Module 1v2

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!!@@.greentext;2021 Curriculum learning syllabus@@ !!!@@.greentext;Stage 1 Pain learning outcomes@@ @@.greentext; ''//Recognises, assesses and treats acute pain independently Differentiates between acute and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * Can recognise, examine, assess and manage acute pain in the surgical and non-surgical patient * Is able to safely and appropriately prescribe medication for pain management * Demonstrates effective communication skills regarding pain management with patients, relatives and carers * Demonstrates the basic assessment and management of acute on chronic and chronic pain in adults * Describes the concept of biopsychosocial multi-disciplinary pain management * Describes the special circumstances in assessing and managing perioperative pain in specific patient groups including children, pregnancy and breast feeding, the elderly and frail, those with learning and communication difficulties, autism, dementia, renal and hepatic impairment and substance abuse * Demonstrates the safe use of equipment used in pain management !!!@@.greentext;Stage 2 learning outcome:@@ @@.greentext;''//Understands the aetiology and management of acute, acute on chronic and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * Utilises a multi-disciplinary approach to the management of complex pain within a biopsychosocial model of care * Can confidently manage acute pain in the whole perioperative pathway in a timely manner * Is able to assess patients, interpret investigations and initiate management of chronic malignant and non-malignant pain in a timely manner under distant supervision * Can assess and manage acute on chronic and chronic inpatient pain in adults and recognise when referral to specialist pain services is appropriate * Identify barriers to effective pain management including those related to patient beliefs, society, culture, and healthcare provision * Explains the risk factors for persistent post-surgical pain including measures to minimise its occurrence !!!@@.greentext;Stage 3 learning outcome:@@ @@.greentext;''//Able to initiate complex pain management for in-patients and to sign-post to appropriate pain management services//''@@ !!!@@.greentext;Key capabilities@@ * Applies knowledge and understanding of assessment and management of pain in a multiprofessional context * Demonstrates safe effective pharmacological management of acute and procedure pain in all age groups * Acts as an effective member of the inpatient pain team * Effectively engages with multi-disciplinary primary and secondary pain services and palliative care when necessary * Recognises the need for and complications of interventional pain procedures * Prescribes appropriately in the perioperative period and recognises the long term implications of not reviewing patient analgesia in the post–operative period following discharge * Plans the perioperative management of patients for surgery who are taking high dose opioids and other drugs of potential addiction [[Back|Core clinical learning objectives]]

Hi $firstname welcome to the Persistent Pain Service. Dr Jones the lead consultant for the service has asked you to take a look at one of the [[referral letters]] and either accept or reject the referal. [[Reject referral]] [[Accept referral]]

Dear Dr Jones ''RE: Mrs Sarah Heath, DOB: 10/06/1968, NHS No: 0000 3333 4444'' Diagnosis: Chronic back pain, Migraine with aura, Hypercholesterolaemia Medications: Naproxen, 500mg BD, Tramadol, 100mg QDS, Amitriptyline 75mg Nocte. Mrs Heath has had back pain that causes her significant distress since a fall while ice skating four years ago. She had a normal lumbar imaging three months after the event. She has failed to gain benefit from analgesics we have prescribed in primary care but is reluctant to stop these due to concerns that her pain would be worse without them. She reports that the pain is preventing her from leading her life and is motivated to ‘try anything’ to improve her present situation. Please would you see Mrs Heath in the Pain Service. Yours sincerely Dr Reid MBBS MRCGP Dip Av Med [[Back->Welcome]]

@@.whitetext; !!!VA_Pain training_1: Persistent pain Enter your first name: <<textbox "$firstname" "">> Enter your surname: <<textbox "$surname" "">> <<set $role = ["-", "Stage 1 Anaesthetist in Training", "Stage 2 Anaesthetist in Training", "Stage 3 Anaesthetist in Training", "Consultant Anaesthetist", "Associate Specialist Anaesthetist", "Speciality Doctor Anaesthetist", "Foundation Doctor", "Doctor (Other)", "Medical Student", "Other health care professional", "Role outside healthcare"]>>''Select your professional role:'' <<listbox "$role">> <<optionsfrom $role>> <</listbox>> <<set $randomid to random(10000000,99999999)>> <<nobr>><span id="ReplaceMe"> <<link "''Next''">> <<script>> Dialog.setup("Analytics"); Dialog.wiki("Users' privacy and data protection are our priorities. Virtual Anaesthetics uses analytics and collects anonymised data to improve your service and provide academic governance including passage function, anonymised scores, playtime, and any feedback comments you provide. This anonymised data may also be used in part or in its entirety for research and publication. For more information on our privacy policy please see ''[[here|https://www.virtualanaesthetics.com/privacy-policy/]]''. Please also be aware that this information is temporarily stored in your local internet browser cache. If using a public or shared computer you can avoid this by clearing your internet history and website data on competition of the scenario."); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[Next|Core clinical learning objectives]]''<br> <</replace>> <</link>></span><</nobr>> <<set $MDT to false>> <<set $Aspinalinjection to false>> <<set $ReducingorstoppingtheTramadol to false>> <<set $Seeingapsychologist to false>> <<set $Seeingaphysiotherapist to false>> <<set $Selfmanagment to false>> <<set $Painmanagmentprogramme to false>> <<set $SeeinganOT to false>> <<set $dischargetoGP to false>> <<set $Dronlythinking to false>> <<set $MDTthinking to false>> <<set $Opioidreductionprogramme to false>> <<set $Occupationaltherapy to false>> <<set $Psychologicaltherapies to false>> <<set $Physiotherapy to false>> <<set $PlaceonthePMP to false>> <<set $Combinationoftheabove to false>>

You read the letter and decide to reject the referral. After all there are lots of things that can be done in primary care for someone with back pain. Two weeks later you're at one of the computers in the shared office taking five minutes to catch up with work when you get an [[email->email 1]] pop-up notification.

It's been two weeks since you accepted Mrs Heath's referral. Thank goodness you knew the [[referral criteria->criteria]] She's been sent the Pain Service Questionnaire which includes three psycometric assessment tools to find a bit more about her pain experience. The completed Pain Questionnaire is on your desk with a note stuck to the front: @@.writing; I thought seeing as you've been involved in this lady's referral you might want to have a look at this and decide if she should be assessed by the MDT or Dr only at this stage? Thanks James @@ [[Pain Questionnaire]]

@@.typing;''From:'' James Jones (Consultant Pain Management) ''Sent:'' Today ''To:'' Dr $firstname $surname ''Subject:'' Mrs Heath's referral Hi $firstname I've just had Mrs Heath's GP on the phone asking me why we rejected her referral. Could you have a look at the service referral criteria? We need to accept her referral and send her an appointment if she suitable. Thanks James@@ [[referral criteria]]

''Persistent Pain Management Service referral criteria'' We accept referrals of individuals: *''Who'' are over 16 years of age (Please contact the pain service directly if considering referral of an individual younger than 16) *''With'' pain typically persisting beyond three months and causing significant distress or functional limitation *''Where'' surgical intervention and/or further investigation of the pain has been completed or is not indicated *''When'' the referrer has explained that the Pain Management Service offers supported self-management of persistent pain and not one-off treatments or cures We generally do not accept referrals of individuals who have: *Outstanding investigations, results, or planned treatments *Outstanding referrals to other specialities for the same problem *Inflammatory conditions (consider discussion with rheumatology) *Red flags of any serious underlying condition *Unmanaged substance misuse *Significant mental health difficulties that are not being managed by the appropriate service *Circumstances making it impossible to engage with self-management strategies *Been seen by the service for the same persistent pain problem and failed to engage or have been previously discharged for recurrent non-attendance If you require any further information, please contact the Pain Management Service on 01234 567890. Yours sincerely Persistent Pain Service <<if $dischargetoGP is true>> [[Back->Discharge back to the GP]] <<elseif $dischargetoGP is false>> [[Next->Change of heart]] <</if>>

It looks like Mrs Heath is eligible to be seen by the service. You write a quick email to Dr Jones saying that you've had a look at the referral criteria and you [[accept the referral->Accept referral]].

@@.roman;''Name:''@@ @@.writing;Sarah Heath@@ @@.roman;''Date of birth:''@@ @@.writing;10th June 1968@@ @@.roman;''Address:''@@ @@.writing;28 Cowslip Drive@@ @@.roman;''Year pain began:''@@ @@.writing;2016@@ @@.roman;''How did it start?''@@ @@.writing;Fell flat on my back while ice skating@@ @@.roman;''How fast did it start?''@@ @@.writing; Instant@@ @@.roman;''How would you describe the nature of the pain?''@@ @@.writing;Aching with sharp shooting pains sometimes, exhausting@@ @@.roman;''What do you do for the pain?''@@ @@.writing;Take the pain killers that the GP gave me. Bought an expensive orthopaedic mattress (didn't help). Try not to stand up too long.@@ @@.roman;''How do you spend a typical day?''@@ @@.writing;Mondays, Tuesdays and Thursdays get the bus to work. Sometimes shop on the way home. Other days I'm so shattered after bad sleep that it's a struggle to get up so I mostly rest@@ @@.roman;''If pain was less of an issue what would you do?''@@ @@.writing;Walk to work (I used to). Socialise more after work, I'm too tired to do that now@@ @@.roman;''Who do you see for your pain?''@@ @@.writing;I've been to the GP dozens of times, I saw a phsyio three months after the injury for four appointments that didn't help@@ @@.roman;''Have you had any investigations for your pain?''@@ @@.writing;I had an MRI six months after the injury which they told me was normal for my age@@ @@.roman;''Are you waiting for any other tests, investigations, treatments?''@@ @@.writing;no@@ @@.roman;''What treatments have you tried for your pain?''@@ @@.writing;Chiropractor, four physiotherapy sessions@@ [[Next->Pain Questionnaire 2]]

@@.roman;''What medications do you take?''@@ @@.writing;Tramadol, amitriptyline, naproxen, vitamins, HRT@@ @@.roman;''What have you tried in the past? Did it help?''@@ @@.writing;Ibuprofen gave me heartburn, co-codamol didn't help, dihydrocodeine didn't help@@ @@.roman;''Does your pain affect your mood?''@@ @@.writing; Yes, I'm so tired it's hard to get motivated about anything@@ @@.roman;''Are you waiting to be seen by the mental health service?''@@ @@.writing; No@@ @@.roman;''Marital status:''@@ @@.writing;Single@@ @@.roman;''Who lives at home with you?''@@ @@.writing;Live alone@@ @@.roman;''Employment status:''@@ @@.writing;Part-time@@ @@.roman;''If working tell us about you job:''@@ @@.writing;Work as an administration assistant for a recruitment agency@@ @@.roman;''Would you like to stay in or get return to work?''@@ @@.writing;yes@@ @@.roman;''Are there any legal actions with regards to your pain?''@@ @@.writing;No@@ @@.roman;''What do you want to get from attending the service?''@@ @@.writing;To not be in so much pain, to sleep better and have the motivation to do things@@ @@.roman;''What are your personal expectations and goals''@@ @@.writing;To get my life back and not feel like the pain controls me@@ [[Next->Pain Questionnaire 3]]

@@.roman;''Pain Self-Efficacy Questionnaire''@@ [[(more info)->info 1]] @@.roman;Please rate how confident you are that you can do the following things at present despite the pain. To answer give a number for each item, where 0 = 'not at all confident' and 6 = 'completely confident'@@ | @@.roman;''I can enjoy things, despite the pain''@@  |  @@.writing;2@@ | | @@.roman;''I can do most of the household chores despite the pain''@@  |  @@.writing;2@@ | | @@.roman;''I can socialise with my friends or family as often as I used to''@@  |   @@.writing;1@@ | | @@.roman;''I can cope with my pain in most situations''@@  |  @@.writing;2@@ | | @@.roman;''I can do some form of work, despite the pain''@@  |  @@.writing;3@@ | | @@.roman;''I can still do many of the things I enjoy doing despite the pain''@@  |   @@.writing;1@@ | | @@.roman;''I can cope with the pain without medication''@@  |  @@.writing;0@@ | | @@.roman;''I can still accomplish most of my goals in life despite the pain''@@  |   @@.writing;1@@ | | @@.roman;''I can have a normal lifestyle, despite the pain''@@  |  @@.writing;1@@ | | @@.roman;''I can become gradually more active, despite the pain''@@  |  @@.writing;2@@ | | @@.roman;''Total''@@  | @@.writing;15@@ | [[Next->Pain Questionnaire 4]]

@@.whitetext; ''The Pain Self-Efficacy Questionnaire (PSEQ)'' is a 10-item questionnaire, developed in the 1980s. It assesses the confidence of people with persistent pain in undertaking activities with ongoing pain. The validity of the PSEQ is reflected in the correlation with pain related disability, unhelpful coping strategies and other more activity specific measures of self-efficacy. Scores range from 0-60 with lower scores indicating a low level of confidence in functioning with the pain and the likelihood of longer term pain-related disability and depression. Lower scores (less than 30) after treatment predict less sustainable gains. Our patient has a score of 15 which indicates she is quite focused on her pain and is at risk of pain related disability and depression.@@ <br> [[Back->Pain Questionnaire 3]]

@@.roman;''Pain Scale''@@ [[(more info)->info 2]] @@.roman;Below you will find a list of statements. Please rate how true each statement is for you with a number. 1 = Never true, to 7 = Always true.@@ |@@.roman;''1. I would do almost anything to get rid of my pain''@@| @@.writing;7@@| |@@.roman;''2. I don't do things that are important to me to avoid feeling my pain''@@| @@.writing;7@@| |@@.roman;''3. When I'm in pain I stay away from other people''@@| @@.writing;5@@| |@@.roman;''4. It is important to control my pain''@@| @@.writing;7@@| |@@.roman;''5. It is important to understand what causes my pain''@@| @@.writing;5@@| |@@.roman;''6. I feel angry about my pain''@@| @@.writing;4@@| |@@.roman;''7. I say things like "I don't have any energy", "I am not well enough", "I don't have time", "I don't dare", "I have too much pain", "I feel too bad", or "I don't feel like it"''@@| @@.writing;5@@| |@@.roman;''8. I avoid doing things when there is risk it will hurt or make things worse''@@| @@.writing;7@@| |@@.roman;''9. I avoid scheduling activities because of my pain''@@| @@.writing;7@@| |@@.roman;''10. I put a lot of effort into fighting my pain''@@| @@.writing;5@@| |@@.roman;''11. It's not me that controls my life, it's my pain''@@| @@.writing;5@@| |@@.roman;''12. I need to understand what's wrong in order to move on''@@| @@.writing;6@@| |@@.roman;''13. Because of my pain I no longer plan for the future''@@|  @@.writing;6@@| |@@.roman;''14. I postpone things on account of my pain''@@| @@.writing;7@@| |@@.roman;''15. I cancel planned activities when I'm in pain''@@| @@.writing;7@@| |@@.roman;''16. I interrupt activities if it starts to hurt or becomes worse''@@| @@.writing;5@@| [[Next->Pain Questionnaire 5]]

@@.whitetext;''The Psychological Inflexibility in Pain Scale'' PIPS is a 16-item scale used to assess psychological inflexibility in people with persistent pain. The PIPS comprises two subscales: ''Avoidance of pain'' (Q2, 3, 7, 8, 9, 11, 13, 14, 15, 16) which measures withdrawal and avoidance behaviours in response to pain and ''Fusion with pain thoughts'' (Q1, 4, 5, 6, 10, 12) which indicates how enmeshed an individual is with their pain-related thoughts and experiences. PIPS scores correlate significantly with other scoring systems. Higher scores indicate greater levels of psychological inflexibility with avoidance scores predicting pain related disability. Variation in scores during engagement with a Persistent Pain Service can help assess the benefit of interventions. Mrs Heath has a avoidance score of 61 and a fusion score of 34. @@ [[Back->Pain Questionnaire 4]]

@@.roman;''Depression, Anxiety and Stress Scale''@@ [[(more info)->info 3]] @@.roman;Please read each statement and write a number 0-3 to show how much the statement applied to you over the last week. There are no right or wrong answers. The rating scale is as follows: 0 = never, 1 = sometimes, 2 = often, 3 = always@@ |@@.roman;''1. I find it hard to wind down''@@|   @@.writing;2@@| |@@.roman;''2. I was aware of dryness of my mouth''@@|   @@.writing;3@@| |@@.roman;''3. I couldn't seem to experience any positive feeling at all''@@|   @@.writing;1@@| |@@.roman;''4. I experience breathing difficulties''@@|   @@.writing;0@@| |@@.roman;''5. I found it difficult to work up the initiative to do things''@@|   @@.writing;0@@| |@@.roman;''6. I tended to over-react to situations''@@|   @@.writing;1@@| |@@.roman;''7. I experienced trembling (e.g. in the hands)''@@|   @@.writing;0@@| |@@.roman;''8. I felt I had a lot of nervous energy''@@|   @@.writing;0@@| |@@.roman;''9. I was worried about situations in which I might panic and make a fool of myself''@@|   @@.writing;0@@| |@@.roman;''10. I felt I had nothing to look forward to''@@|   @@.writing;2@@| |@@.roman;''11. I felt myself getting agitated''@@|   @@.writing;1@@| |@@.roman;''12. I found it difficult to relax''@@|   @@.writing;2@@| |@@.roman;''13. I felt downhearted and blue''@@|   @@.writing;1@@| |@@.roman;''14. I was intolerant of anything that kept me from getting on with what I was doing''@@ |   @@.writing;1@@| |@@.roman;''15. I felt I was close to panic''@@|   @@.writing;0@@| |@@.roman;''16. I was unable to become enthusiastic about anything''@@|   @@.writing;1@@| |@@.roman;''17. I felt I wasn't worth much as a person''@@|   @@.writing;2@@| |@@.roman;''18. I felt I was rather touchy''@@|   @@.writing;1@@| |@@.roman;''19. I was aware of the action of my heart in the absence of physical exertion''@@|   @@.writing;0@@| |@@.roman;''20. I felt scared without any good reason''@@|   @@.writing;0@@| |@@.roman;''21. I felt like life was meaningless''@@|   @@.writing;1@@| [[Next->MRI]]

@@.whitetext;''The Depression, Anxiety and Stress Scale - 21 Items'' (DASS-21) is a set of three self reported scales designed to measure the negative emotional states of depression, anxiety and stress. ''The depression scale'' (Q3, 5, 10, 13, 16, 17, 21) assesses dysphoria, hopelessness, devaluation of life, self deprecation, lack of interest / involvement, anhedonia and inertia. ''The anxiety scale'' (Q2, 4, 7, 9, 15, 19, 20) assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. ''The stress scale'' (Q3, 5, 10, 13, 16, 17, 21) is sensitive to levels of chronic non-specific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset / agitated, irritable / over-reactive and impatient. Scores for depression, anxiety and stress are calculated by summing the scores for the relevant items and interpreted from 'normal' to 'extremely severe' dysfunction. <center> |''Meaning''|''Depression''  |''Anxiety'' |''Stress'' | |Normal|0-9|0-7|0-14| |Mild|10-13|8-9|15-18| |Moderate|14-20|10-14|19-25| |Severe|21-27|15-19|26-33| |Extremely severe  |28+|20+|34+| </center> There is evidence of validity of the scale in both clinical and community settings. From Mrs Heath's questionnaire: Depression = 8, Anxiety = 3 and Stress = 8 @@ [[Back->Pain Questionnaire 5]]

After reading through Mrs Heath's pain questionnaire you type her hospital number into the computer in front of you. There are some routine blood tests done over the last few years but nothing jumps out at you. You open the radiology programme and type her number in again. Her Questionnaire said something about an MRI. The computer brings up a list of entries, you click on the top one, the only [[MRI->MRI image]] in the list.

<center> [[See report->Report]]     [[moreinfo->info 4]]     [[Next->Triage]] @@.whitetext;''Mrs Heath's Lumbar MRI''@@ <img src="images/mri.jpg" style="max-width: 100%;"/> </center>

@@.typing;Patient Name: Mrs Sarah Heath DOB: 10/06/1968 NHS No: 0000 3333 4444 Date of service: 10/24/2016 MRI: Lumbar spine CLINICAL HISTORY: Persisting back pain following fall with intermittent leg pain. TECHNIQUE: Imaging performed in the axial and sagital plane using T1-weighted, T2-weighted and STIR imaging sequences. FINDINGS: At L2/3 there is minimal disc space narrowing with no disc prolapse. At L3-4 there is minimal broad-based left lateral extraforaminal disc and osteophyte which does not abut the adjacent L3 nerve root. At L5-S1 there is minor facet joint arthrosis with no canal stenosis. Lower spinal cord at T11/T12 is normal Dr Harry Wallis Consultant Radiologist@@ [[Back->MRI image]]

Dr Jones comes into the office with an arm full of notes. "Hello $firstname. Ah I see you're looking at that referral, are we assessing her in the MDT clinic or do you think she's a Dr Only appointment?" He pauses, "Either way it might be worth you having a look at the [[NICE guidelines->http://www.nice.org.uk/guidance/ng59]] on back pain, we could do a CbD or CEX when she comes in if you needed one?" [[See her as a Dr Only->Dr only]] [[See her as an MDT->MDT]] <<set $MDT to false>> <<set $Aspinalinjection to false>> <<set $ReducingorstoppingtheTramadol to false>> <<set $Seeingapsychologist to false>> <<set $Seeingaphysiotherapist to false>> <<set $Selfmanagment to false>> <<set $Painmanagmentprogramme to false>> <<set $SeeinganOT to false>> <<set $dischargetoGP to false>> <<set $Dronlythinking to false>> <<set $MDTthinking to false>> <<set $Opioidreductionprogramme to false>> <<set $Occupationaltherapy to false>> <<set $Psychologicaltherapies to false>> <<set $Physiotherapy to false>> <<set $PlaceonthePMP to false>> <<set $Combinationoftheabove to false>>

You ask the admin staff to send out a Dr Only appointment to Mrs Heath. In the back of your mind you wonder if it would have been worth seeing the MDT; after all seeing the [[physios]], [[OT]], and [[psycologist->Psychologist]] will give her a thorough assessment and a comprehensive plan. She could meet up with the [[specialist nurses->Specialist Nurses]] for ongoing care. But the wait is longer for the MDT so actually a Dr Only will let you assess the situation and then involve the rest of the team if it looks like Mrs Heath would benefit. She might even be a candidate for the [[PMP]] that the Persistent Pain Service runs. [[Next->Dr Only appointment]]

You ask the admin staff to send out an MDT assessment appointment to Mrs Heath. After all seeing the [[physios]], [[OT]], and [[psycologis->Psychologist]] will give her a thorough assessment and a comprehensive plan. And she can meet up with the [[specialist nurses->Specialist Nurses]] who can be a point of contact for ongoing care. She might even be a candidate for the [[PMP]] that the Persistent Pain Service runs. [[Next->MDT appointment]] <<set $MDT to true>>

@@.whitetext; Physiotherapists are an essential part of a pain management team. They provide important interventions including ''graded exposure therapy''. This involves patient education to increase the individual's understanding of pain and the importance of breaking maladaptive cycles. They then guide the individual through different aspects of their daily life and identify fear-inducing situations and establish what activities they have been avoiding. These situations and activities are then ranked from least to most fear-inducing. The physiotherapist will then work with the individual on planning gradual exposures, for example Mrs Heath used to walk to work but now gets the bus, she could be supported in making plans to get off one stop away from home and very gradually increase the distance she walks. This allows the individual to safely break the cycle of inactivity with positive reinforcement in achieving their self-set goals and receiving encouragement from their support network. In some cases ''Manual Therapy'' may be appropriate where the physiotherapist manipulates and helps mobilise joints to restore movement lost through lack of use. ''Soft Tissue Treatments'' include massage, trigger point therapy, myofascial release and stretching to improve movement and reduce pain. These may help desensitise the area of pain. Physiotherapy-led ''Pilates Or Postural Exercises'' can helps to build strength and control especially for patients with chronic neck or back pain. @@ <<if $MDT is true>> [[Back->MDT]] <<elseif $MDT is false>> [[Back->Dr only]] <</if>>

@@.whitetext; ''Occupational Therapy'' Occupational therapists have a broad view of the person and understand the sensory, cognitive, and emotional dimensions of multi-factorial pain. They help patients engage in activities that have value and meaning to them despite persistent pain. Frequently individuals with persistent pain have developed unhelpful coping behaviours and beliefs. Occupational therapists establish the individual’s existing attitudes, and degree of self-efficacy (the belief they can affect their pain). This allows them to work with the person to suggest changes and teach skills to manage the pain and facilitate a better quality of life. Relaxation, meditation, and visualization activities to cognitively redirect pain can play an important role. Occupational therapists can also recommend and educate people on the use of appropriate equipment where indicated to reduce pain while carrying out everyday tasks and actions. @@ <<if $MDT is true>> [[Back->MDT]] <<elseif $MDT is false>> [[Back->Dr only]] <</if>>

@@.whitetext; With the evolution of comprehensive pain models incorporating a biopsychosocial approach the fundamental role of psychologists in the persistent pain MDT has been established. Management based on biopsychosocial perspectives must recognise the full range of social and psychological factors that are affecting the individual patient’s pain, distress, and disability. ''Key roles:'' *Provide a comprehensive psychological evaluation of a patient with persistent pain *Assess the ‘stage of readiness’ for treatment and change *Support the patient in establishing realistic goals *Provide targeted counselling *Develop patient understanding of the dynamic interaction between pain and mood *Help reduce emotional distress associated with the chronic pain experience *Support the patient in developing adaptive strategies and skills to cope with stress and pain *Gather critical information about the patient’s substance use history, current medication adherence, and cognitive or behavioural barriers to appropriate medication use *Make specific behavioural observations during interactions about the patient’s obvious or subtle pain behaviours, affect, cognitive limitations, mental status, communication style, and personality indicators *Implement and interpret measurement and assessment tools to guide appropriate interventions and assess the outcome of treatment ''Acceptance and commitment therapy (ACT)'' ACT is a unique psychological intervention with origins in cognitive behavioural and behavioural therapy. ACT uses acceptance and mindfulness strategies to address avoidance, denial, and fear associated with persistent pain, together with commitment and behaviour change strategies, to increase psychological flexibility. The patient learns how to make healthy connections with thoughts, feelings, memories, and physical sensations that they have feared and avoided. They gain the skills to recognise, recontextualize and accept them while developing a greater clarity in personal values, and aspirations alongside the commitment to necessary behavioural change. <<if $MDT is true>> [[Back->MDT]] <<elseif $MDT is false>> [[Back->Dr only]] <</if>>

@@.whitetext; Specialist nurses can provide a consistent point of contact for individuals with persistent pain. They have several important roles within the MDT including: *Undertaking comprehensive assessments including psychosocial needs *Running nurse-led medication follow-up clinics, and reviewing the efficacy and side-effects of drug therapy *Some provide nurse-led TENS and acupuncture clinics *Offering patient education on medication use, relaxation skills, sleep strategies and pacing techniques *Providing ongoing support to people living with pain, and their carers, reinforcing wellness behaviours and normal functioning @@ <<if $MDT is true>> [[Back->MDT]] <<elseif $MDT is false>> [[Back->Dr only]] <</if>>

Three months later and you are in MDT clinic with Dr Jones, the physio, OT, psychologist, and specialist nurse. It's been a busy morning. You look down the list to see how many more patients are in the clinic when you spot a name you recognise, Mrs Heath. Dr Jones comes out of the clinic room and comes over. "Why don't you see her, I'll sit in corner and listen, and you tell me what you think afterwards?" You take her notes and call her through from the waiting room. She gets up a bit stiffly from the chair and follows you through to the consultation room. You both sit down. "Hello Mrs Heath, I'm Dr $firstname $surname and this is Dr Jones one of the consultants. We've had a referral from your GP about some problems you've been having with back pain. Can you tell me a bit about whats been happening?" [[Play audio]] [[Audio transcript]] <<audio mrsheathclinic pause>>

@@.whitetext; ''Pain Management Programmes (PMPs)'' PMPs are based on cognitive behavioural principles and are the treatment of choice for many people with persistent pain which adversely affects their quality of life and where there is significant impact on physical, psychological and social function. The efficacy of cognitive behavioural PMPs as a package, compared with either no treatment or treatment as usual, in improving pain experience, mood, coping, negative outlook on pain and activity levels is supported by high quality evidence. PMPs establish more appropriate use of healthcare resources, reduce pain-related primary care and emergency department attendances, reduce medication use and reduce onward referrals. There is some heterogeneity in how PMPs are delivered throughout the UK. However, a number of unifying and ideal principles underpin successful PMPs. The majority of PMPs are delivered by many different healthcare professionals including doctors, nurses, psychologists, physiotherapists, occupational therapists and specialist nurses. PMPs are usually delivered to groups of around eight participants on an outpatient basis with day or half day group sessions over several weeks. Delivery in a group format helps normalise a participant’s pain experience and allows the participants to learn. Inpatient PMPs may be appropriate for participants with complex needs or who are severely disabled by their pain. ''Participant Education'' is a key component and sessions may include: *Pain mechanisms, associated pathologies, and processes of healthy normal functioning *Anatomy, physiology and pathways of pain *The differences between acute and persistent pain *Psychology and pain: fear, avoidance, stress, distress and depression *Safety and risk in new or increased activities *Appropriate use of aids, treatments and medication *Self-management of ‘flares’ and setbacks *Lifestyle changes for improving or maintained general health ''Graded activation'' guided by participant goals is another core part of PMPs incorporating the domains of general physical activity, self-care, work, social activities and physical exercise and are intended to reduce fear and avoidance. Key features include: *Identifying barriers to activity *Skills to manage barriers *Goal-setting *Developing integrated and sustainable patterns of healthy activity ''Cognitive therapy'' methods are used to identify, examine, and change the impact of distressing, misleading, or restricting thoughts and beliefs. Methods to enhance acceptance, mindfulness and ''psychological flexibility'' are an important feature of PMPs. The overall principle aim of PMPs is to empower people with persistent pain to achieve as normal a life as possible, decrease physical disability and emotional distress and increase the ability to self-manage. PMPs can also help facilitate return to work in those unable to work due to their pain problem. <<if $MDT is true>> There is [[good quality evidence]] that PMPs improve reported physical and psychological wellbeing in people with persistent pain. [[Back->MDT]] <<elseif $MDT is false>> [[Back->Dr only]] <</if>>

Three months later and you are in Dr Only clinic with Dr Jones. It's been a busy morning. You look down the list to see how many more patients are in the clinic when you spot a name you recognise, Mrs Heath. Dr Jones comes out of the clinic room and comes over. "Why don't you see her and tell me what you think afterwards?" You take her notes and call her through from the waiting room. She gets up a bit stiffly from the chair and follows you through to the consultation room. You both sit down. "Hello Mrs Heath, I'm Dr $firstname $surname. We've had a referral from your GP about some problems you've been having with back pain. Can you tell me a bit about whats been happening?" [[Play audio]] [[Audio transcript]] <<audio mrsheathclinic pause>>

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio mrsheathclinic play>> @@.whitetext; If the audio doesn't play automatically press @@ [[PLAY|https://www.virtualanaesthetics.com/Module%201/audio/mrsheathclinic.mp3]] @@.whitetext; (opens in a new screen).@@ <<if $MDT is true>> [[Audio transcript]]    [[Next->MDT thinking]] <<elseif $MDT is false>> [[Audio transcript]]    [[Next->Dr only thinking]] <</if>> <img src="images/hands.jpg" style="max-width: 100%;"/> </center>

@@.typing; I’ve been fit and well most of my life, just the odd migraine. Never been to hospital for anything. I’ve never smoked and don’t drink apart from the odd wedding. <br> It was four years ago I had my accident; I remember it like it was yesterday. It was my niece's tenth birthday and she ‘had’ to have an ice-skating party. My sister asked me to help-out. I’d never ice-skated in my life and thought ‘well it can’t be that hard’. <br> We’d only been going for about ten minutes when my feet just went out from under me and I was suddenly lying flat on my back on the ice, staring up at the ceiling. I could hardly move. I couldn’t get up and the staff had to help me off the ice. It was so embarrassing and to make matters worse the party of ten-year olds thought it was hilarious. Such a stupid accident and its ruined my life. <br> I thought it would just get better on its own. Everyone gets backpain don’t they? I took Nurofen and hobbled round for three weeks, but when it didn’t get any better, I went to see my GP, who said that ‘backpains common, take the Nurofen’. He referred me for some physio but said the wait was pretty long and I’d probably be better before the appointment came through. <br> He asked me lots of questions: Whether I had a history of cancer? Did my legs feel odd or weak? If my bowels or bladder were working as they should? But none of that has ever been an issue though. <br> He was wrong about the physio though; I was still struggling when the appointment came. The physio was nice but every week he’d give me ‘homework’ to do and I’d really try but it just hurt too much and I’d wake up in more pain than before, so I cancelled the last two appointments with them and went back to my doctor again. I was sure there was something seriously wrong for the pain to be going on so long and what if the physio was doing more damage? The GP was a bit dismissive that time, said that four months wasn’t that long in terms of recovery, but he did send me for an MRI, he gave me some codeine that time I think and signed me off for another month. <br> So a couple of months later I had a scan. It took forever to get the results and all that time; I was petrified that I’d done myself real damage form the accident. When I spoke to my GP about it, he said there were ‘degenerative changes’ on the scan and nothing that needed treatment. I remember being really upset on the phone, how could there be nothing they could do when I was in so much pain? I hadn’t really left the house in six months; I’d been off sick from work. He gave me another prescription; it was for naproxen that time. <br> Then I went to see a chiropractor who’d helped a friend with her back, but that was a waste of money and didn’t help. I went back to my GP a couple more times, but he didn’t understand how bad things are because I’d just get another prescription for a different pill. <br> It’s just awful. I had to go back to work or I’d lose my job but sitting at a computer for hours at a time leaves me in agony and my boss just doesn’t understand. I asked to cut my hours but even with that it’s been getting harder and harder to drag myself in. My team feel like I don’t pull my weight and I’ve had so much time off sick I’ve been on a performance review since Christmas. <br> I can’t sleep, I dread going to bed. It’s impossible to get comfortable and sometimes I wake up with my back in spasm; in the middle of the night when I lie there in so much pain it’s hard not to worry that there’s something seriously wrong. So I’m constantly shattered which makes everything so much harder to cope with. On my days off I might stay in bed and sleep till the afternoon but it’s never enough. I told my GP, that if I could just sleep better things wouldn’t be so hard, he gave me some amitriptyline which helped a bit but not enough to make much difference. I think that was when I started the tramadol too, that made me feel really spaced out but never seemed to make the pain better. <br> I used to be really active, I can’t even walk to work anymore, I don’t have any energy and I know if I tried, I’d pay for it later and the pain would be unbearable. I know my diet's not good; coffee and chocolate get me through the day. I can’t be bothered to cook when I get in from work, the thought of standing in the kitchen is impossible. I don’t have a social life anymore. I used to go out with friends but I’m just too tired. I tried a couple of times but after an hour I’d be in so much pain with my back that I had to leave and then they just stopped asking me. <br> I’m scared of losing my job. Who would want to employ me after so much time off sick? I’m sick of the way things are now, I’d try anything that would make things better. I’d like to get some of the old me back, just to be able to spend an evening with friends or to go out shopping for the day without dreading it. <br> That’s why I went back to the GP again. I was just desperate for something to change, He said that ‘chronic pain’ like mine wasn’t going to go away and I should try and live with it. That almost broke me, the thought that it’s going to be like this forever. How am I expected to live with something unbearable? He told me about your service, he said that you help people with similar problems to mine find better ways of coping. Sorry, I’ve gone on a bit. Do you think you could help me? @@ <<audio mrsheathclinic pause>> <<if $MDT is true>> [[Next->MDT thinking]] [[Play audio]] <<elseif $MDT is false>> [[Next->Dr only thinking]] [[Play audio]] <</if>>

Mrs Heath looks at you expectantly across the desk. "Thank you, that's really helped me understand your pain problem and how it affects you. There's a session with the psychologist next. Can I ask you to go back out to the waiting room until they're ready for you? Once you've seen everyone today we can have a chat with you about what we're going to do moving forward. Is that ok?" "Yes, that's great, thank you Dr $surname" Mrs Heath gets up and goes back to the waiting room. [[Next->MDT meeting]]

<<if $Seeingapsychologist is true & $Seeingaphysiotherapist is true & $ReducingorstoppingtheTramadol is true & $SeeinganOT is true>> "Actually Mrs Heath persistent pain is a complex problem and its needs to be tackled in lots of different ways to make your quality of life better. I think the plan we have now hopefully gives you the best chance of that" "Thank you Dr $surname, thats what I've been really struggling with for years, trying physio on its own didn't help nor do all the pills that the GP gives me. You really seem to understand" "I'm glad you feel that way Mrs Heath, is there anything else you'd like to ask or discuss today" "No, thats everything, thank you for your time today, goodbye Dr Jones, Dr $surname." [[Next->follow up 1]] <<else>> Mrs Heath looks at you expectantly. "I think we should consider..." <<if $Aspinalinjection is true>> <<elseif $Aspinalinjection is false>> [[A spinal injection]] <</if>> <<if $Selfmanagment is true>> <<elseif $Selfmanagment is false>> [[Self-managment]] <</if>> <<if $Painmanagmentprogramme is true>> <<elseif $Painmanagmentprogramme is false>> [[Pain managment programme]] <</if>> <<if $ReducingorstoppingtheTramadol is true>> <<elseif $ReducingorstoppingtheTramadol is false>>[[Reducing or stopping the Tramadol]] <</if>> <<if $Seeingapsychologist is true>> <<elseif $Seeingapsychologist is false>> [[Seeing a psychologist]] <</if>> <<if $Seeingaphysiotherapist is true>> <<elseif $Seeingaphysiotherapist is false>> [[Seeing a physiotherapist]] <</if>> <<if $SeeinganOT is true>> <<elseif $SeeinganOT is false>> [[Seeing an OT]] <</if>> <</if>>

<<cacheaudio "mrsheathclinic" "audio/mrsheathclinic.mp3">> <<set $history to []>> <<set $started to 0>>

!!!Red flags indicating serious underlying pathology ''Cauda equina syndrome'' Red flags include: *Bilateral sciatica *Severe or progressive sensory or motor disturbance *Bowel or bladder disturbance *Saddle anaesthesia or paraesthesia ''Spinal fracture'' Red flags include: *History of trauma or osteoporosis or corticosteroid use *Sudden onset, central spinal pain which is relieved by lying down *Point tenderness over a vertebral body *Structural deformity of the spine ''Cancer'' Red flags include: *Aged less than 20 or more than 55 *Unremitting even when supine, disturbs sleep, worse when straining or coughing *Thoracic pain *Localised spinal tenderness *Unexplained weight loss *History of cancer (breast, lung, GI, renal, thyroid and prostate can metastasize to the spine) ''Infection'' (discitis, vertebral osteomyelitis, or spinal epidural abscess) Red flags include: *Fever *Tuberculosis, or UTI *Diabetes *IV drug use *HIV infection or other immunocompromise ~~adapted from NICE 2018 guidelines~~ <<if $Dronlythinking is true>> [[Back->Dr only thinking]] <<elseif $Dronlythinking is false>>[[Back->MDT thinking]] <</if>>

!!!Yellow flags These are psychological indicators that an individual is at risk of long-term disability and chronicity due to their pain: *Belief that pain and activity are harmful *Sickness behaviours, such as extended rest *Social withdrawal *Emotional problems such as low or negative mood, depression, anxiety and stress *Problems and/or dissatisfaction at work *Problems with claims or compensation, or time off work *Overprotective family; lack of support *Inappropriate expectations of treatment, including low expectations of active participation in treatment *Catastrophising, avoidance and misinterpreting bodily symptoms *History of depression or anxiety *Drug or alcohol use ~~Adapted from Nicholas MK, Linton SJ, Watson PJ, et al; Early identification and management of psychological risk factors ("yellow flags") in patients with low back pain: a reappraisal. Phys Ther. 2011 May91(5):737-53~~ [[Back->Dr only thinking]]

"I think we should consider giving you a spinal injection." "What's that?" Mrs Heath asks you. As you start to explain "Well, you inject local anaesthetic with or without steroid.." Dr Jones quietly interupts from where he's been sitting in the corner of the room "We offer different spinal injections targeting the joints between the bones of your spine or to individual nerve roots as they exit your spine. The injection can help to temporarily reduce swelling and inflammation to allow you to progress with other treatments such a physiotherapy." "I can't stand having blood tests so I don't much fancy anything involving needles." Mrs Heath replies. "I understand Mrs Heath, but it is an option we could think about later if you change your mind." Dr Jones says before looking back at you. "Why don't you tell Mrs Heath about some other things we can do to help the situation" <<set $Aspinalinjection to true>> [[Back->Dr only plan]]

"I think we should consider reducing and ideally stopping your tramadol" Mrs Heath looks indignant "I'm not a junky!" You exchange a glance with Dr Jones. "No, no, I'm not saying you are, not at all, but you've said that it doesn't seem to be helping much if at all and that it's been giving you a dry mouth." Mrs Heath looks a bit less annoyed, "Well I suppose that's true, but I'm worried that if I stop them the pain will be unbearable." "I can understand why you might be concerned that might happen and that's why we wouldn't just stop them overnight, it will be a gradual process and we can work out a plan for other ways to help with your pain. The Faculty of Pain Medicine has some patient information on their [[website]], I can write that down for you to take a look in your own time" Dr Jones is nodding in agrement from where he's sitting in the corner. Mrs Heath looks skeptical, "Ok, we can try, it would be good to not have to take so many pills, but what about this plan?" <<set $ReducingorstoppingtheTramadol to true>> <<set $Selfmanagment to true>> <<set $Painmanagmentprogramme to true>> [[Back->Dr only plan]]

"I think we should consider getting you in for some sessions with Melanie our psychologist" Mrs Heath looks perplexed "How would that help when I have a physical problem?" "Melanie would work on something called Acceptance Commitment Therapy with you." She's looking even more perplexed, you carry on "Let me explain..." and you give her a brief explanation of what it is and how it might help. "I can see how that might help but is there anything to do at the same time? I just feel like I need all the help I can get with this." <<set $Seeingapsychologist to true>> <<set $Painmanagmentprogramme to true>> <<set $Selfmanagment to true>> [[Next->Dr only plan]]

"I think we should consider getting Graham our phsyio to do some work with you." "I saw a physio after I first had the accident and it didn't really seem to help. They gave me some exercises but they hurt so much that I stopped doing them and then I was back to square one really." You nod, "I understand, physio and exercise programmes can be part of how we manage your persistent pain problem but there are lots of other things we can do to help make things better." <<set $Seeingaphysiotherapist to true>> <<set $Painmanagmentprogramme to true>> <<set $Selfmanagment to true>> [[Next->Dr only plan]]

You talk through a few things that Mrs Heath could do to help self-manage her persistent pain problem. You cover goal-setting, pacing herself, sleep hygeine and doing some form of exercise she enjoys such as swimming or walking. She nods occasionally and asks a few questions. You feel like you're really making some progress. You ask her what she thinks. "The problem is Dr $surname, I feel like this is such a big thing now that the only way things will be better is if I have something a bit more, well, substantial? I've been trying to self manage for four years and it hasn't really got me anywhere" <<set $Selfmanagment to true>> [[Back->Dr only plan]]

"What's that?" Mrs Heath asks. You pick up a leaflet from the desk about the Persistent Pain Service PMP and hand it to her. She opens it and looks at the glossy picture of a group sitting round together and another where they're all on exercise balls. "Do you really think it will help? This has been going on so long now." "There's [[good quality evidence]] that pain management programmes help people with your kind of problems so I think it's definitely worth thinking about." She nods her head, "Ok, I'm willing to try anything now." You ask her if there's anything else she'd like to talk about today and show her out of the room. [[Next->follow up 2]]

You recap the history as you understand it giving yourself a minute to run through the [[Red]] and [[Yellow]] flags for back pain in your head. Are there any Red or Yellow flags in the history? [[Yellow flags]] [[Red flags]] [[Red & Yellow->Red flags]] [[None->Red flags]] <<set $MDTthinking to true>> <<audio mrsheathclinic pause>>

You recap the history as you understand it giving yourself a minute to run through the [[Red]] and [[Yellow]] flags for back pain in your head. Are there any Red or Yellow flags in the history? [[Yellow flags]] [[Red flags]] [[Red & Yellow->Red flags]] [[None->Red flags]] <<set $Dronlythinking to true>> <<audio mrsheathclinic pause>>

That’s right. There are a number of psychological indicators or yellow flags that Mrs Heath is at risk of long-term disability from her persistent pain. There are no indicators of serious pathology or red flags. Now it's time to talk to her about a plan. <<if $MDT is true>> [[Next->MDT plan]] <<elseif $MDT is false>> [[Next->time to make a plan]] <</if>>

There are a number of psychological indicators or yellow flags that Mrs Heath is at risk of long-term disability from her persistent pain. There are no indicators of serious pathology or red flags. Go back to the previous slide and click the link for more on red and yellow flags <<if $Dronlythinking is true>> [[Back->Dr only thinking]] <<elseif $Dronlythinking is false>>[[Back->MDT thinking]] <</if>>

@@.whitetext; ''Do PMPs work?'' High-quality meta-analyses and systematic reviews have established that PMPs are effective, cost-effective, reduce medication use, reduce healthcare consumption and presentation with pain-related issues. Where a vocational component is included, they also improve the rate of return to work. Further evidence supports a reduction in stress and disability. This is reflected in an improvement across a range of outcome measures in mixed pain groups. A 2012 Cochrane review concluded sufficient high-quality evidence supports the use of CBT-based programmes and no further randomized controlled studies are necessary into their efficacy. Cochrane recommended the patient-related outcomes associated with different PMP components should be the focus of related ongoing research. ''How much benefit to they provide?'' The magnitude of benefit derived by participants varies widely in the literature which likely reflects variation in the types of programme, content, and patient groups. Between one third and two thirds of patients experience improvement in one or more of measured domains with measures of physical and psychological functioning showing the clearest benefits while participants report the pain itself is only transiently improved, if at all. The scant number of studies with long-term outcomes report the benefits of PMPs are maintained at 24 and 36 months with a decrease in healthcare use and an increase in hours of paid employment. !!!The bottom line: Good quality evidence supports the use of PMP in the management of persistent pain. @@ <<if $MDT is true>> [[Back->PMP]] <<elseif $MDT is false>> [[Back->Pain managment programme]] <</if>> [[Show me the evidence->References]]

It's been a busy on-call shift, your bleep hasn't stopped going off since you started. It's not like your persistent pain block, that was quite different, a really great team too, you can't believe its been eight months since you were there. You finally get a minute to yourself to grab a drink and check your emails. That's a coincidence, five emails down the list of twenty is one from good old Dr Jones. [[open email->open email 2]]

A couple of hours later you grab a quick coffee, Dr Jones comes into the room and looks over your shoulder. "Coffee? Excellent idea! Just milk in mine thanks." He disappears off to the meeting room. You follow a minute later carrying the two mugs. The rest of the team are already seated, you recognise Mrs Heath's notes open on the desk in front of Melanie the psychologist. [[ask her what she thinks]]

"Well it's clear from talking to Mrs Heath there are a number of issues impacting on her pain experience. Even though its been ongoing for years now she's still holding out for a cure that completely resolves the issue. But she's also frightened of the pain and almost angry with it because she perceives it limits her so significantly. I think we could work with her to channel those feelings into goal-setting and I think Acceptance Commitment Therapy may be helpful for her" [[hear what the physio thinks]]

"How was she with you Graham?" you ask the physio. Graham scratches his head, "Well it's like Melanie said, Mrs Heath is frightened of making the pain worse when I'm working with her. Her passive range of movements is very good but she's constantly guarding when you ask her to do any active stretches. I agree that goal setting would be really helpful and lots of encouragement could improve her function in a meaningful way for her. We could work on her understanding of persistent pain, and gently give her the confidence to build up her movement in a graded way." Diane the OT is nodding her head. [[hear what the OT thinks]]

"There are several things we could work on. Mrs Heath has got into that vicious cycle of poor quality sleep, feeling exhausted, poor self-care and eating lots of sugary snacks to try and focus at work. She tries to 'catch up' on rest on her days off work but having a really erratic routine where she might stay in bed till 2pm on some days and then be up at 3am the next is just making matters worse." "It also doesn't help that at work she's sat at her computer work station for her whole shift and eats her lunch at her desk." Diane looks round the team, "So there's lots we could work on, what do you think?" [[your turn]]

What do you think? What would you say to the team? What sort of plan would you suggest to Mrs Heath? Write a few notes, make a plan.... [[Case points]]

Did you pick up on these features in Mrs Heath's history? *Avoidance *Low mood *Poor sleep *Lack of motivation *Deconditioning *Chronic opioid use If you have the opportunity you could discuss the case with your Faculty Tutor (Pain) or Clinical Supervisor? [[Next->Whats your plan?]]

"I think we could offer her a place on the Pain Management Programme." You pause for a second, everyone's listening "I think some group work will really make her feel less isolated and the sessions will do a lot to give her the tools to make positive differences to her life." Dr Jones looks pleased, "Well I think thats a plan, you can discuss it with Mrs Heath know and see what she makes of it." [[follow up->follow up 2]]

"Diane said there was lots that she could work on, how about a few sessions on sleep hygiene and pacing activities and ergonomics at work? I think that would make a big difference to her quality of life." Diane is nodding now, "Yes, I agree that would be useful as part of a plan." "Anything else to add $firstname?" Dr Jones asks. [[Next->Whats your plan?]] <<set $Occupationaltherapy to true>> <<set $PlaceonthePMP to true>> <<set $Combinationoftheabove to true>> <<set $dischargetoGP to true>>

"I think we should try and wean Mrs Heath off the tramadol. She said herself she doesn't derive any benefit from it and it might be contributing to her feeling as tired as she does" There are a couple of nods round the table, everyone at the table knows the problems associated with [[opioids in non-cancer pain]]. Dr Jones is nodding too, "We could work on a weaning programme to reduce and stop it. I think you're right that it doesn't appear to be beneficial. We need to make sure it's part of a robust plan, so is there [[anything else->Whats your plan?]] to discuss with her?" <<set $Opioidreductionprogramme to true>> <<set $PlaceonthePMP to true>> <<set $Combinationoftheabove to true>> <<set $dischargetoGP to true>>

"I think we could offer a combination of psychological therapy, some sessions of OT and physio and some sessions with myself or Dr Jones to work on getting her off the opioids." You pause for a second, everyone's listening "I think some acceptance commitment work, some graded exposure physio and sorting out her pain-related coping behaviours could really make a difference to Mrs Heath's quality of life" Dr Jones looks pleased, "Well I think that's a plan, you can discuss it with Mrs Heath know and see what she makes of it." [[Follow up->follow up 1]]

"If she's fixed on a cure, that's on the service [[referral criteria]] as a reason to dicharge her back to her GP." you remember from the document Dr Jones showed you when the referral came in in the first place. Dr Jones sighs, "It is completely correct that fixation on the prospect of a cure makes it very difficult for an individual to engage in a lot of what we can offer. But I think in Mrs Heath's case, she hopes that things will improve, as opposed to a miraculous resolution." "I rather think we have a great deal we can do for Mrs Heath. What could we do?" [[Back->Whats your plan?]] <<set $dischargetoGP to true>>

@@.whitetext; Faculty of Pain Medicine has created the [[Opioids Aware->https://fpm.ac.uk/opioids-aware]] resource for patients and healthcare professionals to support prescribing of opioid medicines for pain. One of the key messeges from the resource is that opioids should be stopped if a patient continues to have severe pain despite treatment. There is guidance on working with patients to safely reduce and stop opioids including easily accessible patient information. @@ [[Back->Opioid reduction programme]]

"I think we should get her in for some sessions with you Melanie." Melanie nods "As I said, I'd be happy to do some Acceptance Commitment work with her. From our session today I think she would benifit. Do you think what we have is enough of a plan for her?" Everyone is looking at you expectantly. [[Next->Whats your plan?]] <<set $Psychologicaltherapies to true>> <<set $PlaceonthePMP to true>> <<set $Combinationoftheabove to true>> <<set $dischargetoGP to true>>

"I think we should consider getting Graham to do some work with her." Graham interrupts "I think thats part of a plan, but she saw a physio in the early days after her injury and is actually quite reluctant to try something she didn't benefit from before. If it was part of a wider plan she might be more willing to engage." Dr Jones nods "Do you think she'd be a candidate for me to do some facet joint injections to alow her to increase her exercise?" "We could discuss that with her as an option. Working with her today she’s got a reasonable range of movement at so I think we can make progress without, but it’s definitely something we can bare in mind " Graham agrees. "What do we think of this [[plan->Whats your plan?]] then?" Dr Jones asks the room. <<set $Physiotherapy to true>> <<set $PlaceonthePMP to true>> <<set $Combinationoftheabove to true>> <<set $dischargetoGP to true>>

<<if $Opioidreductionprogramme is true & $Occupationaltherapy is true & $Psychologicaltherapies is true & $Physiotherapy is true>> "So I think by offering a combination of psychological therapy, OT, physio and some sessions with myself or Dr Jones to work on getting her off the opioids Mrs Heath is likely to have a better outcome." You pause for a second, everyone's listening "I think some acceptance commitment work, some graded exposure physio and sorting out her pain-related coping behaviours could really make a difference to Mrs Heath's quality of life" Dr Jones looks pleased, "Well I think that's a plan, you can discuss it with Mrs Heath and see what she makes of it." [[Follow up->follow up 1]] <<else>> "I think we should offer..." <<if $Opioidreductionprogramme is true>> <<elseif $Opioidreductionprogramme is false>>[[to reduce or stop the Tramadol->Opioid reduction programme]] <</if>> <<if $Occupationaltherapy is true>> <<elseif $Occupationaltherapy is false>>[[Occupational therapy]] <</if>> <<if $Psychologicaltherapies is true>> <<elseif $Psychologicaltherapies is false>>[[Psychological therapies]] <</if>> <<if $Physiotherapy is true>> <<elseif $Physiotherapy is false>>[[Physiotherapy]] <</if>> <<if $Combinationoftheabove is true>> <<elseif $Combinationoftheabove is false>>[[a combination of the above->Combination of the above]] <</if>> <<if $PlaceonthePMP is true>> <<elseif $PlaceonthePMP is false>>[[a place on the PMP->A place on the PMP]] <</if>> <<if $dischargetoGP is true>> <<elseif $dischargetoGP is false>>[[to discharge back to her GP->Discharge back to the GP]] <</if>> <</if>>

It's been a busy on-call shift, your bleep hasn't stopped going off since you started. It's not like your persistent pain block, that was quite different, a really great team too, you can't belive its been eight months since you where there. You finally get a minute to yourself to grab a drink and check your emails. That's a coincidence, five emails down the list of twenty is one from good old Dr Jones. [[open email->open email 1]]

@@.typing;''From:'' James Jones (Consultant Pain Management) ''Sent:'' Today ''To:'' Dr $firstname $surname ''Subject:'' Saw Mrs Heath in clinic today Hi $firstname I saw Mrs Heath in clinic today and she asked if she could be seen by that 'very good doctor I saw last time'. She was very disappointed that you'd rotated away from the service. I thought you'd like to find out how she's getting on with your plan. She has engaged well with Melanie (psychologist), Graham (Physio) and Diane (OT) and her GP and I have managed to reduce her tramadol by half. She says her mood and sleep are better and she feels more in control. Her good days are getting more frequent and objectively she's no-longer under performance management at work. Best of all she's very motivated to carry on with everything so I think she's going to have a much better outcome for seeing us at the pain service. Well done! You should really consider a future in pain managment you know. All the best for the future, James@@ [[END]]

!!!@@.greentext;Scenario learning objectives@@ * Describe the assessment of a patient with a persistent pain problem * Explain in broad terms some of the assessment tools used in the evaluation of persistent pain * Identify red and yellow flags in a person’s history * Refer to the existence of NICE guidance relating to the management of chronic back pain in adults * Understand the possible structure of a persistent pain service multi-disciplinary team * Be aware of the FPM Opioid Aware resources Well done for completing VA_Pain Training_1! If you want to explore alternative outcomes this [[link|Triage]] will take you back to the triage passage. Alternatively to access your completion certificate click the link bellow. [[Credits and certificate|credits]] <<set $historyOutput to "">> <<nobr>> <<set _last to $started>> <<for _event range $history>> <<set $historyOutput to $historyOutput + "<br>Passage: " + _event.passage + ", Seconds: " + setup.toSeconds(_last, _event.time)>> <<set _last to _event.time>> <</for>> <</nobr>> <<nobr>> <<set $passagetimes to $historyOutput>> <<set $id to "VApain1">> <<set $result1 to "-">> <<set $result2 to "-">> <<set $playtimehr to playTime('hours')>> <<set $playtimemin to playTime('minutes')>> <<set _data = {randomid: $randomid, role: $role, id: $id, playtimehr: $playtimehr, playtimemin: $playtimemin, result1: $result1, result2: $result2, passagetimes: $passagetimes }>> <<run sendData4(_data)>> <</nobr>>

@@.typing;''From:'' James Jones (Consultant Pain Management) ''Sent:'' Today ''To:'' Dr $firstname $surname ''Subject:'' Saw Mrs Heath in clinic today Hi $firstname I saw Mrs Heath is clinic today and she asked if she could be seen by that 'very good doctor I saw last time'. She was very disappointed that you'd rotated away from the service. I thought you'd like to find out how shes getting on with your plan. She has engaged well with the PMP. It was a couple of months ago now. Her GP and I have managed to reduce her tramadol by half. She says her mood and sleep are better and she feels more in control. Her good days are getting more frequent and objectively she's no-longer under performance management at work. Best of all she's very motivated to carry on with everything so I think she's going to have a much better outcome for seeing us at the pain service. Well done! You should really consider a future in pain managment you know. All the best for the future, James@@ [[END]]

"I think we should consider getting you in to see Diane our occupational therapist." "Is that like at work?" Mrs Heath asks, she looks worried, you remember shes been on performance management at work. "It's quite different. The OT can help you find strategies that work in your everyday life to make things better for you. That might include things you can do at work like taking breaks to move around so you don't get stiff but it's also things like how you're sleeping and how to make tasks you're struggling with easier for example pacing yourself and doing things at the time of day which is best for you" "That sounds like it could really help, but is there anything else that I can do along side that?" <<set $SeeinganOT to true>> <<set $Painmanagmentprogramme to true>> <<set $Selfmanagment to true>> [[Next->Dr only plan]]

@@.whitetext; !!!VA_Pain training_1 Welcome to the first in a series of interactive scenarios to support learning during pain training. You can find out more on using this scenario ''[[here|howtoguide]]''. ''Disclaimer: Virtual Anaesthetics is not responsible for your use of the information contained in or linked from this site. All users should act within their own competence and according to local and national guidelines and policies. All treatment information contained herein is provided as a general example only and you should always check drug doses in an appropriate formulary. Any descriptions of procedures or techniques is intended as an example only and as a supplement formal training. Individuals should only perform procedures or techniques they have been formally trained in and are competent to perform.'' @@ ''[[Next|Introduction]]'' [[I'm a clinical supervisor or trainer|trainers_area]] @@.whitetext; If you are ''not'' a health care professional please read our brief message first [[here|message]]@@

@@.whitetext; In people without back pain lumbar MRI abnormalities are common and become increasingly so with age: <center> | ''Imaging findings'' | ''20y'' | ''30y'' | ''40y'' | ''50y'' | ''60y'' | ''70y'' | ''80y'' | | Disk degeneration | 37% | 52% | 68% | 80% | 88% | 93% | 96% | | Disk signal loss | 17% | 33% | 54% | 73% | 86% | 94% | 97% | | Disk height loss | 24% | 34% | 45% | 56% | 67% | 76% | 84% | | Disk bulge | 30% | 40% | 50% | 60% | 69% | 77% | 84% | | Disk protrusion | 29% | 31% | 33% | 36% | 38% | 40% | 43% | | Annular fissure | 19% | 20% | 22% | 23% | 25% | 27% | 29% | | Facet degeneration | 4% | 9% | 18% | 32% | 50% | 69% | 83% | | Spondylolisthesis| 3% | 5% | 8% | 14% | 23% | 35% | 50% | |''Age-specific prevalence estimates of degenerative spine imaging findings in asymtomatic patients''^^1^^|c </center> An estimated 84% of adults experience back pain at some point during their lifetime. Less than 1% of these patients have a serious systemic aetiology (eg malignancy or infection) while less that 10% have specific local aetiologies (eg compression fracture or radiculopathy). Immediate lumbar imaging in patients without indicators of serious underlying pathology does not improve short or long-term clinical outcomes^^2, 3^^. Where radiological findings are consistent with the patient’s clinical presentation they do not predictably correlate with the clinical severity or prognosis. Nor does recovery depend on resolution of the pathology on imaging ^^4^^. NICE guidance recommends clinicians "not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica^^5^^". !!!The bottom line: In patients without features of a serious underlying pathology imaging is not indicated and MRI findings are both common and non-specific. @@ [[Show me the evidence->References 2]] [[Back->MRI image]]

Blake C, Cunningham J, Power C, et al. The impact of a cognitive behavioural pain management program on sleep in patients with chronic pain: results of a pilot study. //Pain Med// 2016;17:260–9. British Pain Society. Guidelines for Pain Management Programmes for Adults. London: //British Pain Society//, 2013. Demoulin C, Grosdent S, Capron L, Tomasella M, Somville P.R, Crielaard J.M, Vanderthommen M. Effectiveness of a semi-intensive multidisciplinary outpatient rehabilitation program in chronic low back pain. //Joint Bone Spine// 2010;77:58–63. Dysvik E, Kvaly J, Furnes B. A mixed method study exploring suffering and alleviation in participants attending a chronic pain management programme. //J Clin Nurs// 2014;23:865–76. Dysvik E, Kvaløy J, Stokkeland R, et al. The effectiveness of a multidisciplinary pain management programme managing chronic pain on pain perceptions health-related quality of life and stages of change—a non-randomized controlled study. //Int J Nurs Stud// 2010;47:826–35. Egan A, Lennon O, Power C, et al. ‘I’ve actually changed how I live’ – patients’ long-term perceptions of a cognitive behavioural pain management program. //Pain Med// 2016;18:220–7. Fedoroff I, Blackwell E, Speed B. Evaluation of group and individual change in a multidisciplinary pain management program. //Clin J Pain// 2014;30:399–408. Gatchel R.J, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. //J of Pain// 2006;7:779–798. Gill J.R., Guzman J, Esmail R, Karjanalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. //Br Med J// 2001;322:1511–6. Han X, Geffen S, Browning M, et al. Outcome evaluation of a multidisciplinary pain management programme comparing group with individual change measures. //Clin Psychol// 2011;15:133–8. Hoffman B.., Papas R.K, Chatkoff D.K, Kerns R.D. Meta-analysis of psychological interventions for chronic low back pain. //Health Psychol// 2007;26:1–9. Inoue M, Inoue S, Ikemoto T, et al. The efficacy of a multidisciplinary group programme for patients with refractory chronic pain. //Pain Res Manage// 2014;19:302–8. Kamper S, Apeldoorn A, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. //Cochrane Database Syst Rev// 2014;CD000963. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. Multidisciplinary biopsychosocial rehabilitation for subacute low back pain in working-age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2001;26:262–269. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H. Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. //Cochrane Database of Systematic Reviews//:CD002194 (update of Cochrane Database Systematic Reviews 2003;(3):CD002194) Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache.// Pain// 1999;80:1–13. Morley S, Williams A, Hussain S. Estimating the clinical effectiveness of cognitive behavioural therapy in the clinic: evaluation of a CBT informed pain management programme.// Pain// 2008;137:670–80. Smith J, Knight L, Stewart A, et al. Clinical effectiveness of a residential pain management programme—comparing a large recent sample with previously published outcome data.// Br J Pain// 2015;10:46–58. Stack C, Pang D, Barker E, Kothari S, Woolfenden A. Opiate reduction following Pain Management Programme.// Br J Pain// 7(2), Supplement 1, 2012;67. Takai Y, Yamamoto-Mitani N, Abe Y, et al. Literature of pain management for people with chronic pain. //Jpn J Nurs Sci// 2015;12:167–83. Turk D.C, Okifuji A. Treatment of chronic pain patients: clinical outcomes, cost-effectiveness, and costbenefits of multidisciplinary pain centers. //Crit Rev Phys and Rehab Med// 1998;10:181–208. Turk D.C. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. //Clin J Pain// 2002;18:355–365. Williams AC, de C, Eccleston C, et al. Psychological therapies for the management of chronic pain (excluding headache) in adults. //Cochrane Database Syst Rev// 2012;11:CD007407. Volker G, van Vree F, Woltertbeerk R, et al. Longterm outcomes of multidisciplinary rehabilitation for chronic musculokeletal pain. //Musculoskeletal Care// 2017;15: 59–68. [[Back->good quality evidence]]

# Brinjikji W, Luetmer P, Comstock B et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. //Am J Neuroradiol//. 2015;36(4):811-816 # Chou R, Fu R, Carrino J, Deyo R. Imaging strategies for low-back pain:systematic review and meta-analysis. //Lancet//. 2009;373:463 # Javik J, Gold L, Comstock B, et al. Association of early imaging for back pain with clinical outcome in older adults. //JAMA//. 2015;313:1143 # Barzouhi A, Vleggeert-Lankamp C, LycklamaaNijeholt G, et al. Magnetic resonance imaging in follow-up assessment of sciatica. //N Engl J Med//. 2103;368(11):999-1007 # Bernstein I, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of NICE guidance. //BMJ//. 2017;356:i6748 [[Back->info 4]]

<center> @@.whitetext; ''With thanks to everyone who helped make this scenario happen!'' Our actress: Clwydwen Williams Our scenario advisory support: Abergele Pain Service team Our tech support: Charlie Hargood and Louis Rose Our logistical support: Patrick Wainwright Our editorial team: Sonia Pierce and Richard Wassall Our creative director and lead programmer: Kate Wainwright !!!Well done for completing VA_Pain training_1 <<nobr>><span id="ReplaceMe"> <<link "''certificate''">> <<script>> Dialog.setup("Tell us"); Dialog.wiki("<center> <h3>@@.greentext;You can make Virtual Anaesthetics better. <br><br>Tell us what you think of this scenario [[here|https://forms.gle/QjzbkPQPd5vttkBS7]]. It should take less than a minute. <br><br>Thanks!@@</h3> </center>"); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[certificate]]''<br> <</replace>> <</link>></span><</nobr>> @@ </center>

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Scenario_1@@

<center> !!!BETA Virtual Anaesthetics_Pain training_1 <<link [[What is Beta Testing?|beta]]>> <<set Dialog.setup("What is Beta Testing?")>> <<set Dialog.wiki("@@.greentext;Beta testing is an opportunity for real users to use a product in a production environment to uncover any bugs or issues before a general release. Beta testing is the final round of testing before releasing a product to a wide audience. The objective is to uncover as many bugs or usability issues as possible in this controlled setting.@@")>> <<set Dialog.open ()>> <</link>> !!![[Start scenario|Intro 1]] </center>

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/module1.pdf]]'' [[Back|Introduction]]

''>'' On each page there are clickable links within the text. ''>'' Navigate using the links in the scenario or the forward and back arrows in the left menu bar NOT the forward and back arrows on your internet browser. ''>'' Each scenario should take around an hour. ''>'' Your time spent accessing the scenario is recorded on your completion certificate. ''>'' If you access the scenario several times the certificate will only show the duration of the most recent access. ''>'' For the best platform experience access from a larger screen device such as a tablet ''>'' ''Check you're not on mute''. ''>'' When printing your certificate from a mobile device turn to portrait orientation. [[Back|Intro 1]]

<<set _answer to "">> !!!@@.greentext; Welcome to the trainers area of this scenario@@ Please input the password to continue: <<textbox "_answer" "">> <<button "Check Password">> <<if _answer is "">> <<script>>UI.alert("You did not supply a password");<</script>> <<else>> <<set _answer to _answer.trim().toLowerCase()>> <<if _answer is "vatrainersarea">> <<goto "trainers_area2">> <<else>> <<script>>UI.alert("Incorrect password");<</script>> <<goto "trainers_area">> <</if>> <</if>> <</button>>

p style="text-align:justify">We are absolutely thrilled that you have found us and shown an interest in our learning platform. We wanted to give you the heads up before you get any deeper into the scenario, that like the best medical dramas, bad things may happen. This is to support learning and clinical decision making. It is ''REALLY RARE'' for things like this to happen to otherwise well people undergoing anaesthetics. The Royal Collage of Anaesthetists has some really helpful information explaining the risks of having an anaesthetic if you want further information, available [[here|https://rcoa.ac.uk/patient-information/patient-information-resources/anaesthesia-risk]]. When you are ready, welcome to our virtual world...</p> [[Start|Introduction]]

/* Update the time of the previous history record if there is one. */ <<if $history.length gt 0>> <<set $history.last().time to Date.now()>> <<else>> /* Record the time the first passage was shown. */ <<set $started to Date.now()>> <</if>> /* Add current passage's history record to the array, unless it has a 'no-history' passage tag. */ <<if not tags().includes('no-history')>> <<set $history.push({ "passage": passage(), "time": 0 })>> <</if>>