pain: chronic syndrome · pain: it’s not all in your head chronic pain syndrome and management...
TRANSCRIPT
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Pain: It’s Not All In Your Head
Chronic Pain Syndromeand
Management
Jay Tracy, PA‐C, PsyD, LP
Courage Kenny Rehabilitation InstituteChronic Pain Program
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CHRONIC PAIN SYNDROME
When chronic pain negatively affects almost every area of functioning.
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• It’s Not All In Your Head
• The Tests Don’t Show Everything
• It’s All In Your Head
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Fundamental Attribution Error
(Actor‐Observer Bias)
In attribution theory, the fundamental attribution error (sometimes referred to as the actor‐observer bias) is the tendency for people to over‐emphasize
dispositional, or personality‐based, explanations for behaviors observed in others while under‐emphasizing the role and power of situational influences on the same behavior. In other words, people tend to have a default assumption that
what a person does is based more on what "kind" of person he is, rather than the social and environmental forces at work on that person.
An example is attributing a friend's recent car accident to the fact that the friend is a poor driver rather than to the fact that another car just happened to pull out
in front of her. The former would be a dispositional attribution; the latter a situational attribution.
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Cognitive Stereotypes
•Lazy
•Weak
•Unable to tolerate pain
• Irresponsible
•Fraudulent
•Seeking secondary gains
•Malingering
•Factitious
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Sympathetic and Central Nervous System Responses
• Fight, flight• Excessive anxiety, worry• Hyper‐alertness, hyper‐vigilance, restless, keyed up
• Muscle tightness, tension, irritability, on edge• Fatigue, poor sleep• Dilated pupils• Increased pulse rate, pounding heart, palpitations
• Increased blood pressure• Increased blood sugar• Decreased gastric acid production, but buildup
• Decreased gastric motility• Nausea and abdominal distress
• Increased adrenaline, epinephrine• Trembling or shaking• Sensations of shortness of breath or smothering
• Hyperventilation, feeling of choking• Feeling dizzy, unsteady, lightheaded, or faint• Paresthesias, numbness or tingling sensations• Sweating, chills or hot flashes • Difficulty concentrating, mind “going blank”• De‐realization and de‐personalization• Feeling of loss of control or sense of “going crazy”
• Fear of dying• Chest pain or discomfort• Hypersensitivity to various stimuli
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Muscle Pain
Tight
Tired
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Compartmentalization
SIMPLE (2+2=?)
VS
COMPLICATED (0.15625 +[(5/4+4/5)x 1.875]=?)
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Compartmentalization
• Medical • Physical • Psychological • Vocational • Other
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Compartmentalization
• Diagnosis
• Treatment
• Prognosis
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Compartmentalization
Medical Treatment “Fix it” model
vs
Rehabilitation model
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Compartmentalization
Medical Treatment, “Fix it” model
What the medical providers can do:SurgeriesInjectionsPhysical TherapiesMedications
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Compartmentalization
1. Make pain go away2. Lessen pain as much as possible3. Live better with what remains
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1 2 3 4 5 6 7 8 9 10Make pain Lessen it as Live bettergo away much as with what
possible remains
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Discordant Goals
010203040506070
Make paingo away
Lessen asmuch aspossible
Live betterwith whatremains
PatientsPhysicians
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Sensitivity
• Normal
• Abnormal
• Changeable
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PainDRG = dorsal root ganglionPAG = peri‐aqueductal grayVP = ventro‐posterior thalamus S1 = first somatosensory cortex
SufferingACC = anterior cingulate cortexAmyg = amygdalaHT = hypothalamusPF = prefrontal cortexPPC = posterior parietal complexSMA = supplementary motor areaInsula = social/emotional
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Compartmentalization
Acute _ Chronic____Protective Not protectiveTime IndefiniteRest Activity
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TIME
A C T I V I T Y
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TIME
A C T I V I T Y
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TIME
A C T I V I T Y
endurance
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TIME
A C T I V I T Y
endurance
frustration
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TIME
A C T I V I T Y
endurance
frustration
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TIME
A C T I V I T Y
EnduranceFrustration
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A C T I V I T Y
Endurance Frustration
TIME
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PAIN(Lack ofcontrol)
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PAIN(Lack ofcontrol)
Anger
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PAIN(Lack ofcontrol)
Anger
Depression
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PAIN(Lack ofcontrol)
Anger
Depression
Fatigue
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PAIN(Lack ofcontrol)
Anger
Depression
Fatigue
AlternativeStates
(like drugs oralcohol)
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PAIN(Lack ofcontrol)
Anger
Depression
Fatigue
AlternativeStates
(like drugs oralcohol)
Frustration, Blame,Worry, Inactivity,Guilt, Losses, Fear
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Types of Pain Programs: (see handout)
“Fix it” vs “Rehab”Comprehensive, multidisciplinary, intensive, i.e. 3 weeks…
Syndrome oriented…i.e. Minnesota Head and Neck
Modality oriented…i.e. interventions
Medications mainly
Other (i.e. partial programs)
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Management / Rehabilitation
Validation (factual and emotional levels)Normalization (other patients in group) Motivation (understand patient goals) Education (ongoing) Support (ongoing) Structure (ongoing)
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Two Prongs of Self‐Management: (see handout)
• Lifestyle changes which, when done over time, reduce the sensitization of the dysregulated nervous system.
• Increase abilities to cope with the pain that remains.
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Multidisciplinary
Team Approach
Active Co‐Management
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Identify Strengths
Build on Strengths
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No pain, no gain……….If it hurts, don’t do it.
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STATISTICS / OUTCOMES (78 patients 2015 who accessed Allina Health facilities) (see handout)
Opioids:56% of the patients came into the program on narcotics. 83% of these reported elimination or decrease in narcotic use upon completion of program
Mood/Psych:91% reported better mood (BDI‐2) upon completion of program72% reported better mood (BDI‐2) upon completion of aftercare (4 months)
Medical utilization: (12 months post‐program compared to 12 months pre‐program)ED: 54% decrease in total visits to EDHospital: 77% reduction in hospital admissions
Work: (of those not working when they came into the program compared to 4 months post‐program)33% were working, volunteering, or in active job search33% remained on disability insurance7% were retired27% remained unemployed
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Books:
• Pain: It’s Not All In Your Head; The Tests Don’t Show Everything, Tracy, CreateSpace Publishing, Amazon.com 2002, ISBN: 978-1467923439
• Pain: Nerves on Fire; Changing Neuropathic Pain, Tracy, CreateSpace Publishing, Amazon.com 2012, ISBN: 978-1466476073
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Contact Information:
Matthew Monsein, MD, Medical Director Murray McAllister, PsyD, LP, Program DirectorJay Tracy, PA-C, PsyD, LP
Courage Kenny Rehabilitation InstituteChronic Pain Rehabilitation Program 3915 Golden Valley Road Minneapolis, Minnesota, 55422
Telephone: 612-775-2606 Fax: 612-262-6720