Life Care Planning for People with Chronic Pain
Significant pain can be experienced as a syndrome refers to pain that lasts more major comorbidities, especially psychological (McMahon & Koltzenburg, 2006). Multidisciplinary therapy is often required.
The most common pain complaint is associated with low back pain, an affliction experienced by 80% of the population sometime during their lifetime (Cailliet & Helberg, 1981; Moreo, 2003). Objective definitions of pain have eluded researchers (Weed, 1987). No pain literature available to these writers has been able to satisfactorily define pain objectively. Pain appears to be a subjective experience measured by self-report (Merskey, 1964, 1972; Sternbach, 1968, 1974; Engel et al., 1970; Melzack, 1973; Skinner, 1974; Fordyce, 1976; Shealy, 1976; Bresler, 1979; IASP, 1979; Ramsey, 1979).
Research indicates that the pain threshold is similar from person to person and culture to culture, but pain tolerance can vary dramatically (Shealy, 1976). Sternbach (1968) has simply stated that “pain is a hurt we feel” (p. l). It is defined by the International Association for the Study of Pain (IASP) as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
Monitoring the severity and duration of pain improves patient care. It is widely accepted that pain is a complex experience involving sensory, emotional, psychological, and sociologic factors. The subjective nature of pain explains the difficulty with measurement. The same standards should not be used to measure pain in all circumstances. Alanmanour (2006) described an algorithmic approach to pain assessment varying from the basic interventional formal structured inventories. Pain tools are either unidimensional or multidimensional. The latter take into consideration the motivation and affective dimensions of pain and are typically used when there is (1) persistent acute pain, (2) mixed acute and chronic pain elements, (3) significant psychosocial dysfunction, (4) initial chronic pain evaluations, and (5) disability evaluation addressing the role of sickness impact.
A brief listing of unidimensional and multidimensional pain measurement tools would include (Ramamurthy, Alanmanou, & Rogers, 2006):
Unidimensional: Verbal Descriptor Scale, Visual Analogue Scale, Numerical Rating Scale and Pain Relief Scale
Multidimensional: McGill Pain Questionnaire, Brief Pain Inventory, Dartmouth Pain Questionnaire, the Minnesota Multiphasic Personality Inventory, West-Haven—Yale Multidimensional Pain Inventory and the Quebec Back Pain Disability Scale
The psychological and emotional impact of chronic pain varies among individuals. The impact may be severe, resulting in depression/sense of hopelessness and disruption of family and social roles.
For purposes of this post, chronic pain can be described as daily pain that has lasted anywhere from 6 months to 1 year after the original pain incident. Although there is controversy regarding definitions, most physicians agree that acute pain is from the date of onset to 1 month, subacute pain is defined as daily pain lasting from 1 to 6 months, and chronic pain can thereafter be defined as lasting 6 months or longer (National Institute of Disability and Rehabilitation, 1993).
Chronic pain and the subsequent costs to society, however, do not necessarily include all individuals who have had pain of some type or another for longer than a year. In general, the diagnosis of chronic pain becomes broader as it includes the psychological stress and disruption to the everyday quality of life of individuals who suffer from it. There are an estimated 30 to 40 million adults (representing 15% to 20% of the population) in this country who suffer from chronic pain (Brownlee & Schaf, 1997; Moreo, 2003). Each year millions of people seek relief at hospitals or pain clinics. The overall cost in lost workdays, medical treatment, and additional psychological counseling can be enormous. If directly related to back pain, the cost is estimated at $25 billion
(Moreo, 2003). Counting back pain, migraine and headache pain, osteoarthritis, rheumatoid arthritis, fibromyalgia, failed surgical fusion lumbar or cervical spine, reflex sympathetic dystrophy, causalgia, diabetic neuropathy, and cancer pain, estimates exceed over $40 billion annually. Of the workforce, complaints of pain and related complications of pain result in one-quarter of all the sick days taken, or to put it another way, over 50 million lost workdays per year are due to pain (Beecher, 1959; Davis, 1975; Brownlee & Schaf, 1997).
The history of pain management actually probably dates back to the first known practicing doctors. It has been said that 80% of patient problems prompting a visit to a physician are the direct result of some form of pain—acute, subacute, or chronic. However, most recently, with the advent of chronic pain management programs, more comprehensive multidisciplinary team management for chronic pain and the associated disability/psychological stress/depression and subsequent functional loss have sprung up. Now there are pain management centers in nearly every major metropolitan area in the United States. Pain management has become a subspecialty recognized by the American Medical Association, and numerous societies offer continuing medical education, seminars, legislative lobbying assistance, and national boards of directors to oversee the problems associated with the disease state now classified as chronic pain. Beginning in 1911, workers’ compensation laws were enacted to require employers to assume the cost of occupational disability without regard to fault (Weed & Field, 2001). These laws have dramatically altered the recovery of the individual injured in the workforce since that time. However, additional aspects involving litigation have become more prevalent in the last 20 to 30 years. Because of litigation, an adversarial role between the workplace and the injured worker often develops.
Also of interest are the recent efforts to reduce health care costs by any and all means. Thus, again, injured workers suffering chronic pain ailments are often given little, if any, direct assistance, and anecdotally it appears that legal assistance through litigation has become necessary to allow the patient to pursue more comprehensive treatment of his or her chronic pain condition. It can be said that if a patient truly has significant chronic pain, it will disrupt every aspect of his or her life. This includes vocational as well as avocational pursuits, sleep, and routine daily activities such as dressing, bathing, hygiene, and self-care. Exercise, relationships, sexual relationships, and financial stresses will all ensue. In this way, a comprehensive approach to the treatment of the chronic pain patient embodies all the aforementioned areas, as it focuses attention on restoring the patient to a level of independence to the extent that it is possible. The long-range goal is to achieve a degree of independence of the patient from the health provider. Recent studies seem to indicate that those individuals suffering from chronic pain that are not seeing physicians or receiving constant medical attention may do better.
Diagnostic Efforts in Workup
The first thing necessary for any patient suffering from pain of 6 months’ duration or longer is to review what medical and psychological attention he or she has been receiving. This includes review of diagnostic evaluations, medical and psychological consultations, laboratory, radiological, and surgical intervention. It is important to ensure that indeed the patient’s diagnosis is one of a chronic painful disease rather than an untreated acute pain. In the latter, it is prudent to determine if all acceptable treatment options have been offered or failed before considering the palliative symptomatic management of a chronic painful illness. This is important because the pain pathways and pathophysiolology of chronic pain is very different from acute pain, thus the acute pain signal could be alerting the patient that a serious consequence of tissue injury is imminent.
An example would be the dilemma of the acute pain syndrome known as recurrent acute angina with the propensity for a myocardial infarction requiring extensive cardiac evaluation with each episode of crushing chest pain, versus the chronic pain syndrome known as chronic intractable angina, which although has similar symptoms is typically treated palliatively. The scope of diagnostic evaluations of the patient with chronic pain is quite numerous. There are numerous pain management diagnostic and therapeutic algorithms as well as clinical practice guidelines available to the pain provider. The authors of this post often refer to several resources— Decision Making in Pain Management, the International Spine Injection Society: Guidelines for Diagnostic & Therapeutic Spine Injections, and Interventional Techniques in the Management of Chronic Spinal Pain: Evidenced Based Practice Guidelines. Typically, diagnostic strategies will depend upon the painful area to be evaluated but usually include detailed medical history (including medical record review of all previous evaluations of chronic painful disease and detailed medication history), detailed psychiatric/psychological history, comprehensive physical examination (including signs of nerve injury), laboratory review, radiological review (including magnetic resonance imaging, or MRI, of the affected area, (Note: MRI is not appropriate in all patients, e.g., those with pacemakers and/or ferromagnetic foreign bodies); computed tomography, or CT, scanning; plain-film x-rays; and/or myelograms), electromyographic muscle examinations, and nerve conduction velocity. Radiologic imaging can be overused and costly. The following diagram is an adaptation from Ramamurthy and Alvarado (2006) that simply outlines the use of radiographs in a cost-effective algorithm.
Often more invasive procedures will be necessary to support or refute a chronic painful diagnosis such as laparoscopic surgical evaluation, or diagnostic spine injections (discography, facet joint injections, nerve root injections) in the diagnosis of axial and radicular skeletal-related cervical, thoracic, or lumbar spine pain.
Occasionally multiple specialty consultations are required to achieve such thorough evaluations in our present era of medical specialties. Inclusive of this would be a psychologist for determination via psychological testing, such as with the Minnesota Multiphasic Personality Inventory or other assistive testing, to determine a patient’s psychological status as it pertains to his or her pain
complaints. Benefits of having several specialists evaluate the patient will be that significant overlap of observations, including questionable symptom magnification with litigious patients with secondary gain in mind, will be noted from a variety of clinicians’ vantage points. Despite being a suspicious point of view to include in an evaluation of the patient with pain, it is nonetheless necessary, as certainly questions will arise later regarding the authenticity of the patient’s symptoms. Occasionally it will be difficult to show from the objective testing standpoint that pain has an organic cause that is immediately observable with the aforementioned testing (Beecher, 1959). In these instances, chronic pain management specialists can add a further backdrop from which to define and further assess the patient’s pain complaints.
There are a number of sensory feedback loops to the central nervous system, including the sympathetic nervous system, bones, joints, ligaments, muscles, and, ultimately, the dermatomes of the peripheral nervous system. Despite the insurance company’s desire to be shown where the pain is coming from, many times pain resulting from trauma does not reveal the presence of a herniated disk, fracture, or ruptured ligaments. In these instances, additional documentation or proof as to the nature of the patient’s pain complaints will be required. Ramamurthy and Alvarado (2006) provided a very basic, easy-to-follow algorithm for the evaluation of the chronic pain patient. The insert is an adaptation of his algorithm.
Approaches to Management of Pain
Once complete reviews of all of the aforementioned diagnostic evaluations are performed, a complete list of differential pain diagnoses can be formulated. Although it would be more simple if all of the pain complaints were generated from a chronic painful illness of the same structure (e.g., a single herniated spine disc), it is more common that multiple different pain generators contribute to a single chronic pain complaint. For example, axial back pain can exist on one side of the patient’s low back and the patient may fixate on his or her knowledge that he or she indeed has a herniated disc at that level—but more likely the pain is the result of a combination such as facet joint spine arthritis, with myofascial disease and possibly sacroiliac joint disease. Additionally, the pain generators may be of different pathophysiology. Using the example of chronic foot pain patients, they indeed may have neuropathic pain from nerve injury resulting from chronic diabetic ischemic foot injury—but also may have coexisting nociceptive (tissue injury) pain from arthritis of the foot bones. Identifying the type of pain pathophysiology (nerve injury pain vs. tissue injury pain) will direct the most appropriate types of pain management interventions for treatment. It is often difficult to differentiate which symptoms and signs are from which types of pain etiologies.
This has led to increased referrals to pain management clinics. An anesthesiologist or physiatrist (and occasionally a neurologist or psychiatrist) with special postresidency training in pain management (pain algologist) typically manages these clinics. The pain management clinic is typically comprehensive in its evaluation and treatment of pain and often utilizes interdisciplinary specialists either by referral or directly within its clinic such as psychiatrists, psychologists, physical therapists, and social workers. The majority of these clinics function in an outpatient setting or in the confines of a local hospital. The algologist has been trained to perform diagnostic injections of local anesthetic agents into different tissue regions, thereby blocking the local neuroanatomy and allowing for the cessation of the pain symptom complex. If performed properly (with minute volumes of local anesthetic and into the correct tissue planes), the patient will have a potential pain generator numbed— and if the pain is relieved, that will indirectly alert the provider that this anesthetized structure contributes to the patient’s pain. Of note, there typically is a large placebo effect when performing injections of any type and therefore the provider often will perform two separate diagnostic injection trials with different local anesthetic duration of actions in order to be certain there is a true cause and effect relationship. Depending upon the nature of the pain, its etiology, and its potential for catastrophic bodily injury (e.g., impending spinal cord injury), the patient may require surgical intervention bypassing more conservative treatment options. The most common surgeons involved in spine ailments, including cervical and lumbar spine pain, are the neurosurgeon and the orthopedic surgeon. Specialists in these areas in most major metropolitan regions are familiar with causes and treatment of pain and will offer surgical remedies for their relief. In addition, in this setting in select patients, the pain management clinic algologist or the surgeon also offer minimally invasive spine interventions. Examples include percutaneous discectomy (the Dekompressor procedure), which is a needle aspiration of a spinal disc to decrease a symptomatic disc herniation.
Another resource for the initial treatment for chronic pain would be the less aggressive, more conservative outpatient rehabilitation or physiatrist office. In this setting, the comprehensive nature of the pain is addressed from a number of areas, including medications, sleep restoration, diet and exercise, orthotics, physical therapy, behavioral modifications (back school), electrical stimulation devices, and other neurological diagnostic workups. The decision as to which resource to employ is often selected by the patient.
The majority of patients in the authors’ outpatient pain clinic has been injured for over a year and has already been evaluated by either a neurosurgeon or orthopedic surgeon. These patients typically have been referred to an algologist by a primary care physician or surgeon because of extensive comorbidity (e.g., significant psychiatric disease, substance abuse, or end-of-life issues) or have been unmanageable despite standard of care conservative therapy. Many of them have already undergone surgical intervention and that the algologist will evaluate and employ an interdisciplinary treatment plan. Before describing each of the specific aspects of interdisciplinary therapy, it is important to note that goal setting is the important initial step in the development of the treatment plan. Goal setting is bidirectional, meaning that both the pain provider and the patient-family unit participate in defining the goals of the interdisciplinary pain plan. These goals are very patient specific and can vary greatly from patient to patient. For example, a patient who was highly functional prior to an injury and has full brain function and mobility but cannot use his or her dominant upper extremity secondary to pain may establish goals of using that upper extremity in the future to return to work (e.g., typing, lifting, etc.) or perform activities of daily living that utilize the dominant upper extremity (e.g., dressing, brushing teeth, writing). On the other hand, a patient who has had a significant cervical spinal cord injury with tetraplegia (also known as quadriplegia) and severe spasm and pain of the lower extremities may have just the goal of enough relief of pain and spasm to accept the appropriate lower extremity positioning for urinary bladder catheterizations several times per day. Simply stated, the first case represents a highly physically functioning patient’s rehabilitation requests and goals versus the second case of little to no physical functioning rehabilitation goals. The issue of goal setting is not just for patient and provider satisfaction but also for cost-effectiveness. If the goals are not set or are unrealistic, excessive, unfounded treatments or unnecessary repeated diagnostics (e.g., MRI studies) may be provided that escalate costs and present potential harm to the patient. Goal setting is a dynamic process and must be reevaluated (and often readjusted) after the success or failure of each pain treatment.
The interdisciplinary treatment plan typically includes simultaneous introductions of medication management, interventional therapies, physical therapy, and psychosocial therapies. Medication management must take into consideration that while many medications will relieve pain and suffering for a short period, many of these medications can have inappropriate side effects or consequences when delivered over a lifetime of chronic pain. Therefore, it is of utmost importance that not only the most effective pain reliever be considered but also the most safe analgesic over the expected lifetime of the chronic disease. These authors often explain this issue to patients with the following analogy: “Inhaled anesthetic gasses can certainly relieve your pain for the short time—but would also require a ventilator and a breathing tube and therefore are not an option for your long-term pain strategies. In the same manner, high-dose injectable Ketorolac will certainly assist you with a pain exacerbation in the emergency room but would not be appropriate after more than a few days of your pain exacerbation because of bleeding risks.” The decision to utilize specific types of oral analgesics often follows specific algorithms, such as the Analgesic Ladder, adapted from the World Health Organization Pain Relief Ladder (World Health Organization, 2009).
The intervention strategies include any treatments that are not considered an oral medication, but in the algologist setting they typically refer to minimally invasive injections of nerve, muscles, or painful structures of the spine. Therapeutic injections are categorized into those that modulate
painful tissues and those that neurolyse. Modulation of pain via therapeutic injections includes injecting local anesthetics and long-acting steroids into spine structures (e.g., epidural space, facet joints, sacroiliac joints, and spinal nerves), and injecting narcotics and other types of analgesics into various tissue planes (e.g., spinal fluids, brachial plexus, epidural space). Additionally, modulating therapeutic types of injections include all types of electrical stimulation therapies for pain including implantable spinal cord stimulators, which are electrical wires implanted into the spine to control pain. Because neurolytic injections are often irreversible, they are provided after much consideration of the risk—benefit ratio. Examples of neurolytic injections include killing with heat (radiofrequency ablation of nerves or tissues), killing with cold (cryotherapy), or killing with chemicals (alcohol, phenol, glycerol, Sarapin tissue injections). A newer minimally invasive spine procedure provided by algologists and surgeons, includes vertebral augmentation for bony spine fractures. In this technique algologists place cement or cement-like substances into the spine fracture via a needle and typically render a severe chronic pain cured with immediate resolution of pain. There are a myriad of additional interventional procedures that can assist with the therapy of chronic pain. One additional class of therapies is the implantable devices for pain. As introduced previously, these devices comprise two groups: implantable drug delivery systems (IDDS) and implantable electronic neuromodulation systems (IENS). The IDDS is a small catheter that is implanted into the spinal fluid and tunneled to the abdominal wall to a pump reservoir. This pump has a computerized motor that delivers minute amounts of opioids, local anesthetics, and
other analgesics to the spinal fluid to control pain and limit side effects. It is typically considered in a very select group of patients who have failed all conservative therapies and have a life expectancy greater than 6 months. It is costly and additionally has the risk of infection of the spine, granuloma of the spine, or pump malfunction as well so it is placed only in a very select population of patients. It is totally implantable and requires, about every 3 months, a refill through a needle puncture through the skin. The IENS is also totally implantable and is a small wire that is placed
into the epidural space and is connected to a microcomputer that is indwelling in the abdominal wall or the scapula. The patient can manipulate the amount of electricity through a remote device through the skin. Again this is a costly therapy that has its own associated risks and should only be considered after failing more conservative therapy and after several days of a trial period.
Physical therapy interventions are often felt to be the strength of any good comprehensive pain management plan. In the authors’ practice the patients are expected to continue physical therapy (aquatic based or land based) as a lifestyle to remain an active patient in the pain clinic. While this is labor intensive to monitor for compliance, it has been demonstrated that those patients who remain compliant with physical therapy continue to maintain or restore physical function and have less additive pain syndromes related to the cycle of immobility associated pain. Physical therapists may also employ other low-risk strategies such as transcutaneous electrical nerve stimulation (TENS units, which are devices that use electrical skin surface patches to remove pain), ultrasound therapy, cold, moist heat, traction, and paraffin wax therapy.
If an individual has already undergone several surgeries and a number of injections, then a physician may be reluctant to send him or her back for more invasive procedures. It is important that each patient undergo a thorough evaluation of his or her present condition to determine the etiology of the pain. If a patient’s pain has not been evaluated for 2 or more years, despite a thorough documentation of the presence of a nonoperative lesion from the past, then it is quite possible that further evaluation and diagnostic x-ray information of perhaps a new pain problem may be necessary. There are many pain management algorithms and guidelines in existence that can assist pain providers with implementing therapies in an appropriate manner. The following diagram is an adaptation from King (2006) and is an example of a cost-effective algorithmic approach to the management of low back pain.
Life Care Planning and Chronic Pain
Individual types of pain are especially variable and are almost beyond the scope of this short post. A listing of types of injuries that can result in chronic pain requiring lifetime medical care would include the following:
■ Spinal cord injury: cervical, thoracic, lumbar with paraplegia, or tetraplegia (also known as quadriplegia)
■ Cervical, thoracic, lumbar, or sacral spine bony traumatic injury (e.g., fractures, dislocations)
■ Cervical, thoracic, lumbar, or sacral spine arthritis and degenerative disease states (e.g., degenerative disc disease, facet joint disease, spondylosis, disc herniations)
■ Deafferentation pain syndromes (loss of sensation secondary to nerve injury with increased pain traffic: e.g., postherpetic neuralgia, phantom syndromes, post thoracotomy syndrome, diabetic neuropathies, HIV neuropathy, alcohol neuropathy, multiple sclerosis, central pain)
■ Central nervous system and spinal cord infarctions (post stroke pain)
■ Neuropathy (peripheral neuropathies, plexus neuropathies, cranial nerve neuropathies)
■ Complex regional pain syndromes type 1 (reflex sympathetic dystrophy)
■ Chronic regional pain syndrome type 2 (causalgia)
■ Multiple orthopedic fractures and subsequent claudication injuries
■ Cancer of any organ or any tissue type
■ Traumatic brain injury
■ Abdominal problems (e.g., inflammatory bowel disease, Crohn’s disease, chronic pancreatitis)
■ Genital/urinary problems (e.g., interstitial cystitis)
■ Pulmonary problems
■ Rheumatoid arthritis
■ Systemic lupus erythematosus
■ Trigeminal neuralgia
■ Motor vehicle accidents
■ Failed spinal surgeries
■ Orthopedic joint replacement surgery, including hip and knee surgeries
■ Vascular injuries, including angina
■ Peripheral vascular injuries
■ Peripheral vascular ischemia with crush injuries
■ Headaches, including migraine, cluster, and tension headaches
■ Pelvic inflammatory disease
■ Environmental toxins and exposure
The medical needs and future care for these conditions run the gamut and require a coordinated effort of services that are individually determined. Some of the considerations include the following.
In the comprehensive management of chronic pain, psychological testing and treatment for depression, anxiety, and stress are all components required for maximum improvement. All chronic pain patients should have psychological counseling and psychological testing somewhere in the course of their pain diagnosis or management. The family will also require assistance in coping with the patient’s pain problems, as it is very disruptive to the normal activities of family life following an injury or illness that causes chronic pain. Depending upon when the life care planner becomes involved in the case, an evaluation by a psychologist is commonly recommended, as well as subsequent further recommendations of biofeedback and stress management on a weekly basis for at least 1 year to improve the patient’s ability to initiate and maintain a program that will benefit him or her for the lifetime of the complaint.
There are numerous additional resources from which the chronic pain patient can draw. Selfhelp groups and certain newsletters are available for individual diseases that the patient can access through the Internet. Local posts, usually located by Internet searches, of the larger disease diagnoses that cause chronic pain may be available. These include rheumatoid arthritis foundation groups, fibromyalgia groups, spinal cord injury and recovery groups, brain injury recovery groups, multiple sclerosis groups, local diabetes foundations, and others.
It should be noted that self-treatment through alcohol or illicit drug use is a common feature of our society, which probably increases with the advent of chronic pain. Recently, additional guidelines have been released by the American Academy of Pain Medicine (www.painmed .org), the World Institute of Pain (www.-iapsar.org/WIP/WIP-base.htm), and the American Academy of Pain Management (www.aapainmanage .org). All entities now recognize the therapeutic use of chronic narcotic analgesia for chronic pain. However, medical societies in local as well as state medical boards are concerned about the use of chronic narcotic analgesia for chronic pain. This view seems to reflect our fears of addiction and the subsequent costs and problems that addiction has caused in our society. As this may be a national resource website for life care planning, it is likely that the reader may find in his or her locality a remaining bias toward the avoidance of use of chronic narcotic analgesia for the treatment of chronic pain. The following two diagrams from Marrero (2006) and Alanmanou (2006) demonstrate algorithmic approaches to concerns of addiction and decisions regarding opioids analgesia implementation.
Multidisciplinary pain programs that employ psychologists, social workers, anesthesiologists, orthopedic surgeons, neurosurgeons, neuropsychologists, physiatrists, and allied health professionals are often quite familiar with the local political flavor of the area and will be one of the better resources in determining what a patient’s needs are in general, as well as giving him an understanding of what the trends throughout the nation are at that time.
Additional Considerations for Chronic Pain Management
As mentioned previously, a multidisciplinary team is the best resource for thorough and comprehensive management of chronic pain. Typically the needs of the patient will require five or six comprehensive measures to maximize the outcome of the patient’s ability to manage his or her own condition after a period of 6 months to a year. Most outpatient treatment of a chronic pain patient will result in a very brief 1- to 2-month period of intense evaluation and management followed by a middle period of 3 to 6 months of continued weekly monitoring or monthly monitoring and establishing of a management program that will fit the patient’s needs. Biofeedback, stress management, counseling, psychological testing, and family counseling will be included. Additional areas for maximizing the patient’s independence will include diet, weight loss, and exercise. Normally, most patients with chronic pain have a hard time functioning in the upright position and the normal gravity environment. For that reason, exercise programs, especially ones employing a pool, are very popular and quite prevalent and seem to best suit the needs of the chronic pain exercise program prescription.
A six-step comprehensive program in the treatment of chronic pain patients has been published in the prior edition of this text and is included below. Note that this program occurs in the rehabilitation setting, since the majority of the patients seen in this setting have already undergone pain clinic and surgical options. A comprehensive, conservative chronic pain management program would consist of the following areas:
■ Exercise: A program including a pool for both strength conditioning and checking the effects of the central nervous system related to exercise with serotonin and norepinephrine release. Additional cardiovascular and pulmonary conditioning for weight-loss assistance is also a key element.
■ Diet: A thorough review is usually achieved with a dietary journal kept by the patient for 2 weeks. After the journal is reviewed, recommendations are made with specific restrictions of foods that are clearly harmful to the patient’s diet. For additional help with diet, reading materials and instructions are added for food selection, and a basic understanding of carbohydrates, fats, and protein is taught. Subsequently, the patient’s weight is taken on a weekly basis for his next several visits and further assistance and encouragement are given.
■ Sleep restoration: Patients cannot handle the daily stress of chronic pain without adequate sleep. Sleep achieves a degree of relaxation and resets the thermostat of the central nervous system. Deep sleep has also been shown to be the period in which growth hormone is released and significant tissue repair and restorative processes take place. Paradoxically, deep sleep is often shortened in the chronic pain patients, and very often the sleep additive medications paradoxically decrease deep sleep as well. The sleep-deprived patient will have more difficulty responding to minute-to-minute changes in his or her day and thereby will be much less adaptable to his or her chronic pain condition than those who are sleeping through the night. Pharmacological agents for this are often needed to restore the patient to a restful night’s sleep. Of note, several studies suggest that psychological strategies (e.g., progressive relaxation) for managing the insomnia of the chronic pain patient are more effective than most prescribed sleep agents. Additional concerns would be for patients who have sleep apnea or other obstructive forms of sleep disturbance, which may require expensive equipment (BiPAP devices) to remedy the insomnia. Sleep centers are usually run and directed by a pulmonologist or neurologist and are available in most metropolitan areas. These physician authors have used these clinics as an assistive consultation in helping the patient return to a more restful night’s sleep.
■ Pharmacological agents: The recitation of all medications that are prescribed and used in current pain management would be beyond the scope of this short post. There are five basic categories:
– Antidepressants for pain relief (e.g., Duloxetine, Amitriptyline, Nortriptyline) and anxiolytics.
– Medications for the resolution of nerve pain, which consist of Pregabulin, Gabapentin, Tegretol, Dilantin, and Depakote.
– Muscle relaxants, consisting of Soma, Skelaxin, Robaxin, Flexeril, Baclofen.
– Nonsteroidal antiinflammatory drugs (NSAIDs) or other non-narcotic analgesics that also assist with the reduction in inflammatory joint changes. These would consist of ibuprofen (Advil, Motrin, and others), Releve, Relafen, Oravail, Tramadol, etc.
– Narcotic analgesia. This would depend on efforts of resolving the pain from all other measures and would follow the World Health Organization ladder to analgesics (previously cited in this post). Examples include Methadone, Oxycodone, Morphine, Fentanyl Patch, Levorphanol, etc.
– Side effects. All of these commonly have side effects that affect patient compliance and comfort. For example, NSAIDs can cause gastrointestinal upset, ulcers, and liver and kidney damage. Opioids often result in physical dependence and cause dizziness, fatigue, concentration impairments, drowsiness, nausea, impaired vision, and constipation. Also, some of the newer medications can reach $100,000 per year in cost.
■ Physical therapy and outpatient modalities: Usually patients who have chronic pain also have a sedentary lifestyle as a consequence of trying to avoid pain. A brief burst of physical therapy for 2 to 4 weeks following the intake of a new patient may prove useful. This is usually aimed at providing the modality that may have already been used in other efforts of physical therapy. The difference with the use of physical therapy at this time is to try other physical therapy prescriptions and also to allow patients the use of transcutaneous electric nerve stimulation (TENS) or percutaneous electrical stimulation (PES) units, or other locally available stimulation units to attempt to decrease their pain. Further sessions of physical therapy throughout the course of the patient’s lifetime may also be necessary depending upon brief or prolonged periods of inactivity, which will result in a loss of strength and function. In general, the nature of the comprehensive, conservative measures implemented for chronic pain management attempts to keep the patient from losing significant degrees of function for prolonged periods of time by instituting an exercise program. Nonetheless, a once-per-year physical therapy evaluation may be necessary to forestall more remedial forms of functional loss.
For back pain and other selected central-nervous-system-generated pain, injections into the spinal canal area can provide relief, but often must be repeated regularly and can cause numerous side effects (e.g., nausea, vomiting, headache, transient weight gain, and infections).
■ Orthotics and other adaptive equipment: These products can usually be procured at the local orthotics or prosthetist or durable medical equipment supplier. There are a number of selfcare adaptive aids, such as long-handled reachers, button hooks, and assistive devices for eating, grooming, and daily household tasks. In addition, under this heading would fall the grouping of spinal orthoses such as cervical pillows or orthopedic braces for sleeping and comfort in sitting, driving, walking, and moving about. From this standpoint, electric mobility devices, power chairs, assistive bathing devices, and personalized aids could all be considered for prescription. Throughout it should be mentioned that the patient’s condition is not presumed to be static. Occasional retesting and obtaining x-rays and, in some cases, other surgical, neurosurgical, or orthopedic surgery interventions may be required.
In addition to the previously listed items, various surgical options may be available for structurally identifiable reasons and well-selected patients. Intrathecal morphine pumps, spinal cord stimulators, and repeat surgery are examples. However, there are high failure rates, and costs are substantial (Moreo, 2003). Spinal fusions can total $18,000 to $25,000. Implanted pumps can cost $15,000 to $32,000 for the surgery, an average of $300 per month for medication and other follow-up charges, and $10,000 to $21,000 for pump replacement. Spinal cord stimulation initially can be expected to reach $15,000 to $20,000 or more, and then another $2500 per year for follow-up.
Determining Patient’s Functioning Level
The patient’s needs, at the time of intake as a chronic pain patient and throughout life, can be ascertained most effectively through an outside source of local physical therapy where functional capacity evaluations are performed. A functional capacity evaluation (FCE) (also referred to as a physical capacity assessment) is usually an 8-hour assessment that is typically performed over a 2-day period. During this assessment the patient’s autonomic functions are evaluated, including heart rate, respiratory rate, and skin temperature. Other measurements, such as a visual analog scale of pain, may also be performed.
The majority of the testing includes performance of a variety of tasks that are observed and are also repeated in a number of different fashions to ascertain the patient’s reliability from one task to the next. Typically, insurance companies and other health care providers will request these, as will the workplace at the time of a patient’s disability. They are useful for disability determination, but are typically not adequate for disability rating. Disability ratings come under a different evaluation. Many times the consultants who have been working with the patient throughout the months are not capable or are not interested in performing disability evaluations. Determining individuals who are willing and capable to perform these assessments can be the source of difficulty in bringing the patient’s legal problems to a close. The reader should be aware that the validity of FCE results has been challenged, particularly in litigation settings, and the value of the results may be only as good as the equipment used and the evaluator’s expertise (King et al., 1998).
Life Care Planning and Chronic Pain and Future Concerns
In making preparations in the life care plan for the needs of a patient with chronic pain, it becomes necessary to take into consideration all of the measures listed previously. To this end, identifying someone who will follow the patient and participate in a comprehensive chronic pain management multidisciplinary team approach is preferred. If, however, that is not possible, then the needs from a chronic pain future life care plan would include all of the steps mentioned in the evaluation and treatment of a chronic pain patient at the initial intake. It should be noted that from a chronic pain standpoint, efforts are directed at making the individual with chronic pain self-reliant and avoiding constant medical intervention. Although this is the desired outcome, it is very timeconsuming to achieve this goal, and as with any long-term disease problem, it becomes necessary for routine reevaluations and upgrades in the individual program. Cost estimates for chronic pain include medication and equipment repair and replacement, and 1- to 2-year reevaluations with x-rays, blood work, and consultations of the individual specialists will be necessary. It may also be necessary to include physical therapy and psychological counseling reevaluations. As the patient with chronic pain ages, additional evaluations and treatments with upgrades in equipment and possible surgical interventions may also be required. It once again becomes necessary to include in
an exhaustive fashion a comprehensive listing of the patient’s problems and some future prognosis as to the deterioration of these diagnostic considerations.
Chronic pain has the ability as a diagnostic entity to cause as much disruption in patient care as do the functional, psychological, and social losses involved in the original injury. It should be noted that as a specialty, chronic pain is developing and should be available in its broadest sense from the multidisciplinary approach nearly everywhere in the United States. A carefully arranged initial intake with subsequent development of the six categories outlined should place the life care planner in the position to expertly assess and recommend the appropriate level of care for patients with chronic pain. However, as with all diseases, individuals with chronic pain will suffer variable outcomes based upon their individual application of the programs outlined for them. The responsibility of the patient in chronic pain is not unlike that of a diabetic, who, although having undergone a comprehensive study and treatment program, nonetheless is left on a daily basis to provide the right type of treatment for his or her own condition.
It is incumbent upon the patient to adopt new lifestyle measures, restrict activities, and habituate certain aspects such as biofeedback and relaxation, and not just do the easy thing, which is to take a pill or apply a TENS unit. Patient compliance in this regard is key, and assistance through psychological counseling and frequent monitoring is often the best hope for achieving some degree of success in modifying a patient’s former lifestyle to include measures necessary for a chronic pain management program. The goal of chronic pain planning, therefore, is not to reduce the pain to the level it was before the injury, but to modify the pain such that the patient can enjoy an enhanced quality of life and maintain a reasonable degree of function. It is also pertinent to note that a comprehensive treatment plan that uses all six outlined areas will offer the best chance of success, rather than a patient selectively using two or three modalities. The goal is to reduce the patient’s perceived level of pain to where certain activities that were prohibitive or restrictive are now possible. Clearly this does not necessarily mean that the patient will be able to perform all activities. It is along these lines that the compromise between where the patient was and where the patient is now needs to be identified. In this context, the patient can be encouraged to achieve some degree of compromise with the condition of chronic pain and a future activity level that is beyond where he or she has been functioning. In light of these issues, the life care plan can be a valuable adjunct to assist the chronic pain patient.
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