Chronic Pain - SlideServe by ewghwehws

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									   CHRONIC PAIN

How it can develop and
how best to manage it
              How is pain classified?
          ACUTE PAIN                               CHRONIC PAIN
1. Short term pain                         1. Persistent / longstanding
    < 3 months duration                    > 3 months duration
                                           Pain that persists beyond the time that
                                                can reasonably be expected for
                                                healing
2. Usually relates to tissue damage        2. Usually not an indicator of ongoing
                                                tissue damage

3. Hurt usually = harm                     3. Hurt usually does not = harm

4. Useful warning sign / protective        4. No longer a useful warning sign

5. Biopsychosocial factors are important   5. Biopsychosocial factors are very
     from the outset.                            relevant

6.Usually, as healing takes place the      6.Sometimes, pain does not go despite
     pain settles and normal function          healing having taken place.
     returns (although pain is often       People can learn to manage chronic pain
     recurrent)
                          Aims
To briefly explore limitations of the traditional model of pain
To explore how chronic pain develops
- Biopsychosocial framework

- Biological factors in chronic pain

- Psychosocial factors in chronic pain related disability
To introduce psychosocial yellow flags
To briefly discuss how physiotherapists can help prevent
chronic pain related disability
To briefly discuss how physiotherapists manage patients with
chronic pain related disability
The Traditional Model of Pain
 400 years ago René Descartes
Key Assumptions of traditional
          model
Disease/injury                     Pain

Pain is the result of tissue damage/injury
Pain transmission is directly from the
periphery to the brain
The amount of pain is directly
proportional to the extent of tissue
damage/injury
     What is the relationship between
       symptoms and pathology?
Mrs A Non-                                     Mr B
                                               progressive
specific low                                   spinal tumour,
back pain,     P                               c/o severe pain
c/o severe
               A
pain
               I
               N

                                                Miss D –
Mr C – mild                                     severe OA
                   Pathology / tissue damage
OA hip,                                         hip, c/o little
aches at end                                    pain and has
of long walk                                    good
                                                physical
                                                function
What are the limitations of the Traditional
                 Model?
• IN REALITY pathology and tissue damage not
  directly related to pain intensity
• It is possible to have tissue damage without
  reporting pain
• It is possible to have pain without observable tissue
  damage or pathology
• It is possible to have a very different outcome (e.g.
  pain and function) from the same treatment for the
  same problem.
The degree of reported pain, functional limitation and
   disability are frequently disproportionate to any
     observed pathology / impairment or disability
  Why the traditional model does not fit
            for chronic pain.
In chronic low back pain:
  1) The percentage of people with low back pain
    (LBP) who have serious spinal conditions
    (tumour, infection etc) is….
  = 1%

  2) The percentage of people with LBP who are
    never given a diagnosis based on disernible
    pathology is….
  = 80% (Waddell, 2004)
  Therefore: most people with LBP have non-
   specific back pain (AKA simple, mechanical )
Why the traditional model does not fit
          for chronic pain
3) The correlation between
 signs/symptoms and investigations
 (scans, x-rays etc) is poor (Waddell,
 2004).


Therefore in non-specific chronic pain:
- Hurt does not equate with harm
- Pain is not the bodies warning sign of
  damage
   The current understanding of chronic
                  pain
•Chronic pain is not ‘All in the mind’, made up,
psychosomatic or psychological and patients are
not malingering and do not have psychological
overlay
  Rather
• Pain is a perceptual process
• Pain is always (even in the acute stage) a
  combination of biological, psychological and
  social factors – the biopsychosocial framework
• We need to be mindful of these factors and we
  need to be able to assess and address them.
                          Aims
To briefly explore limitations of the traditional model of pain
To explore how chronic pain develops
- Biopsychosocial framework

- Biological factors in chronic pain

- Psychosocial factors in chronic pain related disability
To introduce psychosocial yellow flags
To briefly discuss how physiotherapists can help prevent
chronic pain related disability
To briefly discuss how physiotherapists manage patients with
chronic pain related disability
                                                       •Employers
  The Biopsychosocial                                  have modified
                                                       his duties for a
  Framework                                            week and
                                                       encouraging
• Wife telling him                                     him to stay at
not to do things     Social & Vocational Environment   work
•Resting, off sick                                     •Returning to
painkillers++,                  Behaviour              gym next
•Worried about                                         week, keeping
diagnosis,                                             moving
prognosis,                     Emotional               •not distressed
whether he will                 Distress
lose his job
•Thinks it’s a                  Attitudes              •Confident that
serious and                                            it’s a pulled
                                & Beliefs
debilitating                                           muscle and will
condition                                              settle

•Non-specific                     PAIN                 •Non- specific
LBP                                                    LBP
                          Aims
To briefly explore limitations of the traditional model of pain
To explore how chronic pain develops

- Biopsychosocial framework

- Biological factors in chronic pain

- Psychosocial factors in chronic pain related disability
To introduce psychosocial yellow flags
To briefly discuss how physiotherapists can help prevent
chronic pain related disability
To briefly discuss how physiotherapists manage patients with
chronic pain related disability
   What actually causes / maintains the bio
    bit of biopsychosocial chronic pain?
  Peripheral sensitisation (1st order nerve – from
  periphery to spinal cord)
  Central sensitisation (second and third order
  nerves- spinal cord and brain)
Sensitisation results in hyperalgesia, allodynia, and
  spontaneous pain
- Hyperalgesia- There is an increase in the magnitude and
  duration of response to stimuli. (i.e what was perceived as
  painful stimuli is perceived as more painful)
- Allodynia- There is a reduction in threshold causing an
  increase in the frequency of neuron firing so that low
  intensity stimuli not normally noxious, become so (i.e.
  stimuli that was perceived as non-painful is now perceived
  as painful)
What actually causes / maintains the bio bit
    of biopsychosocial chronic pain?
  - Spontaneous pain- neurone generates an
   action potential (nerve impulse) in the
   absence of stimulation (ectopics)
   Nociceptive system can remain in a state of
   heightened sensitisation as a result of
   plastic changes (Coderre, Katz,Vaccarino
   and Melzack,1993)
   Changes may last from hours to years
   In certain cases these changes can become
   pathological leading to unresolved
   persistent pain
                          Aims
To briefly explore limitations of the traditional model of pain
To explore how chronic pain develops

- Biopsychosocial framework

- Biological factors in chronic pain

- Psychosocial factors in chronic pain related disability
To introduce psychosocial yellow flags
To briefly discuss how physiotherapists can help prevent
chronic pain related disability
To briefly discuss how physiotherapists manage patients with
chronic pain related disability
  How important are psychosocial
            factors?
Chronic pain versus chronic pain related disability

Psychosocial factors are MORE important
than physical, biomedical or treatment
factors in:
  Pain perception
  The continued report of symptoms
  Health care seeking
  Response to treatment
  Overall outcome
     (Gatchel, 1995; Klenerman, 1995; Symonds, 1995; Burton, 1995; Deyo
               1988; Koes, 2001; Power, 2001; Pincus, 2002)
   How important are psychosocial
             factors?
Psychosocial factors are MORE important
than physical, biomedical or treatment
factors in:
  The prediction of disability
  The development of disability
  The maintenance of disability
  Prolonged workloss
 (Gatchel, 1995; Klenerman, 1995; Symonds, 1995; Burton, 1995; Deyo
           1988; Koes, 2001; Power, 2001; Pincus, 2002)
 Psychosocial factors: Role of
     the physiotherapist
REMEMBER – Even from day one of an
injury/accident/ onset of pain psychosocial
factors are relevant

 No matter how good you are as a
 physiotherapist if you do not assess and
 address psychosocial factors
- Your patients will not get better
- You may be adding to the problem –
 iatrogenics
       Clinicians as a psychosocial
      influence: Iatrogenic distress
Diagnosis
   Conflicting diagnosis or explanations resulting in
   confusion, frustration, anger and loss of faith in
   health profession(s)
   Unfamiliar diagnostic language leading to
   catastrophising (fear of an inevitable poor
   outcome)
Treatment
   Dramatisation of condition by health professional -
   results in dependency on treatments
   Continuation of passive treatment
   Lack of satisfaction with previous treatments
   Vague, inappropriate, alarming, contradictory,
   advice, information and management
 Clinicians as a psychosocial influence:
           Iatrogenic distress
Function
 Advice from professional to change or
 withdraw from activities or job
 Health professionals have sanctioned
 disability, not providing interventions
 geared towards improving function
 Explanations not related to patients
 function and future prognosis
                          Aims
To briefly explore limitations of the traditional model of pain
To explore how chronic pain develops

- Biopsychosocial framework

- Biological factors in chronic pain

- Psychosocial factors in chronic pain related disability
To introduce psychosocial yellow flags
To briefly discuss how physiotherapists can help prevent
chronic pain related disability
To briefly discuss how physiotherapists manage patients with
chronic pain related disability
     What are yellow flags?
There are lots of potential obstacles to
recovery

Yellow Flags = Evidence Based
Psychosocial Risk factors for chronic pain
related disability

We need to assess them and address them
in order to prevent chronic pain related
disability.
  What is the goal in assessing
          yellow flags?
1. To decide whether a more detailed assessment
   is needed
2. To identify important factors that need to be
   addressed, thus improving treatment success,
   saving time and resources

 “An individual may be considered ‘At Risk’ if they
  have a clinical presentation that includes one or
  more very strong indicators of risk, or several
  less important factors that might be cumulative”
        (Kendall, Linton & Main, 1997)
How do we assess yellow flags?
Clinical interview using stem questions to
illicit yellow flags
e.g. “What are you currently doing to
manage your pain?”
Using appropriate questionnaires
e.g Linton and Hallden screening
questionnaire for acute low back pain
(always use questionnaires to guide the
direction of your stem questions, never just
on their own)
 When do we assess yellow flags?
1. At all stages informally using stem questions

2. More formally using stem questions and
   appropriate questionnaires in:
   “All those with low back pain where the symptoms
   have significantly interfered with or prevented
   normal activities, including work for more then 4
   weeks”.
   Those patients who are not making expected
   progress within 2-4 weeks of the onset of
   treatment for an acute low back pain problem.”
   (Watson & Kendall, 2000)
What are the actual Yellow Flags?
      Yellow flags = Evidence Based
  Psychosocial Risk factors for Disability
Attitudes and Beliefs
Behaviours
Compensation
Diagnosis and treatment
Emotions
Family
Work
Which yellow flags most strongly predict a
            poor outcome?
 The following factors are consistently
    predictive of a poor outcome
     Belief that pain is harmful
    Fear avoidance behaviour
    Low mood and withdrawal from social
    activity
    An expectation that passive medical
    treatments are the answer
  What do these yellow flag terms
             mean?
Negative / passive coping strategies
Fear avoidance beliefs and behaviours
Poor self efficacy
External / internal locus of control
Hypervigilance / body scanning
Over / under activity cycling
Pain behaviours
Solicitous spouse
                          Aims
To briefly explore limitations of the traditional model of pain
To explore how chronic pain develops

- Biopsychosocial framework

- Biological factors in chronic pain

- Psychosocial factors in chronic pain related disability
To introduce psychosocial yellow flags
To briefly discuss how physiotherapists can help prevent
chronic pain related disability
To briefly discuss how physiotherapists manage patients with
chronic pain related disability
How do we help prevent people developing
     chronic pain related disability?
 Evidence based clinical
    Guidelines
 1. Clinical Standards
    Advisory Group. (1994)
    Report on Back Pain.
    HMSO. London.
 2. Royal College of General
    Practitioners Clinical
    Guidelines for Acute Low
    Back Pain.
   www.rcgp.org.uk
              Management of chronic pain
     A stepped care approach (Von Korff and Moore, 2001)
 Management depends on duration of problem and yellow flags
•1                                   • Identify and address the common worries of
      •Most patients at the acute
                                     patients with back pain
      stage
                                     • Simple, symptomatic measures
                                     • Information and advice to encourage the
                                     resumption of ordinary activities
•2    •The substantial minority of   •Brief, structured interventions that help
                                     patient to identify obstacles to recovery, set
      patients who do not resume     functional goals, and develop plans to achieve
                                     them.
      ordinary activities by 3-6
                                     •Provide support for physical exercise and
      weeks with simple advice       return to ordinary activities
•3    The small minority of          • Address dysfunctional beliefs and behavior
      patients who have persisting   • A progressive exercise or graded activity
      disability in work or family   program
      life and who require more      • Enable and support patients to return to
      intensive intervention         ordinary activities
          Diagnosis / treatment
Resist the urge /pressure to over-medicalise the
diagnosis
Ensure that the medical diagnosis is truly ‘non-
specific’ and avoid prolonged, unnecessary
investigations and treatments for those conditions
Appropriate specific (individualised) reassurance re.
the nature of the condition and the prognosis
Avoid and reduce iatrogenics
Positive expectation of recovery- should return to
activity and work before pain completely settled
Provide symptomatic treatment to help restore
function but put emphasis on what they do
Shift focus away from signs and symptoms and
towards activity levels and function
          Education and advice
Education about:
– Benign self limiting nature of non- specific low back pain
– Poor correlation between scans/ x-rays and symptoms,
– indications for further investigation / treatment ( only 1% of
  people with LBP have serious spinal pathology requiring
  further investigations)
– the importance of maintaining/ regaining activity as soon as
  possible
– Negative effects inappropriate / frequent rest and the
  benefits of exercise and activity
– What to expect when increasing activity (some increase in
  pain is normal and is not a sign to stop)
Purpose of education is to increase knowledge,
increase understanding and change behaviour
www.tso.co.uk
          Activity / function
Discourage passive / negative coping strategies
Challenge misconceptions, unhelpful thoughts,
beliefs and behaviour
Address FAB’s
Help them id. what they are avoiding/ finding
difficult and how they can gradually build it up
Functional activities are better then specific
exercises
Encourage active self management
Avoid / discourage work absence
                          Aims
To briefly explore limitations of the traditional model of pain
To explore how chronic pain develops

- Biopsychosocial framework

- Biological factors in chronic pain

- Psychosocial factors in chronic pain related disability
To introduce psychosocial yellow flags
To briefly discuss how physiotherapists can help prevent
chronic pain related disability
To briefly discuss how physiotherapists manage patients
with chronic pain related disability
   Physiotherapy management of
           chronic pain
1. Individual physiotherapy

2. Group intervention run by physiotherapists.
    Includes education and exercise e.g back to
    fitness, back school, back rehabilitation
    classes, fitness first etc.

3. Physiotherapists as part of an interdisciplinary
    team on pain management programmes. The
    most distressed, depressed and disabled
    patients. Apply cognitive behavioural principles.
    What is an interdisciplinary pain
     management programme?
A PMP is a psychologically-based
rehabilitative treatment for people with
chronic pain which remains unresolved by
currently available other treatments.
It is delivered in a group setting by an
interdisciplinary team of experienced health
care professionals working closely with
patients.
All staff need extra training and experience in
Pain Management Programmes,
What does a PMP aim to do?
The aim of PMP’s is to reduce the
disability and distress caused by chronic
pain by teaching physical, psychological
and practical techniques to improve quality
of life.
It differs from other treatments provided in
pain clinics in that pain relief is not the
primary goal, although improvements in
pain following participation in a PMP have
been demonstrated.
     Take home messages
Chronic pain related disability is a Bio Psycho
social problem
Psychosocial factors are strongly predictive of
chronic pain related disability
As future physiotherapists –you are an important
psychosocial influence
Prevention of chronic pain related disability
requires physiotherapist to assess and address
yellow flags
The aim of chronic pain management is to help
people manage their pain rather then to cure it
          Some references
Kendall N.A.S., Linton S.J. & Main C.J. (1997)
Guide to assessing psychosocial yellow flags in
acute low back pain: risk factors for long term
disability and work loss. Accident Rehabilitation
and Compensation Corporation of New Zealand
and the National Health Committee. Wellington,
New Zealand. www.nzgg.org.nz.
Watson, P. & Kendall, N. (2000) Assessing
Psychosocial Yellow Flags. Topical Issues in
Pain 2. Ed Gifford, L. CNS Press, Falmouth

								
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