PHYSICAL THERAPY ROLE IN CHRONIC PAIN

MANAGEMENTOctober 2020

Hannah Scholten, PT, DPT, Cert. MDTUF Health Shands JacksonvilleClinical Supervisor – Wildlight Rehabilitation

Presentation Information

Developed by Hannah Scholten, PT, DPT, Cert. MDT.

Funding provided by Florida Blue Foundation and the Florida Medical Malpractice Joint Underwriting Association.

Visit pami.emergency.med.jax.ufl.edu to learn more.

Agenda/Table of Contents

I. My backgroundII. Prevalence of chronic pain in the USIII. History of pain management & the opioid epidemicIV. Current treatment principlesV. PT role in chronic pain management

i. Active vs passive pain managementii. Laying the foundationiii. Graded exposureiv. Neuromobilityv. Desensitizationvi. Self-management

VI. Other (non-PT) resources for pain management

• Shirley Ryan AbilityLab (formerly Rehabilitation Institute of Chicago or RIC) Chronic Pain Management Program

– Full/part time pain programming for adults and pediatrics– Immersive– Individual and group treatment

• Member of 25+ person interdisciplinary team including PT, OT, pain psychology, biofeedback therapy, vocational therapy, physiatry/PM&R, nursing, admin

• Local, national and international level lecturing, pain fellowship lecturing, and marketing/outreach to stakeholders and community

• Leading restructuring of program design in setting of changing healthcare climate and reimbursement standards

My Background

My Background

Clinical Rehab SupervisorUF Health – WildlightPediatric & adult outpatient rehab

Prevalence of Chronic Pain

• In 2016, an estimated 20% of Americans had chronic pain (approximately 50 million people)

• Roughly 8% of Americans had high-impact chronic pain (approximately 20 million people)

• The IOM has reported that chronic pain affects 116 million American adults, which is greater than the total of heart disease, cancer, and diabetes combined.

• Health economists from Johns Hopkins University writing in The Journal of Pain reported the annual cost of chronic pain is as high as $635 billion a year, which is more than the yearly costs for cancer, heart disease and diabetes (and more than cancer and diabetes combined!)

Prevalence of Chronic Pain

• Direct Costs– Physician visits/medical bills– Therapy– Diagnostic tests– Prescriptions– Interventions/surgery

• Indirect Costs– Lost work days/lost productivity– Disability payments

Brief History of Pain Management

• 1800’s: Pain considered existential. No regulation on use of cocaine and opioids. Used widely for anything ranging from toothache to diarrhea.

• 1914: Harrison Narcotic Control Act of 1914. Avoidance of opioids by patients and physicians. Those in pain are considered delusional or abusers. “Opiophobia”

• Late 20th century: Increasing evidence to suggest inadequate treatment of pain in Europe and North America

• 1990’s: American Pain Society and the VA healthcare system adapt “Pain as the Fifth Vital Sign” initiative.

• 2000: The Joint Commission publishes standards of pain management, mandates standardized assessment of pain, and opioid prescriptions rise to meet standards (and avoid consequences, ie decreased federal funding)

• 2000-2012: Opioid consumption in America more than quadruples. Big pharma contributes via financial incentives for doctors.

Opioid Epidemic

• Over-prescription leads to misuse of and addiction to opioids, and subsequently heroin and illegally-manufactured fentanyl

• From 1999 to 2018, more than 450,000 people died from an overdose involving any opioid– In the epidemic peak in 2018, more than 130 people died per day due to

opioid-related drug overdoses

• Epidemic leads to major necessary shifts in pain management such as new Joint Commission standards, new FDA policies, re-examination of cost-benefit analysis of prescription pain medications, mandatory training for all opioid prescribers, electronic prescription monitoring, and increased focus on alternative pain management strategies

Current Treatment Principles

“The National Pain Strategy endorses a population-based, disease management approach to pain care that is delivered by integrated, interdisciplinary, patient-centered teams and is consistent with real-world experience. To succeed, the care model must shift from the current fragmented fee-for-service approach to one based on person-centered care, better incentives for prevention (primary, secondary, and tertiary) and for collaborative care along the continuum of the pain experience—from acute to chronic pain across the lifespan, including at the end of life—at all levels of care and in all settings. “

Current Treatment Principles

• Pain Clinic = medical practice• Decrease pain• Medications• Injections/procedures• Passive modalities

• Functional Restoration Program (FRP) = comprehensive, integrated care

• Improve function > decrease pain• Active strategies• Self-management

PT Role in Chronic Pain Management

Q: “I’ve done lots of PT…how is this going to be any different?”

Definition: Therapy for the preservation, enhancement, or restoration of movement and physical function impaired or threatened by disease, injury, or disability.

PT Role in Chronic Pain Management

A: In some ways, it may not be! BUT….When comparing PT for effective chronic pain management to traditional OP PT, there are many conceptual and philosophical differences

- Active vs Passive Approach- Graded Exposure- Individualized Treatment- Laying the Foundation

PATIENT CENTERED

Active vs Passive

Graded Exposure

Inidividual-ized

Treatment

Laying the Foundation

Acute vs Chronic Pain

Acute vs Chronic Pain

CENTRAL SENSITIZATION

Past experiences

Beliefs

Situational context

Stress

Coping mechanisms

Fear

Cultural background

No longer just an issue in the tissue!

• What are passive approaches to pain management?

What kind of effect do these strategies have on pain?

• When/why is passive pain management appropriate?

Active vs Passive Pain Management

Audience: what are your thoughts on passive approaches?

Active vs Passive Pain Management

• What are active approaches to pain management?

What kind of effect do these strategies have on pain?

• Why do we use active pain management strategies for chronic/persistent pain?

• Sound familiar?

• Consider past experiences and how they may shape how you feel about exercise.

• How do you know how much is “too much” with regards to exercise or activity?

Graded Exposure

How can I exercise if I’m

in pain?

The last time I tried PT, I was in bed for 3

days after!

• Activity Pyramid Principles

Graded Exposure

Red light

Yellow light

Green lightCurrent tolerance

Pain Flare-Up

Acute injury

“Safe & Sore”

• Important to note that activity pyramid and activity tolerances are FLUID– Consider how your tolerances change day to day given your own personal

circumstances?

• With increased self-awareness and knowledge of guiding principles, tolerances will trend upwards gradually over time (weeks to months)– More activities fall into GREEN category = less frequent/more manageable

flare-ups

Graded Exposure

NO PAIN NO GAIN

KNOW your pain,KNOW your gain!

• Two major categories of muscles in our bodies– MOVERS (sprinters)– STABILIZERS (marathoners)

Laying the Foundation

Superficial or “Sprinters”

Deep or “Marathoners”

• What changes in how we use these muscles in the setting of pain?

Laying the Foundation

• Difficulty maintaining postures• Difficulty with transitions

• Overuse of the “sprinter” muscles• Increased tension

• Guarded patterns• Poor joint protection; pain with movements

• Once the foundation is sound, we can gradually build on it

Laying the Foundation

Dynamic stability and functional exercise

Foundational muscle activation and retraining

Patient desired

exercise or activity

wee

ks to

mon

ths

Desensitization

Nervous system on “high alert”

Desensitization through graded exposure to activity

Desensitization

Using the BODY to teach the BRAIN that movement is safe again!

• Chronic Pain leads to… decreased movement tight and weak muscles

• So PT must include general strengthening and stretching!

• Important to learn parameters for strengthening and stretching for lifelong maintenance

General Strength & Mobility

Neuromobility

• Our nerves can get tight and sensitive, just like our muscles, tendons and ligaments!

• Gentle stretching and mobilization can help to desensitize

Self-Management

HomeH

ExerciseE P

Program

• YOU are the expert of your own body!

• Make sure you leave therapy with the knowledge and understanding of meaningful and effective strategies to use for the lifetime

Other Pain Management Tools• Multidisciplinary/interdisciplinary chronic pain management (Functional Restoration)

programs are best option for high-impact chronic pain• Psychotherapy• Occupational Therapy• Biofeedback Therapy• Vocational Rehabilitation

• You are our own advocate! Seek out tools and resources that you can use for SELF-MANAGEMENT for the lifetime, vs repeated “quick fixes”

• Support groups, online resources, and apps• American Chronic Pain Association, National Fibromyalgia and Chronic Pain Association• Ouchie app• Pain Assessment and Management Initiative (PAMI)

1. Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001–1006. DOI: http://dx.doi.org/10.15585/mmwr.mm6736a2external icon

2. Darrell J. Gaskin, Patrick Richard. The Economic Costs of Pain in the United States. The Journal of Pain, 2012; 13 (8): 715 DOI: 10.1016/j.jpain.2012.03.009

3. Jones, M. R., Viswanath, O., Peck, J., Kaye, A. D., Gill, J. S., & Simopoulos, T. T. (2018). A brief history of the opioid epidemic and strategies for pain medicine. Pain and therapy, 7(1), 13-21.

4. Bennett, M., Kaasa, S., Barke, A., Korwisi, B., Rief, W. and Treede, R., 2019. The IASP classification of chronic pain for ICD-11. PAIN, 160(1), pp.38-44.

5. Merskey H, Fessard DA, Bonica J, et al. Pain terms: A list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain 1979;6(3):249–52.

6. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011.

7. National Academies of Sciences, Engineering, Medicine. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: The National Academies Press; 2017.

8. Clark T, Wakim JC, Noe C. Getting “unstuck”: A multi-site evaluation of the efficacy of an interdisciplinary pain intervention program for chronic low back pain. Healthcare (Basel) 2016;4(2):33.

References

Thank you!

Hannah Scholten, PT, DPT, Cert. MDTClinical Supervisor - Wildlight │ Rehabilitative Services

Office: (904) 427-8305Cell: (651) 285-9431UFHealthJax.org