What should/could I do when the patient has red flags?

These are indicators of serious pathology, and the appropriate medical practitioner should be informed as a matter of urgency. Remember that the patient still has pain and requires management for this. They can still be given advice on pain relief and gentle mobilisation.

Hypersensitivity pain states masquerading as acute pain: have faith!

The difference between acute (nociceptive) pain associated with injury or disease and overuse symptoms can be difficult for patients to understand, particularly in patients experiencing episodic neuropathic pain conditions, e.g. low back pain (LBP) or headaches. The tendency to central hypersensitivity will make unaccustomed use symptoms more painful. The presentation of masquerading conditions can be puzzling to lay people, making them fearful of their tissue strength and of instigating appropriate pain management involving movement.

The way that society has publicly managed pain in the past is partly responsible for the development of these behaviours. While professional practice is improving in this area, patients are all too often given inappropriate walking aids for simple sprains, or supports for the back/neck. When aids are provided patients need to know how and when to wean themselves from these.

Patients need to understand the appropriate management of acute pain and chronic hypersensitivity. With no signs of tissue damage, frequent movements, interspersed with brief rest periods can be instigated immediately. Patients need evidence of the strength of their tissues and to appreciate that pain is not a sign of damage: helping them learn from their own experience is vital.

Preventing chronic pain and disability

Addressing key risk factors: flags

Shaw and colleagues’ (2005) early risk factors help focus the treatment plan for yellow flags.

Patients with increased pain affecting sleep despite analgesia

All appropriate methods of attaining pain relief, both drug and non-drug therapies should be discussed with such patients. Benzodiazepines should only be used temporarily: they prevent sleep beyond 2 weeks’ use.

Practical advice on managing pain at night may help, e.g. maintenance of through-night analgesia, position changes, and movement in or out of bed. Advice on using pillows to support fractures/injuries can be invaluable. Nerve blocks to help achieve sleep should be supported where needed.

What a patient does or doesn’t do in the daytime will influence the night. Daytime naps, particularly beyond lunchtime/early afternoon are disruptive to the body clock and sleep. Equally, being overactive in the daytime can increase pain, so that when the body finally rests, sleep will be prevented. Crawford (http://www.painconcern.org.uk/2011/04/leaflets/a-good-nights-sleep) gives good advice on sleep hygiene.

Belief that pain is harmful or potentially disabling

Beliefs about pain can influence behaviour and inhibit healing and recovery, e.g. the assumption that the severity of pain relates to the severity of injury. This can escalate to avoiding painful movements and reduced function on the assumption that activity will inhibit healing or recovery, when in fact the opposite is usually the case.

Fear of pain is more disabling than the pain itself (Waddell 1998, Crombez et al 1999).

Information and patient experience are important factors for reducing fear.

Information that may help patients includes:

• The time limit of inflammation for their particular injury (maximum 7 days) and the expected healing process (maximum 3 months). Don’t mistake hypersensitivity for inflammation; pain doesn’t mean it hasn’t healed.

• An explanation of acute and chronic pain: input about the original damage is altered by central processing; how hypersensitivity develops (http://www.ppip.org.uk/viewdocuments.aspx; Butler and Moseley 2003).

• An explanation of diagnoses such as ‘degeneration’, ‘black or bulging discs’ (normal age-related changes) set in the context of pain-free populations with identical findings.

• The fact that epidemiologically the incidence of severe spinal pain and sciatica becomes increasingly less likely beyond the age of 50.

• The body’s ability to regenerate and improve the health of its tissues with the right conditions.

Intensive neurophysiology education for LBP patients can produce significant improvements in reported function and self-efficacy and physical performance tasks (SLR and forward bending range) (Moseley et al 2004). Information alone does not change behaviour for all patients (Fordyce 1976, Muncey 2002a). It is important that patients learn to change previous beliefs through actual, disconfirming experience.

Fear-avoidance behaviour from fear of pain or fear of harm/causing damage to tissues

Continuing avoidance of pain-provoking activities is a strong risk factor for chronicity and is best tackled pre-emptively when administering acute treatment and advice (e.g. Fordyce et al 1986).

Vlaeyen and colleagues (1995, 2000) proposed a model of fear-avoidance, finding that exposure (the treatment of choice for phobias) is also effective for fear-avoidance related to pain disability (Figure 13.1).

Figure 13.1 Model of fear-avoidance.

Adapted from Vlaeyen J.W.S. and Linton S.J., 2000. Fear-avoidance and its consequences in musculoskeletal pain: a state of the art. Pain 85, 317–322. This figure has been reproduced with permission of the International Association for the Study of Pain® (IASP®). The information may not be reproduced for any other purpose without permission.

Each time a situation and associated anxiety is avoided it becomes more likely that avoidance will occur the next time the situation or activity occurs. Avoidance is reinforced by the feeling of anxiety reduction. Therefore avoidance can occur repeatedly in the long term with patients becoming convinced that they cannot cope in such situations.

By avoiding feared movements or feelings patients fail to learn: