Hello. This is James Fricton. And we're continuing the course on prevention of chronic pain, a human systems approach. And I'm lecturing from the University of Minnesota again. And this module is entitled The Personal Impact of Chronic Pain. And the module has far, five parts, assessment of pain, using a transformative care model,. Characteristics of a pain evaluation. Interviews of people with pain. And then a module on who are you? Reflections on your own seven realms and how they play a role in the risk of chronic pain. So by the end of the module, I hope you'll be able to conduct a pain assessment, describe an examination for musculoskeletal pain. And outline different pain diagnoses and their contributing factors, as well as describe a treatment plan using a transformative care model. At the end of this, I'd like you to assess your own risk for chronic pain in the seven realms of your life. So the first part of this is assessment of pain using a transformative care model. Pain is a personal experience. And chronic pain really is about suffering. And as I mentioned in module one, it has a major impact on work, healthcare costs, and politics. But the most important aspect is the personal suffering that a person has, in every realm of their lives. So let's prevent it before it occurs I'd like to read a excerpt from the internet from a person who is suffering from chronic pain and this excerpt is very personal in her description. Let me just read it. You see I suffer from a disease that you cannot see. A disease that there is no cure for and that keeps medical communion baffled at how to treat and battle this demon, whose attack are relentless. And my pain works silently, stealing my joy and replacing it with tears. On the outside, we look alike. We look a lot like you and I. But you won't see my scars as you would a person who, say, had suffered a car accident. You won't see my pain in the way you would a person undergoing chemo for cancer. However, my pain is just as real and just as debilitating. And in many ways, my pain may be more destructive because people can't see it. And do not understand. And as this cartoon suggests, the doctor is looking at an x-ray. It's as I suspected. Mr. Harding, here, is possessed by demons. That's what it feels like to many people with pain. The pain is very personal. It's an experience that nobody else can see and feel. It's a basic assumption that we make about pain. But at the same time, even though it's personal, cannot be seen, it's a real experience. It's not in a person's mind and it's there for a reason, typically. And what is that reason? Well, whether it's acute pain or chronic pain, pain is protective. It's a warning sign that there is a problem that occurs. Acute pain, the cause is obvious, but with chronic pain it's not so obvious but there are many reasons and as a result of this pain and particularly chronic pain is complex experience. It involves all seven realms including the body, your lifestyle, emotions, society, spirit, behavior and environment. So how do we assess pain disorders, seeing that it's a personal experience? Well we use the same acronym as we use in all of health care. And that is to use a SOAP acronym to assess pain, and SOAP stands for subjective, which in this case are pain characteristics and it's impact. Objective findings including examination and imaging findings. A for assessment, these are the diagnoses and contributing factors. And P is for the plan, and this includes testing treatments, training the patient and the team. Let's go through each one these, of the SOAPS, to understand the different characteristics. So the subjective assessment has an acronym of FRIED. What I look for in my patients is, we examine for frequency and duration. Another number pain days per month is a good example of that. We look at restriction. R for restriction. This is the interference with activities and daily living, and disability days. We also look for I, the intensity, or severity of the pain. This is often used at 0 to 10 scale, but other scales that I'll show you in a minute. And then we look at emotion also, the emotional coping that a person has. How do they react to pain? How do they address and deal with their pain? And finally, D,. Which happens more frequently than we want is the disability associated with it. And we assess that. And I'll go over each one of these in a little more details. First of all, frequency and duration are charted. Here's a couple of questions that I use commonly. In the last six months, how long has pain usually last? Is it just for minutes, or hours, or is it constant? And in the last six months how many days a month have you had pain? In other words, frequency. because half the time, is it every day, is it five days a month? And then you can chart this over time to really see how a patient's improving over time and how their pain. Occurs. Now in addition to that, the definitions of pain are based on these temporal characteristics. For example, intractable pain is pain that continues everyday for months and months, and this is in weeks as described. Whereas chronic pain is prior to intractable and it's a continuous pain but it typically responds to treatment to some extent and becomes hopefully more intermittent as an acute recurrent pain. This is pain that may come on for weeks, but in between there are intervals of no pain. And then the pain occurs periodically into the future, depending upon what aggravates it or brings it on. And then there's subacute and acute pain. Subacute is acute pain that continues on beyond the first few weeks of normal healing, and it's a predictor that chronic pain. Is on the horizon. And then there's acute pain which occurs with a sprained ankle, a sprained wrist, a acute headache, and these typically are self limiting pains and will occur maybe for two to four weeks at the most. In addition to frequency and duration, there are restrictions and activities that are often recorded as a result of the pain. So questions such as how much has pain interfered with daily activities? How much has it changed your ability to take part in social activities? Has it changed your ability to work? 0 is frequently again no change and 10 is extreme change. In these categories. But how many days has it also interfered is another question. And the interference in activities can be noted. For instance, how many days has a pain kept you from your usual activity such as work, school, and housework, is a typical question. Maybe never, maybe sometimes, often, or always. And I is for intensity of pain as measured. So there's many different ways to measure intensity. I mean I typically ask the patient zero to ten. Ten is the most extreme pain, zero is no pain. But there are visual analog scales, or picture scales as shown in the slide. There are category scales as in the McGill pain questionnaire. Or there are Likert scales where you ask the patient to find out where their pain is on a scale from the left side to the right side. With either a number scale or a verbal scale. And we often ask patients to keep a pain diary too, because it's difficult to understand how the pain fluctuates over time and particularly what are the aggravating and alleviating factors. And E is for emotional coping. And this can be categorized in a variety of ways. Some people are passive copers, for they do no self management, they're completely dependent on medications or outside treatments, physical therapy, chiropractic care. And even surgery. Then there are some patients who are dabblers. These are patients who try self-care, see if it works, like, such as exercise, but if it doesn't work, they go right back to the passive treatments. There are some patients who are integrators. Now they use both self-care regularly, as well as come in for treatments. Injections, continue their medication, physical therapy, etc but what we really like are those patients who are self managers these are people who rely exclusively on their self management strategies in each of the seven rounds whether it's exercise, improving diet, making sure they get a good night sleep, pacing themselves over time. These are strategies that do work as well as any treatment. However, patients need to be motivated and understand what they need to do. And there are a variety of approaches to improve coping skills. This slide. Shows the results of the study by Jones, showing that before, after a individual session to explain patients on various ways to cope, it shows which ones are still being relied on three months later. And coping is explaining how they can reduce their pain themselves by improving risk factors. And protective factors. Whereas, improving understanding is just providing information for patients about pain as well as their pain condition and treatment options. Accepting is to help the patients really accept, the expectations with regard to what's going to happen for the pain in the future. And to make a commitment to self management and avoid catastrophizing that this is the end of their lives or they have cancer. And then calming emphasizing decreasing stress and takes many forms. Maybe to progressive relaxation, bio feedback, taking deep breaths. There's a lot of different ways to help calm a patient down. Particularly when the pain is more severe. And finally, there's balancing. Which assists patients in achieving routines to decrease their pain flares and their issues. Such as just simply improving their sleep, saying no to time management and pacing themselves with regard to their daily activities. So this demonstrated that at three months, most of the patients k, who were developing the coping strategies of reducing risk and improving protective factors were used the most. Understanding was also important, 21%. Being in a group with others. That social support they found to be very imp, helpful also. And calming strategies. So finally, with the acronym FRIED, D is for disability. And disability often results from pain. Here's a, a study of the veterans returning from Afghanistan and Iraq and they found that 45% of them are applying for disability as a result of pain. It's a staggering number of veterans coming back. Now if we were able to prevent or to, or manage this pain at an early stage, this disability wouldn't occur. But how do you define disability for something as subjective as pain? How do you know they're suffering from pain? Particularly if there's no imaging results. Well there's a variety of strategies, but it is tricky. And it is subjective. And there's a strategy called Residual Functional Capacity, which uses a variety of different characteristics to measure disability. For example, looking at pain itself, what is the location, the duration, the frequency and the intensity of pain? The functional limitations: what does a patient report that they can't do with their daily activities? Can they not drive, do household chores, prepare meals, hobbies, have interests? How do they sleep? How do they try to work? Can they dress, bathe, shave, or feed themselves? These are things that will help determine whether a patient can really not do them as a result of the pain. But in addition to that, looking at their healthcare use, is important too. The type dosage, effectiveness and side effects of medications taken is very important. What are other treatment that they've used continuously to document the fact that they continue to seek care and need care for pain. And then examining the mental and emotional effects of pain through again, self report strategies, as well as how to do they do self management strategies. Are they completely passive or are they very much self managers? And of course age, education, job skills, are all very important in determining disability. Well, that's the end of this lecture on pain assessments. The next module will be Characteristics of Pain Evaluation. [SOUND] [BLANK_AUDIO]
