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Managing Chronic Pain in Rehabilitation Diagnosis

Managing Chronic Pain in Rehabilitation Diagnosis. Martin Grabois, M.D. Professor and Chairman Physical Medicine and Rehabilitation Professor, Anesthesiology Baylor College of Medicine Houston, Texas Rehab International Regional Meeting Sao Paulo, Brazil November 2011. OBJECTIVES.

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Managing Chronic Pain in Rehabilitation Diagnosis

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  1. Managing Chronic Pain in Rehabilitation Diagnosis Martin Grabois, M.D. Professor and Chairman Physical Medicine and Rehabilitation Professor, Anesthesiology Baylor College of Medicine Houston, Texas Rehab International Regional Meeting Sao Paulo, Brazil November 2011

  2. OBJECTIVES • To differentiate between acute and chronic pain • To understand systems of evaluation and treatment • To appropriately evaluate patient with chronic pain • To appropriately treat patient with chronic pain • To examine results that can be obtained in appropriate treatment • Provide examples of pain evaluation and management in rehab diagnosis

  3. DEFINITION OF PAIN • 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) • Pain is a personal and subjective experience that cannot be fully shared by anyone else

  4. TYPE OF PAIN • Acute • Subacute • Chronic • Chronic Pain Syndrome

  5. CLASSIFICATION OF PAIN • Nociceptive Pain • Somatic Injury or disease of skin, muscles, tendons or ligaments Described as localized sharp or stabbing • Visceral Injury or disease of internal organs Described as diffuse aching or cramping • Neuropathic Pain Injury or disease of the nervous system Described as burning, tingling or lancinating

  6. Neuropathic Pain Syndrome Pain Characteristics NociceptiveNeuropathic Recent, identifiable onset Remote, ill-defined onset Limited duration, healing occurs naturally Cormorbid conditions Consistent with degree of tissue injury Inconsistent with degree of tissue injury Nervous system functionally intact Damaged, dysfunctional nervous system Protective biological function Adjuvant analgesics frequently required Responds to traditional analgesics

  7. FACTORS EXAGGERATING COMPLAINTS OF LOW BACK PAIN Psychological Factors, e.g., personality traits External pressure, or stress, e.g., job, finances, interpersonal relationships Organic Factors e.g. disease, trauma, degenerations Psychiatric pathology Skeletal structure and stability Body Experience Mind Experience Social Experience BACK PAIN

  8. Chronic Pain Syndrome:Impairment, Disability and Functionality Definition 1. Pathology/Disease (a) Injury, infection, vascular, metabolic, neuroplastic disorder (b) May or may not produce loss of bodily function, i.e., lumbosacral strain, herniated disc, CVA, spinal cord injury, arthritis, meningitis, etc. • Impairment Any loss of abnormality of psychological, physiological or anatomic structure or function (this is the same as the WHO definition) i.e., decrease ROM, altered reflex, abnormal EMG/MMPI. Function: walking, sitting, memory, cognition

  9. Chronic Pain Syndrome:Impairment, Disability and Functionality Definition (continued) • Functional Limitations Any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being. That results from an impairment (this is the WHO definition of disability) i.e., typing for hours, housecleaning, visiting friends, communication. • Disability A disadvantage for a given individual, resulting from an impairment as a functional limitation that limits or prevents the fulfillment of a role that is normal (depending on age, sex, social and cultural factors) for that individual (this corresponds with the WHO definition of handicap) i.e., limits in fulfilling a role in life – father, mother, student, worker, etc. It is task specific.

  10. Chronic Pain Syndrome:Impairment, Disability and Functionality Stages in the Development of the Disability Process Premorbid Crisis build-up Demanding work, job dissatisfaction, situational stress, poor general coping skills, stage special model for disability Stage One The accident Relationships among the nature of the accident, the severity of the injury and the claimed inability to work are often weak Stage Two Medical Intervention Following recovery from the injury, patient fails to return to normal social roles and productivity. Repeated medical interventions may be performed, leading to possible iatrogenic complications, chronicity and learned pain. Stage Three Stabilization of Chronicity Confusion, anger and hostility, increasing dependency and idleness, economic preoccupation and difficulty, decline in competence for gainful employment Stage Four Legal Intervention Lack of systematized documentation to support proof of disability and the adversary system further foster attitudes of passivity, exaggerated illness behavior and possibly malingering Stage Five Learned Helplessness Sick role solidifies, loss of hope for health recovery, generalized incompetent coping, frequently irreversible

  11. CHRONIC PAIN SYNDROME CHARACTERISTICS • Dramatic pain complaints which are diffuse • Dysfunction which is manifested by misuse of braces, collars, or ambulatory devices, together with poor posture and inactivity • Drug misuse/overuse (usually of drugs prescribed for acute pain and anxiety) • Dependency on health care system and family • Disability that far exceeds underlying identifiable pathology • Dependency for source of income contingent upon continuing pain complaints

  12. MORE THAN 76 MILLION AMERICANS SUFFER FROM CHRONIC PAIN Total US Population 307.7 mm Chronic Pain 76.5 mm Low Back Pain 34 mm Chronic Low Back Pain 8 mm Osteoarthritis 26.9 mm Cancer Pain 2.5 mm Neuropathic Pain 2mm

  13. COSTS OF WORKMEN’S COMPENSATION CLAIMS BY CASE Percentage Average Conditionof all claims cost/claims Back strain 31 $23,916 Other sprains/strains 19 13,611 Concussions/bruises 11 12,055 Fracture 11 23,138 Laceration/puncture 10 9,722 Dislocation/crushing 3 47,249 Burn 3 12,833 Hernia 3 24,449 Infection/Inflammation 2 13,805 Amputation 1 40,249 Cumulative injury 1 29,166 Occupational disease 1 31,305l

  14. Neuropathic Pain Syndrome Incidence – Estimated prevalence of Neuropathic Pain In the US (based on population of 270 million) ConditionNumber of Cases Painful diabetic neuropathy 600,000 Postherapeutic neuralgia 500,000 Cancer-associated 200,000 Spinal Cord Injury 120,000 CRPS 100,000 Multiple Sclerosis 50,000 Phantom Pain 30,000 Post Stroke 15,000 HIV-associated 15,000 Trigeminal neuralgia (tic douloureux) 15,000 Low-back associated 2,100,000 Total (excluding back pain….1,680,000) Total (including back pain…..3,790,000) [Adapted from Bennett GJ. Hosp Pract, October 15, 1998]

  15. Neuropathic Pain Syndrome Pathology of Neuropathic Pain Nociceptive PainMixed TypeNeuropathic Pain Caused by activity in neural pathways Caused by a combination of Initiated or caused by in response to potentially tissue- both primary injury or primary lesion or damaging stimuli secondary effects or dysfunction in nervous system ExamplesExamples Postoperative Pain Post-therapeutic Neuralgia Arthritis CRPS Mechanical low back pain Neuropathic low back pain Sickle cell crisis Central post stroke pain Sports/exercise injuries Distal polyneuropathy (e.g. diabetic, HIV)

  16. CLINICAL MODEL/PRODCUT LINE COMPARISON CHART Occupational Work Work Pain Medicine ConditioningHardeningProgramming Model Medical Medical/Rehab Rehab Rehab Goal Return to work Return to work Return to work Return to work Timeframe 0-1 month 1-3 months 3-25 months 6+ months Target Acutely injured Subacute injured Subacute to Chronic benign Population workers workers with chronic are pain uncomplicated more complex syndrome voc/psych status voc/psych

  17. CLINICAL MODEL/PRODUCT LINE COMPARISON CHART Occupational Work Work Pain Medicine ConditioningHardeningProgramming Assessment Acute medical Exercise, education Exercise, work Group miles, & Treatment care job site analysis, simulation, behavioral FCE education, modification voc services, psycho, FCE Return to Very high - Probably high - High 85% for Low, due to Work 95% not known workers out chronicity, lack of 3-25 months transfer skills Length of Average of 5 Average of 3/wk 5 visits/week 4-6wks (inpatient Program physician visits for 3 wks for 6 wks or outpatient combination

  18. MANAGED CARE MODEL INJURY/SYMPTOM Primary Care Office Emergency Services Specialty Offices Treatment Failures

  19. MULTIDISCIPLINARY PAIN TREATMENT PROGRAM INJURY/SYMPTOM Emergency Services Primary Care Specialty Offices Treatment Failure Treatment Success Multidisciplinary Pain Treatment Program

  20. CHRONIC PAIN INJURY/SYMPTOM INJURY/SYMPTOM Multidisc- iplinary Pain Center Emergency Services Primary Care: Clinical Algorithms Community Support & Services (PT, behavioral, spiritual, pharmaceutical) Sub-specialty Eval. & mgmt. Recurrent or persistent pain impairing function Integrated Pain Medicine Eval & Services: Med. trials, PT, Blocks, Behavioral mgmt. Treatment Failure

  21. EVALUATION OF THE CHRONIC PAIN PATIENT HISTORY: pain, drug, occupational, social, medical, psychological PHYSICAL EXAM: musculoskeletal and neurological PAIN MEASUREMENT FUNCTIONAL ASSESSMENT PSYCHOLOGICAL: interview, MMPI, other techniques SPECIAL STUDIES: x-rays, vascular studies, CT scans, thermograms, EMG/MNCV, specialty consults

  22. PAIN QUESTIONNAIRE

  23. MEASURING PAIN Scales Verbal Descriptor (mild, moderate, severe) Numerical Pain Scale (0-10) Visual Analog Scale (10 cm line [-------------------------------------] No pain Worst Pain Wong-Baker FACES Pain Scale

  24. CLINICAL ASSESSMENT OF FUNCTIONALITY • Physical: Basic activities of daily living, such as personal hygiene, locomotion, dressing and feeding oneself • Vocational: Work, including household and caregiver responsibilities • Avocational: Leisure activities, such as active recreation, hobbies, and attendance at cultural events • Social: Relationships with family, friends, and colleagues • Psychological: Emotional well-being and cognitive performance

  25. GENERIC FUNCTIONAL ASSESSMENT TOOLS (Part 1) Measurement What is Measured Number of Tool Items --------------------------------------------------------------------------------------------------------------------- Katz Index of Independence Independence in performing 6 In Activities of Daily Living 6 basic activities of daily living (ADLs) --------------------------------------------------------------------------------------------------------------------- Functional Independence Independence in performing 18 Measure (FIM) 18 basic ADL --------------------------------------------------------------------------------------------------------------------- Pain Disability Index Effect of pain on 7 domains of basic 7 physical, social and occupational functioning --------------------------------------------------------------------------------------------------------------------- Functional Status Functioning in multiple areas, e.g., days of 34 Questionnaire (FSQ) restricted activity, sexual activity, health satisfaction

  26. DIAGNOSTIC TESTING • X-rays/CT/MRI • EMG/NCS • Labs • Findings may not correlate with symptoms • May be useful to rule our serious pathology

  27. APPROPRIATE AND INAPPROPRIATE USES OF PSYCHOLOGICAL ASSESSMENT Appropriate UsesInappropriate Uses To determine specific psychological To determine if pain is organic and behavioral contributions to a or functional (i.e., real or patient’s pain and concomitant psychogenic) To detect malingerers To determine appropriate treatment To justify dumping of more strategies difficult patients To provide essential information on particular aspects of a patient’s psycho- social background and current situation that may be affecting the pain problem [Adapted from Turk DC; Pain Manage 1990;3:167-72]

  28. THE PSYCHOLOGY OF CHRONIC PAIN • Depression is present in 10-30 percent of the chronic pain populations compared to 5 to 8 percent of the general population • Chronic pain can cause depression and depression may increase the predisposition to chronic pain • It is difficult to determine whether the pain causes the depression or the depression is due to the pain • Chronic pain patients often deny depression even when it is clearly present

  29. PREVENTION OF CHRONIC PAIN • Linton concluded that the most effective approach to chronic pain would be one of prevention • He tested a secondary prevention program for 36 nurses who had missed work due to back pain at least once in the previous 2 years • The treatment group received physical therapy, exercise, ergonomic training and behavioral therapy • The treatment group showed significantly greater improvement than the control group in pain intensity, anxiety, sleep quality, fatigue, activity, mood and pain behaviors

  30. TREATMENT GOALS • Reduce the misuse of medications and invasive procedures • Maximize and maintain physical activity • Return to productive activity at home, socially and/or work • Increase the patient’s ability to manage pain and related problems • Reduce/eliminate the use of healthcare services for primary pain complaint • Provide useful information to the patient and professionals involved in the case settlement • Minimize treatment cost without sacrificing quality of care. A strong emphasis needs to be placed on increasing the patient’s level of function and ability to manage pain and related problems, even if no reduction of subjective pain intensity is feasible

  31. GOAL OF TREATMENT PROGRAM • Modification of Medication • Modification of Pain Perception • Increase Activity • Modify Pain Behavior

  32. EVIDENCE-BASED DATA ON TREATMENT OF LOW BACK PAIN Beneficial Acupuncture Behavioral therapy Exercise therapy Multidisciplinary treatment program Likely to be Beneficial Analgesics Back schools in occupational settings Massage NSAIDs Unlikely to be Beneficial Bed rest EMG Biofeedback Ineffective or harmful Facet joint injections Traction Unknown effectiveness Antidepressants TENS Epidural steroid injections Thermal therapy Lumbar supports Trigger point injections Muscle relaxants Ultrasound Spinal manipulation

  33. Chronic Pain SyndromeEvaluation and Treatment

  34. ADDING ADJUNCTS TO STANDARD THERAPY Anti-depressants IV opiates Anxiolytics Oral opiates Muscle relaxants Anti-convulsants Non-opioid analgesics Local anesthetics Warm or cold tx Physical measures: RICE protocol Physical therapy

  35. MEDICATIONS UTILIZED IN MANAGEMENT OF CHRONIC PAIN • Anti-inflammatory Agents Celebrex Mobic Motrin Voltaren Gel Flectnor Patch • Tylenol, Ultram and Darvocet • Narcotic Hydrocodone Oxycodone Morphine Opana Fixtanyl Patch Methadone 4. Others: Muscle relaxants, antidepressant, sedation

  36. RISK FACTORS FOR OPIOID ABUSE • History of substance abuse • Family history of substance abuse • Under age 25 • Cigarette smoking • Depression or anxiety

  37. Neuropathic Pain Syndrome Pharmacologic Management of Painful Peripheral Neuropathies • Antidepressants Amitriptyline, imipramine, desipramine, nortriptyline, comipramine, cymbalta, maprotiline, SNRIs, SSRIs • Anticonvulsants Carbamazepine, oxcarbazepine, gabapentin, lamotrigine, phenytoin, lyrica, topiramate, levetiracetam • Antiarrhythmics Mexiletine • Topical formulations Capsaicin, lidocaine, aspirin • Analgesics NSAIDs, COX inhibitors, tramadol, opiates • Others Levodopa, ketamine, dextromethorphan

  38. COMPARISON OF MODALITIES WITH REGARD TO IMDEPENDENT UTILIZATION Independent Use Dependent Use Ice Packs Therapist/Equipment Ice Massage Hydrocollator Packs TENS Ultrasound Microwave & Shortwave Heating Pad Diathermy Hot Packs Traction Canes/Walkers/Assistive Massage Devices

  39. USE OF TENS INDICATIONS AND CONTRAINDICATIONS IndicationsContraindications Neurogenic pain Implanted demand on cardiac pacemakers Sports injuries Pregnancy Fractured ribs [18] Over the carotid sinus or eyes Postoperative Pain [19] Dementia Causaglia [20] Across the chest Intercostal neuralgia [21] Radiculopathy [22] Chronic facial pain [23] Brachial plexus avulsion [24] Osteoarthritis, rheumatoid arthritis [25-27] Arachoniditis [28-29]

  40. THE TRANSISTORIZED PLACEBO

  41. BIOFEEDBACK

  42. BIOFEEDBACK: RESULTS OF TREATMENT

  43. INDICATIONS FOR NERVE BLOCKS WITH LOCAL ANESTHETICS • Diagnostic Blocks a) Help determine mechanism of chronic pain syndromes b) Aid differential diagnosis of the site and cause pain • Prognostic Blocks a) Predict the affects of neurolytic blocks or neurosurgery • Therapeutic Blocks a) Control severe acute postoperative, post-traumatic pain and pain from self-limiting diseases b) Breaking of ‘vicious circle’ involved in some pain syndromes may provide relief c) Provide temporary relief to permit other therapies, or used in combination with other therapies

  44. INVASIVE THERAPIES • Local Injections • Deep Injections • Implantable Pumps • Spinal Cord Stimulators • Surgery

  45. EXERCISE • Essential, but chronic pain patients often are reluctant to participate in an exercise program • Prevents or reverses deconditioning; increases serotonin and endorphin levels • Should include stretching, strengthening and aerobics exercises

  46. PAIN AND WELL BEHAVIORS Pain behaviors • Pain talk, focus, and verbal complaints • Grimacing • Moaning, groaning, and crying • Shifting position, guarded movement, limp • Quiet and withdrawn • Self-neglect and self-denial • Blaming attitude • Avoids self-help groups Well behaviors • Takes responsibility for own actions • Understands own limits and strengths • Sets realistic goals • Exercises regularly • Practices pain-reducing techniques • Appropriate assertive behavior • Positive attitude • Seeks out group support

  47. BEHAVIOR TREATMENT OF CHRONIC PAIN Pain 20 Behaviors Male 15 Age 47 Chronic Low Back Pain 10 5 0 1 2 3 1 5 10 15 20 Treatment Days Baseline Non-Reinforcement Reinforces Non- Reinforcement (Reinforced)

  48. PSYCHOLOGICAL COMPONENTS OF CHRONIC PAIN 80 60 40 20 0 Normal Passive Hysteria Depression Sociopathic Misc Aggressive

  49. RECOMMENDATIONS FOR IMPROVED MANAGEMENT OF CHRONIC PAIN • Recognition of the complex physical, behavioral, social and cultural factors involved in chronic pain • Education of healthcare providers and patients regarding the nature and management of chronic pain • Better care of acute pain and trauma • Early recognition of chronic pain characteristics and behaviors • Early return to work • Focus on increased activity and improved function even in the presence of pain • The use of interdisciplinary teams to manage chronic pain

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