Understanding and Managing Chronic Pain: Current Issues Examined

1. CHRONIC PAIN: AN EXAMINATION OF CURRENT ISSUES Chairman – Nigel Spencer Ley 15TH JUNE 2017

2. Reflections upon the chronic pain experience Deceit, discrepancy and understanding the variable nature of human (dis)ability Dr Rajesh Munglani rajeshmunglani@gmail.com01223 479024

3. Diagnosis • 1.      Diagnoses:a.      Pain • Does it matter ? • CRPS • Chronic pain syndrome not ICD 10 perhaps ICD11

4. Thermographic imaging in CRPS A diagnosis of CRPS does not define Disability, capacity to work or care and assistance

5. I have pain: so what?

6. Even sporty people get pain…

7. Even sporty people get pain. • Even those in the military, who are again selected for being fit before one enters the military, showed that the incidence was 22% in 805 soldiers studied and the incidence of all low back pain was 77% (Roy, 2013). • Here we are talking about the onset of back pain in simply one year.

8. It isn’t pain that disables you….

9. So tell me what you can do? • Even normal people have good days and bads

11. Diurnal variation in pain stiffness and fatigue in FMS Pain Stiffness High pain Fatigue

12. Organic vs. Psychological: • a.      does pain result from an underlying organic problem or psychologicaloverlay, or is it always a combination of the two?b.      is it helpful to attempt to make the distinction between organic andpsychological problems in an individual patient?c.      does the distinction affect treatment and prognosis?

13. “psychosocial factors influence the course and outcome of every illness” Meyer (1866-1950)

14. For the thing which I greatly feared is come upon me, and that which I was afraid of is come unto me. Job 3:25

15. Can we measure fear of movement? • Epidemiology and Economics • There are no exact numbers on the prevalence of clinical fear of pain, because establishing a cut-off point for “clinical levels” of fear of pain is difficult. • Fear of pain is adaptive: it prevents us from doing potentially harmful activities and is helpful in learning to avoid harmful activities. • It becomes dysfunctional when the fear is in excess of the actual risk of harm or injury

16. Tampa scale • NB this is not a psychiatric diagnosis • Usually easily treatable

21. Vulnerability: • 3.      Claimants with pain problems often have a history of presenting with unexplained physical problems. • Is it possible to determine with any confidence what level of disability such Claimants would have developed in the absence of the accident? e.g. can one say that a claimant with a history of somatisation was going to develop a condition such as fibromyalgia or chronic pain syndrome in any event?

24. 2000 patients free of CWP followed for 4 years • 6 physically traumatic events: RTAs, workplace • injury, surgery, fracture, hospitalization (for any reason • other than the above) and, in women, childbirth.

25. CWP is preceded by trauma but presence is accounted for by pre-existing psychogenic factors Nb CWP in control group 10% v 15% or so in trauma group over 4 years

26. CWP in Manchester • Results. • The point prevalence of Manchester-defined chronic widespread pain was 4.7%. CWP(M) was associated with • psychological disturbance [risk ratio (RR) = 2.2], • fatigue [RR= 3.8,], • low levels of self-care [RR= 2.2] • The reporting of other somatic symptoms[RR= 2.0]. Hypochondriacal beliefs and a preoccupation with bodily symptoms were also associated with the presence of CWP(M).

27. Prospective study • Over 15 months 10% developed CWP in absence of trauma • SF12 was useful marker

29. What about diagnosis of type of low back pain? Type of injury Response to injections? Facet joints Controversially one could say No bio factors required to be considered in the Biopsychosocial model

30. Prognosis for FM/CWP? Initially 1990 214 women with self reported pain 21% with non chronic (recurrent) pain, 32% with chronic regional pain 20% with chronic multisite pain 27% chronic widespread pain (CWP -2/3rds fulfill for FM) 5 years later 75% still had symptoms

31. Expectation

33. Its all over in the first 3 weeks…

37. Disability: • 4.     what extent does/should pain impact upon someone'sability to function:a.      should someone with chronic pain be expected to return to work in circumstances where doing so cannot be demonstrated to cause any damage andmay be of psychological benefit?b.      does the provision of care helps or hinders functional independence? • 5.      Treatment:a.      what treatments are available?b.      what works and what does not?c.      is continuing litigation a bar to effective treatment?

38. What really determines outcomes ?

41. Whiplash trauma – a social decline for some Our results show that experiencing whiplash trauma and developing persistent symptoms can be a social decline for some. • In Denmark, it is not possible to receive sickness benefit for more than 1-2 years after which you are transferred to perma-nent health-related benefit or social assistance if you are still sick. Leth-Petersen et al. showed that 5 years after the accident, 16% of the patient group still had lower employment propensity than controls in the general population

42. Secondary Gain • Secondary gain is considered a significant risk factor for chronic pain and disability. This may be a variety of levels including social, work, family and financial gain. • A variety of conditions including pain lend themselves to reporting symptoms to achieve secondary gain. • Estimates vary considerably; however, this is not a rare phenomena and should be considered when evaluating an individual for disability or certain treatment approaches including opioids • (Dworkin, 2007 [Moderate Quality Evidence]).

43. Credibility: • does surveillance help? • what are your red flags?

44. Symptom Magnification • Symptom Magnification refers to the conscious or sub-conscious tendency of an individual to under-rate his or her abilities and/or over-state his or her limitations. • Symptom magnification is measured through assessment of observed functional performance, as compared to a subjective reports of the limitations caused by his or her symptoms. It does not imply intent • (Barber)

45. Malingering • Malingering is a medical term that refers to fabricating or exaggerating the symptoms of mental or physical disorders for a variety of "secondary gain" motives, which may include financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply to attract attention or sympathy.

46. Malingering • Treating health providers often do not consider malingering, even in cases of delayed recovery involving work injuries or other personal injuries, where there may be a significant incentive to feign or embellish symptoms or delay recovery” (Aronoff et al, 2007). • “The term malingering, as a description of behavior or as a diagnosis, usually is considered highly pejorative and controversial. Clinicians may be reluctant to address this behavior directly, even if there is strong evidence, because they are afraid of the consequences (e.g., mislabeling someone, being threatened, or being sued) [Binder & Iverson, 2000].

47. Detection of Malingering • Complaints grossly in excess of clinical findings • Bizarre, absurd, inconsistent symptoms • Atypical fluctuation in symptoms in response to external incentives • Unusual response to treatment that cannot be otherwise explained (e.g., paradoxical response to medication) • Markedly discrepant capacity for work vs. recreation • Substantial noncompliance with evaluation or treatment • Compliance only with passive versus active treatment • Refusal to undergo invasive testing or treatment, regardless of potential benefit • Special Signs/Tests

48. Why there may be discrepancy?

49. Is malingering common?