experiences from a specialized regional clinic for
TRANSCRIPT
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Experiences from a
Specialized Regional Clinic for
Patients with Persistent Neck Pain and Disability after Trauma
Hans Westergren
M.D., Ph.D. Senior Consultant and Medical Director
Specialist in Neurosurgery, Rehabilitation Medicine and Algology
Department of Pain Rehabilitation, Skane University Hospital, Lund, Sweden
Regional Pain Center of Knowledge and Development
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The situation 10 years ago…
• Some patients were referred to us and treated…
• Many patients were ”hidden” in several clinics under several diagnoses
• Earlier treatment algorithms focused on physiotherapy (only)…
• Patient organizations recommending surgery…
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- So, in 2010 we said:
Send them to us!
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- So, in 2010 we said:
Send them to us!
…and there were no protests…
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The Skåne Region 1.2 million inhabitants
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General outline of treatment algorithm
Trauma
Eme
rgen
cy p
has
e
Recovery phase Chronic phase
Primary care Pain rehabilitation unit
3-6 months
Current condition
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General outline of treatment algorithm
Trauma
Eme
rgen
cy p
has
e
Recovery phase Chronic phase
Primary care Pain rehabilitation unit
3-6 months
Cross-section observation studies
Current condition
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Call center
Health care providers
Patients
Relatives
Lawyers
Approx 150 calls a year
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(F)riskfactors = Health factors
• Previously healthy
• Adequeate care in the emergency phase
• Good sleep
• Stable home and job situation with possibilties to recover
• Good body awareness
• Good response to treatment
• High self-efficacy
• Stable social/economic situation
• No problems in the insurance process
• Good coping mechanisms and knowledge about pain
• Etc…
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(F)riskfactors = Health factors
• Previously healthy
• Adequeate care in the emergency phase
• Good sleep
• Stable home and job situation with possibilties to recover
• Good body awareness
• Good response to treatment
• High self-efficacy
• Stable social/economic situation
• No problems in the insurance process
• Good coping mechanisms and knowledge about pain
• Etc…
- What about the other way round?
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Analysis • Questionnaires • Clinical assessment • Additional examinations
Individual treatment • Pharmachology • Physiotherapy (SMIL)
• Psychology
Rehabilitation • Mixed groups • CBT • ACT
Re-referral to Primary care
Patient flow in Pain Rehabilitation
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ICF- domains
Structure/ Function
Activity/ Participation
Environment and
Personal factors
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ICF- domains
Activity/ Participation
Environment and
Personal factors
Social
factors
CNS
reaction
s
Pain-
genera
tors
Psychol
ogical
factors
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Social
factors
CNS
reactions
Pain-
generators
Psychological
factors
Key-areas for assessment of complex persistent pain Department of Painrehabilitation , Lund, Sweden
Westergren et al Scand J Pain, 2014
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• Muscles
• Deep, stabilizing
• Global
• Joints
• Hypomobile
• Hypermobile
• Segments
• Nerves
• Rizopathy
• Myelopathy
• Plexus pain
• Coordination
• Sensitization
• Pain Distribution
• Local
• Regional
• Wide-spread
• Sleep
• Concentration
• Memory
• Dizziness
• Trigger-points
• Vegetative symptoms • Sadness
• Depression
• Worry
• Anxiety
• Catastrophizing
• PTSD
• Coping
• Self image
• Aimlessness
• Stress sensitivity
• Own demands
• Demands from others
• Relations
• Family situation
• Work situation
• Economy
• Insurances
Social
factors
CNS
reactions
Pain-
generators
Psychological
factors
Key-areas for assessment of complex persistent pain Department of Painrehabilitation , Lund, Sweden
Pain interference Activity
Participation Limitations
Westergren et al Scand J Pain, 2014
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The patients….
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Sex and age distribution of 1443 individuals recieving diagnosis ICD 10 – S13.4 During the year 2008. Jöud et al BMJ Open, 2013
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Sex and age distribution of 1443 individuals recieving diagnosis ICD 10 – S13.4 During the year 2008. Jöud et al BMJ Open, 2013
Sex and age distribution of 745 patients with persistent pain after neck trauma. 2010-14 Westergren et al Disability and Rehabilitation, 2017
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Number of patients referred and assessed
Westergren et al Disability and Rehabilitation, 2017
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Types of trauma
Type of trauma Males Females Total
Car crashes
In striking vehicle 69 125 194
In struck vehicle 139 223 362
N/A 6 20 26
582
Other neck trauma
Bicycle accidents 5 14 19
Motor-cycle crashes 5 0 5
Pedestrians 1 5 6
Miscellaneous vehicle accidents 1 9 10
Horse accidents 0 4 4
Sports-related accidents 7 15 22
Falls 13 31 44
Direct head or neck traumas 8 12 20
Assaults or scuffles 8 9 17
Miscellaneous (e.g. exertions,
heavy lifting) 7 9 16
163
Total 745 Westergren et al Disability and Rehabilitation, 2017
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Pain distribution
43%
48%
9%
29%
53%
18%
12% 50% 38%
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Pain distribution vs type of trauma
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Conclusions
• No sex distribution difference in initial trauma diagnosis
• Twice as many females with persistent pain after neck trauma
• Regional or wide-spread pain in allmost 90% of the patients
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Why?
• Higher female vulnerability for neck injury for anatomical reasons
• Higher prevalence for psychological distress in the female population
• Higher risk for females to develop sensitization
• Gender differences in social rolls giving women less opportunity for recovery
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Pain distribution…....and so what?
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• Pain distribution
• Activity
• Pain severity
• Health factors
• Number of reported pain sites
Versus
Clinical assessment Patient reported data
Persson et al in prep
MPI and SF-36
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Pain factors vs Psychological factors
• Pain distribution (clinical assessment)
• Pain interference (MPI)
• Pain severity (MPI)
• Depression (HAD)
• Anxiety (HAD)
• Acceptance (CPAQ)
Åkerblom et al in prep
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• Muscles
• Deep, stabilizing
• Global
• Joints
• Hypomobile
• Hypermobile
• Segments
• Nerves
• Rizopathy
• Myelopathy
• Coordination
• Sensitization
• Local
• Regional
• Wide-spread
• Sleep
• Concentration
• Memory
• Dizziness
• Trigger-points
• Vegetative symptoms
• Sadness
• Depression
• Worry
• Anxiety
• Catastrophizing
• PTSD
• Coping
• Self image
• Aimlessness
• Stress sensitivity
• Own demands
• Demands from others
• Relations
• Family situation
• Work situation
• Economy
• Insurances
Social
faktors
CNS
reaktions
Pain-
generators
Psychological
faktors
Key-areas for assessment of komplex persisting painDepartment of Painrehabilitation , Lund, Sweden
Pain experienceActivity
ParticipationLimitations
Westergren et al Scand J Pain, 2014
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Outcomes in Pain rehabilitation…
• Neck trauma patients lower activity than Fibromyalgia (without trauma)
• No difference in activity related outcome after Multiprofessional Rehabilitation
Persson et al PM&R 2011
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Conclusions
• 250 100 patients a year per million inhabitants
• Clear cut rules about responsibility for the patient care
• Defined ”care-chain”
• Multiprofessional team assessment
• Individual treatment options
• Pain rehabilitation
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Inglehart–Welzel cultural map of the world
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