Managing patients with chronic pain

1. Managing patients with chronic pain Dr Lorraine de Gray Lead Consultant in Pain Medicine, QEH Chair, UK Regional Advisors in Pain Medicine, Faculty of Pain medicine, Royal College of Anaesthetists

2. Back pain - a slippery slope

3. Case scenario 1 • IE is a 55 year old male who presents with a four month history of intractable low lumbar back pain. • He is struggling to work (accounts clerk) • He has tried over the counter analgesics • His wife has made him come and see you • What questions would you ask?

4. Useful to know: • Type of pain • Radiation? • Referral? • Weight loss? • What makes it better? • Sitting, standing, walking? • Any bladder symptoms • Any other relevant clinical symptoms? • Any relevant past medical history • Any relevant past medical history • Smoker?

5. Influences on the pain experience Age Fears Gender Pain Education and understanding Culture Previous pain experience (self/family)

6. Examination • Paraspinal spasm low lumbar bilaterally • Pain worse on extending the spine • Lower limbs normal power, sensation, reflexes • Positive straight leg raise at 60 degrees bilaterally • Looks well otherwise • Outcome measures • Oswestry • Roland Morris • PHQ 9 • HADS

7. What do you do?

8. What do you do? • Reassure • Simple analgesics, NSAIDS +/- muscle relaxant • Heat • Physiotherapy/Manual therapy via back pain pathway • Review in four weeks

9. Four weeks later • No better • Off work • “Physiotherapy made me worse” • His wife comes with him and says you have to sort him out. • What do you do?

12. RED FLAGS • Gross neurology • Sphincter disturbance • Saddle anaesthesia • Up going planters • Weight loss • History of malignancy • Recent significant trauma • Severe thoracic back pain • Severe bilateral leg pain • Spinal deformity • Severe constant night pain • Gait disturbance • Fever or night sweats

13. YELLOW FLAGS Personal • Fear avoidance • Pessimism depression, expressed stress, anger and sometimes sleeplessness • Illness behaviour and adoption of the sick role • Passivity (external locus of control) • Helplessness • Tendency to see pain in a catastrophic light • Family: beliefs, expectations, reinforcement • Work: job satisfaction, difficulty working with pain, flexibility of employer, work options • Non-health problems (financial, marriage?) • Mobility and function • Hobbies and pleasures. Restrictions

14. Pain clinic • Undiagnosed back pain • Likely mechanical • Need to exclude sinister underlying cause • Need to help patient understand why he has pain • Take history • Examine • What do I do?

15. Best tool

16. Why Does The Patient Hurt?

17. Blood tests • Full blood count • Bone profile • PSA • Serum protein electrophoresis – Bence Jones proteins • CRP • ESR

18. Imaging?? • MRI scan or REASSUROgram • Any point in doing a lumbar spine X-ray?

21. Chronic Acute Invalidism Sick leave Avoidance ThePainLadder Depression Weiser, 1997-1999), Main 2000 Helplessness Failed treatment Anger &blame Catastrophising Uncertainty & fear

22. Objectives of Chronic Pain Management • Alleviate pain • Alleviate psychological and behavioural dysfunction • Reduce disability and restore function • Rationalize usage of medicines • Reduction of utilization of health care services • Attention to social, family and occupational issues

23. Management plan • Explain, explain and explain again • Look at medication – is it nociceptive, neuropathic or mixed pain • Practical pain management advice • ?Intervention – role of facet joint injections • Back programme • Support Back to work, ergonomics, employment support

24. Lumbar facet joint injections

26. To intervene or not to intervene? • Spinal injections are simply a way of giving patients a window of pain relief. They are not a long term fix. Even a successful denervation will not last more than eighteen months as a procedure in its own right. • Patients need multidisciplinary input aimed at improving their pain management skills • Pain Management Advice seminars • Back Programme • Individual physiotherapy (including hydrotherapy) • Individual psychotherapy

27. Suggested reading • Back Pain Revolution: Gordon Waddell 2004 2nd edition • British Medical Journal – EDITORIAL Red flags for back pain BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f7432 (Published 12 December 2013) • NICE guidelines – CG 88 (2009)

28. Widespread body pain chronic fatigue syndrome

29. CASE PRESENTATION • 33 year old woman • Five year history of widespread body pain • Chronic headaches, irritable bowel, irritable bladder • Low mood • Constant fatigue, can’t do anything, can’t concentrate, can’t sleep • Joints feel swollen, non dermatomal upper and lower limb pain • Tried a variety of analgesics and anti-depressants – none help • Unable to cope at home, two small children, partner unsympathetic

32. Differential diagnosis • Inflammatory arthropathy • Polymyalgia rheumatica • Somatiform disorder/primary mental health problem • Hypothyroidism • Lyme’s disease

33. Major challenges • Lack of trust in the medical system • Multitude of symptoms • Yellow flags • Keep an open mind • Manage in a holistic way • Engage multidisciplinary pain management • Neuropathic medication • Physiotherapy to improve level of function • Psychology: group, individual • Occupational therapy • Complementary therapy – TENS, acupuncture • Where appropriate involve mental health services • Fibromyalgia Support groups

36. Suggested Reading • Arnold LM, Sarzi-Puttini P, Arsenault P, et al. Efficacy and safety of Pregabalin in patients with fibromyalgia and co-morbid depression receiving concurrent antidepressant therapy: a randomized, 2-way crossover, double-blind, placebo-controlled study [abstract L6]. Presented at: American College of Rheumatology (ACR) 2013 Annual Meeting; October 29, 2013; San Diego, California. Available at https://ww2.rheumatology.org/apps/MyAnnualMeeting/Abstract/39039. Accessed November 11, 2013 • Yunus MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum. Jun 2007;36(6):339-56. [Medline]. • Gracely RH, Petzke F, Wolf JM, Clauw DJ. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum. May 2002;46(5):1333-43. [Medline]. • Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). May 2010;62(5):600-10. [Medline]. • Crombez G, Eccleston C, Van den Broeck A, et al. Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain. Clin J Pain. Mar-Apr 2004;20(2):98-102. [Medline].

37. Neuropathic pain ?causeSpeed is of the essence

38. Clinical presentation • 35 year old female otherwise healthy • Trapped her left index finger in a door a two weeks ago. At the time, finger bruised, treated with cold compress, and simple analgesics • She comes to see you, complaining of severe pain in her left finger and hand. The pain is burning in nature and keeping her awake • What do you ask?

39. Clinical scenario

46. Complex Regional Pain Syndrome • CRPS type I requirements feature causation by an initiating noxious event, such as a crush or soft tissue injury; or by immobilization, such as a tight cast or frozen shoulder. • CRPS type II is characterized by the presence of a defined nerve injury. • Both types demonstrate continuing pain, allodynia, or hyperalgesia that is usually disproportionate to the inciting event.

47. IASP revised criteria for CRPS • Continuing pain that is disproportionate to any inciting event • At least 1 symptom reported in at least 3 of the following categories: • Sensory: Hyperesthesia or allodynia • Vasomotor: Temperature asymmetry, skin colour changes, skin colour asymmetry • Sudomotor/oedema: Oedema, sweating changes, or sweating asymmetry • Motor/trophic: Decreased range of motion, motor dysfunction (eg, weakness, tremor, dystonia), or trophic changes (eg, hair, nail, skin)

48. IASP revised criteria for CRPS • At least 1 sign at time of evaluation in at least 2 of the following categories: • Sensory: Evidence of hyperalgesia (to pinprick), allodynia (to light touch, temperature sensation, deep somatic pressure, or joint movement) • Vasomotor: Evidence of temperature asymmetry (>1°C), skin colour changes or asymmetry • Sudomotor/oedema: Evidence of oedema, sweating changes, or sweating asymmetry • Motor/trophic: Evidence of decreased range of motion, motor dysfunction (eg, weakness, tremor, dystonia), or trophic changes (eg, hair, nail, skin) • No other diagnosis better explaining the signs and symptoms

49. Course of CRPS • The severity rather than the aetiology seems to determine the disease course. • Age, sex and affected side are not associated with the outcome . • Fractures may be associated with a higher resolution rate (91%) than sprain (78%) or other inciting event (55%) . • A low skin temperature at the onset of the disease may predict an unfavourable course and outcome • A retrospective analysis of 1006 CRPS cases, mostly female, and younger patients with CRPS of the lower limb showed an incidence of severe complications in about 7%, such as infection, ulceration, chronic oedema, dystonia and/or myoclonus

50. Recurrence of CRPS • In 1183 patients (Veldman et al) the incidence of recurrence was 1.8% per year. • The patients with a recurrent CRPS were significantly younger but did not differ in gender or primary localization. The recurrence of CRPS presents more often with few symptoms and signs and spontaneous onset.