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Understanding Pain : A Framework for care

Understanding Pain : A Framework for care. Maureen Allen MD CCFP(EM). Learning objectives. What is pain? What role does pain play? What are the different types of pain? Understanding Flare-ups How to get clients active who live with persistent pain. Case 1.

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Understanding Pain : A Framework for care

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  1. Understanding Pain : A Framework for care Maureen Allen MD CCFP(EM)

  2. Learning objectives What is pain? What role does pain play? What are the different types of pain? Understanding Flare-ups How to get clients active who live with persistent pain

  3. Case 1 59 year old female with stroke 6 months ago Pain right side of body, legs greater than arms Pain is burning, occasionally sharp Hurts to touch the skin on right side Investigations show stroke only Pain 8/10 but can increases to 15/10 at times

  4. Case 2 22 year old male with a spiral fracture of his right tibia from hockey injury 1 week ago Pain 5/10

  5. Case 3 94 year old male with end stage lung disease Severe chest pain related to the work of breathing He has refused all treatment He just want to be made comfortable

  6. What is pain? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Classification of Chronic Pain Task Force on Taxonomy. IASP Press 1994

  7. What is Pain? Alarm system Protective Essential for survival But…..Not all pain is the same Nor…..is all pain protective despite it’s severe nature

  8. Often described by its….. Transmission -Nociceptive -Neuropathic Etiology -illness -Injury -Surgery -Unknown Duration -Acute (0-6months) -Chronic (> 6 months)

  9. Subjective experience

  10. Influenced by many factors

  11. Types of Pain:Acute Tissue Muscle Bone Nociceptive Caused by an injury, illness, surgery or unknown cause Results in new pathology or progression of pre-existing disease (Fracture, Crohn’s disease etc.) Predictable Protective Gone by 6 months

  12. Types of Pain:Chronic “Persistent” Baseline pain 5/10 NEUROPATHIC Caused by an injury, illness, surgery or unknown cause Do not come back to a pain free baseline (>6 months) Pain severe but inaccurate and no longer protective Sensitization Lose the ability to filter and process input (Pain nerves never shut off) Chronic illness “Pain baseline” and “Flare-ups” important to know

  13. What do we mean by sensitization?

  14. What do we mean by filter and process?

  15. What do we mean by “Pain baseline” and “Flare-up” Pain Pain “baseline” is the daily average pain that the patient experiences : 2-9/10 Pain “Flare-up” is an increase in the patients pain baseline that can last hours to days Caused by activity (too much or too little), poor sleep and thoughts and feelings Come back to their pain baseline never 0/10 Repeat flare-ups can lead to a Pain spiral

  16. Pain spiral

  17. Activity Pushing through not good for persistent pain Brain still wants to protect the patient “Pacing” Goal is to find an activity they like so they’re motivated to do it Realistic target (distance or time) that they can do on a good day and bad day Plan progression (every 4 days by 10%)

  18. Sleep Bedroom is for sleep an intimacy only No screens: They can make the bedroom a wakeful space Our body and immune system needs to recharge

  19. Thoughts and feelings Brown Brene. Ph.D., LMSW. Daring Greatly. Gotham Books. 2012. The brain can’t tell the difference between emotional pain and physical pain The chemistry is the same “Depression hurts”

  20. Pain scales : Good or bad? IT DEPENDS: What are we measuring? PAIN INTENSITY Describing pain in terms of intensity only is like describing music in terms of it’s loudness

  21. Complexity of Pain and Suffering PSYCHOLOGICAL PHYSICAL PAIN SOCIAL SPIRITUAL 15/10 pain=15/10 suffering

  22. Pacing Cannabinoids Topicals • Noble M, Treadwell JR, Tregear SJ et al. Long term opioid management for Chronic Non-Cancer Pain. Cochrane Database of Systemic • Reviews 2010, Issue 1. Art N.: CD006605. DOI: 10. 1002/14651 858. CD006605. Pub 2.

  23. Treatment goals We alter pain chemistry through pharmacology, and by how we think and feel.

  24. Pharmacological choices? • Sense of entitlement when opioids and Cannabis are requested that • can wear you down. • “Hyperemesis cannabinoid syndrome” Acetaminophen (Tylenol) NSAID’s (Advil, Aleve etc) TCA (Elavil) Anticonvulsants (Lyrica, Gabepentin) Broad spectrum antidepressants (Duloxetine, Effexor) Topicals Opioids (SA vrs LA) Cannabinoids (Smoke, drink or ingest) Maximum is <2 grams a day Lidocaine, Ketamine etc... • Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.

  25. If it only gets you through the day is it holding you back? 15 joints a day?! wtf? Permission granted Chronicle Herald Dec 2013

  26. Addiction Life threatening illness A chronic, life long, relapsing illness A patient with a past history will ALWAYS be at higher risk Neurobiological Can takes a life of it’s own 4 C’s Compulsive use Impaired control over drug use Continued use despite harm Craving

  27. Diversion • Diversion of prescription drugs involves the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace.

  28. Where to begin What type of pain are you dealing with If pain co-exists with addiction, addiction needs to be the priority in addressing care Treatment goals and functional goals different Validate that their suffering is real Multiple strategies needed Medication only one tool Pain self management group

  29. PACING How to get active when you live with persistent pain Needs to be an activity that the client wants to do Based on time or distance Understanding the client’s daily pain baseline Avoiding Flare-ups It’s NOT about getting fit or losing weight It’s about..... Neuroplasticity

  30. Re-booting or Retraining the pain system Neuroplasticity Plasticity of our CNS f MRI data Key to recovery is understanding pain flare-ups and what causes them

  31. Finding Joy and Happiness again

  32. The journey is the client’s You’re there to provide your expertise and to support them But….Not everyone is ready to embrace change Do not measure your success by pain reduction alone Look at your functional and ADL goals Understand what’s realistic with respect to time frame for recovery Nervous system need consistency and to feel safe with the activities

  33. Summary Pain is subjective Validate that the pain and suffering are real Recovery time and approach vary for every client Know what we bring to the table (Attitudes, judgement, stigma) Know what type of pain you’re treating Knowledge is power for you and the client

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