Pain Care Doesn t Have to Be Torture

Transcription

1 Pain Care Doesn t Have to Be Torture How explaining pain to your patient can change the conversation and promote alliance and self-efficacy efficacy PRESENTED BY NORA STERN, PT, MSPT PROVIDENCE ST. JOSEPH HEALTH AND SERVICES Session objectives: Understand biopsychosocialmodel for pain, skills and treatment planning based on this model Learn key phrasing to change conversation about pain Understand resources for further pain education and motivational interviewing 1

2 PT First: $4793 less per episode of care than radiology first (Fritz 2011 n=406) But we have to get this right!!! 2

3 Christina Background Information: 54 year old female, thoracic low back and right > left leg pain, knee arthritis severe. Pain increasing in area and intensity Co-Morbidities: Type II diabetes, obesity, anxiety Pain description: Spreading into lumbar bilateral and left lower thoracic area, Rand L leg pain Hard to tell where it is sometimes Worse with cold weather. 5 Christina continued Function: Physical therapy made me pain worse. Walking limited because she hurts, uses a walker to get around the house Has no hobbies, in bed watching TV majority of day Radiology: Knee findings: severe OA bilateral Lumbar: moderate degeneration at L3-5 bilateral facets 3

4 Physical Therapy: Traditional Approach 2 times per week for 4 weeks Aerobic conditioning Core strengthening Modalities Home exercise program Old Model Pain = Tissue Damage 4

5 Context and meaning Childbirth vs. Trauma Key Points Pain Harm Adapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010 COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 10 5

6 Louis Gifford, 1998 Complex pain is complex 6

7 Acute Injury: Fewer brain processes involved in pain experience Stressresponse activates autonomic nervous system Sensory cortex: identify body part Memory: has this happened before? Problem Solving Sensory Stress Motor Memory Problem-solving: assess situation SNS Motor: acts to protect Input from Tissues COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 13 Persistent Pain: Brain functions change Problem-solving: focus on looking for answers Memory: associates actions with history of pain. Every time I bend over my back hurts. Problem Solving Sensory Stress Motor Memory Stress: chronic stress associated with disability, other life issues Sensory cortex: smudging Motor: decrease in physical activity Input from Tissues? SNS COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 14 7

8 Persistent Pain: More pain functions coupled with pain response Premotor planning: expecting pain with movement, preparing for movement evokes pain Attention: centrality of pain in one s life Fear & Fear Avoidance: associates pain with harm, avoids movement Balance and Visual Input Depression, anxiety & trauma: strongly associated with increase in persistent pain Fear & Fear Avoidance Problem Solving Depression & Anxiety Input from Tissues? Sensory Stress Attention Premotor Planning Motor Memory SNS Balance Visual Input COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 15 Possible Changes Through Understanding Pain Problem Solving Depression & Anxiety Input from Tissues? Sensory Stress Attention Premotor Planning Motor Memory SNS Balance Visual Input COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 16 8

9 Possible Changes Through Understanding Pain Problem Solving: Understanding pain, problems and solutions differently Problem Solving Sensory Stress Premotor Planning Motor Memory Depression & Anxiety Balance Visual Input Input from Tissues? Attention SNS COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 17 Possible Changes Through Understanding Pain Problem Solving: Understanding pain, problems and solutions differently Quieting stress response Problem Solving Sensory Stress Motor Memory Depression & Anxiety Input from Tissues? Attention SNS COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 18 9

10 Possible Changes Through Understanding Pain Problem Solving: Understanding pain, problems and solutions differently Quieting stress response Problem Solving Sensory Stress Motor Memory Depression & Anxiety Input from Tissues? Attention SNS COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 19 Possible Changes Through Understanding Pain Problem Solving: Understanding pain, problems and solutions differently Quieting stress response Addressing depression, anxiety and trauma and validating their role in the pain experience Problem Solving Depression & Anxiety Input from Tissues? Sensory Stress Attention Motor Memory SNS COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 20 10

11 Possible Changes Through Understanding Pain Problem Solving: Understanding pain, problems and solutions differently Quieting stress response Addressing depression, anxiety and trauma and validating their role in the pain experience Understanding fear avoidance and beginning to return to physical activity Problem Solving Depression & Anxiety Input from Tissues? Sensory Stress Attention Motor Memory SNS COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 21 Possible Changes Through Understanding Pain Problem Solving: Understanding pain, problems and solutions differently Quieting stress response Addressing depression, anxiety and trauma and validating their role in the pain experience Understanding fear avoidance and beginning to return to physical activity Problem Solving Depression & Anxiety Input from Tissues? Sensory Stress Attention Motor Memory SNS COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 22 11

12 Central Sensitization Nociceptive NMDA receptor proliferation at neuron Sensory Cortical changes Mirror neuron changes Suffering Pain catastrophizing Social Contributions Fear Avoidance Neuropathic Key Points Pain is a multi-dimensional experience All pain is real pain Nociception is neither necessary nor sufficient for pain Pain occurs when credible evidence of danger outweighs the credible evidence of safety Adapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010 COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 24 12

13 Key Points Pain Harm Adapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010 COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 25 THREAT! MRI and X-Ray results Fear of movement Struggles in living with pain Medication is the only thing that can help me 13

14 Pain Education As A Treatment Intervention Decrease in pain rating (Van Oosterwijck et al 2011, Meeus et al, 2010, Ryan et al, 2010, Moseley, 2002, 2003, 2004) Decrease in fear of re-injury (Van Oosterwijck et al 2011, Moseley, 2002, 2003) Decrease in pain catastrophizing (Meeus et al, Moseley 2004, Louw et al 2011, Arch Phys Med Reh Systematic review) Decrease in postoperative utilization of services (Adriaan Louw, PhD, PT, et SPINE Volume 39, #18) Increase in function (Van Oosterwijck et al 2011, Moseley, 2002, 2003,Louw et al 2011 Arch Phys Med Reh Systematic review) Increase in mobility (Moseley and Hodges, Clin J Pain Louw et al Physiotherapy J, 2011) Safety and Hope Understand pain Sore, but safe Quiet your worry Kisses of time Up to half the people with knee arthritis have no symptoms Bring some fun back in your life 14

15 Pain Assessment 15

16 Identifying pain: A work in progress STarT Back Screening Tool Fear Avoidance Behavior Questionnaire Patient Activation Measure PEG Brief Pain Inventory KeeleUniversity Aug 1, 2007 Hill JC, et al. Arthritis Rheum. 2008;59:

17 All Pain Treated as Biopsychosocial STarT= Low Risk STarT = Medium Risk STarT = High Risk Psychosocial Involvement Monitor Orthopedic Pain-Informed PT Best Practice; Basic Pain Care as indicated Potential referral to Persistent Pain Care Specialists, BH in Medical Home Patient Activation Measure 17

18 PEG validated 3 item tool to assess pain intensity, interference with enjoyment of life and interference with general activity (Krebs, 2009) PEG score = average the 3 questions (30% improvement is clinically meaningful) Interagency Guidelines on Prescribing Opioids for Pain 2015 & CDC Guidelines Brief Pain Inventory 18

19 Pain Care Pain Education Behavioral Health Rehab Written and video material available online, virtual classes currently trialed 38 19

20 Providence Primary Care Rehab Persistent Pain Pathway PCP Standard Pain Visit (Biopsychosocial) Low PAM/ High STarT Higher PAM/ Low STarT BH Pain Protocol Individual or group (including pain class) BH Brief Pain Protocol Persistent Pain Rehab Providence Rehabilitation Caregiver Pain Care Skills Pain Education Motivational Interviewing Pacing &Graded Exposure Physiological Quieting Graded Motor Imagery 20

21 Return to activity Teaching about pain versus harm Pacing: Starting out very slow and giving positive reinforcement for any gains no matter how small Graded exposure: Adding complexity Christina Background Information: 54 year old female, thoracic low back and right > left leg pain, knee arthritis severe. Pain increasing in area and intensity Co-Morbidities: Type II diabetes, obesity, anxiety Brief Pain Interference Scale: 60/70 STarT score = 7/9 PAM = 2 Pain description: Spreading into lumbar bilateral and left lower thoracic area, Rand L leg pain Hard to tell where it is sometimes Worse with cold weather. Function: Physical therapy made me pain worse. Walking limited because she hurts COPYRIGHT (C) 2016 PROVIDENCE HEALTH & SERVICES 42 21

22 Questions References Brinjikji, W., et al "Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations," AJNR Am J Neuroradiol 36: Apr Butler, David, and Lorimer Moseley, Explain Pain, NOIGroup Publishing, Adelaide, Australia Creamer, P., and Hochber, M.C., Why does osteoarthritis of the knee hurt sometimes, British Journal of Rheumatology 0886 Vol36 No 7, 1997 p Fritz, Julie, et al, Implications of early and guideline adherent physical therapy for low back pain on utilization and costs, BMC Health Services Research 2015 National Pain Strategy, 2016 Institute of Medicine, Relieving Pain in America, TeraguchiM, et al. "Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study." Osteoarthritis Cart., 2014;22:

23 Ideas for future skill-building opportunities in complex pain care Pain education Motivational interviewing Shared decision making Trauma informed care Yoga/Feldenkrais Mindfulness Cognitive behavioral therapy/acceptance Commitment Therapy 23