Pain Education for adults with cerebral palsy
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1 Pain Education for adults with cerebral palsy Laura Pizer Gueron, PT, MPH, DPT Gillette Lifetime Specialty Healthcare AACPDM 71 st annual meeting September 13, 2017 I have no financial relationships to report Therapeutic neuroscience education Current best-evidence research shows that when health care professional explains the neurobiology and neurophysiology of pain and client truly understands it, they will have less pain, less disability, move better, perform better in rehabilitation and have improved cognitions regarding their pain On average, will decrease pain 3 points on 10 point pain scale and this will be maintained for 6 to 12 months after education Metaphors can be useful to break through unhelpful beliefs Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety and stress in chronic musculoskeletal pain. Arch Phys Med Rehab. 2011; 92(12): Moseley GL. Joining forces combining cognition with group or individual pain physiology education: A successful treatment for chronic low back pain. J Man Manip Therap. 2003; 11(2): Key Concept Re-conceptualizing pain is the activity and responsibility of the person with cerebral palsy Providing education, incorporating updated concepts of pain neuroscience is the health care providers role 1
2 Pain Education Doesn t stand alone If can eliminate pain with intervention, do that! Combine with appropriate activities/interventions, such as stander use, TENS, stretches, aerobic exercise, etc. This maximizes benefit and efficiency NCHPAD photo used with permission Goals of healthcare team to help patients to: Help to break activities up into small achievable goals Increase function/quality of life and to decrease pain (often can t totally eliminate pain) Great life, despite the pain. Instructions not no pain, no gain and not to stop when you feel any pain. Instead, tease it, touch it, nudge it. (go to edge of pain and explore) Adriaan Louw, PT, OCS, DPT from ISPI Four Pillars of Pain Education and Treatment No matter where client s areas of pain are, teach principles of: 1) Therapeutic Neuroscience Education 2) Instruction in sleep hygiene, positioning 3) Aerobic exercise 4) Goal attainment Avoid reference to anatomical or patho-anatomical models. These are not helpful for our clients with chronic pain and may increase catastrophization and fear avoidance. Gallagher L, McAuley J, Moseley GL. A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain. Clin J Pain. 2013; 29(1):
3 Chronic versus acute pain Acute pain-pathways which have evolved may prevent further damage. When we break a leg, it is important to have pain so that we stop walking. When we get our hand too near a flame, it is important to quickly withdraw our hand to minimize the burn With chronic pain, pain no longer has a protective function and pain will always or often be present even when there is no danger Coakley R, Schechter N. Chronic pain is like The clinical use of analogy and metaphor in the treatment of chronic pain in children. Ped Pain Letter. 2013; 15 (1): 1-8. Louw A, Puentedura EL, Nimtken P. Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: A case report. Physiother Theory and Pract. 2012; 28 (1); When Pain Persists Pain and catastrophization All pain is real Clients must feel that we in health care believe them and that we don t think that the pain is in their head The fear of pain can be worse than the pain itself Explain that there is good pain such as growing pain, protective pain, overuse pain, acute pain acute pain is there to protect Chronic pain is no longer protective Can ask patient to fill out PCS or FABQ if would be helpful to direct treatment/gain insights into their perspectives Nijs J, Rousel N, Van Wilgen P, Koke A, Smeets R. Thinking beyond muscles and joints: Therapist s and patient s attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther. 2012; 18(2): Sloan TJ, Walsh DA. Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. Spine. 2010; 35 (21): E
4 Re-conceptualizing pain Teach clients via metaphor and stories that show that: Chronic pain does not mean that an injury hasn t healed That many people have pain in joint regions well past normal healing time for tissues Pain can occur without injury, injury can occur without pain (bruise example) Worse injuries do not result in worse pain (paper cut versus being shot during battle but unaware examples) Hellsing A, Linton SJ. A prospective study of patients with acute back and neck pain in Sweden. Phys Ther. 1994; 74: Phaneth S, Panha P, Sopheap T, Harlacher U, Polatin P. Education as treatment for chronic pain in survivors of torture and other violent events in Cambodia: Experiences of a group-based pain school and evaluation of its effect in a pilot study. J of Applied Biobehav Res. 2014; 19(1): FABQ PCS 4
5 Placebo versus nocebo effect Language, demeanor, educational materials, explanations influence patients for better or worse Explain PAIN physiology in detail while avoiding frightening images Many people with CP have undergone many painful procedures from childhood on Overuse injuries, dysplasia of hips, issues with excessive tone and difficulty changing positions all can contribute to chronicity of pain, but pain education can still be very beneficial Concepts such as sore but safe and motion is lotion can be helpful and reassuring Blasini, M, et al. Nocebo and pain: An overview of the psychoneurobiological mechanisms. Pain Reports. 2017; 2(2), e585. Brunton L, et al. The prevalence, location, severity, and daily impact of pain reported by youth and young adults with cerebral palsy. J Ped Rehab Medicine , Klinger, R, et al. Nocebo effects in clinical studies: Hints for pain therapy. Pain Reports (2), e586. Help the client to experience success Process starts with goal setting initial evaluation and updating goals mid- way. Can include ADL s, sports, hobbies, etc. What is important to client? Be specific! SMART goals. Break up goals into smaller steps so can successfully achieve goals. Modify and refine as needed. Success breeds success! Growth, self-efficacy, non-dependence on health care team Motivational interviewing technique-highlight previous successes and highlight strengths and skills 5
Therapeutic Neuroscience Education Highlights
Therapeutic Neuroscience Education Highlights (adapted from TNE course taught by Adriaan Louw, PT, PhD, CSMT, co-founder of ISPI, (ispinstitute.com) with permission, by Laura Pizer Gueron, PT) lgueron@gillettechildrens.com
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