“The Case for Killing Granny” was the title of a provocative September 2011 Newsweek article.1 Although it focused on end of life issues with cancer, the article brought out the concern—what happens to people as they age and suffer tremendous pain and disability?
Acute and chronic pain is a growing problem in the United States, affecting at least 116 million adults.2 Chronic pain, usually defined as persistent pain lasting more than 3 months, can be difficult to measure in the elderly due to underreporting and cognitive impairment. Nevertheless, it is one of the most common symptoms reported by adults over the age of 65. In fact, consider these statistics:
- studies have reported a prevalence of chronic pain in the elderly ranging from 38% to 50%
- the prevalence clearly increases with each decade of life and rates as high as 60% have been reported in adults aged 75 and over
- in 2008, Medicare spent over $65 billion on pain, and 14% of all Medicare costs are pain-related2,3
The problem with chronic pain in the elderly will grow as the population ages. It is estimated that 20% of Americans will be over the age of 65 by 2030, an increase from 12% in 2000.2
Chronic pain can have a dramatic effect on quality of life for older persons including physical, social, and psychological aspects. One study in adults over the age of 65 found significant differences in “satisfaction with life” between those who had pain and those who did not. The risk of depression increases with chronic pain, as does the risk of problems with sleep and appetite. In addition, severe pain can result in social isolation.2
The ability to function dramatically decreases with chronic pain. Both inpatients and community-dwelling older adults with chronic pain require additional assistance with activities of daily living (ADLs) such as cooking meals and getting dressed. Chronic pain has also been linked with increased falls. The reason for this is not clear, but one theory suggests that chronic pain may cause a person to alter their normal ADLs, causing loss of balance or loss of physical conditioning.4 Performing instrumental activities of daily living (IADLs) may also be an issue, resulting in significant disability.
AN INTERDISCIPLINARY APPROACH
Pain medicine is an expanding field and is now recognized as a discrete specialty by the American Medical Association. The number of peer-reviewed articles and professional associations in this specialty is also growing. Physicians who are board certified in other specialties can also be board certified in pain medicine. From 2000 to 2009, the American Board of Medical Specialties certified 1,874 anesthesiologists, 1,337 physiatrists, and 277 psychiatrists and neurologists in pain medicine.2
Chronic pain, however, results from a complex interaction of biological, psychological, and cultural factors. The need for an interdisciplinary and multimodal approach to chronic pain management is strongly supported. A comprehensive report recently published by the Institute of Medicine, titled “Relieving Pain in America,” explains the need for chronic pain clinicians to consider pharmacological and nonpharmacological options including rehabilitation specialists, mental health professionals, and alternative therapies.2
THE GROWING DEMAND FOR REHABILITATION SPECIALISTS
Rehabilitation specialists, including but not limited to physiatrists, rehabilitation nurses, and physical, occupational, and speech therapists, play a critical role in the multimodal approach to chronic pain management. A meta-analysis of published research studies found that inpatient pain rehabilitation programs that provide both physical medicine and patient education achieved significant reductions in pain intensity and the use of pain medications.2 In older adults, chronic pain can lead to disuse muscular atrophy and limitations in joint range of motion. Therapeutic exercise is often prescribed and can help to slow physical deterioration and improve functional status. Several studies have shown that therapeutic exercise, including resistance training, can also improve depression in older persons with pain.5 Additional therapies available to rehabilitation specialists include thermotherapy, massage, and electrotherapy (such as transcutaneous electrical nerve stimulation or TENS).
The appropriate type of therapy will obviously depend on the clinical condition of the patient, but patient personal preferences also will be a factor. Chronic pain is a highly subjective experience and can be influenced by personal and cultural beliefs. For example, one Swedish study of chronic pain management in the elderly found that participants who lived alone preferred exercise over prescribed medication while participants who lived with someone else preferred heat over prescribed medication.4 The cause, location, and severity of the pain will also determine the best course of interdisciplinary, multimodal therapy. While cancer is a leading cause of pain in older persons, there are many other examples of common problems such as post-stroke shoulder pain and discomfort due to osteoarthritis.
The prevalence of cancer is estimated to increase from approximately 13 million Americans currently to 18 million in 2020, with the highest increase occurring in adults over the age of 65.2 Rehabilitation clinicians should be aware of the growing demand for cancer rehabilitation services that are delivered by experts in this area of medicine. In fact, the American College of Surgeons’ Commission on Cancer accredits more than 1,400 cancer treatment facilities that treat over 70% of newly diagnosed cancer patients and are required to provide access to rehabilitation services, either on-site or through referral in order to be accredited. This mandate, along with an aging population that faces more cancer diagnoses, is an important opportunity for rehabilitation medicine professionals. They are needed to help decrease pain and disability in the entire cancer population, but particularly in geriatrics where many of these survivors already have functional problems and other pain issues.
Pain is a common symptom in patients under current treatment and in cancer survivors—even in those who do not have metastasis. In a recent survey of people treated for cancer, the majority in remission or cancer free, one in five reported experiencing current pain.2 A meta-analysis of 52 studies published in 2007 reported the prevalence of pain to be 64%, 59%, and 33% of patients in advanced stage disease, active treatment, and post-treatment, respectively.2 This means that one out of every three survivors continued to have pain even after treatment was discontinued.
As with all older persons, chronic pain in cancer patients is associated with functional problems and can prevent patients from performing their usual ADLs or IADLs. A recent survey of 244 patients undergoing outpatient cancer treatment found that patients reporting pain, brain metastasis, obesity, bladder concerns, and weakness were much more likely to report three or more functional problems. In addition, while the symptoms (ie, pain, fatigue, nausea) were well documented in the patient’s medical records, the functional problems (ie, lifting, getting out of bed, bending) were very poorly documented.6 These findings are not surprising considering that many recent publications have detailed an unmet need for rehabilitation services in cancer patients, especially in an outpatient setting.
Interdisciplinary rehabilitation interventions may involve many factors, depending on the patient’s diagnosis, treatment, prognosis, functional status, and a host of other considerations. Prescription medications may be used to decrease pain or fatigue. Physical activity and prescribed exercise are a critical intervention for many cancer survivors. Biofeedback, meditation, and other relaxation techniques may also improve function. Biofeedback is a technique that trains people to control certain body functions such as heart rate, blood pressure, muscle tension, and skin temperature. It is not entirely clear why biofeedback (and other mind-body techniques) works to improve pain, but focusing on something other than the pain while at the same time relaxing the muscles and decreasing stress seems to have a positive effect.
Modalities may need to be used with caution or not at all (especially deep heat, which is generally considered a contraindication). Massage over an area with active malignancy is generally avoided as well. Superficial heat and cold as well as TENS are typically deemed to be safe to use. Cryotherapy (cold packs) tend to cause vasoconstriction and help to decrease inflammation. Cold also causes an anesthetic effect, thereby helping to alleviate pain. Cryotherapy should not be used in areas with poor circulation. Superficial heat causes vasodilation and relaxes the muscles. This, too, may improve pain symptoms. Neither hot nor cold packs should be used for more than 20 minutes or so, because burns are associated with both. The mechanism of action of TENS is biphasic pulsed currents. It is not entirely clear why TENS alleviates pain in some people, although there are several theories. One theory is that it provides a distraction to the pain. Another theory is that it works by stimulating the body’s own natural pain-control mechanisms.
It is clear that a better system for recognizing rehabilitation needs, providing integrated services, and developing evidence-based standards is required. Recognizing needs must go beyond the obvious examples of amputation or lymphedema, as functional problems can result from the accrual of multiple less obvious impairments. Integrated services can be provided only when oncologists work directly with highly qualified cancer rehabilitation specialists. On that note, specialized education for both oncology and rehabilitation providers is essential and should include seminars, workshops, and resident rotations. As systems for recognizing needs and providing integrated services are improved, validated research can take place and protocols for evidence-based standards can be developed.7-9
Pain is common in stroke survivors and generally affects the hemiplegic (or paretic) extremities. Hemiplegic shoulder pain is usually associated with upper limb hypertonicity and is one of the most common sources of poststroke pain. An estimated prevalence of 22% to 23% in general stroke survivors and 54% to 55% in stroke patients in rehabilitation settings has been reported. It can significantly affect the rehabilitation in patients recovering from a stroke and is associated with depression, sleep disturbances, and functional problems.10
Rehabilitation specialists play a key role in both the prevention and treatment of hemiplegic shoulder pain. Prevention begins immediately after a stroke and continues throughout recovery. Preventive measures include focusing on range of motion, positioning, and appropriate use of adaptive equipment and assistive devices. Rehabilitation specialists can help train the health care team and other caregivers in proper physical handling and positioning of patients who are recovering from stroke. Treatment options include oral pain medications and focal injections to reduce muscle spasticity. In addition, therapy to improve range of motion and strengthen weakened muscles is recommended. Soft tissue injuries often respond to stretching and strengthening as well as positioning with splints, slings, or other methods. Modalities may include electrical stimulation, TENS, and heat such as hot packs or ultrasound (if sensation is adequate to ensure safe use). Acupuncture may be beneficial for central pain syndromes and occasionally subacromial injections help with shoulder pain. An association between the reduction of pain and change in passive shoulder external rotation has been reported.11
Osteoarthritis is also a common cause of disabling chronic pain in older adults. Rehabilitation services are an integral component of multimodal therapy that uses both pharmacological and nonpharmacological approaches to reduce chronic pain from osteoarthritis. A recent review of studies of older adults with osteoarthritis found strength training provided significant benefits in lower-extremity extensor strength, function, and pain reduction.12 Treatment for osteoarthritis focuses on the management of symptoms, since there is no cure. Patients should be coached not to expect a cure, but to measure success based on reduction of pain as well as improved function and other quality of life components such as sleep, energy levels, and mood.
A comprehensive rehabilitation approach to patients with osteoarthritis focuses on the treatment of pain and disability through medications (oral, topical, and injected), exercise, positioning, weight loss, energy conservation techniques, adaptive equipment (such as canes to unload joints), and superficial heat and cold modalities. TENS or acupuncture may provide some relief; however, studies have shown inconsistent results. In some cases, surgery (eg, total joint replacement) is an option and rehabilitation interventions typically focus on postoperative resumption of ADLs or IADLs, strengthening, range of motion, balance, gait, and other issues to ensure the best possible result.
As the population ages, the need for rehabilitation specialists who are trained in the treatment of geriatric patients will grow. Specialists who focus on specific disease areas such as cancer, poststroke pain, or osteoarthritis will be in demand and can make a significant contribution to the quality of life for older adults.
Julie Silver, MD, is an assistant professor at Harvard Medical School in the Department of Physical Medicine and Rehabilitation. She is the founder of Oncology Rehab Partners (www.OncRehab.com) and creator of STAR Program® Certifications, which enable hospitals and cancer centers to deliver a best practices model of cancer rehabilitation services. Dr Silver encourages rehabilitation patients to be proactive in facilitating their own recoveries, and offers healing strategies in her book You Can Heal Yourself: A Guide to Physical and Emotional Recovery After Injury or Illness.
Kristin Nally is a freelance health writer who lives in Phoenix, Ariz. For more information, contact .
- Evan T. The case for killing granny: rethinking end of life care. Newsweek magazine. September 11, 2011.
- Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Treatment. Available at: www.nap.edu/catalog/13172.html. Accessed November 1, 2011.
- Pergolizzi J, Boger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008;8(4):287-313.
- Dewar A. Assessment and management of chronic pain in the older person living in the community. Aust J Adv Nurs. 2006;24(1):33-38.
- Christo PJ, Li S, Gibson SJ, Fine P, Hameed H. Effective treatments for pain in the older patient. Curr Pain Headache Rep. 2011;15(1):22-34.
- Cheville AL, Beck LA, Petersen TL, Marks RS, Gamble GL. The detection and treatment of cancer-related functional problems in an outpatient setting. Support Care Cancer. 2009;17(1):61-67.
- Cheville AL, Kornblith AB, Basford JR. An examination of the causes for the underutilization of rehabilitation services among people with advanced cancer. Am J Phys Med Rehabil. 2011;90(5 Suppl 1):S27-37.
- Vargo MM. The oncology-rehabilitation interface: better systems needed. J Clin Oncol. 2008;26(16):2610-2611.
- Silver JK. Strategies to overcome cancer survivorship care barriers. PM R.2011;3(6):503-506.
- Kalichman L, Ratmansky M. Underlying pathology and associated factors of hemiplegic shoulder pain. Am J Phys Med Rehabil. 2011;90(9):768-780.
- Koog YH, Jin SS, Yoon K, Min BI. Interventions for hemiplegic shoulder pain: systematic review of randomised controlled trials. Disabil Rehabil. 2010;32(4):282-291.
- Marciniak C. Poststroke hypertonicity: upper limb assessment and treatment. Top Stroke Rehabil. 2011;18(3):179-194.