Divergent Treatments for Chronic Pain
As I described in the previous post, chronic pain initially
begins, appropriately, as acute pain – a biological event in response to
noxious stimuli. However, as time
progresses, social, psychological, and cultural factors impede and complicate
recovery. These psychosocial factors
become complicit in exacerbating the pain and disrupting pain management.
Unless underlying triggers are recognized and addressed
early on, the treating clinician is left to treat the symptomology of the
patients’ pain, often with repeated surgeries and ever escalating doses of
narcotic analgesics. Such treatments may
not be addressing the real pain generators.
More often than we’d like, surgeries are treating MRI results. As many as 30% of these diagnostic screenings
are potentially inaccurate. MRIs may return false positives that hint at
physiological incongruences that are only potentially associated with the
patient’s pain pathology. Often the
patient’s medical file tells a treatment story of narcotic analgesics in large
doses for multiple years. The present
reality is that the patient is now both physically and emotionally dependent on
these medications.
The question then is what to do with injured workers with
complicating psychosocial factors which can range from adverse childhood events
(ACE) to more recent post-traumatic stress disorder (PTSD). Selected treatments should account for a
patient’s psychosocial and behavioral complications. As an industry we are faced with a myriad of
options and limited guidance as to how best to choose between them. However, the focus should be on providing
carefully selected interdisciplinary care and referring the injured worker for
modalities that can simultaneously address a patient’s pain while building
endurance and addressing the psychosocial drivers of chronic pain.
Assessment
The probable starting point is to identify the goal of
treatment and the disposition of the patient.
It may not be possible to return the injured worker to a pre-injury
state, but treatment should be geared towards restoring the patient to maximum
medical improvement. The goal of this treatment should be to facilitate the
worker’s return to some form of employment - even if that is at a restricted
duty level.
For patients with
longstanding chronic pain Motivational Interviewing (MI) is commonly a good
starting point to assess the patient. It
is a patient-centered treatment modality meant to engage the patient and assess
ambivalence and anxiety. This also
provides a screening opportunity.
You may find that understanding an injured worker’s chronic
back pain, ongoing for 10 or more years, may be attributed to nothing more than
age progression degenerative changes. The spine begins to lose its water
content in the early 30’s which increases the risk of bulges, herniations, and
even annular tears. These degenerative
changes impact almost everyone, even without symptoms. Studies show disc degeneration in about 37%
of all asymptomatic 20 years-olds, 80% of asymptomatic 50 year-olds, and 96% of
all asymptomatic 80 year-olds.
Or you may also find as part of an initial screening of the
patient, a history of a more traumatic event.
Significant diagnoses such as PTSD can occur in instances such as rape,
traumatic brain injury, gun point robbery, severe motor vehicle accidents,
veterans returning from combat, or employees witnessing a shooting incident or
murder. These individuals need to be
referred to a specialist who can provide the necessary interventions
recommended by the American Psychological Association issued in their “A” list
included in the published 2008 guidelines.
Frequently you will find the injured worker’s status can be
improved through referral to multiple modalities addressing pain, function, and
comorbid conditions as well as addressing smoking and weight issues.
Choosing between Coordinated Interdisciplinary Care and a Functional
Restoration Program
Without engagement, a patient chronically treated with
narcotic analgesics, now likely dependent, will be resistant to change and
unlikely to achieve any progress of either their pain or function. It is
critical however that the delivery of care be improved. Common options
include referring the patient to a Functional Restoration Program (FRP) or by
coordinating analogous care by referring to multiple modalities in an
integrated system, inclusive of motivational counseling such as cognitive
behavioral therapy (CBT).
Functional Restoration Programs
A FRP is a rehabilitation program aimed at increasing
physical functioning, improving pain-coping skills, and returning the patient
to a productive lifestyle at home and at work.
These treatment programs will be inclusive of multiple provider types,
commonly including physical therapists, addictionologists, psychiatrists and/or
psychologists, orthopedists and others.
These programs excel at providing coordinated care through treatment
teams that jointly assess and construct treatment plans weaving multiple
modalities together.
However, FRP programs cost anywhere from about $40,000 on
the low-side to upwards of $90,000 on the higher end. Unfortunately, due to their size and volume,
a number of these programs do not have peer reviewed, published, prospective,
randomized controlled studies to support their published claims of
outcomes. While there are fantastic
programs available, they come at significant cost and with refutable evidence
of their program's ability to produce improved functionality, pain control,
medication management, or return to work.
When considering the incredible cost of these programs, it
is important to also account for patients who are poor candidates for such a
program. Patients who are retired, or
who will never return to work in any function, would not be good candidates for
referral. Additionally patients with
comorbidities that would prevent full participation in all the modalities of an
FRP (e.g., suicidal ideations, unstable heart conditions, uncontrolled
hypertension, asthmatics, exertional dyspnea etc.) would not be good
candidates. Other poor candidates
include patients who have previously failed CARF accredited programs, have
unrealistic expectations of treatment such as immediate cure, or patients who
are depressed or not motivated to fully participate. Those who are already dependent on narcotics
with existing neurobiological changes may not recover as expected.
There is no advantage for the payer, physician, patient or
anyone else to refer a patient for therapy that will not provide efficacy for
that individual patient.
Cognitive Behavioral Therapy
Depending on diagnosis, CBT when used in
conjunction with other treatment modalities (such as needed physician consults
by orthopedist, psychiatrist, psychologists etc.) biofeedback, physical therapy
(PT), aqua PT, or other PT modalities such as Alexander or McKenzie’s protocol
which may help to centralize or relocate the pain, can restore patients to
function in a shorter time than putting them through all the sessions of the
FRP. It can often be even more
beneficial as FRP programs often require the patients be housed near the campus
which silos the patient away from their family and support systems.
Utilizing this integrated coordinated
outpatient delivery of care, the patient can also be taught protocols to be
done at home after they are mastered in the facility ,allowing the injured
worker better continuity of care.
Including a dietitian can also help the patient by reconstructing their
diet around anti-inflammatory foods, limiting sugars, fats, sodium intake and
introducing more plant-based fibrous foods into their diets. This has the added advantage of addressing
other elevated medical risk-associated with raised BMI levels.
All of this can be provided for the
patient while keeping them at or close to home at a much lower cost to the
payer.
Evidence for Coordinated Care
When coordinate care delivery programs are utilized in a
hospital facility, various specialty providers have weekly group strategy
meetings focused on each patient's needs.
The team sets treatment goals for each patient and each team member then
coordinates their intervention to achieve the team goal.
Other team members like an addiction specialists,
nutritionists and a vocational rehabilitation provider, can also be brought in
as needed, to help address patient detox, weaning, medication management, and
return to work. This often includes the
assistance of a psychotherapist with associated lifestyle goals such as weight
reduction and return to work with necessary modifications. In this setting a PM&R specialist
sometimes act as the team coordinator.
In 2007 G. Roche et al., published a comparison of an FRP
intervention and an active individual therapy (AIT) intervention post five-week
study period(1). The included a study
groups included the FRP program utilized
fort 25 hrs/wk, versus active individual physical therapy group utilizing 3
hrs/wk for patients with chronic low back pain.
The objective of this randomized controlled trial was to compare short
term outcomes of each intervention.
The study was conducted within two Rehab Centers and private
ambulatory PT facilities. There were a number of outcome measures including
flexibility and endurance, daily activities, reports of work ability,
resumption of sports and leisure activities. The results showed all outcome measures improved except the
endurance in the active individual PT group. There was inter- group difference
in pain intensity or Dallas Pain Score, daily activities or work and leisure
activity scores. However, better results were observed in FRP for the other
outcome measures.
Low cost ambulatory AIT is effective. The main advantage of
FRP is improved endurance. They speculated that this may be linked to better
self-reported work ability and more frequent resumption of sports and leisure
activities. Personally, I would think
being at a facility 25 hours per week as opposed to 3 hours would lend itself
to more availability of other aerobic sport and leisure activities to build
endurance, this can be done just as well in a community gym etc.
Conclusions
Treatment of chronic pain starts with careful assessment of
the patient. This in turn relies
strongly on an engaged treating physician and solid patient-physician
relationship. When coordinating the
delivery of interventional care it is critical that the right care be selected
to achieve the greatest impact for the patient with the least wasted
expense. Not all care is equally
effective, and not all patients of similar diagnoses will be similarly impacted
by identical care. Leading with a
motivational assessment is a good place to start when choosing between care
delivery models. While integrated and
collaborative care delivery as is provided in hospital settings and intended to
be provided by FRPs is the gold standard when it comes to chronic pain
interventions, finding such a program close to a patient's home, with the
necessary modalities, with objective outcomes, and at an acceptable cost is
often an impossible task. In many cases
these hindrances to care outweigh the benefits that may be obtained. Analogous, low cost care can be provided
through carefully integrated and coordination for each injured worker with
multiple modalities.
Dr. Thomas
1. Roche G,
Ponthieux A, Parot-Shinkel E, et al. Comparison of a functional restoration
program with active individual physical therapy for patients with chronic low
back pain: a randomized controlled trial. Arch Phys Med Rehabil.
2007;88(10):1229-1235. doi:10.1016/j.apmr.2007.07.014.
