Chronic Pain 4 - PT tx considerations

Question 1

Medical model

Answer 1

Lots of people working to help solve chronic pain epidemic - where do we as PTs fit in?
We should be able to have an impact in all aspects

Question 2

Role of PT

Answer 2

Early recognition and tx is a critical component in managing chronic pain
Limit the barrage of input - MT, TE, Education, Modalities, etc
Afferent input is the most powerful driver of neuroplasticity

Question 3

As pain persists…

Answer 3

it gets more complex requiring a more comprehensive plan for treatment

Psych tx - we can talk to them and touch and help them move
So a lot that we do with PT addresses this

Question 4

Mature model revisited

Answer 4

Cognition and beliefs are intertwined in a pts clinical pain presentation
Fear avoidance and pain catastrophization significantly impacts a pain experience
One way to normalize pain experiences associated with misbeliefs is pt education

Teaching them about their pain will decrease their pain - take it a step further though with various interventions - but know that education is effective

Question 5

Deconstructing faulty beliefs

Answer 5

Well established that when a person is confronted with “new” healthcare information they have 3 options

• No way
• Get it (superficially)
• Yes, yes get it

Question 6

Can you determine stages of your own patients - bx change model

Answer 6

Pre contemplation - I don’t want to be here (maybe need to fail PT before sx)

Contemplation/Preparation - Someone said I should come see you about your approach

Action - Comes back to follow up appts and they have questions - THIS IS WHAT WE WANT

Question 7

Stats - providing the right info at the right time can help progress pt through stages - but not easy

Answer 7

:)

Question 8

Backfire effect

Answer 8

You are not trying to prove them wrong - can’t go at it that way - you are likely to create a dissociation - it is critical to build a strong trusting relationship and be sure that you replace it with relevant facts - if you are going to tell them their DJD is not causing their pain, you need to give them something to anchor to but you need to have a trusting relationship to do this

Let them come to the realization through your snippets of information rather than you just telling them the information - almost feeding them to come to the conclusion on themselves

Question 9

Deconstructing faulty beliefs

Answer 9

Current educational models used for teachign people about pain have significant limitations
Does not explain the complexities associated with pain
Does not embrace interdisciplinary approach
Does not improve pain and function
Likely induces more fear and anxiety and misbeliefs

Question 10

Current best evidence proves that if a pt is taught more about their pain experience from a biological and physiological perspective and “get it” they

Answer 10

Experience less pain
Move better
Function better
Have dec pain catastrophization
Exercise more
Spend less money on healthcare

Question 11

Correcting maladaptive beliefs about pain using VOMIT

Answer 11

poster that goes through normal prevalence of some pathology
Need to introduce it to pt at the right time though and explain it in a way that helps them understand they it is more complex

85% show knee arthritis, 50% bball have meniscal injury
Guy that tore 3 RTC and didn’t know at time - 20% have partial tears (no pain)
Cspine - disc bulges are normal aging
Lumbar - changes after age 20

Question 12

Pts learn best via

Answer 12

metaphors, examples, and pictures
Pictures of nail in shoe (and actually btw toes) - Nail in skull (and just tooth pain) - can use these to help pts understand

Question 13

PNE (pain neuroscience education) basics

Answer 13

Be simple - not dumb it down - keep simple and smart
Use pictures in color
Meet pt at his or her level - pain education should be slightly different for everyone
Personalized - apply it to situation at hand

Question 14

PNE basics - individualizing it

Answer 14

Each clinician should individualize their stories and adapt to their environment
Develop and use new stories
Practiced - like any other technique
Be seen as a shopping cart - diff stories for diff conditions, starting and end points diff for each pt, number and sequence of stories will be diff for each pt too

Question 15

Example stories

Answer 15

1 NS as body living alarm system
2 Extra sensitive alarm system
3 Computer processing
4 Speeding buses vs ankle sprains
5 Nerve sensors - ion channels
6 Pain meetings in the brain

Question 16

Example stories - NS as living alarm system

Answer 16

Put hand on stove, you want to know about it - engage pt and ask them how they would know about it

400 nerves stretch for 45 miles
Danger messages to brain
Brain process info and produce pain if there is sufficient reason
Focus of story is to teach about normal and brain as central component

Question 17

Example stories - Extra sensitive alarm system

Answer 17

We have a little electricity in our nerves all the time - we have a threshold that if gets enough input it goes to brain and then settles back down - in some cases though 1 in 4 individuals instead of it coming back down to resting it stays elevated (predictive coding - is in protective state) - for the pt, now their nervous system is more sensitive so something that did not used to produce pain is now producing pain

Home security system example - if wind rattles doors it sets off alarms - so maybe something that they think they need to be worried about (bending forward is painful) is something that might not need to be worried about

Question 18

Example stories - Extra sensitive alarm system - delivery of it - message is meant to

Answer 18

explain sensitization, hyperalgesia, and allodynia as protective mechanisms

Can then relate to the pts subjective reports of contribution to their elevated system, work, family, multiple explanations for pain, persisting pain, etc.

Bringing it together for them that our NS can be too active sometimes

Question 19

Example stories - computer analogy

Answer 19

Can describe central sensitization, peripheral sensitization

Comp when function normal - you press D key sends info from keyboard to comp and it outputs a D on the screen

In pt computer, they press D and instead of putting one D it is putting 20 Ds

Can be used for allodynia too where no matter what key your press (hot/cold, light
touch) the same “D” danger signal of pain will be the output

Helps them learn that it is not their fault that they are in pain

Question 20

Example stories - speeding buses vs. ankle sprains

Answer 20

Imagine you are walking and step off curb and sprain ankle
But imagine you see a speeding bus coming at you - will you feel your ankle sprain? No - your brain knows it is more important to get out of the way of the speeding bus

This can help a patient understand that peripheral vs processing pain is dissociated

Question 21

Example stories - nerve sensors ion channels

Answer 21

Peripheral sensitization driven from the brain
Multifactorial nature of pain
There is hope!

Injure themselves as bend forward -
Ion channels change though in response to our thoughts and beliefs
So our brain can put high volume of sensory in movement of bending forward so it can scrutinize this more

Every 2 to 3 days though this is changing so if we can provide right environment in the absence of fear we can change this!!!

Question 22

Example stories - pain meetings

Answer 22

How pain can affect other areas of the brain
Thoughts/beliefs are impulses too

With chronic pain multiple brain areas are activated and each serve specific functions
When overwhelmed with pain those areas are impaired too so can have multiple s/s
- so can help describe other contributions to their pain - like decreased appetite for example

Question 23

McClinton notes

Answer 23

Make them stories that are relevant to the patient - in exam you have to listen and hear their stories so that you can bring them back in

Individualize your metaphors that you use - and do less than what you think at first because it might overwhelm the patient and you have not earned that alliance with the patient yet