1. Presentation to Rehabilitation Case Managers Professor Milton Cohen St Vincent’s Campus, Sydney and Faculty of Pain Medicine, ANZCA 9 May 2016 RTW for the Worker with Chronic Pain

2. …the Worker with Chronic Pain What to do about… How to think about…

3. Courtesy of Prof Deborah Schofield

4. “To have pain is to have certainty; to hear about pain is to have doubt.” Elaine Scarry, 1985 “Johnny, are you in pain?” “No, Mummy. The pain is in me.” The Advertiser, 1927 Quoted in The Lancet, 30 June 2012 “Your pain is the breaking of the shell that encloses your understanding.” Kahlil Gibran

5. Themes  Complex biology of pain  Sociopsychobiomedicala ssessment and management  “Treatment” of (the person with) pain Not a “broken part” but a changed person “The body” is not the only thing Self-management is the aim

6. P A I N An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

7. P A I N An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

8. What is “chronic” pain?  Pain that persists after “natural healing” OR  Pain that persists without an obvious “cause”

9. Acute painChronic pain Active tissue damage Altered nervous system Changed person

10. Themes Not a “broken part” but a changed person “The body” is not the only thing Self-management is the aim Complexity Context Containment

11. Themes Not a “broken part” but a changed person “The body” is not the only thing Self-management is the aim Complexity Context Containment

12. PAIN DISEASE (nervous system) Biomedical Model

13. Problems with Biomedical Model of Pain  Implies hard-wired certainty  Absence of nociception (“tissue damage”) defaults to psychogenesis (“in the mind”)  Excludes narrative of the sufferer

14. A problem for clinicians and case managers  Our clients believe that they can be “fixed”  Not all our clients get better  Our interactions have unpredictable effects

15. CNCP is a complex phenomenon [Campbell et al, Pain 2015;156:231-242; NDARC, UNSW Australia] N=1514, CNCP taking prescribed opioids for >6 weeks  Low rates of employment/ income  Multiple “pain conditions”, poor physical health  ~30% abuse/neglect  ~ 50% depression; ~25% anxiety; >40% suicidal ideation  >30% concurrent BZD; >50% concurrent antidepressant  1:8 cannabis use disorder; 1:3 alcohol use disorder

16. social psycho Bio Socio psycho biomedical

17. BRAIN AND NERVOUS SYSTEM ENVIRONMENT PERSON BODY

18. BRAIN AND NERVOUS SYSTEM ENVIRONMENT PERSON BODY What’s happening to your body (-biomedical”) What’s happening to you as a person (-”psycho-”) What’s happening in your world (“socio-)

19. DISTRESSDISABILITY NOCICEPTION BELIEFS CULTURE MEMORY EDUCATION

20. BLACK FLAGS BLUE FLAGS YELLOW FLAGS ORANGE FLAGS RED FLAGS

21. Tenderness Allodynia  Pain in response to a non-damaging stimulus (touch, pressure, movement)  Sensitisation of “pain-signalling” pathways

22. CENTRAL SENSITISATION OF NOCICEPTION  “Pain…might not necessarily reflect the presence of a peripheral noxious stimulus.”  “Pain could…become the equivalent of an illusory perception…” Woolf C. Pain 2011;152:S2-S15 “Switch-on” of “pain-signalling” pathways in the central nervous system (spinal cord and brain)

23. CLINICAL FEATURES SUGGESTING CENTRAL SENSITISATION  Absence of obvious tissue damage or disease  Sensitivity to touch or movement  Worsening pain after repetitive use

24. SOME IMPLICATIONS OF CENTRAL SENSITISATION “Top-down” AND “bottom-up” No language (yet) Avoid chasing nociception in region of pain Potential for perpetuation Nervous system re-education

25. Themes Not a “broken part” but a changed person “The body” is not the only thing Self-management is the aim Complexity Context Containment

26. BRAIN AND NERVOUS SYSTEM ENVIRONMENT PERSON BODY What’s happening to your body (-biomedical”) What’s happening to you as a person (-”psycho-”) What’s happening in your world (“socio-)

27. BLACK FLAGS BLUE FLAGS YELLOW FLAGS ORANGE FLAGS RED FLAGS

28. Comcare Employee experiencing pain Provider Employer

29. Adolphs & Damasio 1995 Our point of view as observers does not allow us to know what it is like to be the system being observed

30. Risks – to the patient - of having chronic pain  Challenge observers’ view of the world  Reinforce clinicians’ uncertainty  Fail to validate health professionals’ effectiveness Marginalisation Discrimination Stigmatisation

31. Risks – to the clinician – of chronic pain  View of the world challenged  Uncertainty reinforced  Effectiveness not validated “Negempathy” Conscious avoidance of compassion Negative projection

32. CLINICAL/OFFICE ENCOUNTER SOCIAL DETERMINANTS LANGUAGELANGUAGE

33. CLINICAL/OFFICE ENCOUNTER EXPERIENCE ATTITUDES & BELIEFS PSYCHOLOGICAL DISTRESS ILLNESS BEHAVIOUR KNOWLEDGE ATTITUDES & BELIEFS AFFECT CLINICAL BEHAVIOUR EMPATHY HONESTY TOLERANCE PREJUDICE HOSTILITY SUSPICION

34. REFRAMING THE ENCOUNTER Shared expertise Neurobiology Empathy Language

35. PLACEBO (CONTEXTUAL) EFFECT(S) Change(s) in illness attributable not to a specific pharmacological or physiological effect of a treatment but rather to the sociocultural context in which the treatment occurs

36. Comcare Employee experiencing pain Provider Employer

37. Themes Not a “broken part” but a changed person “The body” is not the only thing Self-management is the aim Complexity Context Containment

38. CLINICAL FRAMEWORK PRINCIPLES 1.Measure and demonstrate the effectiveness of treatment 2.Adopt a biopsychosocial approach 3.Empower the injured person to manage their injury 4.Implement goals focused on optimising function, participation and return to work 5.Base treatment on the best available research evidence Clinical Framework for the Delivery of Health Services TAC and WorkSafe Victoria, June 2012

39. CLINICAL FRAMEWORK PRINCIPLES - from a physician’s perspective - 1.Adopt a sociopsychobiomedical approach 2. Implement goals focused on optimising function, participation and return to work 3. Empower the injured person to manage their injury 4. Base treatment on the best available research evidence 5.Measure and demonstrate the effectiveness of management

40. RTW Twin Goals Injury Rx

41. PRINCIPLES OF THERAPY AIMS Decrease pain as much as possible Increase function as much as possible Minimise adverse effects of treatment MODALITIES Psychological Physical Pharmacological Procedural

42. PHARMACO- THERAPY PROCEDURES PSYCHOTHERAPY PHYSICAL THERAPY

43. What’s happening to your body What’s happening to you as a person What’s happening in your world “Treatment” of person with chronic pain Exploring the body Movement ?Medications ?Procedures Reframing New learning ?Medications Relationships Security Work

44. Evidence: “Everything works and nothing works”  Shoulder pain “There is some evidence from methodologically weak trials to indicate that some physiotherapy interventions are effective for some specific shoulder disorders.” (Green et al. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD004258)  Low back pain “In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, analgesics, antidepressants, back schools, behavioural therapy, electromyographic biofeedback, exercise, injections (epidural corticosteroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), non-surgical interventional therapies (intradiscal electrothermal therapy, radiofrequency denervation), spinal manipulative therapy, surgery, traction, and transcutaneous electrical nerve stimulation (TENS).” (Chou R. Clinical Evidence [Clin Evid (Online)] 2010 Oct 08)

45. What does good pain management look like?  Reframes the problem  Recognises the context  Respects the nervous system

46. Early detection? BLACK FLAGS BLUE FLAGS YELLOW FLAGS ORANGE FLAGS RED FLAGS Symptoms persisting past “healing” New pathology Iatrogenic factors Mental health disorders Personality disorders Threats to financial security Sense of injustice Litigation Low social support Unpleasant work Low job satisfaction Excessive work demands Problems outside of work Unhelpful beliefs about injury Poor coping strategies Passive role in recovery

47. BLUE FLAGSYELLOW FLAGS Low social support Unpleasant work Low job satisfaction Excessive work demands Problems outside of work Unhelpful beliefs about injury Poor coping strategies Passive role in recovery What can be done in the workplace?

48. Fear avoidance “A behavioural response to pain characterised by a person excessively restricting involvement in activities and exercises due to heightened fear or anxiety about pain or re-injury (i.e. worry that any pain could cause tissue damage).” Clinical Framework for the Delivery of Health Services TAC & WorkSafe Victoria

49. Fear avoidance “A behavioural response to pain characterised by a person excessively restricting involvement in activities and exercises due to heightened fear or anxiety about pain or re-injury (i.e. worry that any pain could cause tissue damage).” Clinical Framework for the Delivery of Health Services TAC & WorkSafe Victoria

50. What physical treatments are you recommending? Do you know what’s happening to your patient as a person? Do you know what’s happening in your patient’s world? What to ask treatment providers? Exploring the body Movement ?Medications ?Procedures Reframing New learning ?Medications Relationships Security Work

51. What physical treatments are you recommending? Do you know what’s happening to your patient as a person? Do you know what’s happening in your patient’s world? What to ask treatment providers? Movement ?Medications ?Procedures Understanding Mood ?Medications Relationships Work Recreation

52. Summary Not a “broken part” but a changed person “The body” is not the only thing Self-management is the aim Complexity Context Containment Socio-psycho- biomedical Sensitisation “Flags” Interaction Evidence- assisted Beware the hammer

54. Case 1: F43  Ankle injury 2y ago: “sprained”  Physio/hydro/benzodiazepine  No RTW  “Mild CRPS” diagnosed 4m later  4w inpatient PMP: pregabalin/nortriptyline/opioid/intrathecal  Suicidal ideation 6m later  5+w admission for (long-standing) depression: drugs/psychotherapy/TMS/ECT  Personality and interpersonal issues identified…

55. Case 1: analysis Bio psycho social Socio psycho biomedical Biomedical focus (? diagnosis) Medicalisation: drugs/procedures/hospital Late (or non-) recognition of psychological issues Trivial biomedical component Why no return to work? Delayed recognition of context

56. Case 2: F55  Fell off chair 3y ago: “lumbar sprain”  Massage/“physiotherapy”/heat/TENS  Palexia/Lyrica/Maxigesic  Requests for:  “denervation” -? Repeat  TENS  massage  “Adjustment reaction with depression”  Antidepressant drugs/counselling  “Pain management not helpful”

57. Case 2: analysis Somatic focus but no diagnosis More-of-the-same treatment Patient “struggles with emotional component of pain” Bio psycho social Why is this person so distressed? What else is happening? Yellow flags? Orange flags? Blue flags? Sociopsycho biomedical