Chronic Pain Early Signs?

Transcription

1 Chronic Pain Early Signs? Dr Stephen L Hill Clinical Lead Pain Clinic Royal United Hospital

2 Chronic Pain Pain is an almost universal experience 60-70% of the population have had a day or more of pain in the last 4 weeks Pain impacted normal work, including housework, by 30-50% on these days Chronic pain > 3months is common and increases with age, it affects more than 10% of the population. Back pain is commonest single diagnosis

3 Reasons to seek medical help Expectation of investigation, treatment and cure Reassurance Severity of pain Unremitting pain, VAS Sleep disturbance, low mood, anxiety Loss of function, normal work Spectrum of stoicism to hyper-vigilance

4 A non-patient Aged 19 early 1970 s Professional motorcycle racer with Norton RTA results in right sided brachial plexus avulsion Non- functional and painful right arm Initial treatment limited Medical advice No medical attendance for 21 years

5 A Patient 40 year old female Care Assistant Worked in Care Home Back strain when patient fell on her Now disabling low back pain No neurology Not working for 18 months DLA application Compensation claim Limited walking and exercise tolerance Low mood Poor sleep Single parent, money worries MRI shows degenerative disc disease with annular bulge Not suitable for surgery

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7 Douglas Bader He could be arrogant, selfish and breathtakingly rude. He treated underlings appallingly and was thoroughly disliked by many of his comrades. He was prone to boasting and showing off.

8 Yellow Flags in Back Pain, 1997 Prognostic features for chronic dissability ( Belief that Pain and activity are harmful Sickness behaviour, extended rest Low mood, social withdrawal Treatment that does not fit best practice Problems with claims, compensation Problems at work, poor job satisfaction, Unsociable hours, heavy work Overprotective family or lack of support

9 Other features Fear avoidance Vlaeyen and Linton (2000) Catastrophic thinking Sleep disturbance External locus of control, low self-efficacy Poor concentration, irritability, helplessness Non verbal pain communication, use of aids Overlap between CFS, ME, Fibromyalgia History of physical/psychological/sexual abuse

10 Real or Psychological? All pain has both psychological and physical dimensions Reported pain is accepted as real, fmri imagining Pain can lead to excessive resting Resting leads to a global reduction in sensory input Reduced sensory input leads to loss of neuromodulation, spinal cord, brain stem and thalamus Return to activity may cause a flare up of pain Anxiety, fatigue, poor sleep, low mood, loss of activity and hypervigilance, perpetuate the pain state

11 Minor Injury to Chronic Pain Injury Pain, swelling Restin g No fear Resolution Fear Avoidance Return of use Continued Resting Increased pain with physical activity Loss of Neuromodulation Physical changes Muscle weakness joint stiffness

12 Minor Injury to Chronic Pain Injury Social Isolation Poor Sleep Pain, swelling Restin g No Fear Fear Avoidance Resolution Return of use Continued Resting Low Mood Increased pain with physical activity Loss of Neuromodulation Physical changes Muscle/ joint stiffness

13 Injury Minor Injury to Chronic Pain Benefits, Compensation Social Isolation Pain, swelling Restin g No Fear Fear Avoidance Resolution Return of use Over/Undersupportive family Poor Sleep Continued Resting Low Mood Increased pain with physical activity Loss of Neuromodulation Physical changes Muscle/ joint stiffness

14 CRPS

15 CRPS mechanisms/ causes A previous theory that CRPS was a psychosomatic condition has been disproved because research shows people with CRPS undergo very real physical changes in their nervous system. (ww.nhs.uk/conditions/complex-regional-pain-syndrome) Obvious physical changes, makes it seem different to back pain, fibromyalgia etc Research Interest Fear avoidant behaviour Neural plasticity Neurogenic oedema, distal limb, (not everyone can do this) Movement disorders, tremor, dystomia Self harm

16 Minor Injury to Chronic Pain Injury CRPS Pain, swelling Restin g No fear Resolution Fear Avoidance Return of use Continued Resting Increased pain with physical activity Loss of Neuromodulation Physical changes Muscle/ joint stiffness

17 Treatment Address the fear Reassurance, education, analgesia (inc blocks) Physical rehabilitation, CBT, return to work schemes Avoid doing too much or too little (medically) Avoid doing too much or too little (pacing) Start regular 2-3 times a day exercise PMP

18 The End

19 Somatoform Conditions Tension Headache TMJ Syndrome Regional musculo-skeletal pain Myofacial pain RSI IBS Chronic Sinusitis Burning mouth syndrome Non cardiac chest pain Costochondritis Biliary dyskinesia PCS Interstitial Cystitis Female urethral syndrome Vulvodynia

20 Somatoform disorder Multiple unexplained symptoms, no organic diagnosis 2-4% Fibromyalgia 4% somatoform disorder 1 % Chronic fatigue Multiple chemical sensitivity Exposure syndromes, Gulf war, silicone breast implants, sick building, mercury filings