Saturday, March 31, 2012

Personal Injury, Chronic Pain and Comorbidities

Dr. Daniel Gouws completed his medical degree at University of Stellenbosch before emigrating to work in Southland, New Zealand, and Saskatchewan before coming to British Columbia. He passed his Master of Sciences at McGill University in Occupational Health Sciences before becoming a board member of the Occupational and Environmental Medical Association of Canada. He is an extremely intelligent, lucid presenter whose clinical experience is obvious from his revealing insights into the care of patients.  His talk, "Comorbidities and Timelines - What to watch when for when your injured patient or client isn't getting better" was a most informative.
The objective was to identify the factors that could contribute to a poor outcome in patients with soft tissue injuries.
The Trial Lawyers Association of British Columbia, Essential Soft Tissue Injury Conference provided a CD with the notes of speakers and other relevant information. I made some notes during the presentation relevant to my own personal interest. It doesn't do true justice to the wealth and breadth of information that Dr. Gouws presented or give you the slides both medical and humorous that accompanied his presentation.  It does give a glimpse and for that reason alone I think it's worth including them here.
Soft Tissue Injury Conference, TSABC, Vancouver Convention Centre
Comorbidities and Timelines, What to watch for when your injured patient or client isn’t getting better
Dr. Daniel Gouws,
South Africa
Occupational Health McGill
Mechanism of Injury
  • whiplash injuries occur when head accelerates relative to the body, excessive torgue and shear...damage through compression and distraction
Forces involved are considerable, at an imact speed of 20mph (32 km/hr) the human head reachs a peak acceleration of 12 g during extension
If the individual head is in slight rotation, a rear end impact will force the head further into rotation before extension occurs.
In addition to neck pain
visual disturbances
cognitive deficits
They can often be presenting also with symptons of concussion
Clinical course
Majority of patients improve spontaneously over the first three months
don’t know which go sour
Medical Model
  • History (subjective)
  • Exam (objective)
  • Ass
  • Plan
Acute pain versus chronic pain
  • chronic pain doesn’t get better
Role of patient with pain is different for acute versus chronic
Acute - follow treatment advice
Chronic pain - ‘partner’ relationship in care , patient responsible for daily management, very different from treatment of appendicitis
Chronic Pain
-lasts more than 3-6 months
varies in intensity from mild to excruciating
one area or multiple areas
emegence of complications
  • increased sensitivity to pain
  • emotional and cognitive distress
  • non restorative sleep
  • fatigue
What is happening in backgrown
  • dogs in background of slides
Chronic Pain
  • chronic co morbidities
Patients get frustrated with us
We get frustrated with them
Blame game
-There is no exact relationship among - degree of pain, extent of pathological change and extent of impairment
-We do not prove or disprove pain with special investigations.  Special investigatiosn are only considered to be appropriate if they will change the management of the patient
-It is inappropriate to request special investigaton in the abscenede of clinical findings such as nerve root entrapment or potentially surgically correctable lesions.
  • psychosocial
  • what is the effect of the injury and comorbidities
  • deconditioning
  • post traumatic stress
  • substance abuse
  • Depression and anxiety
  • Chronic pain patients who are depressed are 9x more likely to be disabled
  • Untreated psychopathology is greatest likelihood for poor outcome
Loss of Control
  • Regression
  • Isolation
All my friends are dead
Diagnostic Dilemna
  • extensive assessment by multiple physicians
  • numerous investigations (included repeated diagnostic studies) without any real improvement or resolution of symptons
  • chronic pain is not an emergency, should get appropriate appointments at appropriate times
  • beware of opiates
  • Canada has distinction of being one of the top prescribers of opiates in the world
Cognitive Distortions
  • unconscious complications of chronic pain
  • non uncommon - we are all prone to cognitive distortions - ex ‘the little engine that couldn’t because he was a worthless bum like your father’
  • emotional reasonling
  • mind reading
  • entitlement
  • ‘la belle indifference’  - patient smiling while saying her pain is 9/10
  • hopelessness
limits activity
limits treatment compliance
becomes self perpetuating - less action - less activity - more pain
  • research shows relationship between catastrophising and heightened pain intensity -
Relationship problems
-less interest in sex
-once pain is under control I’ll do more
-I have to wait for my MRI because I can do anything (like take out garbage)
Loss of control
  • fundamental to ability to cope
  • learned helplessness
  • the ability to gain a sesnse of control is fundamental to the ability to cope - self control likened to an energy source and fatigue
  • once you become disabled a lot of that which was taken for granted becomes a bid decision
Workplace Factors
  • adverse outcomes in pain study
  • 1)do you enjoy your job
  • 2) do you get along with your supervisor
Workplace autonomy
  • a factor - disability of chronic pain - less work autonomy - more pain disability
After 6 months chance of return to work drop
Discuss return to work considerations
What can be done?
-individual cognitive behavioural psychotherapy
-work conditioning/work hardening
-ergonomic modifications
-modalities used in conjunction with active exercise
  • pain self-management programs
  • PDP, PGAP programs
-set personal goals
  • improve sleep
  • -increase physical activity
  • manage stress
  • etc
Loss of control
Goal therapy can be effective in helping patients regain control
Chronic Pain Self Management Program

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