Early intervention to prevent the development of long term disability post spinal surgery

Transcription

1 Early intervention to prevent the development of long term disability post spinal surgery Catherine Ketsimur- Sanders BPhty, MSc (Pain) Pain Management Research Institute, University of Sydney Northern Private Pain Centre

2 Outline * Extent of ongoing pain and disability * Preoperative Factors and Management * Intraoperative Contributors * Postoperative Factors and Management

3 The extent of the problem * Generally 10% - 20% of patients after surgery * Spinal surgery shows higher rate of persistent post- surgical pain: 30-70% Hinrichs- Rocker et al., 2009 * e.g. discectomy 26% Parker et al., 2015 * Not sure if due to: * tissue and technique involved * length of surgery * reason for surgery * individual patient characteristics Kehlet et al., 2006

4 Pain is complex Tracey, 2008

5 When pain persists: Interacting contributors and effects Nerve damage; changes in central nervous system (Neuropathic or Neuroplastic Mechanisms, eg. Sensitization) REDUCED ACTIVITY UNHELPFUL BELIEFS & THOUGHTS PHYSICAL DETERIORATION (eg. muscle wasting, put on weight, joint stiffness) CHRONIC PAIN REPEATED TREATMENT FAILURES DEPRESSION, HELPLESSNESS, FRUSTRATION ANGER POOR SLEEP EXCESSIVE SUFFERING & DISABILITY Injury; Tissue Damage (Nociceptive Mechanisms) LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS SIDE EFFECTS (eg. stomach problems, lethargy, constipation) LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS INPUT FROM: FAMILY; HEALTHCARE PROVIDER(S); COMMUNITY; EMPLOYER M. Nicholas. 2012

9 Pre- operative risk factors * Pain, moderate to severe, lasting more than a month * Repeat surgery * Psychological vulnerability * Preoperative Anxiety * Female * Younger adults * Workers Compensation * Genetic predisposition * Inefficient Diffuse Noxious Inhibitory Control (DNIC) Schug 2011 * Pre- operative depression, chronic stress, psychological distress Hinrichs- Rocker et al 2009

10 Preoperative Management * Assess: * Presence of pre- existing pain (local and remote) * History: previous surgery, compensation/litigation * Functional consequences * Neurophysiologic assessment * Psychosocial assessment * Gene analysis* Kehlet and Rathmell 2010

11 Preoperative Management * Education re: * Surgery * Pain management e.g. PCA * Physical function e.g. log roll, rehab plan * Set goals * Helps to: * Reduce anxiety and stress * Increase postop adherence * Earlier DC * Increase satisfaction Papanastassiou et al 2011

12 Preoperative Management * Setting goals: SMART * Why are they having the surgery? * What would they like to be able to do/do better? * Tools: Goal sheets, Patient Specific Functional Scale

13 Total score = sum of the activity scores/number of activities Preoperative Management The Patient-Specific Functional Scale This useful questionnaire can be used to quantify activity limitation and measure functional outcome for patients with any orthopaedic condition. Clinician to read and fill in below: Complete at the end of the history and prior to physical examination. Initial Assessment: I am going to ask you to identify up to three important activities that you are unable to do or are having difficulty with as a result of your problem. Today, are there any activities that you are unable to do or having difficulty with because of your problem? (Clinician: show scale to patient and have the patient rate each activity). Follow-up Assessments: When I assessed you on (state previous assessment date), you told me that you had difficulty with (read all activities from list at a time). Today, do you still have difficulty with: (read and have patient score each item in the list)? Patient-specific activity scoring scheme (Point to one number): Unable to perform activity (Date and Score) Able to perform activity at the same level as before injury or problem Activity Additional Additional Initial Stratford et al, 1995

14 Intraoperative Contributors * Surgery itself and handling of nerves * Disease/reason for the surgery Kehlet and Rathmell 2010

15 Intraoperative Contributors * Intraoperative nerve damage: high risk factor for ongoing postoperative pain Werner and Khelet, 2010 * Nerve injury leads to Wallerian degeneration * effects on the injured nerve as well as neighboring uninjured nerves. Rotshenker, 2011 * Deep tissue dissection (not incision) appears important factor in the degree of postoperative pain Dorr et al 2007

16 Intraoperative Considerations * How this effects our intervention: Knowledge of surgery: Possible nerve involvement Extent of tissue dissection Awareness of inflammatory and immune contribution McMahon et al, 2005

17 Postoperative Risk Factors * Acute moderate to severe pain * Radiation therapy * Chemotherapy * Depression * Psychological vulnerability * Neuroticism * Anxiety Schug 2011

18 Postoperative Risk Factors * Medical conditions (multi- morbidity) affecting the immune system or endocrine system such as diabetes, chronic stress, or hypothyroidism may hinder recovery and contribute to maintenance of pain * Bulk of the evidence in orthopaedic surgery supports central nervous system changes including dorsal horn sensitization Nikolajsen et al., 2009, Harden et al., 2003

19 Postoperative Management * Assess: Early Postoperatively * Pain intensity and character * Pain treatment modality used * Neurophysiologic assessment * Later Postoperatively * Pain intensity and character * Neurophysiologic assessment * Psychosocial consequences * Function Kehlet and Rathmell 2010

22 Postoperative Management * Assess: * Pain: NRS, description/character (neuropathic element?) * Beliefs: * Pain harm normal postop; however is management optimal? * Post- op instructions * Goals: review or set * Function: set baselines

23 Postoperative Management Why is it important to recognize a neuropathic component? * Neuropathic changes start immediately * Can lead to extensive neuroplastic changes * Poor prognosis if not recognized and addressed

24 Postoperative Management Neuropathic Pain * Pain caused by a lesion or disease of the somatosensory nervous system * Central or peripheral * Mechanisms: peripheral, spinal and supraspinal Neuroplastic * Changes in neurons: functionally, structurally or chemically * Mechanisms: peripheral, spinal and supraspinal IASP Taxonomy 2011

25 Postoperative Management * Neuropathic pain recognition Description Tool: LANSS, paindetect Sensory testing Jones and Backonja 2013

26 Mechanism based treatment considerations NOCICEPTIVE NEUROPATHIC COMPONENT Simple analgesics, NSAIDs, Opioids Physical therapies (encourage rehab and confidence in moving) Psychological therapies (education, attentional, thought management, exposure, mood/ reactivity/anxiety management) Neuropathic pain meds Less aggressive physical therapy (confidence v mechanism) (e.g. gradual pacing-up activities) Psychological therapies (education, attentional, thought management, exposure, mood/ reactivity/anxiety management)

27 Guidelines for the management of back pain Acute Advice to stay active, exercises, activity- focused printed and verbal information and behavioural interventions NHMRC Guidelines for the Evidence- based Management of Acute Musculoskeletal Pain (2005) Chronic Cognitive- behavioural interventions encouraging activity/exercise European Guidelines for the Management of Chronic Nonspecific Low Back Pain. Eur Spine J (2006) 15 (Suppl.2): S192- S300 Slide courtesy of Lois Tonkin

28 Pain Management * Active coping strategies (doing things yourself) is more effective * An exercise routine, keeping as active as possible, using a relaxation technique to maintain sense of control or calmness * All better than waiting for next therapy session * Passive coping strategies (having things done to you) is associated with higher pain- related disability Blyth et al, 2005 Slide courtesy of Lois Tonkin

29 Postoperative Management * Goals * Graded Activity and pacing * Coping Strategies * Thought Challenging and Problem Solving * Medication management * Managing Flare- ups and setbacks

30 Goals

31 Graded activity and pacing * Pacing up rehab as well as function * Gradually increase activities despite pain * Using quotas (measured reps/time) * Write a plan and record progress high ACTIVITY low TIME (DAYS OR WEEKS) pacing line (using quotas) Manage Your Pain Nicholas et al, 2011

32 Adherence to activity pacing and effect size on Roland- Morris Disability Questionnaire Pre-post data, Nicholas et al. EJP 2012 Slide courtesy of Professor Nicholas

33 Adherence to activity pacing and effect size on pain severity Slide courtesy of Professor Nicholas

34 Coping Strategies * thoughts and behaviours that are used to manage or cope with stressful situations, such as pain or demands made by other people Nicholas et al 2011 * Can include * Relaxation, distraction, activity, thought challenging * Taught to adolescents post scoloisis surgery Day 2 * Decreased pain by day 4 La Montagne et al, 2003

35 Medication Management * Postoperative recovery depends on effective pain management * Measure with function and mobility pain score * Encourage use of appropriate medication Joshi et al, 2014 * Multimodal best but not clear what combination Devin and McGirt 2015 * Change/decrease medication with guidance

36 Flare- ups and set backs * Discuss with patient: Prepare plan ahead If flare up: stop and think, and go to plan * Active strategies: Relaxation, stretching etc. Review and reassure afterwards (self) Manage Your Pain Nicholas et al, 2011

37 Postoperative Management * Resources: aci.health.nsw.gov.au/chronic- pain/health- professionals/resources- for- chronic- pain eppoc questionnaires: ahsri.uow.edu.au/eppoc/forms/index.html

38 Pilot study PMRI * Preadmission (N=45) * Psychological (anxious/worried, depressed, tense/stressed, pain will not end), pain (severity, risk of persistence) and surgery (will surgery eliminate pain, current claim) questions * Ease of questions (80% said very easy ) * Surgery (type, expected length of stay, revision), history of medical conditions, opioid medications * Ease of questions (79% said very easy ) Dr Overton, Dr Macpherson, Dr Costa, Ms Wilson, Prof Nicholas

39 Pilot study PMRI * Post surgery (N=34) * Current level of pain (at rest, during activity), hypo/ hyperesthesia on first and second day post- surgery * Ease of questions (91% said very easy ) * 1- month Follow up (N=29) * Medications, current level of pain (at rest, during activity), hypo/hyperesthesia, new pain (description, reasons) * Ease of questions (83% said very easy ) Dr Overton, Dr Macpherson, Dr Costa, Ms Wilson, Prof Nicholas

40 If you want to know more

41 Continuing and postgraduate education in pain management

42 Summary ID and start intervention early - preoperative if possible Our role: to teach Their role: to do Active management it doesn't work if you don t do it

43 Summary Postoperative recovery Is dependent on effective pain management Measured by function

44 Acknowledgements * PMRI team * Lois Tonkin * Professor Michael Nicholas Pain Management Research Institute Douglas Building Royal North Shore Hospital NSW 2065 AUSTRALIA T: F: * Dr Duncan Sanders * Dr Overton, Dr Macpherson, Dr Costa, Ms Wilson Thank you