Transcript Returning to Function and Patient Self

PEOPLE IN PAIN Know that Exercise is Important
 The problems:
› Fear avoidance
› Myths about pain
› Myths about chronic pain
› Attitudes to recovery
› Increased activity and exercise hurt
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WE Know that Exercise is Important
What does the patient need from us?
A consistent message about pain
A consistent message about persistent pain
A clear message that no matter how much medical management is
required, self management is also required
Guidance to increase success with returning to function
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Basic Pain Science
 Nociceptive neurons respond to potentially
dangerous stimulation
 Spinal cord neurons process input from
sensory neurons
› Integrating this with descending input
from the brain
 Some signals go directly to emotional
areas of brain
 Some signals make their way to cortical
areas related to sensory processing
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Basic Pain Science
Nociceptive
Neurons
Respond
Spinal Cord
Neurons
Process
Some Signals Go
to Emotional Areas of
Brain
Some Signals Go
to Cortical Areas for
Sensory Process
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Basic Pain Neuroscience
Text
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What is the Purpose of Pain?
 Protection
› If it hurts enough, you will stop ... or
at least yield.
› Muscle spasm is a protective
mechanism.
› Muscle inhibition is a protective
mechanism.
› Fatigue, catastrophic thinking,
anxiety, anger, ... are all protective
mechanisms.
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Ignoring the Protection Alarms
 In acute pain, this usually works.
 In chronic pain, typically the
organism will find another way
to protect itself, or the
alarms will get more intense.
 Many people with chronic pain learn,
and are taught, that the best thing to do is ignore the pain.
› This is not helpful for returning to function.
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Pain is a biopsychosocial experience
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Pain is a biopsychosocial experience
If you tell your patient a story in which the only
reason for the pain is tissue damage,
it is harder for the patient to understand when the
pain doesn’t resolve as expected and then you say
they need to get more active despite the pain.
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Pain is a biopsychosocial experience
“The best way to decrease your pain
is to decrease stress in our life and
start a daily practice of calm breathing and relaxation”
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Basic Science of Chronic Pain
 More and more aspects of the nervous systems become woundup and sensitized
› If the cells and systems practice protection 24 hours a day ->
they get better at protection
› They DO NOT habituate as expected when pain persists
 Peripheral neurons
 Central nervous system
 Autonomic nervous system
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Basic Science of Chronic Pain
 Neuroplasticity
› The nerve cells, nerve pathways and networks, and the
nervous systems themselves get better at whatever they
practice.
› These ARE NOT permanent changes in the nervous
system.
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Chronic pain is a biopsychosocial experience
When we have chronic pain,
there is a problem in the body
and the protective systems are too responsive.
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Basic Science of Chronic Pain
 Vicious cycles develop between pain and its effects
› Pain - shallow, tight, apical breathing - pain
› Pain - altered body awareness - pain
› Pain - muscle inhibition - pain
› Pain - muscle tension - pain
› Pain - altered body image - pain
› Pain - anxiety - pain
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Chronic pain is a biopsychosocial experience
“The best treatment will address both problems:
the body
and
the nervous systems.”
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Can an individual change pain?
Is pain management ALL about covering up pain and learning to live
despite its severity?
If you believe it is possible to change pain, your patient is much
more likely to?
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When pain persists, pain becomes an adverse
effect of movement.
 How to move in the face of pain?
 How do we answer the patient who says that every time I try
exercise or to be more active, the pain gets worse.
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Succeeding with Return to Function
“We need to teach your nervous systems to be less protective when
you move.
The best place to start is learning and practicing
calm breathing and muscle relaxation.”
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Box Breathing
Review
 The purpose of pain is not to accurately tell us:
› where the problem is
› what the problem is
› how bad the problem is
 Pain’s job is to make us stop!
 Our patient’s need treatment and guidance to make these
protective responses less sensitive.
 Wind down the nervous system
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Case Study 1
 38 year old woman
 Neck pain and headaches and unable
to work
 Not improving 5 weeks after whiplash
injury
 Xrays show degenerative changes
throughout lower cervical spine, with C4-5
reported as having more arthritic changes.
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Scripts 1
There is hope, and, finding ease of movement is the first step.
 This type of pain you are experiencing is chronic pain ... but that
doesn’t mean it will always be like this, or that it will continue to
worsen.
 Pain can be changed, and my job is to help you with that.
 This medication I am giving you should make you feel that the pain
is in control, and it should help you move better. I want to see you
back here next week to make certain it is working for both things.
 You showed me how much you can move your neck and arms
today and we will recheck that next week.
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Script 2 - same patient one week later
Calm breathing decreases pain and helps move with more ease.
 The medication helps to decrease pain temporarily, but her
movement is no better.
 When you ask her to move, she holds her breath, and tenses her
neck, shoulder and face muscles.
 “Close your eyes and breathe as calmly as you can for the next
minute.” After a minute passes, “now try those movements again.
 “remember that your protective systems are on high alert. It will be
difficult to calm them down if you hold your breath and tense up so
much every time you move.”
 “It’s important to stop sending the message that movement is
really dangerous.”
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Case Study 2
 48 year old construction worker
 Slow to resolve low back pain and right
leg nerve root irritation pain (seems L5
distribution but no conduction deficits)
 MRI 8 weeks after a lifting injury shows
L4-5 lateral disc bulge, central stenosis
and osteoarthritic changes
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Scripts 3
Brief description of chronic pain, and the roles of relaxation and
medication.
 Patient asks - “What can you do to fix this?”
 “You have a problem in your back, and irritated nerves. The best
treatment we can do is to work on calming down the irritation.
 Your job in this plan is to spend time every day relaxing and
getting your body and breathing to feel as calm as possible.”
 (we do not know the best dose of this, so fit it into the patient’s day)
 “The job of this medication is to let you move more easily. If it is
not doing that, we need to try something else.”
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Case Study 3
 43 year old woman with fibromyalgia
 Previously high-level, high-paid executive
position
 Unwilling to try medications until now
 Exercise has made her worse
 Meditation and sitting still make her
more anxious
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Scripts 4
Brief explanation of fibromyalgia pain, and why initial attempts at
what should help are sometimes unsuccessful.
 I am pleased you are ready to try some things other than just
being tough and trying to win a battle with this pain.
 We know that in fibromyalgia many aspects of the nervous
systems are cranky and over-sensitive.
 Our job, together, is to find ways to calm them down again. It’s not
easy, but it’s possible.
 The medication we are trying should let you move with less pain.
The yoga you are doing should also help with that.
 Remember that the strength you have to be tough and carry on in
the face of this pain is not helping you get better. Somehow you
need to stay tough, but don’t push so hard.
 You need to pay more attention to your body and pain, not less.
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Case Study 4
 64 year old active employed male
 10 weeks post TKA, and his pain
and function are worsening
 He is angry, believing that the pain
must be from faulty surgical technique
and that the surgeon is
saying he is making this pain up
 Orthopaedic surgeon has investigated and the prosthesis is not
the problem
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Scripts 5
Post-surgical pain can be related to sensitization and wind-up. Pain
education is often the first step needed in such cases.
 “When pain persists like this and we cannot find the reason for it from the
tissue or the surgery, we know that the problem includes unexpected
responses from the pain system.
 This is something you need to learn much more about so we can work
together to help you out. Here is a link to the Pain BC webinars where they
talk about this in much more detail, and it would help to read this book ...
you can get it from the library. We will need to talk some more about this,
because it will sound different from what we have discussed before.”
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Scripts 6
Reassuring the person in pain that we know what to do, and,
providing the understanding that a team approach is needed.
 “Your pain is real. It may not be easy to change it, but we can.
 This medication is to help you move better, and not pay for it so much.
 Your nervous systems have become far too agitated - by the pain before the
surgery, and all the stress after it. I want you to see this counsellor to learn
breathing and relaxation techniques. And I will contact your physiotherapist
to make certain she is getting you to do as much work on calming down the
nerves in your knee as working on getting you stronger.
 If we all work together we can help you best with this.”
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Resources
 www.painbc.ca
› Empowering Self Management of Pain series
› The Pain Toolkit
› Yoga for People in Pain series
 Chronic Pain Self-Management Program (University of Victoria)
 Understand Pain, Live Well Again
Pearson, N. Patient education book available in all BC public libraries
 Explain Pain
Butler D, Moseley L. www.noigroup.com

http://www.physicalactivityline.com/
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Practice Support Program Tools
 MH algorithm (http://www.gpscbc.ca/psp-learning/mentalhealth/tools-resources)
 CBIS from PSP’s adult mental health module
 Problem list
 Resource list
 Brief Action Planning
 Bounce back DVD
 Anti-depressant skills workbook
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Mental Health Algorithm
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Cognitive Behavioural Interpersonal Skills (CBIS)
Manual
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Problem List
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Resource List
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“Is there anything you would like to do for your health in the next week or two?”
Behavioral Menu
Elicit a Commitment Statement
SMART Behavioral Plan
“How confident (on a scale from 0 to 10) do you feel about carrying out your plan?”
If Confidence <7, Problem Solve Barriers
“Would you like to check in with me to review how you are doing with your plan?”
Brief Action Plan
Follow-up
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BounceBack
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Antidepressant Skills Workbook
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