Self Management of Chronic Pain Mackid Symposium 2016

Dr. Ted Findlay, Corinne Bryant, Debra McDougall, Erin McAdam

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Presenters: Dr.Ted Findlay, Corinne Bryant, Dr. Debra McDougall, Erin McAdam

No relationships with commercial interests:– Grants/Research Support: No– Speakers Bureau/Honoraria: No– Consulting Fees: No– Other: No

Disclosures

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Participants will:

1. Better understand chronic pain and the role of self-management in the care of patients with chronic pain.

2. Become familiar with a range of self-management strategies that enhance patients’ ability to cope with chronic pain.

3. Recognize the benefits of interdisciplinary team in the management of chronic pain and better understand the roles within the team.

Objectives

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• Define chronic pain and pain self-management.

• An overview of self-management strategies for patients living with chronic pain.

• The interdisciplinary team approach for working with patients with chronic pain.

• Describe the various roles within the CFPCN Extended Team• Physician, pharmacist, mental health consultant, nursing, physiotherapy, kinesiology, occupational therapy

Agenda

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Acute Pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described by such damage. (International Association for the Study of Pain)

Chronic Pain: lasting more than 3 months (or 6 months). - beyond the normal healing time for the underlying injury or disproportionate to such injury and lacking objective findings. (The Supreme Court of Canada)

--a complex bio-psycho-social experience.

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Chronic Pain

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from “Butler & Moseley: Explain Pain”

Acute versus Chronic Pain

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• The ability to monitor one’s condition and to effect the cognitive, behavioural, and emotional responses necessary to maintain a satisfactory quality of life. (Barlow, Wright, et al., 2002)

• Collaboration with providers

• More than patient education. Involves skill-development.

• Requires self-efficacy – the confidence to carry out a behavior necessary to reach a desired goals. (Bandura, 1997)

• A person’s readiness to take on self-management is affected by the degree to which they accept that their pain is chronic. (Gleason - National Fibromyalgia and Chronic Pain Association)

Pain Self Management

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Creating a Pain Self Management Toolkit

• Recognize stress / depression / anxiety

• Consume wisely

• Use medications appropriately

• Access support / ask for help

• Psychological shift ‘I can…’

• Set realistic goals

• Become informed

• Self-awareness through self-monitoring

• Optimize sleep

• Movement / activity

• Self-calming strategies

• Pacing

• Social & leisure connections

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You

Pain Specialty

Physiotherapy

Kinesiology

Occupational Therapy

Social Work

Mental Health

Nurse

Pharmacy

Nutrition

Family Physician

Health Care Team

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Multidisciplinary vs Interdisciplinary

• Multidisciplinary:

– Multiple Providers

– Multiple Skill Sets

– Silo’s

– Limited opportunities for interaction

– Authority may be limited to one or a few clinicians

• Interdisciplinary:

– Multiple Providers

– Multiple Skill Sets

– Co-Located

– Ample opportunity for formal and informal consultation

– Shared authority– Team case management

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Interdisciplinary Care

• Advantage

– Shared responsibility

– Shared authority

• Time and Team

– Required for complex patient care

• Disadvantage

– Shared responsibility

– Shared authority

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Communication

• Internal:

– Formal team rounds

– Informal team consults

• External:

– Referring Physician

– Other resources as needed

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• Listen to the patient’s story

• Diffuse tension/confusion from mixed messages

• Negotiate goals & monitor progress/”stuckness”

• Introduce language of self-management (reduce pain, improve function)

Provider Tool: Build Trust

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Provider Tool: Common Language

• Active listening & validate/normalize patients’ feelings• “Given what you’re dealing with I would be surprised if you didn’t feel overwhelmed”

• Communicate positive expectancy, but not false hope• “Improvement is possible, but it will require time and effort on both of our parts”

• Resist ‘why’ in favour of ‘what’ and ‘how’

• Consider readiness• Importance, willingness, confidence

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Role of the Pharmacist (CFPCN Model)

• Education Groups

• Case Management

• Team consults (rounds)

• Individual patient consults

• Medication management between physician consults

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Role of the Physician

• History

• Physical Examination

• Diagnostic Formulation

• Treatment Plan

• Communication

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History

• Review of:

– Referring information

– Patient questionnaires (BPI, PHQ-9, EQ5DL,etc)

– Team records including intake evaluation, group reports (explain pain lecture)

– Netcare: Consultations, lab, imaging

– PIN: prescription and OTC (acetaminophen/codeine)

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History

• Patient History

– Focus on signs/symptoms, not previously offered diagnoses

– Prioritize complaints

– Why now?

– Goals and expectations

– Red Flags

– Yellow Flags

– Functional Impact

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Physical Examination

• Can’t be skipped!

• To Skin!

• Commonly missed in chronic pain:– Back pain + leg pain = back pain + leg pain, not sciatica

– Joint above and Joint Below:• Shoulders• Hips

– Myofascial Pain vs Fibromyalgia Syndrome

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Diagnostic Formulation

• Anatomical and biomechanical diagnoses– Based on history and physical examination, not on findings of imaging

• Fibromyalgia Syndrome

• Myofascial Pain Syndromes

• Mental Health/Mood disorders

• Sleep Disorders/Apnea

• Medical co-morbidities

• Barriers to recovery: eg social, occupational

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Treatment Plan

• First: Do No Harm– Stop non-productive or harmful treatments/medications– Avoid inappropriate labeling (eg “degenerative changes”)

• Further investigation (should be rare)

• Referral when indicated (CPC Richmond Rd, orthopedics, neurology, rheumatology)

• Interventional considerations– http://www.ihe.ca/research-programs/hta/aagap/lbp

• Medications– Opioids: Evidence for short term use. ? Role in chronic condition. Functional goals.– Non-opioid

• Self Management

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Role of the Mental Health Consultant

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Recognizing & Responding to Stressors

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Role of Allied Health Team

• Intake

• Case management

• Patient education

• Provide referrals and/or resources – internal and external to program

• Emotional support – instill hope!

• Often, treatment to date has focused on reduction of pain to increase function, whereas our focus will be on increase function to help reduce pain THEY NEED TO GET THIS!

– If we can get a 10% improvement in function, we can get an overall reduction in pain

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Physiotherapy

• Understand the patient’s story– Previous injuries, diagnostics, relevant medical history, current lifestyle, medications

• Obtain/verify an accurate diagnosis– General screens, observe movement patterns, specific testing, palpation

• Restore function– Strength, ROM, injury prevention

• Patient education– Hurt versus harm, how to self manage on their own

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Physiotherapy: General Treatment

1. Posture!– Symptom reduction

2. Balanced stretching program – Restore ROM

3. Progressive strengthening – Address deficits

4 Education – Hurt vs. harm, treatment expectations, injured muscle tissue heals with scar tissue- not muscle

5. Local modalities – Help control pain and speed recovery (ultrasound, cold laser, TNS, IFC, heat)

6. Other procedures/intervention (ex. massage/acupuncture) – Can help speed recovery, reduce discomfort, and allow for more active based treatment.

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Kinesiology

• How is it different from physiotherapy?– No diagnosis, hands on treatment, or passive therapies

• Focus on lifestyle and an active approach to self management

• Counselling/education– Dispel myths re:activity/exercise– Hurt versus harm– Pain diary/tracking/journalling– Pacing– Flare up planning

• Activity and/or exercise prescription

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Activity & Exercise for Chronic Pain

• Starting point: 3-5 simple exercises - PACING– Affected areas– Establish tolerance – Bolster confidence, then improve pain/function– ROM, strength, proprioception/balance

• REVIEW exercises pts are doing at home – Often something goes wrong or is forgotten

• Activity is the meat and potatoes, passive therapy is the gravy– Correct improper movement patterns, and fix the small stuff – be very specific

• Confidence, medication, hurt vs. harm, stress management, sustainable changes, progression on their own, flare up plans....

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Occupational Therapy

• Works in tandem with other allied health disciplines, especially Physio and kin in a rehab model

• Lifestyle adaptation– Creating balance in daily life (work/self-care/leisure)– Prioritizing activities & pacing to support function– Establishing new habits to support function– Learning new skills to support function

• Adaptation of daily activities– Use of new methods/devices to complete activities – Re-engagement in valued activities

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Nursing

• Support for physician, pharmacy and other staff members

• Patient education, reinforce messaging to the patient from team– Diagnosis – Medications – Mental health – Diet– Exercise

• Connect patient with resources, address barriers – Food, housing, employment, etc

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Case Management

• Identify priorities and develop a treatment direction/goals

• Identify barriers / consult as needed

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Nice Info- But Does This Work??

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Comments From Extended Team Patients 2016

• “The pain remains but how I see myself in relation to my chronic pain has really improved a lot, and that makes a big difference in pain management and general well being”

• “I am ever so glad its there for people like me who really need it. I realize some folks "use the system" but I am grateful today for all the help. I was feeling VERY HOPELESS. I am now HOPEFUL. I would like to thank everyone at Crowfoot Crossing. I came away with so much more confidence and hope. The pain, when care for properly, has eased considerably. I now accept that I will never do what I used to. And that's ok!!! Thanks again everyone. I am a much better person because of all of you.”

• “I was heard, I felt accepted because I wasn’t alone in my frustration”

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• The management of chronic pain presents complexity and challenge to patients and their health care providers.

• Self-management brings patients into the centre of developing a treatment plan that helps them to enhance coping and improve function.

• An interdisciplinary team supports each patient as they build their own personal toolbox to manage their chronic pain.

Summary

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• Canadian Guideline for Safe & Effective Use of Opioids for Chronic Non-Cancer Pain http://nationalpaincentre.mcmaster.ca/opioid/

• Opioid Manager www.cpsnb.org/english/documents/OpioidManagerEnJuly2011.pdf

• Opioid Treatment Agreement http://www.rxfiles.ca/rxfiles/Search: opioid agreement Opioid Treatment Agreement (PDF)

• Opioid Conversion Table (need to register)www.hopweb.org/hop/hop.cfm?cfid=2126919&cftoken=96264839

Provider Resources: Opioids

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• 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome http://fmguidelines.ca/

Provider Resources: Fibromyalgia

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• Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance (www.cfpc.ca)

• New medical marijuana regulations: the coming storm CMAJ, September 2, 2014, 186(12)

• Medicinal cannabis: Time to lighten up? : CMAJ, September 2, 2014, 186(12)

• Standards of Practice: Marijuana for Medical Purposes (www.cpsa.ab.ca)

• Health Canada: How to Apply for Marijuana for Medical Purposes (www.hc-sc.gc.ca)

Provider Resources: Medical Marijuana