Hello, this is James Fricton again. This part two of the module two, on the personal impact of chronic pain. The title of this part is Characteristics of a Pain Evaluation. I like acronyms, as you probably noted. And this acronym, is up for the objective assessment and is stands for TIRED, T-I-R-E-D. And they stand for T is for tenderness, we have to look for help for tenderness within the muscle joints through palpation. Second is Imaging, what are the results of MR, radiographs and other images. R is for range of motion E is for entrapment, whether there's any nerve impingement and D is for dysfunction with regard to the joints. So let's go through each one of these in more detail. A muscle exam has five components. There are muscle trigger points, tenderness, weakness spasm and twitching. Palpation is really the most critical, and this looks at not just subjective pain reports, but are the muscles tender, does the patient report soreness in muscles. Now the palpation technique is very specific for trigger points. These are some of the steps, to accomplish that. First of all, you need to know the pain pattern. If a muscle hurts in a certain area, say the temporalis, where is the pain pattern in that area? So you want to find the pattern, and trace back to the individual muscle that's involved. So with regard if you have a temporal headache you'd be looking at the anterior temporalis through the temporalis muscle. So within that you would find the taut band. You roll your fingers back and forth to really identify that taut band or tight band of muscle. And you roll your fingers across it like I'm doing right now. The fourth aspect is that as you forego up and down that taut band find the most tender area. Yeah right here that's it, the patient will tell you, yeah, that's it as you press, and you have to press very firmly. So once you find that tender spot the most tender spot in in the taut band, then you ask him does that duplicate your pain? Does that feel like your pain? And if they say, yeah, that feels just like my headache in the temples, then you know there's a relationship between that tenderness in the muscle and the pain. And these are very specific characteristics, so it's easy to press a different area right here and see of their patient has any exacerbation or amplification, exaggeration of the pain. So the next one is the five components of a joint evaluation. Now this includes tenderness of the joint, range of motion which is real critical, pain in range of motion. Whether there's a soft or a hard end field in terms of the range of motion and dysfunction in the range of motion. So tenderness of the joint simply is pressing over the joint itself, opening and closing, or in the cervical neck finding the joints and pressing on those particular joints. See if it's tender, range of motion Is looking at the range of motion, move the joints and I'll grow through each one of these in a little bit more detail. So for cervical range in motion for instance, you're going forward and backwards as shown in this illustration. You're going left and right rotation which is about 70 degrees in each direction and then you are doing lateral flexion which is about 45 degrees to each side. For lumbar range of motion it is very different obviously. And you have to touch your toes and see what kind of range of motion there is. You should be able to get about, in the back extension, 30 degrees. In the front flexion would be about 90 degrees, and then in lateral bending would be about 35 degrees on each side. And then for rotation, you can see here it's approximately 30 degrees. So you also, with regard to the mandible and this is a range of motion where you measure between the incisors, the upper and lower incisors. And it's typically about three fingers or 42 to 60 millimeters of range of motion, but about three fingers is the normal range of motion of the jaw. And then you do lateral movements and they usually occur somewhere between 8 millimeters and 12, 14 millimeters on each side. In each of the range of motions, you also want to determine, does it hurt? And secondly, you want to see if it's at a soft end feel or a hard end feel. So with regard to the neck, if you're going to one side and they restrict it because of pain, but can they extend it even further or bend it even further? So if they can bend it further, that means there may be some muscle restriction or muscle pain associated with it, if it's a hard end feel, typically it's a joint restriction. The next one is assessment, which includes diagnosis and contributing factors. So the diagnosis is what's causing the pain. In another words, what is the tissue that is involved in the pain? Obviously, in this situation it is either joints or muscles but there are many co-morbid conditions that are associated with chronic pain conditions and we need to identify those. Particularly any mental health or psychiatric co-morbid conditions, such as depression. And we also want to identify the contributing factors. Now these are factors that are typically the risk factors or protective factors but they do occur in sequence and I'll describe them in a little bit. So the diagnosis is very critical to some extent, we want to know particularly is it a muscle problem or is it a joint problem. And the source of pain in most of these situations is really from the muscles. In several studies that were found looking both at muscle and joint and nerve problems. And there are 4 typical disorders associated with muscle pain. The most common is Myofascial Pain which is a pain with localized tenderness in the muscle called trigger points. But there's also Myositis which is a generalized inflammation and tenderness of the muscle. There's Contracture where you have fibrosis or scar tissue that causes chronic, limited movement. And then there's Muscle Spasm, which can also cause acute limited range in motion, that has a soft end feel and you can generally, gradually, stretch it out. There are many other sub types of muscle disorders, but these are probably the most common with regard to pain. One of the organizations that's involved in helping understand soft tissue pain and other muscle pains is the International Myopain Society. Currently, I am President of the IMS, and I wanted to talk a little bit about this briefly. It is a multi-disciplinary international community to improve our knowledge and care of muscle and soft tissue pain. We have journals, we have international congresses. We have a number of different national meetings and regional meetings including workshops. We have one coming up in Minneapolis. Our international meeting is coming up in Hawaii in 2014. We have a library with lots of educational resources that are online. We have research funding. Patient forms and networks and referrals. So I do invite you to join if you have interest in chronic pain or prevention of chronic pain. And here is the website. Well, joint pain is also very common and there are a lot of organizations are focused on joint pain. And skeletal joints are the next largest tissue in the body, second to muscles, it's at 15% of the body weight. But it is the most common cause of disability from pain. There are about 4 different typical disorders that are most common. The one that we see the most in the head and neck area is Arthralgia which is basically joint tenderness and pain. But there's also Disc Disorders particularly in the spinal area, they can cause noise, limitation, pain, radiation of pain. And then there is Arthritis which we are all familiar with and we obviously we'd like to avoid and that's pain with degeneration of the joints. And finally, there's Arthrosis too, where there's a lot of patients who have degeneration with no pain associated with it. And this is basically a remodeling of the joints in response to stresses and strain. And these diagnosis are important but in many cases, the diagnosis is not as important in other things. As this cartoon suggest, I'm sorry, the doctor no longer makes diagnoses. So if that's the case, if the muscles or the joints or other diagnosis are as important or is difficult to determine, what, where is the action? Is it in the pathophysiology? Really it's in the contributing factors. This is where patients differ significantly from a couple of risk factors and many protective factors tomany different risk factors and no protective activities that the patient's doing. So from a temporal perspective these contributing factors occur in a relationship to the pain. Some cases there are predisposing factors such as stress and depression. Then in the progression of pain, there's that initiating factor, that factor that sort of pushes somebody over the brink. Pushes over the edge, so they went from maybe intermittent pain to chronic pain, or from no pain to having persistent pain. But once pain occurs, some of these predisposing factors then shift and become perpetuating factors, and then of course the pain brings on perpetuating factors also. And these are all common risk factors, such as repetitive strain, poor posture, tensing. And then finally, when pain persists over a period of time, it by itself will cause a significant number of risk factors that perpetuate the pain. These can able to disrupt your sleep, for instance, it can contribute to significant stress cause you to tense more. So it begins these cycles that are set up, and there are so many more contributing factors. And here is an example of a series of studies we did on head and neck pain that looks at the different factors and when they impact the temporal relationship of the pain. So for instance, patients start at no pain and we found in head and neck and jaw areas that about 80% per year progress to acute pain. And acute pain is present in about 47.6% of the populations that we studied. Then we found that the initiating events and many of the head, neck, and jaw problems were tensing habits and trauma. Trauma was clearly the number one initiating factor. And then we found that those patients who had acute pain, and we followed them over time, developed chronic pain in about 14.3% of the cases. Or a 3.3% of the total population that went from acute pain to chronic pain. So clearly, most people heal, most people improve in their pain condition and do not progress to chronic pain. And this is why it's so important to obviously address those risk factors for chronic pain while it's still acute. Much more difficult to treat chronic pain once it's been developed and persistent over a period of time. And then finally from chronic to intractable there is a lot of factors that lead to treatment failure. This is why patients often see doctors over and over again or physical therapist or chiropractors because the pain is at a certain point intractable. Due to a number of different peripheral, and central nervous system changes. And we found that about 38.3% of these cases, of chronic, became intractable that means that, despite all of our efforts to manage it. And all their historical efforts, they still continued to have significant daily pain. And these resulting factors played a significant role in leading and predicting chronic pain to become intractable. Depression, self-esteem issues, a lot of social factors, disability can play a significant role. And we need to understand these risk factors and we need to understand how they occur in the different seven realms of the light. And this is the focus of the course, this is what we're going to talk about in the subsequent modules. We'll go through each realm, and identify what are those protective factors, risk factors, and what are those studies that support how they play a role in chronic pain. And then finally, the last aspect of the S.O.A.P note, is plan. And we need to develop a treatment plan for ourselves, for patients. And I like to say that it involves four T's that are associated with transformative care. First of all, in some cases we need to do additional testing, we need to determine, and rule out any significant problems other than muscular skeletal. So we ordered diagnostic tests, such as imagings and labs. Then the second T is treating. Now, we still believe in the biomedical model, we believe that it's very important that medications can be avocatious that surgery can be very helpful and that rehabilitation is also important. But in addition to that, we need to train the patients, we need to reduce risk and enhance protective factors. And to do that effectively, we need to do it with a team, so the fourth T is care for the whole patient using a team approach. And we need to deal with the risk factors. There are many different risk factors, and they're summarized here in the seven rounds. And you can kind of read that, some of the ones that are most common are confusion, or emotional issues, anger. Some patients are very injury prone and continued to re-aggravate their condition. There's many different risk factors, at the same time, we also need to build the protective factors. And we'll focus on each one of these realms over the course of this course. This would include things such as sleeping well, and exercising, improving posture organizing your environment, creativity, calming your emotion and many other factors. And what we know about risk factors and protective factors is their focus is really about prevention, and prevention is the key and that's focus of this course. As I like to say to patients an ounce of protective factors are worth a pound of risk factors. We need to boost protective factors more than anything else. Thank you.
