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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
• 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