Persistent Pain Eval/Treatment Flashcards
3 parts of the pain assessment
- characteristics
- meaning
- effect on individual
5 goals of eval/pain assessment
- create the therapeutic alliance/relationship
- identify symptom behaviors
- identify yellow flags
- identify the pain dominance
- identify asterisk signs
why do we need to create the therapeutic alliance/relationship?
- association with outcomes
- increases ability to challenge their beliefs
identify yellow flags
- beliefs/expectations
- psychological irritability
subjective information
- symptom behavior and irritability
- pain intensity - relies on patients memory
short term memory
- relatively accurate average pain intensity
- poor agreement for worst/least pain
long term memory
- inaccurate recall of pain intensity
- good recall of location and activities that decrease pain
persistent pain patients have …..
- seen multiple providers
- been given multiple diagnoses
- received multiple treatments
- had multiple failures
ALL LEADING TO POOR EXPECTATIONS AND MALADAPTIVE BELIEFS
patient’s beliefs are significantly influences by…
providers
- we can have a strong effect over beliefs and expectations by modifying content
- identify/change maladaptive beliefs and negative expectations
yellow flags
- psychosocial risk factors that may be barriers to progress
- fear
- anxiety
- fear avoidance
- maladaptive beliefs
- low social support
Yellow flags - emotions
- fear of increased pain
- depression
- irritability
- anxiety
- stress
yellow flags - behaviors
- extended rest
- poor compliance w/ exercise
- excessive reliance on aids/devices
- high intake of medication or alcohol
yellow flags - family
- overprotective
- punitive response (“I’ve got to do everything now”)
yellow flags - work
- fear that returning to work with damage the spine
- belief that work is harmful
- unhappy at work
- previous negative experiences with work/LBP
yellow flags - compensations
- extended time off work
- number of WC claims
- previous history of LBP
- lack of incentive to return to work
yellow flags - diagnosis and intervention
- sanctioning disability
- conflicting diagnoses
- too many healthcare providers
- passive treatments
- lack of satisfaction
- selling treatment in numbers
- interactions with the provider
yellow flag screening tools
- OMPSQ: self administered pain screening questionnaire
- Central sensitization inventory
- Tampa scale of kinesiophobia
- pain catastrophizing scale
- fear avoidance beliefs questionnaire
- neurophysiology of pain questionnaire
- patient specific functional scare
Orebro Musculoskeletal Pain Screening Questionnaire
- drill down on the intake forms and questionnaires
- why did they answer the way they did?
- how the answers affect their lives?
- what they feel like the barriers to changing these are?
- use through episode of care
What is psychological irritability
- how aggressively can you challenge beliefs before the patient goes on the defensive
- How difficult will it be to get the patient to “return to baseline”
What is psychological irritability determined by?
- strength of patient beliefs
- strength of therapeutic alliance
is psychological irritability static or dynamic?
- dynamic
- constantly changing over the course of treatment
- increased trust –> decreased psychological irritability
motivational interviewing
OARS
- open ended questions
- affirmations
- reflective listening
- summarizing
motivational interviewing
- RISE
- roll with resistance (avoid arguing)
- identify discrepancies
- support self-efficacy
- engage with empathy
Nociceptive dominant pain pattern summary
- pain initiated by activation of peripheral receptors of primary afferents in response to noxious chemical, mechanical, or thermal stimuli
peripheral neuropathic pain dominance summary
pain initiated or caused by primary lesion or dysfunction the peripheral nervous system
central sensitization pain dominance summary
- pain initiated or cased by dysfunction in the CNS
where is pain located with nociceptive pain dominance
- pain localized to area of injury/dysfunction
pain patters in nociceptive pain dominance
- clear, proportionate mechanical/anatomical nature to aggravating and easing factors
- usually intermittent and sharp with movement/anatomical provocation; may be dull or throb at rest
nociceptive pain dominance has an absence of:
- pain in association with other dysthesias
- night pain/disturbed sleep
- antalgic postures/movement patterns
- pain variously described as burning, shooting, sharp, electric shock like
Peripheral neuropathic pain dominance pain patterns
- pain referred in a dermatomal cutaneous distribution
- pain/symptoms provocation with mechanical/movement tests that move/load/compress neural tissue
peripheral neuropathic pain dominance history
history of nerve injury, pathology, or mechanical compromise
central sensitization pain dominance pain pattern
- disproportionate, non-mechanical, unpredictable pattern of pain provocation in repose to multiple/non-specific aggravating/easing factors
- pain disproportionate to the nature and extent of injury or pathology
- diffuse/non-anatomical areas of pain/tenderness on palpation
what does central sensitization pain dominance have a strong association with ?
maladaptive psychosocial factors
how do we identify pain dominance?
- we ID the dominant/driving feature of pain experience
- patients will have aspects of all domains
if a patient has neurological symptoms, radiating pain, weakness, what should you do?
perform full neuro screen/exam
nociceptive pain dominance evaluation
- standard PT eval
- consider language (avoid nocebo, pathoanatomic, damage-specific language)
- take opportunity to reinforce adaptive beliefs of the body’s resilience vs maladaptive beliefs of frailty
peripheral neuropathic pain dominate evaluation
- full neuro screen
- nerve palpation
- neurodynamic testing
- PPT
nerve palpation
- perpendicular palpation
- sustained pressure (up to 30 sec)
- “twang” the nerve
- Tinel’s Sign
Positive nerve palpation findings
- reproduction of symptoms
- bilateral differences
- retrograde firing - paresthesia
- pressure threshold
+ neurodynamic test findings
- reproduction of symptoms
- bilateral asymmetry
- sensitizing maneuver- unload/load tension in system remotely
key things when performing neurodynamic testing
- active before passive
- cue patient for sensitization maneuver before passive test
- use your body/table to control all motions
- order matters - changes sensitization of symptoms
What s pain pressure threshold
minimum force applied with induced pain
what is PPT commonly used for?
evaluating tenderness
how to do PPT testing
- slow application of force until the patient states that the sensation has changed from pressure to pain
- 3 measurements with 30 sec between trials - use average
what are the hallmark signs of central sensitization pain dominance
- hyperalgesia
- allodynia
central sensitization pain dominance evaluation
- hyperalgesia
- allodynia
- PPT
- movement dysfunction
- laterality testing
- 2PD
what does laterality testing assess
cortical smudging - structural and functional changes
what is laterality testing
- determining handedness of object
- form of motor imagery
- implicitly motor imagery
- activates cortical network involved in limb representation and preparation for movement
- does NOT activate S1 or S2
laterality testing norms
- > 80% accuracy
- 1.6 +/- 0.5 sec/slide for neck/back
- 2 +/- 0.5 sec/slide for hands/feet
laterality testing - acute pain state
the initial presumption towards the acutely injured hand results
laterality testing - chronic pain state
- the initial presumption is towards the non-painful side/part
- protective response
persistent pain leads to
cortical reorganization
increased 2PD correlated with
- decreased body awareness
- decreased proprioception
- increased pain
2PD norms
- lumbar spine: 55.5m
- posterior neck: 45.9-55.4 mm
- lateral mandible: 10.4 mm
- forehead: 14.9 mm
goal setting
- pt’s goals guide specific treatment choices
- functional and specific to pt experience
- pt-centered goals
- check in on goals every session
- develop with the patient
things to consider when goal setting
- asterisk sign
- functional limitations
- movement dysfunction
- endurance
- yellow flags
patient specific functional scale
- pt identifies 3 functional goals
- rate on a scale of 0-10
- 0: can’t do it now
- 10: no problem at all
