Back pain and MDT Flashcards
MDT
Utilising a biopsychosocial model, pain management necessitates coordinated treatment by specialists from varying disciplines who form a multidisciplinary team to manage chronic pain, each of whom share the same philosophy, goals and treatment plans
Non-hierarchical
Biopsychosocial model
Nociception
Cognition
Affective (suffering)
Illness (pain behavior)
Social environment
Red flags
!Cauda equina
!Spinal fracture
! Infection
! Malignancy
However! In the presence of red flags, whilst surgery, radiotherapy, chemotherapy may be necessary there will be psycho-social components that will need addressing with a potentially life-changing diagnosis and treatment……
Chronic pain
“Chronic primary pain is when pain has persisted for more than 3 months and is associated with significant emotional distress and/or functional disability, and the pain is not better accounted for by another condition. As with all pain, the article assumes a biopsychosocial
Pain (2019) 160: 28-37
International Classification of Disease ICD-11
framework for understanding CPP, which means all subtypes of the diagnosis are considered to be multifactorial in nature, with biological, psychological, and social factors contributing to each.”
Chronic pain
“Chronic primary pain is when pain has persisted for more than 3 months and is associated with significant emotional distress and/or functional disability, and the pain is not better accounted for by another condition. As with all pain, the article assumes a biopsychosocial
Pain (2019) 160: 28-37
International Classification of Disease ICD-11
framework for understanding CPP, which means all subtypes of the diagnosis are considered to be multifactorial in nature, with biological, psychological, and social factors contributing to each.”
Disease and illness
! Disease implies biomedical
! Illness infers biopsychosocial construct
The Pain Clinic MDT
!Pain Consultant
!Clinical Psychologist
!Specialist Nurse
!Physiotherapist
!Occupational Therapist
Pain Management – what’s it all about?
! To improve function/QoL. To help people live more satisfying lives without necessarily changing the pain.
!Helping people to learn how to manage the way they experience their pain and associated emotional distress in more productive ways – integrating ideas of the wider MDT.
!NOT about ‘curing’ pain
! A message is emphasised that people are not helpless in dealing with their pain and it should not control their lives. Help them take a more active approach to managing their pain.
Pain and the MDT
• ”Upward” AND “downward” pathways are important in processing and experience of pain.
• Persistent pain is less about ongoing or recurrent damage, but more to do with unhelpful changes in the nervous system.
• The nervous system becomes “sensitised”
• There are many things that can influence experience of pain, many of which patients can have some influence over.
• Our role as Multi disciplinary team at PMC is to educate patients about their pain and help them to understand their own experience of pain to optimise their self management strategies.
Physiotherapy in Pain Management
!Less focus on:
! Manual techniques
!More focus on:
!Knowledge about pain
!Understanding physiology and anatomy
!Using exercise to help manage symptoms
!Understanding what the pain means to the patient
Aims:
!Increase patient’s confidence in their body and its capabilities
!Increase functional ability
!Increase understanding of anatomy and physiology
(explaining imaging, dispel myths)
!Reduce the need for any further medical interventions !Increase cardiovascular fitness
!Increase muscle tone and stamina
!Improve core stability
Strategies:
!Patient education
!Goals and expectations
!Look at function/meaningful activities
!Parameters of exercise: Stretching, Strength, Aerobic
!Start with an achievable level
!Gradual increments – monthly rather than weekly/ daily
Clinical Psychology - What are we trying to achieve and how?
! Helping patients live a fulfilling life, even in the presence of difficult circumstances (metaphors, experiential practice)
! Increase AWARENESS of reactions to internal and external experiences and how these can impact on behaviour (e.g. mindfulness skills- being in the here and now)
! Increase OPENESS and WILLINGNESS to experience these difficult experiences (acceptance and defusion strategies- observer self)
! In the service of ENGAGING with doing what matters to us (reconnecting with values- values directed goals)
Acceptance and Commitment Therapy (ACT) and Chronic Pain
! Proposes that suffering is normal and often attempts to control and avoid internal negative experiences (including pain) becomes the primary problem.
! People with chronic pain are often focussed on controlling or avoiding pain. This can lead to avoidance of activity/exercise, poor pacing of activity, difficulties engaging with self-management approaches and poorer Qol.
! ACT proposes increasing awareness and changing relationship with internal experiences, both positive and negative, in the service of moving towards valued based activities/goals. NOT about reducing pain.
! Focus on changing behaviour rather than changing thoughts & feelings
! ACT has been shown to have positive effects in chronic pain and meta- analyses of ACT for chronic pain showed improvements in depression, anxiety, pain intensity, physical functioning and quality of life (Ost 2014)
The Role of Medication in Chronic Pain Management
! Persistent non-cancer pain serves no physiological purpose and is influenced not only by tissue injury but by a number of emotional, social and cognitive variables
! Medicines generally, and opioids in particular are often less effective for persistent pain than for other types of pain.
! When medicines are prescribed they should be used in combination with other treatment approaches to support improved physical, psychological and social functioning.
! Side effects are relatively common – these need to be considered and balanced with potential benefits. If patients continue to take medicines that provide limited analgesic benefit then they are exposed to harms unbalanced by the benefit that the medicines provide.
! When medicines don’t give sufficient analgesia there is a risk of dose escalation. This is rarely helpful.
Group work – Pain Management Seminars
!Delivery of pain education from a multi-disciplinary perspective – Physiotherapist, Specialist Nurse, Occupational Therapist, Psychologist and expert patient.
!Unique opportunity to help patients understand that pieces of the jigsaw are interlinked and rarely work in isolation of each other.
!1 x 2hr session followed by an individual appointment.
Group Work – Pain Management Programme
!Gold standard of non-interventional Pain Management. !Patients offered 10 x 3.5hrs sessions. More in-depth focus on
how the ‘jigsaw pieces’ are interlinked.
!Timetable includes a weekly practical exercise session, a review of personal value based goals and a psychology session.
!Qualitative outcomes focused on patient’s own values and goals – often related to hobbies, relationships or practical gains rather than reduction in measured / VAS pain scores.
