This was a presentation made at NITTE University during their first Physiotherapy Conference where I was invited as a Speaker. I am posting this thinking if this will be useful revision for those who attended and may be of some use to those who could not listen.

1. Evidence Based Assessment
and Management of Complex
Pain Conditions
Saurab Sharma, MPT
Lecturer/ Physiotherapist
Kathmandu University School of Medical Sciences
Dhulikhel Hospital Kathmandu University Hospital
Nepal

2. Outline
• Chronic pain – why a burden?
•Chronic pain conditions
•Assessment
•What?
•Why?
•How?
•Management options
Saurab Sharma - NITTE-PHYSIOCON 2017 2

3. Case Study 37 year
old
House-
wife
Mother of a kid
Stable family
® lateral elbow
pain X 7 months
Can’t lift heavy
objects, squeeze
heavy clothes
Rest, medicine,
TENS
Elbow support
Eccentric exercise
Isometric exercise
No
improvement
 Injections
Wrong
illness
perception
Advise of
surgery
Painful touch
Entire extremity painful
Can’t brush, comb, eat,
dress
Thought of movement
painful
Detailed
evaluation
Saurab Sharma - NITTE-PHYSIOCON 2017 3

4. “Pain is a distressing experience associated with
actual or potential tissue damage with sensory,
emotional, cognitive, and social components.”
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5. How does pain become chronic?
Saurab Sharma - NITTE-PHYSIOCON 2017 5
Injury
Acute pain
• Signs of
inflammation
• Tissue damage
3 months
Chronic pain
• No signs of
inflammation
• No tissue damage
• Wrong treatment or No Rx
• Pathoanatomical Diagnosis
• (Mis-) Education
• Prolonged rest
• Passive coping strategies
• Surgery/ injections
• Depression
• Anxiety
• Catastrophizing
• Resilience
• Optimism
• Sex
• Extent of injury
• Social support
• Genetic

6. Bio-psychosocial model of Pain
BiologySociolo
gy
Psychol
ogy
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Biology
Sociolo
gy
Psycho
logy
Acute Pain Chronic Pain

7. Leading causes of Years Lived with Disabilities
in 2015 (India)
Saurab Sharma - NITTE-PHYSIOCON 2017 7
http://www.healthdata.org/gbd

8. Life expectancy – in India
Saurab Sharma - NITTE-PHYSIOCON 2017 8
http://www.healthdata.org/gbd

9. Chronic pain conditions
•Chronic low back pain (± radiculopathy)
•Chronic neck pain (± radiculopathy)
•Complex regional pain syndrome
•Myofascial pain syndrome
•Fibromyalgia syndrome
•Chronic widespread pain syndrome
•Chronic fatigue syndrome
Saurab Sharma - NITTE-PHYSIOCON 2017 9

10. Characteristics of chronic pain
• Input ≠ output
•Pain disproportionate to injury
•Pain for longer than usual healing time
•Catastrophizing
•Thought of movement painful
Saurab Sharma - NITTE-PHYSIOCON 2017 10

11. Saurab Sharma - NITTE-PHYSIOCON 2017 11
Filipe Reis, 2017 Pain in Motion

12. Brain of Individual without pain versus
Individuals with Chronic pain
6/2/2017 12
Work
25%
Famil
y
20%
Self
18%
Enjoy
ment
18%
Other
19%
Normal
Pain
75%
Work
8%
Family
6%
Self
6%
Enjoyme
nt
6%
Other
9%
Chronic Pain
Saurab Sharma, 2016

13. Characteristics of chronic pain
•Central sensitization
•Hyperalgesia – increased pain response
•Allodynia – painful touch
•Increased area of pain
•Fear avoidance/ Kinesiophobia
•Depressed and or anxious
•Low resilience
•Pessimists
•Higher intensity of pain
Saurab Sharma - NITTE-PHYSIOCON 2017 13

14. ASSESSMENT OF
CHRONIC PAIN
Saurab Sharma - NITTE-PHYSIOCON 2017 14

15. Gold Standard Tests
•X-rays, MRI, CT-scans, Musculoskeletal Ultrasound
•Gold standard tests aren’t really “Gold standard”
•Radiographs poorly correlate with pain and disability
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16. Why Outcome Measure?
•To assign numbers to objects in such a way as to represent
quantities of an attribute.
How much pain does he have?
• 5/10 on a Numerical Rating Scale for Pain.
How much depression does Mr. X have?
• 43/63 in Beck Depression Inventory
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17. Why Outcome Measure?
•Assess the effect of treatment – getting worse,
no change or improving?
•Verify if the results we are getting is clinically important?
•Motivate patients by demonstrating improvement in
various outcomes.
• To provide information to a third party.
17Saurab Sharma - NITTE-PHYSIOCON 2017
Stokes 2009

18. Barriers to use of Outcome Measures
1. Lack of knowledge about measures: 82% and 75%
2. Limited availability of measures: 51% and 50%
3. Lack of time: 52% and 55%
4. Not meeting needs of clients: 33% and 60%
5. Lack of professional consensus on what to use: 27%
Mayo et al 1993, Cole et al 1995
18Saurab Sharma - NITTE-PHYSIOCON 2017

19. IMMPACT recommendations
1. Pain
2. Physical functioning
3. Emotional functioning
4. Participant ratings of improvement and satisfaction with
treatment
5. Symptoms and adverse events and
6. Participant disposition
Dworkin, Pain, 2005
24Saurab Sharma - NITTE-PHYSIOCON 2017

20. Assessment of Pain Intensity
1. Numerical Pain Rating Scale (NRS)
2. Visual Analogue Scale (VAS)
3. Verbal Rating Scale (VRS)
4. Faces Pain Scale – Revised (FPS-R)
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21. Assessment of Pain Quality
Saurab Sharma - NITTE-PHYSIOCON 2017 26

22. Assessment of Pain Quality
English दुखाई को प्रकार
छैन
ननकैकम
थोरै
ठीकै
धेरै
अनि-धेरै
Burning भि-भि पोल्ने
Tingling झम-झम गने /
झमझमाउने
Piercing सियोले घोंचेको जस्िो
(चिक्क)
Heavy गरुङ्गो
Numb ननदाएको जस्िो
Cramping बाउंडेको जस्िो
Stretching िन्के को जस्िो
Achy कट-कट खाने
Like infection घाउ पाके को जस्िो
27Saurab Sharma - NITTE-PHYSIOCON 2017
CSI, PCS; Significance <0.001

23. IMMPACT recommendations
1. Pain
2. Physical functioning
3. Emotional functioning
4. Participant ratings of improvement and satisfaction with
treatment
5. Symptoms and adverse events and
6. Participant disposition
Dworkin, Pain, 2005
28Saurab Sharma - NITTE-PHYSIOCON 2017

24. Physical Function (1)
Patient Specific Functional Scale (PSFS)
•Valid and reliable for variety of clinical conditions, different
body parts.
•Good to excellent psychometric properties.
•Assesses activity limitation component of ICF.
Stratford, 1995
Sharma et al., 2016 (Manuscript under preparation)
29Saurab Sharma - NITTE-PHYSIOCON 2017

25. Physical Function (1)
Patient-Specific Functional Scale
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26. Physical function (2)
Pain Interference Scale
•PROMIS Pain Interference Scale – Short Form
•6 items
1. How much did pain interfere with your enjoyment of life?
2. How much did pain interfere with your ability to concentrate?
3. How much did pain interfere with your day to day activities?
4. How much did pain interfere with your enjoyment of
recreational activities?
5. How much did pain interfere with doing your tasks away from
home (e.g., getting groceries, running errands)?
6. How often did pain keep you from socializing with others?
31Saurab Sharma - NITTE-PHYSIOCON 2017

27. Physical function (3)
Shoulder Disability
•Disability of Arm Shoulder and Hand (DASH) and Quick-
DASH.
•Shoulder Pain and Disability Index (SPADI).
•Excellent reliability coefficients (>0.8 for both measures)
K.C. et al. Thesis, Uni of Sydney
32Saurab Sharma - NITTE-PHYSIOCON 2017

28. IMMPACT recommendations
1. Pain
2. Physical functioning
3. Emotional functioning
4. Participant ratings of improvement and satisfaction with
treatment
5. Symptoms and adverse events and
6. Participant disposition
Dworkin, Pain, 2005
33Saurab Sharma - NITTE-PHYSIOCON 2017

29. Depression and Anxiety
1. Hospital Anxiety and Depression Scale (HADS)
• 14 items: 7 anxiety and 7 depression,
• Total score: 42
2. Beck Depression Inventory (BDI)
• 21 items
• Total score – 63
3. Beck Anxiety Inventory (BAI)
• 21 items
• Total score – 63
34Saurab Sharma - NITTE-PHYSIOCON 2017

30. IMMPACT recommendations
1. Pain
2. Physical functioning
3. Emotional functioning
4. Participant ratings of improvement and satisfaction
with treatment
5. Symptoms and adverse events and
6. Participant disposition
Dworkin, Pain, 2005
35Saurab Sharma - NITTE-PHYSIOCON 2017

31. Global Rating of Change (GROC)
•15, 11 or 7 point scale
36
Sharma et al., Preparation
Saurab Sharma - NITTE-PHYSIOCON 2017
Kamper, 2009

32. Other measures
1. Sleep quality
2. Resilience
3. Optimism
4. Pain catastrophizing
5. Central sensitization
Saurab Sharma - NITTE-PHYSIOCON 2017 37

33. MANAGEMENT OPTIONS
1. Surgical
2. Conservative
a. Pharmacological
b. Non-pharmacological
Saurab Sharma - NITTE-PHYSIOCON 2017 44
EBP

34. How is the treatment decided?
45
Prognosis &
Management
Pain
mechanism
Contributing
factors
Sources of
symptoms
Precaution/
Contra-
indications
Impairment/
dysfunction
Tissue
mechanism

35. Success of treatment
Clinician
factor
Social
factor
Patient
factor
46Saurab Sharma - NITTE-PHYSIOCON 2017
Treatment outcome

36. Qualities of a therapist required to
manage chronic pain
47Saurab Sharma - NITTE-PHYSIOCON 2017
Patient
Empathy
Educator
Knowledge
able –
assurance
Friendly
Trustworth
y
Exercise
promotor
Evidence
based

37. What works for chronic pain?
Works May work Doesn’t work
Education Deep brain
stimulation
Drugs – opioids
Exercise Transcranial brain
stimulation
Surgery
Assurance /
reassurance
Manual therapy –
joint and nerve
techniques
Soft tissue technique
(works only short
term)
Mindfulness
Acceptance and
commitment therapy
Cognitive behavioral
therapy
48Saurab Sharma - NITTE-PHYSIOCON 2017
Active
Treatment
Passive
treatment
Adjunct

38. Train the brain
Rationale
• Changes at the brain level
• Thought of movement painful
• Seeing others move is painful
• “Something terribly is going wrong in the tissue”
49Saurab Sharma - NITTE-PHYSIOCON 2017

39. Train the brain – cognitive
• “Nociception is neither sufficient nor necessary for
pain”
50
How dangerous
is it?
Is it safe?
Rx – convert danger
signals to safety
signalsBodyinmind.org

40. Emphasis of Explain Pain
6/2/2017 51
Credible evidences
of danger
Credible evidences
of safety
Increases
Pain
Decreases
Pain
Dangers in Me (DIMs) Safety in Me (SIMs)
Moseley and Butler, JoP, 2015

41. Training the brain
52
Most Threatening
Least threatening
Functional task
Movement
Reduce speed, range, duration,
frequency
Explicit Motor Imagery
Implicit Motor Imagery
Motor empathy
Moseley @ bodyinmind.org
Reducing the
threat of imagined
movement
Training
the
brain

42. Implicit motor imagery
(Left/ Right Judgment task)
53

43. Explicit motor imagery
(Imagine movements)
54
Imagine adopting these postures by
your own hands, and returning to where
it was.
Imagine smooth, pain-free movements

44. Movement (mirror)
• Adopt the posture of ‘good
hand’ in the affected side
Focus on:
•Easy movement that affected
side can produce
•No (or little) provocation of
pain
55

45. Movements/ Exercises
• Start with movement in head
• Move distant joints first (e.g., ankle for low back
pain)
• Start with small range of movement
• Progress to larger range
• Focus on the functional movements
56

46. Take Home Message
•Identification of biopsychosocial contributors are important
by complete assessment.
•Clinical reasoning important
•Consideration of biopsychosocial assessment may lead to
better treatment outcomes.
•Incorporate measures of function (physical, psychological/
emotional and social)
Saurab Sharma - NITTE-PHYSIOCON 2017 57

47. Any questions ?
Email: saurabsharma1@gmail.com
www.linkphysio.com
Twitter: link_physio
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