Early Identification and Treatment of Long Term Pain: Waiting for All the Evidence! What to do with the “Pain” Patient? Janet Holly BHSc. P.T. MSc Clinical Specialist in Pain Sciences The Ottawa Hospital Rehabilitation Ctr

Pain as the 5th Vital Sign

• In 1999 the American Veterans Administration decreed pain as the 5th vital sign

• Since then, there has been an outcry that the prescribing of opioids has skyrocketed

• A recent look at opioid deaths in Ontario, identified that a quarter were suicides and had been under the care of a physician within the last 14 days with a diagnosis of pain or a mental health diagnosis. (Dhalla et al., 2009)

– 50% of people on pain clinic wait lists have moderate to severe depression and 34.6% are have suicidal ideation (Choiniere, Dion et al., 2010)

• So many feel caught in the middle (Mularski et al., 2006)

Challenge:

Can pain be controlled without or with less pharmaceuticals?

The “Whys” Behind our Project?

How do you shorten OP pain management wait lists?

How do you maximize rehabilitation outcomes?

• Uncontrolled pain: – Affects immune function

– Will promote tumour growth

– Delay healing

– Increases morbidity and mortality following surgery (Liebeskind,1991)

• Therefore, control of pain is a desired outcome for almost all rehabilitation populations.

PREVENT IT FROM DEVELOPING!

• Historically, PT has been a leading discipline at managing pain

• Pain management has evolved to include many new strategies for the identification and management of pain (beyond medication)

What Is the Best Way to Manage

Persistent Pain?

• ‘The biological and psychological foundation for long-term persistent pain is in place within hours of injury’ (Carr & Goudas, 1999)

• A permanent memory of pain is in place within four days of the pain experience (Henry, James, 2012)

When does the problem start?

Condition Incidence of

Pain Comments Reference

Stroke 53% Incidence of CRPS in stroke= 23% Cacchio et al., 2009

Stroke (novel pain) 39% Kilt et al., 2011

SCI 80% Have chronic pain Borsook et al., 2012

Parkinson's 83% Only 34% on any analgesic medication Borsook et al., 2012

MS 86% Khan & Pallant, 2007

Alzheimer's 57% Borsook et al., 2012

Guillain Barre 89% Borsook et al., 2012

HIV 90% Borsook et al., 2012

SCOPE OF THE PAIN PROBLEM

Surgery Type Conservative

Prevalence %

Liberal

Prevalence %

Thoracic Sx 34.5 37

Breast Sx 31 41

Abdominal Sx 11 11.5

Donor Nephrectomy 9.6 21.3

Gynaecological Sx 13.7 17

Prostatectomy 14 21

Groin Hernia Repair 7 12

THA/TKA 19.8 27

Iliac Crest Bone Harvest 18.7 23.5

Mandibular Osteotomy 10 10

Varicose Vein Sx 4.7 4.7

Cardiac Sx 10

(Haroutinunian et al., 2013);

Choiniere et al.,

PERSISTENT POST-SURGICAL PAIN

The Stigma of Chronic Pain

• Patients report being stigmatized by friends, family and health care providers (Werner et al., 2003)

• They strive to be heard by the health care community but also to strike a balance of not being too strong nor too weak.

• They try to fit in with normal biomedical expectations of correctness –appropriately assertive, surrendering or appearances. (Werner et al., 2003)

• Or my personal favourites – they cannot have chronic pain – They are too normal!

– They are a guy’s guy!

• How we react early on can positively affect a patient’s long term prognosis and affect their quality of life!

– Listen, engage, empathize – Determine the patient’s personal context. – Acquire detailed pain data

• Versus iatrogenic harm!

– Words we use

– Your surgeon spent 8 hours for your surgery – longer then he expected

– The police said your car was a tin can!

– That is the worst looking degenerative changes that I have seen in a long while

– Look at the big red disc bulge on this spine…

– Be really careful moving as your fusion hasn’t healed and…..

– Big scary medical speak….

– Not listening…… – It is not possible to hurt that bad…

– Oh I had that problem and you just need to get going…..

– Look for the positives instead of listening

– Not understanding the different types of pain

Our Project Goal

• Purpose: Can an active education program for PTs working in all domains of practice identify patients at risk for developing long term pain and reduce the incidence of long term pain?

• This corporate program provided information and validated tools for the early identification of neuropathic and centrally sensitized pain, a decision algorithm and treatment ideas within the scope of physiotherapeutic practice.

The Process

• A physiotherapy program was established whose goal was the early identification of neuropathic/centrally sensitized pain

• Learning needs and pre-program confidence treating pain was identified in a qualitative survey – Confidence was rated on a VAS scale

• Establish contextual realities of service delivery sites – Site visits

– Representatives from all sites were part of the project

– These clinician reps became the site champions

• Establish two mandatory online learning models on general pain knowledge to ensure everyone was at minimum competency level

The third education module was an on-site pain neurophysiology interactive update. It included prevalence/incidence rates of pain progressing to long term pain in various diagnostic groups

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Pain ≠ Nociception

Nociception ≠ Pain

There is no pain nerve!

WHAT IS PAIN?

International Association for the Study of Pain

Since We Went to School….

• Updated knowledge: – Pain is an output from the brain

– Role of the immune system

– Reversible neuroplastic changes in the brain

– Role of genetics

Types of Pain

• Nociceptive

• Neuropathic

• Centrally sensitized and mediated pain

• Mixed

Tools to Distinguish Between Types of Pain

• Brief Pain Inventory

• Leeds Short Assessment for neuropathic pain

• DN4

Brief Pain Inventory

• Key words to pay attention to if circled:

– Tingling

– Shooting

– Stabbing

– Burning

– Deep

– Numb

– Cramping

Brief Pain Inventory

• Indicators other than pain – Function

– Mood

– Mobility

– Sleep

– Life enjoyment

SCREENING FOR FLAGS(Van Tulder, 2011)

Psychiatric flagsPersonality disorders

Schizophrenia

Etc

Validated Outcome Tools that Identify Neuropathic Pain

Two easiest tools to use:

• S-LANSS- short form of the Leeds Assessment for Neuropathic pain. – Scores of 12 and above are indicative of neuropathic pain

• DN4 – Score = or >4 test is +ve for neuropathic pain

– Sensitivity: 82.9%; specificity: 89.9%

• Anxiety

– GAD-7

• Depression

– PHQ-9

• Restorative sleep

– Pittsburgh Sleep Quality Index

Screening for Barriers to Progress

Pittsburgh Sleep Quality Index The PSQI has a sensitivity of 89.6% and specificity of 86.5% for identifying cases with sleep disorder, using a cut-off score of 5.

Addressing Pain • The fourth module was a second on-site interactive education session with regards to the P.T. Toolkit

• The detailed physiotherapy tool kit was reviewed.

• Empowered clinicians to discuss type of pain and treatment with teams and to take the lead in pain management.

• Initial clinical mentoring and support by therapists with expert knowledge in pain.

• Explored technological resources to assist with education – Data phones

– I pads

– Books

– Websites

The Toolkit

Medications – the domain of medicine and nursing solely?

Or is it?

Knowledge of Pharmaceuticals

• What type?

• When was the drug administered? – Prn vs straight – Half life of drug – Long vs short acting – Prior experience of patients with pain meds

• When do you see your patient? – Timing of therapies,

– What can we do now?

– What should wait? – graded activity

• Pain meds or others?

Medications

PHARMACOLOGY

Medication Brand Neuropathic/Nociceptive Comments

ACETOMINOPHEN

Acetominophen Tylenol Maximum 3 g/day

NSAIDS AND COX-2 INHIBITORS

Diclofenac Voltaren

GI risksIbuprofen Advil, Motrin

Naproxen Aleve, Naprosyn

Celecoxib Celebrex

ANTI-CONVULSANTS

Gabapentin Neurontin First line alternative for

neuropathic pain

Pregabalin Lyrica

Carbamaxepine Tegretol

Divalproex Epival

Lamotrigien Lamictal

Topiramate Topamax

Phenytoin Dilantin

Empowerment

• Identification of type of pain neuropathic/centrally mediated pain or mixed

• Determine appropriateness of pain meds for identified type of pain

• Open a discussion with the treating physician if required

Addressing Anxiety and Depression

• Do they possess a diagnosis of anxiety/depression or other behavioural/mood issues?

• Does their mood and behaviour negatively impact recovery?

• If suspected: – Screen for need for assessment

– Screen is positive - Are they followed by psychology/psychiatry?

Addressing Sleep

• If severe dysfunction – discuss findings with physician and possible need for medications or a sleep study. – Use of Apps

• Address the sleep dysfunction from a physiotherapy point of view: – Relaxation exercises

– Positional changes (1/4 off positions)

– Education – Healthy sleep habits.

Healthy Sleep Habits • Maintain a regular bed and wake time schedule, including weekends

• Establish a regular, relaxing bedtime routine

• No TV, computer, I-pad and some e-readers or stimulating activities 1 hour before bed

• Get a minimum of 8 hours of sleep per night with a bedtime before midnight

• Create a sleep-conductive environment that is dark, comfortable and cool

• Sleep on a comfortable mattress and pillow

• Use your bedroom only for sleep and sex

• Exercise regularly; best to complete your workout at least a few hours before bedtime

• Finish eating at least 2-3 hours before your regular bedtime

• Avoid caffeine close to bedtime as it can keep you awake; it can take 6-12 hours for caffeine to leave the system (e.g. coffee, tea, soft drinks, chocolate)

• Avoid alcohol close to bedtime

• Use a sleep diary to record your sleep habits and activity

• Discuss problems with your doctor to help treat the problem or refer to a sleep specialist

Adapted from the National Sleep Foundation Healthy Sleep Tips)

Relaxation Exercises: Pain Control or to Assist with Sleep

• Quick and Dirty: – Mental Imagery:

– Deep breathing

– Inhale/relaxed exhale: focusing on air entering base of lungs and then gently flowing out

• Guided relaxation

• Downloading wave noises, or nature sounds to MP3s or IPods

Exercise Guidelines for Patients with Chronic Pain: Nijs et al., 2012

• Appropriate exercises for patients with centrally sensitized pain – Aerobic in acute care can be quite low level but still aerobic.

• Evidence based medicine sometimes causes tunnel vision and it is easy to prescribe exercises that are great for admitting diagnosis but actually worsen the pain!

Exercise Guidelines for Patients with Chronic Pain: Nijs et al., 2012

If you are trying to strengthen an area with neuropathic (central sensitization) pain, you cannot use traditional strengthening protocols

1. Eccentric exercise is not appropriate for areas affected by neuropathic pain.

2. Include exercises for the non-painful areas of the body.

3. Pain should not be increased one hour after the exercise

4. Be conservative when setting baselines for exercise – better to undershoot then overshoot intensity this will help build confidence to exercise and not trigger pain.

5. Use multiple and long-recovery breaks between exercises – good time for relaxation techniques.

6. Monitor symptom flares and change the exercise prescription accordingly

7. If a patient is having a major symptom flare do not ramp up the exercise protocol – reflect - it may need to ramp down or be changed

Pain Neurophysiology Education

• Some of the best evidence around management of persistent pain can be found in education. (Moseley et al., 2004; Van Oosterwijck et al., 2011, 2013; Nijs 2011)

– 1:1 / Group

– Books:

– Explain Pain by Butler and Moseley

– Painful Yarns, Metaphors and Stories to Help Understand the Biology of Pain by Moseley

– The Pain Truth and Nothing But by Jam, B

– Apps: – I- Pain 101

Pain Neurophysiology Education- Virtual Media

Web Links:

• www.noigroup.com

• ww.paintoolkit.org

• http://www.painbc.ca/support-and-education

• http://www.bboyscience.com/pain http://www.bboyscience.com/pain-education/

• BBC The Secret of Pain - http://www.youtube.com/watch?v=150oynsUoQ8

• http://pain-topics.org/patient_resources/

• http://painaction.com

• Everything you need to know about pain in 5 minutes or less

• http://www.youtube.com/watch?v=4b8oB757DKc&feature=email

• Canadian Physiotherapy Association –Pain Sciences Division

• https://www.physiotherapy.ca/Pain-Science-Division/Member-Resources/Pain-Management

• APTA - http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=e6dabed7-c6d5-4362-8260-9ce807427619#.UyLiYqC9KSP

Return to Work Plan

• Barriers/Facilitators – Identify them in advance and plan appropriately

– They are not all physical (workplace ergonomics)

– Consider environment:

– Noise

– Temperature

– Activity level

Return to Work Plan

• Psychosocial Factors – Does the patient need support:

– Anxiety, fear etc.

– Analyze the context of the work place. – Enablement - Well meaning staff:

– Hostile- Less supportive staff:

– Work Life Balance: – It is important with patients with persistent pain that there is energy to do other things other then work while on the return to work plan.

– Do they need support for other issues (single Mom with child with disabilities)?

• Talk about return to work early in rehabilitation to acclimatize them to the concept and reduce anxiety

Title Goes Here

Acute Pain

Resolving and < 4/10

Yes No

Flags present

No: monitor status

Yes

Quality of pain: Burning, stabbing, electric shock, painful P&N CENTRAL PAIN

MECHANISM

No

Initiate appropriate strategies (PT, discuss re pharma, scheduling of therapies versus timing of meds)

Holistic Treatment Management:

Screen for depression/ anxiety/ sleep dysfunction: present?

Consideration of present pharmacological

management – does it include a central action

mechanism? (TOH experts consultation if required)

Yes: appropriate management plan? (sleep study, psychiatry, counseling, S.W., meds etc..)

No

Initiate P.T. toolkit

Introduce relaxation exercises

Address and reduce fear

Appropriate exercises for admitting Dx with consideration of sensitized CNS

(Nijs et al., 2012)

Pain neurophysiology education

Relaxation exercises

Specific pain interventions

Unloading (mobility aids)

Graded Motor

imagery

Plan to address known flags

Paced activity

Plan to address known flags

Yes

Sensory Integration

To be used with permission of the Ottawa Hospital: Holly J; Theriault E

Outcomes • Patients with neuropathic/centrally sensitized pain are being identified and started on appropriate treatment earlier in the acute and rehabilitation wards. – More consults generated to specialized PTs and champions in acute care. – Adjusted rehabilitation programs that consider neuropathic and centrally sensitized pain

• Patients with Complex Regional Pain Syndrome are being identified immediately at the majority of sites

• In-patients with SCI, Resp, ABI, trauma are being registered in Explain Pain classes

• Although survey results showed a decreased confidence in treating pain; qualitative analysis of comments revealed therapists were reporting that they were unaware of their knowledge deficits vis-a-vis identification/treatment of neuropathic/centrally sensitized pain.

Unexpected Outcomes

• Implementation of a pain project by Occupational Therapists to repeat the process within their discipline at their request demonstrates further knowledge translation that was unplanned.

• Shared the algorithm with the Alberta College of Physiotherapists who are developing guidelines for management of chronic pain

• Many clinicians in the acute and rehab environments have or can be taught the skills to coach patients towards better pain control

• Physiotherapists are ideally suited to take the lead in pain management and are cost effective.

• Physiotherapists need to consider their evidence based exercise protocols patients with neuropathic and centrally sensitized pain or the very exercises meant to assist with regaining function will become a barrier to successful rehab outcomes. (Nijs et al., 2012)

WE CANNOT CURE PAIN ONLY THE PATIENT CAN LEARN / BE EMPOWERED

TO MODULATE IT!