PEOPLE IN PAIN Know that Exercise is Important

 The problems: › Fear avoidance › Myths about pain › Myths about chronic pain › Attitudes to recovery › Increased activity and exercise hurt 2

WE Know that Exercise is Important

What does the patient need from us?

 A consistent message about pain  A consistent message about persistent pain  A clear message that no matter how much medical management is required, self management is also required  Guidance to increase success with returning to function 3

Basic Pain Science

 Nociceptive neurons respond to potentially dangerous stimulation  Spinal cord neurons process input from sensory neurons › Integrating this with descending input from the brain  Some signals go directly to emotional areas of brain  Some signals make their way to cortical areas related to sensory processing 4

Basic Pain Science

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Nociceptive Neurons Respond Spinal Cord Neurons Process Some Signals Go to Emotional Areas of Brain Some Signals Go to Cortical Areas for Sensory Process 5

Basic Pain Neuroscience

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What is the Purpose of Pain?

 Protection › If it hurts enough, you will stop ... or at least yield.

› Muscle spasm is a protective mechanism.

› Muscle inhibition is a protective mechanism.

› Fatigue, catastrophic thinking, anxiety, anger, ... are all protective mechanisms.

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Ignoring the Protection Alarms

 In acute pain, this usually works.

 In chronic pain, typically the organism will find another way to protect itself, or the alarms will get more intense.

 Many people with chronic pain learn, and are taught, that the best thing to do is ignore the pain.

› This is not helpful for returning to function.

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Pain is a biopsychosocial experience

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Pain is a biopsychosocial experience

If you tell your patient a story in which the only reason for the pain is tissue damage, it is harder for the patient to understand when the pain doesn’t resolve as expected and then you say they need to get more active despite the pain.

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Pain is a biopsychosocial experience

“The best way to decrease your pain is to decrease stress in our life and start a daily practice of calm breathing and relaxation” 11

Basic Science of Chronic Pain

 More and more aspects of the nervous systems become wound up and sensitized › If the cells and systems practice protection 24 hours a day -> they get better at protection › They DO NOT habituate as expected when pain persists  Peripheral neurons  Central nervous system  Autonomic nervous system 12

Basic Science of Chronic Pain

 Neuroplasticity › The nerve cells, nerve pathways and networks, and the nervous systems themselves get better at whatever they practice.

› These ARE NOT permanent changes in the nervous system.

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Chronic pain is a biopsychosocial experience

When we have chronic pain, there is a problem in the body and the protective systems are too responsive. 14

Basic Science of Chronic Pain

 Vicious cycles develop between pain and its effects › Pain - shallow, tight, apical breathing - pain › Pain - altered body awareness - pain › Pain - muscle inhibition - pain › Pain - muscle tension - pain › Pain - altered body image - pain › Pain - anxiety - pain 15

Chronic pain is a biopsychosocial experience

“The best treatment will address both problems: the body and the nervous systems.” 16

Can an individual change pain?

Is pain management ALL about covering up pain and learning to live despite its severity?

 If you believe it is possible to change pain, your patient is much more likely to?

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When pain persists, pain becomes an adverse effect of movement.

 How to move in the face of pain?

 How do we answer the patient who says that every time I try exercise or to be more active, the pain gets worse.

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Succeeding with Return to Function

“We need to teach your nervous systems to be less protective when you move.

The best place to start is learning and practicing calm breathing and muscle relaxation.” 19

Box Breathing

Review

 The purpose of pain is not to accurately tell us: › where the problem is › › what the problem is how bad the problem is  Pain’s job is to make us stop!

 Our patient’s need treatment and guidance to make these protective responses less sensitive.

 Wind down the nervous system 21

Case Study 1

 38 year old woman  Neck pain and headaches and unable to work  Not improving 5 weeks after whiplash injury  Xrays show degenerative changes throughout lower cervical spine, with C4-5 reported as having more arthritic changes.

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Scripts 1

There is hope, and, finding ease of movement is the first step.

 This type of pain you are experiencing is chronic pain ... but that doesn’t mean it will always be like this, or that it will continue to worsen.

 Pain can be changed, and my job is to help you with that.

 This medication I am giving you should make you feel that the pain is in control, and it should help you move better. I want to see you back here next week to make certain it is working for both things.  You showed me how much you can move your neck and arms today and we will recheck that next week.

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Script 2

- same patient one week later Calm breathing decreases pain and helps move with more ease.

  The medication helps to decrease pain temporarily, but her movement is no better.

When you ask her to move, she holds her breath, and tenses her neck, shoulder and face muscles.

   “Close your eyes and breathe as calmly as you can for the next minute.” After a minute passes, “now try those movements again. “remember that your protective systems are on high alert. It will be difficult to calm them down if you hold your breath and tense up so much every time you move.” “It’s important to stop sending the message that movement is really dangerous.” 24

Case Study 2

 48 year old construction worker  Slow to resolve low back pain and right leg nerve root irritation pain (seems L5 distribution but no conduction deficits)  MRI 8 weeks after a lifting injury shows L4-5 lateral disc bulge, central stenosis and osteoarthritic changes 25

Scripts 3

Brief description of chronic pain, and the roles of relaxation and medication.

 Patient asks “What can you do to fix this?”    “You have a problem in your back, and irritated nerves. The best treatment we can do is to work on calming down the irritation. Your job in this plan is to spend time every day relaxing and getting your body and breathing to feel as calm as possible.”  (we do not know the best dose of this, so fit it into the patient’s day) “The job of this medication is to let you move more easily. If it is not doing that, we need to try something else.” 26

Case Study 3

 43 year old woman with fibromyalgia  Previously high-level, high-paid executive position  Unwilling to try medications until now  Exercise has made her worse  Meditation and sitting still make her more anxious 27

Scripts 4

Brief explanation of fibromyalgia pain, and why initial attempts at what should help are sometimes unsuccessful.

      I am pleased you are ready to try some things other than just being tough and trying to win a battle with this pain.

We know that in fibromyalgia many aspects of the nervous systems are cranky and over-sensitive.

Our job, together, is to find ways to calm them down again. It’s not easy, but it’s possible.

The medication we are trying should let you move with less pain. The yoga you are doing should also help with that.

Remember that the strength you have to be tough and carry on in the face of this pain is not helping you get better. Somehow you need to stay tough, but don’t push so hard.

You need to pay more attention to your body and pain, not less.

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Case Study 4

 64 year old active employed male  10 weeks post TKA, and his pain and function are worsening  He is angry, believing that the pain must be from faulty surgical technique and that the surgeon is saying he is making this pain up  Orthopaedic surgeon has investigated and the prosthesis is not the problem 29

Scripts 5

Post-surgical pain can be related to sensitization and wind-up. Pain education is often the first step needed in such cases .

 “When pain persists like this and we cannot find the reason for it from the tissue or the surgery, we know that the problem includes unexpected responses from the pain system.

 This is something you need to learn much more about so we can work together to help you out. Here is a link to the Pain BC webinars where they talk about this in much more detail, and it would help to read this book ... you can get it from the library. We will need to talk some more about this, because it will sound different from what we have discussed before.” 30

Scripts 6

Reassuring the person in pain that we know what to do, and, providing the understanding that a team approach is needed.

 “Your pain is real. It may not be easy to change it, but we can.

 This medication is to help you move better, and not pay for it so much.

 Your nervous systems have become far too agitated - by the pain before the surgery, and all the stress after it. I want you to see this counsellor to learn breathing and relaxation techniques. And I will contact your physiotherapist to make certain she is getting you to do as much work on calming down the nerves in your knee as working on getting you stronger.

 If we all work together we can help you best with this.” 31

Resources

 www.painbc.ca

› Empowering Self Management of Pain series › › The Pain Toolkit Yoga for People in Pain series  Chronic Pain Self-Management Program (University of Victoria)  Understand Pain, Live Well Again Pearson, N. Patient education book available in all BC public libraries  Explain Pain Butler D, Moseley L. www.noigroup.com

 http://www.physicalactivityline.com/ 32

Practice Support Program Tools

 MH algorithm ( http://www.gpscbc.ca/psp-learning/mental health/tools-resources )  CBIS from PSP’s adult mental health module  Problem list  Resource list  Brief Action Planning  Bounce back DVD  Anti-depressant skills workbook 33

Mental Health Algorithm

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Cognitive Behavioural Interpersonal Skills

(CBIS)

Manual

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Problem List

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Resource List

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“Is there anything you would like to do for your health in the next week or two?” Behavioral Menu SMART Behavioral Plan Elicit a Commitment Statement “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” If Confidence <7, Problem Solve Barriers “Would you like to check in with me to review how you are doing with your plan?”

Brief Action Plan

Follow-up 38

BounceBack

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Antidepressant Skills Workbook

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