Download Johnny, are you in pain?

RTW for the Worker with Chronic Pain
Presentation to Rehabilitation Case Managers
Professor Milton Cohen
St Vincent’s Campus, Sydney and Faculty of Pain Medicine, ANZCA
9 May 2016
How to think about…
What to do about…
…the Worker with Chronic Pain
Courtesy of Prof Deborah Schofield
“Johnny, are you in pain?”
“No, Mummy. The pain is in me.”
The Advertiser, 1927
Quoted in The Lancet , 30 June 2012
“Your pain is the breaking of the shell
that encloses your understanding.”
Kahlil Gibran
“To have pain is to have certainty;
to hear about pain is to have doubt.”
Elaine Scarry, 1985
Themes
 Complex biology of pain
 Sociopsychobiomedicala
ssessment and
management
 “Treatment” of
person with) pain
Not a “broken part”
but a changed person
“The body”
is not the only thing
(the
Self-management
is the aim
PAI N
An unpleasant
sensory and emotional experience
associated with
actual or potential tissue damage
or described in terms of such damage
PAI N
An unpleasant
sensory and emotional experience
associated with
actual or potential tissue damage
or described in terms of such damage
What is “chronic” pain?
 Pain that persists after “natural healing”
OR
 Pain that persists without an obvious “cause”
Acute pain
Chronic pain
Altered nervous system
Active tissue damage
Changed person
Themes
Not a “broken part”
but a changed person
“The body”
is not the only thing
Self-management
is the aim
Complexity
Context
Containment
Themes
Not a “broken part”
but a changed person
“The body”
is not the only thing
Self-management
is the aim
Complexity
Context
Containment
Biomedical Model
PAIN
(nervous system)
DISEASE
Problems with Biomedical Model of Pain
 Implies hard-wired certainty
 Absence of nociception (“tissue damage”) defaults
to psychogenesis (“in the mind”)
 Excludes narrative of the sufferer
A problem
for clinicians and case managers
 Our clients believe that they can be “fixed”
 Not all our clients get better
 Our interactions have unpredictable effects
CNCP is a complex phenomenon
[Campbell et al, Pain 2015;156:231-242; NDARC, UNSW Australia]
N=1514, CNCP taking prescribed opioids for >6 weeks
 Low rates of employment/ income
 Multiple “pain conditions”, poor physical health
 ~30% abuse/neglect
 ~ 50% depression; ~25% anxiety; >40% suicidal ideation
 >30% concurrent BZD; >50% concurrent antidepressant
 1:8 cannabis use disorder; 1:3 alcohol use disorder
Socio
psycho
social
psycho
Bio
biomedical
ENVIRONMENT
PERSON
BRAIN
AND
NERVOUS
SYSTEM
BODY
ENVIRONMENT
PERSON
BRAIN
AND
NERVOUS
SYSTEM
BODY
What’s happening
in your world
(“socio-)
What’s happening
to you as a person
(-”psycho-”)
What’s happening
to your body
(-biomedical”)
DISTRESS
BELIEFS
CULTURE
DISABILITY
MEMORY
EDUCATION
NOCICEPTION
BLACK FLAGS
BLUE FLAGS
YELLOW FLAGS
ORANGE FLAGS
RED FLAGS
Tenderness
Allodynia
 Pain in response to a non-damaging stimulus
(touch, pressure, movement)
 Sensitisation of “pain-signalling” pathways
CENTRAL SENSITISATION OF
NOCICEPTION
“Switch-on” of “pain-signalling” pathways
in the central nervous system (spinal cord and brain)
 “Pain…might not necessarily reflect the presence of
a peripheral noxious stimulus.”
 “Pain could…become the equivalent of an illusory
perception…”
Woolf C. Pain 2011;152:S2-S15
CLINICAL FEATURES SUGGESTING
CENTRAL SENSITISATION
 Absence of obvious tissue damage or disease
 Sensitivity to touch or movement
 Worsening pain after repetitive use
SOME IMPLICATIONS
OF CENTRAL SENSITISATION
“Top-down” AND “bottom-up”
No language (yet)
Avoid chasing nociception in region of pain
Potential for perpetuation
Nervous system re-education
Themes
Not a “broken part”
but a changed person
“The body”
is not the only thing
Self-management
is the aim
Complexity
Context
Containment
ENVIRONMENT
PERSON
BRAIN
AND
NERVOUS
SYSTEM
BODY
What’s happening
in your world
(“socio-)
What’s happening
to you as a person
(-”psycho-”)
What’s happening
to your body
(-biomedical”)
BLACK FLAGS
BLUE FLAGS
ORANGE FLAGS
YELLOW FLAGS
RED FLAGS
Employer
Provider
Employee
experiencing
pain
Comcare
Our point of view as observers
does not allow us to know
what it is like to be
the system being observed
Adolphs & Damasio 1995
Risks – to the patient - of having chronic pain
 Challenge observers’ view of the world
 Reinforce clinicians’ uncertainty
 Fail to validate health professionals’ effectiveness
Marginalisation
Discrimination
Stigmatisation
Risks – to the clinician – of chronic pain
 View of the world challenged
 Uncertainty reinforced
 Effectiveness not validated
“Negempathy”
Conscious avoidance of compassion
Negative projection
CLINICAL/OFFICE ENCOUNTER
SOCIAL DETERMINANTS
L
A
N
G
U
A
G
E
CLINICAL/OFFICE ENCOUNTER
ILLNESS
BEHAVIOUR
EMPATHY
HONESTY
PSYCHOLOGICAL
DISTRESS
ATTITUDES
& BELIEFS
EXPERIENCE
TOLERANCE
PREJUDICE
HOSTILITY
SUSPICION
CLINICAL
BEHAVIOUR
AFFECT
ATTITUDES
& BELIEFS
KNOWLEDGE
REFRAMING THE ENCOUNTER
Shared expertise
Neurobiology
Empathy
Language
PLACEBO (CONTEXTUAL)
EFFECT(S)
Change(s) in illness
attributable not to a specific pharmacological or physiological
effect of a treatment
but rather to the sociocultural context
in which the treatment occurs
Employer
Provider
Employee
experiencing
pain
Comcare
Themes
Not a “broken part”
but a changed person
“The body”
is not the only thing
Self-management
is the aim
Complexity
Context
Containment
CLINICAL FRAMEWORK PRINCIPLES
1. Measure and demonstrate the effectiveness of treatment
2. Adopt a biopsychosocial approach
3. Empower the injured person to manage their injury
4. Implement goals focused on optimising function,
participation and return to work
5. Base treatment on the best available research evidence
Clinical Framework for the Delivery of Health Services
TAC and WorkSafe Victoria, June 2012
CLINICAL FRAMEWORK PRINCIPLES
- from a physician’s perspective 1.
Adopt a sociopsychobiomedical approach
2.
Implement goals focused on optimising function,
participation and return to work
3.
Empower the injured person to manage their injury
4.
Base treatment on the best available research evidence
5.
Measure and demonstrate the effectiveness of
management
Twin Goals
Rx
Injury
RTW
PRINCIPLES OF
THERAPY
AIMS
 Decrease pain as much as possible
 Increase function as much as possible
 Minimise adverse effects of treatment
MODALITIES
 Psychological
 Physical
 Pharmacological
 Procedural
PSYCHOTHERAPY
PHYSICAL
THERAPY
PHARMACOTHERAPY
PROCEDURES
“Treatment” of person with chronic pain
What’s happening
in your world
Relationships
Security
Work
What’s happening
to you as a person
Reframing
New learning
?Medications
What’s happening
to your body
Exploring the body
Movement
?Medications
?Procedures
Evidence:
“Everything works and nothing works”

Shoulder pain
“There is some evidence from methodologically weak trials to indicate that some
physiotherapy interventions are effective for some specific shoulder disorders.”
(Green et al. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.:
CD004258)

Low back pain
“In this systematic review, we present information relating to the effectiveness and
safety of the following interventions: acupuncture, analgesics, antidepressants,
back schools, behavioural therapy, electromyographic biofeedback, exercise,
injections (epidural corticosteroid injections, facet joint injections, local injections),
intensive multidisciplinary treatment programmes, lumbar supports, massage,
muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), non-surgical
interventional therapies (intradiscal electrothermal therapy, radiofrequency
denervation), spinal manipulative therapy, surgery, traction, and transcutaneous
electrical nerve stimulation (TENS).”
(Chou R. Clinical Evidence [Clin Evid (Online)] 2010 Oct 08)
What does good pain management
look like?
 Reframes the problem
 Recognises the context
 Respects the nervous system
Early detection?
•Symptoms persisting past “healing”
•New pathology
•Iatrogenic factors
ORANGE FLAGS
•Unhelpful beliefs about injury
•Poor coping strategies
•Passive role in recovery
BLUE FLAGS
•Threats to financial security
•Sense of injustice
•Litigation
RED FLAGS
•Mental health disorders
•Personality disorders
YELLOW FLAGS
•Low social support
•Unpleasant work
•Low job satisfaction
•Excessive work demands
•Problems outside of work
BLACK FLAGS
What can be done in the workplace?
YELLOW FLAGS
BLUE FLAGS
•Unhelpful beliefs about injury
•Low social support
•Poor coping strategies
•Unpleasant work
•Passive role in recovery
•Low job satisfaction
•Excessive work demands
•Problems outside of work
Fear avoidance
“A behavioural response to pain characterised by
a person excessively restricting involvement in
activities and exercises due to heightened fear or
anxiety about pain or re-injury (i.e. worry that any
pain could cause tissue damage).”
Clinical Framework for the Delivery of Health Services
TAC & WorkSafe Victoria
Fear avoidance
“A behavioural response to pain characterised by
a person excessively restricting involvement in
activities and exercises due to heightened
fear or anxiety about pain or re-injury (i.e.
worry that any pain could cause tissue
damage).”
Clinical Framework for the Delivery of Health Services
TAC & WorkSafe Victoria
What to ask treatment providers?
Do you know what’s happening
in your patient’s world?
Relationships
Security
Work
Do you know what’s happening
to your patient as a person?
Reframing
New learning
?Medications
What physical treatments
are you recommending?
Exploring the body
Movement
?Medications
?Procedures
What to ask treatment providers?
Do you know what’s happening
in your patient’s world?
Relationships
Work
Recreation
Do you know what’s happening
to your patient as a person?
Understanding
Mood
?Medications
What physical treatments
are you recommending?
Movement
?Medications
?Procedures
Summary
Complexity
Context
Containment
Not a “broken part”
but a changed person
•Socio-psychobiomedical
•Sensitisation
“The body”
is not the only thing
•“Flags”
•Interaction
Self-management
is the aim
•Evidenceassisted
•Beware the
hammer
Case 1: F43
 Ankle injury 2y ago: “sprained”
 Physio/hydro/benzodiazepine
 No RTW
 “Mild CRPS” diagnosed 4m later
 4w inpatient PMP:
pregabalin/nortriptyline/opioid/intrathecal
 Suicidal ideation 6m later
 5+w admission for (long-standing) depression:
drugs/psychotherapy/TMS/ECT
 Personality and interpersonal issues identified…
Case 1: analysis
•Biomedical focus (? diagnosis)
•Medicalisation:
drugs/procedures/hospital
•Late (or non-) recognition of
psychological issues
Sociopsychobiomedical
Biopsychosocial
•Trivial biomedical component
•Why no return to work?
•Delayed recognition of context
Case 2: F55
 Fell off chair 3y ago: “lumbar sprain”
 Massage/“physiotherapy”/heat/TENS
 Palexia/Lyrica/Maxigesic
 Requests for:
 “denervation” -? Repeat
 TENS
 massage
 “Adjustment reaction with depression”
 Antidepressant drugs/counselling
 “Pain management not helpful”
Case 2: analysis
•Somatic focus but no diagnosis
•More-of-the-same treatment
•Patient “struggles with emotional
component of pain”
•Why is this person so distressed?
•What else is happening?
•Yellow flags?
•Orange flags?
•Blue flags?
Biopsychosocial
Sociopsychobiomedical