CHRONIC PAIN: AN EXAMINATION OF - PowerPoint Presentation

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CHRONIC PAIN:

AN EXAMINATION OF

CURRENT ISSUES

Chairman – Nigel Spencer Ley

15

TH

JUNE 2017

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Reflections upon the chronic pain experience

Deceit, discrepancy and understanding the variable nature of human (dis)ability

Dr

Rajesh Munglani

rajeshmunglani@gmail.com

01223 479024

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Diagnosis

1.      Diagnoses:

a.      Pain

Does it matter ?

CRPS

Chronic pain syndrome not ICD 10 perhaps ICD11

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Thermographic imaging in CRPS

A diagnosis of CRPS does not define

Disability, capacity to work or care and

assistance

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I have pain: so what?

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Even sporty people get pain…

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Even sporty people get pain.

Even those in the military, who are again selected for being fit before one enters the military, showed that the incidence was 22% in 805 soldiers studied and the incidence of all low back pain was 77% (Roy, 2013).

Here we are talking about the onset of back pain in simply one year.

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It isn’t pain that disables you….

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So tell me what you can do?

Even normal people have good days and

bads

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Diurnal variation in pain stiffness and fatigue in FMS

Pain Stiffness

Fatigue

High

pain

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Organic vs. Psychological

:

a.      does pain result from an underlying organic problem or psychological

overlay, or is it always a combination of the two?

b.      is it helpful to attempt to make the distinction between organic and

psychological problems in an individual patient?

c.      does the distinction affect treatment and prognosis?

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“

psychosocial factors influence

the course and outcome of every

illness”

Meyer (1866-1950)

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For the thing which I greatly feared is come upon me, and that which I was afraid of is come unto me

.

Job 3:25

14

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Can we measure fear of movement?

Epidemiology and Economics There are no exact numbers on the prevalence of clinical fear of pain, because establishing a cut-off point for “clinical levels” of fear of pain is difficult.

Fear of pain is adaptive: it prevents us from doing potentially harmful activities and is helpful in learning to avoid harmful activities.

It becomes dysfunctional when the fear is in excess of the actual risk of harm or injury

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Tampa scale

NB this is not a psychiatric diagnosis

Usually

easily treatable

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Vulnerability:

3.      Claimants with pain problems often have a history of presenting with unexplained physical problems.

Is it possible to determine with any confidence what level of disability such Claimants would have developed in the absence of the accident? e.g. can one say that a claimant with a history of somatisation was going to develop a condition such as fibromyalgia or chronic pain syndrome in any event?

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2000 patients free of CWP followed for 4 years

6 physically traumatic events: RTAs, workplace

injury, surgery, fracture, hospitalization (for any reason

other than the above) and, in women, childbirth.

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CWP

is preceded by trauma

but

presence is accounted for by pre-existing psychogenic factors

Nb

CWP in control group 10% v 15% or so in trauma group over 4 years

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CWP in Manchester

Results.

The point prevalence of Manchester-defined chronic widespread pain was 4.7%. CWP(M) was associated with

psychological disturbance [risk ratio (RR) = 2.2],

fatigue [RR= 3.8,],

low levels of self-care [RR= 2.2]

The reporting of other somatic symptoms[RR= 2.0]. Hypochondriacal

beliefs and a preoccupation with bodily symptoms were also associated with the presence of CWP(M).

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Prospective study

Over 15 months 10% developed CWP in absence of trauma

SF12 was useful marker

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What about diagnosis of type

of low back pain?

Type of injury

Response to injections?

Facet joints

Controversially one could say

No bio factors required to be

considered in the

Biopsychosocial model

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Prognosis for

FM/CWP?

Initially 1990

214 women with self reported pain

21% with non chronic (recurrent) pain,

32% with chronic regional pain

20% with chronic multisite pain

27% chronic widespread pain (CWP -2/3

rds

fulfill for FM)

5 years later 75% still had symptoms

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Expectation

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Its all over in the first 3 weeks…

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Disability:

4.     what extent does/should pain impact upon

someone'sability

to function:

a.      should someone with chronic pain be expected to return to work in circumstances where doing so cannot be demonstrated to cause any damage and

may be of psychological benefit?

b.      does the provision of care helps or hinders functional independence?

5.      Treatment:a.      what treatments are available?

b.      what works and what does not?c.      is continuing litigation a bar to effective treatment?

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What really determines outcomes ?

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Whiplash trauma – a social decline for some Our results show that experiencing whiplash trauma and developing persistent symptoms can be a social decline for some.

In Denmark, it is not possible to receive sickness benefit for more than 1-2 years after which you are transferred to

perma-nent

health-related benefit or social assistance if you are still sick.

Leth

-Petersen et al. showed that 5 years after the accident, 16% of the patient group still had lower employment propensity than controls in the general population

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Secondary Gain

Secondary gain is considered a significant risk factor for chronic pain and disability. This may be a variety of levels including social, work, family and financial gain.

A variety of conditions including pain lend themselves to reporting symptoms to achieve secondary gain.

Estimates vary considerably; however, this is not a rare phenomena and should be considered when evaluating an individual for disability or certain treatment approaches including opioids

(Dworkin, 2007 [Moderate Quality Evidence])

.

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Credibility:

does surveillance help?

what are your red flags?

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Symptom

Magnification

Symptom Magnification refers to the conscious or sub-conscious tendency of an individual to under-rate his or her abilities and/or over-state his or her limitations.

Symptom magnification is measured through assessment of observed functional performance, as compared to a subjective reports of the limitations caused by his or her symptoms. It does not imply intent

(Barber)

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Malingering

Malingering

is a medical term that refers to fabricating or exaggerating the symptoms of mental or physical disorders for a variety of "secondary gain" motives, which may include financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply to attract attention or sympathy.

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Malingering

Treating health providers often do not consider malingering

, even in cases of delayed recovery involving work injuries or other personal injuries, where there may be a significant incentive to feign or embellish symptoms or delay recovery” (

Aronoff

et al, 2007).

“The term

malingering, as a description of behavior or as a diagnosis, usually is considered highly pejorative and controversial.

Clinicians may be reluctant to address this behavior directly, even if there is strong evidence, because they are afraid of the consequences (e.g., mislabeling someone, being threatened, or being sued) [Binder & Iverson, 2000].

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Detection of Malingering

Complaints grossly in excess of clinical findings

Bizarre, absurd, inconsistent symptoms

Atypical fluctuation in symptoms in response to external incentives

Unusual response to treatment that cannot be otherwise explained (e.g., paradoxical response to medication)

Markedly discrepant capacity for work vs. recreation

Substantial noncompliance with evaluation or treatment

Compliance only with passive versus active treatment Refusal to undergo invasive testing or treatment, regardless of potential benefit Special Signs/Tests

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Why there may be discrepancy?

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Is malingering common?

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Malingering in cognitive tests after whiplash

The prevalence of underperformance was 61% in the context of litigation,

cf

29% in the outpatient clinic .

The malingering post-whiplash patients scored as low as the patients with a control group of closed head injury on most tests.

Both litigating and non litigating whiplash patients scored badly on such tests

The cognitive complaints of non-malingering post-whiplash patients are more likely a result of chronic pain, chronic fatigue, or depression

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Naïve people faking is probably easier to spot than symptom exaggeration

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20% -40% of FMS applying for benefits failed the test

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25% presented with primarily widespread pain (often diagnosed as fibromyalgia) presented with

hemisensory

or

quadrotomal

deficits to pinprick and other cutaneous stimuli on the side of lateralized pain or worse pain.

The NDSD limbs often had impairment of vibration reduced strength, dexterity or movement, and extreme sensitivity to superficial skin palpation or profound insensitivity to deep pain. Spatial, temporal, qualitative, and evolutionary patterns of NDSD emerged associated with cognitive/affective symptoms.

NDSD subjects were more often born outside Canada, more likely to be injured at work, present with abnormal pain behavior, and have negative investigations

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How objective are the medical experts ?

The ‘Priming’ of medical experts

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Medical observers, who read a text about the possibility of misuse and social deception

within the health care system, provided less positive ratings about target patients than did observers who read a more neutral text.

The less positive ratings about the patients, in turn, were predictive of lower ratings of pain and sympathy as well as of larger discrepancies between patient and observer pain reports.

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The results indicate that discounting pain in the absence of medical evidence may involve negative evaluation of the patient.

Further, the patient’s pain expression is a moderating variable, and psychosocial influences negatively impact the degree to which patients’ self-reports are taken into account.

The results indicate that contextual information impacts observer responses to pain.

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How reliable is patient reporting?

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There was a moderate association between the self-reported and objectively assessed activity levels .

The discrepancy between the two was significantly and negatively related to depression, indicating that…

Patients who had higher levels of depression judged their own activity level to be relatively low compared to their objectively assessed activity level

.

Pain intensity was not associated with the perception of a patient’s activity level

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Patients were divided on the basis of scores on the Anxiety Sensitivity

Index, (a measure related to fear of pain),

low anxiety patients shifted attention away from stimuli related to pain

high anxiety patients (responded dramatically) regardless of the (magnitude) of presentation.

These results suggest that the operation of the information processing system in patients with chronic pain may be dependent on a patient’s trait predisposition to fear pain

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T

ests

/

W

addell’s

Signs

Waddell’s

Ligh

t

P

inch

Non

-

ana

t

o

m

i

c

a

l

t

ende

r

ne

ss

to

ligh

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pin

c

h.

W

adde

ll’s

A

xi

a

l

V

ertical

Load

i

ng

Ve

rt

i

c

a

l

loadin

g

o

n a st

andin

g

pa

t

ien

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sk

ul

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odu

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es lo

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ba

ck

pain.

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adde

ll’s

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imu

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ss

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ck

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istracti

on

Di

scr

epan

cy

be

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wee

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f

inding

s

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i

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in

g

an

d s

upine

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aigh

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verreacti

on

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s

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ion

,

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or

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du

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ina

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ion.

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Non

-

o

r

ganic

Physical

Signs

(“

W

ad

d

ell’s

sig

n

s”)

N

on

-anat

omic

w

eaknes

s

o

r

sensor

y

loss

N

on

-anat

omic

superfici

a

l

tenderness

S

imu

l

a

ti

o

n

tes

ts

w

ith

axi

a

l

l

oad

i

n

g

an

d

en

bl

oc

rot

a

ti

o

n

produci

n

g

pain

D

istracti

o

n

test

o

r

flip

test

in

w

h

ic

h

p

t

has

no

pa

in

w

ith

f

u

ll

extensi

o

n

o

f kne

e

w

h

ile

seated, but

t

h

e

supi

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e

S

L

R

is

m

arked

ly

positive

O

ver-reacti

o

n

verbally

o

r

exaggerat

e

d

body

l

anguage

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Inter observer reliability 50% agreement

Intra observer (repeatability by same examiner) 70%

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From the Oracle

“Thus, the presence of nonorganic signs per se does not necessarily mean that a patient is lying or attempting to deceive the examiner, and that conclusion cannot be based on this clinical finding alone”.

“

However,various

studies (Green 2003, Halligan et al 2003) suggest that 20-30% of compensation claimants who have a genuine injury demonstrate some degree of ‘lack of effort’ or exaggeration of their complaints.”

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Pain is a form of communication

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Overall participants who were working scored lower on all the measures than did participants who were not working

participants who were litigating scored higher on all the measures than did participants who were not litigating.

There was a significant time factor

The present research further demonstrated that both litigation and employment were significant factors influencing recovery from injury

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PSYCHIATRIC ASPECTS OF

CHRONIC PAIN

Dr Dinshaw Master

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‘Diagnoses’

Chronic pain

Chronic pain disorder

Chronic pain syndrome

Pain disorder

Chronic widespread pain

Fibromyalgia

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Psychiatric diagnoses

ICD-10 (World Health Organization, 1992)

DSM-5 (American Psychiatric Association, 2013)

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ICD-10

F45.4 Persistent somatoform pain disorder

The predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences. The result is usually a marked increase in support and attention, either personal or medical. Pain presumed to be of psychogenic origin occurring during the course of depressive disorders or schizophrenia should not be included here.

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DSM-5 Somatic symptom disorder (300.82)

Diagnostic Criteria

One or more somatic symptoms that are distressing or result in significant disruption of daily life.

Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

2. Persistently high level of anxiety about health or symptoms.

3. Excessive time and energy devoted to these symptoms or health concerns.

Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Specify if: With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.

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Clinical features

May or may not be associated with another medical condition

High levels of worry about illness

Appraise normal bodily sensations as threatening

Avoidance behaviour

Symptoms dominate interpersonal relationships

High levels of medical consultation

Underlying belief about undiscovered cause

Reassurance not accepted for long

Concurrent anxiety/depression common

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Marcel Proust [1871-1922]

‘For one disorder that doctors cure with drugs (as I am told they occasionally do succeed in doing) they produce a dozen others in healthy subjects by inoculating them with that pathogenic agent a thousand times more virulent than all the microbes in the world, the idea that one is ill.’

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Iatrogenic morbidity

Side effects of drugs

Medical errors

Medical negligence

Unnecessary investigations and treatment

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Lexigenic

morbidity

Stress of litigation

Possible disincentivisation to engage in treatment

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Vulnerability

Family history

Pre-accident history

Childhood history of abuse

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Treatment

Depression

PTSD

Alcohol

Psychological pain management

Care

Return to work

Analgesic

withdrawal

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Psychological treatment

Group vs individual

Residential vs outpatient

Therapist availability

Therapeutic relationship

Discuss nature of pain symptoms

Functional improvement not pain reduction

Baseline measures

Behavioural activation

Co-therapist

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