Hans Westergren M.D., Ph.D. Senior Consultant and Medical Director - - PowerPoint PPT Presentation

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Nov 22, 2022 238 likes •571 views

Experiences fro from a a Specializ ized Regional Clin linic for Patients wit ith Pers rsistent Neck Pain in and Dis isabilit ity after rauma Tra Hans Westergren M.D., Ph.D. Senior Consultant and Medical Director Specialist in

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Experiences

fro from a a

Specializ ized Regional Clin linic for Patients wit ith Pers rsistent Neck Pain in and Dis isabilit ity after Tra rauma

Hans Westergren

M.D., Ph.D. Senior Consultant and Medical Director Specialist in Neurosurgery, Rehabilitation Medicine and Algology Department of Pain Rehabilitation, Skane University Hospital, Lund, Sweden Regional Pain Center of Knowledge and Development

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The situation 10 years ago…

Some patients were referred to us and treated…
Many patients were ”hidden” in several clinics under several diagnoses
Earlier treatment algorithms focused on physiotherapy (only)…
Patient organizations recommending surgery…

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So, in 2010 we said:

Send them to us!

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So, in 2010 we said:

Send them to us! …and there were no protests…

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The Skåne Region 1.2 million inhabitants

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General outline of treatment algorithm

Trauma Emergency phase Recovery phase Chronic phase Primary care Pain rehabilitation unit 3-6 months Current condition

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General outline of treatment algorithm

Trauma Emergency phase Recovery phase Chronic phase Primary care Pain rehabilitation unit 3-6 months Cross-section observation studies Current condition

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Call center

Health care providers Patients Relatives Lawyers

Approx 150 calls a year

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(F) F)riskfactors = Health factors

Previously healthy
Adequeate care in the emergency phase
Good sleep
Stable home and job situation with possibilties to recover
Good body awareness
Good response to treatment
High self-efficacy
Stable social/economic situation
No problems in the insurance process
Good coping mechanisms and knowledge about pain
Etc…

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(F) F)riskfactors = Health factors

Previously healthy
Adequeate care in the emergency phase
Good sleep
Stable home and job situation with possibilties to recover
Good body awareness
Good response to treatment
High self-efficacy
Stable social/economic situation
No problems in the insurance process
Good coping mechanisms and knowledge about pain
Etc…
What about

the other way round?

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Analysis

Questionnaires
Clinical assessment
Additional examinations

Individual treatment

Pharmachology
Physiotherapy (SMIL)
Psychology

Rehabilitation

Mixed groups
CBT
ACT

Re-referral to Primary care

Patient fl flow in Pain Rehabilitation

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ICF- domains

Structure/ Function Activity/ Participation

Environment and Personal factors

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ICF- domains

Activity/ Participation

Environment and Personal factors

Social factors CNS reaction s Pain- genera tors

Psychol

gical

factors

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Social factors CNS reactions Pain- generators Psychological factors

Key-areas for assessment of complex persistent pain

Department of Painrehabilitation , Lund, Sweden Westergren et al Scand J Pain, 2014

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Muscles
Deep, stabilizing
Global
Joints
Hypomobile
Hypermobile
Segments
Nerves
Rizopathy
Myelopathy
Plexus pain
Coordination
Sensitization
Pain Distribution
Local
Regional
Wide-spread
Sleep
Concentration
Memory
Dizziness
Trigger-points
Vegetative symptoms
Sadness
Depression
Worry
Anxiety
Catastrophizing
PTSD
Coping
Self image
Aimlessness
Stress sensitivity
Own demands
Demands from others
Relations
Family situation
Work situation
Economy
Insurances

Social factors CNS reactions Pain- generators Psychological factors

Key-areas for assessment of complex persistent pain

Department of Painrehabilitation , Lund, Sweden

Pain interference Activity Participation Limitations

Westergren et al Scand J Pain, 2014

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The patients….

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Sex and age distribution of 1443 individuals recieving diagnosis ICD 10 – S13.4 During the year 2008.

Jöud et al BMJ Open, 2013

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Sex and age distribution of 1443 individuals recieving diagnosis ICD 10 – S13.4 During the year 2008.

Jöud et al BMJ Open, 2013

Sex and age distribution of 745 patients with persistent pain after neck trauma. 2010-14

Westergren et al Disability and Rehabilitation, 2017

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Number of patients referred and assessed

Westergren et al Disability and Rehabilitation, 2017

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Types of trauma

Type of trauma Males Females Total

Car crashes

In striking vehicle 69 125 194 In struck vehicle 139 223 362 N/A 6 20 26 582

Other neck trauma

Bicycle accidents 5 14 19 Motor-cycle crashes 5 5 Pedestrians 1 5 6 Miscellaneous vehicle accidents 1 9 10 Horse accidents 4 4 Sports-related accidents 7 15 22 Falls 13 31 44 Direct head or neck traumas 8 12 20 Assaults or scuffles 8 9 17 Miscellaneous (e.g. exertions, heavy lifting) 7 9 16 163 Total 745

Westergren et al Disability and Rehabilitation, 2017

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Pain distribution

43% 48% 9% 29% 53% 18% 12% 50% 38%

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Pain distribution vs type of trauma

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Conclusions

No sex distribution difference in initial trauma diagnosis
Twice as many females with persistent pain after neck trauma
Regional or wide-spread pain in allmost 90% of the patients

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Why?

Higher female vulnerability for neck injury for anatomical reasons
Higher prevalence for psychological distress in the female population
Higher risk for females to develop sensitization
Gender differences in social rolls giving women less opportunity for recovery

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Pain distribution…....and so what?

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Pain

distribution

Activity
Pain severity
Health factors
Number of reported pain sites

Versus

Clinical assessment Patient reported data

Persson et al in prep MPI and SF-36

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Pain factors vs Psychological factors

Pain distribution

(clinical assessment)

Pain interference

(MPI)

Pain severity

(MPI)

Depression (HAD)
Anxiety (HAD)
Acceptance (CPAQ)

Åkerblom et al in prep

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Muscles
Deep, stabilizing
Global
Joints
Hypomobile
Hypermobile
Segments
Nerves
Rizopathy
Myelopathy
Coordination
Sensitization
Local
Regional
Wide-spread
Sleep
Concentration
Memory
Dizziness
Trigger-points
Vegetative symptoms
Sadness
Depression
Worry
Anxiety
Catastrophizing
PTSD
Coping
Self image
Aimlessness
Stress sensitivity
Own demands
Demands from others
Relations
Family situation
Work situation
Economy
Insurances

Social faktors CNS reaktions Pain- generators Psychological faktors

Key-areas for assessment of komplex persisting pain

Department of Painrehabilitation , Lund, Sweden

Pain experience Activity Participation Limitations

Westergren et al Scand J Pain, 2014

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Outcomes in Pain rehabilitation…

Neck trauma patients lower activity than Fibromyalgia (without

trauma)

No difference in activity related outcome after Multiprofessional

Rehabilitation

Persson et al PM&R 2011

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Conclusions

250 100 patients a year per million inhabitants
Clear cut rules about responsibility for the patient care
Defined ”care-chain”
Multiprofessional team assessment
Individual treatment options
Pain rehabilitation

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Inglehart– Welzel cultural map of the world

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