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Comprehensive Assessment and Management Presented By: Date: - - PowerPoint PPT Presentation

Sep 26, 2023 180 likes •916 views

Chronic Pain in Older Adults Comprehensive Assessment and Management Presented By: Date: December 4, 2019 Carlo Ammendolia D.C., Ph.D Carlo Ammendolia DC PhD Assistant Professor, IHPME University of Toronto Staff

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Chronic Pain in Older Adults Comprehensive Assessment and Management

Date: December 4, 2019 Presented By: Carlo Ammendolia D.C., Ph.D

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  • Assistant Professor, IHPME University
  • f Toronto
  • Staff Clinician/Associate Scientist,

Mount Sinai Hospital

  • Professorship in Spine, Dept. of

Surgery U of T

Carlo Ammendolia DC PhD

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Agenda

Definitions/prevalence & burden/complexity Key principles/components for assessment & management Practical tips for management New evidence for effectiveness

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Disclosures

No Relationships with Commercial Interests Funding: Canadian Chiropractic Research Foundation (CCRF) Founder spinemobility Research & Resource Centre- Not-for-Profit Organization

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Pain defined: IASP (1986): an unpleasant sensory and emotional experience associated with actual or potential tissue damage

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Chronic Pain

More than half the days in pain over 6 months period. Pain > 3 Months

IASP 2019

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Diagnosis: Nociceptive vs. Neuropathic

Nicholson BD (2003) Comerci G (2014)

Pain Nociceptive

Normal stimulation of nociceptors Thermal, chemical, mechanical

Neuropathic

Abnormal nervous system activation

Somatic Visceral Central Peripheral

Existential

Pain that occurs upon questioning and doubting the value of one’s ongoing existence as a living, sentient being

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Prevalence 60% of individuals

  • ver age 65

79% of individuals

  • ver age 85

Shi et al. Pain 2010,

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Canada's Aging Population

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Aging related neurophysiological changes influence pain processing, and reduced pain tolerance from deterioration of the pathways involved in endogenous inhibition

Hadjistavropoulos et al 2014

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Burden

Severity and disability risk increases with age 85% have pain multiple areas LBP and lower extremities most common High risk for reduced mobility & Balance

Gibson, SJ 2007, Moulin, D et al., 2002, Kemp C. et al. 2005

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Burden High risk for falls 36% of individuals 65 or older will suffer fall in 24 months

Tricco et al. JAMA 2017

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Burden Associated with hopelessness, depression, anxiety, sleep disturbances and isolation

Baumbauer et al. 2016

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Burden Comorbidities Physical & Cognitive Abilities Diabetes, CHF, COPD, Alzheimer Disease

Makris et al. JAMA 2014

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Polypharmacy

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Chronic Pain: Patients’ Pain Diagrams

Ceko et al. 2013. Canadian Pain Society

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“NIFTI” Red Flag Screening

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Screening “Yellow Flags”

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Physical Examination

Posture Gait Balance Muscle Mass

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Range of Motion

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Neural Tension - SLR

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Hip Osteoarthritis

  • Definitions
  • Patho-physiology
  • Prevalence

27% adults > 45y have radiographic hip OA

  • 9% symptomatic

Devin et al, J Am Acad Orthop Surg 2012

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Hip-Spine Syndrome

  • Definitions
  • Patho-physiology
  • Simple – one clear

source of disability

  • Complex – no clear

source of disability

Devin et al, J Am Acad Orthop Surg 2012

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Greater Trochanter Pain Syndrome (GTPS)

  • Definitions
  • Patho-physiology
  • Prevalence

10-25% of population- higher in elderly second leading cause

  • f adult hip pain
  • Risk factors

– Older, female, ITB pain,

  • besity and LBP

Williams BS, 2009, Tortolani PJ 2002, Gordon EJ 1961, Segal NA 2007, Stephens MB 2008

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Neuropathy

Diabetic neuropathy Hypothyroidism Vit B12, Vit B1 and Folic acid Cervical and/or Dorsal Spinal Stenosis

Differential Diagnosis

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Lumbar Disc Herniation

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Rationale & Principles Standardized Evidence- Based Comprehensive

Chronic Pain Management in Elderly

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Self-Management Training Programs 2 x w – 6w Goals & Objectives Program & Patients Road Map Implementation Guides Exercise, Manual Therapy, Condition Specific Outcome Measures Patient & Condition Specific

Standardized

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PHYSICAL Pain Mobility Function PSYCHOLOGY Attitudes & Beliefs Expectations SOCIAL Interaction with Environment

Comprehensive/Biopsychosocial

Foster et al. Lancet 2018

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Exercise Cognitive Behavourial Approach

Comprehensive

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Exercise Cognitive Behavourial Approach

fear avoidance harm vs. hurt attitudes & beliefs expectations

Comprehensive

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Exercise Cognitive Behavourial Approach

fear avoidance skills knowledge harm vs. hurt self-confidence attitudes & beliefs expectations

Comprehensive

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Exercise Cognitive Behavourial Approach

fear avoidance skills knowledge harm vs. hurt self-confidence attitudes & beliefs expectations SMART goals pacing problem solving

Comprehensive

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Exercise Cognitive Behavourial Approach

fear avoidance skills knowledge harm vs. hurt self-confidence attitudes & beliefs expectations relaxation imagery SMART goals pacing problem solving

Comprehensive

mindfulness

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Exercise Cognitive Behavourial Approach

fear avoidance skills knowledge harm vs. hurt self-confidence attitudes & beliefs expectations positive reinforcement relaxation imagery SMART goals pacing problem solving

Comprehensive

mindfulness

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Exercise Cognitive Behavourial Approach

fear avoidance skills knowledge harm vs. hurt self-confidence attitudes & beliefs expectations positive reinforcement relaxation imagery SMART goals pacing problem solving

Comprehensive

mindfulness Makris et al. JAMA 2014

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Positive Health “ ability to adapt and to self-manage in the face of social, physical and emotional challenges”

Huber et al BMJ 2011  Contextual Factors  Living well with chronic pain  Positive expectations

Buchbinder et al Lancet 2018

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Translating Exercises Activities of Daily Living Recreational Activities

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  • Self management
  • Self monitoring
  • Flexion exercises
  • Strength training
  • Manual therapy
  • Body re-positioning
  • 2x w- 6weeks

Boot Camp Program Lumbar Spinal Stenosis

Emphasis on standing/walking/functional abilities Cognitive Behavoural Approach

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Intervention & Control

Comprehensive (Boot Camp Program) vs. Self Directed Program (Control)

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Comprehensive Boot Camp Program

  • 2x w- 6weeks
  • Manual therapy
  • Home flexion exercises
  • Home Strength training
  • Self management
  • Self monitoring
  • Body re-positioning
  • Emphasis standing &

walking abilities

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Self-Directed Boot Camp Program

  • One educational

session

  • Home flexion exercises
  • Home Strength training
  • Self management
  • Self monitoring
  • Body re-positioning
  • Emphasis standing &

walking abilities

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Outcomes & Analysis

Primary Outcome

  • Self-Paced Walk Test
  • mean difference in distance

Secondary Outcomes

  • ZCQS, ZCQF, ODI, ODI walk, NPS back, NPS leg, SF36

Follow-up

  • 8w, 3m, 6m and 12m

Responder Analysis

  • > 30% and > 50% improvement in SPWT
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Primary Outcome (SPWT)

Group 1 = comprehensive, Group 2 = self-directed

* * * *

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Primary Outcome

85 88 79 81 61 67 64 59 8 w 3m 6m 12m

> 30% Improvement SPWT Distance (%)

Comprehensive Self directed

*

*

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Secondary Outcomes

17 14 23* 26* 3 5 6 9

8 w 3m 6m 12m

> 30 Minutes SPWT (%)

Comprehensive Self Directed

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  • Comprehensive Program- Superior benefit
  • walking ability, symptoms and function
  • large magnitude and long-term

sustainability of the benefit

  • Highly relevant findings in this population

with limited walking ability

Summary

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Schneider et al, JAMA Networks 2019

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Retrospective Study Findings

**All differences in outcomes were both clinically and statistically significant at 3.5 years except NPS LBP

10 20 30 40

Oswestry Disability Index Baseline 6-weeks 3.5 years

Chow et al, JMPT in press

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Agenda

Definitions/prevalence & burden/complexity Key principles/components for assessment & management Practical tips for management New evidence for effectiveness

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Not-for-Profit Research & Resource Centre

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Contact info: cammendolia@mtsinai.on.ca

Carlo Ammendolia DC, PhD

Funded by the Canadian Chiropractic Research Foundation and The Arthritis Society

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Q&A

Carlo Ammendolia D.C., Ph.D Spinemobility info@spinemobility.com www.spinemobility.com