Pain Science Test 2 Flashcards
MPQ
McGill pain questionnaire
Quantitative profile of pain:
Sensory-discriminative
Motivational-affective
Cognitive-evaluative
Components: diag, meds, pain hy, present pain pattern, accompanying symptoms, modifying factors, effects of pain, list of words
Word list: 102 words
Expectation
Include expectation in clinical decision making process
Maximize expectation (“This intervention is known to significantly reduce pain in some patients”)
Be aware of unrealistic expectations- maximize realistic expectations
OSA (obstructive sleep apnea)
Recurrent episodes of upper airway blockage during sleep which leads to decreased oxygen saturation and increased effort to breathe
TSK
Kinesiophobia measure
Total score range 17-68
Higher score = higher fear
The chosen intervention is ____ why patients with pain respond to treatment
Just one factor in why
BPI
Brief pain inventory
Initially derived for cancer patients receiving palliative care
Has been validated for non-cancer patients (chronic pain, LBP, OA)
Quadruple NPRS; relief w/ meds, pain interference with ___ (activity, mood, sleep, work, relationships, etc); pain language; duration of pain; open ended descriptions; somatization
A neural signal is activated whenever…
The brain perceives a threat
FABQ
Screen pt w/ LBP for potential for long term disability
FABQ-PA > 15
FABQ-W > 22/29/34
High risk prolonged disability
Therapist contextual factors
Clinical equipoise-
Lack of preference or uncertainty for a treatment (lack of equipoise can impact outcome)
Good for research to not introduce bias, but in the clinic
you want.
Therapeutic alliance
Warm, friendly manner Active listening Empathy Periods of thoughtful silence Communication of confidence and positive expectation
Peripheral neurogenic symptoms and sign clusters
Indicate individuals w/ these features are 150x more likely to accurately predict a clinical classification
Pain in dermatomal or cutaneous distribution
Positive neurodynamic tests and palpation (mechanical tests)
History of nerve pathology or compromise
6 clinical measures of pain
- VAS (visual analogue cale)
- NPRS (numeric pain rating scale)
- Body diagram
- Brief pain inventory
- McGill pain questionnaire
- PPT (pain pressure threshold)
“It sounds like you are frustrated with…”
“So you are angry about the lack of support you are getting…”
Are examples of
Reflective “leads”
Part of active listening
Patient educated on the concept of the nervous system as the body’s alarm system, and the role of nociception to warn the body of danger. Peripheral nerve sensitization, hyperalgesia and allodynia were explained using metaphors to promote deep learning
Sensitive nerves
Quota-based restoration of function regardless of symptoms
Graded activity
Combined contextual factors
Therapeutic alliance
Collaboration, warmth and support between therapist and patient
Patient was educated regarding endogenous mechanisms and strategies to increase the brain’s production of chemicals to decrease pain, such as aerobic exercise and improved pain knowledge. The concepts of pacing, graded exposure, “sore but safe,” and “hurt does not equal harm were discussed. Sleep hygiene and diaphragmatic breathing topics were introduced to help calm the nervous system and reduce stress.
Calming sensitive nerves
Quantitative sensory testing
Multidimensional testing paradigm including….
PPT Mechanical detection threshold Thermal pain threshold Vibration perception threshold 2 point discrimination
NPRS
Numeric pain rating scale
11 point Likert scale
Chronic pain patients prefer NPRS
But- chronic LBP and knee OA found NPRS inadequate
MCID (2: LBP; 3 points or 27% reduction)
CSI
25 questions 0-4 points each
> = 40 indicative of central sensitization
3 important factors that influence our perception of pain
Memory
Hyperviligance
Catastrophization
Patient contextual factors
Expectation
Preference-
patients desire information; don’t necessarily desire a role in the clinical decision making process
Nociceptive symptom and examination clusters
Indicate individuals w/ these features are 100x more likely to accurately predict a clinical classification
Proportionate pain
AGGs and EASEs
Pain : intermittent sharp, dull ache, or throb at rest
No night pain, dysesthesia, burning, shooting or electric symptoms
Bottom-up vs Top-down approach to pain
Bottom-up
Change tissues/unload tissues
Alter environment somewhat
Reduce threat and brain produces less pain
Most traditionally used of therapy
Ex: TENS, manual therapy, othodics, pool therapy
Top-down
Brain used to alter the experience
Ex: education
Nocebo
Opposite of placebo
Negative expectations = negative outcomes
People given a placebo drug will complain about the exact same side effects that they were warned about.
VAS
Visual analogue scale
Single or multiple item scale (current, best, worst…)
MCID
MPQ- short form
McGill pain questionnaire- short form
15 words
Each rated 0-3 (0=none, 3=severe)
Central sensitization symptoms and sign clusters
Indicate individuals w/ these features are 486x more likely to accurately predict a clinical classification
Disproportionate pain
Disproportionate AGG and EASE
Diffuse palpation tenderness
Psychosocial issues (fear avoidance and pain catastrophization)
The majority of chronic MSK pain cases are characterized by _____. More specifically ____.
Alterations in central nervous system processing
More specifically the responsiveness of central neurons is augmented, resulting in a pathophysiological state corresponding to central sensitization, characterized by generalized or widespread hypersensitivity.
RLS (restless leg syndrome)
A neurological condition characterized by a persistent and overwhelming urge to move the legs while resting and typically presents with concomitant complaints of burning, itching, throbbing, or other unpleasant sensations. Movement typically provides temporary relief
Ideal time to schedule chronic pain patients
Mid-morning through early afternoon
Clinic usually quietest and cortisol levels higher (chronic pain patients often have difficulty with focus and concentration- so cortisol high gives you their most aroused state where concentration/focus likely highest, but as levels starting up drop not too overstimulated)
BPI- short form
Ideal for clinical practice
Quadruple NPRS Relief w/ meds Pain interface with- General activity Mood Walking Work Relationships Sleep Enjoyment of life
Chronic insomnia
Difficulty falling asleep, maintaining sleep, or waking up too early at least 3 nights per week for the past 3 months
PCS
13-item 5 point scale
Higher score = higher catastrophization
18 is median for healthy
> 30 clinically relevant catastrophization
“Why do patients get better?”
- Treatment specific effects
- Factors unrelated to treatment (natural hy, regression to the mean, repeated measuring)
- Preliminary elements (improvement after scheduling, providing diag prior to treatment onset)
- Non-specific factors (patient provider relationship, expectations, practice ambience)
Merle SBST
9-item “agree” or “disagree”/ “not at all” “extremely”
Established predictors of disabling LBP
OA score (1-9) used to separate into low (3 or les) and medium (4 or more) risk subgroups
Distress subscale (5-9) to separate into medium (3 or less) and high risk (4 or more)
Total > 4
5-9 > 4
PPT
Pressure pain threshold
Algometer or dolorimeter
Normally average of 3
Lower PPT inversely correlated with higher pain
3 pain mechanisms
Nociceptive
Peripheral neurogenic
Central sensitization
TNE
Therapeutic neuroscience education
Structured communication
SBAR
Situation
Background
Assessment
Recommendation
Usually referring back to primary physician
Pain is not isolated to sensory input (vs nociception)
Pain is output of the brain that incorporates…
Expectations Knowledge Prior history/experiences Emotional state Fear Location/setting
Patient educated regarding spreading pain symptoms, and taught that feeling pain in adjacent areas of the body does not indicate definite tissue injury. Hyperalgesia, immune responses and central sensitization topics were introduced using metaphors to promote deep learning
Spreading pain
Top 5 factors tied to success
- Listening to patient
- Spending time with the patient
- Patient developing trust
- Thorough interview
- Thorough physical exam
Turning down the alarm system therapeutically
TNE/PNE Aerobic exercise Manual therapy Breathing, relaxation, meditation Modalities Etc..
Patient introduced to the topic of pain neuroscience education and improving knowledge of how pain works to promote improved recovery and rehabilitation. Current knowledge and understanding of patient on pain related topics was explored to create baseline
PNE intro (pain knowledge)
Pre-op TNE for lumbar radiculopathy - Multicenter RCT
The group with TNE/PNE at 1 year follow up: better results for pain (back and leg), catastrophization, fear avoidance, pain knowledge, satisfaction with surgery, 42% healthcare savings
Establishing framework with patient
Tell patient what to expect: History Examination Discussion of the diagnosis/prognosis Joint decision about the course of therapy Begin with compassion/caring Listen
Patient educated on the concept of neuroplasticity, and how factors such as temperature, stress, movement, immunity and blood flow affect pain via ion channel expression. Instruction provided regarded homeostasis/ion channel balance disruption might occur based on what your brain thinks is needed for survival
Nerve sensors
Preventing nocebo
Frame the instruction
40% get a sore arm
OR
60% do not have a problem with this side effect
You will feel a bee sting
OR
(the anesthetic will) numb the area so that you will be comfortable
Gradual resumption of feared activities
Graded exposure
