe Hurt does not equal harm Use images & language that validates without evoking fear Fatigued, sore, deconditioned Making a passive intervention a component of an active treatment plan Avoid Reinforcing pain contingent activity/decisions No pain, no gain If you hurt, don t do it Inflammatory images & language Ripped, torn, bulging, damaged, degenerative, severe, subluxed Making a passive intervention contingent on failing active interventions 22

23 PEARLS Chronic pain is complex and involves more than just body tissues and nerves. Past events, beliefs, emotions, stress, and the environment have a larger influence on pain. Assessment and treatment of pain must take this into account in order to maximize efficacy. Your words matter. Language is powerful and can impact the pain experience. Key Concepts of Pain Science: Nerves act like an alarm system. Pain is normal & is designed to keep you safe. The sensitivity of that alarm can increase or decrease based on a number of factors. There are things that you can do to influence this process. Treatments are geared toward decreasing the sensitivity of the system and increasing tolerance for activities. PNE RESOURCES- ONLINE Pain Fundamentals and Treatment Fundamentals by Greg Lehman: Free downloadable workbooks on pain science and pain treatment methods that can be used with patients to guide treatment Websites with courses, books for patients, videos and handouts International Spine and Pain Institute: Neuro Orthopaedic Institute: PNE RESOURCES- BOOKS Explain Pain by D. Butler & GL Moseley Why Do I Hurt? And other diagnosis specific and perioperative tools by A. Louw Painful Yarns by G. L. Moseley Pain Neuroscience Education: Teaching Patients About Pain by Louw, Puentedura, Schmidt, & Zimney Protectometer patient education tool : and other NOI tools including Explain Pain and Explain Pain Supercharged 23

24 ONLINE PAIN VIDEOS Understanding Pain in 5 Minutes Why Things Hurt - TED Talk Lorimer Moseley Understanding Pain Brainman Chooses Understanding Pain Brainman Stops His Opioids 23 ½ Hours the single best thing for health RSA ANIMATE: The Empathic Civilisation (Mirror Neurons and Empathy) Dr Mike Evans- Low back Pain Dr Mike Evans- Hip & Knee replacement surgery preparation Arthur s Story & Arthur s Transformation - Never, Ever Give Up REFERENCES Butler, D. and G. Moseley (2003). Explain Pain. Adelaide, Noigroup. Brummett, C. M., Urquhart, A. G., Hassett, A. L., Tsodikov, A., Hallstrom, B. R., Wood, N. I., Clauw, D. J. (2015). Characteristics of fibromyalgia independently predict poorer long-term analgesic outcomes following total knee and hip arthroplasty. Arthritis & Rheumatology (Hoboken, N.J.), 67(5), Deyo, R. A. and S. K. Mirza (2006). "Trends and variations in the use of spine surgery." Clin Orthop Relat Res 443: Gifford L S 1998 Pain, the tissues and the nervous system: A conceptual model. Physiotherapy84(1): Hoffmann, T.C., Maher, C.G., Briffa, T., Sherrington, C., Bennell, K., Alison, J., Singh, M.F., Glasziou, P.P.. (2016) Prescribing exercise interventions for patients with chronic conditions. Canadian Medical Association Journal; DOI: /cmaj Louw, A. (2013). Why Do I Hurt?: A patient book about the neuroscience of pain. Minneapolis, MN: Orthopedic Physical Therapy Products. Louw, A. and Puentedura, E. (2013). Therapeutic Neuroscience Education: Teaching patients about pain. Minneapolis, MN: Orthopedic Physical Therapy Products. Louw, A, Zimney, K. Puentedura, E.J., & Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. PHYSIOTHERAPY THEORY AND PRACTICE. Moseley, G.L. (2003). Unraveling the barriers to reconceptualisation of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology. J Pain. 4(4): Moseley, L. and Butler, D. (2015). The Explain Pain Handbook: Protectometer. Adelaide, Noigroup. O'Connor, S.R., Tully, M.A., Ryan, B., Bleakley, C.M., Baxter, G.D., Bradley, J.M., McDonough, S.M. (2015) Walking Exercise for Chronic Musculoskeletal Pain: Systematic Review and Meta-Analysis. Archives of Physical Medicine and Rehab, 96: Smart, KM, Blake, C, Staines, A, & Doody, C (2010). Clinical indicators of nociceptive, peripheral neuropathic and central mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians. Manual Therapy. 15, Swanson, Aaron. How Movement Goes From Inputs to Outputs Via the CNS. Digital image. Aaron Swanson PT. N.p., 1 May Web. 10 May Vlaeyen, J.W. & Linton, S.J. (2000) Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain85: