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A tool for pain assessment

Lester Jones, APAM
1 December 2016


Lester Jones, APAM, provides an overview of his recent presentation at the NSW Bringalong Dinner, ‘Introducing the Pain and Movement Reasoning Model: a tool for capturing the complexity of pain’.

The intention of this presentation, delivered over dinner at the Epping Club in Sydney on 14 October, was to introduce attendees to a clinical reasoning tool I co-authored with Des O’Shaughnessy, APAM. The presentation was divided into two 40-minute parts—either side of the main course being served.

Part one focused on developing a shared understanding of pain, that is that pain is part of the body’s protection system and, therefore, inclusive of, and influenced by, prior experiences of danger and stress. The plasticity of the neuro-immuneendocrine systems was illustrated through examples from media reports of pain and injury related to Australian Rules Football, with reference to the recent finals series. This included a 1977 quote, ‘pain is a thing of the mind’, by famous AFL coach Ron Barassi, that mood makes postmatch soreness worse (Jimmy Bartell) and that the focus on playing in a big event can help distract from the pain of injuries (Wayne Carey). Then, a speculative analysis of a couple of injuries to AFL players highlighted the need to consider the role of non-pain related stress, the potential for molecular memory (ie, epigenetics) and the priming of neuroimmune-endocrine responses in acute injury pain report.

The conclusion to this is that all pain is complex but sometimes presents simply. I also cheekily proposed a new pain term ‘same leg pain’ (which could be expanded to ‘same limb pain’ or ‘same side pain’, given the frequent clinical presentations I encounter), and perhaps is analogous to the catastrophically named ‘double crush syndrome.

With a feeling that people were now engaged with the concept that nociception is not pain, and that we need to be more sophisticated, part two opened with a figure I had created in 2007 representing the importance of the state and structure of the nervous system, the influence of the threat value of information coming in from receptors and the significance of being alert to the person’s perceived vulnerability based on her/his beliefs and prior learning.

To support this, a list of things that might be interpreted as threatening and things that might reduce threat was presented—paralleling Professor Lorimer Moseley, FACP, and APA Musculoskeletal Physiotherapist David Butler’sDIMS and SIMS’. From this broad list of influences, the rationale for a clinical reasoning tool that helped clinicians capture the complexity of pain was established.

The Pain and Movement Reasoning Model was developed in London in the mid-2000s but published in Manual Therapy in 2014. The theoretical influences included neuromatrix theory, a truly integrated biopsychosocial framework and the fledgling (sub) discipline of psychoneuroimmunoendocrinology (ie, the study of biological mechanisms underpinning mind-body interactions). I presented a brief overview of the model, its three categories—local stimulation, regional influences and central modulation—and the use of the central grid in the model (to ensure integration of information from all the three categories), before illustrating its use with some clinical examples.

In finishing, I shared the adaptions of the model across clinical areas and disciplines including the Breastfeeding Pain Reasoning Model which I developed with medical expert Lisa Amir for publication in Australian Family Physician. The final slide was an important quote attributed to Myron Tribus, which essentially states that people need to have experiences of applying different ways of doing things before they truly understand new information that is presented to them. This married nicely with taking a look at pain in a new and sophisticated way, as well as the subtext of the presentation—ie, a Melbournian trying to sell AFL to Sydneysiders!

I am very grateful to the NSW Branch organisers for the invitation to present— it was a very enjoyable evening and it was great to wander around the tables after my presentation to further explore some of the themes I presented. There was certainly a nice energy and plenty of enthusiasm in the room.

 

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