L24: Persistent Pain Part 1 Flashcards
Persistent musculoskeletal pain is associated with a complex interaction of factors across the ________ spectrum.
biopsychosocial
What are 3 factors that don’t involve structurally or biomechanically?
- cognitive
- psychological
- social
______ and ______ factors predict poor prognosis AND are the most important mediators for patient outcomes
Cognitive; psychosocial
Successful outcomes are linked to changes in _____ and _____ factors (Build up confidences..etc) not changes in ______ factors (eg. muscle strength) which are often the main targets for treatment
cognitive; psychological; physical
fMRI has demonstrated that persistent pain disrupts the natural resting state of the brain, known as the Default Mode Network (DMN). In persistent LBP, cortical changes in the brain after LBP are _____(more/less) consistent with LBP than MRI findings in the spine
more
Brain at resting state is different with _____ pain VS _____ pain
persistent; no persistent
What are 6 documented side effects of persistent pain?
- lower overall health
- elevated blood pressure
- depression and anxiety
- financial hardship
- cognitive impairments
- difficulty with concentration, focus and decision making
Once persistent pain is present –> Can affect other things as well –> it is important that it is managed well
Persistent pain is ______ sensitisation.
central
What is the scale of lumbar or pelvic pain in terms of sensitisation?
What are 14 features in the subjective?
- Disproportionate, non-mechanical & unpredictable pattern
- Multiple/non-specific aggravating/easing factors.
- Pain persisting- Can’t go back to sleep, hours of pain
- Pain disproportionate to the nature and extent of injury or pathology.
- Widespread, non-anatomical distribution of pain.
- History of failed interventions
- Likely maladaptive psychosocial factors
- Unresponsive to NSAIDS and/or more responsive to anti-epileptic or antidepressant medication.
- Reports of spontaneous symptoms
- High levels of functional disability
- More constant/unremitting pain
- Night pain/disturbed sleep- Changes in NS due to pain –> unable to maintain normal sleep patterns
- Pain in association with other dysesthesias
- Pain of high severity and irritability
What are 3 features in the physical examinations in unpredictable relationship between stimulus and symptoms?
- Disproportionate, inconsistent, non-mechanical/non-anatomical pattern of pain provocation in response to movement testing.
- Hyperalgesia and/or allodynia and/or hyperpathia within the distribution of pain.
- Diffuse/non-anatomic areas of pain/tenderness on palpation.
What are 2 factors that contribute to the chronicity of pain? What to both prolong?
- Constant/persistent nociception factors
- Constant non-nociception factors (cognitive-affective)
Vast majority –> MOI, aggravating factors Both prolong the activity of the pain neuromatrix. “increased sensitivity to noxious as well as non-noxious input and corrupt the integrity of motor output”
What is the neuromatrix?
“multiple parts of the central nervous system work together in response to stimuli from the body and/or the environment to create the experience of pain”
What are 5 goals with the persistent pain patient?
- Independence- Not using passive treatments (not relying on professionals to improve)
- Functional restoration
- Return to normal and meaningful activities
- Return to workplace activities or other social requirements
- Ensure they understand to not to discontinue management when they have improved
Why is it important to continue management in the long term for persistent pain?
Pain can come and go
What are 6 Important clinical elements?
- thorough examinations
- paced education (an active process)
- Using patient education and scaffolding from day 1 (eg. key concepts on day 1 and then a couple days later and next session= more key concepts
- exercise programs
- graded exposure- Gradual and slowly build up tasks
- goal setting
- self-efficacy
- Building confidence (graded exposure is hepful) Reassurance and praise when tasks done well or if improvement is seen
What are the 3 aims of managing the neuromatrix?
- Reduce the cognitive threat of the input
- Enhancing self-efficacy without aggravating symptoms
- Graded re-exposure to functional tasks
Manage how pain is processed, perceived and how it affected the patient
Why do we traditionally use biomechanics to explain persistent back pain?
- Many health professionals profit from ongoing treatments and invasive approaches, products and surgery
- Patient education regarding pain involves a paradigm shift
- Physio taught that way
- Physio can profit (eg. can give ongoing treatment = no use)
What are the 5 outdated, traditional beliefs are easy to explain and sell?
- “Repairing” spinal biomechanics
- Injury, re-injury, re-injury = not healing
- Blaming posture
- ‘Hunting’ for the source of pain
- “wear and tear”
Anatomical, biomechanical, or pathoanatomical models have proven _____(high/limited) efficacy compared to pain education
limited
These models can increase fear, anxiety and faulty beliefs, which all contribute to a _____(increased/decreased) pain experience
increased
The dichotomy of teaching people suffering from pain about anatomy, versus pain science, may be a reason why educational models often ______(succeed/fail)
fail
What are the 3 increasing efficacy of education for decreasing things?
- Pain
- Disability
- Catastrophization
- Healthcare utilization
People in pain are interested in learning more about ____, not necessarily anatomy, biomechanics, and pathoanatomy
pain
Research demonstrates that physiotherapists are capable of incorporating effective ______ approaches alongside our other treatments.
psychological
Pain education alone is effective but when combined with ______ or _____ is far superior.
exercise; manual therapy
Increasing understanding of _____ is the first step to reducing the threat.
pain
What are the 4 things that physio aims to educate the patient about?
- the anatomy of pain and the nervous system
- How large? (brain, spinal cord and nerves In the body and how it changes?
- how persistent pain differs from acute pain
- Alarm system goes on in acute pain but can stay on in the long term
- what the danger messages mean
- how pain processing is affected by time and other factors
- Stress, over time, not moving = worse How these relate to their experience
Current clinical practice and research studies have shown that pain education can be delivered in _____ minutes depending on patient-specific needs
10–20
Do not spend more than _____ mins to discuss pain education in acute pain
10
Meaningful communication is a key component of pain ______
reconceptualisation
Most patients with persistent pain experience poor _____ and become increasingly frustrated when they are unheard
communication
Both _____ and _____ are key elements predicting the success of pain education
fear-avoidance; pain catastrophization
What is the aim of interview in persistent pain? What are 5 questions?
The aim is to develop a deep understanding of the person’s experiences, as well as discover what may motivate the patient
- What do you think is going on with your back?
- What do you think should be done for your back?
- Why do you think it has not improved?
- What are you concerned about?
- What do you think will happen if you tried to…..`
Convey results without ____, ____ words
inflated, fear-inducing
A haphazard, quick examination may undermine the _____. An overly focused examination on small details, which may not be relevant is not appropriate or helpful
relationship
What are 7 beliefs that can identify beliefs, barriers and change opportunities?
- Previous findings on investigations
- Previous explanations from health professionals
- Difficulty coping with societal requirements
- Lack of physical activity
- Fear avoidance
- Reliance or expectation around success of passive approaches
- The need for protective movement habits.
- Why? Are you afraid it will make it worse or does it actually hurt?
Pain education may need to start with ‘de-education’. What does that mean?
correcting misinterpretations or unhelpful beliefs
“De-education” may include sharing ______, helping understand that “findings” on tests and imaging may not correlate to pain.
normative data
Eg. have graphs that show normative data = show that it is normal (what you are getting)
We can reiterate “bulging” discs appear on MRIs of people ____ (with/with no) LBP various studies have shown that “bulging” discs reabsorb over time and typically resolve in a few months.
with no
Pain ____ (does/does not) equal pain.
does not
Based on research/ evidence based practice, the only thing and most effective management is _____ for persistent back pain
exercise
What are 5 key messages when reducing the cognitive threat of input?
- Simple messages should be used
- Based on what the patient already understands or is wanting to know
- Address patient’s concerns
- Address unhelpful beliefs
- Can you give messages that are based on what the patient already recognises?
- Stress or worrying = more pain
- Bracing or not moving = more pain
- Exercise/active coping = better function and less pain.
Eg. if they know that when they are stressed, they have more pain. What does that mean?
- Emphasise this and use research to teach the patient
- Show that it is not helpful = need to change
What are 7 key messages for new beliefs and behaviours?
- The spine is strong, resilient and adaptable
- One of the strongest structures f the body
- All tissues in the spine are adaptable
- We can load it in different ways and it can adapt to that
- Pain is poorly related to tissue damage
- Protection can persist when there is no longer the need to protect
- Pain that persists is more about sensitivity to it rather than the damage
- Alarm system keeps going even after the cause has gone away
- Many factors influence sensitivity both positively and negatively.
- Recognising these and managing them is a key to recovery
The patient should be made aware of the sheer vastness and complexity of the nervous system: “There are more than 400 individual nerves that combined make more than 45 miles of nerves within your body, and they all are connected like a network of roads” This assists the patient in understanding that pain is complex, and therefore managing pain isn’t a one-step fix.
If they understand NS, more likely to understand their pain
What are the metaphors/analogies for persistent pain?
- The research currently shows pain education works best by using metaphors, examples, and pictures
- Pain metaphors are used to convey the message that pain may not necessarily be a true reflection of the health of their tissues and persistent pain is usually not
What are 5 things that Metaphors and analogies are often used to explain?
- How to understand pain
- Why pain persists
- Why tests show nothing ‘wrong’
- Self-management strategies
- What “feels” dangerous might not actually “be” dangerous
This may help patients ____ their pain experience and aim to avoid patients falling into the mindset of “you think my pain is in my head.”
reconceptualize
What is a good metaphor for persistent pain?
Sun burn metaphor - low tissue damage but high pain levels
- Pain is not a true reflection of damage
What is a good metaphor for persistent pain in terms of sensitivity?
An example is whereby the body’s nervous system is metaphorically described as an alarm system In one in four people, the alarm system does not calm down after ramping up, but remains extra sensitive
What to know when damage has been causes (eg. step on nail)? • Force us to do something about it (avoid infection, gangerene) 1/4 get persistent pain • Hyper-sensitivity = less tolerance (eg. allodynia) • Changes in life • Why does it not come down? ○ Fear ○ Worries ○ Stress • How to turn it down? ○ Biological –> exercise, sleep, relaxation, meditation, diet…etc Can be helpful to draw a graph = tolerance can go down (NS changing)
A
What is the alarm system metaphor?
Before the onset of this pain, the alarm system had lots of tolerance for activities, but since being extra sensitive, there is less tolerance Now, after a safe task or movement, the alarm system goes off. This metaphor of nerve sensitization gives the patient a different paradigm about why they still hurt
What are 4 issues that that contribute to the alarm system remaining sensitive?
- failed treatments
- sleep, diet
- work stress and anxiety
- different explanations from health professionals
