Mr John Moffat. Mr Chris Gregg. Dr Chris Hoffman. Dr Wei Chung Tong

Transcription

1 Mr Chris Gregg Physiotherapist TBI Health Wellington Mr John Moffat Clinical Psychologist TBI Health Group Wellington Dr Chris Hoffman Medical Director and Spine Surgeon TBI Health Auckland Dr Wei Chung Tong Specialist Anaesthetist TARPS (The Auckland Regional Pain Service) Auckland 14:00-16:00 WS #19: Pain Management Symposium 16: WS #25: Pain Management Symposium (Repeated)

2 Pain self management Dr Wei Chung TONG Pain medicine Specialist

3 Aim Try to explain the nebulous concept of pain self management

4 Reception calls: Unscheduled appointment for 4:30pm. Ongoing pain.

5 Right! I will send you to the pain clinic, they will help you

6 Dear doctor, Thank you for your referral. We have triaged your patient for a comprehensive pain assessment. Our waiting list is currently 1 year.

7 While you wait you raid the cupboards. Put out fires, one at a time.

8 Dear doctor, I saw your patient in pain clinic. He has chronic pain. Please reduce his medication. I have not made further follow-up plans. Yours Sincerely

9 Reception calls: Unscheduled appointment for 4:30pm. Ongoing pain.

10 What do they do in pain clinic?

11 New Zealand Health Survey 2011/12, 16% of adults reported chronic pain (defined as pain that occurs every day, for at least 6 months) That is about 600,000 adults

12 1 year 12 months 52 weeks 365 days 8760 hours People with long term health conditions spend about 3 hours a year with their health professional The remaining 8757 hours they are on their own

13 600,000 people X 8757h = a lot of hours alone

14 Solution = patient takes care of themselves

15 Pain Self Management

16 What is pain self management? What it is NOT It is not medication It is not physiotherapy It is not psychological support It is not a surgical procedure It is not something done to the patient It is not coping your patients are already doing it

17 What is pain self management? Manage pain by choosing ACTIVE and sustainable strategies to target the areas affected by pain.

18 Active pain management skills 1. Good sleep hygiene to improve sleep 2. Limiting rest 3. Establish regular physical activity

19 Educational component Education around why pain persists Collaborative goal setting Coping skill acquisition Physical activity pacing, graded exposure Psychological relaxation, attention regulation, communication, problem solving, cognitive restructuring

20 Learning to self manage It is like driving a car Where does the instructor sit? Where does the learner sit?

21 That s so hard! Are you sure there are no medication or injection to try?

22 Pharmacology often fails High dose opioids No high quality evidence Methadone No conclusion can be made Tapentadol further studies needed Pregabalin note effective in chronic conditions which nerve damage is not the prime source of pain Gabapentin and pregabalin in preventing migraine attacks not effective Antidepressives for NSLBP No evidence Muscle relaxants for NSLBP short term relief, adverse effects require caution NSAIDS for NSLBP Short term relief, effect size is small NSAIDS for low back pain and sciatica not more effective than placebo in reducing sciatica. Overall improvement but results should be used interpreted with caution Prolotherapy for chronic low back pain conflicting evidence Botox for lower back pain and sciatica low or very low quality Injection therapy for subacute and chronic low back pain insufficient evidence to support use of injection therapy NSAIDs low quality evidence in osteoarthritis. No evidence for other chronic painful condition. Paracetamol No evidence to support or refute provide pain relief Vitamin D No consistent pattern Vit D better than placebo. More research is needed. Gabapentin for fibromyalgia No good evidence Pregabalin for fibromyalgia Provided pain relief 10% more than placebo Milnacipran for fibromyalgia Provided pain relief to 10% more than placebo, it will not work for most people. Duloxetine for fibromyalgia low quality evidence duloxetine is effective Botox for myofascial pain inconclusive evidence Pregabalin for chronic prostatitis. Chronic pelvic pain one RCT showing that pregabalin does not improve CP/CPPS Cannabinoids FPM PM10

23 Multiple dimensions of health affected

24 Let me give you a metaphor to put self management into context.

25 Choice Engagement Change Shift in focus Partnership Time Independance

26 Ideal situation for pain management Patient: - Early chronic pain - Job attached - Surgically/ medically cleared - Motivated or willing to look at a different approach Treatment team: - Multidisciplinary team - Rehabilitation approach - Strong emphasis on self management not passive therapy - Flexible and accommodating

27 What do they do in pain clinic? Comprehensive assessment - Medical clearance for rehabilitation - Medication review and optimisation - Organise appropriate on referral, imaging or intervention - Assess impact of pain: biopsychosocial approach - Assess readiness to change - Assess barriers to change Provide pain management education and experiential guidance.

28 If patients are not ready? Patience and compassion Upskill your and patients knowledge around neurophysiology of persistent pain Encourage exploration of pain management as an alternative Reinforce current evidence Explore and identify area of life impacted by pain Adhoc supports psychology only, physiotherapy only, medication trial Harm minimisation

29 Retrainpain.org

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31 Thank You