|From left, Carol Linnell, MSW, LCSW, applies connections from a portable biofeedback unit to client Alexander Slanger, as David N. Alexander, MD, and Alexis Kulick, PhD, of the Centinela Freeman Regional Medical Center’s pain management team observe.
Current thinking about chronic pain arising from osteoarthritis, herniated discs, tendon tears, and numerous other musculoskeletal conditions holds that treatment works best when delivered using a multidisciplinary approach.
“No single specialty has all the answers for chronic pain patients,” says Alexis D. Kulick, PhD, clinical psychologist and pain management specialist at Centinela Freeman Regional Medical Center in Los Angeles. “The multidisciplinary approach is one that brings together physicians, physical therapists, occupational therapists, psychologists, exercise therapists, biofeedback specialists, recreation therapists, case managers, and others. For chronic pain patients, the problem involves not only the organic injury, but also the pain response to that injury as well as various aggravating factors, such as emotional state, lifestyle, comorbidities, and medication dependency. As a result, each type of specialist possesses only a piece of the puzzle and can address only parts of the problem. Put them all together and you have the complete picture.”
Patients in pain are patients for whom movement is difficult and, often, guarded. That is why many chronic pain programs now routinely include whole-body movement therapies and deep-breathing/stretching exercises to help patients conquer their fear of movement. The emphasis is on physical reconditioning with the use of exercise sessions that focus on strength, flexibility, and endurance. Useful too in this regard is aquatic therapy. “The value of aquatic therapy for pain patients is the buoyancy—in the water, bodily motions have less impact on the injured areas, so the patient can accomplish more in terms of exercise than might be possible on dry land,” Kulick says. “Also, if the pool is adequately heated—92 degrees being the ideal temperature—muscles and joints become more flexible, further increasing the ability of the patient to exercise.”
Once patients have regained flexibility, it is appropriate to begin strengthening their muscles. “We start by putting the patient through some basic movements and exercise, keeping an eye on that person for indications of what they can do aerobically,” says Steven Stanos, DO, medical director of the Chronic Pain Care Center at the Rehabilitation Institute of Chicago. “From there, the patient might spend some time on a treadmill. We slowly increase the amount, intensity, and duration of exercise. The trick here is to make sure we don’t titrate up too quickly because then the pain may increase—and if the patient experiences increased pain, the guarding impulse takes over again and then the patient will be fearful of that movement or activity or won’t want to engage in it.”
Accessibility to pool facilities can create obstacles, however, not only for individuals who seek aquatic therapy but also for clinics that want to offer pool-based programs.
|Psychologist and pain management specialist Alexis Kulick, PhD, left, explains the benefits of biofeedback to Alexander Slanger.
Health clubs, community centers, and hotels are among the off-site resources that can provide swimming pool facilities to therapy clinics that want to offer aquatic therapy but lack their own facilities. Though a number of hotels already have policies in place that allow them to provide pool use for aquatic therapy programs, issues with pool overcrowding and fluctuating water temperature underscore how a clinic’s lack of control over a facility can suffer under such arrangements. Special seating, lifts, or hand rails also may not be available at pool facilities originally designed for vacationers, which are generally more shallow than pools designed for therapy.
Aquatic therapy programs are enjoying a resurgence despite the challenge some clinics face to provide such programs. As the population of older adults expands in the next several years, the demand for pool-based exercise programs that can minimize age-related pain symptoms is also likely to climb.
STILL COOL, STILL HOT: WHY THE CLASSICS NEVER DIE
Hot and cold therapy have enjoyed a relationship with the healing arts for centuries, and their simple, effective principles of vasodilation and vasoconstriction offer a low-tech pain management solution not only for chronic conditions such as arthritis but for sports injuries as well.
Since cold packs and heat packs are staples of the modality, treatment can be carried over to the home without great expense or technical expertise required by the patient. It is not unusual for both modalities to be used in one rehab session. For athletes, hot therapy can be used to loosen muscles or injured areas early in the day, and since repeated usage of an injured area throughout the day can generate discomfort, switching back to ice or a cold pack later on to reduce pain and swelling is appropriate.
Heat and cold modalities used together form the foundation of contrast baths, which work by using vasoconstriction caused by cold, and vasodilation caused by heat. The result is a “pumping action” that helps remove waste products and excess fluid from the injured area and decreases swelling. Though hot/cold modalities are widely practiced, both demand a watchful eye: overexposure to heat can cause a patient’s skin to burn, while applying cold therapy for too long can raise a patient’s risk of ischemia.
Hot and cold modalities can help manage postoperative pain even among individuals who have undergone spinal fusion as a surgical intervention to treat chronic back pain. Some orthopedic surgeons, however, say the effects of such passive modalities are only temporary, and that substantive benefits through physical rehabilitation can be realized only through exercise-related programs, core strengthening, and stretching.
Transcutaneous electrical nerve stimulation (TENS)—which delivers electrical impulses to nerve fibers—relieves pain by blocking pain signals to the brain and by stimulating the production of endorphins. Usually, TENS electrodes are placed around the pain area or on acupressure points and can be applied at the sensory, motor, subsensory, or noxious level (different stimulation methods result from altering the TENS unit’s pulse rate/frequency, pulse width/duration, and intensity/amplitude). The effects of TENS are cumulative and safe; side effects such as nausea and drowsiness are virtually unknown.1
Another modality that has been found advantageous against chronic pain is low-level laser therapy (LLLT). By targeting affected parts of the body with LLLT, tissues at the cellular level begin secreting increased levels of adenosine triphosphate. This results in an energy gain that promotes higher rates of cell metabolization, which, in turn, accelerates the natural process of bodily repair. Laser therapy has been found effective for treatment of chronic arthritis, tendonitis, carpal tunnel syndrome, fibromyalgia, and others; many patients who undergo LLLT report less chronic pain and, by extension, less reliance on medication.2
WHERE TECHNOLOGY AND INSURANCE MEET
Whether a treatment is considered “medically necessary” by a patient’s insurance company can impact the therapy options available to a chronic pain sufferer. As new technologies become available for clinical use, insurance companies watch and wait to gauge their efficacy before including them for coverage.
Modalities such as ultrasound and iontophoresis used in the clinical setting have received mixed responses from insurance firms over the coverage that will be provided for their use. Patients who benefit from using the modalities to treat chronic pain sometimes discover their insurance policies will allow only a limited number of therapy sessions, though the pain they experience will be ongoing.
Ultrasound, a heating modality, uses penetrating, deep heat to treat areas that cause pain from conditions such as built-up scar tissue or hardened fluid. Some therapists find the modality useful in combination with soft tissue massage, which can work together to break down scar tissue. Muscle tissue does not absorb ultrasound as well as areas that have high collagen density, according to some therapists, which makes the modality particularly effective for tendon injury or ligament sprain.
Because it is a heating modality, ultrasound may be considered a duplicative treatment by some insurers. In other cases, however, where ultrasound is used with another superficial heat modality within the same therapy session, ultrasound may be considered “medically necessary,” and meet coverage requirements.
Iontophoresis also gets a watchful eye from some insurers. Considered “investigational” by some insurance companies, iontophoresis provides diffuse drug administration without multiple hypodermic punctures or tunneling to increase injection area. Some physicians consider iontophoresis ideal for drug deposition around inflamed tendons and diffusion into joints, and it does not present the potentially damaging side effects of injected anti-inflammatory medications. The modality, however, does not always meet the efficacy criteria of insurers and therefore fails coverage under some policies.
STATE OF MIND
Chronic pain patients are frequently found to be suffering from significant psychologic and social dysfunctions. However, unless these issues are addressed, modalities and exercise may not be as effective as they otherwise might, experts warn.
“Depression is a big factor for chronic pain patients,” Kulick says. “Not infrequently, we come across patients in chronic pain for which there is no easy or clear-cut explanation as to what’s causing the pain, and that usually leads to a diagnosis of depression or of there being a psychosomatic condition at the root of things. However, I caution people against implying that a pain patient’s condition is all in their head or that it is caused solely by a psychological factor. What depression can do is intensify pain that’s already present and that may have an actual physical source. It plays out like this: first, the physical pain interferes with the patient’s ability to work and play—in some circumstances the pain entirely puts an end to those activities. When that happens, the patient may enter into a state of grieving, leading to a depressive reaction. The relationship between pain and depression is a cyclical one. People in pain often develop depression, and the presence of depression increases perceptions of pain.
“In any event, depression needs to be dealt with because it leads to feelings of helplessness and hopelessness,” Kulick adds. “Patients overcome by such feelings seldom can muster the interest or motivation in even trying to get better. If anything, they reinforce themselves in the role of being sick and of having no purpose. That’s incredibly counterproductive.”
Stanos says that PTs, OTs, and other rehabilitation therapists must be prepared to dole out both gentle prodding and tough love as needed to help patients overcome the maladaptive thoughts and behaviors that can hinder progress. “Pain patients routinely come into a pain management program expecting to fail or experience increased pain and dysfunction, since many times previous active treatments have not helped,” he says. “That’s why it’s important to keep the patients encouraged. We do it with words, we do it with a supportive environment, we do it with a collaborative patient-centered approach to therapy.”
Something else for which pain patients need encouragement is pacing—the fine art of not overdoing things, conserving their energy, and knowing when to rest. “There will be times,” Kulick says, “that patients feel pretty good, and it is at those times that they are at greatest risk of overexertion. When that happens, they can crash and burn. If that occurs, they will be out of commission and unable to continue with therapy for several days at least.” Inability to move forward with therapy could mean a delay or, worse, a setback to progress,” she hints.
PRINCIPLES ARE CONSISTENT
Stanos says his institution’s chronic pain program draws on the same basic formula whether the diagnosis is back trouble, severe arthritis, muscle pain syndromes, or neuropathic pain. “The underlying principles of chronic pain management are consistent no matter the source or cause of the problem,” he says. “However, one thing we do here that is a bit different from other programs is we take into account the status of the patient’s entire kinetic chain rather than just pieces of it. Consider an arthritic knee, for example. Usually, the pain source will not be exclusively the joint—there also may be interconnected problems above and below the joints, such as at the hip, ankle, and related gait pattern.”
The Team Approach to
The outpatient chronic pain management program conducted by the Rehabilitation Institute of Chicago offers a mix of individual and group treatment, all of it delivered via an interdisciplinary model. “Interdisciplinary means all the treatment disciplines work together usually under one roof, whereas by contrast multidisciplinary implies that treatment is directed by one person with disciplines in various locations not necessarily collaborating as a team” says Stanos, DO, medical direcot of the Rehabilitation Institute of Chicago’s Chronic Pain Care Center.
Admission to the program is by referral. “Prior to admission, we perform a comprehensive assessment,” says Stanos. “The success we achieve with the program hinges on how well we identify the real impairments up front.” The assessment process includes a 90-minute medical workup by a physiatrist, a pain psychology interview, and a vocational assessment. “Each of us utilizes standardized psychometric testing tools in developing our workups, including psychological screening tools. These include the McGill pain questionnaire and functional tools such as the Pain Disability Index.”
With the assessments completed, the practitioners convene as a team to compare notes—including a discussion of the patient’s motivation for treatment and/or potential obstacles for success—and, together, decide whether the patient is an appropriate candidate for admission to one of the 1-day-per-week, 5-week (modified) or 5-day-per-week, 4-week comprehensive day program. “In some cases, the patient may need only a combination of pharmacologic management, injection therapy or individual physical therapy,” Stanos indicates. The team is usually led by a physician or psychologist. “Once the therapy part of the program gets under way, the team has conferences once a week where we go through each discipline and set or adjust short- and long-term goals for each patient,” he says. “Our belief is that treatment must constantly be adjusted in response to changes or lack of changes noted in the patient. And the key to being able to make those adjustments is ongoing communication. Interdisciplinary programs are perfectly positioned for such sharing of information and ideas.”
At the Rehabilitation Institute of Chicago, up to 10 chronic pain patients at a time are treated with individual and group therapy for 8 hours a day over the course of 4 weeks. On weekends at home, patients are encouraged to put into effect the pain-management techniques they have learned during the preceding 5 days—techniques that include psychologic and cognitive behavioral techniques, physical exercises, and activity pacing. “A crucial objective of any of the formal programs is to encourage patients to change the way they normally do things,” Stanos says. “Injections and other medical interventions are incorporated into the therapy or are completed prior to the start of the patients’ participation in the program. Medications are adjusted during scheduled physician visits focusing on reducing pain, improving mood, and restoring quality sleep.”
At the conclusion of the 4-week program, patients are sent back to their referring physician. All of them will receive follow-up with important team members approximately 1 month after the conclusion of the main program. “We’ve found this is effective to prevent relapse—the worst thing is to discharge a patient from a pain program then have no follow-up or structured maintenance plan,” Stanos says. “When they come in for the follow-up visit, they’re seen again by a team PT, psychologist, physician, and biofeedback therapist for a reevaluation focusing on how well they’ve been able to incorporate at home what they learned in the program. As necessary, modifications in their home program are made. Follow-up occurs again 3, 6, and 12 months post-discharge, but at each of those times, it will be with just their physician.”
The results achieved by the program are noteworthy. “On a 0-to-10 pain scale, we typically see a reduction of two to three points in our patients after completing their program,” Stanos reports. “We also see marked improvements in function, reduced disability, and improved psychosocial functioning. Of the patients who enter our program, most return home feeling better—physically and emotionally. Pain is no longer the intractable burden it once was for them. Our goal is to teach them they can successfully manage the pain.”
The outpatient chronic pain management program conducted by the Rehabilitation Institute of Chicago offers a mix of individual and group treatment, all of it delivered via an interdisciplinary model. “Interdisciplinary means all the treatment disciplines work together usually under one roof, whereas by contrast multidisciplinary implies that treatment is directed by one person with disciplines in various locations not necessarily collaborating as a team,” Stanos says.
Admission to the program is by referral. “Prior to admission, we perform a comprehensive assessment,” Stanos says. “The success we achieve with the program hinges on how well we identify the real impairments up front.” The assessment process includes a 90-minute medical workup by a physiatrist, a pain psychology interview, and a vocational assessment. “Each of us utilizes standardized psychometric testing tools in developing our workups, including psychological screening tools. These include the McGill pain questionnaire and functional tools such as the Pain Disability Index.”
With the assessments completed, the practitioners convene as a team to compare notes—including a discussion of the patient’s motivation for treatment and/or potential obstacles for success—and, together, decide whether the patient is an appropriate candidate for admission to one of the 1-day-per-week, 5-week (modified) or 5-day-per-week, 4-week comprehensive day programs. “In some cases, the patient may need only a combination of pharmacologic management, injection therapy, or individual physical therapy,” Stanos indicates.
The team is usually led by a physician or psychologist. “Once the therapy part of the program gets under way, the team has conferences once a week where we go through each discipline and set or adjust short- and long-term goals for each patient,” he says. “Our belief is that treatment must constantly be adjusted in response to changes or lack of changes noted in the patient. And the key to being able to make those adjustments is ongoing communication. Interdisciplinary programs are perfectly positioned for such sharing of information and ideas.”
Rich Smith is a contributing writer for Rehab Management.
- Bowman S. [removed]Managing pain in weekend warriors[/removed]. Physical Therapy Products. 2006;17(2):34-39.
- Spine Universe. LLLT explained. Available at: www.spineuniverse.com/displayarticle.php/article1748.html. Accessed September 24, 2007.