Pain Sciences Division Newsletter

8/3/2019 Pain Sciences Division Newsletter

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ISSUE 5 Nov-Dec 2011

O FF IC IA L NE W S LE TTE R O F THE P A IN S CIE NCE D IV IS IO N O F THE CA NA DIA N P HY S IO THE RA P Y A S S O CI

Nociception?ws and information to help clinicians improve the lives of patients with pain.


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rom the Editor

Message from the Chair

Dave Walton, Chair

[email protected]

Debbie Patterson, Secretary

[email protected]

Lesley Singer, Treasurer

[email protected]

Diane Jacobs, Member-at-large

[email protected]

Susan Tupper, Newsletter Edito

[email protected]

Neil Pearson, Past Chair

[email protected]

Executive members

this final issue ofNociception?for the year 2011 we have an

teresting collection of articles covering a broad range of topics

ated to physiotherapy and pain. The feature article for this is-

e was written by Dr. Fiona Russell, a post-doctoral fellow con-

cting basic science research at the University of Calgary on pain and

ociception. This article reviews the neuro-anatomy and

europhysiology of nociception and pain. A good foundationalowledge of how nociception works and how it is related to pain helps

hysiotherapists explain this complex process to their patients. There

e two research study reviews provided by Dr. Steven Kamper and Dr.

manda Hall highlighting the role of psychological factors on the rela-

nships between pain intensity and disability. Neil Pearson has pro-

ded a commentary that looks at the fear avoidance model of chronic

ain from a different perspective. A Mother's Story draws attention to the

pact of pain on caregivers as well as patients and provides important

nsiderations when treating an adolescent with pain. The final article is

profile of the Saskatoon Chronic Pain Centre, a publicly funded

ultidisciplinary pain management centre in Saskatchewan. This profileovides information on the structure of the program, clients, outcome

easures, staff and goals for outreach and access. The pain clinic

ofile is a new regular series in which we will be profiling different pain

anagement centres across the country in each issue. I hope that you

d this broad range of topics interesting and informative. As always, we

elcome your suggestions, submissions and feedback on the

ewsletter. All the best for the holiday season!

ncerely,

usan Tupper

elcome to our final newsletter for 2011. The PSD is looking forward to some exciting events occurring in 2012 tha

ope will have an impact on both the PSD and physiotherapy more broadly. The National Pain Summit is scheduled

ccur April 24, 2012 in Ottawa. A similar national event in Australia has led to increased awareness and funding for

eatment and research, and we hold hope that the same will occur here in Canada. Farther abroad, the Internation

ssociation for the Study of Pain will hold their biennial international conference in Milan, Italy August 27-21, 2012.

always a great conference, and perhaps a good excuse to head to Milan.

oser to home, PSD continues to work with clinicians, teachers and researchers from within and outside of

hysiotherapy to create new and innovative learning opportunities for physiotherapists. Look for increased

oss-divisional representation in the CPA's teleconference program the first half of 2012, and some potential linkag

th other health care disciplines (more on that to come later).

the meantime enjoy the newsletter. My thanks go out to our new editor Susan Tupper and assistant editor Aaron

r their work in pulling this excellent issue together. I am personally excited to see so many contributions from expe

respective fields, and strongly encourage you as a reader and as someone with a clear interest in pain manageme

nsider submitting your own piece for publication. Only through sharing knowledge can we improve pain treatmen

.

nd finally, regardless of whether you celebrate Christmas, Hannukkah, Eid, Kwanzaa or any other holiday this time

ar, I wish you all a happy and healthy holiday season and a safe and prosperous New Year. Until next year!

ave Walton


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Figure 1. The mechanisms of pain signalling

A)The process involved when sensing a pastimulus such as heat, leading to an acute locapain.

B) The increased signalling and receptor activationoccurs during inflammatory conditions which leadpain hypersensitivity. Inflammatory mediators sucbradykinin, protons (H+), prostaglandins (PGE2), NGrowth Factor (NGF) and Brain derived neurotrofactor (BDNF) cause the activation and upregulatioreceptors in the periphery as well as enhanresponses centrally through transcriptional posttranslational mechanisms.

ain and Nociception

iona Russell, PhD

stdoctoral Fellow, Joint Inflammation and Pain Laboratory

partment of Physiology and Pharmacology, University of Calgary

he ability to perceive pain is a necessary safety mechanism so that organisms can remove themselvom the painful stimulus and away from any further harm. However, pain can become a severe problem if

ecomes prolonged and can manifest itself as one or more of the following; hyperalgesia (the increasensitivity to noxious stimuli), allodynia (pain from non-noxious stimuli) and spontaneous pain (pain arisi

the absence of any external stimuli). Pain is a major healthcare problem and chronic pain, defined as paersisting for longer than 3 months, affects approximately 1 in 5 of the adult population.

ormal pain sensation

nder normal conditions, the unpleasant sensory emotion that is termed pain is experienced due to tocess of nociception. Nociception is defined, according to the International Association for the Study ain (IASP), as the neural process that occurs upon detection of a noxious stimulus. It is important to noat under normal conditions nociception does not necessarily imply pain and vice versa.

ociception is initiated when a noxious thermal, mechanical or chemical stimulus causes the activation gh threshold sensory receptors called nociceptors. These nociceptors are located on the peripherrminals of primary afferent nociceptive neurons that are uniquely specialized to detect actual or potent

ssue damage. The subsequent opening of neuronal voltage gated ion channels triggers an action potenthich conducts the signal from the peripheral nerve terminals to the spinal cord. Transmission of this signthe spinal cord dorsal horn is mediated by the neurotransmitter, glutamate, (released from the cent

rminals) acting on ionotropic -amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors orsal horn neurons (Figure 1). Once nociceptive information is received by dorsal horn neurones, it is theonducted via projection neurones to higher centres of the brain, such as the thalamus, resulting in terception of a transient, localised pain. The organism can then remove themselves from the stimulus event further damage.


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Nociceptive neurons can be divided into two populations of primary afferents, C fibres and A fibresuman skin, approximately 70% of all primary afferent neurons are C fibres and 10% are A fibres. emaining 20% are A fibres which normally only transmit non-nociceptive information. A fibres h

medium-diameter cell bodies and fast-conducting thinly myelinated axons and when stimulated elicit a ra

sharp pain. C fibres differ from A fibres in that they have small-diameter cell bodies with unmyelinalowly conducting axons. Activation of C fibres results in a dull aching pain. Functionally, C fibres can eiespond to all three types of noxious stimuli (thermal, mechanical and chemical) and are known as polymoociceptors or they can just respond to a subset of these stimuli. A fibres have large cell bodies

myelinated axons with conduction velocities faster than both C and A fibres. Under normal conditionsbres only sense innocuous mechanical stimuli such as touch, vibration and pressure, thus activationhese fibres does not result in pain. However, under pathological conditions, activation of these fibres ead to pain.

Nociceptive neurons can also be characterised by their sensitivity to capsaicin, the active ingredient of hilli peppers. Capsaicin-sensitive neurons include a major subpopulation of polymodal C fibres anmaller population of A fibres. Exposure to capsaicin elicits a sensation of burning pain, due to the selecctivation of these nociceptive neurons. Capsaicin creams have been developed as a treatment optionelieving some types of pain, including pain from osteoarthritis. The proposed mechanism through wuch creams act is that prolonged capsaicin treatment may lead to depletion of neurotransmitters and desitization of peripheral nociceptors. In 1997, the capsaicin receptor was identified and is now known asransient receptor potential vanilloid receptor 1 (TRPV1; Caterina et al., 1997). TRPV1 is a ligand gated nelective cation channel that can also be activated by noxious heat (>43C) and extracellular protpH


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ain and Nociception

iona Russell, PhD

eripheral sensitisation is mediated by inflammatory molecules that are released from damaged cells during tissuury. These mediators can either act directly on their specific receptors on sensory nerve terminals or can Indirectfluence sensory nerve activation through stimulating the release of neuroactive agents. These effects combine tuse an overall increase in the excitiability of the sensory neuron. Sensitisation can also be amplified throug

anscriptional changes whereby increased expression of receptor and effector molecules occurs. However, due te time necessary for transcription and transport of new proteins, this effect is only seen several hours after thnset of inflammation.

entral sensitisation can occur if there are repetitive or high intensity stimuli, leading to increased glutamate releasnd activation of another glutamate receptor on the dorsal horn, the N-methyl-D-aspartate (NMDA) receptor. A higtensity stimulus will also lead to release of neuropeptides, particularly substance P, which can act on the neurokin(NK1) receptor on the dorsal horn. This generates a higher postsynaptic response and leads to greater Ca

2+ influto the dorsal horn and activation of kinases such as protein kinase C (PKC). PKC can phosphorylate NMDA anMPA receptors resulting in alterations in their channel kinetics. For example, normally Mg2+ is bound to the NMDceptor preventing its activation but phosphorylation of this receptor prevents the Mg2+ block thus allowing NMDA

ecome more responsive to glutamate. These modifications result in the ability of sub-threshold inputs to activatorsal horn neurons and, consequently, pain can now occur from non-noxious stimuli and noxious stimuli result ven greater pain (Figure 1).

nother important change which contributes to inflammatory pain hypersensitivity is the apparent ability for henotypic switch in a subset of myelinated primary sensory neurons. A sensory nerve fibres express touch receprs that normally only respond to low threshold stimuli. However, it has been shown that during inflammation thes fibres can start to express the pro-nociceptive neuropeptide, substance P. Therefore, A fibres stimulated by on-noxious stimuli such as a light touch, respond by releasing substance P from their central terminals. As menned above, substance P can activate NK1 receptors expressed on dorsal horn neurons resulting in an increase

xcitability of these dorsal horn neurons. This ultimately means that a light touch that stimulates A fibres, now relts in the perception of pain and is referred to as tactile allodynia.

here is also a subset of C fibres (approximately 10-20% of all C fibres in the skin) that under normal conditions d

ot respond to acute noxious stimuli, thus are referred to as silent nociceptors. However, under inflammatornditions, these nociceptors can be sensitised and activated by various inflammatory mediators thus increasing thverall C fibre input in the dorsal horn.

europathic pain

his article has focused on normal pain processing and inflammatory pain but it is important to remember that pain also be caused by damage or disease of the sensory nervous system. This type of pain is termed neuropath

ain. Diseases that can result in neuropathic pain include stroke and diabetes.

or an in-depth discussion on the induction of pain see the comprehensive review by Millan, 1999.

hough much more is known now about pain mechanisms, there is still a lot of work to be done to fully understan

ain in order to provide adequate relief. Currently available pain treatments are often unsatisfactory for many pants and commonly result in serious side effects. More pain research is required to understand this complex probm and to enable the development of novel therapies.

eferences

terina M.J., Schumacher M.A., Tominaga M., Rosen T.A., Levine J.D. & Julius D. (1997) The capsaicin receptor: a heat-activated ion channthe pain pathway. Nature 389, 816-824.

lan M.J. (1999) The induction of pain: an integrative review. Prog Neurobiol 57 (1), 1-164


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StudentsWe need YOU and you need COFFEE!

The editors ofNociception?are looking for 6 students to be part of a

student contributors panel. As a prestigious member of this panel,

you would write one short piece (1-2 pages) for a new segment in the news-

letter. The segment will profile different pain clinics from across the country.

You can see the first edition on page 15. There is a template to follow for

gathering information and you would receive writing assistance from one of

the editors. This opportunity will provide you with valuable skills in interview-

ing, and writing for a journal/newsletter. You will even get publication credit for

your piece - looks great on the CV. It gets better! To thank you for your par-

ticipation, all 6 members of the student panel will receive a $15 gift card to

Starbucks. To apply, simply send your preferred email address and name to

[email protected].

Neil Pearson will be offering pain science and pain management courses to health care professionals inKingston, Montreal, San Francisco, Maui, Vancouver, Ottawa, Banff, and Golden in 2012. Neil will also pro-vide instructional courses in 2012 to yoga teachers and yoga therapists interested in how to safely and effectively provide yoga to people in pain. Locations and dates at www.lifeisnow.ca.

Neils popular patient education book, Understand Pain, Live Well Again is now being translated to FrenchThis ten-section book has taken some intense work to translate while maintaining the simple conversationatone. Plans are to make it available www.lifeisnow.cain French by mid-2012.

People in pain with an interest in self-management and Yoga can now immerse themselves in gentle Yogapractices specifically designed to address the issues of chronic pain. Four days might sound like a lot for aperson in pain to tolerate, but the practices are gentle, with as much focus on breathing, meditation and bodawareness techniques as there are on yoga movement practices. Neil Pearson, PT, MSc, has expanded histherapeutic yoga beyond classes in Penticton, to retreat centres on Salt Spring Island, Comox and Na-ramata. Level one retreats will be offered in a variety of centres each year, while Level 2 retreats will alter-nate between Salt Spring Island and the Okanagan Valley. For more information, visit www.lifeisnow.ca/pip/retreats.

Neil has also updated his website offering more resources and assistance for people in pain. Transcriptionsof body awareness and of breathing techniques are now available for those who cannot afford audio CDs.Anyone can simply open the file, and then read the transcription into a microphone (on a computer or smartphone). Free self-management assistance supports our patients whose pain has negatively impacted theirfinances. Additionally, some say that there can be huge power in hearing your own voice guiding you withbreathing techniques and meditation.
http://www.lifeisnow.ca/http://www.lifeisnow.ca/http://www.lifeisnow.ca/http://www.lifeisnow.ca/http://www.lifeisnow.ca/pip/retreatshttp://www.lifeisnow.ca/pip/retreatshttp://www.lifeisnow.ca/pip/retreatshttp://www.lifeisnow.ca/pip/retreatshttp://www.lifeisnow.ca/pip/retreatshttp://www.lifeisnow.ca/http://www.lifeisnow.ca/


7/18

Research News and Reviews

oes fear of movement mediate the relationship between pain intensity and disability in patientsllowing whiplash injury? A prospective longitudinal study

amper SJ, Maher CG, Menezes Costa LD, McAuley JH, Hush JM, Sterling M. Does fear of movement mediate the relationshiptween pain intensity and disability in patients following whiplash injury? A prospective longitudinal study. Pain. 2011 Nov 2.pub ahead of print]

he mechanism by which pain results in disability or functional limitation in musculoskeletal conditions is not well unerstood. Fear avoidance theory is one model that suggests a cognitive process may explain this relationship. Theeory proposes (more or less) that people believe their pain is representative of some catastrophic pathology, therere they reduce their activity in order to avoid doing more damage and making their pain worse. The aim of ourudy was to test fear avoidance theory (as measured by the Tampa scale and the PFActS) in a cohort of people withiplash injuries. To do this we used mediation analysis. In its simplest form, mediation analysis aims to quantifyhat proportion of the relationship between two variables (pain and disability) can be explained by the influence of ard variable (fear avoidance). The ultimate goal is to delineate causal pathways, in this case; does pain result in dis

bility in people with whiplash injuries due to fear avoidance.

e found that about 20-40% of the relationship between pain at baseline (


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Do symptoms of psychological distress mediate the relationship between initial low back pain andersistent symptoms of disability?

Hall AM, Kamper SJ, Maher CG, Latimer J, Ferreira ML, Nicholas MK. Symptoms of depression and stress mediatehe effect of pain on disability. Pain. 2011 May;152(5):1044-51.

Chronic pain is used to describe conditions in which a patients symptoms last weeks, months or years beyond thexpected recovery time. The mechanism(s) underlying the transition from an initial episode of pain to chronic pain inclear. In the case of non-specific low back pain, the majority of patients tend to recover within 4-6 weeks afterain onset. However, approximately one third of patients develop chronic back pain, reporting on-going symptomsor more than 12 weeks. Unfortunately, for this population, current treatment options offer only small to moderateenefits. A question that has been plaguing clinicians and researchers is why do some patients recover quickly andthers develop chronic symptoms? A theoretical model linking initial pain with chronic disability via symptoms ofsychological distress has been proposed. In this model, it is suggested that the initial experience of pain can in-

uce symptoms of psychological distress in the patient, ie symptoms of stress, anxiety or depression, and theseymptoms themselves can induce ongoing symptoms of disability for the patient. Following this model, if theymptoms of psychological distress are treated then perhaps ongoing disability can be prevented. This model,owever, has yet to be tested and determining its validity is an important first step for the direction of future researc

n chronic low back pain. The aim of our study was to test the model using mediation analysis. This analysis wassed to quantify the proportion of the relationship between sub-acute pain and chronic disability that can bexplained by symptoms of psychological distress. Pain was assessed using the 0-10 numerical rating scale,

Disability was assessed with the Roland Morris Disability Questionnaire, symptoms of psychological distress weressessed using the Depression Anxiety and Stress Scale (DASS).

We used data from an existing data set in which 231 patients with sub-acute low back pain (pain persisting for 6-12weeks) were recruited for an RCT investigating the effects of a 6 week course of physiotherapy. Outcomes of pain,isability and psychological distress were assessed at 3 time points; (i) baseline directly before study, (ii) directlyfter the 6 week treatment and (iii) 6 weeks after the treatment finished. We found that about 25-30% of the relationhip between sub-acute pain (measured at baseline) and long-term disability (measured 6 weeks after treatment

s explained by symptoms of depression and stress. Thereby, for this sample of patients, a proportion of how anpisode of pain leads to chronic disability was due to their levels of depression and stress. Interestingly, anxiety waot found to be a significant mediating variable. As this was an exploratory study, there are several limiting factors tonsider when interpreting the results in terms of causation. These include the nature of the analyses, the timing ofata collection, and issues surrounding accuracy of the measures. For example, patients in this study already hadain for at least six weeks, therefore the first measure of symptoms of psychological distress we have is also at leaix weeks after pain onset, thus it is unclear whether these symptoms were in fact pain-induced or if they werelready present before the onset of pain.

Overall, while limitations exist, this study provides further evidence to support the influence of psychological distres

n particular depression and stress) in the transition from acute to chronic low back pain. These findings provide anpportunity to decrease the risk of chronic pain with early identification and appropriate interventions. However,

while it might appear that screening for and targeting treatments towards psychological distress is the next step foruture research, this may be premature, as there are still a number of unanswered questions. At this point, futureesearch should focus on testing the model in a more rigorous study design to confirm the existence of the causalathways. Once there is further confirmation of the hypotheses, the mechanisms for how pain induces psychologicaistress and eventual disability should be explored to inform effective treatment design.

Submitted by,

Amanda Hall, PhD, Post Doctoral Research Fellow TheGeorge Institute for Global Health, Australia.


9/18

There is a huge gap in our view of patients from a fear avoidance model.

here are many research papers on fear-avoidance that explain to us that fear of pain, fear of movement and/or feaf injury are important aspects of the development of chronic pain conditions. If I understand the model correctly, pa

may lead to anxiety and catastrophic thoughts about such things as damage in the body, or beliefs of a new fragilityhe body, or the permanence of the pain. When pain is associated with a movement, fear then will become associa

with the movement, and as such the fear of the pain will cause an individual to avoid movements that might causeain. This avoidance of movement will then lead to deconditioning, and this deconditioning in and of itself becomeserpetuating factor for the pain and fear and avoidance behaviours.

his sounds plausible, and I guess we shouldnt really dispute it too much because there is so much written about ind so much research using the model. Then again, you probably have guessed correctly that I am going to ask yoo look at it from a different perspective. It is not that I would suggest we toss the model aside. Rather we should coider whether other research supports it, and whether the model is helpful for us as clinical physical therapists. A reent article by Pincus et al. (2010), also suggests we need to look at fear avoidance differently. It is worth a read.

ets start with the positive. Fear of movement is a mediating factor in the development and persistence of chronicain. (Leeuw 2007). There is also some evidence that when we provide interventions that change the individuals fe

f movement, there are measurable increases in actual movement and decreases in pain.(Leeuw et al. 2008)

We also have ample evidence that it is possible to create fear of movement by associating the movement with painMeulders et al. (2011) have recently reported an interesting research paradigm that even allows us to differentiateear of movement related to predictable versus unpredictable pain. This will help our understanding of fear of move

ment in people whose pain arises predictably from specific movements versus those in whom the pain is difficult toredict such as those with fibromyalgia.

Moseley (2011) explains to us in a recent commentary that there is accumulating evidence that pain disrupts senso

nd motor processing in a manner consistent with avoidance behavior. As such, it appears that our systems are cr

ting avoidance behaviours as protective responses, and that these may not be specifically driven by cognitive proc

sses. This suggests that we should consider that fear and avoidance behaviour likely has two components ones

hat are automatic and ones that are cognitive. As physical therapists (PTs) we should be addressing our interven-

ons to both of these. When we provide pain education this addresses cognitions. When we teach people to move

with less pain, improve motor patterning, or assist with sensory distortions, we may be directly accessing the auto-

matic processing. When the patient gains awareness of the ability to self-manage this will also leads to cognitive

hanges. In other words, treating fear-avoidance at both levels is well within the scope of PT practice.Kamper et al. (2011) have recently shown that 20-40% of later disability can be accounted for by initial pain in peopwith whiplash associated disorder (WAD). This is enough relationship for them to state that this supports the fear-voidance model. They go on to state, it is well recognized that factors other than pain intensity influence the disaby levels of people with WAD.

his is where I believe PTs must take a closer look at this model as well as conclusions that support it. When ourssessment finds someone scoring high on fear avoidance, we must recognise that it is not the only barrier to recovry, and may not even be the most important one. Individuals may get better regardless of their beliefs about move

ment and pain, or regardless of their emotional fear of movement, when we are able to address other aspects of thhronic pain effectively. Alternatively, the fear of movement may shift substantially when other factors are resolver improved.

ommentary


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he situation becomes even more complex when we consider that your patients reports of fear avoidance may beiven by many apparently unrelated psychological and social factors. For example, Alschuler et al. (2011) found arong relationship between activity avoidance and family dynamics. Such relationships reinforce the importance ofterdisciplinary care and possibly inclusion of families in successful pain management and that the fear itself mayot be the problem we need to address even when the questionnaires say it is present.

ousema et al. (2007) suggest that results of questionnaires on fear avoidance provide different findings thanbservational measures of avoidance behaviors Unlike others, these authors measured daily activity levels andness levels (weight, body fat and strength). In their longitudinal cohort study over one year with people with lowack pain (LBP), they found no evidence to support that people with chronic LBP suffer from disuse and physicalnditioning." This does not seem to support the fear avoidance model (as an aside, J Vlaeyan was an author of thisudy). Without a test of behaviour (likely one that is sensitive enough to differentiate the automatic from conscious

ntrol of movement) we will not have an accurate evaluation of how fear really impacts behaviour. I'm notcommending that you throw out the TSK and PCS, rather, that PTs are aware of their limitations. One of themitations of these questionnaires that I notice is that they do not ask respondents if they use any other copingrategies when they approach movement.

hat do we take from this? First, the premise that pain leads to deconditioning is open to debate. As such, weould question (for many other reasons as well) the idea that getting people back into shape will decrease their

ain. I propose that it does not. Resuming normal activities and fitness activities are still beneficial, but likely for otheasons such as improved motor and sensory functioning, improved self-efficacy, decreased hopelessness and

elplessness, reconnecting a person to their identity and community and reversing neuroplastic changes.

econd, we need to look closely at the difference between reports of fear of movement, and actual movement and

nction. Do our patients demonstrate fear of movement? Is this task specific or related to all movements? Whatbout the people who use their strength of will to get the job done, and then pay for it later. It seems rare when wed a person who doesnt report this as an active coping strategy. Yet is this fear avoidance behaviour? Maybe theirar of the consequences of not accomplishing something drives them to avoid paying attention to the pain. Yet, thisnot how we view the model. Maybe the reason these people do not show up in research is that the popularestionnaires do not ask questions about what Hasenbring and colleagues (2010) call task persistence or

ndurance behaviour. There are very few studies in the area of chronic pain that discuss the grit your teeth andush ahead behaviour. As such, Hasenbrings paper is worth a look. Be wary of the language though, as even theyl to the default biomedical position that pain is from tissues. For instance, they state, Patients that will exclusivelow an (endurance response) pattern, with high scores on endurance behavior despite severe pain will have agh risk for physical over-activity leading to overuse or overload of physical structures. It remains all too easy toame the tissues for pain.

s PTs helping people regain motor, sensory and life function, it is imperative that we see beyond the fear avoidancodel view of our patients. We must assess fear of movement cognitively and physically, and for specific tasks. Thee provide appropriate treatment and activity prescription to address our findings, with our eyes focused towards aain science view of the person and their limitations. We must recognise that if we only look at the scores of disabilitdexes and scales of fear and kinesiophobia, this is not necessarily providing an accurate indication of the individ-als actual daily activity or their approach to movement or activity. When we assume it does, we become stuck inne view of patients. The application of critical thinking about the tools we use, and our approach to patients willow us to provide the best possible care when helping our patients manage their pain and improve their function.

ubmitted by,

eil Pearson MSc, BScPT, BA-BPHE, CYT, RYT500inical Assistant Professor, UBC

here is a huge gap in our view of patients from a fear avoidance model.


11/18

eferences:

lschuler K., Hoodin F., Murphy S., Rice J., Geisser M.E. (2011) Factors contributing to physical activity inchronic low back pain clinical sample: A comprehensive analysis using continuous ambulatory monitorin

ain 152: 25212527.

Moseley L. (2011) A new direction for the fear avoidance model. Pain 152:2447-2448.

amper S., Maher C., Menezes C.L. Does fear of movement mediate the relationship between pain inten-ty and disability in patients following whiplash injury? A prospective longitudinal study. Pain. 2011 Nov 2

Epub ahead of print].

eeuw M,Houben R,Severeijns R,Picavet H,Schouten E,Vlaeyen J. 2007. Pain-related fear in low backain: a prospective study in the general population. Eur J Pain,11(3):256-66.

eeuw M, Goossens M, van Breukelen G, de Jong J, Heuts P, Smeets R, Kke A, Vlaeyen Jl. 2008. Expoure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized con-olled trial. Pain. 15:192207.

Meulders A., Vansteenwegen D., Vlaeyen J. (2011) The acquisition of fear of movement-related pain andssociative learning: A novel pain-relevant human fear conditioning paradigm. Pain 152: 24602469.

ousema E., Verbunt J., Seelen H., Vlaeyen J., Knottnerus A. (2007) Disuse and physical deconditioning the first year after the onset of back pain. Pain 130: 279286.

asenbring M., Verbunt J. Fear-avoidance and endurance-related responses to pain: New models of be-

aviour and their consequences for clinical practice. Clin J Pain 26:747753.

incus T., Smeet R., Simmonds M., Sullivan M. (2010) The fear avoidance model disentangled: Improvinghe clinical utility of the fear avoidance model. Clin J Pain 26:739746.

urther recommended reading:

cascighini L, Sprott H. (2008) Chronic nonmalignant pain: A challenge for patients and clinicians. Nat Reheumatology 4: 74-81.

There is a huge gap in our view of patients from a fear avoidance model.

Neil Pearson MSc, BScPT, BA-BPHE, CYT, RYT500
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Leeuw%20M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Leeuw%20M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Houben%20RM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Houben%20RM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Severeijns%20R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Severeijns%20R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Picavet%20HS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Picavet%20HS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Schouten%20EG%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Schouten%20EG%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Vlaeyen%20JW%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Vlaeyen%20JW%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/16546425http://www.ncbi.nlm.nih.gov/pubmed/16546425http://www.ncbi.nlm.nih.gov/pubmed/16546425http://www.ncbi.nlm.nih.gov/pubmed?term=%22Vlaeyen%20JW%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Schouten%20EG%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Picavet%20HS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Severeijns%20R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Houben%20RM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Leeuw%20M%22%5BAuthor%5D


12/18

CIRPD Chronic Pain Needs Assessment Survey

Dear Friends and Colleagues,

CIRPD is collaborating with partners at the University of British Columbia to promote our Chronic Pain

Needs Assessment Survey. We are seeking input from people with chronic or persistent pain to better

understand what types of information resources they are seeking.

As a health professional, community advocate or researcher, you may have people you come in contact

with who suffer from chronic pain. We ask that you provide the information about this survey to your

clients, friends, constituents, staff or peers by:

Sending an email blast

Posting the information on your website or in an e-newsletter

Tweeting this information

Posting the attached PDF flyer announcing the UBC Chronic Pain Needs Assessment Survey at

your front desk or on a public bulletin board/staffroom etc.

Below is sample content for e-mail, website or newsletter posting with all of the pertinent information on

the survey.

UBC Chronic Pain Needs Assessment Survey

CIRPD is collaborating with partners at the University of British Columbia to promote our Chronic Pain

Needs Assessment Survey. We are seeking input from people with chronic or persistent pain to better

understand what types of information resources you are seeking. By completing this online survey you

can help define the tools and information most urgently needed by people suffering from chronic pain.

This survey takes approximately 20-25 minutes to finish. If you have not already participated, we encour-

age you to do so and help shape the tools and resources available to people with pain.

Over 200 Canadians have already responded. Join the conversation and let researchers, organizations

and health professionals know what resources you need for your pain management!

Take the Survey Now!

Please pass this link on to others who suffer from pain as well!

Canadian Institute for the Relief of Pain and Disability, 204 916 West Broadway Avenue, Vancouver,

BC V5Z 1K7 Canada

Tel: 604 684-4148, North American 800-872-3105 Fax: 604 684-6247

www.cirpd.org


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UBC Chronic Pain Needs AssessmentInternet Web Survey

Invitation to ParticipateDO YOU SUFFER FROM CHRONIC PAIN?

ARE YOU 16 YEARS AND OLDER?

WE ARE SEEKING input from people with chronic or persistent pain to better understand what typesof information resources you are seeking.

What does it involve?

The online survey takes 20-35 minutes.

Participants will have access to a summary of survey results.

Participants will be invited to review web resources created as a result of the study.

For further information contact:Tonya Hyde604-684-4148

Researchers

Marc I White PhDClinical Assistant ProfessorDept of Family Practice, UBCKenneth Craig PhDProfessor EmeritusDept of Psychology, UBC

Izabela Schultz PhDProfessorCounseling Psychology, UBCCarlo Marro PhDAssociate Professor

Faculty of Pharmaceutical Sciences, UBC

Learn how you can participate:GO TO THE SURVEY WEBSITE:

http://bit.ly/cirpdsurvey-org


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A MOTHERS STORYSubmitted by: Debbie Patterson

Olivia is a 15 year old with a 2 year history of endometriosis, which progressed to a diffuse painpicture and indications of strong central sensitization.

There are many biomechanical issues that needed to be addressed, including extremely poorbreathing, however, the larger pain picture needed to be addressed.

She has been treated in physiotherapy with an emphasis on understanding pain, identification ofctive coping strategies, and functional goal setting. The treatment was provided in her home, or

via Skype.

Olivia has very graciously allowed herself to be videotaped to tell her story with the hope that shean help some other teenage girl with a similar struggle with pain. However, her mother also has

good insights that are helpful to us as treatment providers. The following is her contribution.

Being a mum of a teen in chronic pain has been the battle of my life. To have a child in pain, isolated fromchool, without answers for so long, is soul destroying.

The journey is a roller coaster of emotions and the unknown outcome is frightening.

After a year of pain tests, surgery, complications, and medications, Olivia was deconditioned to such anxtent that she was using a wheelchair. Within one week of using pain management techniques, she wasmuch calmer person. Within 6 weeks she was walking, playing volleyball and swimming. It was still a

ong haul from there of physical rehabilitation, cognitive recovery and life management.

Please consider:

. Drugs arent always the answer.

. These are young adults: LISTEN to them and treat them as such.

. Screen your teens in pain early for risk of chronic pain and provide some information on tools that canhelp turn the pain system down. There might be a wait for treatment resources, but at least give them

some options.. Stop the deconditioning.

. DO NOT tell them to just go back to school and everything will be better. There is a lot of tedious pro-gress that has to happen gradually and successfully.

am lucky because I have a daughter who doesnt quit, and we found a physiotherapist who works withhronic pain. We now have resources to help us with the best care for Olivia.


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Program

Structure

The CPC, open since 2004, provides a program that is 6 weeks induration. For the first 4 weeks, clients attend daily for 4 hours per day. Fothe fifth week, clients do not attend the CPC program. Instead they work

on self management strategies learned in the previous weeks. For the 6thweek, clients return to the CPC for a final week of daily sessions for 4hours per day.

Scheduling

Clients who meet the criteria and agree to attend the program are sched-uled to attend in blocks, meaning that all clients attending a particularblock start and finish the program on the same day. There are 8 clients peblock.

Program Com-ponents

All clients are scheduled to work with PT, OT, psychologist, RN and thephysician during the program, but the individual content and frequency ofthe scheduling depends on the client needs. All clients attend group

education and exercise sessions daily. Weekly group sessions include:goal setting, mindfulness, relaxation, and a discussion session with thepsychologist or OT. Two aquatic exercise sessions in a warm pool(located within the hospital) are scheduled during the 6 week program.Clients have scheduled self-management time daily to use at theirdiscretion that they can use either to practice the skills they have learnedduring the program, or use other pain self-management strategies thatthey find effective.

Follow-up

3 months following discharge, clients return to the CPC for a 2 hour

follow-up session at which they fill in questionnaires and participate in adiscussion.

Group Educa-tion Session

Topics

neurophysiology of chronic painsleep hygienegoal settingcore strengthexerciseflare-up managementnutritionmedications (taught by pharmacist)managing health

tissue healing

ClinicName

Chronic Pain Centre (CPC)

Location 8th floor of Saskatoon City Hospital, Saskatoon, SK

Email [email protected]

http://www.saskatoonhealthregion.ca/your_health/ps_chronic_pain_about.htm

Multidisciplinary Chronic Pain Management Centre Prof

Profile contributed by: Susan Tupper, PT, PhD CandidateInterview provided by: Anna Power-Horlick, RN, Client Care Coordinator for the CPC
mailto:[email protected]:[email protected]:[email protected]


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Outcomes

Client Re-ported Out-

comes

Each profession bases treatment on individual assessment ofclients. At intake, on discharge, and at follow-up clients completethe following 8 questionnaires:

Tampa Scale for Kinesiophobia (TSK-13)Beck Depression InventoryMultidimensional Pain Inventory

Canadian Occupational Performance MeasurePain Disability IndexPain Coping ScaleChronic Pain Acceptance Questionnaire - Revised (CPAQ-R)Self Efficacy Scale (CPSS)

PT Func-tional Meas-

ures

PT collects the following functional measures at intake anddischarge:

Single leg stance balance (time to first touch-down and totalbalance to 30 seconds)

20 metre speed walk (time to complete)Stair climb (number steps in 1 minute)Sit to stand (number completed in 1 minute)

Sit and reach (centemetres)

Clients

General

The CPC in Saskatoon is the only dedicated, inter-professional,publicly funded program of its kind in the province and thereforeis intended to serve the entire adult population of Saskatchewan.

Inclusionsand Exclu-

sions

The CPC is available for clients 19 years of age and older. Clientsmust be diagnosed with chronic pain, have no ongoing medicalinvestigations or open litigation, and be willing to attend theprogram after it has been thoroughly described by the client'sfamily doctor or other referring health care provider. Clients areexcluded from the program if they have frail health, unstablepsychiatric conditions or ongoing addictions issues. The CPC is a

supportive program for individuals with chronic pain and not areturn to work program.

Staff

Staff Compo-nents

1.5 PT1 RN1 PhD Psychologist1 OTphysician support 1 day/week1 administrative assistant

Role of PTThe PT role is to provide direct patient care with assessment andinterventions. PTs provide individual and group educationsessions and facilitate group exercise classes.

Current Concerns of the CPC

Approximately 80% of the clients attending the CPC live within the

city of Saskatoon. Travel and accommodation for out-of-townresidents is at their own expense and presents a barrier to accessfor those not living nearby. The CPC is currently investigating waysof improving access to care for individuals unable to attend theCPC including telehealth and outreach clinics.

Community Support

Staff at the CPC provide education for community health careproviders (e.g. family medicine grand rounds) and support forinter-professional education for various health disciplines. Staffoccasionally act as resources for community therapists.

T - physical therapist OT - occupational therapist RN - registered nurse

Multidisciplinary Chronic Pain Management Centre


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osition statements on Advertising and Product/Course reviews in Nociception?

. Advertising

he PSD newsletter will include advertisements of treatments, education or products which meet the following critea:

Are within the scope of practice of PTs in CanadaAre consistent with a biopsychosocial model of pain and interdisciplinary management.

he PSD newsletter will not include advertisements of treatments, education or products:

That include claims not supported by sound evidence.That solely promote a biomechanical or biomedical view of pain.That claim guaranteed or consistent effectiveness without regards to the uniqueness of people in pain

. Reviews of products

he PSD newsletter editor will consider Reviews of Products that meet the following criteria:

The product must have scientific evidence supporting effectiveness. (at present we cannot exclude educational

courses that do not show evidence of positive changes in participant clinical practice no one is studying this).

If this is basic science rather than outcome studies, the review must include this information.

The reviewer must provide evidence to support their view of the products efficacy beyond patient preference/

testimonials.

The reviewer must disclose any conflict of interest in which he/she stands to gain either financially or otherwise

through adoption of the product

he PSD newsletter editor will not publish Reviews of Products for the following reasons:

The product is not in the scope of practice of physiotherapists.

The product is deemed to lack scientific credibility.

When there is a potential conflict of interest with any PSD executive member.

is not the role of the PSD, including the newsletter editor, to perform a thorough review of the evidence in support

f or refuting a particular approach to treatment. Rather, it is the responsibility of the person submitting the review

ake an unbiased and objective stance, identifying both strengths and weaknesses of the approach, product or tech

ique, and to convince the editor that due diligence has been exercised in providing a fair review. While personal

xperience with a product or technique is valuable and potentially publishable, the likelihood of publication will in-

rease if the reviewer has demonstrated that even a cursory search for evidence has been performed, or has soug

ut the opinions of respected others (colleagues, patients, experts in the field, etc).

BUSINESS


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We want your submissions!

Attention budding and seasoned writers alike: were looking for you! Nociception?Is a bi-monthly electronicpublication that is available to all Pain Science Division members.

Opinion papers, reviews of the scientific literature, abstracts, courses or books, all are welcome as submissionsto our newsletter editor. Submission are reviewed by our editorial team and considered for inclusion in thenewsletter. If youve got something youd like to submit, send an electronic copy to Susan Tupper at:[email protected] with the subject heading "Newsletter submission."

For those wishing to submit an item to be included, please observe the following deadlines:

All submissions should be prepared in a file format compatible with Microsoft Word (any version), which wouldnclude documents prepared in Microsoft Works, OpenOffice and Apples iWork. Note that documents notprepared in Microsoft Word may suffer from formatting problems when opened in Word, which might result in adelay in publishing your submission. It is recommended that those who prepare their submissions in a differentword processor environment try to open it in Word prior to submitting it, to ensure that all formatting, special

characters and images or tables look as intended.

Documents should be prepared using 12-point Arial or similar font, not compressed (ie. not Arial Narrow).Margins should be maintained at 1 around the document. A 5-page limit, not including references or appendi-ces, is loosely enforced. Longer submissions can be negotiated with the newsletter editor. References shouldbe arranged in alphabetical order in a list at the end of the document, following guidelines of the Journal ofOrthopedic and Sports Physical Therapy, available at:http://www.jospt.org/docLib/20110113_January2011InfoandInstructionstoAuthors.pdfCitations throughout the text should be superscript numbers referring to the position of the citation in the refer-ence list. Images and tables are welcome, although clarity cannot be guaranteed for highly detailed or complexmages.

Issue Deadline

January-February December 2

March-April February 15

May-June April 15

September-October August 15

November-December October 15

ubmissionsSubmissions
http://www.jospt.org/docLib/20110113_January2011InfoandInstructionstoAuthors.pdfhttp://www.jospt.org/docLib/20110113_January2011InfoandInstructionstoAuthors.pdfhttp://www.jospt.org/docLib/20110113_January2011InfoandInstructionstoAuthors.pdf