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Physiotherapy research Barriers to the implementation of evidence-based chronic pain management in physio outpatients.

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Presentation on theme: "Physiotherapy research Barriers to the implementation of evidence-based chronic pain management in physio outpatients."— Presentation transcript:

1 Physiotherapy research Barriers to the implementation of evidence-based chronic pain management in physio outpatients


3 2010 research project Shelley Barlow Physiotherapist Ballina Community Health 25+ years as outpatient physiotherapist Research scholarship CETI 2010-2012

4 pain What is it about pain that bothers us so much?





9 Or does it? Where things are at in the world of pain!

10 The human faces of pain



13 Building hope This presentation will outline some of the ‘how and why’ through pain to self management and recovery

14 What is being done? To change pain there is a need to shift beliefs and attitudes towards people in pain Less pain and living well with chronic pain are more about health then they are about medicine (Neil Pearson 2011)

15 Pain Summit Canberra March 2010 130 organisations united to back the worlds 1 st national pain strategy De-stigmatise chronic pain Introduce of standardised interdisciplinary pain management networks

16 National pain summit Mission To improve quality of life for people with pain and their families minimise burden of pain on individuals and the community

17 Pain summit National representative body include all stakeholders Recognition pain as condition in own right Treatment chronic disease model of care Introduction interdisciplinary linkages through all stages of treatment from prevention, PHC, community to secondary and complex tertiary care

18 Pain summit Community-led program De-stigmatise in Minds community and health professionals Better education to public that a wider range of help-beyond pain killers –is available

19 Pain summit Pain as 5 th vital sign Formal coding system for pain in hospitals to allow prevalence and other data to be tracked Item numbers in PHC, Dr’s to be reimbursed Pain not seen as just a symptom reconceptualising as a disease in its own right

20 National Pain strategy Pain management for all Australians Developed from independent process including pain summit Developed by the national pain summit initiative march 2010

21 Mission To improve the quality of life for people with pain and their families, and to minimise the burden of pain on individuals and the community Pain 3 rd most costly health problem Realisation there are more people with the problem of chronic pain then initially thought

22 findings Pain management is inadequate in most of the world due to…. Inadequate access to treatment of acute pain Failure to recognise chronic pain is a serious chronic health problem Requiring management akin to other chronic diseases eg cardiac/diabetes

23 And Aim to  recognise Intrinsic dignity of all persons therefore Withholding treatment wrong Leads to unnecessary suffering Which is harmful

24 and Pain medicine not recognised as a distinct speciality WHO estimates 5 billion people live in countries low or no access medicines or adequate treatment moderate or severe pain Restrictions on adequate use opioids and other essential medicines

25 and Major deficits in knowledge of health care professionals Regarding mechanisms and management of chronic pain Chronic pain with or without a diagnosis highly stigmatised Countries poor or no policies regarding research spending and education

26 Prioritising pain 1 in 5 Australians will suffer chronic pain in their lifetime 80% will miss out on appropriate treatment Cost 34 billion annually

27 Chronic pain Constant daily pain for a period of 3 or more months in the last 6 Pain that extends beyond the expected healing time of an injury, or can accompany chronic illness such as arthritis or lupus

28 They face the following Disease not officially recognised as a disease or public health issue People around them often don’t believe they are in pain Many health professionals receive little or no training May have to wait up to a year for service

29 And They have little access community support Productivity at work lowered leads to unemployment and impoverishment They are personally likely to carry 50% of the total economic cost

30 People with chronic pain have Increased risk: Depression Anxiety Physical de-conditioning Poor self esteem Social isolation Relationship breakdown


32 Goals People in pain as a national health priority Knowledge, empowered and supported consumers Skilled professionals and best-practice evidence-based care Access to interdisciplinary care at all levels

33 Goals continued Quality improvement and evaluation Research

34 Declaration Montreal IASP Sept 2010 Declaration of Montreal 2010 September Declaration that access to pain management is a fundamental human right

35 3 human rights The right of all people to have access to pain management without discrimination To acknowledgement of their pain and be informed about how it can be assessed and managed To have access to appropriate assessment and treatment by trained health professionals

36 Case for change Governments becoming aware of impact of chronic pain on communities Aging associated increased burden painful pathology Gains made by: prevention, community awareness, early intervention and access pain services

37 Traditional views Pain symptoms telling you there is damage to the tissues and structures in the body As damage heals pain goes away There is nothing that can be done Take medication, learn to ignore, distract Learn to live with it

38 Current understanding Pain changes everything; Chemistry, cells, tissues, systems, Breathing, thinking, physical ability, roles in life Emotions, sense of self, role in community Ref: Neil Pearson 2011

39 Biological changes Changes in central nervous system may develop during a transition phase acute to chronic Already have treatments that can prevent transition, chronic pain is learned Also treatment by targeting neuroplasticity in CNS Pain reduced not often eliminated

40 Pain is an Output of the Brain !


42 Pain invisible People try to convince practitioners of the intensity and discomfort Met with disbelief and despair Treatment must look beyond the origin of the pain


44 Specialist pain clinics Model of care for high risk and complex Long waiting lists Poorly integrated into community and primary health care Lack of continuum of care Poor feedback and discharge between services

45 Community based services Community based services shown to be effective for other chronic diseases No infra structure for chronic pain

46 Draft National primary health care strategy Reduce waiting times specialist pain clinics Improve access to effective interdisciplinary pain management PHC Triage criteria referral pain clinics Role medicare locals?

47 How? Skilled workforce consisting integrated interdisciplinary teams Improved understanding of roles Appropriate infrastructure Group activities and Co-location services Shared care

48 How? Strengthened regional PHC partnerships Supplementary funding Standardised evidence-based approaches Flexible tailored care Supported self management Personalised shared care plans

49 How? Information and IT for decision support and outcome measures Focus on prevention and early intervention including effective treatment acute pain

50 NSW state plan for pain management Completed and with the minister Clinical innovations pain management group Representatives from all areas on working parties Chronic pain Australia involved What might this mean for us?

51 Where my project fits in? Barriers to the implementation of evidence-based chronic musculoskeletal pain management in physiotherapy outpatient departments Rural and regional focus Shelley Barlow 2010-2012

52 Where my project fits in? Qualitative research Phenomenological model or lived experience of phenomenon Asking physiotherapists who volunteered their experiences Semi-structured interviews Series of questions

53 Questions What do you like or dislike about outpatients? What does chronic pain mean to you? What does chronic pain management mean to you? How do you identify someone with chronic pain?

54 Questions continued How do you work with someone who has chronic pain? What do you like/dislike about working with people with chronic pain? Are you familiar with Evidence-based practise for people with chronic pain? What are the essential elements?

55 Questions continued What would you do differently with these people is you were able to? What support and training would you need to work with these people?

56 14 physios interviewed 15 physios volunteered 14 interviewed entry criteria working in outpatients In-depth interviews Recorded Transcribed Coding and analysis of the data Literature review

57 Data early adopters Physios who engage confidently with people with chronic pain have had; exposure to new models, self directed learning, worked in pain clinics, introduced to the principles of chronic pain management, attended courses by pain specialist physios

58 Data early to late majority Physios who are less confident tend to be uncertain about how to introduce the concepts of CPM and who would benefit Less exposure to the theory and the modelling of CPM Uncertain about when and when not to use manual therapy Uncertain about using therapeutic neuroscience as an intervention Would like to learn more

59 Data not thinking about adopting Physios who aren’t as interested in treating people with CP tend to refer on people with CP Find their current practise is reliable for who they treat Use a biomechanical approach Not wanting to engage Aren’t interested in implementing the broader focus of CPM

60 General Data outpatients suggests;  Physiotherapists come to work with the intention of helping people  Results and outcomes important  PT’s like a variety of clients and problem solving  People with chronic pain perceived as difficult unless have confidence with what doing

61 Data continued Education, training and exposure to evidence-based pain management models and strategies important to implementation ‘Hands on and/or hands off’ there is an ambivalence around when, how treatment options can be implemented in context Use of psychological strategies not well integrated into practise

62 Data continued Rural isolation and lack of resources an issue difficult to access support ie PD and training, space, different time frames for working with complex and often distressed people Limited availability psychologists trained in pain management Perceived/real lack of access tertiary services

63 Data Perceived significant burden of responsibility on physios to get people better (traditional thinking acute) People with chronic pain perceived as being challenging intellectually and emotionally

64 Lack of understanding of all of the EBP What is the evidence-based practise exactly?  Research, literature, guidelines AND Negotiation with patients/clients AND Professional experience/expertise

65 What is the Evidence-based practise ? Biopsychosocial model of care

66 References: Engel, George L. The need for a new medical model, Science 196: 129-136, 1977. PMID 847460., Loeser, Fordyce, Waddell

67 Research says best treatments Combined CBT and progressive activity re activation and exercise (operant conditioning, behavioural model) (although less then 50% get better with these programs) Problems with the body, problems with the nervous system, changes to the psyche

68 Evidence-based model Multidisciplinary or interdisciplinary model of care (doesn’t have to be elaborate) Wholistic focus

69 Evidence-based practise Intensive pain neurophysiology education Take advantage of the neuroplasticity Can be retrained, not easy to do Changes to the nervous system cannot be considered permanent (see books on brain reorganisation eg brain that changes itself, Norman Doidge MD)

70 Education structural pathology Traditional anatomical education Education aimed at structural pathology may promote chronic pain By heightening attention on the pain Emphasising the spines vulnerability (threat) And increases persons use of health services

71 Evidence-based practise Shoulder ROM increases after education patients on therapeutic neuroscience Reference: Moseley, G.L. Nicholas, M.K. Hodges, P.W.2004. A randomised Controlled Trial of Intensive Neurophysiological Education in Chronic Low Back Pain. Clinical journal of pain 2004;20:324-330.

72 Active approaches Graded exposure in vivo Graduated activity increases Learning tolerances and limits to establish capacity Setting baselines Pacing Deal with thoughts and feelings and behaviours about increasing activity

73 Relational aspects care Patient-centred Emotion-handling skills Joint goal setting Physio as partner in the process not the expert Problem-defining and solving Communication Advocacy

74 Evidence-based practise Discomfort management Identify coping styles active or passive Address fear avoidance CBT cognitive-behavioural therapy Flare-up and set back management Re-engagement with pleasurable activities Relaxation

75 5 essential messages Pain is real and is a complex experience involving body sensations, feelings and emotions, thoughts and behaviours Body and mind together forever Pain has a profound impact on the persons life


77 2 nd message Persistent pain result of Changes to the input, output and modulation systems within the central nervous system CNS sensitisation Imbalance in modulation Hurt therefore doesn’t mean Harm




81 3 rd message Passive approach usually results in greater disability and increases transition acute to chronic pain Passive approach what exactly do you mean? Disability not related to injury Pain not always related to nociception (nociception = danger signals)

82 Loss of belief in ability to perform tasks resulting in reduced activity. Fear and avoidance of all activities including pleasurable ones. Not enough activity to stimulate endorphin production. 3 rd message  Major issues are:



85 4 th message Moods states directly effect descending modulation, serotonin Fear/anxiety linked to pain responses Cognitive processes modulate intensity and unpleasantness Psychological processes related to pain behaviours ‘Not all in your head’



88 5 th message Environment significant contributor to persistent pain states Biomedical model contributor Reinforcement by others either invalidation of experience or solicitous behaviour Lack of support for vulnerable person Unmodulated fear and threat eg dealing with medical system, centalink, workers comp, past experiences (trauma, sexual abuse)



91 Pain neuroscience Difference acute pain and chronic pain or part of a continuum Difference male and female modulation Inputs from three different neural complexes; Cognitive/Evaluative Sensory/ discriminative Motivational/affective


93 Pain neuroscience Nociception input into dorsal horn wind up signs are hyperalgesia and allodynia Ad rapid escape threat C promotes avoidance protection injured tissue Super-sensitivity DH everything amplified Central sensitisation Over-rides the descending modulation

94 Ascending modulation Dorsal horn crosses over spinothalamic tracts to Thalamus Then to limbic system (fear and evaluation of threat to life) and somatosensory system (where is it) Pathway to frontal (what does it all mean?)

95 Descending modulation where the biggest bang for your buck is!!! Limbic to Periaquiductal gray To Rostral Ventromedial Medulla (on and off cells) to DH Neurotransmitters endogenous opioids (can be induced from exercise), dikepahalons and GABA

96 Identification of clients Comprehensive assessment Biopsychosocial domains all covered Red flags serious pathology Yellow flags psychological factors Pain assessment signs of central sensitisation Ascertain Perceived Level of threat

97 Ascertain perceived level of threat Questionnaires How else may you do this?

98 Pain management programs Goals: Improve the understanding of their situation Improve level of physical functioning despite ongoing pain Modify the persons perceived level of pain and suffering

99 Pain management programs Provide coping skills and strategies for dealing with chronic pain, disability, distress and life changes Promote confidence in self-management which can reduce reliance on others, medication and therapy Return person to ADL’s pre-pain state

100 Referral to specialist tertiary services when there is…… Failure medical and surgical treatment Maladaptive pain or illness behaviour Perception over-reliance medication or therapies Pronounced inactivity Significant depression or anxiety Perception inadequate coping

101 Interdisciplinary care Modified programs Usually PT and psych or OT Not as intense Research shown significant results Client group maybe less desperate c/o tertiary MDPP Training needed for health professionals

102 reference Smeets, J.E.M, Vlaeyen, W.S, Hidding, A.,Kester, A.D.M et al. 2008. Chronic low back pain: Physical training, graded activity with problem solving, or both? The one-year post-treatment results of a randomised controlled trial. Pain 134 (2008) 263-276

103 But wait there’s more….. 3-4 episodes of uncontrollable pain creates changes to the body and the brain Elicits feelings of powerlessness and hopelessness How do we change the neuroimmunopsychophysiology ?

104 Imagery Imagined movements activate the nervous system in a way that can be used to change pain signatures and pain experience Practising moving the body changes the nervous system, use of dynamic neural modulation, eg sliders, gliders Reference; Explain Pain By David Butler

105 Real time functional MRI Research teams looking at which parts of brain overactive and underactive whilst in MRI Then get people to try and turn up parts and turn down parts after getting feedback on what’s been altered

106 Change autonomic nervous system Yoga Tai chi and gigong Meditation Martial arts Feldenkrais Mindful movement beneficial for long term changes

107 Body Schema changes We can alter maladaptive body schema and altered sense of self This is associated with lessening of pain Teach detection maladaptive body images eg lateralisation/Recognise training Graded motor imagery Reference; Lorimer Moseley Bodymind group

108 Stress management Stress affects pain Change input from the body Sensory identification and mapping Create positive neuroplastic changes in brain changing or augmenting sensory input Desensitisation with touch, use of skin eg dermoneuromodulation (Diane Jacobs PT)

109 Repetitive rhythmic movement Changes nervous system and neurochemistry Rhythmic walking, breathing, gum chewing, dancing Increases serotonin levels Motion is lotion

110 Research Barriers to the implementation of evidence-based chronic pain management in physiotherapy outpatient departments ?

111 Barriers? Is it possible to implement effective evidence-based chronic pain management in rural practice? What is needed?

112 references www.Canadian pain coalition British Columbia Neuroscience and pain science for manual therapists, facebook. Dancing with pain http://dancingwithpainhttp://dancingwithpain Butler, DS,Moseley GL.Explain Pain.Adelaide:Noigroup Publications, 2003. Neurorthopaedic institute Noi site Moseley et al.2004. A randomised controlled trial of intensive neurophysiological education in chronic low back pain. Clinical journal of pain,20:324-330.

113 References continued Neil Pearson physiotherapist, transcript from neuroscience for manual therapists facebook site. Doidge, N. The brain that changes itself. Turk, D.2007 Gervani, Sj.(image) IASP, Sept 2010 Declaration Montreal

114 References continued National primary health care strategy. NSW government. NSW Health pain management plan 2011. www.Chronicpain, Australia Engel, G.l. 1997.The need for a new medical model. Science 196:129- 136.PMID 847460

115 References: Smeets. Etal.2008. Chronic low back pain. Physical training, graded activity with problem-solving or both? The one-year post treatment results of randomised controlled trial. (134,263-276).Pain. Diane Jacobs, dermoneuralmodulation treatment, 2009.

116 References: Rural health education foundation. DVD. When Pain Persists: Pain management in Primary Health. Dept health and Ageing. Nicolas,M. Molloy,A.Tonkin,L.Beeston, L. Manage your pain. 2006.Book. University Sydney Pain management centre. NSW government website

117 References: Moore,P. Cole, F. 2009.The Pain toolkit. Australian pain management association. Flor,H. Turk,D.C. 2011. Chronic Pain.An Integrated Biobehavioral Approach.IASP press.Seattle. Utube: chronic pain and neuroscience

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