Hello, this is James Fricton again.
This is part two of the module two on the personal impact of chronic pain.
The title of this part is Characteristics of a Pain Evaluation.
I like acronyms, as you've probably noted,
and this acronym is for the objective assessment.
And it stands for TIRED, T-I-R-E-D.
And they stand for, the T is for tenderness.
We have to look for help, for
tenderness within the muscles and joints through palpitation.
Second is imaging, what are the results of MR, radiographs, and other images.
R is for range of motion.
E is for entrapment, whether there's any nerve impingement.
And D is for dysfunction with regard to the joints.
So let's go through each one of these in more detail.
A muscle exam has five components.
There are muscle trigger points,
tenderness, weakness, spasm, and twitching.
Palpitation is really the most critical, and this looks at
not just subjective pain reports, but is are the muscles tender.
Does the patient report soreness in muscles.
Now the palpitation technique is very specific for trigger points.
These are some of the steps to accomplish that.
First of all you need to know the pain pattern.
If a muscle hurts in a certain area, say
the temporalis, where is the pain pattern in that area?
So you want to find trace, find the pain pattern
and trace back to the individual muscle that's involved.
So, with regard to the, if you have a temple headache,
you'd be looking at the anterior temporalis in the temporalis muscle.
So, within that, then you find the taut band.
You roll your fingers back and forth to really
identify that taut band or tight band of muscle.
And you roll your fingers across it like I'm doing right now.
The fourth aspect is then, is you go up and
down that taught band and find the most tender area.
Yeah, right here, that's it.
The patient will tell you, yeah that's it.
As you press.
And, you have to press fairly firmly.
So once you find that tender spot, the most tender spot in the taut band.
Then you ask them, does that duplicate your pain?
Does that feel like your pain?
And if they say yeah, that feels just like my headache in the temples
then you know there's a relationship between
that tenderness in the muscle, and the pain.
And these are very specific characteristics.
So it's easy to press a different area right here, and see if their patient
has any exacerbation or amplification, exaggeration of the pain.
So, the next one is the five components of a joint evaluation.
Now this includes tenderness of the joint, range of
motion, which is real critical, pain in range of motion.
Whether there's a soft or a hard end feel in terms
of the range of motion, and dysfunction in the range of motion.
So, tenderness of the joint simply is pressing over the joint itself.
Opening, closing, or in the cervical neck, finding the, the
joints and pressing on those particular joint, see if it's tender.
Range of motion is looking at the range of motion, move the joints
and I'll go through each one of these a little bit more detailed.
So, for cervical range of motion for instance, you're
going forward and backwards as shown in this illustration.
You're going left and right, rotation, which
is about 70 degrees in each direction.
And then you're doing lateral flexion, which is about 45 degrees on each side.
For lumbar range of motion, it's very different, obviously.
And you have to touch your toes and see what kind of range of motion there
is, should be able to get about in the back extension, 30 degrees in the front.
Flexion would be about 90 degrees.
And then in laterals, lateral bending would be about 35 degrees on each side.
And then for rotation you can see here is approximately 30 degrees.
So you also, with regard to the mandible, and this is a range of motion
where you measure between the incisor, the upper and lower incisors.
And it's typically about 30, three fingers or
42 to 60 millimeters of range of motion.
But about three fingers is the normal range of motion of the jaw.
And then you do lateral movements, and they usually occur
somewhere between 8 millimeters and 12-14 millimeters on each side.
And each of these range of motions you also want to determine, does it hurt?
And secondly, you want to oversee is it if is at a soft end feel or a hard end feel.
So with regard to the neck, if you're going to one side and they restrict it
because of pain, but can they extend it even further, or, bend it even further.
So if they can bend it further, that means
there may be some muscle restriction or muscle pain associated.
If it's a hard-end feel, typically it's a joint restriction.
The next one is assessment, which
includes the diagnosis and the contributing factors.
So the diagnosis is what's causing the pain.
In other words, what is the tissue that's involved in the pain.
Obviously in this situation it is either joints or muscles.
But there are many co-morbid conditions that are associated
with chronic pain conditions, and we need to identify those.
Particularly any mental health or
psychiatric co-morbid conditions, such as depression.
And we also want to identify the contributing factors.
Now these are factors that are typically the risk factors or protected factors,
but they do occur in sequence and I'll describe them in a little bit.
So the diagnosis is very critical to some extent, we want to know
particularly is it a muscle problem or is it a joint problem?
And the source of pain in most of these situations is really from the muscles
in a, several studies that were found, looking
both at muscle and joint and nerve problems.
And there are four typical disorders associated with muscle pain.
The most common is myofascial pain, which is a
pain with localized tenderness in the muscle called trigger points.
But there's also myositis which is a
generalized inflammation and tenderness of the muscle.
There's contracture where you have fibrosis or
scar tissue that causes chronic limited movement.
And then there's muscle spasm, which can also cause acute limited range
of motion that has a soft end feel and you can generally, gradually stretch it out.
There are many other subtypes of muscle disorders but
these are probably the most common with regard to pain.
One of the organizations that's involved in helping understand soft
tissue pain and other muscle pains, is the International Myopain Society.
Currently, I am president of the IMS, and I
wanted to talk a little bit about this briefly.
It's a multi-disciplinary international community to improve our
knowledge and care of muscle and soft tissue pain.
We have journals, we have international congresses, we have a
number of different national meetings and regional meetings including workshops.
We have one coming up in Minneapolis.
Our international meeting's coming up in Hawaii in 2014.
We have a library with lots of educational resources that are online.
We have research funding, patient forums, and networks, and referrals So I do invite
you to join if you have interest
in chronic pain or prevention of chronic pain.
And here is the website.
Well, joint pain is also very common.
And there are a lot of organizations that are focused on, on joint pain.
And skeletal joints are the next largest tissue in the body.
Second to muscles, at 15% of the body weight.
But it is the most common cause of disability from pain.
There are about four different typical disorders that are most common.
The one that we see the most in the head and
neck area is arthralgia, which is basically joint tenderness and pain.
But there's also disc disorders, particularly in the spinal
area that can cause noise, limitation, pain, radiation to pain.
And then there's arthritis which we're all familiar with and we, obviously,
would like to avoid, and that's pain with degeneration of the joints.
And finally, there's arthrosis too where there's a lot of
patients who have degeneration with no pain associated with it.
And this is basically a remodeling of
the joints in response to stresses and strains.
And these diagnoses are important, but in many cases
the diagnosis is not as important as other things.
As this cartoon suggests.
I'm sorry, the doctor no longer makes diagnoses.
So if that's the case, if the muscles or the joints or other
diagnoses aren't as important or as
difficult to determine, where is the action?
Is it in the path of physiology?
Really it's in the contributing factors.
This is where patients differ significantly from a
couple of risk factors or protect, and, and
many protective factors to many different risk factors
and no protective activities that the patient's doing.
So from a temporal perspective, these contributing factors
occur in, in a relationship to the pain.
Some cases there are predisposing factors, such as stress and depression.
Then in the progression of pain there's that initiating factor,
that factor that sort of pushes somebody over the brink.
Pushes over the edge so they went for maybe intermittent pain
to chronic pain, or from no pain to having persistent pain.
But once pain occurs, some of these
predisposing factors then shift and become perpetuating factors.
And then of course the pain itself brings on perpetuating factors also.
And these are all common risk factors
such as repetitive strain, poor posture, tensing.
And then finally, when pain persists over a period of time, it
by itself will cause significant number of risk factors that perpetuate the pain.
This can be, it'll disrupt your sleep, for instance, it
can contribute to significant stress, cause you to tense more.
So it begins the cycles that are setup
and there are so many more contributing factors.
And here is an example of a series of studies we did on head and neck
pain that looks at the different factors and
when they impact the temporal relationship of the pain.
So for instance, patients start at no pain and we found in head
and neck and jaw areas, about 8% per year progress to acute pain.
And, acute pain is present about 47.6% of the populations that we studied.
Then we found that the initiating events in many of the
head and neck and jaw problems were tensing habits and trauma.
Trauma was clearly the number one initiating factor.
And then we found that those patients who had acute pain, and we
followed them over time, developed chronic pain in about 14.3% of the cases.
Where at 3.3% of the total population that went from acute pain to chronic pain.
So clearly, most people heal, most people improve in
their pain condition and do not progress to chronic pain.
And this is why it's so important to obviously address
those risk factors for chronic pain while it's still acute.
Much more difficult to treat chronic pain once it's
been developed and persistent over a period of time.
And then finally, from chronic to intractable, there's
a lot of factors that lead to treatment failure.
This is why patients often see doctors over and
over again, or physical therapist or chiropractors because the
pain is at a certain point intractable due to
a number of different peripheral and central nervous system changes.
And we found that at about 38.3% of these cases of chronic, became intractable.
That means that despite all of our efforts to manage it, and
all their historical efforts, they still continued to have significant daily pain.
And these result, these resultant factors play a significant
role in leading and predicting chronic pain to become intractable.
Depression, self-esteem issues, a lot of social
factors, disability, can play a significant role.
And we need to understand these risk factors.
And we need to understand how they occur
in the different seven realms of their life.
And, this is the focus of the course.
This is what were going to talk about in the subsequent modules.
We'll go through each realm and identify
what are those protective factors, risk factors,
and what are the studies that support how they play a role in chronic pain.
And then finally, the last aspect of the S.O.A.P. note is plan.
And we need to develop a treatment plan for ourselves, for patients.
And we, I'd like to say that it
involves four Ts that are associated with transformative care.
First of all, in some cases we need to do additional testing.
We need to determined and rule out
any, any significant problems other than musculoskeletal.
So we order diagnostic tests such as imaging and labs.
Then the second T is treating.
Now we still believe in the biomedical model.
We believe it's very important.
That medications can be efficacious.
That surgery can be very helpful.
And that rehabilitation is also important.
But in addition to that, we need to train the patients.
We need to reduce risk and enhance protective factors.
And to do that effectively, we need to do it with a team.
So, the fourth T is care for the whole patient using a team approach.
And, we need to deal with the risk factors.
There are many different risk factors and
they're summarized here in the seven realms.
And you can kind of read that, some of the ones
that are most common are confusion, or emotional issues, anger.
Some patients are very injury prone and continue to reaggravate the condition.
There's many different risk factors.
At the same time we also need to build the protective factors.
And we'll focus on each one of these realms over the course of this course.
This would include things such as sleeping well, and exercising, improving
posture, organizing your environment, creativity, calming
your emotions and many other factors.
And what we know about risk factors and protective factors is, their focus is
really about prevention and prevention is the
key and that's the focus of this course.
As I like to say to patients, an ounce
of protective factors are worth a pound of risk factors.
We need to boost protective factors more than anything else.
Thank you.
[BLANK_AUDIO]