2. Understanding and Explaining Pain Level 2 Pain Training Fife Integrated Pain Management Service

3. Aims Cross the gap between lab to clinic Understand the pain related biology of the patient in front of you Be able begin to reassure, explain and give understanding to a patient of what is going on

4. “The fear of pain is worse than pain itself”

11. Feedback Burglar & Cat

12. Structure of the Nervous System (or threat detection system)

15. Melzack & Wall

19. Limbic System SENSORY Conscious Brain Thinking AFFECTIVE Feelings Wind-up and long term potentiation Central sensitization Spinal cord Fear, anxiety, sleep, punishment autonomic changes Location rational “oh bother” Muscle tightening Recruitment Sensitivity Sometimes – most of the time feedback

20. Timeline of pain Pain? Tissue Healing Time of injury 3 months

22. Sensitisation What is it? Why does it happen? How does it happen? Forms of sensitisation – – Primary hyperalgaesia – Secondary hyperalgaesia Cold hyperalgaesia – risk factor – Allodynia – Wind up

23. Central Sensitisation Highly common in chronic pain syndromes e.g. CLBP, FMS, CRPS How to recognise? Sensitive to light, noise, smell, chemicals, to touch, pressure, vibration Is not an indication of harm or damage Can be alarming for patient Can lead to many investigations, tests, appointments

24. Mechanisms of Central Sensitisation Plasticity - Strengthening of existing synaptic connections - Formation of new ones Hebbian Plasticity ‘Nerves that fire together wire together’ ‘nerves that fire apart wire apart’ ‘past behaviour predicts future behaviour’ Disinhibition accounts for spread of pain and other symptoms.

25. Neuropathic Pain Pain caused by a lesion or disease of the somatosensory nervous system. From peripheral nerve, nerve root (peripheral) From spinal cord or brain (central e.g. thalamic pain) Pain often described as shooting, electric shock-like, burning – commonly associated with tingling or numbness The painful region may not necessarily be the same as the site of injury – Pain occurs in the neurological territory of the affected structure (nerve, root, spinal cord, brain)

26. Putting it all together! Copyright Body in Mind 2012

27. A Unifying Theory of Pain and its Symptoms – the Neuromatrix

29. Case Studies

32. YELLOW FLAGS Attitudes & Beliefs - towards the current problem. Does the patient feel that with appropriate help and self management they will return to normal activities? The most common worry is that the patient feels they have something serious causing their problem. 'Faulty' beliefs can lead to catastrophisation. Attitudes & Beliefs - towards the current problem. Does the patient feel that with appropriate help and self management they will return to normal activities? The most common worry is that the patient feels they have something serious causing their problem. 'Faulty' beliefs can lead to catastrophisation. Behaviours - adopting disabled role, rest, use & abuse of medication Behaviours - adopting disabled role, rest, use & abuse of medication Compensation - Is the patient awaiting payment for an accident/ injury at work/ RTA? Compensation - Is the patient awaiting payment for an accident/ injury at work/ RTA? Diagnosis - or more importantly Iatrogenesis. Inappropriate or confusing communication can lead to patients not being sure what the problem is, the most common examples being 'your disc has popped out' or 'your spine is crumbling'. Diagnosis - or more importantly Iatrogenesis. Inappropriate or confusing communication can lead to patients not being sure what the problem is, the most common examples being 'your disc has popped out' or 'your spine is crumbling'. Emotions - Patients with other emotional difficulties such as ongoing depression and/or anxiety states are at a high risk of developing chronic pain. Emotions - Patients with other emotional difficulties such as ongoing depression and/or anxiety states are at a high risk of developing chronic pain. Family - There can be two problems with families, either over protective or under supportive. Family - There can be two problems with families, either over protective or under supportive. Work – If there are difficulties, people are more likely to develop chronic problems. Work – If there are difficulties, people are more likely to develop chronic problems.

37. Explain Pain Examples Steve and Neil demonstrate

38. Small groups Use A3 paper – Learning intention – Success criteria – Ideas board

39. Thank You!