Lydia BonGiorni MS OTRL Objectives Participants will be able to define chronic pain and its impact on the TBI population Participants will be able to discuss potential challenges and barriers to managing chronic pain in the TBI patient ID: 933806
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Slide1
Beyond Opioids: Non-Pharmaceutical Strategies to Manage Chronic Pain After Brain Injury
Lydia BonGiorni, MS, OTR/L
Slide2Objectives
Participants will be able to define chronic pain and its impact on the TBI population.
Participants will be able to discuss potential challenges and barriers to managing chronic pain in the TBI patient.
Participants will identify a minimum of three non-pharmacological strategies to assist with addressing and managing chronic pain within the TBI population.
Slide3What is PAIN?
“An unpleasant sensory and emotional experience associated with actual
or potential
tissue damage” (
International Association for the Study of Pain,
emphasis added)
Acute pain
: Lasts less than three months, responds to treatment, and diminishes over time
Chronic pain
: Lasts more than three months and beyond the expected healing timeframe despite interventions
Slide4Chronic Pain
Estimates of the prevalence varies
2012 study reports 11.2% of adults report daily pain lasting more than three months
Clinical, psychological, and social consequences to chronic pain
Limitations in physical activity
Lost work productivity
Loss of social and familial roles
Reduced quality of life
Social stigma
Slide5Chronic Pain
High cost to medical community/society
Frequent or excessive use of medical services and providers
Challenges with being over or under treated via prescriptions for pain
Multiple surgeries, lost productivity
Slide6Chronic Pain in Brain Injury Patient
Considered a secondary complication to primary diagnosis
VA study that found common reports of chronic pain in the form of headaches, back/neck pain, other musculoskeletal conditions, and neuropathic pain
Wide range of pain complaints at more than two years post injury in multiple locations
Slide7Chronic Pain—A Patient Profile
63 year old male
28 surgeries (back, left arm, left leg) stemming from workplace injury >15 years ago
Returning as hand therapy patient for his fourth wrist surgery (a fusion)
Reports using opioids throughout the day, every day, to manage pain and Ambien every night to fall asleep
Reports his pain has not diminished since surgery in Fall 2017, plans to go to another surgeon for further intervention if he cannot find relief
Slide8How do we talk about pain?
Slide9Common Pain Terminology
Nocioceptive
pain: General term for pain caused by tissue damage
Neuropathic pain: General term for pain caused by nerve damage
Central nerve pain: Chronic pain that stems from damage to the central nervous system
Complex regional pain syndrome: Chronic pain that can follow a serious injury and typically involves a persistent burning sensation
Myofascial nerve pain: Pain that is set off by trigger points in the muscles (such as with fibromyalgia)
Slide10Common Descriptions of Pain
Burning
Aching
Stinging
Sharp
Stabbing
Dull
Throbbing
Others…?
Slide11Pain is… Brain?
Regardless of pain category or description, research supports that pain is ultimately a somatosensory experience that is processed by the brain
Current efforts to shift the medical framework of pain treatment to a
brain based
approach rather than a
symptom based
approach
(… but more on this later
)
Slide12Assessing Pain
Slide13Assessing Pain
Pain is completely subjective
A person’s emotional and psychological response to pain is usually more problematic to treat than the physical response to pain
Emotional and psychological responses to pain include
Anxiety
Fear
Catastrophizing
Slide14Assessing Pain
No shortage of pain scales! Examples include…
Numeric (1-10) pain scale
Faces pain scales (typically Wong-Baker)
McGill pain scale
Color pain scale
Behavioral pain scale
Checklist of non-verbal pain indicators (CNPI)
Brief pain inventory (BPI)
Visual analog scale
(And these are just for adults--pediatric pain scales are usually separate specialized tests)
Slide15Personalized Scale
Weekly Tracking
Assessing Pain—Personalized Scale for Chronic Pain Patient
Slide16What do we do about pain? (up to now, at least)
Slide17Pharmaceutical Interventions
NSAIDs (non-steroidal anti-inflammatory drugs)
Select anti-
convulsants
(gabapentin,
pregabalin
)
Select anti-depressants (tricyclics and SNRIs)
Injections of every kind! (corticosteroids, ketamine, platelet rich plasma, epidural)
Opioids (immediate release, long-acting release, extended-release)
Slide18Opioids—Types
Hydrocodone/acetaminophen
(Vicodin,
Lorcet
)
Hydromorphone (
Dilaudid
)
Meperidine (Demerol)
Methadone
Morphine
Oxycodone (OxyContin)
Oxycodone and acetaminophen (Percocet)
Oxycodone and naloxone
Slide19Opioids—Side Effects and Complications
Sedation
Dizziness
Nausea
Vomiting
Constipation
Tolerance/withdrawal symptoms
Physical dependence
Respiratory distress
Addiction
Opioid use disorder
Overdose/death
Slide20“Opioid Epidemic”
While other leading causes of death (heart disease, cancer) have decreased over the past decade, opioid related deaths have risen significantly
259 million prescriptions for opioid medications in 2012 (primarily in outpatient settings); translates to one bottle of pills for every adult in the US
Slide21“Opioid Epidemic”
National Institute on Drug Abuse reports between 30,000-35,000 deaths involving opioid drugs in 2015 in the US, a 2.8-fold increase since 2002 statistics, and approximately half of those attributed to prescription opioids alone
“In one year, drug overdoses killed more Americans than the entire Vietnam War did,” title of article for 2016 statistics
Slide22New Guidelines
In response to the opioid epidemic, ALL major institutions, such as the CDC, VA/DOD, WHO, and FDA, have updated their guidelines for treating chronic pain to include the same, first line defense:
“
Nonpharmacologic
therapy and
nonopioid
pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with
nonpharmacologic
therapy and
nonopioid
pharmacologic therapy, as appropriate” (CDC)
Slide23A New(ish) Approach
Slide24The Evolution of Pain Theory
Descartes’
Treatise of Man
(1662): Sensations “tugged” on “tubes” and the more intense tugs, the more serious the response (viewed brain as homogenous, “common sensorium”)
Charles Bell,
Idea of a New Anatomy of the Brain, submitted for the observation of his friends
(1811): Pain sensations followed a dedicated pathway and the brain was heterogeneous with dedicated areas to process different stimuli (foundation of Specificity Theory)
Underscored by the discovery of specific touch receptors—i.e.
Pacinian
corpuscles, Merkel cells,
Ruffini
end-organs—later in the 19
th
century
Slide25The Evolution of Pain Theory
von Frey’s hairs (1894-1896): Experiments with localizing stimulus thresholds using hair fibers revealing a “mosaic” of sensation distribution
Became the foundation of a concurrent theory of pain, Intensity Theory
Sherrington’s “simple reflex arc” (1947): Easily bridged the two the two competing theories of pain
J.P.
Nafe’s
Pattern Theory (1929): Ignored theories about specific or intensive pathways and instead postulated “any
somaesthetic
sensation [occurs in a] specific and particular pattern of neural firing” and that the profile of the peripheral nerves “encoded the stimulus type and intensity”
Slide26Gate Theory of Pain
Melzack
and Patrick’s Gate Theory of pain (1965): Nobel Prize winning model that explained and expanded evidence from the Specificity and Pattern theories of pain
Acceptance of pain and touch receptors as well as patterns of movement along the spinal cord
Identified three areas of spinal cord where sensation was transmitted—
substantia
gelatinosa
, dorsal column, and what they termed “transmission cells”
Argued that the
substantia
gelatinosa
acted as a “gate” in the dorsal horn (an area that modulates sensory information)
Slide27Gate Theory of Pain
Ascending pathways control the “gate”
Large fibers “close” the gate (inhibiting)
Small fibers “open” the gate (facilitating)
Descending pathways originating in
supraspinal
regions (i.e. the brain itself) can also modulate the “gate” when thresholds cause it to “open”, leading to the experience of pain and pain related behaviors
Slide28Pain Theory Limitations
Advancements in science, technology, and research deem these theories
oversimplfied
Only accounts for acute, not chronic, pain
Focus on cutaneous pain as opposed to visceral, deep, or muscular pains
Does not account for the phenomenon of
bioplasticity
, where not only neural and peripheral cells, but also glial cells, can modify over time; this discovery has a tremendous impact on the maintenance of chronic pain
Slide29The Neuromatrix of Pain Theory
Theory that was advanced in the 1980s by Canadian psychologist Ronald
Melzack
in an attempt to explain phantom limb pain
Challenged “specificity theory” of singular stimulus/response connection to explain pain and instead
Melzack
proposed that “pain is actually generated by neural activity in a network composed of several different structures in the brain, and that this network can generate pain even when there is no sensory stimulus to trigger it”
Neurological imaging developed years later supports this theory
(
Canadian Institute of Health Research: Institute of Neurosciences, Mental Health, and Addiction
, 2002)
Slide30The Neuromatrix of Pain Theory
Sensory: where it is and how much it hurts
Primary and secondary somatosensory cortices
Thalamus
Posterior insula
Affective: emotional valence of pain
Anterior cingulate cortex
Anterior insula
Amygdala
Cognitive: similar to affective plus prefrontal regions
(
Clauw
, D.J. (2010).
Neurobiology of Chronic Pain: Lessons Learned from Fibromyalgia and Related Conditions
)
Slide31Slide32Slide33“Pain is Brain”
Educational concept developed in Australia by Dr. David Butler and Dr. G.
Lorimer
Moseley for patients and clinicians
Challenging “
pathoanatomical
” singular causes as root of chronic pain
Emphasizes the “
neuromatrix
” and neuroplasticity concepts within pain management research
Belief that education and a deeper understanding of the experience of chronic pain can best combat this medical challenge
Dr. Butler, founder of
Neuro
Orthopaedic
Institute group (NOI), which focuses on developing and providing evidence-based information about the “pain is brain” approach
Slide34“Pain is Brain”
“Our vision is to seed ‘healthy notions of self through neuroscience knowledge’ worldwide. There are currently five critical conceptual change issues which underpin this:
Injury or disease does not mean that you feel pain.
The nervous system moves and stretches as we move.
Pain, stress and performance are outputs of the brain.
Knowledge and movement are the greatest pain and stress liberators.
Nervous system plasticity gives new hope and technique.”
(http://www.noigroup.com/en/About)
Slide35Hey Lydia, this sounds super neat! What does this mean for us as health professionals?
Slide36It Takes a Village
Slide37Client Factors
Appreciating the
biopsychosocial
approach
Identifying spectrum of client factors
Cognitive/perceptual
Environmental/behavioral
Psychological/emotional
How do those in the chronic pain cycle experience things psychologically and physically?
Slide38Shifting Roles
Appreciating the
active
role of the patient in treating chronic pain through
self-management
strategies
Health provider’s role as collaborator and coach
Understanding that traditional modalities and interventions are likely considered passive interventions for the chronic pain patient and therefore have short term effects
Long term success emphasizes education, continuing collaboration, re-framing the pain experience, and re-gaining trust between the patient and provider
Slide39Expanding the Treatment Team
Physical medicine and rehabilitation/pain management MD
Occupational therapist
Physical therapist
Psychology (behavioral, health, neuro)
Nutritionist
Case managers
Nursing
Integrative medicine
Slide40Fear Avoidant Model
Slide41Rehabilitation Modalities/Interventions
Heat/cold therapy
Exercise
TENS/e-stim
Ultrasound
Iontophoresis
Aquatic therapy
Manual therapy
Splinting
Pain cycle education
Coping strategies education
Medication management
Mindfulness
Pacing
Life/role balance
Relaxation techniques
Illness education
Dry needling
Cranial-sacral massage
Pain flaring planning
Realistic goal planning
Slide42Alternative/Integrative Medicine
Acupuncture/acupressure
Cupping: heated glass cups applied to meridians of the body to promote energy flow
Moxibustion
: burning
moxa
(dried
mugwort
) over the skin to promote the flow of Qi (the “circulating life force”)
Tai chi/Qigong: holistic movement therapies focused on coordinated posture, movements, and breath to address stress and promote balance
Gua
sha
: scraping skin with a massage tool to promote blood flow
Chinese herbal medicine: practiced since 3
rd
century BC and usually free of side effects
Yoga
Slide43Nutrition
Education on how an inflammatory response in the CNS can impact chronic pain pathways
Avoiding pro-inflammatory foods such as
Sugars
Highly processed foods
Dairy
Caffeine and other stimulants
Including CNS supporting foods such as
Vegetables (5+ servings a day)
Healthy fats
Spices and fermented foods
Slide44Clinical Settings
Primarily in the clinical outpatient setting
Explorations in
telerehab
and home based setting
Role of the inpatient setting
Establishing self-management practices
Collaborating with patient and family through education
Empowering patient and family through collaboration, such as when to receive pain medications
Slide45Emerging Chronic Pain (ECP) Program—An Interdisciplinary Approach
Slide46ECP—What is it?
“An eight week treatment program designed to reduce the impact that physical pain has on the daily lives of our patients and to help them live better with chronic pain. In meeting these goals, we hope to help our patients safely incorporate appropriate physical activity, exercise, and healthy lifestyle strategies into their daily lives.”
Slide47ECP Team
Physical medicine and rehabilitation MD
Physical therapists
Occupational therapists
Health psychologist
Case manager
Slide48Physical Medicine and Rehabilitation MD
Prescription management and education
Opioid monitoring/education
Alternative medicine (which includes medical marijuana education)
Slide49Physical Therapy
Evaluation of patient
Participation in group treatments twice a week
Focus on movement, strengthening, balance, cardiovascular conditioning, flexibility, and pain management techniques
Examples of treatment sessions
Tai chi
Yoga
Aquatic therapy
Slide50Occupational Therapy
Evaluation of patient
Participation in 90 minute group treatment one time a week
Focus on therapeutic lifestyle strategies for improved participation in daily routines
Explore realistic ways to incorporate positive pain coping techniques into daily routine
Examples of treatment sessions
Cooking
Activity Pacing
Environmental modifications
Life roles management
Slide51Health Psychologist
Evaluation of patient
Group treatment format one time a week, 90 minute session
Examples of sessions
Link between pain, mood, and activity level
Stress management techniques
Sleep hygiene
Slide52Case Manager
Manages patient referrals, insurance authorizations
Coordination of care
Patient and family advocate
Patient outreach and problem solving
Slide53ECP Areas of Opportunity
Modifying program to meet the needs for the brain injury population
Emphasis on one-on-one session format
Involvement of family member/caregiver as needed
Merging with RETURN! Brain injury program at Sinai Hospital
Expanding treatment team to include integrative medicine
Community outreach programs for easier access
Pilot studies to assess the efficacy and success of the program to date
Slide54Additional Information
Patients can be referred from anywhere
Primarily worker’s compensation and orthopedic injury at this time, although all diagnoses welcome
Patients who are evaluated and not appropriate for the group format setting, do have the option for one-to-one treatment instead
Offers “Beyond Pain” support group on the last Wednesday of every month from 4-5pm and is free and open to anyone in the community
Slide55In Summary
Call to action from governing institutions to adhere to new guidelines for treating chronic pain
Recognition of a paradigm shift in how the medical community understands and treats pain
Appreciation for challenges unique within the brain injury population dealing with chronic pain as a secondary complication to primary diagnosis
Consideration of a multimodal approach to addressing chronic pain that emphasizes education, collaboration, and self-management strategies
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Slide61http://thebrain.mcgill.ca/flash/a/a_03/a_03_cr/a_03_cr_dou/a_03_cr_dou.html
https://www.hopkinsarthritis.org/physician-corner/rheumatology-rounds/round-35-neurobiology-of-chronic-pain-lessons-learned-from-fibromyalgia-and-related-conditions/
http://slideplayer.com/slide/6582388/23/images/17/Processing+of+Pain+in+the+Brain+Occurs+in+Several+Regions.jpg