Dr Chris Hoffman Orthopaedic Surgeon Auckland Mr Chris Gregg Physiotherapist TBI Health Wellington Dr Julie Zarifeh Senior Clinical Psychologist Professional Practise Fellow CDHB University of Otago 14:00-16:00 WS #12: Pain Symposium 16:30-18:30 WS #17: Pain Symposium (Repeated)
Chronic Pain = Reassurance Chris Hoffman Spine Surgeon
The Problem.. Chronic Musculoskeletal Pain One of the most common reasons to visit the GP Untreated => depression, poor quality of life and loss of independence Often begins with an acute nociceptive event Majority of episodes are short and self limiting Why do some persist? Causes are multi-factorial An individuals genetics and neurophysiology have a role
Most patients with pain see their health care professional because: they are in pain and they want it to stop. they will be worried and they need reassurance. they want information about the source of the pain and the prognosis.
RCT - UCLA Back Pain Study GP vs Chiropractor treatment Clinically equal outcome But more satisfied with Chiro 2 reasons - Receipt of self care advice - Explanation of treatment Hurwitz EL et al, Spine 2006 Mar 15;31(6):611-21
BioPsychoSocial Model Hurt vs Harm Illness vs Disease Activity vs Rest
Classification of Chronic Pain Can be based on major pain features or body region Musculoskeletal (mechanical) Myofascial Neuropathic Fibromyalgia Chronic headache syndromes BMJ Best Practice Chronic Pain
Classification of Chronic Pain Can be based on major pain features or body region Musculoskeletal (mechanical) Myofascial Neuropathic Fibromyalgia Chronic headache syndromes BMJ Best Practice Chronic Pain
Acute vs Chronic Pain
Chronic Pain Disorders
Chronic Pain Disorders
Chronic Pain Disorders
New Term = Nociplastic pain International Association for the Study of Pain Pain arises from altered nociception Can follow on from acute nociceptive pain Impact on patient Impaired physical function / Disability Person / Social setting / Work setting
Pain or Disability? Pain is not disability. The focus is resolving the disability not resolving the pain. Disability resolution needs both behavior and cognitive therapies. Determine the underlying mechanical triggers
Regions affected Back pain (53%) Headache (48% -?cervical / muscular) Joint pain (46%) When re-evaluated in 12 months 46% persist
Focus on 4 common areas Cervical Spine pain Lumbar Back pain Shoulder joint pain or instability Knee pain
Trauma? Often a triggering event Particularly in NZ = ACC Needs to be a history of application of external force Problem is age related degenerative changes
Degenerative? Age-related change Normal range of aging Life-style / genetics
Cervical / Lumbar Patterns of pain Neck/Back Dominant Consider Red Flags Arm/Leg Dominant Radicular pain Radiculopathy? Most resolve quickly Most can be treated without imaging Red Flags Constant Pain Significant Trauma Myelopathy Cauda Equina Syndrome History of Cancer wt loss Fever
Back Pain Pattern 1 Flexion Pattern 2 - Extension History = Back Dominant Back or Buttock Worse with flexion Constant or Intermittent History = Back Dominant Back or Buttock Worse with Extension Always Intermittent Never worse with flexion
Pattern 3 - Sciatica Pattern 4 - Stenosis History = Leg Dominant Below the Gluteal Fold Pain affected by back movement Previously/currently constant History = Leg Dominant Leg pain worse with activity Leg pain better with position Intermittent
Pain Pacifying Strategies Pattern 1 Pattern 2 Pattern 3 Pattern 4 Learn how to do the Sloppy Push-Up. Learn how to do the Kneesto-Chest Stretch and the Pelvic Tilt. Proper positioning to minimize your leg pain during the first few days. Embark on a long-term strengthening program, focusing on the abdominal muscles.
Shoulder Pain History of Trauma Episodes of instability Yes Xrays Fracture/instability =>refer Cuff injury Yes Ultrasound Massive tear =>refer Red Flags Unexplained swellings Significant weakness History of Cancer Fever Any Pulmonary or Vascular compromise
Shoulder Pain Rotator Cuff Tear Minor <5cm or single tendon Sub-acromial Bursitis Osteoarthritis Frozen Shoulder Initial referral for rehab
Knee Pain History of Trauma Meniscal / ligament injury Anterior Pain Tendinopathy Bursitis Ultrasound Osteoarthritis Xray?severity Pain vs degree of OA? Red Flags Unexplained mass / swellings Erythema / Fever New deformity
Knee Pain and Degree of OA High Pain / Low Pain Pain Stimulated = Mild OA / Severe OA Measure Sensitization High Pain / Mild OA = Central sensitization High Pain / Severe OA =?inflammatory Low Pain / Mild OA = Appropriate response Low Pain / Severe OA = Resilient?how Finan P et al Arthritis Rheum 2013 Feb 65(2) 10
Why am I still in pain? Resolution of the nociceptive pain Mal-adaptation to ongoing pain Nociplastic pain becomes the problem Analogy Priming of immune response Stimulus has triggered response System changes now responds to normal stimulus Treatment? re-train the guard dog Ensure no further mechanical stimulus Normalize Activity /Exercise Focus on reducing disability
Pain self management
Aim Try to explain the nebulous concept of pain self management
Reception calls: Unscheduled appointment for 4:30pm. Ongoing pain.
Right! I will send you to the pain clinic, they will help you
Dear doctor, Thank you for your referral. We have triaged your patient for a comprehensive pain assessment. Our waiting list is currently 1 year.
While you wait you raid the cupboards. Put out fires, one at a time.
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
Reception calls: Unscheduled appointment for 4:30pm. Ongoing pain.
What do they do in pain clinic?
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
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
600,000 people X 8757h = a lot of hours alone
Solution = patient takes care of themselves
Pain Self Management
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
What is pain self management? Manage pain by choosing ACTIVE and sustainable strategies to target the areas affected by pain.
Active pain management skills 1. Good sleep hygiene to improve sleep 2. Limiting rest 3. Establish regular physical activity
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
Learning to self manage It is like driving a car Where does the instructor sit? Where does the learner sit?
That s so hard! Are you sure there are no medication or injection to try?
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
Multiple dimensions of health affected
Let me give you a metaphor to put self management into context.
Choice Engagement Change Shift in focus Partnership Time Independance
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
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.
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
Retrainpain.org
Thank You
Thank you