Western Montana Pain SymposiumTreating Persistent Pain Does Not Need to Be Painful—Improving Outcomes throughPain Education Nora Stern, PT, MS PTProvidence Persistent Pain ProjectProgram ManagerPortland, Oregon

Conflict of Interest Disclosure Nora Stern, PT, MS, PT

Has no real or apparent conflicts of interest to report.

Objectives

• Understand pain as an output of the nervous system

• Evaluate clinical decision-making reflecting this understanding

• Understand role of pain education and team based care in treatment of persistent pain

What is the purpose of pain?

• Pain is a protector• When you have persistent pain, beyond tissue

healing, what is the pain protecting you from?

Previous model

Current Model– CHAOTIC

Pain and the Brain

Central Sensitization

From Nocioceptive Input to Processing to Output

• Changes that occur with persistent pain

Peripheral Sensitization: Elevation of resting state of neuron

• Nocioceptive Input Travels Up Spinothalamic Tract to Brain

Brain functions

Central Nervous System

Wetware:- Amino acids, peptides, amines, all play a role in excitation or inhibition

Hardware: – Neurons– Glia

Brain centers for pain neuromatrix• Thalamus and Hypothalamus: stress response, autonomic regulation, motivation• Amygdala: fear, fear conditioning, addiction: If you know it’s going to hurt, then

it’s going to hurt!• Sensory homunculus: tells us where sensation occurs. This can become blurred

and “smudged” with changes in movement habits• Primary motor cortex: organizes and prepares for movement. Affected by fear of

hurting oneself• Prefrontal and frontal cortex: makes sense out of the situation. Decides if the

danger signal is a real threat• Cingulate cortex: concentration and focus, affected by attention to pain• Cerebellum: Perception of movement

• Hippocampus: memory, spatial cognition, fear conditioning

Brain functions for pain neuromatrix• Thinking: looking for answers

Feeling: Fear avoidance, catastrophizing• Sensing: sensory homuncular organization,

kinesthetic sense• Acting/moving: motor planning, anticipating

pain with motion

Mirror neuron function25% of our brain’s neurons may have a mirror capacity

Output 1. Pain sensation as an output: assigned to the virtual body representation

2. Message to Autonomic Nervous System Neuroendocrine System Neuroimmune System

Fight or flight response left turned on

Stress/pain relationship with CRPS

Allen, R, et al, Phys Ther, 2011 4:32-42

Allen, R, et al, Phys Ther, 2011 4:32-42

PARADIGM SHIFT

• PAIN ≠ HARM

• PAIN IS AN OUTPUT FROM THE BRAIN

• ALL PAIN IS REAL PAIN

• NOCICEPTION IS NEITHER NECESSARY NOR SUFFICIENT FOR PAIN

adapted from material from G. Lorimer Moseley: Understand and Explain Pain course material 2010

Managing and Coping with Chronic Pain

Understanding and Treating Persistent Pain

Reference: “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research,” Board of Health Science Policy, Institute of Medicine, of National Academies, Washington 2011

VS.

Pain Education:A treatment intervention

Pain Education As A Treatment Intervention

Decrease in pain rating (Van Oosterwijck et al 2011, Meeus et al, 2010, Ryan et al, 2010, Moseley, 2002, 2003, 2004)

Decrease in fear of reinjury (Van Oosterwijck et al 2011, Moseley, 2002, 2003)

Decrease in pain catastrophizing (Meeus et al, Moseley 2004)

Increase in function(Van Oosterwijck et al 2011, Moseley, 2002, 2003

Pain education as treatment

Brain activity: persistent pain patient, baseline

S/P 2 weeks practice of abdominal strengthening

Brain activity same day, following pain education

Moseley, G. L, “Brain activity before and after 1:1 pain education with physiotherapist.” Australian Journal of Physiotherapy 2005 Vol. 51

Outcomes After Pain Education in ED

Oliviera et al • Spine • Volume 31 • Number 15 • 2006

Persistent Pain Project Patient Outcomes

Total Bev Hlth Rehab0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

12.80%

37.22%

47.00%% Change Improvement in Catastrophizing

n = 43

n = 11

n = 4

Components of pain education: Providence Oregon

Phrasing• All providers able to explain pain as an output– Provider training: rehab, primary care– Upcoming: inpatient

• Written material• Video• Patient classes

Patient access online

Providence Pain Video

http://providenceoregon.org/video/pain

• How do we do better?– Speak the same language and explain pain– Address the issues that are causing central

sensitization in primary care, behavioral health, rehab, complementary medicine

– Team care: medical home– Advocate for adequate coverage for high risk

patients

Fighting central sensitizationOne patient at a time