Pain & Therapy

By Danny Rix Oct 2014

Aims and Objectives

Increase understanding of pain Physiology of pain Overview of commonly used medications Psychological and Environmental issues

surrounding pain Role of Physiotherapists in Pain

Management & a caseload video

Definition of Pain

“Pain is an emotion experienced in the brain, it is not like touch, taste, sight, smell or hearing”

The British Pain Society

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or

described in terms of such damage”International Association for the Study of Pain (IASP)

Statistics

Exact statistics unknown

Around 10 million Britons suffer daily pain levels which majorly impact on their quality of life and occupation

Chronic Pain currently troubles an individual constantly or intermittently for more than 3 months.

31% Men and 37% Women with Chronic Pain

(sample of 8610 adults)

Percentage Increases with age.

Health Survey for England 2011(published Dec 2012)

Mainly Musculoskeletal Pain

Site do not vary by age.

Around a quarter have pain in more than one site.

WHAT IS PAIN ?

•A physiological and psychological experience

•Warning sign of actual or perceived tissue damage

•Acute: biological function – days to weeks

•Chronic: persists beyond normal time of healing

Reflexion 1

Subjective experiences like pain can be difficult for other people to understand!

Example: Think of a situation when you or a family member have been assessed by a healthcare professional in regards to a pain

problem.

Did you feel the professional fully understood the experience of pain?

Was the significance of your pain experience fully acknowledged ?

Did you feel the professional fully believed or doubted the severity of your pain ?

- Nociception – The Pain Transmission System

•The nervous systems way of detecting, transmitting and processing potential damage

•Potential damage detected by nociceptors

•Nociceptors are an alarm system

Pain Gait

PERCEPTION OF PAINPERCEPTION OF PAIN

The end result of the neuronal activity of pain transmission

A conscious multidimensional experience

Painful stimuli are transmitted to the brain stem and thalamus, multiple cortical areas

Such as:» The reticular system:

» Somatosensory cortex:

» Limbic system:

MODULATION OF PAINMODULATION OF PAIN

Involves changing or inhibiting transmission of pain impulses in the spinal cord

Descending modulatory pain pathways (DMPP) lead to an a decrease in transmission (inhibition) of pain impulses .

Descending inhibition involves the release of inhibitory neurotransmitters that block or partially block the transmission of pain impulses

Pain modulation helps to explain the wide variations in the perception of pain Pain modulation helps to explain the wide variations in the perception of pain in different peoplein different people

Pathophysiology of Pathophysiology of chronic painchronic pain

Following injury, rapid and long-term changes occur in CNS & PNS involved in the transmission and modulation of pain

Mechanisms involved in the pathophysiology of chronic pain are complex and remain unclear

Inflammatory Soup Hyper-algesia – Primary & Secondary Allodyna Peripheral Sensitization Central Sensitization

“Here is the most difficult thought to accept about pain. We experience pain only and entirely as we interpret it. It seizes us

as if with an unseen hand, sometimes stopping us in mid-sentence or mid-motion,

but we capture it and re-shape it ”

(Morris 1991)

Reflection 2Reflection 2

Think about a pain you have on a Think about a pain you have on a regular/episodic basisregular/episodic basis

Concentrate on that area for a moment & think about how that pain feels….

When do you find it hurts

(Stressed – run down – pre/post exercise)

How does the pain effect your mood What do you do to cope with the pain when it occurs Do you believe the pain is associated with harm

Medication (1)

Standard Pain Medications on WHO’s Pain Relief Ladder

Non – Opioid's: (inc. Over the Counter and NSAID’s)e.g. Acetaminophen (Paracetamol), Aspirin, Ibuprofen, Diclofenac, Naproxen, Celecoxib

Weak Opioid's:e.g. Codeine, Dihydrocodiene, Tramadol

Strong Opioid's: e.g. Morphine, Oxycodone, Fentanyl, Buprenorphine, Oramorth, MST

Increasing pain and

persistence+ Non-Opiod

and other medication

Medication (2) Non- Standard Medications used for pain:

Medications originally used to treat other illnesses.

Anti-depressants:•Amitriptyline•Nortriptyline•Imipramine•Venlafaxine•Duloxetine

Anti-epileptics:•Gabapentin•Pregabalin

Anti-depressants – often used to treat neuropathic pain but at a lower dosage. They improve the effect of chemicals in the brain that reduce with depression or pain.

Anti-epileptics – often used to treat nerve damage or when nerves are oversensitive. Affect the nerve activity.

Medication (3)

Wide range of side effects often treated with other medications: Feeling sleepy, Dizziness, Nausea and/or Vomiting, Indigestion (common

with NSAID’s), Weight gain (often with anti-epileptics), Constipation (often with Opioids), Reduced sex drive, Itching, Feeling confused, Increased likelihood of stomach ulcers/bleeding/CVA/Kidney/liver issues and Breathlessness/Asthma

Long term Effects inc. increased pain!

+ stronger Opiod’s in particular can lead to problems with dependancy

Combination Painkillers:•Co-codomol = Paracetamol and codiene•Co-Dydramol = Paracetamol and dihydrocodiene•Tramacet = Paracetamol and Tramadol

INTERACTION OF PATHOLOGICAL & PSYCHOLOGICAL COMPONENTS

•A sensory and emotional experience influenced by psychological factors

• Individuals pain perceptions & beliefs influence perceived pain intensity

•Acute pain developing into chronic pain when underlying pathological cause no longer evident

MANAGEMENT MODELS NEED TO SHIFT MANAGEMENT MODELS NEED TO SHIFT AWAY FROM ACUTE BASED APPROACHES AWAY FROM ACUTE BASED APPROACHES

FOR CHRONIC PAINFOR CHRONIC PAIN

DO YOU HAVE UNDERSTANDING, DO YOU HAVE UNDERSTANDING, EMPATHY AND PATIENCE TO LESS EVIDENT PAIN ?EMPATHY AND PATIENCE TO LESS EVIDENT PAIN ?

IS THAT PERSON’S PAIN LESS REAL FOR THEM ?IS THAT PERSON’S PAIN LESS REAL FOR THEM ?

PSYCHOLOGICAL COMPONENTS OF PAIN

» Anxiety & Fear

» Suffering

» Stress

» Grief

» Personality

ENVIROMENTAL COMPONENTS OF PAIN

Family influences

Culture/ethnicity

Secondary gain

Socio-economic factors

AMPLIFICATION AND AMPLIFICATION AND MAINTENANCE OF PAINMAINTENANCE OF PAIN

» The Belief That One Is Sick

» The Sick Role

» Patient’s symptom Perception and Illness Understanding

Explain pain video

ASSESSMENT OF PAIN

Is asking “ Can you rate your pain 0 to 10 “ enough ?

Important considerations – Clinical utility Reliability Validity

Types of measurement - Self report (scales, drawings, questionnaires & diaries) Observational (measurements of behaviour, function –

ROM) Physiological (Heat rate or pulse)

Required before intervention as important to complete holistic picture the of the patients needs

and areas of difficulty

Cognitive /language/ learning barriers Time limitations vs. insufficient information

ASSESSMENT OF PAIN

ASSESSMENT OF PAIN

To ensure the quality of information obtained a therapist should be attentive of certain aspects into

any pain discussions:

Provide time to develop a collaborative relationship to establish the persons needs and situation

Expand on formal assessments and elaborate on a patients responses

Actively listen – notice signals and guarding Attempt to understand implications on lifestyle & quality of

life

Are you in control of the discussion or facilitating it ? Are you in control of the discussion or facilitating it ?

Role of PT vs Pain

Identify:Identify: Abnormal movement patterns,

Compensations or fixation

Unfavourable beliefs or mind sets

Individual treatment desires and beliefs

Role of PT

Treatment options: Providing education & challenge beliefs Develop coping strategies Reconceptualising - pain gait theory Encourage active role in treatments & self-efficacy Exercise – mobilizations – manipulations and stretching Electro physical agents – heat/cold/ultrasound/Tens – pain

gait or placebo! Developing individualised goals and constant revaluation

and reinforcement of progressions CBT vs CFT

CASE STUDY

Any questions?Thank you for listening

?

References (1)

British Pain Society (2013). FAQ’s. URL: http://www.britishpainsociety.org/media_faq.htm]

Health and Social Care Information Centre (2012). Health Survey for England - 2011, Health, social care and lifestyles. URL: http://www.hscic.gov.uk/catalogue/PUB09300

International Association for the Study of Pain (2012). IASP Taxonomy. URL: http://www.iasp-pain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/default.htm World Health Organisation (2013). WHO’s Pain Ladder for Adults. URL: http://www.who.int/cancer/palliative/painladder/en

Cardiff and Vale University Health Board (2009). Extended day and seven-day physiotherapy service in acute medicine. URL: http://www.library.nhs.uk/qipp/ViewResource.aspx?resID=330625

Department of Health (2006b). A joint responsibility: doing it differently: Musculoskeletal Service Framework. London: Department of Health.