Author of Lecture:

Nicholas, Michael (Prof.)

Title of Lecture:

Living With Disability

(Problem 6.02, PPD, 2013)
COMMONWEALTH OF AUSTRALIA
Copyright Regulations 1969
WARNING
This material has been reproduced and
communicated to you by or on behalf of the
University of Sydney pursuant to Part VB of the
Copyright Act 1968 (the Act).
The material in this communication may be subject
to copyright under the Act. Any further reproduction
or communication of this material by you may be the
subject of copyright protection under the Act.
Do not remove this notice

Living with chronic pain is easy to say, but

how?

Professor Michael Nicholas

Pain Management Research Institute, Sydney Medical SchoolNorthern, University of Sydney, Royal North Shore Hospital,

Summary
Pain is primarily a warning signal and useful
But pain can also cause major suffering and disability
Especially when it persists (and becomes chronic)
As there is no cure for chronic pain, the only realistic
option is to manage it
Just as required for other chronic diseases (eg.
diabetes, asthma)
The question is: How?
A challenge for all chronic pain sufferers and health
professionals

Useful reference for this talk

Persistent pain by age and sex

NSW 1997 Health Survey (Blyth et al., 2001)

18.6

80+

21.3
20.3

70-74
60-64

19.3

50-54

19.7
18.5

40-45
14.1

30-34
20-24
8.2

13
10.9
11.9
11.6
13.8
11.6

All
0

10

15

30.5
26.4
27.8
26.4
29.3
23.1
28.3
25.8
29.1
27.3
23.9

males
females

15.9
16.9
16.8

17.1

20.1
20

25

30

35

What does this mean?

Almost 1 in 5 Australians have some form of
chronic pain
Multiple possible causes
Disability due to pain reported by about 60%
Many with chronic pain also have other health
problems = extra load to cope with
Especially depression
Chronic pain + depression = worse quality of life
6

Traditional Bio-medical model of pain,

shared by most people in community

Injury/disease
(Nociception
or
neuropathy)

Pain

Impact on activity, mood

Treatment implications?

Nociception
or
neuropathy

No
Pain-free
Pain

Normal activity & mood restored

e.g. Bogduk N. Management of chronic low back pain. Med J Aust 2004; 180 (2): 79-83

This model works

(Usually) in acute pain
For example: Headache?

Paracetamol

(Often) in some chronic pain conditions with

orthopaedic procedures (eg. hip replacements)
But for most who develop chronic pain?
On average about 30% reduction in pain, at best
Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic
pain. Clin J Pain 2002; 18: 355-65).

Despite all the advances in medical

technology.

For people with chronic pain, curative treatment

is very unlikely and its very pursuit may not be
risk-free.
Deyo et al. Overtreating chronic back pain: Time to back off? J Am Bd Fam Med 2009; 22: 62-68
Goucke CR. The management of persistent pain. Med J Aust 2003; 178(9): 444-447.
Loeser JD. Mitigating the dangers of pursuing cure. In: Cohen MJM, Campbell JN, eds. Pain Treatment Centers
at a Crossroads: A Practical and Conceptual Reappraisal. Seattle, IASP Press, 1996:101-108.

Concerns rising about management of

persisting pain
Sydney Morning Herald June 8, 2009
Rise in addiction prompts call for painkiller policy
(Julie Robotham Medical Editor)
DOCTORS groups are urging a radical rethink of how
opioid drugs are supplied and controlled, amid evidence of
a surge in the number of people addicted to prescription
painkillers.
Unfortunately, the focus was on addiction, it should have been on
pain management
If pain management was better understood and practised in the
community then drug problems would be much less of a problem
It seems addiction is more interesting than pain management to
the media and politicians

Concerns about treatment of chronic pain

elsewhere too

Deyo et al. notedsince the

mid-1990s..
A 629% increase in (US) Medicare expenditures for
epidural steroid injections;
A 423% increase in expenditures for opioids for back
pain;
A 307% increase in the number of lumbar MRIs among
Medicare beneficiaries; and
A 220% increase in spinal fusion surgery rates.
Yet, no good evidence of general improvements in patient
outcomes or disability rates.
Note: In Australia, Medicare-funded prescriptions of
oxycodone has quadrupled Australia-wide since 2000 to
1.6 million in 2007.(RACP, Prescription Opioid Policy, 2009)

More access to opioids?

Martell et al. Ann Intern Med. 2007;146:116-127:
Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence,
Efficacy, and Association with Addiction

Concluded:
Opioids are commonly prescribed for chronic back
pain and may be efficacious for short-term pain relief.
Long-term efficacy (>16 weeks) is unclear.
But this is a chronic condition, we re talking years

14

In the UK, also recognition of the problem of

treating persisting pain

So, we are all in agreement?

Chronic pain is common however it is caused

Treatments that can help acute pain not as helpful
But can make matters even worse
What are our options?

16

If one or two dont work, try more?

You gotta be kidding your back still hurts??

Maybe we need to step back and try to

make sense of the problem of chronic
pain?

When pain persists: Interacting contributors and effects

- a biopsychosocial perspective
Nerve damage;
changes in central
nervous system
(Neuropathic or
Neuroplastic
Mechanisms, eg.
Sensitization)

CHRONIC
PAIN

Injury; Tissue
Damage
(Nociceptive
Mechanisms)

REDUCED
ACTIVITY

PHYSICAL
DETERIORATION
(eg. muscle wasting,
put on weight, joint
stiffness)

UNHELPFUL
BELIEFS &
THOUGHTS

REPEATED
TREATMENT
FAILURES

LONG-TERM
USE OF ANALGESIC,
SEDATIVE DRUGS

DEPRESSION,
HELPLESSNESS,
FRUSTRATION
ANGER
POOR SLEEP

EXCESSIVE
SUFFERING
& DISABILITY

SIDE EFFECTS
(eg. stomach
problems, lethargy,
constipation)

LOSS OF JOB, FINANCIAL

DIFFICULTIES, FAMILY
STRESS
INPUT FROM: FAMILY; HEALTHCARE PROVIDER(S);
INSURERS; EMPLOYER

M. Nicholas. 2012

So, more than a pain problem

Persisting pain
Pain triggered by normal activities
Disability affecting many normal activities or roles
Unhelpful beliefs (catastrophising, fears)
Depression, anger, sleep disturbance
Side-effects from medication
Multiple losses (financial, personal, family, social)
Changes for family, employer, friends
In short chronic pain can dominate most aspects of your life

20

If this many contributing factors are

operating
Is it likely just tackling one or two will be enough?
Consider targeting the pain OK to start, but later?
What about exercise? could help fitness & weight
But what about pain, depression, sleep, side-effects
of medication, work, family life?
The reality is there is unlikely to be a single quick
fix

21

Wouldnt it be more likely to help if we target as many of

these contributors
as possible?
Set realistic
goals
& pace up
PHYSICAL
activities,
DETERIORATION
exercises
(eg. muscle wasting,
wt gain, joint
despite pain; diet
stiffness)
plan
UNHELPFUL about
Schedule pleasant
Education
BELIEFS &
activities (not just
pain
& treatments
THOUGHTS
work), improve
+ identify &
sleep habits,
anger
challenge
DEPRESSION,
HELPLESSNESS,
management
unhelpful
REPEATED beliefs
FRUSTRATION
REDUCED
ACTIVITY

Targeted
medication,
Desensitising,
Relaxation,
Distraction

NEUROPATHIC or
NEUROPLASTIC
MECHANISMS

CHRONIC
PAIN

TREATMENT
FAILURES

ANGER
POOR SLEEP

EXCESSIVE
SUFFERING
& DISABILITY

Maintenance
Rationalise &
plan chronic
cease
pain will
unhelpful
fluctuate, need to
LONG-TERM
NOCICEPTIVE
USE
OF
ANALGESIC,
drugs
MECHANISMS
plan for these,
SIDE EFFECTS
SEDATIVE DRUGS
(eg. stomach
and for dealing
Review
problems, lethargy,
Negotiate with
constipation)
with other
transferable skills,
employer , agree
stressors
LOSS OF JOB, FINANCIAL
retraining, job
on work &
DIFFICULTIES, FAMILY
applications, modify
management STRESS
work, negotiate
plan with HCPs
M. Nicholas. 2012
INPUT FROM: FAMILY; HEALTHCARE PROVIDER(S);
roles with family
INSURERS; EMPLOYER

Achieving these changes not easy strong

community belief that pain relief should come first
Survey of insurance company staff

A reduction in pain is necessary before a person

can start resuming normal functioning
40%
35%
30%
25%
20%
15%
10%
5%
0%
Totally
Agree - 0

Totally
Disagree 5

But the health care providers have

obstacles too
Consider their beliefs about pain
Houben et al. European J. Pain 9 (2005) 173183.
Differentiated between physical therapists on their biomedical vs
biopsychosocial orientations towards non-specific back pain.
Those with biomedical orientation viewed daily activities as more
harmful for the back of a lbp patient
('be careful', 'let pain be your guide')
If these views are transmitted to their patients what might we see?
Activity avoidance

Disability ?

24

Physicians recommendations for activities

in Chronic low back pain
Rainville et al. Spine 2000; 25: 2210-2220
Concluded:
Wide variations noted, often restrictive (don t do..)
Seemed to reflect personal attitudes (of physicians)
as well as patients clinical symptoms

So, it s not just the pain sufferer who needs to

update their understanding of chronic pain

Health care providers and the general community too

Think about it how often have you had others find it
hard to believe your pain is ongoing?
The good news is that community beliefs can be
changed

26

What if the community accepted the idea

that being active despite pain was OK?
Buchbinder et al. Spine 2001;26:25352542
Population-based, state-wide public health intervention to alter beliefs
about back pain and its medical management
In Victoria in late 1990 s
Short ads on TV and signs by roadsides
Evaluation:
4,730 interviewed 2.5 yrs apart; 2,556 GPs interviewed 2 yrs apart.
1 state (Victoria) = intervention, another state (NSW) = control

Buchbinder et al, BMJ, 2003

Outcomes?

In Victoria:

Decline in claims for back pain,

rates of days off, and costs of
medical management (~ $65m)

In NSW:

No change

Conclusion: Changing community s beliefs about

back pain led to change in behaviour of patients
and the behaviour of their GPs.

The Truth about Chronic Pain Treatment

When you seek help for your chronic pain, no doctor
or physio or chiropractor can do it all by themselves
it must be a collaborative effort
Medical care for chronic illness is rarely
effective in the absence of adequate self-care (by
patient).
Collaborative care = patients + providers : shared
goals, sustained working relationship, mutual
understanding of roles/responsibilities, requisite
skills for carrying them out.
Von Korff et al. (1997) Ann Int Med, 127, 1097-1102

Pain self-management methods: many to choose

from, they might include:
Hot/cold packs
TENS machines
Alternative medicines, alcohol, marijuana
Meditation, relaxation, distraction techniques, self-hypnosis
Prayer
Acceptance mindfulness; challenging unhelpful thoughts
Exercise (fitness, stretch, strength)
Negotiate change of roles with family, workplace
Rest/avoid activities
Hot pools/hot showers
Modulating activities, using pacing, setting priorities/goals
31

Some might ease your pain, briefly, others may not

But if the pain is chronic, which ones and how many?

How will they fit into the big picture?

32

NSA Pain Study, PAIN 2005;113:285-292

2092 adults in NSA

474 with chronic pain
Randomly selected from
community

33

NSA Pain Study, PAIN 2005;113:285-292

34

NSA Pain Study, PAIN 2005;113:285-292

Divided pain self-management into 2 broad categories:
1. Passive (rest/avoidance, hot packs, alcohol)
2. Active (exercise, maintaining/modifying activities)
Found:
Passive coping strategies strongly associated with higher
pain-related disability (compared to active strategies)
So, self-management methods not all equally helpful

35

New study: Nicholas et al. Euro Jnl of Pain, 2012

Evaluated adherence to active self-management strategies
At end of intensive (3 week) pain management program
Strategies studied:
Setting goals, activity pacing, exercising,
desensitising, thought challenging

Compared to those who used these strategies irregularly

Those who used these strategies consistently made greater
gains in
Usual pain, disability, depression, less medication, less
catastrophising, higher self-efficacy

New study we found the difference was still there at 1-yr

36

In summary
Regular use of active self-management strategies
improves quality of life for people with chronic pain
Many work out their own methods
But, if not, they can be taught
But it is not black or white, or one size fits all
Each person needs to work out a balance of methods
that suit them
In the end, it is what helps you to achieve your aims
and to maintain a healthy lifestyle despite pain
37

Postcard from chronic pain patient

We have been treking in the Annapurna region (in Nepal)
- proof (if you needed more) that your treatments work!!!
How did she do it?
A regular (stable) dose
of slow release
analgesic
and
pain self-management
strategies, including
pacing, relaxation,
cognitive strategies

Conclusions when pain persists

Chronic pain can cause great suffering and disability
There is no treatment or health professional who can fix it all
It is risky to expect the doctor to have all the answers
As with all chronic diseases, the person in pain must play an
active role
If they do, chronic pain can be managed and a good quality of
life is possible, despite ongoing pain
Working with one's doctor in a collaborative way, often with
others (like a physiotherapist or psychologist), offers hope
But the person in pain must play their role and apply
themselves consistently until it becomes a habit
39