The impact of pain: Unrelenting chronic pain continues to be one of the greatest challenges faced by healthcare providers. The number of Americans suffering chronic pain has grown from 76.5 million in 20061 to 100 million in 2011.2 Pain impacts all aspects of life, and can leave many individuals feeling out of control of their pain and their lives—restricted in their activities and depressed.3 Chronic pain is also one of the most costly problems in the United States today. In terms of the incurred costs of healthcare due to pain and the indirect costs of pain from lower productivity, the annual cost of chronic pain is estimated to be as high as $635 billion per year. This exceeds the yearly costs for cancer, heart disease, and diabetes combined.4 Interdisciplinary chronic pain management programs that emphasize self-management are cost-effective and help people gain control of their pain and their lives.
A paradigm shift
In the acute and subacute stages, therapists treat mechanical dysfunction and impairments. As pain becomes chronic, changes in the central nervous system result in altered sensory processing, eg, central sensitization. Treatment needs to shift from focusing solely on the periphery (eg, the mechanical dysfunction, tissues, and symptoms) to addressing central nervous system processes. Providing education about pain, and the factors that can increase or reduce it, helps patients actively engage in therapy programs to increase strength and flexibility and reach functional goals.
It may not take a village, but it helps to have a team when treating an individual’s chronic pain symptoms. Medications or therapies alone are often insufficient for successful treatment of chronic pain. Interdisciplinary pain management is widely supported by the evidence as the treatment of choice for people disabled by chronic pain.5,6 A team of specialists—in one location—integrate medical, physical, and cognitive-behavioral approaches to pain management. At Spaulding’s Outpatient Pain and Functional Restoration Program in Medford, Mass, the emphasis is on self-management. Strategies and tools that address the physical, emotional, cognitive, and functional impact of the pain empower clients to take control of their recovery, their lives, and their pain.
We know programs that include pain education demonstrate greater maintenance of gains compared to those that do not.7 A frustrated patient who is affected by chronic pain is often concerned that people think the pain is “all in their head.” Explaining how pain works in the body, through pain physiology education, promotes acceptance and understanding of the role that stress and negative cognitions have on pain. Patients change their attitudes about their pain and their obsession with their pain, and facilitate motivation to actively engage in therapy programs.8 Patients learn that there are many ways to influence the physiologic pain response and adopt new strategies to function in their daily lives.
Passive vs active participation
Modalities: Electromedical modalities have been a staple among therapeutic treatments for pain in a variety of settings for years. Electrical stimulation and ultrasound are two therapeutic modalities some clinicians have turned to as an aid for relieving patients’ pain symptoms. E-stim excites nerve or muscle tissue while ultrasound uses sound waves to generate heat in a particular area of the body. Low level laser therapy is a modality also used by some clinicians for treatment of acute and chronic conditions. This modality uses specific wavelengths of light to interact with tissues for purposes of reducing pain and inflammation.
Passive therapies, such as massage, ultrasound, iontophoresis, etc, may be useful in the short term, but have overall limited benefit in chronic pain conditions.9 For example, if a patient comes in and receives soft tissue techniques, performs exercises, and utilizes a topical modality, they may feel great when leaving the clinic. However, once home, the results will most likely be short-lived, unless they have alternatives to maladaptive movement and behavior patterns.
Unlike other passive modalities, however, TENS is portable, is geared more toward self-management, and can be utilized during daily activities. The evidence for TENS is mixed, possibly due to the variability of TENS settings across studies, type of outcome measures used, and lack of consistent comparisons.10 Clinically, however, many patients report benefit and enjoy being able to use it while working or participating in daily tasks.
Patients are also instructed to use hot/cold packs and ice massage on a regular schedule, rather than waiting until the pain level elevates. Moist heat combined with exercise has been shown to lower pain levels in low back pain.11 Cold packs yield mixed results in the literature; however, to our knowledge, proactive use of thermal modalities in this manner has not been studied. Zemke et al12 report that both ice massage and cold packs are equally effective in decreasing intramuscular temperature. Ice massage, however, decreases intramuscular temperature faster and results in more immediate relief than cold packs.
Exercise: Individualized programs are designed and modified, so all exercise is performed without elevating pain levels. Exercise is increased by a steady amount at regular intervals. This strategy helps to increase tolerance, diffuse fear, and prevent pain protective mechanisms from impeding activity. Patients learn that activity is safe, even on “bad” days. Tai chi incorporates gentle movement, mindfulness, imagery, and breathing. It can improve exercise adherence and balance, reduce mood disturbance, enhance functional outcomes, and decrease pain.13 Adaptive home exercise programs can be videotaped on the patient’s cell phone to promote proper technique outside the clinic.
Cognitive Coping Strategies: Cognitive behavioral therapy (CBT) has a positive impact on pain, mood, and disability.14 Patients are instructed in a variety of coping strategies as outlined in Table 1. They learn how to use relaxation techniques to decrease muscle tension. They develop an understanding of how their thoughts affect their behavior and pain. Learning to pace one’s daily activities can be one of the greatest challenges. Patients practice cooking, working, and leisure activities, integrating pain control tools and taking frequent mini-breaks. On a recent outing to a shopping mall, a group of patients practiced using a timer and sitting for 2 minutes every 15 minutes. They got ice at the food court, used tennis balls against the wall, and practiced stretching and breathing. One patient, who had previously stopped going shopping, was shocked to realize that not only did she have a great time, but her pain was lower by the end of the trip.
Table 1. Self-management Tools and Techniques
|Graded quota base strengthening||Pacing daily activities|
|Daily Stretching||Diversional activities|
|Aerobic Conditioning||Relaxation and mindfulness exercises, daily|
|T’ai Chi +/or Yoga||Paced breathing exercises|
|Self massage (tennis balls or hand held massage/trigger point release tools)||Use of assertive communication to ask for or politely decline help, say “no,” etc.|
|Proactive use of moist heat or cold packs before pain becomes elevated ? 3x/day||Graded exposure to avoided activities in safe and comfortable ways|
|Ice massage directly to the painful site or acupuncture areas||Cognitive restructuring – replacing fearful, negative thoughts with more positive adaptive ones|
|Safe body mechanics for all daily tasks||Planning ahead|
|Ergonomic and environmental modifications/aids when needed||Having a pain management tool kit to bring out into the community|
|Desensitization techniques||Identifying and following a structure|
|TENs||Sleep hygiene strategies|
|Hot and cold packs||Support groups and social interaction|
|Identifying flare-up plan|
|Education regarding the neuroscience of pain|
Cost = effectiveness of comprehensive pain management program
The high direct and indirect cost of treating chronic pain has been the focus of many studies to determine the most cost-effective approach among this patient population. A comprehensive review of the scientific literature demonstrates that interdisciplinary pain management programs offer the most efficacious and cost-effective treatment for persons with chronic pain when compared to widely used conventional medical treatment.15 Despite this undeniable body of evidence supporting the clinical efficacy and cost-effectiveness of an interdisciplinary self-management approach, many insurers continue to be reluctant to reimburse the interdisciplinary pain programs as a means of cost containment.16 The payors view these programs as too costly “up front.”
Pain medication alone continues to be in the forefront of treatments for chronic pain. Medication, in the absence of any additional care, costs up to $21,500 per patient per year, despite the fact that the efficacy of this approach has been shown to be inconsistent.17 In contrast, the median standard care for comprehensive pain management is about $17,000 per patient per year, with well-documented therapeutic efficacy in the scientific literature.18
Our patients are not the only ones who benefit from education. As healthcare providers, we need to continue to educate third-party payors regarding the cost/benefit ratio of comprehensive, interdisciplinary care for our patients who are in pain. Although the price may appear high initially, in terms of functional outcomes and overall costs, it is actually significantly less in the long run compared to conventional care.
The cost of healthcare in the United States is unsustainable and the suffering of our patients who are in pain is great. One of the ways to reduce this astronomical figure is cost containment. Patients often seek out or are sent to numerous providers to try a multitude of treatments that often are ineffective and—at times—unnecessary. Self-management can help reduce overutilization of healthcare. Chronic pain patients learn to look to themselves to control their pain, reduce flare-ups, increase activity level, and reengage meaningfully in their lives.
The self-management approach is evidence-based, efficacious, and cost-effective for treating chronic pain. People learn to control pain rather than being controlled by it. They feel as if they can once again plan their lives with the confidence that when pain occurs, they are equipped with the tools and understanding to deal effectively with it.
Eve Kennedy-Spaien, OTR/L, is an occupational therapist and Certified Pain Management Specialist. She is the Clinical Supervisor of the Pain and Functional Restoration Program at Spaulding Rehabilitation Outpatient Center, Medford, Mass. She has 25 years of experience working in inpatient and outpatient pain management programs. Additionally, she has published articles, and presented at many venues including NIH and AOTA.
Fay Maneii, DPT, is a licensed and board-certified physical therapist. She received her master’s and doctorate degrees in adult orthopedics from MGH Institute of Health Professions, Boston. Currently working at Spaulding Medford Outpatient Center providing care to patients with musculoskeletal issues, she is also a member of a multidisciplinary pain management team providing care to patients with chronic pain. For more information, contact [email protected]
1. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press; 2011.
2. Global Industry Analysts Inc Report. Pain Management, a Global Strategic Business Report. 2011. Available at: http://www.prweb.com/pdfdownload/8052240.pdf. Accessed November 8, 2014.
3. Michaelson, David & Co. Voices of Chronic Pain. American Pain Foundation. 2006. Available at: http://www.davidmichaelsoncompany.com/Documents/Voices%20of%20Chronic%20Pain%20Report.pdf. Accessed November 8, 2014.
4. Gaskin DJ, Richard P. The economic costs of pain in the United States:. J Pain. 2012;13:715-724.
5. Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management past, present, and future. Am Psychol. 2014;69(2):119-30.
6. Scascighini L, Toma V, Dober-Spielmann S, Sprott H. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology. 2008;47:670–678.
7. Carnes D, Homer KE, Miles CL, et al. Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain. Clin J Pain. 2012;28(4):344-54.
8. Nijs J, Van Wilgen CP, Oosterwijck JV, et al. How to explain central sensitization to patients with “unexplained” chronic musculoskeletal pain: Practice guidelines. Manual Therapy. 2011;16(5):413-418.
9. American Chronic Pain Association. The ACPA Resource Guide to Chronic Pain Medication and Treatment. 2014 ed. Available at: http://www.theacpa.org/uploads/ACPA_Resource_Guide_2014_FINAL.pdf. Accessed November 8, 2014.
10. Sluka KA, Bjordal JM, Marchand S, Rakel BA. What makes transcutaneous electrical nerve stimulation work? Making sense of the mixed results in the clinical literature. Phys Ther. 2013;93(10):1397-402.
11. French SD, Cameron M, Walker BF. Superficial heat or cold for chronic low back pain. Cochrane Database of Systematic Reviews. 2011.
12. Zemke JE, Andersen JC, Guion WK, McMillan J, Joyner AB. Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag. J Orthop Sports PhysTher. 1998;27(4):301-7.
13. Peng PW. Tai chi and chronic pain. Reg Anesthes Pain Med. 2012;37:372-382.
14. Eccleston C, Morley SJ, Williams AC. Psychological approaches to chronic pain management: evidence and challenges. Br J Anaesth. 2013;111(1):59-63.
15. Gatchel R, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. (Written for the American Pain Society Task Force on Comprehensive Pain Rehabilitation, Glenview, Ill) J Pain. 2006;7:779-793.
16. Turk DC, Swanson K. Efficacy and cost effectiveness treatment of chronic pain: An analysis and evidence–based synthesis. Chronic Pain Management Guideline for Multidisciplinary Program. 2007: 15-38.
17. Gilron I, Johnson AP. Economics of chronic pain: How can science guide health policy? Can J Anesth. 2010;57:530-538.
18. Noe C, Williams CF. The benefits of interdisciplinary pain management. J Fam Pract. 2012;61(4 Suppl):S12-16.