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Forster Dean CPD Chronic Pain Talk Liverpool 11th May 2015


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chronic pain presentation to Forster Dean CPD group 11.05.2015

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Forster Dean CPD Chronic Pain Talk Liverpool 11th May 2015

  1. 1. Lecture to Forster Dean Liverpool 11.05.2015
  2. 2. Dr Ilan Lieberman FRCA FFPMRCA Consultant in Pain Medicine South Manchester University Hospitals NHS Foundation Trust 4 Consultants, 3 Nurse Specialists, 2 Clinical Psychologists 2 Specialist Physiotherapist's Pain Management Program 4 per year Injection therapies Specialist clinics in Refractory Angina, Breast Pain & Urinogenital Pain
  3. 3. Chronic Pain "Pain is a more terrible lord of mankind than even death itself." * Dr. Albert Schweitzer1931 “Pain is an unpleasant physical or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. * A painful condition which lasts more than 3 months is referred to as chronic. IASP International Association for the Study of Pain British Pain Society * Mersky H: Classification of Chronic Pain IASP Press 1994, p210.
  4. 4. The new thinking is that Chronic Pain Seen should be viewed as a Disease-Like State or “5th vital Sign”
  5. 5. Chronic Pain • Incidence • Chronic benign (non cancer) pain 2 - 40% of population dependent on the study • 1 in 7 prevalence in UK • Netherlands chronic back pain costs 1.7% GDP • Netherlands lost work as a result of back pain costs 1.5 million $ per hour • In the USA rate of disability claims associated with lower back pain has increased over the rate of population growth by 1400%
  6. 6. Chronic Pain • Incidence of significantly disabling pain • Up to 80 primary care consults presenting with pain • Neck 2 - 5% • Fibromyalgia 2.5% • Back 2 - 6% • Angina 4% • Migraine 10% • Post shingles 1.5%
  7. 7. Qu 1. What are the scientific explanations for patients who do not appear to be suffering any recognisable organic symptoms, but nonetheless complain of chronic pain?
  8. 8. First some theory……
  9. 9. Pain Pathways
  10. 10. Gate Theory Pain Control  Pat Wall  Ron Melzack  Gate Theory Pain Control 1965
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  14. 14. Pain Physiology - Plasticity
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  16. 16. ilanlieberman@mac.comW. Brinjikji et al American J Neurology April 15 Mayo Clinic NIH Funded study
  17. 17. Wadell’s Signs Waddell, et al. (1980) described five categories of signs: • Tenderness tests: superficial and diffuse tenderness and/or nonanatomic tenderness • Simulation tests: these are based on movements which produce pain, without actually causing that movement, such as axial loading and pain on simulated rotation • Distraction tests: positive tests are rechecked when the patient's attention is distracted, such as a straight leg raise test. • Regional disturbances: regional weakness or sensory changes which deviate from accepted neuroanatomy. • Overreaction: subjective signs regarding the patient's demeanor and reaction to testing NOT A CHECKLIST FOR MALINGERING Are an indicator that the underlying psychosocial issues need to be explored carefully
  18. 18. Psychology Attitudes/Emotional (distress) • Symptom awareness and concern • Depressive reactions; helplessness • Anger & hostility Beliefs/ Cognitive (beliefs about pain and disability) • Significance; controllability • Fears and misunderstanding about pain Behaviours/ Behavioural (pain behaviour and coping strategies) • Guarded movements and avoidance patterns • Coping styles and strategies
  19. 19. Qu 2 Are there any methods test to see if such pain is genuine, or if it may be malingering in order to support a financial claim for compensation (which may be substantial)?
  20. 20. Client is assumed (by the experts) to be honest Experts need to be focused on highlighting exaggeration which is far commoner than complete deception Psychological assessment of malingering Close inspection of all records Time with the client Consideration by the expert of client reliability Functional questions within the report Attention to detail of daily tasks (shopping cycle, wheelie bins, driving and carrying) Repeated questions and inter-question reliability fMRI
  21. 21. Functional Questions • Sports • Cycling • Pets, dog walking • Gym membership • Shopping cycle • Hobbies • Wheelie bins • Ask the same question several ways • Cooking • Food preparation • Holidays (flights) • Driving (time) • Passenger (time) • Work journey
  22. 22. Please can you provide any tips and pointers to help us when reading a Claimant's medical report and the sort of questions we should be putting to the Claimant's expert. What are the pertinent, searching ,difficult to answer questions we should be asking on behalf of our client? • How long did the client spend with the expert ? • Did the expert examine the client ? • Did they undress the client to do so? • Was the expert chaperoned? • If neuropathic pain is alleged was formal sensory testing of the modalities undertaken (cold hot pin prick light touch) is there a map / photo / sketch of the area of loss? • Is variation in function covered? • Time between interview and report? • Detailing of medical records. Discrepancy between applications for benefit and contemporaneous medical reports and HR records.
  23. 23. Please can you provide any tips and pointers to help us when reading a Claimant's medical report and the sort of questions we should be putting to the Claimant's expert. What are the pertinent, searching ,difficult to answer questions we should be asking on behalf of our client? • How long did the client spend with the expert ? • Did the expert examine the client ? • Did they undress the client to do so? • Was the expert chaperoned? • If neuropathic pain is alleged was formal sensory testing of the modalities undertaken (cold hot pin prick light touch) is there a map / photo / sketch of the area of loss? • Is variation in function covered? • Time between interview and report? • Detailing of medical records. Discrepancy between applications for benefit and contemporaneous medical reports and HR records. • Previous claims history • Specific section on report on pre- existing vulnerability
  24. 24. What will a doctor know that a solicitor won't? If he were the solicitor, what would he do? ? Routinely detail to the expert pre instruction if necessary and always post instruction Much of the issues around pain require a thorough biospychosocial assessment Imaging may not be terribly helpful Nerve conduction studies may not be terribly helpful Clinical medical records only describe a partial truth as the clinicians never have time or facility to access full records and invariably accept patient statements at face value.
  25. 25. Definition of Neuropathic Pain Neuropathic pain arises as a direct consequence of disease or injury affecting the somato-sensory system
  26. 26. Negative and Positive Signs in Neuropathic Pain Negative signs (impaired or lost neural activity) Numbness, lack of sensation Weakness Reduced function Clumsiness Loss of balance Confined to the territory(ies) supplied by the affected nerves or central sensory and motor pathways Positive signs (excessive neural activity) Increased sensitivity (touch becomes pain) Disproportionate pain from painful stimuli Pain continuing long after stimulus removed Discolouration of affected skin Trophic changes in affected area Extend outside the territory(ies) supplied by the affected nerves or central somatosensory pathways
  27. 27. Terms in Neuropathic Pain Hyperalgaesia Lowering of pain threshold and increased response to noxious stimuli Allodynia Evocation of pain by non noxious stimuli Hyperpathia Variant of hyperalgaesia & allodynia, explosive pain from cutaneous areas with increased sensory detection threshold Paroxsysms Shooting electrical pain occurring spontaneously or after stimualtion Paraesthesia Abnormal but non painful sensations (pins and needles) Dysasthesias Abnornormal and unpleasant sensations
  28. 28. Clinical Features of Neuropathic Pain – Herpes Zoster and Post-herpetic Neuralgia
  29. 29. CRPS Complex regional pain syndrome (CRPS) is a chronic pain condition. The key symptom of CRPS is continuous, intense pain out of proportion to the severity of the injury, which gets worse rather than better over time. CRPS most often affects one of the arms, legs, hands, or feet. Often the pain spreads to include the entire arm or leg. Typical features include dramatic changes in the color and temperature of the skin over the affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating, and swelling. We aren’t sure what causes CRPS. In some cases the sympathetic nervous system plays an important role in sustaining the pain. Another theory is that CRPS is caused by a triggering of the immune response, which leads to the characteristic inflammatory symptoms of redness, warmth, and swelling in the affected area. Some CRPS may be caused by a mismatch between the S1 and M1 cortex Lateral view of the brain
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  31. 31. Complex Regional Pain Syndrome
  32. 32. Theory of why MVT should work Lateral view of the brain Coronal View of sensory and motor cortices  Sensory cortex is a hard wired map of the body  Lies adjacent to motor cortex  Integrates with the motor cortex  Disruption of stimulation to S1 felt as “loss” by S1  Overgrowth of adjacent areas into areas of loss proposed as cause of phantom pain and now ? CRPS, ?? Stroke pain ??? Neuropathic limb pain  ??? Normalization of S1 activity leads to resolution of CRPS
  33. 33. Fibromyalgia - Introduction • Widespread chronic pain • Multiple symptoms • fatigue • sleep disturbance • cognitive dysfunction • depression • Associated disorders • IBS • Chronic fatigue • Irritable bladder • Interstitial cystitis • TMJ dysfunction
  34. 34. Fibromyalgia Epidemiology • Common • 4 women: 1 man • 1-8% of women • Age of onset 20-50 • 10-40% of new rheumatology referrals • Often co-existing diseases e.g. OA, SLE
  35. 35. • What its not • Somatisation • Mad women • Idiopathic • Functional • WHAT IT IS • Prototypical “CENTRAL PAIN SYNDROME” Fibromyalgia - What is it?
  36. 36. Fibromyalgia - History Remember Migraine Condition described for centuries 1904 Fibrositis - Sir William Gowers 1904 to 1977 Fibrositis = common cause muscular pain = Psychogenic Rheumatism 1977 Smythe & Moldofsky = Fibromyalgia 1981 Yunus reports other clinical manifestations 1990 ARC criteria (RESEARCH) 1992 onwards push towards central mechanism hypothesis driven by functional imaging techniques and general advances in central pain mechanisms
  37. 37. Fibromyalgia - Etiology • Genetics • Familial 8 fold increased risk in 1st degree relatives • Family members more sensitive to pain and more likely to have co-occurring pain disorders (IBS, TMD & headache) • Twin studies half risk genetic half risk environmental • Environmental Factors • Trauma (trunk) • Infection (parvovirus, EBV, Lymes Disease, Q fever) • Psychological Stress • Hormonal alterations • Drugs & Vaccines
  38. 38. Fibromyalgia - Stress Stressors Predisposition to adult pain syndromes following childhood trauma - sexual - physical - injury - disease Complex interplay between expectation, duration, frequency, locus of control, psychological coping capacity, social support, & expectation Sleep & Exercise 2007 Arnson “Physical exercise protective in ex- combatants with PTSD developing widespread pain disorders” Neuroendocrine HPA studies inconclusive to date
  39. 39. Randomly measured pain thresholds not influenced by levels of distress * Petzke 99 01 & 03 Fibro patients more sensitive to pressure stimuli* Petzke 99 01 & 03 Fibro patients not hypervigilant Fibro patient response to other modalities (heat, cold, electrical stimulation) same as control EXEPT noxious auditory Diffuse noxious inhibitory control attenuated or absent Fibromyalgia - Sensory Processing
  40. 40. Fibromyalgia - DNIC Diffuse noxious inhibitory control DNIC Mediated by descending opiodergic serotonergic- noradrenergic pathways In Fibro opiodergic activity normal or enhanced (thats why opioids may not be that effective) In Fibro patients serotonergic-noradrenergic activity reduced (thats why compounds that enhance this activity may work) In Fibro Substance P levels enhanced (substance P involved in windup) In Fibro Glutamate (excitatory neurotransmitter) increased
  41. 41. f-MRI • f-MRI functional magnetic resonance imaging
  42. 42. Lateral view of the brain Fibromyalgia - Functional Imaging • decreased rCBF caudate thalamus • increased in somatosensory cortex • longitudinal studies of amitriptyline shows normalisation of rCBF • Hypothesis that there is a left shift in the sensory settings or volume gain in brain sensory processing • role of other psychological factors assessed
  43. 43. Fibromyalgia - Sleep Juries out Sleep disturbance commonly seen Chicken or egg? Clinically correction of sleep disorders may not lead to improvements in core symptoms
  44. 44. Fibromyalgia - Behavioural & Psychological factors Lots of noise on this topic Incidence of Psychological disorders may be as high as 30 to 60% Early studies now thought to be flawed as conducted in tertiary centres which may have a biased patient group 3 patient groups low level anxiety depression normal cognition mild tenderness high depression more pain catastrophize and external locus of control (3ry care) low depression more pain no psychological or cognitive issues
  45. 45. Fibromyalgia - Diagnosis ARC criteria were designed for research Pain main feature waxes wans frequently migratory Associated symptoms fatigue, sleep difficulties, weakness, memory issues, hot / cold intolerance, morning stiffness, subjective swelling of the extremities. Functional disorders associated include chest pain, hear burn palpitations, IBS, dysmenorrhoea, endometriosis, interstitial cystitis, vulvodynia, prostatitis Exclude any inflammatory disorder
  46. 46. Fibromyalgia - Diagnosis
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  50. 50. Fibromyalgia - Drug Treatments • Strong evidence • Tricycilics amitriptyiline • Dual reuptake inhibitors duloxetine venlaflaxine milnacipran • alpha 2 ligands gabapentin pregablin • Modest evidence • Tramadol, SSRIs citalopram, dopamine agonists priamipexole, gamma- hydroxybutyrate • Weak evidence • Growth hormone, 5-HT, tropisetron, 5 adenosyl-l- methionine • Not effective • Opioids, steroids, benzodiazepines, melotonin, guanifensin, dehydroepiandosterone
  51. 51. Fibromyalgia -Non drug treatments • Cognitive behavioural therapy • CBT based pain management programs • Graded exercise programmes • have all been shown to be efficacious • sustained improvements in fibromyalgia at > 1yr shown for both CBT & exercise • Mindfullness
  52. 52. Chronic Lower Back Pain Psychology as important as Anatomy What you say to a patient REALLY matters Healthcare industry probably as harmful as it is helpful Large number of perverse incentives Reimbursement to treat not for the outcome
  53. 53. Back Pain Back Pain is some of where our taxes go Possibly 16.5 million suffers 3 to 7 million GP consults / yr 1.6 million OPD consults / yr 100,000 inpatients / yr 24,000 operations / yr NHS cost £481 million Non NHS health costs £197 million DSS £1.4 billion Lost production £3.8 billion Work Loss in UK from Back Pain 1955 1965 1975 1985 1992 0 10 20 30 40 50 60 70 80 90 Years Working days lost (millions)
  54. 54. Back Pain • History • Exam • Exclude red flags • Note yellow flags • Note signs of non organic pathology • Investigate • Rehabilitate
  55. 55. • Biomedical: • review diagnostic • triage nerve root problem • serious spinal pathology • ESR and plain X-ray • Psychological: • attitudes and beliefs about back pain • fear avoidance beliefs about activity and work • personal responsibility for pain and rehabilitation • psychological distress and depressive symptoms • illness behaviour • Social: • family attitudes and beliefs about the problem • reinforcement of disability behaviour • Work physical demands of jobjob satisfaction • other health problems causing time off or job loss • non-health problems causing time off or job loss
  56. 56. Risk factors for chronicity • Previous history of low back pain • Total work loss (due to low back pain) in past twelve months • Radiating leg pain • Reduced straight leg raising • Signs of nerve root involvement • Reduced trunk muscle strength and endurance • Poor physical fitness • Self-rated health poor • Heavy smoking • Psychological distress and depressive symptoms • Disproportionate illness behaviour • Low job satisfaction • Personal problems - alcohol, marital, financial • Adversarial medico-legal proceedings
  57. 57. Back or Leg Pain • Simple backache • Presentation between ages 20-55 • Lumbosacral region, buttocks and thighs • Pain "mechanical" in nature varies with physical activity varies with time • Patient well • Prognosis good • Nerve root pain • Unilateral leg pain worse than low back pain • Pain generally radiates to foot or toes • Numbness and paraesthesia in the same distribution • Nerve irritation signs reduced • SLR which reproduces leg pain • Motor, sensory or reflex change • limited to one nerve root • Prognosis reasonable • 50% recover from acute attack within six weeks
  58. 58. Attitudes and Beliefs about Pain Belief that pain is harmful or disabling resulting in fear-avoidance behaviour, eg, the development of guarding and fear of movement Belief that all pain must be abolished before attempting to return to work or normal activity Expectation of increased pain with activity or work, lack of ability to predict capability Catastrophising, thinking the worst, misinterpreting bodily symptoms Belief that pain is uncontrollable Passive attitude to rehabilitation
  59. 59. Behaviours Use of extended rest, disproportionate ‘downtime’ Reduced activity level with significant withdrawal from activities of daily living Irregular participation or poor compliance with physical exercise, tendency for activities to be in a ‘boom-bust’ cycle Avoidance of normal activity and progressive substitution of lifestyle away from productive activity Report of extremely high intensity of pain, eg, above 10, on a 0-10 Visual Analogue Scale Excessive reliance on use of aids or appliances Sleep quality reduced since onset of back pain High intake of alcohol or other substances (possibly as self-medication), with an increase since onset of back pain Smoking
  60. 60. Compensation Issues Lack of financial incentive to return to work Delay in accessing income support and treatment cost, disputes over eligibility History of claim/s due to other injuries or pain problems History of extended time off work due to injury or other pain problem (eg more than 12 weeks) History of previous back pain, with a previous claim/s and time off work Previous experience of ineffective case management (eg, absence of interest, perception of being treated punitively)
  61. 61. Emotions Fear of increased pain with activity or work Depression (especially long-term low mood), loss of sense of enjoyment More irritable than usual Anxiety about and heightened awareness of body sensations (includes sympathetic nervous system arousal) Feeling under stress and unable to maintain sense of control ll Presence of social anxiety or disinterest in social activity Feeling useless and not needed
  62. 62. Family Over-protective partner/spouse, emphasising fear of harm or encouraging catastrophising (usually well- intentioned) Solicitous behaviour from spouse (eg, taking over tasks) Socially punitive responses from spouse (eg, ignoring, expressing frustration) Extent to which family members support any attempt to return to work Lack of support person to talk to about problems
  63. 63. Work related issues History of manual work, notably from the following occupational groups: Fishing, forestry and farming workers Construction, including carpenters, builders and truck drivers, Nurses Disrupted Work history, including patterns of frequent job changes, experiencing stress at work, job dissatisfaction, poor relationships with peers or supervisors, lack of vocational direction Belief that work is harmful; that it will do damage or be dangerous Unsupportive or unhappy current work environment
  64. 64. Work related issues (continued) Low educational background, low socioeconomic status Job involves significant bio-mechanical demands, such as lifting, manual handling heavy items, extended sitting, extended standing, driving, vibration, maintenance of constrained or sustained postures, inflexible work schedule preventing appropriate break Job involves shift work or working unsociable hours Minimal availability of selected duties and graduated return to work pathways, with unsatisfactory implementation of these Negative experience of workplace management of back pain (eg, absence of a reporting system, discouragement to report, punitive response from supervisors and managers) Absence of interest from employer
  65. 65. Thank you 07958388881 0161 883 2728 @ilanlieb