Multidisciplinary Treatment of Persistent Post-Surgical Pain

This is a longitudinal pilot study aiming to assess the feasibility of a multidisciplinary Transitional Pain Management Service for participants discharged from St Vincent's Hospital Sydney following surgery or traumatic injury. Participants with risk factors for persistent post-surgical or post-traumatic injury pain will be recruited from the Acute Pain Service as inpatients. They will then attend the outpatient St Vincent's Hospital Transitional Pain Management Service face-to-face or via Telehealth, attending three sessions each with a specialist pain medicine physician and a pain physiotherapist (at 1 month, 2 months and 3 months post discharge). Specialist pain medicine physician consultations will be 30 minutes duration and include: Assessment of biomedical recovery following surgery or injury: - Full history and physical examination of relevant systems - Detailed pain history including trajectory of acute pain, plus other chronic pain problems, including numerical rating scale reports of worst, average and best pain Assessment of biomedical complications: - e.g Evidence of wound infection, thromboembolism, other post surgical complications Assessment of medication use (including opioid medications): - Both pre and post surgery/injury Assessment of functional recovery in personal, employment, social domains: - e.g. Assessment of personal and domestic activities of daily living, return to work, leisure activities Assessment of mental health and substance use: - e.g. Assessment of mood, anxiety, other mental health problems - e.g. Assessment of interpersonal relationships - e.g. Assessment of substance use including alcohol and tobacco Referral to other health services if appropriate: - e.g. To surgical teams if surgical complications, to mental health services if significant mood issues. All sessions will be recorded by contemporaneous notes in the participant's medical file, and a letter outlining each consultation will be sent to their nominated primary care physician. Physiotherapy sessions will 1 hour for the initial consultation and 30mins for subsequent consultations, and will be delivered by a specialized pain physiotherapist. Sessions will include: Assessment and identification of risks or barriers that may hinder a return to presurgery/preinjury level of functioning, e.g: - Fear avoidant behaviours - Unhelpful motor patterns - Anxiety with movement - Unhelpful thinking patterns - Sleep disturbance - Lack of support from family and/or friends - Home environment barriers e.g. no appropriate modifications or aids Functional outcome measures as appropriate for each participant e.g: - Timed up and go test (TUG) - 6 minute walk test (6MWT) - 30 second chair stand test (30 CST) - Near tandem stance test - Wall push ups in 1 min Depending on individual participant context, other physiotherapy may include but is not limited to: Pain education e.g: - What to expect as recovery progresses, expectation setting regarding pain especially with movement, non-pharmacological techniques to manage pain including pacing education, modification of movement/use of aids and up-titration of activity as healing progresses Exercise therapy: - Exercise therapy will be trialed during the consultation and a smart watch will be worn by the patient to ensure exercise intensity is under 70% of maximum heart rate Balance training Goal setting - As per NSW Agency for Clinical Innovation SMART guidelines for goal setting - https://aci.health.nsw.gov.au/chronic-pain/brain-injury/understanding-pain/goal-setting- and-maintaining-the-changes Relaxation therapy Correcting unhelpful motor patterns Addressing fear avoidant behaviours Education on pacing Education on scheduling daily activities appropriate to stage of recovery Providing online/print resources Sleep hygiene General dietary advice Referrals to other health professionals / services e.g: - When a patient presents with any condition that is outside the scope of physiotherapy practice such as undiagnosed fractures, tendon / ligament rupture, mental illness eg depression. To monitor adherence to the intervention, patients will complete an exercise recording sheet/ diary which will be assessed in subsequent sessions for issues/progress. All physiotherapy sessions will be recorded by contemporaneous note taking in the patient's medical file. Participants will be asked to complete online self-report questionnaires at baseline and 3-month, 6-month, and 12-month follow ups, which will include: Demographic data Medical history Healthcare utilization Medication use Brief Pain Inventory (BPI) Depression Anxiety Stress Scales (DASS21) Pain Self-Efficacy Questionnaire Pain Catastrophising Scale (PCS) Tampa Scale of Kinesiophobia (TSK) The questionnaires will take approximately 15-30 minutes to complete.