10/24/2016
1
Easing the Strain
of Pain on the Brain:
How a New Service Was Developed to
Teach Pain Self-Management Skills for
Brain Injury Survivors, and Useful Take-
Home Principles for Your Practice
Presenters:
Bonnie Cai-Duarte – PT
Bronwen Moore – OT
Co-authors:
Cara Kircher - OT
Sarah Sheffe - OT
We have no conflicts of interest to disclose
Objectives
LEAP
How we redeveloped
Background research
Practice tips
Service model
Evaluation
Objectives 1. Tell you about the LEAP service
2. Review research about pain after brain
injury and the role of self-management
3. Learn about emerging best practice tips
for pain self-management
4. Describe how we redeveloped our
service, and key strategies
5. Discuss client and stakeholder
partnerships in the development process
LEAP
How we redeveloped
Background Research
Practice tips
Service model
Evaluation
LEAP In Brief
• LEAP: Living Engaged and Actively with
Pain
• Open to Toronto Rehab Brain & Spinal Cord
clients with a neurological condition and pain
• Outpatient group programs:
Pain self-management,
mindfulness, and exercise
• Inpatient and outpatient
one-to-one consultations
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Why Redevelop?
Redevelopment
needs:
• Changing
organization priorities
• Focus on neurological
population
• Need for update to
services
Former chronic
pain service:
• Any diagnosis
• Outpatient groups
only
• Running 20+ years
LEAP
How we redeveloped
Background Research
Practice tips
Service model
Evaluation
Research Overview:
Pain, ABI, and Self-Management
Pain 101
Pain Basics
Nociceptors pick up changes in temperature, mechanical force, or chemistry
Spinal neurons become excited and send message along spinal cord to brain
Sensory information arriving from the spinal cord is processed in hundreds of areas
Peripheral
nerves
Spinal
cord
Brain
Glutamate
Spinal cord neuron Nociceptor
Pain Pathway Brain
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Area Major Function
1 Premotor/motor
cortex
Organize and prepare
movements
2 Cingulate cortex Concentration, focusing
3 Prefrontal cortex Problem solving, memory
4 Amygdala Fear, anxiety, anticipation
5 Sensory cortex “Virtual body”
6 Hypothalamus/
thalamus
Stress response,
autonomic regulation
7 Cerebellum Movement and cognition
8 Hippocampus Memory
PAIN
EXPERIENCE
The Pain Experience is Complex
(Butler & Moseley, 2014)
When Pain Persists, the Nervous
System Can Become Sensitized How Does The Nervous System
Get Sensitized?
Inflammation Chemistry
Spinal cord neurons Brain pathways
Urban, 1999)
(Hass-Cohen & Findley, 2009;
Newton-John & Geddes, 2008;
Neuropathic Pain
• Due to changes to the nervous system:
– Increased excitability of neurons
–Growth and spread of pain-transmitting
neurons into other regions
• The brain may not get a clear signal (or any
signal) from parts of the body
• It can decide that this partial information is
a sign of danger, and interpret it as pain
(Bonin, 2015)
Pain in the “Virtual Body”
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Does Pain Always Mean that the
Body is Being Harmed?
Is the Feeling of Pain Always In
Proportion to the Injury?
No!
If You’ve Been Injured, Can Pain
Be Felt in a Totally Different Area?
Yes!
Can Pain Go On, Even Long
After the Body Has Healed? Yes
again!
(Butler &
Moseley, 2014)
Persistent Pain and ABI
Pain is Common After ABI
• Estimates of prevalence of chronic pain
in ABI ranges broadly, e.g. from 43% -
89%
• Synthesis of 20 studies (3289 clients)
shows persistent pain rate of 51.5%
• Seen more often in mild TBI (e.g. 75%)
vs moderate to severe TBI (e.g. 32%)
(Nampiaparampil, 2008)
Common Types of Pain After ABI
Post-traumatic headaches
Neuropathic pain (caused by damage to
neurons in brain or periphery)
Complex regional pain syndrome
(usually affects an arm or leg)
Heterotopic ossification
(Tyler & Lievesley, 2003)
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Post-Traumatic Headaches
• Most common sequelae of CHI
• 80% of clients report headache at some
stage of recovery
• After 2 months, rate is 60%
• After 6 months, rate is 44%
• Often seen together with neck pain
(Branca & Lake, 2004)
Why Worry About Pain After ABI?
(Iezzi, Duckworth, Mercer & Vuong, 2007; Martelli, Zasler, Bender & Nicholson, 2004)
• Symptoms of pain and ABI are similar – masking can occur
Misdiagnoses
• Physical
• Functional
• Psychological Impairment
• Anticipation of pain disrupts cognitive efficiency by activating ACC and HPA Axis
Cognition
Risk Factors for Persistent Pain
Thoughts Catastrophizing
Beliefs / Expectations
Low self-efficacy
Feelings Depression
Anxiety, Stress
Anger
Behaviours Fear / avoidance
Sedentary lifestyle
Poor follow-through
Stressors Competing priorities
Lack of social support
Limited physical resources
Risk Factors
(Mann, Lefort & VanDenKerkhot, 2013; Martelli, Zasler, Bender & Nicholson, 2004)
What Helps Persistent Pain?
Best Therapeutic Approaches
CBT Stanos & Houle, 2006
ACT Vowles, Sowden &
Ashworth, 2014
Mindfulness Hassed, 2013
Motivational Interviewing
Miller & Rollnick, 2013
Gentle Exercise
Lee, Crawford & Shoomaker, 2014
Tailoring Interventions
Contemplation “I need to help myself manage
this pain, but I don’t know how!”
Action “I know what helps and what
makes the pain worse.
I have some control.”
Maintenance “I feel I am managing my pain
to the best of my ability.”
Pre-Contemplation “Someone should cure me of this
pain!”
For best results, match intervention to client’s stage of change:
(Prochaska, 1984; Mann, Lefort & VanDenKerkhot, 2013)
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Contemplation
Action
Maintenance
Pre-
Contemplation
Preparation
Raise awareness,
explore benefits of change Address barriers
to change
Monitor, problem-
solve, reward
change
Support,
remind,
trouble-
shoot
Inform,
plan change
Self-Management Education Works!
Self-efficacy
Cognitive coping
Task persistence
Acceptance
Pain (gains can last years)
Catastrophizing, anxiety
Use of analgesics
Healthcare access, ER visits, hospitalizations Pain behaviours
(Hoffman et al., 2007; Mann, LeFort & VanDenKerkhot, 2013;
Nash, Ponto, Townsend, Nelson & Bretz, 2013)
Treatment Goals • Train a variety of coping skills
• Active participation and responsibility
• Relate differently to the pain
Learn
• Pain intensity
• Reliance on pain medication
• Use of healthcare services Decrease
• Physical activity
• Psychosocial functioning
• Engagement in life activities
• Social support
Enhance
(Stanos & Houle, 2006)
Best Pain Coping Skills - ABI
Pacing Stress
management
Sleep hygiene
Managing thoughts
Exercise Task persistence
Assertive-ness
Cultivate acceptance
Relaxation
Managing emotions
(Sommer & Witkiewicz, 2004;
Iezzi, Duckworth, Mercer, & Vuong, 2007; Tyler & Lievesley, 2003)
Relating Differently to Pain
• Encourage task persistence
–Opposite of fear/avoidance pattern
–Linked with better outcomes with pain,
function, mental health and disability (Molton, Jensen, Ehde, Carter, Kraft & Cardenas, 2014)
• Cultivate Acceptance
–Shifting of focus from cure to coping
–Uses active coping strategies
–Predicts adjustment to pain & function
(Stanos & Houle, 2006)
Special ABI Challenges
• People with ABI report less control over
pain than those without ABI (Tyler & Lievesley, 2003)
(Branca & Lake, 2004)
Cognitive impairment
Decreased insight
Mental health comorbidities
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Adapting Pain Treatment for
Clients with ABI
• Provide written & verbal information
• Set up routines, practice and procedural
learning within group
• Involve peers and family
• Plain, clear language and repetition
• Use structured checklists and planning
tools (Sommer & Witkiewicz, 2004)
LEAP
How we redeveloped
Background Research
Practice tips
Service model
Evaluation
Best Practice Tips for Pain
Self-Management Education
Always Ask About Pain
• It’s okay not to have all the answers
• Acknowledge, validate and be curious
• Ask about patterns: “What makes the
pain even a little bit better? What makes
it worse? What do you do when pain
arises?”
• Find out if pain is new or longstanding
Help Clients To Learn About
How Pain Works
• Decreases fear
• Increases
function
(Moseley, Nicholas, & Hodges, 2004)
Good Websites About Pain • www.youtube.com - Videos on YouTube:
– Lorimer Moseley – “Why Things Hurt”
– Hunter Medicare Local – “Understanding Pain: What to do
about it in less than 5 minutes”
• www.cirpd.org
– Articles and videos about pain and the latest research
• www.canadianpaincoalition.ca/
– Articles and videos about pain, research and events
• www.chronicpaincanada.com/
– Lists support groups and education events in Canada
• www.pain.com/
– This site has listings of pain management clinics in Western
Canada, news and message boards
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8
Good Books About Pain
• Managing Pain Before It Manages You.
By M. Caudill (2015)
• The Brain’s Way of Healing by N.
Doidge (2015)
• Explain Pain. By D.Butler & L. Moseley
(2013)
Help Clients Find Ways to
Escape from the Pain
• Distraction
• Social support
• Heat/cold
• Massage
• TENS
• Creams
(Pearson, 2009)
Distraction Works
This brain is
too busy to
process the
pain!
Teach Ways to Calm the Mind
and Body
• Relaxation techniques
• Meditation
• Breathing
• Music
• Sleep strategy education
• Emotional self-management
• Coping thoughts
• Work with catastrophic thoughts
• Willingness vs struggle
(Sommer & Witkiewicz, 2004;
Iezzi, Duckworth, Mercer, & Vuong, 2007; Tyler & Lievesley, 2003)
Relaxation Resources
• Websites – www.guilford.com/MBCT_audio
– health.ucsd.edu/specialties/psych/mindfulness/mbsr/audio.ht
– www.youtube.com
• Jon Kabat-Zinn Meditations
• Cara Kircher (relaxations recorded by LEAP Service)
• Books – The Relaxation & Stress Reduction Workbook By M.
Davis. E.R. Eshelman & M. McKay (2008)
– The Mindful Way Workbook, by J. Teasdale, M.
Williams & Z. Segal (2014)
More Relaxation Resources
• CDs – Letting Go Of Stress: www.drmiller.com
– The Relaxation Experience CD: Meditations for
Optimum Wellness: www.forhealth.ca/order.html
• Apps and Podcasts – Podcasts: Meditation Oasis
(meditationoasis.com/podcast/listen-to-podcast/)
– Cleveland Clinic Stress Free Now App
– Smiling Mind App
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Support Your Client to Challenge the
Pain with Gentle Activity
• Exercise – gentle, novel,
with awareness, build slowly
• Pacing
• Task persistence
• Work with fear/avoidance,
e.g. graded exposure
• Activity adaptation
• Identify highest values, and
invest in those activities
• Assertiveness training (Molton, Jensen, Ehde, Carter, Kraft & Cardenas, 2014;
Sommer & Witkiewicz, 2004; Iezzi, Duckworth, Mercer, & Vuong, 2007; Tyler &
Lievesley, 2003)
Gentle Exercise Resource
• www.youtube.com
–Search: Cara Kircher
–Gentle chair yoga routine (193,000
views and counting!)
–Gentle mat yoga routine
–Coming soon: Gentle tai chi routine
Practice, Practice, Practice!
• Neuroplastic changes
take time (weeks)
• Encourage clients to
stick with strategies
• Approach with low
expectations and lots
of curiosity
• Reward small steps
forward
LEAP
How we redeveloped
Background Research
Practice tips
Service model
Evaluation
LEAP Service
Redevelopment Process
Integrating (March 2015 – June 2015)
Evaluating (June 2015 – Present & Ongoing)
Program/ service creation
Marketing & communication
Set long term goals
Research
Interviews
Logistics
Client and clinician
feedback
Planning (Sept. 2014 – April 2015)
How Did We Do It?
10/24/2016
10
Goodbye / Hello
• Leaving behind the former
service
• Determining and
responding to the needs of
the organization and our
clients
• Reflecting on our strengths
as a team and as
individuals for a fresh start
Planning Okay, Now What?
Brainstorming
Determined
operating
parameters
Met with former
clients
Met with
stakeholders
at all referral
sites
Created a
plan and
timeline
Planning
Needs Assessment
Interviews with clients
Staff surveys
Interviews with staff
Meetings with management
Database review of former service
7 139
8 15
2532 client visits
Planning Research, Research,
Research
• Collected information on program
development and quality improvement
processes
• Conducted a thorough lit review on the
following subjects: fear of movement,
pain catastrophizing, ACT, CBT, self-
management, outcome measurement,
Planning
…and More Research
• Read 40 articles
• Standardized our process for taking
notes on literature according to template
to streamline sharing information among
team members
• Upgraded staff education through
courses in Motivational interviewing, the
ACT matrix, CBT, Depression
management, and hydrotherapy
Planning
Service
Creation Integrating
Travelling Cart with Education
Info
1:1 goal setting
consults during groups Follow up
workshops for
graduates
Provide staff
education workshops
in pain
Adapted pain management
groups
Pool Group/Exercise group leading
into CBT groups
Module Based groups
Offer groups
based on functional
level
Pain management group
Mindfulness group Workshops
1:1 Inpatient consultations
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Conducting a Phased Roll Out Integrating
Marketing &
Communication
• Attended team business meetings
• Provided staff education sessions
• Due to ongoing evaluation feedback,
increased communication with referral
sources using follow-up emails after
referral, intake / consult)
Integrating
Long Term Goals
1. Research project
2. Publish Manual
3. Share PMG model
Integrating
Changing Your Pain Pathways:
Ways to cope with pain in daily life
LEAP Pain Service – Brain and Spinal Cord Service University Health Network, Toronto Rehab
LEAP
How we redeveloped
Background Research
Practice tips
Service model
Evaluation
Service Evaluation Strategy
& Outcome Measures
Learning How
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Service Evaluation Strategy
Inpatient
Rating scales for
IP consults
Outpatient
Outcome measures
Client feedback surveys
Group exit
interviews
Focus group
Staff
Online survey
Focus groups
Pain Vigilance and Awareness Questionnaire (PVAQ)
Roland Disabaility Questionnaire (RDQ)
Tampa Scale of Kinesiophobia (TSK)
Illness Behaviour Questionnaire
Cognitive Coping Strategies Inventory (CCSI)
Coping Strategies Questionnaire (CSQ)
K-Scale
Pain Disability Index (PDI)
The Vanderbilt Pain Management Inventory
Brief Pain Inventory (BPI)
Centre for Epidemiological Studies – Depression Scale
Non-communicating Children’s Pain Checklist
Satisfaction with Life Scale (SWLS)
Rand Mental Health Inventory (MHI-5)
SF-36
Chronic Pain Grade
Pain Beliefs and Perceptions Inventory (PBPI)
SOPA – survey of pain attitudes
Multidimensional scale of perceived social support
Multidimensional Pain Readiness to Change Questionnaire
Pain Self-Efficacy Questionnaire (PSEQ
Brief Pain Coping Inventory – 2 (BPCI-2),
Pain Anxiety Symptoms Scale (PASS)
Patient’s Global Impression of Change
Hopsital Anxiety and Depression Scale (HADS)
Utrecht Activities List (UAL)
Life Satisfaction Questionnaire (LiSat -9)
Pain Cognition List (PCL – 2003)
Medical Outcomes Study Short Form Health Survey - 12
Multidimensional Pain Inventory - SCI Version (MPI)
Pain Response Self-statement Scale
Moorong Self-Efficacy Scale (MSES
Ways of coping inventory
Outcome Measures Pain Vigilance and Awareness Questionnaire (PVAQ)
Tampa Scale of Kinesiophobia (TSK)
Cognitive Coping Strategies Inventory (CCSI)
Coping Strategies Questionnaire (CSQ)
K-Scale
Pain Disability Index (PDI)
The Vanderbilt Pain Management Inventory
Brief Pain Inventory (BPI)
Satisfaction with Life Scale (SWLS)
SF-36 and Study Short Form Health Survey – SF 12
Pain Beliefs and Perceptions Inventory (PBPI)
SOPA – survey of pain attitudes
Multidimensional Pain Readiness to Change Questionnaire
Pain Self-Efficacy Questionnaire (PSEQ)
Brief Pain Coping Inventory – 2 (BPCI-2)
Patient’s Global Impression of Change
Life Satisfaction Questionnaire (LiSat -9)
Pain Cognition List (PCL – 2003)
Multidimensional Pain Inventory - SCI Version (MPI)
Moorong Self-Efficacy Scale (MSES)
Ways of coping inventory
32!
21!
Chosen Measures - PMG First outcome measures package
Pain Catastrophizing Scale (PCS)
Chronic Pain Acceptance
Questionnaire (CPAQ)
Canadian Occupational Performance
Measure (COPM)
Numeric Pain Rating Scale (NPRS)
Chronic Pain Coping skills Inventory
(CPCI - 42)
Physical activity level / stage of
change
Second version
of package
PCS
CPAQ
COPM
Third version of
package
PCS
CPAQ
COPM
NPRS
SF – 36 (QoL)
Chosen Measures - MMG
• Considered 5 questionnaires
• Based on length, readability, and
psychometrics we chose:
the Mindful Attention
Awareness Scale
(MAAS)
(and the
CPAQ)
What We Found So Far
Good!
Bad
Outcome Measures
Measure 1 Measure 3 Measure 2
Legend:
Before PMG
After PMG
Shhh! Evaluating the Inpatient Consults
• Limits of the consults:
–1 hour
–Not resourced for ongoing follow up
–Brief assessment and education
• Meaning: We were unable to use
formal outcome measures
• Instead: we developed rating scales
based on the COPM scales
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4.3 4.4
7.2
8.7 8.5
0
1
2
3
4
5
6
7
8
9
10
Goal knowledge Goal confidence How well we metexpectations
Inpatient Knowledge, Confidence And Satisfaction Ratings (n=41)
Pre-consult Post-consult
Staff Online Survey &
Focus Group
• Surveyed 51 staff about the service 6
months into the roll-out
• Conducted two focus groups with staff
who were eligible to refer clients to
LEAP
What We Found So Far Top 3 reasons why staff
refer clients to LEAP: Online Survey
• To engage clients in self-management (86%)
• To get information about pain management (86%)
• To work towards pain-related goals (86%)
Focus
Groups
• Mood and pain are the biggest therapy barriers
• Prevention: referring clients before pain becomes chronic
• Strategies generalize beyond pain coping
• Validation and normalization of pain experiences
“Pain and mental health issues are
common. If someone is walking around in
pain and so focused on that, they can’t
function well in work, school and
relationships.
The strategies you teach are not
necessarily specifically for pain. It may
transfer over to sleep, anxiety, and
depression. I think it’s hugely beneficial.”
- Referring clinician
What We Changed
More ongoing
communication back to
referral source
Outpatient consult option
Exercise groups
(hydrotherapy and chair
yoga/tai chi)
Client Feedback Surveys, Exit
Interviews & Focus Group
• Surveyed 40 clients who attended a
LEAP group
• Conducted a focus group with 4 clients
who had attended LEAP groups
• Conducted exit interviews with all clients
who attended a LEAP group
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0
1
2
3
4
5
Pain Management Group Feedback (n=40)
5 = Excellent 4 = Good 3 = Satisfactory 2 = Poor 1 = Very poor
Feedback Themes Group
interactions: Group discussions and
sharing were very important to the learning experience,
even when difficult.
Quality: The group was helpful and
appreciated.
Strategies & perspective:
Clients have made concrete lifestyle changes, and
changed their perspectives on pain.
Barriers to learning:
There are barriers to learning – visual, hearing, cognitive,
language & pain.
Length of group / timing:
The group should be longer (more time for discussion,
relaxation and movement), if clients could tolerate it.
Manual: The manual was helpful,
though some found it a bit lengthy.
Breathing and relaxation:
Breathing and relaxation techniques were valuable.
Exercise: Movement breaks were
generally appreciated; but one client found them
distracting.
Logistics: The group is well organized.
“This course clears the clouds. It opens
the opportunity for change. It made a
bridge for me to cross in my life.”
- LEAP Client
In Their Words In Their Words
“I realized that my life could go on,
despite the pain. I learned that it was not
all “outside my control”. I learned that I
had the power to change the way I
thought about pain and reacted to pain.
…Although I can’t always make the pain
go away, there are things I can do to
make it better, to make it easier for
myself.”
- LEAP Client
What we changed
Altered group session layout
to add more time for exercise
and discussion
Optional community resource
session
Currently creating additional
peer support session
Constant Upgrading Collect, Analyze, Upgrade
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Are You Redeveloping?
Here Is Our Advice
Advice and Strategies for
Those Facing Redevelopment
Building the New Service
• Ask a lot of questions up front from
those driving the change
• Be open to many possibilities
• Use lots of types of evidence
• Take the strengths from your old service
• Roll out gradually
Evaluation
• Be ready to show progress at any time
• Evaluate everything
• Let go of things that aren’t working
• Build in time for processing service
evaluation data & cycling in changes
• Get lots of stakeholder input
Growing
• Expect a period of uncertainty
(for us: ~ 1 to 1.5 years)
• Stay flexible (don’t share plans too
soon!)
• Set many short-term goals with clear
leaders and deadlines
• Communicate often about priorities
• Keep the long-term vision in mind
Marketing & Communication
• Market early and often
• Be clear about “what’s in it for them”
• Be clear about what you don’t do
• Report back to referral sources often
• Build bridges (but keep your own goals
front and centre)
• Make referral easy
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Take Care of Yourself
• Take slow, deep breaths
• Find something to get excited about
• Invest in your team
• Be open to new ideas
• Be realistic about time
• Play to your strengths
New Service Model:
LEAP Current State
LEAP
How we redeveloped
Background Research
Practice tips
Service model
Evaluation
Operating Parameters
• Resources:
–2.4 FTE staff (1.8 OT, 0.6 PT)
• Serving:
–3 sites: University, Lyndhurst and
Rumsey Centres
–5 populations: SCI, ABI, MS, Stroke, CP
– Inpatient and Outpatient
Who Can Refer?
• All clinicians, nurses and physicians
• Toronto Rehab Brain and Spinal Cord
program only (no external referrals)
Eligibility
• Patient in TRI Brain and Spinal Cord
program
• Have a neurological diagnosis and pain
• Open to self-management approach
• Able to communicate (at least yes/no)
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Eligibility for Groups
• Appropriate cognition & behaviour
• Sufficient English proficiency to follow
discussion
• Manage transportation and toileting
while on site
• Not intended for management of crises
Inpatient Services: Focused
Consults
• Topics:
• Pain education
• Stress management
• Family education
• Pain Resources
• Relaxation
Outpatient Services Provided
• Pain Management Groups
• Mindfulness Meditation Groups
• Exercise groups
–Hydrotherapy
–Chair yoga and tai-chi
• Individual education sessions
• Group follow-up (refresher workshops)
Pain Management Group
• 9 weeks, 1 x / week, 2 hours, 8-15
members
• Each class: 30 minute relaxation, 1.5
hour content, adapted movement break
• $30 Materials cost requested
Pain Management Group Outline
1. Understanding pain
2. Doing what matters
3. Stress, relaxation and breathing
4. Exercise & Movement
5. Sleep
6. Thoughts about pain
7. Dealing with moods
8. Communication
9. Re-cap & flare-up plan
Mindfulness Meditation Group
• 9 weeks, 1 x / week, 2.5 hours, 8-15
members
• Focus on mindfulness practice and
discussion
• Based on “The Mindful Way Workbook”
• $30 Materials cost requested (but book
available for free at Public Library)
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Exercise Groups
• Hydrotherapy
• Chair yoga and tai-chi
–4 to 6 weeks long
–Designed to teach a program clients
can do independently at community
pool/home
Example Of Patient Care
Pathway
Step 1: Inpatient Consult
Step 2: Outpatient
intake
Step 3: Pain Mgt
Group
Step 4: Exercise Group
Step 5: Mindfulness Meditation
Group
Step 6: Refresher
Work-shops
Questions?
Our Contact Info:
LEAP @uhn.ca
(416) 597-3422 ext. 5298
Thank you for your time!
References
Branca, B., & Lake, A. E. (2004). Psychological & neurological integration in
multidisciplinary pain management after TBI. Journal of Head Trauma
Rehabilitation, 19, 40-57.
Bonin, R. (2015). Running from pain: mechanisms of exercise-mediated
prevention of neuropathic pain. Pain,156(9), 1585–1586,
http://dx.doi.org/10.1097/j.pain.0000000000000302.
Butler, D., Moseley, G. L. (2014). Explain pain (2nd Ed.). Australia: Noigroup
Publications.
Hass-Cohen, N., Clyde Fidnlay, J. (2009). Pain, attachment, and meaning
making: Report on an art therapy relational neuroscience assessment protocol.
The arts in Psychotherapy, 36: 175-184.
Hassed, C. (2013). Mind-body therapies use in chronic pain management.
Australian Family Physician, 42(3), 112-117.
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