Transcript Nora Stern: Treating Persistent Pain Does Not Need to Be Painful

Western Montana Pain Symposium
Treating Persistent Pain Does Not Need to Be
Painful—Improving Outcomes through
Pain Education
Nora Stern, PT, MS PT
Providence Persistent Pain Project
Program Manager
Portland, Oregon
Conflict of Interest Disclosure
Nora Stern, PT, MS, PT
Has no real or apparent
conflicts of interest to report.
Objectives
• Understand pain as an output of the nervous
system
• Evaluate clinical decision-making reflecting
this understanding
• Understand role of pain education and team
based care in treatment of persistent pain
What is the purpose of
pain?
• Pain is a protector
• When you have persistent pain, beyond tissue
healing, what is the pain protecting you from?
Previous model
Current
Model–
CHAOTIC
Pain and the Brain
Central Sensitization
From Nocioceptive Input to Processing
to Output
• Changes that occur with persistent pain
Peripheral Sensitization:
Elevation of resting state of neuron
• Nocioceptive Input Travels Up Spinothalamic
Tract to Brain
Brain functions
Central Nervous System
Wetware:
- Amino acids, peptides, amines, all play a role
in excitation or inhibition
Hardware:
– Neurons
– Glia
Brain centers for pain neuromatrix
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•
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•
Thalamus and Hypothalamus: stress response, autonomic regulation, motivation
Amygdala: fear, fear conditioning, addiction: If you know it’s going to hurt, then
it’s going to hurt!
Sensory homunculus: tells us where sensation occurs. This can become blurred
and “smudged” with changes in movement habits
Primary motor cortex: organizes and prepares for movement. Affected by fear of
hurting oneself
Prefrontal and frontal cortex: makes sense out of the situation. Decides if the
danger signal is a real threat
Cingulate cortex: concentration and focus, affected by attention to pain
Cerebellum: Perception of movement
•
Hippocampus: memory, spatial cognition, fear conditioning
•
•
•
Brain functions for pain neuromatrix
• Thinking: looking for answers
Feeling: Fear avoidance, catastrophizing
• Sensing: sensory homuncular organization,
kinesthetic sense
• Acting/moving: motor planning, anticipating
pain with motion
Mirror neuron function
25% of our brain’s neurons may have a mirror
capacity
Output
1. Pain sensation as an output:
assigned to the virtual body representation
2. Message to
Autonomic Nervous System 
Neuroendocrine System 
Neuroimmune System
Fight or flight response left
turned on
Stress/pain relationship with
CRPS
Allen, R, et al, Phys Ther, 2011 4:32-42
Allen, R, et al, Phys Ther, 2011 4:32-42
PARADIGM SHIFT
• PAIN ≠ HARM
• PAIN IS AN OUTPUT FROM THE BRAIN
• ALL PAIN IS REAL PAIN
• NOCICEPTION IS NEITHER NECESSARY NOR SUFFICIENT
FOR PAIN
adapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010
Managing
and Coping
with
Chronic
Pain
VS.
Understanding
and Treating
Persistent Pain
Reference: “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and
Research,” Board of Health Science Policy, Institute of Medicine, of National Academies, Washington
2011
Pain Education:
A treatment intervention
Pain Education As A Treatment
Intervention
Decrease in pain rating (Van Oosterwijck et al 2011, Meeus et al, 2010, Ryan et al, 2010,
Moseley, 2002, 2003, 2004)
Decrease in fear of reinjury (Van Oosterwijck et al 2011, Moseley, 2002, 2003)
Decrease in pain catastrophizing (Meeus et al, Moseley 2004)
Increase in function(Van Oosterwijck et al 2011, Moseley, 2002, 2003
Pain education as treatment
Brain activity:
persistent pain patient,
baseline
S/P 2 weeks practice of
abdominal strengthening
Brain activity same day,
following pain education
Moseley, G. L, “Brain activity before and after 1:1 pain education with physiotherapist.”
Australian Journal of Physiotherapy 2005 Vol. 51
Outcomes After Pain Education in ED
Oliviera et al • Spine • Volume 31 • Number 15 • 2006
Persistent Pain Project Patient
Outcomes
0.5
% Change Improvement in Catastrophizing
47.00%
0.45
n=4
0.4
37.22%
0.35
n = 11
0.3
0.25
0.2
0.15
12.80%
0.1
n = 43
0.05
0
Total
Bev Hlth
Rehab
Components of pain
education:
Providence Oregon
•
•
•
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Phrasing
All providers able to explain pain as an output
– Provider training: rehab, primary care
– Upcoming: inpatient
Written material
Video
Patient classes
Patient access online
Providence Pain Video
http://providenceoregon.org/video/pain
• How do we do better?
– Speak the same language and explain pain
– Address the issues that are causing central
sensitization in primary care, behavioral health,
rehab, complementary medicine
– Team care: medical home
– Advocate for adequate coverage for high risk
patients
Fighting central sensitization
One patient at a time