Transcript How to Get an End Result In A Chronic Pain Case

HOW TO GET
AN END RESULT
IN A
CHRONIC PAIN CASE
JAMES W. ATCHISON, DO
MEDICAL DIRECTOR
RIC CENTER FOR PAIN MANAGEMENT
PROFESSOR OF PHYSICAL MEDICINE AND REHABILITATION
FEINBERG SCHOOL OF MEDICINE
LEARNING OBJECTIVES
 1. Identify psychological and pharmacologic variables
that are “yellow flags” for indicating probable delayed
recovery in cases.
 2. Contrast active vs passive forms of treatment in
patients with delayed recovery
 3. Discuss the domains of patient improvement that
occur with functional restoration programs
 4. Apply the principles of MMI status and
determination of physical capacities to case closure.
POSSIBLE OUTCOMES
 FULL RECOVERY
 PARTIAL RECOVERY
 NO RECOVERY
WHAT ARE BARRIERS?
 PSYCHOSOCIAL FACTORS
 JOB DISSATISFACTION
 PRIOR INJURY
 INCORRECT DIAGNOSIS
 DELAYED APPROVALS FOR USUAL TREATMENT
WHAT ARE BARRIERS?
 LIMITED RESPONSE TO USUAL TREATMENT
 CONTINUED TX WITH LITTLE RESPONSE
 TREATMENT OUTLIERS
 TOO MANY OR TOO LITTLE STUDIES
 NEED FOR LITIGATION
WHAT ARE BARRIERS?
 ARE WE TRULY GOING TO
START TO WORRY ABOUT
OUTCOMES INSTEAD OF
JUST COST AND CLOSURE?
WHO IS RESPONSIBLE?
HOW DID WE GET HERE?
 BIOMEDICAL MODEL!
 PASSIVE TREATMENTS
•
•
•
•
MEDICATIONS
INJECTIONS
SURGERIES
MODALITIES
 WHAT ABOUT PATIENT EMOTIONAL STATUS?
• FEAR
• PERCEIVED INJUSTICE
• HOPELESSNESS OR HELPLESSNESS
THE BIOMEDICAL MODEL
Pain as a sensory event reflecting
underlying disease or tissue
damage
NATIONAL PAIN STRATEGY
DEFINITIONS OF PAIN
 Acute pain – An expected physiologic experience to
noxious stimuli that can become pathologic, is
normally sudden in onset, time limited, and motivates
behaviors to avoid actual or potential tissue injuries.
 Chronic pain - Pain that occurs on at least half the
days for six months or more.
 High-impact chronic pain is associated with
substantial restriction of participation in work, social,
and self-care activities for six months or more.
Pain Behavior
Suffering
Pain Perception
Nociception
John Loeser, MD
CHRONIC PAIN
 PAIN CONTINUES PAST THE TIME OF HEALING FOR
THE INITIAL INJURY
 ADDITONAL CHALLENGES/ISSUES:
•
•
•
•
•
•
•
GUARDING OF THE INJURED AREA
FEAR OF MOVEMENT AND REINJURY
ADOPTION OF THE SICK ROLE
CULTURAL BELIEF ABOUT PAIN
THE LOSS OF PRODUCTIVITY AND/OR INCOME
DECREASE IN BENEFICIAL LEISURE ACTIVITES
CHANGE IN FAMILY AND COMMUNITY ROLES
INTERDISCIPLINARY FUNCTIONAL RESTORATION, FEINBERG, GATCHEL, STANOS ET AL; CH. 82 IN
COMPREHENSIVE TREATMENT OF CHRONIC PAIN BY MEDICAL, INTERVENTIONAL AND INTEGRATIVE APPROACHES,
DEER ET AL, 2013, AMERICAN ACADEMY OF PAIN MEDICINE
MANAGEMENT
OF CHRONIC PAIN
 CHRONIC PAIN IS A DISEASE OF THE
PERSON, AND THAT A TRADITIONAL
BIOMEDICAL APPROACH CANNOT
ADEQUATELY ADDRESS ALL OF THE
PAIN-RELATED PROBLEMS OF THIS
PATIENT POPULATION.
INTERDISCIPLINARY CHRONIC PAIN MANAGEMENT: INTERNATIONAL PERSPECTIVES,
SCHATMAN ME, IASP PAIN CLINICAL UPDATES , DEC 2012, ISSUE 7, pp 1- 4
Biological
PAIN
Psychological
Social
THE TRIAD: PAIN, SLEEP, AND MOOD
Pain
Functional
impairment
Depression
/anxiety
Sleep
disturbances
PSYCHOSOCIAL “YELLOW FLAGS”
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
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Expectations and pain behavior
Heightened emotional activity
Maladaptive beliefs
Reinforcement of pain
Job dissatisfaction
Poor social support
Compensation
1. New Zealand Accident Comp Corp. 1997;23-66.
2. Cairns MC, Spine 2003; 28(9):953-59.
PSYCHOLOGY FACTORS
Increased:
Decreased:
Pain
Catastrophising
Self-efficacy
Pain Coping Strategies
Pain-related
Anxiety and Fear
Readiness to Change
Acceptance
Helplessness
Increased:
Pain
Psychological Distress
Physical Disability
Keefe FJ, et al. Annu Rev Psych, 2005.
MEDICATION “YELLOW FLAGS”
 Continued use w/o pain reduction or improved
function
• Despite continuation of side effects
• Beyond the Natural History of Recovery






Escalating doses w/o benefit
Multiple opioids
Early use of Long Acting opioids
Size of opioid dose (>200 Meq)
Use of opioids w/ benzodiazepines
Intolerance of PT w/ medications
WHAT ABOUT A CASE?
PERTINENT ISSUES
 PAIN NOT CONTROLLED
•
POORLY LOCALIZED
 DEPRESSION AND ANXIETY
•
FEARFUL OF ADDITIONAL
PAIN OR INJURY
 POOR SLEEP
 LIMITED ACTIVITY AND
FUNCTION
•
UNABLE TO MANAGE FLARES
 INEFFECTIVE MEDICATIONS
•
FAILED PROCEDURES
Duck or Rabbit?
LET’S HAVE YOU GET AN EVALUATION
AT RIC CENTER FOR PAIN MANAGEMENT!
WHAT CAN WE CHANGE
IN A PERSON WITH CHRONIC PAIN?
 OUTCOME MEASURES
• OVERALL FUNCTION
• MORE BENEFIT FOR:






SLEEP
MOOD
PHYSICAL FUNCTION/ACTIVITY
COPING WITH PAIN
MANAGEMENT OF FLARES
MEDICATION EFFECTIVENESS
• PAIN – ONLY A LITTLE
WHAT DO WE DO AT EVALUATION?
 TRY TO ASSESS THESE KEY DOMAINS
• SLEEP

TROUBLE GETTING TO SLEEP OR STAYING ASLEEP?
• MOOD

WHAT IS YOUR BIGGEST FEAR?
 ARE YOU ANGRY/IRRITABLE WITH THE PEOPLE YOU LOVE?
 WHAT DO YOU LIKE TO DO FOR PLEASURE?

STILL DOING?
WHAT DO WE DO AT EVALUATION?
 TRY TO ASSESS THESE KEY DOMAINS
• PHYSICAL ACTIVITIES

ARE YOU WORKING?


WHY NOT?
ARE YOU EXERCISING?

WHY NOT?
• FLARES

WHAT DO YOU DO WHEN PAIN GOES UP?
• MEDICATION PROFILE

EXACT RESPONSE, TIMEFRAME, SIDE EFFECTS
WHAT DO WE DO AT EVALUATION?
 ASSESS READINESS FOR CHANGE
• ACCEPTANCE?
 ASSESS PARTICIPATION IN EXAM
• HESITATION?
• FEARS?
• UNWILLINGNESS?
 ARE THERE ANY OTHER NECESSARY TESTS OR
PROCEDURES?
PATIENTS COME
TO THE EVALUATION THINKING?
 CURE?
• MEDICATIONS
• PROCEDURES
• SURGERY
 HOPELESSNESS?
•
•
•
•
ANGER
IRRITABILITY
FRUSTRATION
FATIGUE
THE DOCTOR SAYS
 GOOD NEWS!
 NOTHING STRUCTURALLY
WRONG
• THE PAIN IS EXPANDING
DUE TO SENSITIZATION OF
THE NERVOUS SYSTEM
 INTERDISCIPLINARY PAIN
PROGRAM WILL HELP!
• THIS PROGRAM INCLUDEs
PT, OT, BIOFEEDBACK, &
PSYCHOLOGY!
THE PATIENT SAYS (BUT THINKS)
(BUT IS THINKING):
• “IT HURTS TOO MUCH
TO BE THE MUSCLES”

(THIS DOCTOR
DOESN’T KNOW WHAT
S/HE IS TALKING
ABOUT!)

(I DON’T TRUST THIS
DOCTOR!)
THE PATIENT SAYS (BUT THINKS)
(BUT IS THINKING):
• “SHOULDN’T WE DO
ANOTHER MRI?”

(THE LAST DOCTOR
SAID THE REPORT
INDICATES MORE
DEGENERATION?)
• “WON’T SURGERY OR
MORE INJECTIONS
TAKE AWAY THE
PAIN?”

(I WANT SOMEONE TO
DO SOMETHING TO ME
AND FIX ME!)
THE PATIENT SAYS (BUT THINKS)
(BUT IS THINKING):
• I’VE ALREADY DONE PT,
AND IT DIDN’T WORK!



(IT HURT AND I DON’T
WANT TO DO IT AGAIN!)
(I’M AFRAID TO DO IT!)
(I HAVE TO DO THE
WORK?)
• “SO YOU THINK IT IS ALL
IN MY HEAD?”


(I’M NOT DEPRESSED OR
ANGRY!)
(IT’S “THEIR” FAULT!)
PROCESSING OF PAIN IN THE BRAIN
OCCURS IN SEVERAL REGIONS
Somatosensory
cortex
Pain + emotion
Pain only
Insular cortex
Prefrontal
cortex
Thalamus
Hippocampus
Anterior cingulate
cortex
Amygdala
Adapted from Apkarian AV, et al. Eur J Pain. 2005;9:463-484.
Image courtesy of Apollo Marcom.
FUNCTIONAL MRI
THE DOCTOR SAYS
 YOU’LL BE ABLE TO CHANGE
YOUR MEDICATIONS FOR
BETTER RELIEF
• REDUCE THE USE OF
OPIOIDS
• TREAT SLEEP

TCA OR TRAZODONE
• TREAT MOOD (AND MAYBE
PAIN) – SNRI
 DULOXETINE OR
VENLEFEXINE
THE PATIENT SAYS (BUT THINKS)
• MY PAIN PILLS ONLY
“TAKE THE EDGE OFF”


(I NEED MORE PAIN
MEDICATION!)
(I WOULD LIKE TO
SLEEP BETTER!)
• “IT WORKS BETTER
WHEN I TAKE IT WITH
THE ALPRAZOLAM”

(I WOULD LIKE MY
ANXIETY TREATED!)
“YOU CAN DO IT WITHOUT OPIOIDS!”
“IF THEY WORKED - YOU WOULDN’T BE HERE!”
 OPIOID CESSATION AND MULTIDIMENSIONAL
OUTCOMES AFTER INTERDISCIPLINARY CHRONIC PAIN
TREATMENT
•
MURPHY ET AL, CLIN J PAIN 2013;29:109-117.
 LACK OF CORRELATION BETWEEN OPIOID DOSE
ADJUSTMENT AND PAIN SCORE CHANGE IN A GROUP
OF CHRONIC PAIN PATIENTS
•
CHEN ET AL, J PAIN 2013 APR; 14(4): 384-92.
 LOW PAIN INTENSITY AFTER OPIOID WITHDRAWAL AS A
FIRST STEP OF A COMPREHENSIVE PAIN
REHABILITATION PROGRAM PREDICTS LONG-TERM
NONUSE OF OPIOD IN CHRONIC NONCANCER PAIN
•
KRUMOVA ET AL, CLIN J PAIN 2013; 29: 760-769.
HOW DO WE CHANGE THIS THINKING?
 PAIN MAY NOT CHANGE WITH ANYTHING!
 REGAIN SOME OF YOUR LIFE!
• POSTURE, PACING AND PROPER BODY MECHANICS
TO RESUME MOVEMENTS!
 REGAIN CONTROL OF LIFE!
• SELF-MANAGEMENT TOOLS/TECHNIQUES!
• ACTIVE NOT PASSIVE!
• USE THE BRAIN!
 YES, THEY HAVE TO DO THE WORK!
WHAT SHOULD THEY ASK THEIR DOCTORS IF
DIFFERENT TREATMENTS ARE RECOMMENDED?
 WHAT WILL CHANGE?
•
INJECTION

•
HOW MUCH SHOULD IT LOWER MY PAIN? HOW LONG?
SURGERY

WHAT ARE INDICATIONS FOR SURGERY?



•
DO I HAVE INSTABILITY, DEFORMITY, CONCURRENT PAIN?
WILL IT REDUCE PAIN? HOW MUCH?
WILL IT CHANGE MOTION OR FUNCTION?
MEDICATIONS

OPIOIDS



HOW MUCH SHOULD PAIN GO DOWN? HOW LONG SHOULD IT LAST?
CAN I STOP THEM IN THE FUTURE?
NON-OPIOID


DOES IT HELP SLEEP, MOOD?
WHEN SHOULD I NOTICE THE EFFECTS?
WHAT DOES
A
GOOD PROGRAM
LOOK LIKE?
WORLD HEALTH ORGANIZATION
PAIN REHABILITATION GOALS




FUNCTIONAL IMPROVEMENT
IMPROVEMENT IN ACTIVITIES OF DAILY LIVING
RELEVANT PSYCHOSOCIAL IMPROVEMENT
RATIONAL PHARMACOLOGIC MANAGEMENT
•
ANALGESIA, MOOD, SLEEP
 RETURN TO LEISURE, SPORT, WORK, OR OTHER
PRODUCTIVE ACTIVITY
INTERDISCIPLINARY FUNCTIONAL RESTORATION, FEINBERG, GATCHEL, STANOS ET AL; CH. 82 IN
COMPREHENSIVE TREATMENT OF CHRONIC PAIN BY MEDICAL, INTERVENTIONAL AND INTEGRATIVE APPROACHES,
DEER ET AL, 2013, AMERICAN ACADEMY OF PAIN MEDICINE
RIC INTERDISCIPLINARY TEAM
WHAT REALLY HAPPENS
WHEN THEY COME TO CPM?
 Educational
 Skills training
 Application and
relapse prevention
 Team Conference
• Individual Goal
Setting
• Reassess &
Readjust
PHYSICAL THERAPY
•
•
•
•
•
•
Comprehensive
assessment
“Active” instead of
“Passive” tx
Movement based
Strengthening
Aerobic conditioning
Home exercise plan
OCCUPATIONAL THERAPY
•
•
•
•
•
•
•
•
Positioning/Posture
Pacing Techniques
Body mechanics
Stress Loading
Desensitization
Graded Motor Imagery
(Left/Right
discrimination; Mirror
Therapy)
Graded Activity Exposure
Functional Capacity
Evaluation (FCE)
Activity Pyramid
Activities:
1:
2:
3:
Can change all lines by 5
minutes in either direction
Injury
Flare up / Inflammation
Behavior:
1: Severe spike in pain that stops you from
performing the activity
2: Pain persists for more than 3 days to
weeks
3: CHANGE in range of motion or strength (ability)
Plan: SEEK MEDICAL ATTENTION
Behavior:
1: Pain spikes during the activity
2: Pain persists after activity for ____________
3: No change in range of motion OR strength
Plan: rest, ice, medication as needed for 72 hours.
YELLOW-RED LIGHT
Tolerance for my condition
NO HARM
Behavior:
1: Pain spikes during the activity
2. Pain NO worse in ______________
3. No change in range of motion OR strength
GREEN LIGHT
OT PYRAMID
PAIN PSYCHOLOGY
•
•
•
•
•
•
•
Mind-Body Connection
Coping Skills Training
Emotion Regulation
Cognitive Behavioral
Training (CBT)
Cognitive Restructuring
Stress Management
Family Education
MINDFULNESS TRAINING:
4
RELAXATION TRAINING/ BIOFEEDBACK
• Deep Breathing
• Imagery and
Visualization
• Progressive Muscle
Relaxation (PMR)
• Biofeedback
MUSCLE TENSION
MONITORING
Left shoulder
Right shoulder
Self-confidence in capabilities to control tension
47
FULL DAY PROGRAM SCHEDULE
Monday
Tuesday
Wednesday
Thursday
Friday
8a
Weekend
review
Gym
Feldenkrais
Relax (G)
Psych
9
Nursing
lecture
OT
Tolerance
Psych
Biofeedback
MD visit
10
PT
OT tolerance
Conditioning/Gy
m
Voc
OT
11
MD visit
Video
Pool
Conditioning/Gy
m
PT
12
Lunch
Feldenkrais
Lunch
Pool
Lunch
1
OT (G)
Lunch
Biofeedback
OT (G)
Psych (G)
2
Biofeedback
OT
OT (G)
Relax (G)
Relax (G)
3
Nursing
Psych
OT (G)
4
Relax (G)
Wii Group
Mindfulness (G)
OT (G)
Family meeting
(G)
OT (G)
MEDICAL MANAGEMENT
•
•
•
Team lead by a Physiatrist, pain medicine
specialist
Initial evals with Physiatrist and Psychologist
• Which program is best fit?
Medication adjustments
• Sleep Assistance?
• Treatment of mood?
• Nerve Pain?
• Myofascial Pain?
• Opioids?
• Taper? Detox?
COORDINATE THE MEDICATIONS!
ANTISPASMODICS
ANTIEPILEPTICS
ANALGESICS
DECREASE PAIN
INCREASE FUNCTION
ANTIDEPRESSANTS
ANTIANXIETY
SLEEP
ASSISTANCE
NSAIDs
HOW DOES IT WORK?
51
WE CAN TREAT
 PAIN?
 ABILITY TO COPE
WITH PAIN?
 MOOD?
 SLEEP?
 ABILITY TO MANAGE
FLARES?
 PHYSICAL
FUNCTIONING?
 PAIN MEDICATION
EFFECTIVENESS?
RIC Full Program Completers 2013
Very Much
Worse
No Change
Very Much
Improved
Patients with WC
Very Much
Worse
No Change
Very Much
Improved
Patients with WC versus Patients without WC
Very Much
Worse
No Change
Very Much
Improved
INTERDISCIPLINARY PROGRAM
WC OUTCOME DATA 2013
wc
COMPLETED
wc
INCOMPLETE
PAIN DURATION 35.5 MONTHS
33.7 MONTHS
MMI
88.2% (95.7%)
27.8%
RELEASED
TO WORK
80.4% (97.6%)
29.4%
RELEASE
STATUS
FULL: 90.2%
GRADUAL: 2.4%
FULL: 100%
FCE
84.3%
55.6%
FCE VALID
58.1%
80%
INTERDISCIPLINARY PROGRAM
WC OUTCOME DATA 2013
FCE STRENGTH
wc
COMPLETED
wc
INCOMPLETE
SEDENTARY
7%
20%
SEDENTARY-LIGHT
2.3%
LIGHT
39.5%
LIGHT-MEDIUM
18.6%
MEDIUM
14%
MEDIUM-HEAVY
7%
HEAVY
4.7%
MISSING
7% (n=3)
40%
40%
INTERDISCIPLINARY PROGRAM
OUTCOME DATA 2014
F
wc
COMPLETED
wc
INCOMPLETE
N=
36
22
NO CONTROLLED MED AT
END OF 4 WK
20/36
(55.5%)
6/22
(27.3)
ON TRAMADOL
3/36
6/22
ON CII/CIII
13/36
10/22
ON NO CII OR CIII AFTER
CONT TX
28/36
(77.7%)
ON TRAMADOL
5/13 SWITCH
ON SUBUTEX
2/3
ON HYDROCODONE
3/5
ON OXYCODODONE
2/4
ON BUTRANS
1/1
SUMMARY
 Acute and chronic pain are different and need to be
treated differently!
 Monitor patients for various warning signs or “flags”
for developing behaviors of chronic pain
 Talk to patients about expectations and outcomes
• Let them know what will change!
SUMMARY
 Interdisciplinary treatment leads to improvement in
physical functioning
• Combining physical and cognitive treatment most effective
• Treat the Brain!
 Don’t be afraid to take them off medications that are
not helping their function!
 Direct communication regarding MMI status and FCE
outcomes are necessary!
THANKS!