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Practical Tools & Tips from an Interdisciplinary Pain Teamfor Use in the Busy Family Physician’s Office

Dr. Matt Graham, R. PsychJimena Malzahn, B.Sc.(PT)

Cara Rodrigues, B.Sc., B.Sc.(OT)

OrionHealth Rehabilitation & Assessment Centres

exercise

objectives

our Lens: how we see the chronic pain patient (biopsychosocial)

our Approach: literature understandable language

some Tools: translated for the sole practitioner

key messages for our patients

validate the pain experience acutechronic pain neurophysiology

active vs passive coping treatment vs management talk ‘nervous system sensitivity’ language

function focus ADLs/IADLs and the value of WORK “it hurts but it’s not harm”

what does the literature say

regarding approach

“An approach that would include a focus on fear and avoidance beliefs, catastrophizing, and depression could greatly improve patient functioning and enhance the secondary prevention of chronic disability, including sick leave.” (p 165)

(Boersma & Linton, 2006)

biopsychosocial

Reference: Main, C.J., de C Williams, A.C. (2002) ABC of psychological medicine: Musculoskeletal pain.  British Medical Journal, 325, 534- 537.

yellow flags—early signs of Pain Disability

Early warnings of pain disability Belief that back pain is harmful or potentially severely

disabling Fear and avoidance of activity or movement Tendency to low mood and withdrawal from social

interaction Expectation of passive treatment(s) rather than a belief

that active participation will help

Reference: Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss, 1997

yellow flags updated: (Nicholas, Linton, Watson, &

Main, 2011)

Beliefs, appraisals, and judgments Unhelpful beliefs about pain; indication of injury as uncontrollable or likely to worsen

Expectations of poor treatment outcome, delayed return to work

Emotional Responses Distress not meeting criteria for diagnosis of mental disorder

Worries, fears, anxieties

Pain Behaviour Avoidance of activities due to expectations of pain and possible re-injury

Over reliance on passive treatments (hot packs, cold packs, analgesics)

Key tool today: starts with how we talk about pain

video—Understanding Pain: what to do about it in less than 5 minutes (http://youtu.be/4b8oB757DKc)

Lorimer Mosely: pain as an OUTPUT

acute chronic

generally accepted as pain due to damage in body tissue

generally accepted as pain that persists longer than expected healing time

pain is still an output less about tissue and more about maladaptive output from the brain

(today)stories connect people

what pain scales don’t show us

tools:

• pain neurophysiology hurt vs harm (language)

• prescription for movement

• mindfulness /breathing practice

• cognitive awareness tool• activity log/journal• work as a determinant

of health

why work?

The longer a person is off work, the less likely they are to return (Crook and Modolfsky, 1994)

Early return to work contributes to decrease in overall work disability (Lydell et al., 2009, Loisel et al. 1994)

how we shape recovery?

May inadvertently promote fear avoidance in our language and actions (Linton et al., 2002)

Taking people off work when they can do their job, modified or alternate duties can contribute to fear avoidance

Need a culture where we talk about sustaining or returning to work as a given step in recovery

summary: key message

summary: key message

movement

summary: key message

work

take home messages

hold an interdisciplinary mindset

see pain from a nervous system sensitivity perspective vs tissue damage

watch out for reinforcement of fear and avoidance active vs passive

support for movement & work

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why are we hopefulour work

why we love it

resources

Butler, D, & Mosely, G.L., Explain Pain. Pearson, N., Understand Pain Live Well Again.

NOI group website: www.noigroup.com; great resources/anecdotes

Pain BC website: www.painbc.ca; Pain Toolbox download

Dr. Matt Graham, R. PsychJimena Malzahn, B.Sc.(PT)Cara Rodrigues, B.Sc., B.Sc.(OT)

OrionHealth Rehabilitation & Assessment Centres

Thank you

references

Boersma, K.& Linton, S.J. (2006). Psychological Processes Underlying the Development of a Chronic Pain Problem: A Prospective Study of the Relationship Between Profiles of Psychological Variables in the Fear–Avoidance Model and Disability. Clinical Journal of Pain, 22 (2), 160 – 166.

Crook, J., Modolfsky, H.(1994). The probability of recover and return to work from work disability as a function of time. Quality of Life Research, 3 (Supplement 1), S97 - S109.Providers: Are We Fear Avoidant? Journal of Occupational Rehabilitation,12 (4), 223-232.

Linton, S.J., Vlayeyn, J., Ostelo, R. (2002). The Back Pain Beliefs of Health Care Providers: Are We Fear Avoidant?Journal of Occupational Rehabilitation,12 (4), 223-232.

Loisel, P., Durand, P., Abenhaim, L., Gosselin, L., Simard, R., Turcotte, J., & Esdaile, J. M. (1994). Management of occupational back pain: the Sherbrooke Model. Results of a pilot and feasibility study. Occupational and Environmental Medicine, 51, 597-602.

Lydell, M., Grahn, B. Mansson, J., Baigi, A., Marklund, B. (2009). Predictive Factors of Sustained Return to Work for Persons with Musculoskeletal Disorders who Participated in Rehabilitation. Work, 33, 317-328.

Moseley, G.L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140.

Nicholas, M.K., Linton, S.J., Watson, P.J, & Main, C.J.(2011) Early Identification and Management of Psychological Risk Factors (“Yellow Flags”) in Patients With Low Back Pain: A Reappraisal. Physical Therapy, 91, 737-753.

Neil Pearson (2012, January 23). Acute versus Chronic Pain: Understanding the difference and choosing appropriate treatment. Retrieved from: www.orionhealth.ca.