dr chris hoffman mr chris gregg dr julie zarifeh
TRANSCRIPT
Dr Julie ZarifehSenior Clinical Psychologist
Professional Practise Fellow
CDHB
University of Otago
Dr Chris HoffmanOrthopaedic Surgeon
Auckland
14:00 - 16:00 WS #12: Pain Symposium
16:30 - 18:30 WS #17: Pain Symposium (Repeated)
Mr Chris GreggPhysiotherapist
TBI Health
Wellington
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
Pattern 1 – Flexion Pattern 2 - Extension
History = Back Dominant
• Back or Buttock
• Worse with flexion
• Constant or Intermittent
Back Pain
History = Back Dominant
• Back or Buttock
• Worse with Extension
• Always Intermittent
• Never worse with flexion
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
Pattern 3 - Sciatica
Pain Pacifying Strategies
Learn how to
do the Sloppy
Push-Up.
Learn how to
do the Knees-
to-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.
Pattern 1 Pattern 2 Pattern 3 Pattern 4
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
Manage pain by choosing
ACTIVE
and sustainable strategies to
target the areas affected by pain.
What is pain self management?
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 manageIt 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?
High dose opioids – No high quality evidence Methadone – No conclusion can be madeTapentadol – further studies neededPregabalin – note effective in chronic conditions which nerve damage is not the prime source of painGabapentin and pregabalin in preventing migraine attacks – not effectiveAntidepressives for NSLBP – No evidenceMuscle relaxants for NSLBP – short term relief, adverse effects require cautionNSAIDS for NSLBP – Short term relief, effect size is smallNSAIDS for low back pain and sciatica – not more effective than placebo in reducing sciatica. Overall improvement but results should be used interpreted with cautionProlotherapy for chronic low back pain – conflicting evidenceBotox for lower back pain and sciatica – low or very low qualityInjection therapy for subacute and chronic low back pain – insufficient evidence to support use of injection therapyNSAIDs – low quality evidence in osteoarthritis. No evidence for other chronic painful condition.Paracetamol – No evidence to support or refute provide pain reliefVitamin D – No consistent pattern Vit D better than placebo. More research is needed.Gabapentin for fibromyalgia – No good evidencePregabalin for fibromyalgia –Provided pain relief 10% more than placeboMilnacipran 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 effectiveBotox for myofascial pain – inconclusive evidencePregabalin for chronic prostatitis. Chronic pelvic pain – one RCT showing that pregabalin does not improve CP/CPPSCannabinoids – FPM PM10
Pharmacology often fails
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 managementPatient:- 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