(1)
Wisconsin Rehabilitation Medicine Professionals, Milwaukee, WI, USA
How I Came to Embrace Multidisciplinary Treatment
Since the age of four, I wanted to be a physician and I had expected to become an orthopedic surgeon, as I was always interested in the function of bones, joints, and muscles. Later, my interest was also in the nervous system and its control of the musculoskeletal system. I emigrated to the United States in 1973, after finishing my medical school training in India, and undertook a year of surgical training in Honolulu, Hawaii. However, I did not find surgery as rewarding as I had anticipated. By serendipity, I met a physiatrist in 1973 who suggested I consider the field of physical medicine and rehabilitation, a specialty that would let me care for individuals with a variety of musculoskeletal and neurological disabilities.
I soon began a residency in Physical Medicine & Rehabilitation at the medical college of Wisconsin in Milwaukee. This work and the knowledge I gained as I pursued certifications by various pain medicine related boards, strengthened my belief in the value of a multidisciplinary approach to pain management. Chronic pain, a condition in which pain lasts beyond the normal healing period, has no clear cause or cure and is associated with disability and often depression and drug misuse, is ideally suited for a multidisciplinary approach because it addresses the multiple psychosocial and biologic factors behind it. As we noted in the introduction to this book, multidisciplinary rehabilitation with its team of medical professionals who are experts in their varying fields treats the “person” not the pain.
During this same time period, I was becoming trained in the disability systems in the United States and performing medicolegal work. It was abundantly clear how much the US’ social security disability, Workers’ Compensation and personal injury systems could benefit from incorporating a multidisciplinary approach in assessment of disability and in treatment recommendations.
In the late 1970s, I was fortunate to join the International Association of Study of Pain, the American Pain Society and one of its branches where I resided, the Midwest Pain Society. This was during the “golden age” of chronic pain management when multidisciplinary treatment prevailed. Through active participation in these organizations, I had the opportunity to work closely with notable scientists and “super specialists” including Dr. Dennis Turk, Dr. Richard Chapman, Dr. Wilbert Fordyce, Stephen Brena, M.D. and John Loeser, M.D. These leaders in the pain field, further convinced me that painrelated disability is indeed a treatable problem using the rehabilitation principles I had learned as a physiatrist.
In 1983, the American Academy of Pain Medicine (AAPM), a group composed only of physicians, was formed in the interests of becoming a member group of the American Medical Association (AMA), considered the “voice of medicine” in the United States. While involved with the AAPM, I had the opportunity to serve as President. The AAPM also created the American Board of Pain Medicine (ABPM), to provide certification of physicians who had board certification in other specialties such as Anesthesiology, Neurology, Neurosurgery, Physical Medicine & Rehabilitation (PM&R or Physiatry), Internal Medicine, Family Practice, etc. I was fortunate to be the first and founding President of ABPM, which instituted a certification process for physicians treating individuals with pain.
Although the initial goal was to develop a distinct specialty of Pain Medicine recognized by the American Board of Medical Specialties (ABMS) similar to orthopedic surgery, anesthesiology or neurosurgery, we have yet to see success. However, the ABMS did succeed in interesting the American Board of Anesthesiology (ABA) in establishing a subspecialty in Pain Management/Pain Medicine in the late 1990s.
By 2000, the American Board of Anesthesiology allowed board-certified physicians from the Boards of PM&R and Neurology/Psychiatry to achieve certification in the new subspecialty through taking exams offered by the ABA. By the time this opportunity had arisen, I had personally already gained lifetime Board certification in PM&R in 1978, and by the American Board of Pain Medicine in 1991. I also received the ABA’s Certificate of Added Qualification in Pain Medicine and have received 10-year certifications from the American Board of PM&R in the subspeciality of Pain Medicine from 2000 to 2010 and from 2010 to 2020. I also have a lifetime certification from the American Board of Electrodiagnostic Medicine which began in 1979.
Medical professionals who see patients with chronic pain certainly realize that the medical profession is long overdue in recognizing pain as a specialty: as the Institute of Medicine notes, of the 27 institutes in the National Institutes of Health (NIH) not one is dedicated to pain!
Since 1977, I have served as the Medical Director of the multidisciplinary pain clinic at the Curative Rehabilitation center which is part of the Medical College of Wisconsin in Milwaukee. From 1984 to 2000, I served as the Medical Director of a comprehensive pain rehabilitation program at Elmbrook Memorial hospital in Brookfield, Wisconsin. I also directed the Center for Pain and Work Rehabilitation at St. Nicholas Hospital in Sheboygan, Wisconsin, from the early 1990s until 2013.
Since 1994 to the writing of this book in 2015, I have served as Medical Director of the Center for Pain Rehabilitation at Community Memorial Hospital in Menomonee Falls, Wisconsin. I provide care and medical direction for the Center’s multidisciplinary treatment, focusing on biopsychosocial and rehabilitation approaches with the goal of improving function and returning patients to work, where possible, while trying to reduce pain. The program, located at the North Hills Health Center, is a joint venture between Community Memorial and Froedtert hospitals and physicians from the Medical College of Wisconsin Community Physicians group.
Everything I share in this book results from my work with such programs which treat the “whole patient” through welcoming families to participate in conferences and treatment meetings and empowering patients through helping them educate themselves about pain.
On the basis of these comprehensive multidisciplinary programs, which I have been privileged to work with since 1977, I sincerely wish that new medical school graduates would be taught to appreciate the psychological, social, cultural, vocational, and environmental factors that may add to or accentuate patients’ biological symptoms of pain.
Instead of multiple injections, interventions and repeated surgeries to eliminate or decrease the pain‚ future physicians can empower their patients through education and enlisting them in their own treatments in shared decision making. In addition to greatly improving the quality of life for chronic pain patients, eliminating excessive expenditures for uncoordinated pain treatments would make a huge difference in healthcare costs.
Multidisciplinary pain rehabilitation “shifts the focus from searching for the pain source, which may not even be identifiable on a test, to what.. .[a patient] can do to become more functional,” writes David Hanscom, M.D. (2012). Multidisciplinary treatment “addresses all the factors contributing to chronic pain and a turbo-charged nervous systems—lack of sleep, anxiety, medications, goal setting, physical conditioning, and anger—and goes through the best way to deal with them one by one.”
“If you don’t stand for something, you will fall for everything”
Patients need to know their choices and the details of the treatments offered before consenting to passive, irreversible treatments such as surgery, stimulators, morphine pumps, and other invasive procedures.
Recently, I came across an editorial in a medical journal that lamented how an “increase in the number of patients per physician” had created the “busy doctor” always attending to “something more urgent than the immediate situation” (James 1974). Patients who were polled for the article saw physicians lacking in time, warmth, and “real” concern for them. The irony is, the editorial was written in 1974, more than 40 years before the writing of this book! Certainly, because of increasing patient loads today and reimbursement patterns, it is easier to offer a patient unimodal and often expensive treatments for chronic pain than our time and listening ear.
Unless the psychological and social factors behind chronic pain are addressed, physical rehabilitation, pharmacotherapy and interventional approaches in isolation will be inadequate to treat the multiple needs of patients with chronic pain.
Sridhar Vasudevan, M.D.
Fundamentals in Treating Pain Patients
Reeducation
By the time we see most pain patients they have internalized some myths about their pain, either from their own unsuccessful course of treatments or simply from living in a society that greatly misunderstands chronic pain. Many of these myths are found in Treat Your Own Back, a helpful book for pain patients, the main points of which are shown in Table 6.1 (McKenzie 1980).
Table 6.1
Eight myths of back pain adapted from Treat Your Own Back
Myth | Truth |
|---|---|
Back pain is short-term | For at least half of patients, it is recurrent |
Spinal manipulation gives the best results | Gives limited benefits, encourages patient passivity |
Ultrasound/electrical therapies are helpful | No long-term benefit, healing not accelerated; underlying problem not addressed |
Inflammation causes back pain | Inflammation may accompany some conditions like rheumatoid arthritis but most are entirely mechanical in nature |
Pain comes from “degeneration of the spine” | Changes shown on X-rays are rarely pain generators |
Pain requires rest | After 1 or 2 days, mobility should be regained |
Stop sports like jogging or golf | Patients can likely return to their sports as they recover |
Weather causes the pain | Damp conditions and drafts are not behind back pain |
Helping the Patient Reframe His Pain
In over 37 years of treating chronic pain patients, I have become convinced that, unless the psychological and social factors behind chronic pain are addressed, physical rehabilitation, pharmacotherapy and interventional approaches will be inadequate. If the biopsychosocial factors are not included in chronic pain treatment, patients often end up with pain conditions that are characterized by dysfunction, disuse, dramatic pain behaviors, drug misuse/abuse, and disability that far exceed the physical findings.
Then and now I see many patients presenting with failed back surgery syndrome (FBSS), fibromyalgia, complex regional pain syndrome, headaches, neck and extremity pain, and other stubborn conditions in which pain has been firmly established. Many have become discouraged and started to think of themselves as disabled. Yet, almost all of these patients, if they alter their attitude toward their pain and situation—“reframing” their pain—and become open-minded to multidisciplinary treatment, improve. We regularly see them achieve independence, new psychological skills, gain control of their pain and their life, and find alternative work that is compatible with their physical and medical restrictions. They achieve self-responsibility and self-efficacy in the management of their pain and a positive, long-term outcome.
To usher along this transformation, I suggest observing these rules at all times in your treatment of pain patients as shown in Table 6.2.
Table 6.2
Four rules for clinicians to observe when treating patients with chronic pain
Pain Is Always Real |
Pain Is Always in the Brain |
Inform About Choices |
Search Your Own Soul |
Rule 1: Pain Is Real
I never question the existence of a patient’s pain. In my decades of pain medicine experience, I have applied the rule that I would not judge the existence of someone’s pain but would judge the underlying cause, if it can be found, and consider the appropriate combination of treatment to address the “person and the pain.” As medical professionals, it is our responsibility to first rule out significant, treatable or correctable pathologies contributing to the pain condition, while not conceding to inappropriate demands for test or treatment. Then, if there is no clear curable disease/pathology, our focus should be on the person experiencing the pain and not the pain itself.
Rule 2: Pain Is Always in the Brain
We know from the main theories of pain presented in Chap. 3, that the brain modulates almost all pain responses. This is one reason Cognitive Behavioral Therapy techniques and relaxation methods, explained in Chap. 4, and some antidepressants and antiseizure drugs are effective in chronic pain. It certainly does not mean the pain is “imaginary.” I am surprised and saddened by the fact that medical students graduating today are often unaware of the Gate Theory and the chemical, behavioral, and learning theories of pain described in Chap. 3, including Loeser’s Model of pain. Too often, when recent graduates listen to a patient describe his pain or see him demonstrate pain behaviors, they assume there must be an underlying disease or tissue injury in keeping with the Door Bell Theory which says when there is pain, there is a pain generator at the “door.”
Unfortunately this biomedical and unimodal perspective can and does lead to seeking the “pain generator” in diagnostic imaging and to physicians and surgeons “reading” the X-ray not the patient. The “X-ray diagnosis,” as I sometimes term it, omits consideration of a patient’s social, psychological, vocational, legal, cultural, and environmental milieu. It often leads to numerous interventional techniques, though there is little evidence that multiple injections and long-term use of opioids actually lessen pain.
Rule 3: Inform Patients About Their Choices
There is an alternative to the uncoordinated unimodal care most patients have received by the time we see them—multidisciplinary care. Our first responsibility to patients is to avoid harm including the harm of giving them limited information or clarifications about treatments they have been receiving, especially interventions and excessive drug use. The “new road” of pain management requires more self-responsibility, learning, effort, and participation than most patients expect or want. The current healthcare system encourages patient passivity, especially when it comes to chronic pain, and patients have understandably adjusted to the role.
When I see new pain patients, I make it clear that there is an alternative road to the chronic opioid therapy, disability, injections, multiple surgeries, and feelings of hopelessness they have endured. While they may not return to their condition prior to their injury or illness, if patients are willing to learn new skills such as appropriate exercises and body movements from physical and occupational therapists and Cognitive Behavioral techniques from psychologists their pain can be managed and they can have a high quality of life. The basics of the biopsychosocial approach, which have been effective through centuries and practiced all over the world, have been and will always be the mainstay in managing chronic pain as well as other chronic illnesses.
Rule 4: Search Your Own Soul
It never hurts for you to apply what my colleague jokingly refers to as the “your mama test” with your pain patients—would I recommend the same test, procedure, medication, surgery, or any other course of treatment for my own mother? Or family?
In addition to always taking a patient’s pain seriously, we also need to ask ourselves if our practice changes significantly depending on the patient’s insurance carrier. Physicians often treat patients with generous insurance coverage such as Workers’ Compensation with more tests or diagnostic procedures than patients with limited or no coverage. This may be realistic, based on “covered services” but our philosophy of treatment should be consistent regardless of insurance coverage or payor source.
Finally, when it comes to disability, we need to ask ourselves if we understand the long-term implications of recommending a permanent disability rating on patients. Clearly, some patients with injuries or illness, despite optimal treatment, may have to be restricted permanently from certain activities to prevent them from harming themselves or aggravating, precipitating or accelerating an underlying condition. But permanent restrictions, in addition to affecting a patient’s future employment and insurance status, also lead to iatrogenic disability. These important issues are explored further in Chap. 7, Evaluation of Disability in Patients with Chronic Pain.
In Chaps. 1, 2, 3, 4, we explored the tremendous effect a patient’s belief system, cultural and social milieu, and psychological makeup have on his experience of pain. Several theories suggest the extent to which a patient expresses pain behaviors and feels stress, anger or resentment exert a significant influence on pain. It should be good news to medical professionals seeing chronic pain patients, then, that regardless of the type of pain they present or their particular set of biopsychosocio circumstances, the treatment goals for most chronic pain patients remain remarkably similar!
Our goals are to induce in the patient a sense of self-efficacy and self-responsibility and empower him as a partner in his own pain management through multidisciplinary care, as shown in Table 6.3. This process usually begins with elimination of narcotics and identification of appropriate medication, increasing physical activity, addressing the patient’s psychological and emotional issues and educating the patient about pain and pain management.
Table 6.3
Six goals for treating the patient with chronic pain
Eliminate all nonessential medications, especially opioids |
Improve sleep patterns and control depression |
Increase physical activity, flexibility and endurance; functional improvement is the goal |
Improve coping skills through psychological support; encourage self-efficacy |
Improve socialization and recreational activities with friends and family |
Return patient to work if he is able, even if a different job than before if retiredimprove quality of life |
Multidisciplinary pain rehabilitation offers a patient a “cafeteria” of treatments from stretching and strengthening exercises to physical modalities like heat and Transcutaneous Electrical Nerve Stimulation units (TENS) to psychological tools like Cognitive Behavioral Therapy. To improve a patient’s function, control disability and decrease his dependence on the healthcare system, all avenues of pain management should be explored including drugs, injections, and surgeries when appropriate.
An astounding 30–50 % of patients are abusing medications by the time we see them which is why eliminating all nonessential medication is an early and continuing goal. Whether these medications are opioids like oxycodone and hydrocodone, benzodiazepines like Xanax or other habit forming drugs, assessing the patient’s current drug use and titrating him off nonessential drugs should be addressed as soon as possible.
If patients have become habituated to opioids, benzodiazepines or related drugs, they usually have a firm conviction that their pain will worsen if they are titrated off the medications and will resist such a plan. Except in rare instances, long-term use of such drugs worsens chronic pain. Many patients share that, contrary to their expectations, their pain actually subsided when they titrated off opioids. The services of an addictionologist are often useful as you help the patient titrate off nonessential medicine.
While, methadone maintenance is often used to reduce or eliminate prescribed opioids, followed by self-monitored abstinence, buprenorphine replacement therapy is gaining hold in helping addicted patients (Ruetsch 2014). Studies suggest “that the commonly used 6-month (minimum) maintenance period for treating opioid abuse may be compressed to 2 weeks of buprenorphine stabilization.”
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