The Foundation for Medical Excellence 27th Annual Pain & Suffering Symposium http://tfme.org

1. S
Practical Tools & Tips from an
Interdisciplinary Pain Team
for Use in the Busy Family Physician‟s Office
Dr. Matt Graham, R. Psych
Jimena Malzahn, B.Sc.(PT)
Cara Rodrigues, B.Sc., B.Sc.(OT)
OrionHealth Rehabilitation & Assessment Centres

2. exercise

3. objectives
S our Lens: how we see the chronic pain
patient (biopsychosocial)
S our Approach: literature understandable
language
S some Tools: translated for the sole
practitioner

4. key messages for our patients
S validate the pain experience
S acutechronic
S pain neurophysiology
S active vs passive coping
S treatment vs management
S talk „nervous system sensitivity‟ language
S function focus
S ADLs/IADLs and the value of WORK
S “it hurts but it‟s not harm”

5. what does the literature say regarding
approach
“An approach that would include a focus on fear and
avoidance beliefs, catastrophizing, and depression could
greatly improve patient functioning and enhance the
secondary prevention of chronic disability, including sick
leave.” (p 165)
(Boersma & Linton, 2006)

6. biopsychosocial
Reference: Main, C.J., de C Williams, A.C. (2002) ABC of psychological medicine: Musculoskeletal pain. British
Medical Journal, 325, 534- 537.

7. yellow flags—early signs of
Pain Disability
Early warnings of pain disability
S Belief that back pain is harmful or potentially severely
disabling
S Fear and avoidance of activity or movement
S Tendency to low mood and withdrawal from social
interaction
S Expectation of passive treatment(s) rather than a belief that
active participation will help
Reference: Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain:
Risk Factors for Long-Term Disability and Work Loss, 1997

8. yellow flags updated: (Nicholas, Linton, Watson, & Main, 2011)
Beliefs, appraisals, and judgments Unhelpful beliefs about pain; indication
of injury as uncontrollable or likely to
worsen
Expectations of poor treatment
outcome, delayed return to work
Emotional Responses Distress not meeting criteria for
diagnosis of mental disorder
Worries, fears, anxieties
Pain Behaviour Avoidance of activities due to
expectations of pain and possible re-
injury
Over reliance on passive treatments
(hot packs, cold packs, analgesics)

9. Key tool today:
starts with how we talk about pain
S video—Understanding Pain: what to do about it in
less than 5 minutes (http://youtu.be/4b8oB757DKc)
S Lorimer Mosely: pain as an OUTPUT
acute chronic
generally accepted as pain
due to damage in body
tissue
generally accepted as pain
that persists longer than
expected healing time
pain is still an output less about tissue and more
about maladaptive output
from the brain

10. (today)
stories connect people

11. what pain scales don‟t show us

12. tools:
• pain neurophysiology
hurt vs harm (language)
• prescription for movement
• mindfulness /breathing
practice
• cognitive awareness tool
• activity log/journal
• work as a determinant of
health

13. why work?
S The longer a person is off work, the less likely they
are to return (Crook and Modolfsky, 1994)
S Early return to work contributes to decrease in
overall work disability (Lydell et al., 2009, Loisel et al. 1994)

14. how we shape recovery?
S May inadvertently promote fear avoidance in our
language and actions (Linton et al., 2002)
S Taking people off work when they can do their job,
modified or alternate duties can contribute to fear
avoidance
S Need a culture where we talk about sustaining or
returning to work as a given step in recovery

15. summary: key message

16. summary: key message

17. summary: key message

18. take home messages
S hold an interdisciplinary mindset
S see pain from a nervous system sensitivity perspective vs
tissue damage
S watch out for reinforcement of fear and avoidance
S active vs passive
S support for movement & work

19. S
why are we hopeful
our work
why we love it

20. resources
Butler, D, & Mosely, G.L., Explain Pain. Pearson, N., Understand Pain Live Well Again.
NOI group website: www.noigroup.com; great
resources/anecdotes
Pain BC website: www.painbc.ca;
Pain Toolbox download

21. Dr. Matt Graham, R. Psych
Jimena Malzahn, B.Sc.(PT)
Cara Rodrigues, B.Sc., B.Sc.(OT)
OrionHealth Rehabilitation & Assessment Centres
Thank you

22. references
Boersma, K.& Linton, S.J. (2006). Psychological Processes Underlying the Development of a Chronic Pain Problem: A Prospective Study of the Relationship
Between Profiles of Psychological Variables in the Fear–Avoidance Model and Disability. Clinical Journal of Pain, 22 (2), 160 – 166.
Crook, J., Modolfsky, H.(1994). The probability of recover and return to work from work disability as a function of time. Quality of Life Research, 3 (Supplement
1), S97 - S109.Providers: Are We Fear Avoidant? Journal of Occupational Rehabilitation,12 (4), 223-232.
Linton, S.J., Vlayeyn, J., Ostelo, R. (2002). The Back Pain Beliefs of Health Care Providers: Are We Fear Avoidant?Journal of Occupational Rehabilitation,12 (4),
223-232.
Loisel, P., Durand, P., Abenhaim, L., Gosselin, L., Simard, R., Turcotte, J., & Esdaile, J. M. (1994). Management of occupational back pain: the Sherbrooke Model.
Results of a pilot and feasibility study. Occupational and Environmental Medicine, 51, 597-602.
Lydell, M., Grahn, B. Mansson, J., Baigi, A., Marklund, B. (2009). Predictive Factors of Sustained Return to Work for Persons with Musculoskeletal Disorders who
Participated in Rehabilitation. Work, 33, 317-328.
Moseley, G.L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140.
Nicholas, M.K., Linton, S.J., Watson, P.J, & Main, C.J.(2011) Early Identification and Management of Psychological Risk Factors (“Yellow Flags”) in Patients With
Low Back Pain: A Reappraisal. Physical Therapy, 91, 737-753.
Neil Pearson (2012, January 23). Acute versus Chronic Pain: Understanding the difference and choosing appropriate treatment. Retrieved from:
www.orionhealth.ca.