Resources & Education

For health professionals and their chronic pain patients

In the TAPMI model, referring practitioners play an active role in the treatment of their patients. Below are lists of resources for clinicians and frequently asked questions.


Project Echo Ontario (Extension of Community Healthcare Outcomes)

Project ECHO links primary care providers in local communities across the province with expert interprofessional teams. Primary care providers and the TAPMI clinics all become part of a learning and support community, where they receive mentoring and feedback from the team of experts.

Through this mentorship, community providers get the support and skills they need to care for their patients with complex chronic pain issues. Knowledge transfer is achieved by a case-based learning model. The team meets weekly for 2 hour video-conferencing sessions which include a 20 minute didactic presentation related to pain, followed by 1-2 patient case presentations by ECHO participants.

Questions and suggestions are provided by participating primary care providers and the inter-professional pain specialist team. Case presenters are then provided with a list of recommendations generated from the session discussions which they can apply immediately to the care of their patients.

 The sessions are CME accredited for physicians and may be put towards continuing professional development hours for other health care professionals. Any primary care or allied healthcare provider can participate individually or as a team.

 To sign up for an ECHO Program, please visit

Chronic Pain FAQs

  • What is the definition of pain?

    Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

    • Chronic pain can be described as ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury or more than 3 to 6 months, and which adversely affects the individual’s well-being.
    • Chronic or persistent pain is pain that continues when it should not.
  • What is the different between acute and chronic pain?

    Acute pain:

    • nociceptive pain that follows a trajectory of decreasing pain intensity as tissue heals.
    • Adaptive - encourages the individual to rest, withdraw, and protect the injury.

    Chronic pain:

    • persists long after the tissue has healed.
    • Maladaptive, causes patient to develop kinesiophobia.


  • What is the pathophysiology of pain?

    The pathophysiology of pain follows a 1-2-3 sequence:

    1. Nociceptors sit on peripheral nerves, the peripheral nerves carry the message up to the spinal cord
    2. At the level of the spinal cord; the peripheral nerves synapse with spinal nerves in the dorsal horn. The message crosses over and travels up the spinal cord
    3. The spinal nerves synapse in the thalamus message is sent to various areas of the brain including the somatosensory cortex and the Limbic system.
  • How do we sense pain?

    1. Pain stimulates nociceptors
    2. Stimulus is transferred via primary sensory neuron to the spinal cord (second order neuron).
    3. Message ascends the spinal cord, gets processed in the thalamus (third order neuron) and finally reaches the cerebral cortex where the final perception occurs.
  • Why do my patients experience variability in sensing pain?

    Non-physical factors such as social, emotional and spiritual aspects that together with the physical factors comprise the concept of “Total Pain”.

  • What active diseases should be ruled out for chronic pain?

    • Systemic diseases:
      • Rheumatoid/Osteoarthritis
      • Lupus
      • Sickle cell disease
      • Inflammatory bowel disease
      • Endometriosis
      • Rheumatoid arthritis
      • Osteoarthritis
      • Lupus
      • Sickle cell disease
      • Inflammatory bowel disease
    • Cancer: itself and treatment
    • Trauma
  • What are high risk factors (yellow flags)?

    Yellow flags are psychosocial factors shown to be indicative of long term chronicity and disability:.

    They include:

    • Negative attitude that back pain is harmful or potentially severely disabling
    • Fear avoidance behaviour and reduced activity levels
    • An expectation that passive, rather than active, treatment will be beneficial
    • A tendency to depression, low morale, and social withdrawal
    • Social or financial problems
  • What is pain catastrophizing in patients?

    Pain catastrophizing is when patient's ruminate, magnify and feel helpless about their chronic pain. The pain catastrophizing scale is a 13 item questionnaire  that assesses the patients rumination, magnification and helplessness about their chronic pain.

    Interdisciplinary approach:

    • Participation in an interdisciplinary pain program (education, physiotherapy, exercise and psychological interventions) lead to a 40% reduction in scores on the pain catastrophizing scale.

    For example:

    • The Nova Scotia Workers Compensation Board used the pain catastrophizing scale on a sample of injured workers who had initiated a time loss claim with the Nova Scotia Workers Compensation Board
    • For patients who scored higher than 30
      • 70% remained unemployed one year post injury
      • 70% described themselves as totally disabled
    • Catastrophic thinking might be a risk factor for chronicity.
    • The literature on pain catastrophizing recommends that if the patient scores higher than 30 (considered clinically relevant level of catastrophizing) on the pain catastrophizing questionnaire that they would benefit from a pain self management group or a CBT group for chronic pain. Research shows that cognitive interventions for these patients can reduce their catastrophizing and help them with more realistic thinking.
  • How does PTSD impact chronic pain?

    • PTSD symptoms are characterized by 3 major symptom clusters including
      • re-experiencing symptoms (e.g., thought intrusion, nightmares)
      • avoidance symptoms (e.g., avoidance of stimuli associated with the traumatic situation, social withdrawal)
      • arousal symptoms (e.g., hypervigilance, heightened startle reactions)
    • PTSD symptoms are prevalent in whiplash injuries following MVA (25%).
    • PTSD symptoms add to the burden of disability following whiplash injury and might contribute to the heightened risk of chronicity

Resource Modules for Healthcare Practitioners

SleAP Program and Fellowship Program

Click on the links below to learn more information about the Sleep, Anesthesiology, And Pain Medicine (SleAP) Program and Fellowship:

Sleep, Anesthesiology, And Pain Medicine (SleAP) Program

SleAP Fellowship Program


76 Grenville St. Toronto, ON M5S 1B2 Canada

TAPMI Hub Clinic

Phone: 416-323-6269 Office Fax: 416-323-2666 Hours: 8:00 a.m. – 4:00 p.m. Monday – Friday


Dr. Tania Di Renna, Medical Director Sandra Robinson, Administrative Director