Persistent pain Flashcards
define acute pain
warning system to protect tissue.
driven by peripheral factors (nerve endings).
resolves within 3months (inflammation, healing, nociceptive signals)
define chronic pain
been there for 3months or more,
multifactorial: psychosocial, biological, social..)
Pain that has outlived its function of protection.
chronic pain classification
primary - eg: fibromyalgia, non-specific LBP.
secondary - from another pathology, eg: cancer, post surgery/trauma, neuropathic, msk..
define nociplastic pain/centrala sensitisation
no proof of neither nociceptive or neuropathic mechanism - no tissue damage, no neural damage.
altered nociception on CNS (allodynia, hypersensitivity, co-morbidities)
define nociceptive pain
from tissue damage/disease
sharp, intermittent, mechanical, , non-neural, localised (w/out referral)
define neuropathic pain
from nerve damage/disease
peripheral - N compression, radicular pain. - changes in sensation, dermo/myotomal distribution.
central - post stroke, S.C damage. - spontaneous and unpredictable.
define central sensitisation
process of how pain is transmitted and amplified before processing at the brain.
6 biopsychosocial factors of persistent pain
unhelpful psychological state
increased peripheral N ending sensitivity (peripheral sensitisation)
increased activation profile of neurons (central sensitisation)
change in immune response
decreased control of descending pain inhibition signal
changes in cortical/subcortical network (activation adn communication
pain questionaires
pain catastrophising
fear avoidance beliefs
pain self-efficacy
DAS
pain intensity + interference
(taken at baseline and at intervals)
OREBRO questionaire
predicts who, with acute/chronic MSK) is more at risk of developing persistent pain/disability/delayed recovery
score of above 50 = high risk
questions:
- thoughts and feelings on impovement, return to routine, current situation.
- physical activity
- physical abilities (sleep, chores, social, sport, ADLs)
ABCDEFW in Persistent pain assessment
attitude + beliefs
behaviours
comprehension, culutral-social factors, comorbidities
diagnosis
emotions
family
work
what is boom - bust activity cycle
increase and decreases of activity from pain flare ups during or post exercise ( decreased compliance/adherence)
what is the patient specific functional scale (PSFS)
patient lists activities they have limitations in and gives them a score of 0-10 based on their ability to do it with presence of pain (unable -> as prior to injury).
add scores and divide by number of activities.
assess prior, during and post intervention.
factors that affect PA/exercise levels in chronic pain
- belief systems (perception of condition/tx, self-efficacy, confidence..)
- hypersensitivity (peripheral and central, decreased pain modulation + impaired EIH, exercise induced hypERalgesia, mechanical allodynia)
- psychological-social-behavioural-cultural factors (fear of pain/mvmts, pain understanding, pain catastr, self efficacy, family, unhelpful PA thoughts).
- disuse (fatigue, flexibility, decreased CV fitness, strength loss, decrease neuromotor control)
- sleep ( decreased restorative sleep = day time fatigue, decreased functioning, irritaability)
Tool box for chronic pain
cognitive pain education: EP, PNE (advice, reassurance)
graded exercise
mobs and manips
posture/gait reeducation
TENS, thermotherapy
ergonomic modification, orthotic support, lifestyle changes
relaxation, sleep strategies
soft tissue massage
chronic pain management: cognitive intervention - EP
what it is: formal educational intervention for pain.
aim: shift from pain as damage indication to protection need perception. decreasing threat value of pain for following interventions.
education components:
- anatomy + physiology in ACUTE pain experience
- acute vs chronic pain exp
- hypersensitivity (car alarm)
- psychosocial + lifestyle factors influence
- immune + endocrine influence
- EIH, graded exercise in decreasing pain.
chronic pain management: behavioural interventions
- graded exercise
- activity pacing
- graded exposure therapy
Graded exercise
assess baseline of activity level they can do over several sessions.
take average over several days, cut by 20% and start there. increase by 10% every 2-3 sessions.
activity pacing
programme an active-rest cycling of ADLs
set a goal and measure baseline
use reminders to rest and restart
document in diary and obtain feedback for goal tracking.
graded exposure therapy
step 1:assess faer/harm related associated w ADLs
step 2:gradually expose/practice feared mvmt
(start at an intensity which doesnt increase fear and progress intensity).
positive reinforcement and explanation that nothing is being damaged with activity is key to increase exposure levels and reach goal)
define self management
ability to manage symptoms, Tx, psychosocial and physical consequences of living with chornic pain.
aims in self management approach as physio
to aid Pt to actively participate and take responsibility in management if their pain.
decrease or avoid symptom exacerbation.
achieve functional goals
skills to train in self management strategies
educate patient on:
goal setting
pain education
cognitive restructuring- catastrophic thinking, avoidance beleifs/behaviours.
behavioural activation - pacing, flare up pla, future actions, reward.
cognitive defusion - identify and distance from -ve thoughts/emotions, relaxation
improve sleep hygiene
teach helpful postures
pain educational sources
lifestyle changes
Flare up plan
- avoid it by sticking to plan, recognising and acting on early warning signs.
- emergency strategy:
- dont panic - review progress
- decrease activity BUT dont stop
- coping strategies (relaxation = rest, +ve self talk, short term meds, doc consultation)
- monitor improvement within flare up.
- self encouragement
plan to return ASAP to activity - reassess baseline.
enrvmtal factors of SM - social and work
work load and exposure.
social support - roles in social surroundings, who they have, overprotective close ones.
physical envrmt - buildings, transport
medication and SM
we need to ensure:
- it is improving function
- be aware of correct dosage, dependence, adherence, review, effects
- pain ladder
- abuse
sleep and pain in SM
sleep affects the inflammatory markers = increases sensitisation
it influences mental states + moods = motivation changes
there is a bidirectional relationship
relaxation techniques in SM
- autogenic relaxation - self hypnosis
- progressive muscular relaxation
- deep diaphragmatic breathing
- guided imagery
mechanisms of relaxation in SM
- decreases cortisol levels
- inhibits inflammation processes
-decreases SNS activity - decreased muscle tension
- promote coping and relieves anxiety
SM barriers and enablers
barriers:
- unsupportive ambience
- distress
- low motivation from overwhelming effort needed
enablers
- self discovery
- supportive ambience
- feeling empowered - knowledge, pacing, relaxation, exercise, tracking…