UNDERSTANDING AND DEALING WITH PAIN. Lorimer Moseley Talk. Disclosure. Patient C.C. Patient C.C. Goals 06/12/2017

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1 UNDERSTANDING AND DEALING WITH PAIN DAVID V. SMITH MD CHKD SPORTS MEDICINE Lorimer Moseley Talk ALEXANDRA LARAMEE, LCSW CHKD BEHAVIORAL HEALTH 2017 Disclosure Patient C.C. I have nothing to disclose 13 y/o female with right knee pain I am not a pain specialist By giving this talk I am not seeking to care for patients with amplified or chronic pain Putting this talk together has been an exercise in trying to understand pain better as a physician and how to treat patients with difficult pain better Injured right knee yesterday ice skating and twisted knee with valgus movement most pain medial Extreme pain, cant bear weight or bend it ER normal xrays, immobilizer crutches Goals Patient C.C. I plan to review our current biologic understanding of pain, lay framework for understanding differing individual pain perception, review amplified pain and to help us all understand how behavioral therapy can treat pain Alexandra Laramee will discuss the role of behavioral therapy and some ways we can employ it to better treat our patients pain Hx: anxiety, migraines Exam: Diffuse hypersensitivity to light touch surrounding knee and extending prox and distally Most pain over MCL, pain with valgus stress Refuses to flex or attempt to bear weight Plan -> RICE, HEP, f/u 2 weeks 1

2 Patient C.C. Traditional Pain Pathway Mom calls pain uncontrollable, worried, requesting MRI F/U: MRI normal, labs normal, exam unchanged Upset with normal results - Something's wrong! We all have patients like C.C. What s different about them? How can we better care for them? Transduction Peripheral nociceptor stim -> nerve Thermal, Mechanical, Chemical stim Transmission Transmission from periphery to CNS A-delta fast fibers sharp intense pain C-fibers- unmyelined slow dull diffuse pain Perception Activation of higher level functions Leads to response from brain Modulation Efferent nerves have inhibitory or stimulatory effects Pain and Nociception Nociception vs. Pain Nociception is the sensory nervous systems response to harmful or potentially harmful stimuli Pain is the unpleasant sensory and emotional experience of harmful or potentially harmful stimuli Model gives good framework for understanding mechanics of pain sensation We can understand where different receptors are, why certain drugs may help Doesn t explain individual differences in perception or chronic pain Doesn t reflect new understanding of complexity Evolution of Pain Why is pain so painful? Smoke Alarm Theory Individual sensory variation Natural selection tends to shape regulation mechanisms with hair triggers, following what we call the smoke-detector principle. A smoke alarm that will reliably wake a sleeping family in the event of any fire will necessarily give a false alarm every time the toast burns. The price of the human body s numerous smoke alarms is much suffering that is completely normal but in most instances unnecessary Nesse,

3 Individual sensory variation Spinal Cord Neuronal Modulation Recent research demonstrates neuronal cells involvement in amplification of chronic pain in spinal cord Individual Pain Variation Spinal Cord Integrations Congenital Insensitivity to pain 1: 1,000,000 Na Channel mutations: SCN9A mutation SCN11A Transcription Factor mutation PRDM12 mutation The dorsal horn is the major locus of integration of peripheral sensory input and descending super spinal manipulation. Peripheral non-neuronal input Dorsal Horn Circuitry Dysregulation Non-neuronal cells modulate pain pathways at all levels Non-neuronal cells produce pronociceptive(red) and antinociceptive mediators(blue) Dorsal horn contains large number of excitatory and inhibitory interneurons Numerous studies have focused on dysregulation within the dorsal horn circuit (right) as contributing to the expression of mechanical allodynia. 3

4 Emotional Integration Pain Perception Top Down Control Projection neurons relay information up to brain Project to qualitative areas and affective(emotional areas) Anxiety Depression Prior Trauma Parental / Family Input Stressfull/Adverse Life events Academics Peer Relationships/Bullying Medical System Response VS Pain Perception Top Down Control 2 groups of subjects- Each told they would be subjected to different likelihood of high intensity pain stimuli and low intensity stimuli Group 1 : 80/20 Group 2: 50/50 Then delivered same stimuli and asked to identify high or low painful stimuli Circuitry of pain and its modulation is complex These complex models don t include cognitive and emotional component Weich, K Science. Nov 2016 Pain Perception Top Down Control Prior information can modulate perception Pain can be amplified through negative expectations Pain can be reduced through expectations of pain relief Incoming sensory information is not analyzed de novo, but interpreted based on prior information. Pain is an actively constructed experience that is determined by expectations and their modification through learning Expectations are shaped by the information that is provided by health care practitioners. How could information be designed to optimally guide expectations for maximum treatment outcome? Weich, K Science. Nov

5 Patients complaints about pain that persists despite numerous treatment attempts are often dismissed as being all in their head. There is a difference between they are crazy and it s all in there head Weich, K Science. Nov 2016 Numerous diagnostic terms for pediatric chronic pain Evidence suggests a common thread of signal amplification central or peripheral Amplified Pain Syndromes is a term used to refer to forms of amplified and chronic pain - Treatments 5

6 Simple CBT in office PCP / PT References How can we use simple CBT techniques in office to help these patients? 1. Restructuring maladaptive behaviors requires setting realistic goals of treatment and dispelling misinformation PCP role Reviewing all normal imaging / labs / tests -> everything this pain is not Likely cause of pain and pain is real Expected recovery times and course This will get better 1. f 2. Two common maladaptive behaviors in chronic pain are catastrophic thinking and fear avoidance/guarding Therapist / PT Using CBT and mindfulness techniques/tools on a frequent basis Take care not to contribute to maladaptive behavious Kitchen sink treatment and overreaction to setbacks Summmary Pain is a sensory and emotional experience Pain sensation, modulation, and processing is complex and we are understanding more than can account for variation Summary We re good at treating mechanical source of pain Not as good at recognizing and treating cognitive and emotional components of pain Room for improvement Patients with APS are difficult and frustrating to treat Keep and open mind as to why they may have aberrant pain 6