Pain Management
Returning to Function
Learning Session 2
Presenter’s name here
Location here
Date here
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
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Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
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Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
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Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
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Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
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Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
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$1,540.18
$160.00
Setting Functional Goals
Review
 The purpose of pain is not to accurately tell us:
› where the problem is
› what the problem is
› how bad the problem is
 Pain’s job is to make us stop!
 Our patient’s need treatment and guidance to make these protective
responses less sensitive.
 Wind down the nervous system
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Case Study 1
 38 year old woman
 Neck pain and headaches and unable
to work
 Not improving 5 weeks after whiplash injury
 Xrays show degenerative changes throughout
lower cervical spine, with C4-5 reported as
having more arthritic changes.
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Scripts 1
There is hope, and, finding ease of movement is the first step.
 This type of pain you are experiencing is chronic pain ... but that doesn’t
mean it will always be like this, or that it will continue to worsen.
 Pain can be changed, and my job is to help you with that.
 This medication I am giving you should make you feel that the pain is in
control, and it should help you move better. I want to see you back here
next week to make certain it is working for both things.
 You showed me how much you can move your neck and arms today and
we will recheck that next week.
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Script 2 - same patient one week later
Calm breathing decreases pain and helps move with more ease.
 The medication helps to decrease pain temporarily, but her movement is
no better.
 When you ask her to move, she holds her breath, and tenses her neck,
shoulder and face muscles.
 “Close your eyes and breathe as calmly as you can for the next minute.”
After a minute passes, “now try those movements again.
 “remember that your protective systems are on high alert. It will be
difficult to calm them down if you hold your breath and tense up so
much every time you move.”
 “It’s important to stop sending the message that movement is really
dangerous.”
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Case Study 2
 48 year old construction worker
 Slow to resolve low back pain and right leg
nerve root irritation pain (seems L5
distribution but no conduction deficits)
 MRI 8 weeks after a lifting injury shows L45 lateral disc bulge, central stenosis and
osteoarthritic changes
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Scripts 3
Brief description of chronic pain, and the roles of relaxation and
medication.
 Patient asks - “What can you do to fix this?”
 “You have a problem in your back, and irritated nerves. The best
treatment we can do is to work on calming down the irritation.
 Your job in this plan is to spend time every day relaxing and getting your
body and breathing to feel as calm as possible.”
– (we do not know the best dose of this, so fit it into the patient’s day)
 “The job of this medication is to let you move more easily. If it is not
doing that, we need to try something else.”
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Case Study 3
 43 year old woman with fibromyalgia
 Previously high-level, high-paid executive
position
 Unwilling to try medications until now
 Exercise has made her worse
 Meditation and sitting still make her
more anxious
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Scripts 4
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Brief explanation of fibromyalgia pain, and why initial attempts at
what should help are sometimes unsuccessful.
I am pleased you are ready to try some things other than just being
tough and trying to win a battle with this pain.
We know that in fibromyalgia many aspects of the nervous systems are
cranky and over-sensitive.
Our job, together, is to find ways to calm them down again. It’s not easy,
but it’s possible.
The medication we are trying should let you move with less pain. The
yoga you are doing should also help with that.
Remember that the strength you have to be tough and carry on in the
face of this pain is not helping you get better. Somehow you need to stay
tough, but don’t push so hard.
You need to pay more attention to your body and pain, not less.
Case Study 4
 64 year old active employed male
 10 weeks post TKA, and his pain
and function are worsening
 He is angry, believing that the pain
must be from faulty surgical technique
and that the surgeon is
saying he is making this pain up
 Orthopaedic surgeon has investigated and the prosthesis is not the
problem
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Scripts 5
Post-surgical pain can be related to sensitization and wind-up. Pain
education is often the first step needed in such cases.
 “When pain persists like this and we cannot find the reason for it from the tissue or
the surgery, we know that the problem includes unexpected responses from the
pain system.
 This is something you need to learn much more about so we can work together to
help you out. Here is a link to the Pain BC webinars where they talk about this in
much more detail, and it would help to read this book ... you can get it from the
library. We will need to talk some more about this, because it will sound different
from what we have discussed before.”
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Scripts 6
Reassuring the person in pain that we know what to do, and,
providing the understanding that a team approach is needed.
 “Your pain is real. It may not be easy to change it, but we can.
 This medication is to help you move better, and not pay for it so much.
 Your nervous systems have become far too agitated - by the pain before the
surgery, and all the stress after it. I want you to see this counsellor to learn
breathing and relaxation techniques. And I will contact your physiotherapist to
make certain she is getting you to do as much work on calming down the nerves in
your knee as working on getting you stronger.
 If we all work together we can help you best with this.”
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Resources
 www.painbc.ca
› Empowering Self Management of Pain series
› The Pain Toolkit
› Yoga for People in Pain series
 Chronic Pain Self-Management Program (University of Victoria)
 Understand Pain, Live Well Again
Pearson, N. Patient education book available in all BC public libraries
 Explain Pain
Butler D, Moseley L. www.noigroup.com

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http://www.physicalactivityline.com/
Practice Support Program Tools
 MH algorithm (http://www.gpscbc.ca/psp-learning/mentalhealth/tools-resources)
 CBIS from PSP’s adult mental health module
 Problem list
 Resource list
 Brief Action Planning
 Bounce back DVD
 Anti-depressant skills workbook
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