Persistent Pain in an Orthopaedic Setting

Question 1

What is the essential message regarding mind and body in illness?

Answer 1

Mind and body contributions are intimately interwoven in the presentation of signs and symptoms of illness and disability.

Question 2

What should a clinician consider when a patient presents with symptoms?

Answer 2

The contribution of thoughts, emotions, beliefs, and experience to their presentation and how their physical symptoms impact on these.

Question 3

Define Persistent Somatic Symptoms (PSS).

Answer 3

Presence of pain or physical symptoms persisting beyond an expected time for the initiating condition and not fully explained by established biomedical pathophysiology.

Question 4

What percentage of the general population experiences Persistent Somatic Symptoms?

Answer 4

5 - 10%.

Question 5

What percentage of patients in primary care exhibit Persistent Somatic Symptoms?

Answer 5

20% +.

Question 6

What gender is predominantly affected by Persistent Somatic Symptoms?

Answer 6

Females.

Question 7

List some common musculoskeletal presentations of PSS.

Answer 7

• Back pain
• Complex regional pain syndrome (CRPS)
• Fibromyalgia

Question 8

What are some common gastrointestinal presentations of PSS?

Answer 8

• Non-specific abdominal pain
• Irritable bowel syndrome (IBS)

Question 9

According to IASP 2020, how is pain defined?

Answer 9

An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Question 10

What are some implications regarding pain and tissue damage?

Answer 10

• There may not be measurable tissue damage
• All pain is real and must be respected

Question 11

What factors may contribute to pain aside from physical injury?

Answer 11

• Emotional factors (anxiety, guilt, anger, etc.)
• Life experiences, especially prior trauma

Question 12

What is nociplastic pain?

Answer 12

Pain processing error (a disorder of our nervous system) that can be more widespread and intense than expected.

Question 13

What does neuroplasticity refer to?

Answer 13

The ability of neurological pathways to expand or contract according to their usage.

Question 14

What is the role of the brain in pain perception?

Answer 14

The brain receives multiple inputs and creates a sensible story; if it concludes there is danger, it sends a warning signal (pain).

Question 15

Fill in the blank: Pain intensity is modified by _______.

Answer 15

[psychosocial factors]

Question 16

What happens if the brain misinterprets incoming signals?

Answer 16

• Unnecessary pain
• Unnecessary protective behaviour
• Persistent pain and inflammation

Question 17

List some red flags indicating when to ask for help in the context of persistent pain.

Answer 17

• Anxiety
• Depression
• Panic
• Substance misuse
• Secondary gain

Question 18

What are some factors associated with a positive outcome for persistent pain?

Answer 18

• Early diagnosis
• Good response to initial treatment
• Good therapeutic alliance with the clinician

Question 19

What is the primary aim of developing a conceptual model for patients with pain?

Answer 19

To help explain how the brain and nervous system work and how pain sensations occur.

Question 20

What approach should be taken towards patients presenting with persistent pain?

Answer 20

• Normalise and validate symptoms
• Show compassion
• Understand that pain is always pain

Question 21

What are the psychosocial factors that modify pain intensity?

Answer 21

Thoughts and beliefs, emotions, stress, context

These factors can influence how pain is perceived and experienced.

Question 22

In cases of persistent pain, what is a poor predictor of tissue damage?

Answer 22

Pain intensity

This suggests that other factors play a significant role in pain experiences.

Question 23

What can happen if the brain misinterprets incoming signals due to psychosocial environments?

Answer 23

• Unnecessary pain
• Unnecessary protective behaviour
• Persistent pain and inflammation

Question 24

What are the steps of the medical model?

Answer 24

• Symptoms
• Examination
• Investigations
• Diagnosis
• Treatment

Question 25

What is an example of an unhelpful approach to persisting pain in orthopaedics?

Answer 25

* Reassurance that there is no physical cause * Suggesting the patient should see a psychiatrist/psychologist

Question 26

What problems can arise from the medical model approach to persistent pain?

Answer 26

* Frustration and disappointment for both patient and doctor * Anger directed at the doctor * Tendency to seek further opinion and investigations * Failure of the medical model to serve either party well

Question 27

What challenges do doctors face when explaining pain without a clear cause?

Answer 27

* Explaining how and why they have pain * Sticking to a medical model way of thinking * Fear of missing a diagnosis * Avoiding the impression that the patient is exaggerating symptoms

Question 28

What are some key approaches to persistent somatic symptoms (PSS)?

Answer 28

* Normalise and validate symptoms * Show compassion * Recognize that pain is pain regardless of cause * Consider brain misinterpretation of messages * Provide a conceptual model for understanding pain

Question 29

What should a conceptual model of pain include?

Answer 29

* It should be plausible * Not necessarily medically exact * Simple and understandable to the patient

Question 30

What factors are associated with a positive outcome in pain management?

Answer 30

* Early diagnosis * Good response to initial treatment * Good therapeutic alliance with the clinician

Question 31

What factors are associated with a poor outcome and relapse in pain management?

Answer 31

* Multiple physical symptoms * Long-standing symptoms * Poor physical functioning * Comorbid personality disorder * Beliefs that symptoms are irreversible * Illness-related financial benefits

Question 32

What are some red flags that indicate a need for help in managing pain?

Answer 32

* Anxiety * Depression * Panic * Substance misuse * Secondary gain * Excessive doctor shopping * Relationship with pain becoming obsessive

Question 33

What are key learning points regarding pain sensations?

Answer 33

* They arise from tissue injury and psychosocial factors * Persistent somatic symptoms and nociplastic pain are common * Always consider psychosocial contributions * Develop a conceptual model for understanding brain and nervous system function * Understanding is crucial

Question 34

Fill in the blank: Pain sensations arise from contributions from _______ and psychosocial factors.

Answer 34

tissue injury