Transcript 2- Utilizing a Multidisciplinary Approach

Multidisciplinary Approach to Pain
Management
Sarah Endrizzi, MD
Advanced Pain Management
Medical College of Wisconsin
Objectives
• Epidemiology of chronic pain
• Pain as a disease
• What is multidisciplinary pain management
(MDPM)
• Discuss goals of MDPM
• Treatment modalities
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Medications
Interventions
Pain psychology
PT/OT
Complimentary and alternative medicine
So why are you here?
• Primary care MD/NPs are the predominant
providers managing pain in the US
▫ Little previous teaching
 Medical students receive on average <10 hours
on pain physiology, neuroanatomy, physiology,
diagnosis, management and treatment (Mezei et al,
2011)
 Medical students receive on average 1 hr of
education on analgesics (Institute of Medicine Report,
2011)
 Housestaff education in pain management is
not substantially better (Ogle et al, 2008)
2013 Hurley©
Pain Epidemiology and Impact
• 100 million adults in the US with chronic pain
(Medical
expediture panel, 2008)
• #1 cause for disability
• Patients with pain cost ~$4,500/year more than
match no pain controls
(Iom, 2011)
▫ Direct medical costs - $293,000,000,000
▫ Back Pain was 72% of these costs
▫ Approximately 150 million work days lost per year
because of back pain
Comparison to Other Diseases
• Direct and Indirect Costs in Billions
(IOM, 2011)
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Pain - $635
Cardiovascular – $309
Cancer - $243
Trauma/Poisoning - $209
Endocrine/metabolic - $127
Digestive System - $112
Respiratory System - $112
Why is proper evaluation and
treatment of chronic pain important?
• Chronic pain itself is a disease
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Anatomical changes
Physiological changes
Pharmacological changes
Psychological changes
Altered responsiveness to medications
Chronic Pain State
• Cortical thinning in CLBP compared to controls
• Reversal of cortical thinning with treatment of pain
• Reversal of cortical thinning with treatment
Seminowizc, 2011, J Neurosci
Central Pain Disorders
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Fibromyalgia
Post-stroke pain
Headache (tension>migraine)
Chronic pelvic Pain
Chronic Low Back Pain
Myofascial Pain/Widespread Chronic Pain
TMJD
Interstitial Cystitis
Phillips & Clauw. 2011
Development of chronic pain
• Pain that remains after the expected healing
from an injury
• Pain that is NOT exclusively peripherally driven
• Central Nervous System amplifies and distorts
the painful response so that it no longer is
directly related to the peripheral input or
stimulus
• An uncoupling of the expected stimulusresponse relationship
Chicken or the egg?
• Are the differences pre-existing?
▫ Do they predispose patients to chronic pain
• Do they result from chronic medication
exposure?
• Are they the result of anxiety, depression,
decreased physical activity, reduced social and
intellectual stimulation?
What is Multidisciplinary Pain
Management (MDPM)?
• Multiple Providers of various specialties who work
together to assess and develop a comprehensive
treatment plan for a patient
• Often includes Medicine, psychology, & PT/OT
• May also include alternative medicine
▫ Massage
▫ Acupuncture
▫ Chiropractic
Why MDPM?
• Because many Chronic Pain Disorders are
disease states
• Many Pain states coexist with depression &
anxiety
• We can’t treat all of these changes with one
modality
• We are in the midst of an opioid addiction
epidemic
Goals in Multidisciplinary Pain
Management
• Improve or Maintain physical functioning
• Facilitate Re-engagement in typical activities
▫ Maintain or return to employment
▫ Perform ADLs
▫ Ability to participate in leisure activities
• Making Removal of Pain as a primary goal can
be counter productive
Engaging patients in their treatment
plans
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Discuss risk/benefits for all interventions
Offer options
Provide realistic, incremental goals
UTILIZE PAIN PSYCHOLOGY!!
Medications
• Focus on non-opioid options
 Membrane stabilizers
 NSAIDs
 Topicals
 Antidepressants
• Wean current opioid regimen
Results of Opioid Weaning
Harden et al. Pain Medicine 2015
Interventions
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Done under fluoroscopy or ultrasound
Epidural steroid injections
Joint injections
Nerve ablations
Sympathetic blocks
Spinal cord stimulators
IT pumps
Pain Psychology
• 18-85% of patients with chronic pain have a
comorbid psychiatric condition (Doan, Neural Plasticity, 2015)
• 35% with Chronic back/neck pain have
depression or anxiety disorder (Katz, Spine. 1997,1999)
• Correlation between severity of pain and degree
of depression (Fishbain, CJ of Pain, 1997)
• Cognitive approaches include CBT, biofeedback,
hypnosis
PT/OT
• Physical Therapist/Occupation Therapist
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Educate on physiological basis of pain
Teaches body mechanics, pacing
Role in physical rehabilitation
Address vocational issues
Techniques for managing pain on the job
Gatchel, Am Psychologist. 2014
Physical Therapy
• Active Treatment (better evidence)
▫ Gait Training
▫ Core Strengthening and stability
▫ Postural re-education
• Passive Treatment (less evidence)
▫ TENS
▫ Heat/ Cold
▫ Ultrasound
CAM Therapies
• Acupuncture
▫ Improvement in Pain, but not long lasting (Furlan
2010)
• Massage
▫ Little Evidence to support use (Furlan. Cochrane 2015)
• Manipulation
▫ Better than placebo at improving pain, function
(Furlan 2010)
• Yoga and tai chi
Prolonged duration of Pain Worsens Outcomes
• Facet RF: Cohen et al. CJP 2007
• Spine surgery: Quigley Surg Neurol 1998, Jacobs Eur Spine J
2011
• Epidural steroids: Kwon et al. Skel Radiol 2007, Benzon Pain
1984
• Pharmacotherapy for CRPS: Perez et al. Pain 2003
• IA injections for knee OA: Tanaka et al. Rheum Int 2002
• Physical therapy for DJD: Jansen et al. Eur J Phys Rehabil Med
2010
• Vertebroplasty: Ryu & Park J Korean Neurosurg Soc 2009
TAKE HOME MESSAGE….SEND PATIENTS EARLY….
Thank you!
Pain Centers of Wisconsin- Wauwatosa Clinic
Medical College of Wisconsin in partnership with Advanced Pain
Management
959 N Mayfair Road
Wauwatosa, WI 53226