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Copyright © 2016 Providence Health & Services
Moving on with it: Rehab (PT/OT/ST) for the Patient with Persistent Pain
Presented by TJ Melville, MPT
Providence Rehab Northeast
Objectives:
1. To learn how rehab can play a vital role in treating patients with
persistent pain
2. To understand what resources Providence Rehab offers for
patients with persistent pain
3. To learn how to set patients up for success in rehab
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Where we’ve been
Copyright (C) 2016 Providence Health & Services
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Pain
Specialist/
MD
InjectionsImaging
Imaging
Imaging
Narcotic RX
Narcotic RX
Unidentified Persistent Pain Patient
MD/PC
PT/OT
IC/ED
PT/OT
Narcotic RX
Narcotic RX
Inpatient stay for
intractable pain
Surgical consult and
surgery
Narcotic RX
Physical Therapy: Traditional Approach
•2 times per week for 4 weeks
•Aerobic conditioning
•Core strengthening
•Modalities
•Home exercise program
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Old Model
Pain
=
Tissue Damage
Louis Gifford, 1998
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Reprinted with permission from Kevin Cuccaro, D.O., Straight Shot Health LLC
Pain = threat
New Model
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Score of ≥4/9 total or ≥ 4 on psychosocial subscore= High risk, pain care indicated
Providence Oregon Rehab Services Pain Care
STarT= Low Risk
All Pain Treated as Biopsychosocial
Potential referral to Persistent Pain Care
Specialists , BH in Medical Home
Orthopedic Pain-Informed PT
Best Practice;Basic Pain Care as
indicated
STarT = High Risk Psychosocial Involvement
STarT = Medium Risk
Monitor
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Hill, et al, “Comparison of stratified primary care management for low back pain with current best practice (StarT back): a randomized controlled trial, Lancet, Vol 378, No 9802, p 1560-71
Providence Oregon Rehab Services Pain Care
Providence Rehabilitation Caregiver Pain Care Skills
Graded Motor Imagery
Return to Activity
Physiological Quieting
Pain Education
Motivational Interviewing
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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 re-injury (Van Oosterwijck et al 2011, Moseley, 2002, 2003)
Decrease in pain catastrophizing (Meeus et al, Moseley 2004, Louw et al 2011, Arch Phys Med Reh Systematic review)
Decrease in postoperative utilization of services (Adriaan Louw, PhD, PT, et SPINE Volume 39, #18)
Increase in function (Van Oosterwijck et al 2011, Moseley, 2002, 2003,Louw et al 2011 Arch Phys Med Reh Systematic review)
Increase in mobility (Moseley and Hodges, Clin J Pain. 2004 Louw et al Physiotherapy J, 2011)
12/1/2017 Creamer et al , British Journal of Rheumatology 0886 Vol 36 No 7, 1997 p 726-7 14
10% with no arthritis on xray have severe pain!!
Half of people with severe arthritis in the knee have no symptoms
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Written and video material available online, in-person and virtual class options
Providence Rehabilitation Caregiver Pain Care Skills
Graded Motor Imagery
Return to Activity
Physiological Quieting
Pain Education
Motivational Interviewing
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Copyright © 2016 Providence Health & Services
Providence Rehabilitation Caregiver Pain Care Skills
Graded Motor Imagery
Return to Activity
Physiological Quieting
Pain Education
Motivational Interviewing
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Copyright © 2016 Providence Health & Services
Kinesthetic Sense
•Awareness of muscular movement and position which helps us control and coordinate movement
•Yoga , Pilates, Tai Chi
•Breathing, body scan, progressive muscle relaxation
Copyright (C) 2016 Providence Health & Services 20
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Providence Rehabilitation Caregiver Pain Care Skills
Graded Motor Imagery
Pacing &Graded Exposure
Physiological Quieting
Pain Education
Motivational Interviewing
Stress response creates chemical changes that cause pain
Providence Oregon Rehab Services Pain Care
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Healthy balance in your day creates better sleep
Active
Restful
Easier sleep due to healthy balance over the day
Copyright (C) 2016 Providence Health & Services
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Day Night
Day Night
Lack of balance during the day creates poor sleep
Active
Restful
Why can’t I get to sleep??!?
Copyright (C) 2016 Providence Health & Services 24
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Providence Rehabilitation Caregiver Pain Care Skills
Graded Motor Imagery
Pacing &Graded Exposure
Physiological Quieting
Pain Education
Motivational Interviewing
Graded Motor Imagery (GMI)
• A treatment progression which involves gradual exposure to the mental representation of movement, without body movement.
• Uncouples the link between the movement neurotag and pain neurotag
• 3 components: R vs L discrimination, mental imagery, mirror therapy
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7.57.8
6.66.3
7.8
6.7
8.79.1
8.79.0 9.0
9.3
6.0
6.5
7.0
7.5
8.0
8.5
9.0
9.5
May June July Aug Sept Oct
VIS
ITS
Pain Rehab Treatment Efficacy with Complex Patients
Labeled Pain n = 689 Labeled Ortho n = 14,256
Linear (Labeled Pain n = 689) Linear (Labeled Ortho n = 14,256)
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Setting patients up for success
•Warm hand-off
•Reinforce the treatment plan
•Focus on function
•Acknowledge effort and accomplishments
•Emphasize a sense of Safety and Hope
Providence Oregon Rehab Services Pain Care
Safety and
Hope
“Kisses of time”Up to half the people with knee arthritis have no symptoms
Understand painSore, but safe
Bring some fun back in your life
Quiet your worry