The Emerging Role of Physiotherapists in Tertiary Care Chronic Pain Programs in Ontario: Challenges, Opportunities, and Next Steps

Gillian Grant, PT, MScPT Toronto Academic Pain Medicine Institute (TAPMI) Women’s College Hospital Toronto, Ontario Giulia Mesaroli, PT, MScPT Pediatric Chronic Pain Clinic The Hospital for Sick Children Toronto, Ontario Kyle Vader, PT, MScPT Adult Chronic Pain Clinic Kingston Health Sciences Centre-Hotel Dieu Hospital site Kingston, Ontario

Session Objectives

Learning Objectives: 1. Understand the current landscape of tertiary care chronic pain programs in Ontario

(paediatric and adult); 2. Understand the role of the physiotherapist within the interdisciplinary tertiary care chronic

pain programs; 3. Describe the challenges, opportunities, and next steps for physiotherapists in tertiary care

chronic pain programs in Ontario.

Classification of Chronic Pain

Classification of Chronic Secondary MSK Pain

Prevalence of Chronic Pain (Adults)

Chronic Pain Locations (Adults)

Impact of Chronic Pain

Cost of Chronic Pain

Pediatric Chronic Pain

● 1 in 4 children in Canada suffer from recurring or chronic pain ○ Most types of pain are more prevalent with

increased age and females ○ Psychosocial variables that affect the prevalence of

chronic pain include: anxiety, depression, lower socioeconomic status, parental factors (catastrophizing, low education)

● Gold standard for treatment = 3-P approach ● Most research studies examining interventions focus on

inpatient/day-treatment approach

Pain Type Prevalence

Headache 8-83%

Abdominal Pain 4-53%

Back Pain 14-24%

Musculoskeletal Pain 4-40%

Other 5-88%

Multiple pain locations 4-49%

Chronic Pain Initiatives in Ontario

Provincial Advisory Boards Paediatric and Adult Advisory Boards have been established in Ontario to develop a networked system with a common information registry and standard models of care (refer to appendices).

Project ECHO Project ECHO (Extension of Community Healthcare Outcomes) Ontario Chronic Pain connects primary care providers from across Ontario with each other and with interdisciplinary pain specialist teams via weekly video conferencing sessions. Sessions include didactic presentations related to pain care followed by case presentations by primary care providers.

Patient Engagement The provincial Chronic Pain Network is committed to ensuring that chronic pain services meet the diverse needs of people living with chronic pain. Patients are being integrated into all levels of committees from the provincial committee level to each individual chronic pain clinic.

Chronic Pain Initiatives in Ontario

Self Management Programs Local Health Integration Networks (LHINs) offer self management programs for people living with chronic conditions such as heart disease, stroke cancer, diabetes and chronic pain.

HQO Quality Standards Health Quality Ontario has developed three new quality standards related to opioids (Opioid Use Disorder, Opioid Prescribing for Chronic Pain, and Opioid Prescribing for Acute Pain). Quality standards are currently in development for Chronic Pain Management.

Pediatric Chronic Pain Network

Tertiary Care Chronic Pain Programs

● Unimodal treatment: the application of exercise treatment by a physiotherapist. ● Multimodal treatment: the use of pregabalin and opioids for pain control by a physician; the use of

NSAID and orthosis for pain control by a physician. ● Multidisciplinary treatment: the prescription of an anti-depressant by a physician alongside

exercise treatment from a physiotherapist, and cognitive behavioral treatment by a psychologist, all the professions working separately with their own therapeutic aim for the patient and not necessarily communicating with each other.

● Interdisciplinary treatment: the prescription of an anti-depressant by a physician alongside exercise treatment from a physiotherapist, and cognitive behavioral treatment by a psychologist, all working closely together with regular team meetings (face to face or online), agreement on diagnosis, therapeutic aims and plans for treatment and review.

Ontario Chronic Pain Programs

Adults:

Children & Adolescents:

Care Pathway - Adult

Referral from PCP Triage

- Urgency level - Provider or service - Site

Information Session or

Pain Education Workshop

And/Or

Specific Provider - Pain medicine - Physiotherapist - Pharmacist - Social Work - Nurse practitioner

Group Programming - Comprehensive self management

program (education, exercise, CBT skills)

- Exercise + education - Cognitive Behavioural Therapy - Mindfulness-Based Stress reduction - Pet therapy (coming soon!)

Team members: Psych, MD, RN/RPN, NP, OT, PT, PharmD, SW

Care Plan - Referral - Recommendations - Limited 1-on-1 follow-

ups - Opioid tapering support Next Steps

- Other Program - Support to PCP - Discharge w/

community resources

Care Pathway - Pediatric

Referral from PCP Triage

- Urgency level - Provider or service - Site

Information Session or

Pain Education Workshop

And

Interdisciplinary Assessment x 2 hours

- MD, PT, Psych, Nurse

Group Programming (Limited) - Exercise (Yoga,

Hydrotherapy) - Mindfulness-Based Stress

reduction - Research: Fibromyalgia

Integrative Training (Exercise + CBT)

Team members: Psych, MD, RN/RPN, NP, OT, PT, PharmD, SW, Psychiatrist

Care Plan - Referrals - Recommendations - Primarily 1-on-1

follow-ups incl. Videoconferencing

- Limited focus - Opioid tapering support

- School support - Family therapy and

parental training

Next Steps - Other Program - Support to PCP - Discharge w/

community resources

Day-Treatment Holland Bloorview

Get Up & Go

Patient Example - Adult

Diana - 56 year old female referred by GP ◼ 1.5 years persistent post-concussion/WAD symptoms and cervical & lumbar myofascial pain

from a fall when bus stopped suddenly ◼ Symptoms: headache, dizziness, trouble concentrating, photosensitivity, neck/shoulder pain,

widespread tenderness and numbness/tingling ◼ Imaging: CT & MRI - mild degenerative findings, incidental meningioma, neurological testing

normal ◼ Treatment history: ++ physio, chiro, massage. Lyrica, anti-depressant, 5 mg oxycodone ◼ Psychosocial: severe depression, social withdrawal, on LTD, relies completely on daughter

Patient Example - Adult

Management Plan ◼ Initial Physio consult & Psychological assessment ◼ 1 time OT consult for cognitive strategies, connect with brain injury rehab clinic ◼ Mindfulness program ◼ Neck/Upper Limb focused exercise program

◼ 7 week Physio-run group; pain education and supervised exercise) ◼ Small improvements on fear of movement & pain self-efficacy scales

◼ Highly motivated to join PainU (comprehensive self-management program) ◼ Eventual discharge back to family physician, recommendation & community resources

Patient Example – Pediatric

Alex, 14 year old female with chronic widespread pain x 18 mo after a virus ◼ Physical: withdrew from gym class and volleyball team “too painful, I’ll probably just injure

myself further” ◼ School: Gr 10, attends 4/5 days per week, sometimes arrives late or leaves early ◼ Sleep: takes 60-90 min to fall asleep, awakens 1-2 times per night ◼ Social: misses 4/10 social interactions, prefers to do quiet activities (watching movies) and

use social media ◼ Family: Dad has chronic low back pain, 2 younger siblings - 1 with autism

Patient Example – Pediatric

Management Plan ◼ Pain Neuroscience Education ◼ Pharmacological: Duloxetine ◼ Psychological: Psychological assessment, Dx Anxiety, Mindfulness group therapy (8-week) ◼ Physical: Graded exercise program, long term goal: participate in 75% of gym class and

obtain a credit! If she progresses well - refer back to PCP with community supports as needed If she continues to have moderate level of functional disability - referral to HBKRH Get Up and Go

Physiotherapy Role – Assessment & Treatments

Assessments Treatments Comprehensive physical assessments to diagnose the dominant pain mechanism

Pain Neuroscience Education

Communicating a diagnosis Graded Exercise Program

Fear of movement Activity Pacing

Hydrotherapy

Standardized tools: Graded Motor Imagery

-Brief Pain Inventory Group treatments - exercise and education based

-Tampa Scale Kinesiophobia Interdisciplinary Inpatient/Day-treatment

-Pain Catastrophizing Scale Incorporating Motivational Interviewing skills

-Pain Self-Efficacy Questionnaire Goal Setting

Challenges

Patient factors: Readiness for change or functional rehabilitation Complex medical and psychiatric co-morbidities

Beliefs about Physiotherapy: Focus on “hands on” treatment “I’ve tried Physio before, it didn’t work”

Program Factors Travel and availability during daytime is required, barrier for some patients

System factors: High volume of referrals, long wait list Limited OHIP funded community physiotherapy and mental health support (psychology,

psychiatry, etc) Limited 1-1 time for treatment - takes time to shift beliefs and change behaviours

Opportunities/Next Steps

Research Evaluation of existing PT interventions Advocacy Physiotherapy representation at the level of the MOHLTC Chronic Pain Network Improved access to PT in primary healthcare Expanded Scope Advanced practice roles for PTs? Technology/Innovation GuestLink/Videoconferencing (Telerehabilitation 1-1, Group Based Education)

Summary

Questions

Want to learn more about Chronic Pain? Have a patient with Chronic Pain and want to consult experts? Register for Project ECHO! https://www.echoontario.ca/

People need access to specialty care for their complex health conditions.

There aren't enough specialists to treat everyone who needs care, especially in rural and underserved communities.

ECHO trains primary care clinicians to provide specialty care services. This means more people can get the care they need.

Patients get the right care, in the right place, at the right time. This improves outcomes and reduces costs.

References

King, S., Chambers C.T., Huguet, A., MacNevin, R.C., McGrath, P.J., Parker, L., & MacDonald, A.J. (2011). The epidemiology of chronic pain in children and adolescents revisited: A systematic review. Pain, 152: 2729–2738. Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., ... & Giamberardino, M. A. (2019). Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the: International Classification of Diseases:(: ICD-11:). Pain, 160(1), 19-27. Fayaz, A., Croft, P., Langford, R. M., Donaldson, L. J., & Jones, G. T. (2016). Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ open, 6(6), e010364. Breivik, H., Collett, B.,Ventafridda, V., Cohen, R., & Gallacher, D. (2006). Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European journal of pain, 10(4), 287-333. Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., ... & Abraham, J. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet, 380(9859), 2163-2196.