Persistent pain

Question 1

define acute pain

Answer 1

warning system to protect tissue.
driven by peripheral factors (nerve endings).
resolves within 3months (inflammation, healing, nociceptive signals)

Question 2

define chronic pain

Answer 2

been there for 3months or more,
multifactorial: psychosocial, biological, social..)
Pain that has outlived its function of protection.

Question 3

chronic pain classification

Answer 3

primary - eg: fibromyalgia, non-specific LBP.
secondary - from another pathology, eg: cancer, post surgery/trauma, neuropathic, msk..

Question 4

define nociplastic pain/centrala sensitisation

Answer 4

no proof of neither nociceptive or neuropathic mechanism - no tissue damage, no neural damage.
altered nociception on CNS (allodynia, hypersensitivity, co-morbidities)

Question 5

define nociceptive pain

Answer 5

from tissue damage/disease
sharp, intermittent, mechanical, , non-neural, localised (w/out referral)

Question 6

define neuropathic pain

Answer 6

from nerve damage/disease
peripheral - N compression, radicular pain. - changes in sensation, dermo/myotomal distribution.
central - post stroke, S.C damage. - spontaneous and unpredictable.

Question 7

define central sensitisation

Answer 7

process of how pain is transmitted and amplified before processing at the brain.

Question 8

6 biopsychosocial factors of persistent pain

Answer 8

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

Question 9

pain questionaires

Answer 9

pain catastrophising
fear avoidance beliefs
pain self-efficacy
DAS
pain intensity + interference

(taken at baseline and at intervals)

Question 10

OREBRO questionaire

Answer 10

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)

Question 11

ABCDEFW in Persistent pain assessment

Answer 11

attitude + beliefs
behaviours
comprehension, culutral-social factors, comorbidities
diagnosis
emotions
family
work

Question 12

what is boom - bust activity cycle

Answer 12

increase and decreases of activity from pain flare ups during or post exercise ( decreased compliance/adherence)

Question 13

what is the patient specific functional scale (PSFS)

Answer 13

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.

Question 14

factors that affect PA/exercise levels in chronic pain

Answer 14

1. belief systems (perception of condition/tx, self-efficacy, confidence..)
2. hypersensitivity (peripheral and central, decreased pain modulation + impaired EIH, exercise induced hypERalgesia, mechanical allodynia)
3. psychological-social-behavioural-cultural factors (fear of pain/mvmts, pain understanding, pain catastr, self efficacy, family, unhelpful PA thoughts).
4. disuse (fatigue, flexibility, decreased CV fitness, strength loss, decrease neuromotor control)
5. sleep ( decreased restorative sleep = day time fatigue, decreased functioning, irritaability)

Question 15

Tool box for chronic pain

Answer 15

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

Question 16

chronic pain management: cognitive intervention - EP

Answer 16

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.

Question 17

chronic pain management: behavioural interventions

Answer 17

1. graded exercise
2. activity pacing
3. graded exposure therapy

Question 18

Graded exercise

Answer 18

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.

Question 19

activity pacing

Answer 19

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.

Question 20

graded exposure therapy

Answer 20

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)

Question 21

define self management

Answer 21

ability to manage symptoms, Tx, psychosocial and physical consequences of living with chornic pain.

Question 22

aims in self management approach as physio

Answer 22

to aid Pt to actively participate and take responsibility in management if their pain.
decrease or avoid symptom exacerbation.
achieve functional goals

Question 23

skills to train in self management strategies

Answer 23

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

Question 24

Flare up plan

Answer 24

1. avoid it by sticking to plan, recognising and acting on early warning signs.
2. 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.

Question 25

enrvmtal factors of SM - social and work

Answer 25

work load and exposure.
social support - roles in social surroundings, who they have, overprotective close ones.
physical envrmt - buildings, transport

Question 26

medication and SM

Answer 26

we need to ensure:
- it is improving function
- be aware of correct dosage, dependence, adherence, review, effects
- pain ladder
- abuse

Question 27

sleep and pain in SM

Answer 27

sleep affects the inflammatory markers = increases sensitisation
it influences mental states + moods = motivation changes
there is a bidirectional relationship

Question 28

relaxation techniques in SM

Answer 28

• autogenic relaxation - self hypnosis
• progressive muscular relaxation
• deep diaphragmatic breathing
• guided imagery

Question 29

mechanisms of relaxation in SM

Answer 29

• decreases cortisol levels
• inhibits inflammation processes
  -decreases SNS activity
• decreased muscle tension
• promote coping and relieves anxiety

Question 30

SM barriers and enablers

Answer 30

barriers:
- unsupportive ambience
- distress
- low motivation from overwhelming effort needed

enablers
- self discovery
- supportive ambience
- feeling empowered - knowledge, pacing, relaxation, exercise, tracking…