powerpoint presentation · effective mx of the chronic non cancer pain (cncp) patient “that’s a...
TRANSCRIPT
2019-12-12
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The Efficient Ax &
Effective Mx of the Chronic Non Cancer Pain (CNCP) Patient
“That’s a Wrap”
Dr John F. Flannery, FRCP(C)
Faculty/Presenter Disclosure
Dr John F. Flannery
• Medical Director of the MSK and Multisystem Rehab Program
• Operation’s Lead of Project ECHO Chronic Pain and Opioid Stewardship
• Co-Director of Project ECHO Ontario Training
Relationships with commercial interests:
• None
The Final ECHO Presentation of the cycle
All the learning will lead to….GREAT Outcomes in your
travels
The potentially overwhelming sense of managing Chronic Disease Patients
The 20% of the practice that take 80% of the TIME!
Chronic Disease Principles Ed Wagner – Feb 2000 BMJ
People• Interprofessional Team
• Nursing, Pharmacy, PT, OT, SW, Psychology, Chirop, Trainers/PSW, Admin support
• Interspecialty Team and Consultants
• In clinical and educational roles (outside of conventional role)
Process• Critical elements:
• Population Mgt
• Protocol based regulations (e.g. guidelines)
• Self Mgt support
• Intense follow-up
CNCP = The Prototype for Chronic Disease mgt!
Goals:1. Primum Non Nocere – First do no harm!2. Help the Pt 3. Avoiding the Bad experience4. Try to stay at the “META” Level
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Today’s Journey
• Pain Context– Overview/Definition
• Assessment - Pearls and Approach
• Diagnosis
• Management Strategies
• Putting it All Together • Motivational Interviewing to get commitment of goals
• Collaboration – Patient and Team
• Communication Skills
Learning Objectives
Elicit at least 5 principles of Chronic Disease mgt
Recall the 5 key Pillars for a comprehensive pain assessment
Describe at least 5 management strategies
Recall the 5 common communication strategies
Recall the most important person in this equation
By the end of this session, participants will be able to:
Pain and Chronic Pain
“The friend that warns you or the enemy that destroys you”Dr. John Marshall (NeuroSx Queen’s Med School 1984)
“Friend” - Withdrawal response / avoid the use of the injured body part – FUNCTIONAL
“Enemy” - Pain that becomes counter-productive or debilitating – DYSFUNCTIONAL
The Context of Pain
• Confusing and complex field with multiple factors at play
• Not a static field : “Hit the moving target!”
• pain reports may change as a result of time or in response to Tx
• research is changing our ideas and concepts
• Many opinions - not all are based on understanding of the pain process
Definitions
“Neuropathic Pain”:
• A type of chronic pain mediated through nerve injury
• 3 cardinal symptoms present to variable degrees:
• Allodynia
• Radiation of pain
• Paroxysmal pain
“ADDOP” The 5 Pillars of Pain Mgt (Smith/Gordon)
• Assess: Symptoms and Risk
• Define the problem: where and what is it?
• Diagnose the kind of pain and treat it
• Other issues: mood, anxiety, sleep, addiction, sex
• Personal management, self management
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Pillar 1: Assessment “Horses are Common - Zebras Aren't!”
• General history –• for LBP -> “Core Back Tool” • NOTE: only about 2 - 3% of LBP in neurologic
• Neurological history
• Pain history• Identify the individuals with the greatest risk of aberrant behaviour NOT
to stigmatize, but to improve care• NB: Chronic pain and addiction can co-exist in a patient
Pillar 2: Define the Underlying Problem
• General and Neuro/MSK exam • Simon Carette – 3 min Back Exam
https://uhn.echoontario.ca/knowledge-base/the-3-minute-primary-care-low-back-examination/
• Dr. Don Miettinen – “ Don’t forget the Sensory Exam”
• Investigations “not fishing expeditions” • Recall - Caution Re MRI’s
• WHERE AND WHAT is the lesion?
• Applies to neurological conditions and non-neurological conditions
• Treating an underlying or coexisting disease often helps treat pain
Pillar 3: Diagnose- Nociceptive vs. Neuropathic
Nicholson BD (2003)
Pain
Nociceptive Normal stimulation of nociceptors
Neuropathic Abnormal nervous system activation
Somatic Visceral Central Peripheral
Pillar 4: Other Symptoms and Conditions
• Depression• Sleep• Anxiety• Fatigue• Sexual Function• Addiction
Pillar 5: Personal Responsibility and Self-Management
• WHO’s working harder ? – Reality check! • hold yourself and the patients accountable
• “TRUST” - Therapeutic alliance is key; it may be any team member
• “Master of Patience with patients” –• Why all the urgency ?
• Always Be respectful!
• Lack of prompt recovery we tend to repeatedly apply “medical model” – more consults, tests, drugs….
• Step wise approach – Gerald Flannery: “John - don’t be too smart by half”
• Other modalities – psychological and otherwise – are left out
Pillar 5: Personal Responsibility and Self-Management ctn’d
• “Interprofessional care model”• Clinicians need to practice it (not just talk about)
• Pt will often consciously or unconsciously try to split the team
• The “Refractory patient” • Lack of buy-in and self management is likely a key component
• “Proactive” management vs “Reactive”
• Establish realistic expectations
• “External Locus of Control” • Need to educate patient and family about pain mgt techniques
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The Clinical Exam*Watch the Video by Dr. Pam Squires on the ECHO Home Sitehttps://uhn.echoontario.ca/knowledge-base/physical-exam-for-dermatologic-pain-dr-squire-video/
Fundamentals:
• Good Eye Contact
• Aware and Acknowledge that the exam may be painful but very important to understanding the pain issues
• Observe prior to touching / examining
• Proper draping to enable efficient exam time
• Tools for the exam present and explain
The Flannery “KISS” MethodKeep it Simple, Stupid
• Determine if Pain is:
• Neuropathic Pain vs Nociceptive
• Determine if Pain is:
• Anatomical (Peripheral Nerve or Dermatomal)
Versus
• Non Anatomical (Wide Spread) sensory patterns• Non Dermatomal Sensory Deficits (NDSD)
• + (gain) or – (loss)
• Often “Quadratic” or “hemi body”
Physical Exam - Recall Pam Squires/ Simon Carette videos
Common and Challenging CNCP Diagnosis
• CLBP/Failed Back Syndromes – Core Back tools, min MRIs
• FMS – No opioids…Please!
• OA – Team work important ( Ortho, PT, Chirop, OT…)
• Complex Regional Pain Syndrome (CRPS) and Neuropathic pain Syndromes – Accurate Dx
• Headaches
• Myofascial (often pain superimposed on underlying issue) • Dr Janet Travel book, www.mytriggerpoint.net
• Opioid induced problems
Today’s Journey
• Pain Context– Overview/Definition
• Assessment - Pearls and Approach
• Diagnosis
• Management Strategies
• Putting it All Together • Motivational Interviewing to get commitment of goals
• Collaboration – Patient and Team
• Communication Skills
Management Strategies
All of these are Free! • Education, Education, Education…… Education! (Got it Yet?!)
• Communication of Diagnosis … You must commit to a Dx
• Goals Focused Behaviours – “Its All about YOU”/ SMART Goals
Sorry ….I lied – They do Cost = TIME! Yours and Theirs
Management Strategies (ctn’d)
• Drugs:• Opioid “trials” - after a good goal focused trial if it don’t work then stop!
• Non Opioids(Acetomin, NSAIDS, TCAs, anti-seizures, SSRIs, SNRIs, ….)
• Topicals
• Cannabinoids
• Interventions:• goal focused outcomes not just VAS
• Manage the comorbidities
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Before you make the decision to begin a treatment or intervention ….
… you have already screened and established that the patient is a good or ideal candidate for that treatment or intervention
It’s important for the patient to set goals so that you have an agreed upon objective way to measure functional progress
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What are the steps involved with “Effective Motivated Goals” ?
1.Engaging: The relational foundation
2.Focusing: Clarify directions: What is the horizon?
3.Evoking: The person’s own arguments for change
4.Planning: Developing commitment to change + formulating a plan of action
Miller and Rollnick, 2013
Engaging
Focusing
Evoking
Planning
The Technique to “Engagement”
Paddling your way through “Murky Waters” with “OARS”
• Open ended questions
• Affirmation
• Reflection
• Summarize
The Underlying Intention of
“Effective Goal Setting”
•Trust
•Rapport
•Collaboration
Collaboration with Patients and FamilyCollaboration with Team
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What is Self-Management?
“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition”(Barlow et al, 2002)
“Let’s work on your internal medicine cabinet”
You’ve suggested to your patient that the Self-Mgt or the Mindfulness might help
and THEY Say:• “I don’t like groups”
• “It won’t work for me”
• “I don’t have time”
• “I’ve tried everything, nothing works”
• “Doc, just give me my pills, that’s all I want”
• …..
1 more Reason “WHY WE NEED A TEAM”!
Patrice/Paul/Amy/Mandy/Lucy/Carlo/Pearl
HELP!!!!!!!!“What can you offer the Patient”
OT/PT/SW/Nursing /Psych …Roles Breaking down barriers
• Talk about their previous experiences with self management. • What education have they received/pursued?
• What strategies have they tried, and for how long?
• How did it go? What was the reaction? Was there something that really spoke to them?
• What informal strategies / approaches do they apply?
Today’s Journey
• Pain Context– Overview/Definition
• Assessment - Pearls and Approach
• Diagnosis
• Management Strategies
• Putting it All Together • Motivational Interviewing to get commitment of goals
• Collaboration – Patient and Team
• Communication Skills
The Goals of an Effective Hx and PxEncourage Open Dialogue
• Build Trust that you care Start with open ended questions
• The Px – we touch the patient Shows you care
• Have Clear Picture of Sx Direct closed ended questions
• Train your patient about what you are looking for
• Is the feeling - Present or Absent ?
• If present - Normal or Abnormal ?
• If abnormal - Increased or Decreased ?
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A patient-centered approach to a good interview with CNCPs
A patient centered approach
does not mean
a patient controlled interview
Crucial Conversation - SUMMARY
•Encourage Open Dialogue – “Heart and Head”1. From the heart
2. Watch and listen
3. Control emotions and thoughts
4. State your path listen to theirs
5. Action plan
Putting it ALL Together
• Education, Education, Education…… Education! (Got it Yet?!)
• Communication of Diagnosis … You must commit to a Dx
• Goals Focused Behaviours – “Its All about YOU”/ SMART Goals
• Therapy • Self mgt to Physical to Psych to Cognitive to Life Mgt/ Stress mgt/ CBT….
• Drugs• Opioid “trials” - after a good goal focused trial if it don’t work then stop! • Non Opioids(Acetomin, NSAIDS, TCAs, anti-seizures, SSRIs, SNRIs, ….) • Topicals• Cannabinoids
• Interventions
• Manage the Co-morbidities
AND ….Follow – Up!
Learning Objectives
Elicit at least 5 principles of Chronic Disease mgt People: Interprof’l and Interspec’y Teams; Process: Pop’n mgt; Guidelines; Self Mgt; Intense Follow-up
Recall the 5 key Pillars for a comprehensive pain assessment
(ADDOP)
Describe at least 5 management strategies
(Dx, Educ’n, Goals, Drugs, Interv’ns, Co-morb’y)
Recall the 5 common communication strategies
(“Heart and Head”)
By the end of this session, participants will be able to:
Flannery Principles in CNCP
People
• Create a GREAT Interprofessional Team
• Trust yourself
• Build Trust with your patient BUT never forget “Humans are Humans”!
• “Master of Patience with patients”
Process• Start with SMART Goals
• Your are in it for the “Long Haul”/ the “Horizon is far off” = Start Small
• Keep pts accountable (Goals/ Behaviours) for their actions and then “Reset more Goals”
• The “Refractory patient” • Lack of buy-in and self management is likely a key
component
• Pt. Proactive management vs Reactive
• Realistic expectations
Discussion