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Persistent Pain - Pre professional development (terminology (somatic pain:…
Persistent Pain - Pre professional development
theories/physiological mechanisms
past experiences play a significant role in persistent pain
Mental health can exacerbate persistent pain
Patient education essential for reducing persistent pain levels.
MDT approach has best evidence for successfully improving patient pain levels
focus on improving function rather than improving pain levels
Reduced emphasis on medical model including scans/tests
focus on return to normal movement patterns rather than specific physiotherapy exercises for isolated muscle groups
= fear reduction
Mindfulness/Meditation/Thai Chi extremely beneficial due to mental health component
terminology
somatic pain: musculoskeletal pain
neuropathic pain: pain related to nerve injury
persistent pain: pain for longer than 3 months
Referred pain: Can be neural or not. Can sometimes be the brain localising incorrectly.
hypersensitivity: extreme sensitivty to any stimuli
allodynia: increased sensitivity to touch
Wind-up: CNS becomes involved and overly sensitised. Increases pain levels
nociception
modulation: all afferent pain signals processed and modulated in various areas of the brain
Persistent Pain programs/set guidelines
Block therapy shown to have the most effect for patients and most economical effect for health services.
Individualised assessment and exercise prescription
Group therapy completion
Group education classes
Individualised assessment and treatment for severe cases
telehealth an emerging mode of block therapy. No specific evidence yet
8 - 12 week programs effective. 1 - 2 sessions per week
Psychologist Input Essential.
discussion of past experiences
midnfulness
mental health diagnoses and management in persistent pain setting
Persistent pain conditions/assessment/management
management
specific handouts provided each session
time for questions at start of every session relating to previously provided education handouts
specific goal setting
alignment of expectations
graded generalised movement - normalising movement
hydrotherapy
gait correction
exercise diary
low resistance, gradually higher repetition
exercise prescription coordinated with education/handouts
Referral to other allied health disciplines
Referral to medical (inc tertiary persistent pain facility) for nerve blocks/medication optimisation
gentle core activation
low impact recreational exercise return
Referral to reboot program for maintanence
assessment
subjective examination
history
symptoms (pain pattern)
medications
medical/allied health intervention to date
SocHx
MedHx
pain beliefs and knowledge base
red flags
yellow flags
black flags
pain questionnaires
Objective Examination - graded over multiple sessions to reduce irritability
thorough examination of core muscle condition
gentle standard assessment features based on S/E.
thorough examination of posture and gait
AROM
MMT
palpation
biofeedback unit Ax
proprioception
neural examination
red flags
sensitivity
hyperalgesia
allodynia
Conditions
persistent pain - traumatic
Less focus on physical labels, scan results, medical intervention
Extensive education Re pain rather than the physiological mechanisms of the injury
psychological referral
ankylosing spondylitis
inflammatory rheumatological condition
usually first noticed in 20'. More common in men than women
inflammatory pain pattern - worst in early AM
physiotherapy effective (Manual therapy and exercise prescription
advice and education VERY important
diagnosis: x-ray to assess SIJs, rheumatological blood tests
persistent pain - non-traumatic
Psychologist referral
Standard MDT treatment - focus on education
complex regional pain syndrome (CRPS)
Due to either trauma or neuropathic pain
hot, sweaty, colour change, extra hair growth, swollen
less cortical representation in advanced cases
altered motor patterns. Lack of use
Consider patient trauma/mental health history/mechanism of injury
physiotherapy: graded exposure, education, reassurance
phantom limb pain
due to severed nerves
cortical reorganisation
sensory and musculoskeletal changes
burning stabbing pain, hot, itching sensations, nil pattern
some opioids have limited effect
nerve ablation in extreme cases
physiotherapy: advice and education, MSK optimisation, referral to persistent pain tertiary facility
Fibromyalgia
globalised pain
rheumatologist management
often accompanied by other auto-immune diseases
varying evidence for physiotherapy
Persistent pain medications
opioids
variety of types. Very poor evidence base for persistent pain
Addiciton risk
NSAIDS
Used early in pain management
Used of specific secondary inflammatory component detected
Steroids
Used for nerve blocks at times
Used for rheumatological diseases
Nerve blocks
Variety of areas, medicines used
elected if specific neuropathic pattern is seen - usually spinal related
Cannabis
Emerging area. Controversial. Available with strict policing in Australia