Treating Pain Lecture Flashcards

Introduction to Comprehensive Pain Management

• Agenda and Overview: The comprehensive approach to treating pain involves several key areas of focus:

  • Patient identification and education.

  • Considerations for patients experiencing persistent pain.

  • The specific role of the Physical Therapist (PT).

  • Treatment approaches including Pain Neuroscience Education (PNE).

  • Other modalities: Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Trauma-Informed Care, and Motivational Interviewing.

• Understanding Pain Causes:

  • The primary goal is to identify the source of the pain and fix the underlying issue.

  • Simple Pain Treatment: This is applicable for clear nociceptive pain using direct treatment methods.

  • Persistent Pain Challenges: These cases involve high complexity and require a fundamentally different treatment approach compared to acute or simple pain.

Identifying and Screening Patients

• Combination of Screening Methods: To gather complete information, clinicians should use:

  • Intake Forms: Initial gathering of patient history and information.

  • Subjective Questions: Interviews to understand the patient’s symptoms from their perspective.

  • Objective Screening: Physical assessments to evaluate the patient's condition.

• Neuro Screening Importance:

  • Essential to ensure the patient actually has a neuromusculoskeletal issue.

  • Assessment for Red Flags: Critical for confirming that the patient is appropriate for physical therapy treatment or if they require referral.

• Referral Considerations:

  • Providers may sometimes miss critical diagnostic information.

  • Clinicians must always verify the patient's condition independently to ensure safety and efficacy.

Patient Education and Prognostication

• Nature of the Problem:

  • Education is a core component of management; understanding pain is crucial to reducing it.

  • Patient's Role: Patients must understand their pain so they can take specific actions to influence their recovery.

• Prognostication Components:

  • Timeline for Recovery: Clinicians should provide clear timelines for when symptoms are expected to improve.

  • Functional Expectations: Set expectations for movements and tasks.

  • Goal Setting: Establish clear short-term and long-term goals for recovery.

• Promoting Self-Care and Empowerment:

  • Active Participation: Treatment must be viewed as an active process, not a passive one. Patients should feel empowered to help themselves.

  • Internal Locus of Control: The goal is to help patients understand they have control over their own health and recovery process.

The Clinical Value of Movement and Fear Reduction

• Importance of Early Movement:

  • Movement is often overlooked but is a vital treatment for pain reduction.

  • Mechanotransduction: This process promotes healing at the cellular level by converting mechanical stimuli into cellular output, specifically relevant to tissue injury.

  • The Brain's Role: Movement demonstrates to the brain that no further injury is occurring, which helps adjust safety thresholds set by the central nervous system.

• Addressing Fear of Movement:

  • Fear of movement is a powerful predictor of whether pain will become persistent.

  • Short-term Effects: Fear inhibits effective healing.

  • Long-term Effects: Persistent fear results in significant cortical changes in the brain and reinforces fear-avoidance behaviors.

• Helping Patients Experience Success:

  • Provide Hope: Instill a belief in recovery and maintain a positive outlook.

  • Motivation: Success acts as a powerful motivator, increasing morale and the determination to continue with treatment.

Skilled Physical Examination and Treatment Logic

• Performing the Examination:

  • Importance of Touch: Touch enhances the thoroughness of the exam and is central to establishing a therapeutic alliance.

  • Communication: Ensure results are communicated clearly to build trust, rapport, and patient understanding.

• Linking Treatment to Biological Evidence:

  • Focus on the biological nature of the problem rather than just the "syndrome" or geographical location (e.g., just "back pain").

  • Avoid Broader Classifications: Do not use vague terms like "low back pain" or "failed back surgery."

  • Biopsychosocial Balance: While biological focus is important, avoid overemphasizing it to the point of symptom perseveration or fear avoidance. A balanced biopsychosocial approach is necessary.

• Managing Acute Pain:

  • The intensity and duration of acute pain can predict persistent pain. It should be reduced as quickly as possible.

  • Interventions: Spinal manipulation, dry needling, or simple aids like a heel lift or a cane.

  • Promotion of Healthy Movement: Managing pain early allows for fear-free and pain-free movement.

Multidisciplinary Management and Social Factors

• Minimizing Treatments and Contacts:

  • Seeing too many providers can lead to increased imaging, medical tests, and conflicting opinions.

  • Multiple providers may inadvertently validate the condition as "severe," which correlates with poorer outcomes.

• Multidisciplinary Collaboration:

  • Recognize the limits of PT practice. If psychological or social anxieties are beyond those limits, involve other providers like psychologists for comprehensive care.

• Addressing Physical Dysfunctions:

  • Biological: Specific tissue issues.

  • Pain Types: Nociceptive, neuropathic, and neuroplastic.

  • Psychological: Fear avoidance and perseveration.

  • Social: Financial restrictions, workplace issues, and pressure from family or peers.

• Assessing General Physical Fitness:

  • Promote sleep hygiene, nutrition, mental well-being, regular exercise, and healthy weight.

  • Creative Outlets: Evaluate how pain impacts the patient's creative or loved activities and set goals to resume them.

The Role of Physical Therapists in Persistent Pain

• Key Strengths of PTs:

  • Biological knowledge and expertise in pain mechanisms.

  • Specialization in exercise design and movement.

  • High amount of time spent with patients compared to other providers.

  • Lower cost and lower risk profile.

  • Psychology-Informed Practice: Proficiency in motivational skills and being a direct-access profession.

Comprehensive Treatment Approaches for Persistent Pain

• Movement Modalities:

  • Traditional: Aerobic, resistance, isometric, and endurance training.

  • Non-Traditional: Pilates, Yoga, Feldenkrais, and aquatic therapy.

• Calming the Nervous System:

  • Mindfulness, meditation, sleep hygiene, biofeedback, and breathing exercises.

  • Graded Motor Imagery (GMI), manual therapy, and neural mobilization.

  • Social interaction, humor, and creating a safe, compassionate healing environment.

• Cognitive and Medical Therapies:

  • Cognitive Therapy: PNE, CBT, Positive Psychology, and Motivational Interviewing.

  • Medical: Use of membrane stabilizers and anti-depressants.

  • Therapeutic Actions: Posture and "positions of power/confidence," journaling, and nutrition.

Patient Education Essentials and Communication

• Five Key Questions Patients Have:

  1. What is wrong with me?

  2. How long will it take?

  3. What can I do for it?

  4. What can you do for it?

  5. How much will it cost?

• Words that Heal vs. Words that Harm:

Pain Neuroscience Education (PNE)

• Evidence and Evolution:

  • Emerged in the 1990s as a high-efficacy intervention, often more effective than medications like gabapentin or antidepressants.

  • Benefits: Improves pain knowledge, reduces disability, decreases pain catastrophizing, and minimizes fear avoidance.

• Content of PNE Sessions:

  • Covers central and peripheral sensitization, inhibition/facilitation, neuroanatomy/physiology (axons, synapses, plasticity).

  • Methodology: Uses easy-to-understand metaphors to replace technical jargon.

  • Delivery: Best delivered in a one-on-one approach.

• Who Needs PNE?:

  • Patients with central sensitization or high fear avoidance/catastrophizing.

  • Patients with persistent pain who are ready to change.

• Clinical Application:

  • Should take approximately $10 \text{ minutes}$.

  • Notable Metaphor: The "sensitive alarm system."

  • PNE+: PNE should not be a stand-alone treatment; it is far more effective when paired with exercise and movement. In PNE+, there is an expectation to return to full activity within $4 \text{ weeks}$.

Cognitive and Psychological Frameworks

• Cognitive Behavioral Therapy (CBT):

  • Gold Standard: Focuses on changing beliefs, attitudes, and fears to influence feelings through controlled thoughts.

  • Coping Skills: Teaches mindfulness, relaxation, and emotional regulation.

  • Requires a rationale for treatment and support while applying skills to various situations.

• Acceptance and Commitment Therapy (ACT):

  • Promotes non-reactivity to negative thoughts.

  • Psychological Flexibility: Focuses on being open to experiences rather than avoiding them due to pain.

  • Goal is not necessarily symptom reduction, but increasing response to limiting experiences.

• Trauma-Informed Care (The 4 Rs):

  1. Realizes: The widespread impact of trauma.

  2. Recognizes: Signs and symptoms in clients and staff.

  3. Responds: Integrates knowledge into practices.

  4. Resists: Efforts to avoid re-traumatization.

  • Safety Focus: Always ask permission to touch.

• Positive Psychology:

  • Linked to increased use of endogenous opioids and cannabinoids.

  • Focuses on pathways to satisfaction: feeling good, engaging fully, mindfulness, and self-compassion.

Motivational Interviewing

• Core Purpose: To explore and resolve ambivalence and elicit change using the individual's own motivational processes and values.

• Three Essential Elements:

  1. Conversation about change: Collaborative counseling.

  2. Collaborative approach: Person-centered partnership.

  3. Evocative method: Drawing out intrinsic motivation.

• OARS Technique:

  • O: Ask Open-ended questions.

  • A: Follow up with Affirmations.

  • R: Utilize Reflections.

  • S: Provide Summaries.