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Assessing and managing chronic pain after spinal cord injury: a new tool for GPs & Practice Nurses.

Assessing and managing chronic pain after spinal cord injury: a new tool for GPs & Practice Nurses. James Middleton 1,2, Philip Siddall 3, Lyndall Katte 4, Kathryn Nicholson Perry, Janet Long 2 1 State
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Assessing and managing chronic pain after spinal cord injury: a new tool for GPs & Practice Nurses. James Middleton 1,2, Philip Siddall 3, Lyndall Katte 4, Kathryn Nicholson Perry, Janet Long 2 1 State Spinal Cord Injury Service, Agency for Clinical Innovation 2 John Walsh Centre for Rehabilitation Studies, University of Sydney 3 Pain Management Research Group, University of Sydney; Director Pain Services, Greenwich Hospital 4 Project Officer, SCI Pain Project, Agency for Clinical Innovation 31 October 2014 Introduction Chronic pain commonly accompanies SCI - present in about two-thirds, severe in one-third Contributes to poorer health and well-being and reduced participation beyond SCI effects alone Significant negative impact on mood, sleep, daily activities, social integration & quality of life (Jensen et al, 2005; Middleton et al, 2007; Rintala et al, 1998; Westgren and Levi, 1998; Widerström-Noga et al, 2001) often difficult to manage despite many treatments Types of Pain after SCI NOCICEPTIVE NEUROPATHIC Above-Level Musculo-skeletal At-Level Below-Level Visceral The Biopsychosocial Model Social Psycho Social environment Culture/Sick role Coping and pain behaviour (disability) Emotional distress (suffering) Attitudes & Beliefs Pain perception Bio After Loeser, 1982 Tissue damage Pain generator Resource Development Recent collaboration between ACl Pain Network and State SCI Service (funded by NSW LTCSA) Interactive evidence-based decision support tool (SCI Pain Navigator) for use by GPs, practice nurses & allied health professionals to guide assessment, decision-making and generate a PMP Web-based consumer self-management resources Pain management strategies and videos Information, handy hints and useful links Downloadable pain management plans and SCI pain assessment forms (at SCI Pain Questionnaire Screening activates Pain Management Plan Pain Assessment: Pain severity & interference Pain Location (above, at or below SCI lesion) Pain Features & Type Aggravating and Easing Factors Treatment & Medications details Red Flags Yellow Flags Treatment Pain Management Plan Referrals Resources Re-assessment Case Study 58-yr old man, high speed MBA in 2011, sustaining burst #/T12 incomplete paraplegia. Describes burning, stabbing & aching pain in lower limbs, with pins and needles in feet right left Intermittent sensation of intense crushing pain in right foot Pain is constant, varies in intensity being worse in afternoon Increases with stress and fatigue and wakes him at night. Relieved by distraction and oxycodone, but medication side effects are a problem. Reports reduced pain when on holiday s recently and using manual wheelchair (r/t walking with Canadian crutches and bilateral AFOs). Case Study Medications include: Tramadol 200mg SR bd, Paracetamol 500mg 8/day, Gabapentin 600mg qid, Oxycodone 10mg prn, Sertraline 50mg nocte. Other health issues include PHx depression, constipation, frequent fatigue. Works 8-9 hours/day, 5 days/wk running own business. Previously actively involved in business as builder, now managing the business and supervising team this new role has been a big change needing adjustment. During pain flare ups goes to bed and takes Endone. Pharmacological treatment options Non-pharmacological treatment options Pain Management Plan At level and Below level Neuropathic Pain Treatment Medications - Stepwise Protocol: Physical: Psychosocial: First line medications: Continue anticonvulsant Gabapentin, consider trial substitution of Pregabalin if concern about sedation. Rationalise medications: reduce opioid use in medium term once other strategies in place Exercise/fitness program Equipment or seating review Address identified yellow flags Activity pacing (to avoid cycle of over & underdoing) prioritise, plan and pace (break up) activities Atttention management strategies (relaxation & distraction techniques) Cognitive behavioural therapy for persistent pain including management of unhelpful thinking Flare up Plan Questions? ACKNOWLEDGEMENTS Lifetime Care & Support Authority Contact: A/Professor James Middleton Director, ACI State SCI Service Level 4, Sage Building 67 Albert Avenue, Chatswood NSW 2067 PO Box 699 Chatswood NSW 2057 T F
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