Pain Management Through Non-PharmacologicalApproaches

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Pain Management Through Nonpharmacological Approaches

Objectives

• Participants will be able to:

– Compare the impacts of pharmacological and nonpharmacological pain management in older adults in post-acute episodes of recovery or chronic pain.

– Identify physical-therapy interventions for pain management supported by evidence and physical therapy guide to practice.

– Discuss patient-centered care plans demonstrating value and greater outcomes for older adults impaired by pain.

– Identify best practices for identification and management of pain in the Home Care Environment.

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CDC Guidelines for Pain

• Recommends nonopioidapproaches for chronic pain

• Encourages checking that nonopioid therapies have been attempted

• If opioids are prescribed, “start low and go slow.”

• Cancer tx, palliative care, end-of-life care and certain acute-care situations are cited as cases where opioid txmay be appropriate.

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Opioid Epidemic Statistics

• 2017: 17.4% of the U.S. population received one or more opioid prescription.

– Average person taking 3.4 prescriptions

• 2016: 48.5 million people in the U.S. or 18% of persons aged 12+ reported use of illicit drugs or misuse of prescription drugs in the past year.

– 11% of adults experience daily pain.

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Gender

Male: 14.8%

Female: 19.9%

Source:  2018 CDC Drug Surveillance Report

Age

• > 65: 26.8%

• 55-64: 26.3%

• 45-54: 23.1%

Source:  CDC 2018 Drug Surveillance Report

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Geography

Highest rates:

• Alabama – 107.2

• Arkansas – 105.4

• Tennessee – 94.4

• Mississippi – 92.9

• Louisiana – 89.5

Lowest rates:

• Washington, D.C. – 28.5

• Hawaii – 37.0

• New York – 37.8

• California – 39.5

• Massachusetts – 40.1

Source:  CDC 2018 Drug Surveillance Report

Deaths• 2016: 63,632 deaths due to drug

overdoses

• 66.4% were related to opioids

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American Physical Therapy Association

• #ChoosePT provides resources for patients and clients.

• Raises awareness about risks of opioids.

• Supports safe and effective physical therapy for pain management.

• Provides downloadable pain assessment to facilitate treatment conversations.

• MoveForwardPT.com/ChoosePT is another good resource.

Resource: APTA

Chronic Pain vs. Acute Pain

• Chronic pain

– Persistent

– Lasts longer than 3-6 months

• Acute pain

– Sudden onset

– Resolves when the underlying cause is resolved

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Characteristics of Chronic Pain

• Headaches

• Low back pain

• Cancer pain

• Arthritis pain

• Neurogenic pain

• Psychogenic pain

Symptoms of Pain

• Facial grimacing or frown

• Moaning, whimpering

• Restlessness and agitation

• Writhing or constant movement

• Appearing uneasy or tense

• Verbalizes pain sensation

• Elevated pulse or blood pressure

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How to Describe Pain

• Onset• Location• Duration• Course over time• Type of pain

– Burning– Aching– Sharp– Shooting– Nagging

• Aggravating factors• Alleviating factors

Best Practice

Listen closely to your patients and clients describing their pain to ensure they feel heard and to detect signs of depression or concerning behaviors.

Educate your patients and clients about the dangers of opioids.

Set realistic goals for pain and function based on the diagnosis.

Ask about past or present problems with substance abuse or addiction.

Ask if there is a family history of substance abuse or addiction.

Refer your patients and clients if you suspect a substance abuse or addiction problem.

Resource: APTA

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Alternatives to Opioids

• Exercise

• Manual Therapy

• Stress Management

• Video Resources/Stretching

• Neuromodulation

• Sleep Management

• Intensive Stimulation

• Graded Motor Imagery

• Guided Imagery

Risk Factors for Chronic Pain

• Disease history

• Cognitive and Psychological factors

• Beliefs

• Sedentary lifestyle

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Managing Pain in the Home

• Strategy and Persistence

• Understanding warning signals chronic pain creates

• Layered solutions – multiple options

• Use of Distractions

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Managing Pain

• Exercise– People who exercise regularly experience less pain. 1

Conditioning Strength Musculoskeletal imbalance

• Manual Therapy– Manual-therapy techniques are effective at reducing pain 2,3

Massage MFR Craniosacral Therapy Mobilization

Managing Pain

• Stress Management

– Stress reduction is effective in helping patients reduce pain. Methods that achieve stress reduction include:

Mindfulness

Relaxation

Visualization

• Video Resources and Stretching

– Kinesiology tapes

– Yoga

– Pilates

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Managing Pain

• Intensive Stimulation– Stimulating the Pacinian corpuscle pressure receptor with: Roller balls Trigger Point Therapy Foam rollers TENS

• Sleep Management– Evidence has shown that sleep deprivation can increase sensitivity levels and contribute

to increased stress and pain. 4 Ways to manage sleep include: Meditation Warm baths Exercise “Bed”/Pillow/mattress

Managing Pain

• Neuromodulation– The alteration of nerve activity through the targeted delivery of a stimulus: Electrical Chemical Pressure

• Graded Motor Imagery (GMI)– Brain Exercises Normalizing laterality Motor imagery Mirror therapy Sensory discrimination Sensory integration

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Managing Pain

• Guided Imagery

– Relaxation technique

– Focus on images

– Enlists all the senses

Plan of Care

• Frequency and duration considerations

• Goal establishment

• Documentation of skilled service

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Frequency and Duration

• How often does the patient need to be seen to mitigate pain?

• What is the patient’s history with pain-relief interventions?

• What is the patient’s health literacy?

• Does the patient have support in the home?

Goals and Interventions

• Goal examples:– Patient will demonstrate a decrease in pain to 2/10 through joint-protection techniques to

improve quality of life and ADL performance.– Patient will perform self-guided imagery at least 2 times when pain is self-assessed at

>5/10 with good results.• Intervention examples:

– Heat application for pain management– Infrared therapy for pain management– Joint-protection strategies– Pain management, instruction and education– Soft-tissue mobilization – Ultrasound for pain management– E-stim therapy for pain management

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Documentation of Skilled Services

• Documentation of why particular activities or therapeutic interventions were chosen

• What is progressed, modified or altered?

• Teach therapists to avoid a reiteration of patient ‘statistics’ and move toward documentation of what they are doing or thinking when interacting with the patient.

Example:

Patient demonstrated a decrease in pain to 2/10 through joint-protection techniques which improves the patient’s quality of life and ADL performance. The patient is now able to safely dress her lower body with no overt S/S of pain. OT performed skilled observation of the patient’s technique and provided cuing for technique mastery for transition to independence.

Organizations for Pain Advocacy

• Agency for Healthcare Research and Quality (AHRQ)

• American Chronic Pain Association (ACPA)

• Chronic Pain Research Alliance

• Live Support Group

• National Association of Drug Diversion Investigators (NADDI)

• Patient Mind Inc.

• Sports Injury Rehab Resources

• U.S. Pain Foundation

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Resources:

1. Holth, H.S., Werpen H.K.B., Zwart J-A, and Hagen, K. Physical inactivity is associated with chronic musculoskeletal complaints 11 years later: results from the Nord-Trøndelag Health Study. BMC Musculoskeletal Disorders 2008; 9:159. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2606680/. Accessed April 2, 2018. doi: 10.1186/1471-9-159.

2. Fernández-de-Las Peñas, C., Ortega-Santiago, R., de la Llave-Rincón, A.I., et al. Manual physical therapy versus surgery for carpal tunnel syndrome: a randomized parallel-group trial. The Journal of Pain. 2015; 16 (11):1087-94. https://www.ncbi.nlm.nih.gov/pubmed/26281946. Accessed April 2, 2018. doi: 10.1016/jpain.2015.07.012

3. Delitto, A., George, S.Z., Van Dillen, L., et al. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the OrthopaedicSection of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy 2012; 42(4): A1-57. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893951/. Accessed April 2, 2018. doi: 10.2519/jospt.2012.42.4.A1

Resources:

4. Finan, P.H., Goodin, B.R., and Smith, M.T. The association of sleep and pain: An update and a path forward. The Journal of Pain 2013; 14(12): 1539-1552. doi: 10.1016/j.pain.2013.08.007

5. Centers for Disease Control and Prevention 2018 Surveillance Report of Drug-Related Risks and Outcomes – United States, https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf

6. Forward, J.B., Greuter, N.E., Crisall, S.J., and Lester, H.F. Effect of Structured Touch and Guided Imagery for Pain and Anxiety in Elective Joint Replacement Patients--A Randomized Controlled Trial: M-TIJRP. Permanente Journal 2015; 19(4):18–28. doi:10.7812/TPP/14-236

7. American Physical Therapy Association, Opioid Epidemic, Advocating for Safe Approaches to Pain Management, 2019, www.apta.org/OpioidEpidemic/

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