De bio-psychosociale aanpak versus invasieve pijntherapie: hoe samenwerken? Prof Dr J Devulder UZ Gent
VC L (patient) female 24/8/1959 (1/2) Failed back surgery syndrome 2006-2007 (3 operations). Symptoms: back pain + pain in both legs. Mixed nociceptive neuropathic (NRS 7/10). MRI : extensive fibrosis in the epidural space and around the nerve roots. EMG: old neuropathic lesions in L5 S1 nerves bilateral. First consult with the doctor at the Pain Clinic: 2009. During the consultation: -signs of fear (fear for going to shop ). Intake in the multidisciplinary approach: Medical drugs (tramadol), flupirtine, TENS Intake for treatment in the multidisciplinary team especially working around: -better movement (using a crutch). - psychological guidelines: i.e. going to the shop and asking questions at the staff workers. Good evolution with a minimal mixed bio psycho behavioural treatment.
VC L(patient) (2/2) -2 years later : going worse: patient visits on own initiative an orthopedic surgeon (+ surgery without improvement). -Referal to MPC: clinical identical situation. However psychological much better. Clinical more severe pain without worthwhile response on nerve root Infiltrations and radiofrequency treatment. -Confronted with staff members MPC: -Candidate for Spinal Cord Stimulation trial under conditions from the MPC team (psychological follow up ).
G.L (patient) male 18 years (1/2) Familiar juvenile carpal tunnel syndrome (father, brother). 2 operations on the left right side (2007). 1 Reintervention on the right side without improvement (2008). Neuropathic pain in both arms and hands (NRS 7-10/10). EMG peripheral neuropathy median nerve bilateral with interference in using the upper limbs. Used different drugs (antidepressives; anticonvulsants..) without any pain relief. Has problems with the fine motor skills and strength in the hands. Writing is difficult, so he uses tablet. He has school guidance but even there problems. Leisure is impaired leading to family problems with parents and older brothers (conflict situations). Has run away from home during several days. Has bad results in the school (goes only 4 days per week to school).
G.L. (patient) 2/2 Followed already extensive pluridisciplinary kinesitherapy. Sleep problems during the night and sleeping during the day. Some years ago so much pain : depression with suicide ideas. The patient hopes that Spinal Cord Stimulation will relief all symptoms. Patient shows clear signs of fear avoidance, social impairment and need to redirect some life style perspectives. Intake in multidisciplinary team and trial to treat with CBT -stress management, learn to deal with family tensions : no medical interventions neither surgery nor invasive pain treatment. Need for physical therapy : (special gloves (VIGO organisation), swimming, neuromobilisation). Social nurse and occupational therapy (a complete interdisciplinary approach).
Conclusions (1/2) -For the patient, the physician is the first point of contact: -for medical problems but the latter has to be willing to notice during the conversion if red and yellow flags (fear, sleep problems, drug abuse, familiar problems, negative attitude.) are present. - The physician must take time during consultation to intervene if some unusual signs are mentioned. (a pain consultation is not a common consultation: intellectual action) -If yellow flags are present: the patient is a candidate for intake in the Multidisciplinary screening - If the screening concludes treatment: MPC treatment (different programs) -Depending the medical situation minimal invasive treatment can be necessary (medication, infiltrations, implantations..). - If the medical interventions would influence the positive pain attitude ( obtained by some MPC recommendations than medical therapy is likely contraindicated!!): -Some treatments iniate the patient s idea that the biomedical thinking is better than the biopsychosocial approach (improvement is not by CBT but by medical treatment). -Role of social nurse, occupational therapy as well the interdisciplinary approach with other physicians and organisations are important!!
Conclusions 2/2 -In the MPC approach the patient must work at his /her condition to become better. With those advices (proposals, training etc of the multidisciplinary team) it must become possible that the patient performs as much as possible without abusing medical treatments or the health security system. -Returning as much as possible to normal life. -The beliefs that his/ her physical improvement is only by the physician s treatment could be very temporarily and finally bring the patient in a worse condition than before. -If the medical intervention (biomedical view) is an adjuvant to the biopsychosocial interventions there are no contraindications. -If treatment: discuss it with the MPC caregivers!!!
Nederlands Tijdschrift voor Pijnbestrijding 2009,28:5-9
Yellow flags - meerdere pijnbehandelingen die zonderresultaat blijven - een toenemend psychisch en emotioneel onwel bevinden -inadequate copingstijl - lage inschatting van zelfeffectiviteit - fear-avoidance,...
Yellow flags by Koes -Increasing physical deterioration -Increasing psychological and physical condition -Decreasing self esteem -Taking multiple types of pain killers without any benefit -Emotional reactions on the pain -Fear and concerns about the pain -Catastrophizing about the complaints -Behavioural changes by the pain -Avoidance behaviour for many items (work, friends etc) -Pain behaviour not conform the lesions -Increased intake in pain killers, medical shopping and -Prolonged absenteeism
Yellow flags and Koes ( rehabilitation physician) -het in toenemende mate ervaren van functionele beperkingen - allerlei lichamelijke klachten, afnemend psychisch en emotioneel welbevinden. - verminderd zelfbeeld. -pijnmedicatie zonder effect op de klacht. -de emotionele reactie op de pijn. - angst en bezorgdheid omtrent de klachten. -fixatie van de patiënt op mogelijke ernstige afwijkingen en fatalistische, catastroferende gedachten over de pijn ( ik kan niks staat daarbij voor aangeleerde hulpeloosheid). - gedragsveranderingen als gevolg van de pijnklachten. -vermijdingsgedrag en aanpassing dienen achterhaald te worden. -inadequaat pijngedrag. -overmatig medicijngebruik, medisch shopgedrag en langdurig ziekteverzuim.
Ghent University Hospital multidisciplinary pain programm
Pain questionnaires used in the MPC Ghent University Hospital HADS SF36 NEO-FFI Multidimensional pain questionnaire Pain disability Index Tampa questionnaire The Pain Catastrophizing Scale Illness Cognition List