Chronic Pain Management: Contemporary Principles and Methods

[bernard]

I found that little program on PPA group
http://www.ppaonline.co.uk/

E-mail: suzy.williams@rnhrd-tr.swest.nhs.uk

To review the broader social and healthcare context of chronic pain and disability by reviewing history and epidemiological data.
To gain familiarity with a basic behavioural framework of pain that considers functional influences on patient behaviour relevant to health and participation in daily life - this view includes aspects of operant, cognitive-behavioural, and current behaviour analytic models but may be new to many people.
To learn the aspects of a functional analytic approach to assessment and review some useful assessment strategies for patient selection and treatment outcome.
To review and practice a number of standard behaviour interventions (e.g., relaxation, habit reversal) and acceptance based strategies (e.g., meditation, sensate focus, other experiential tasks).

Have you some comments?

[nari]

Bernard

I want to respond to this with my program, but have not had the time yet to sit down and three-finger type it out. i would like opinions on my approach to the intriguing management of chronic/persistent pain.

It is really a very exciting area!!

Bon soir


nari

[nari]

Hi Bernard

There is little in the way of 'protocols' for management of chronic pain; too few people are in the business. Primarily, it is the team at a chronic pain clinic that is in touch with the chronic pain phenomenon; and these guidelines are linked to multidisciplinary goals.

My approach is as follows:

principles:
No manual therapy except in assessment process. These PPP (persistent pain people) have had all sorts of hands-on and have gained mostly short-term relief. Many are indifferent towards physiotherapy, as they have found their pain increased during sessions, leaving them with a negative experience of the profession. A good example of this is the PPP with an ongoing painful shoulder, sometimes post-surgery, sometimes not. There has often been a peripheral approach, strong forceful exercises and machines. (Sorry, Bernard!)

I listen to their story and expand on what is heard from them.
I take close notice of yellow flags, and include them in assessment approaches. This may take 2 sessions.

I assure them that they will not be asked to do anything 'physical' in the sense they have to do ten exercises with resistance, etc.

I test extensively, and very cautiously, their neural tension. It may be impossible to go anywhere near their primary source/s of pain.
I find several movements which are painfree but close to the source of pain and encourage them to do them. They must be functional in nature.

ROM and strength are largely irrelevant. A blatantly obvious loss of ROM, say in the shoulder, can be noted. Tell them you are are not concerned with strength until the pain has lessened.

I try to "Explain" their pain. Most understand quickly, or have worked it out for themselves. They will feel relieved that they are not 'faking' pain.

I do not talk about 'pain' any more than necessary. VAS is quite useless for PPPs; it will vary like blood pressure from one hour to the next. Roland Morris and Quebec scales can be useful. I will also ask 'do you feel your pain is controlling you?' or, after explaining the nature of the pain: 'Your brain is perpetuating the pain without your permission' will also cheer them up.

I focus on what they can do, not what they can't.

I set mutual goals. What do they want to do that they have had to give up? What do they enjoy doing? If they are doing nothing at all (many are in that position), they have to find ONE thing they would like to do.

The goals are theirs. I don't care if they are trivial, as long as they are theirs. I like to try and empower them - self-esteem is usually poor.

I tell them I cannot cure their pain, but we will aim for 50-70% improvement, to the point they should be able to manage by themselves.

According to what is found on Ax, they will have homework - all neural based. A maximum of 2 movements. Sometimes all it will be is ULNT(1) at 40 deg Abd, full elbow ext and 20 deg wrist ext. Three reps of wrist ext, every 2 hours or so. The second might be breathing control practice, then incorporate that into the first movement.

I then will use manual therapy (eg mobilisation) AFTER their pain is reduced to the point where their lives are more normalised.) Often a previously painfree neck becomes tender and stiff after the arm pain has resolved.
I figure McKenzie is onto something with his centralisation principles, and it ain't got nothin' to do with discs!!

Much as with headache treatment, I ask them down the track a bit to keep note of what might trigger sensitivity, and to keep track of their good and lousy days, to see the pattern. for instance, a patient might record on Day 10 (since first visit) that the flare-ups occur every 2-3 days and last up to 3 days. By Day 30, this should be every 1-2 weeks and last only hours or a day..... and so on.

Of course the challenge of our lives is the patient who wants a cure; who is not prepared to deal with their pain; and who is quite happy with the massive cocktail of drugs and just wants physio to 'clear up the rest of the pain'. I do not continue to see these folk once the picture is clear to me that they are passive, and remain passive after several attempts.

They are the "failures", usually.

The excitement in 'treatment' of PPPs is the astounding reduction of their pain after 2, 5, 10 and even 25 years.


Nari

[rolf]

Hi Nari!
Ilike your aproach regarding PPP.I feel at home reading your topic.
We have to show the patients that we care about their problem,health,etc but they have to understand that theywill not manage to reduse their pain without doing what we recomend/tell them to do.More or less i feel like a teacher/coach who gives the patients homelessions to do.If they dont do their lession i will not be able to now if my pain theory is wrigh or not.They have to learn to take responsibility over their own life/body.
Iam there to guide them back to a less painfull road.,but this wiil not be possible if they arent able to see that theyre sitting behind the steering-wheel.
Rin :wink:

[nari]

Where are the failures of the protocols?

Ah - do we have protocols? Our own, or developed from what we have learned over ten years or so with regard to chronic/persistent pain?

Common failures from where I stand:

Lack of motivation from patient -they want a quick fix, be it medication or physiotherapy input;

Not many physiotherapists know how to approach chronic pain;

Most doctors do not understand our role and refer far too late;

We do not know enough about management to form a series of protocols.
Each person is different, with individual yellow flags and symptoms.

There was an incident where a specialist MD, investigating a patient's pain at a workshop (or similar) found the ULNT tests all strongly positive, limiting ROM. He said:..."but that is not relevant".

Sigh.........


Nari

[bernard]

Nari,

The evil is more profound. Media carries ever what some mad MDs told it?

there is no evidence for on-going pathology, therefore patients with chronic back pain must have suspect personalities

Could we, for a moment, imagine that Medicine is going on a wrong way?

[nari]

Hi Bernard

I can easily imagine that most doctors do not understand the nature of chronic pain and therefore do not know how to manage it appropriately.
If they did, there would be a stronger move to establish more pain clinics where it can be tackled.


Nari

[bernard]

Nari,

Does Medecine understand pain?

[BB]

Nari,
What a great description of an approach!
Can you speak more to the goal setting aspect....how do you help people set appropriate goals? How do you get functional goals from the people who are so focused on thier pain that they cannot even think of function more active than watching TV?
Cory

[nari]

Bernard -

Some purveyors of Medicine do understand pain - but they are few. If they are up to scratch on the physiological process, they may not understand the physiotherapist's role.

BB -

Setting goals can be tricky. In another post I mentioned that a lot of women do not have many leisure activities; they clean, cook, iron, and garden. Most of this activity is flexion- based. I suggest they try a walk, even if only twenty minutes, or ten minutes, and increase it by 3-5 minutes each day. If that does not work out, I can usually extract one thing they would like to try, and it is often something they liked in the past but gave up because of pain.
I never care what it is - that is not important. It should be something they would like to do;and something they have not done at all since their pain started.

It MUST be functional. If a patient says "oh, I used to do situps every morning.." I recommend that is not a good way, and tell them why.
One woman, with quite nasty UL pain, said she would love to crochet again. So we worked out a way to do 5 minutes, resting both elbows on pillows, and stop. I said she had to wait 5 minutes before starting again.
She became so impatient she broke the 'rule' and ended up flaring. BUT she knew why. So she learned to control her impatience, control her pain better, and achieve a goal; a very paced goal. She was quite pleased that she was able to complete a crocheted item.

However..........there are some who do not learn, flare up and give up.
Sometimes they sound almost pleased: "I knew I could not do it"...

Win some, and lose some.

Nari :?

[bernard]

Nari,

If they are up to scratch on the physiological process, they may not understand the physiotherapist's role.

I have some difficulties to interpret correctly your words, could you explain further?

[nari]

Hi Bernard

Sorry - I use cliches that are likely Aussie in origin.

I meant to say that if the doctors are not familiar with the updated knowledge on chronic pain, they will not understand the physio's role.

I left out the word "not"....


Nari :oops:

[Diane]

I just reread, incredibly slowly, your fabulous post of March 21 Nari. It is brilliant. You are teaching people, these PPPs, the "failures" of the medical system, the chiro system, the PT system, probably the osteopath system too... you are teaching them "awareness." Literally to detach from their pain.

Loved the whole, "your brain is doing something to you without your permission" idea. You are trying to connect to their highest conscious faculty, get THEM to connect to their highest faculty, and reassure them with every word you say and don't say, every move you make or don't make, every move you have them make, that this bit IS the one in charge.. I can see why, now, with this particular group, you are hands-off. Anything else would defeat them in their side of the treatment encounter, which is to BE in charge, of their life, of their own intersection with others and with their own bodies. Get back the sceptre. Can't be done if a PT is busy handling the spectre for them. (Sceptre in this case is a burning torch, and they are in it; it is their very body.)

You are teaching them to wrestle with their own brain, which has conjured up a pain state that no one else can "touch." You are their martial arts coach, giving them clear concise instruction in techniques with which they conduct their own inner battle to vanquish their own pain demon that got so big it swallowed them, help them turn it inside out again to be back in charge, and never judge them for having allowed such a monster to grow in the first place..or any other practitioners for having contributed to the construction. And you have to earn their trust first, to do it, so they have to budge a little in order to get to the place where they can learn to push into themselves, how slow, how gently, from which direction.. and you do all that verbally, through their anxiety and their apparent defeat and their depression. Your only advantage is that they have already exhausted everything else and there you are, still there.. carefully choosing words. Carefully providing a frame around their tissue issues. Touching them only with your sound waves and your presence.

Wow. My hat is well off to you. I think I finally get what you do. You are a zen woman, who practices PT at a master level.
Diane

[Diane]

Here's an essay, which discusses expectations of how one might feel after an event versus what actually happens. It's a bit abstract, but there might be some kernals in there for us to chew on as PT practitioners treating pain in people, each in our own way.
http://www.edge.org/3rd_culture/gilbert03/gilbert_index.html
Diane

[nari]

Diane, thank you for your complimentary words.

My inspiration to follow through with chronic pain has been my consistent interest in neurosciences, and both of David Butler's courses, starting in 1991. He really fired my interest in an intriguing topic, and my ongoing interest is due to his teaching skills.


Nari