Uncomplicated spinal pain alone is the most common condition behind workers' compensation claims filed in the United States. The estimated cost ranges from $50 billion to $100 billion annually. This condition is responsible for 40% of absences from work, and is second only to the common cold as the most frequent cause for sick leave. Spinal pain, in particular low-back pain, is the leading cause of work-related disability. Almost 102 million workdays are lost as a result of spine pain in work-related cases, with a wage loss of almost $14 billion.1
Well known to the health care community, and particularly to the managed care industry, acute (non-chronic) musculoskeletal and spinal problems affect 70 to 80% of all American adults at some point in life.
Unfortunately, more the rule than the exception is the health care provider who inadvertently allows acute pain to progress to the chronic stage, which brings its own set of economic complications plus human suffering. Recent studies demonstrate that chronic pain is a destructive disease process that creates pathologic changes in the central nervous system, and that these changes self-perpetuate. Physicians must begin a treatment paradigm shift, understanding chronic pain as a serious medical disease that demands early and aggressive treatment, not as a simple disorder.
Chronicity, coupled with disability, is one of the most expensive health problems in the United States today. It costs about $50 billion annually in direct medical expenses, lost income, lost productivity compensation payments, and legal fees, according to the National Institutes of Health. More than 75 million Americans live with serious pain, and each year another 25 million experience acute pain as a result of injuries or surgeries. Forty-five percent of all Americans seek care for persistent pain at some point in life. Apart from these statistics, the personal consequences of mismanagement of patients suffering from pain are immeasurable.2
Classic Examples of Relatively Successful Multidisciplinary Treatment
a) In the absence of intervertebral disk annular tear, chronic spinal facet syndrome (synovitis) that has proven refractory to both traditional medical and chiropractic treatment is a candidate for multidisciplinary treatment. In such cases, the clinical treatment pathway may very well include concurrent medication management, functional restoration, manual medicine, and facet joint blockade in the Ambulatory Surgery Center setting. A successful intervention (injection) would indicate candidacy for radio frequency neuroablation of the medial branch of the recurrent nerve of von Luschka, thus abolishing pain for a period of up to two years. The absence of pain then allows for successful functional restoration and strengthening of spinal structures, and the reestablishment of optimal neurological engramming (muscle memory). Appropriate patient selection results in an approximate 70 to 75% success rate in cases where no relief was previously forthcoming.
b) Non-surgical intervertebral disk herniation with or without nerve root entrapment is another candidate. The multispecialty approach would include medication management for pain and muscle spasm control, concurrent functional restoration (graded), manual medicine (flexion/distraction), and a fluoroscopically guided transforaminal epidural steroid injection to the site of herniation. Depending on the degree of compression to the nerve root, such an approach decreases the edematous reaction at the disk/nerve root interface and consequently the radiculopathy (if present), allowing for ongoing, graded functional restoration and eventual resolution.
c) Chronic, unstable sacroiliac joint syndrome may prove to be a frustrating clinical entity for most health care providers, including doctors of chiropractic. The repeated "adjusting" of an unstable SI joint only leads to a remissive/exacerbative cycle of never-ending treatment, with progressively worsening dysfunction of the kinetic chain (maladaptive mechanical syndrome). The multispecialty approach to these conditions is to assess the patient's candidacy for Prolotherapy of the target joint. The injection of a sclerosing agent interarticularly results in the establishment of fibrotic/collagen tissue with eventual stabilization of the joint. Concurrently, the patient undergoes a functional restoration program with attention directed to developing dysfunction(s) of the kinetic chain. Adjusting of the SI joint in question is contraindicated.
d) Chronic, post-traumatic musculoskeletal injury resulting in both latent and active trigger points of an anatomical site may respond well to multidisciplinary treatment. Notwithstanding previous extensive medical, and chiropractic treatment, the recrudescence of these conditions is usually a given if not appropriately addressed by means of trigger point infiltration (marcaine, lidocaine), and concurrent functional restoration, therapeutic massage, medication management, restoration of function, and application of appropriate articular adjustment.
e) Acute musculoskeletal injury can also be very successfully managed by means of appropriate multispedalty treatment. Depending on the degree of injury and the comorbidities associated with the condition, the treating health care provider often is the cause of iatrogenic impairment and/or disability. Not realizing the potential for developing chronicity, the practitioner relies on single-mode treatment while the window of opportunity for complete recovery closes. Once disability establishes itself, the condition transforms itself into a multi-factorial issue of not only physical impairment with its attendant pain, but also into a progressive kinetic chain dysfunction that produces significant mental health issues (anxiety, fear, depression, secondary gain), requiring the extensive combined treatment of both physiatry and psychological counseling.
In many acute and chronic conditions, the potential for successful rehabilitation (treatment) and possible secondary gain issues needs to be assessed by an experienced pain psychologist. This has a direct impact on successful treatment, and in many cases it is the single element disregarded by many practitioners the patient is no longer responding appropriately. At this juncture, the case becomes far more complicated with costs and frustrations escalating, both for the practitioner and the third-party payers. Understandably, early assessment by appropriate specialty providers usually circumvents the transformation of simple injury to that of a chronic condition, with its attendant complications in both the therapeutic and economic areas.
The application of the multispecialty treatment model that includes chiropractic manipulative procedures as an integral element has proven to be exceedingly effective from both a therapeutic and cost-efficiency standpoint.
Identifying the Problem
It is well known that diagnostic triage forms the basis of appropriate referral and division between primary care and specialized services. Diagnostic triage and decisions about referral take place at the point of first contact in primary care. Primary care physicians must detect the few patients with specific pathology among a vast majority with uncomplicated mechanical spinal pain, and obtain appropriate specialized intervention. However, the risk that the uncomplicated spinal pain patient will progress to chronicity and disability-with all the attendant complications-is high if the treatment paradigm relies on deferring effective care and waiting for spontaneous recovery.
Unfortunately, many patients with non-specific pain problems receive fragmented treatment instead of a concentrated, integrated approach to their problem. Delays and protracted ineffective treatment also defer more effective management, leading to chronicity and disability. Expensive specialty consults and hospital investigation and treatments that may be evidencebased or empirical, depending on the doctor's background, training, experience, and chiropractic philosophy, also consume a large portion of the health care dollars spent on musculoskeletal and spinal pain syndromes. Consequently, there is much ineffective and wasteful use of health care resources when the patient is placed on the proverbial "medical merry-go-round."
The treating physician's main initial strategy for the acute and sub-acute pain patient should center on the fact that time is of the essence. Waiting for spontaneous recovery by supporting the status quo allows for the patient to slide into chronicity and disability. All the evidence suggests that effective care rendered within the first 3 to 6 weeks is crucial in preventing chronicity. For the patients who have progressed to a chronic stage of pain, health care resources must be redirected to pain management and rehabilitation. Clinical management must provide timely symptomatic relief, early functional restoration, and the prevention of disability-all of which determine effectiveness.
Solving the Problem
A treatment method that returns about 2/3rds of people with chronic spinal pain to work and improved activities of daily living, lowers their subsequent health care bills, and is cheaper than a common alternative should be embraced by providers, health plans, and the employer. Unfortunately, multidisciplinary pain centers-which accomplish these goals-often see patients with chronic pain after they have endured many years of pain and failed surgery, have lost their jobs, and, in many cases, are on disability.3
Single-site, multidisciplinary treatment centers focused on timely triage and end-point, evidence-based treatment interventions could solve the problem. Delays in access to skilled pain medicine providers can, and do, prove costly. Treatment for the various conditions in question must always take into account the time and the risks of chronic pain and disability, as costs escalate exponentially once the patient is allowed to enter this phase.
A growing body of evidence suggests that multidisciplinary pain centers significantly increase the spinal pain patients' ability to function and return to productive life much sooner than when treated in other settings.3-7 A relatively recent analysis of 65 studies found that multidisdplinary pain centers' patients were about twice as likely to return to work or to show improvement in activity levels as those who refused treatment, were wait-listed, or were treated with only one type of care, such as traditional medicine (drugs) or physical therapy.8
The treatment of painful conditions evolved rapidly through the late '80s and mid-'90s, to the point where it has become a subspecialty of medicine. Interdisciplinary treatment programs evolved from a need to develop effective programs to treat the most challenging chronic pain syndromes, particularly those resulting from musculoskeletal injuries. Various treatment philosophies have guided attempts to define and treat the needs of these patients. Some have maintained that pain relief is the ultimate goal of treatment. Others have emphasized the importance of extinguishing pain-related behaviors, and still others have focused on correcting structural instabilities or attempting to relieve pain through surgery. A growing consensus now maintains that improved physical function and the return to normal life and work, as opposed to only subjective pain relief, are the true indices of overall patient improvement.
The professional strengths of each discipline often led to a focus on a single treatment approach; however, these single methods have generally failed to provide consistent and enduring positive results with most chronic pain patients. In the past several years, professionals from different disciplines have realized that only by combining their strengths in interdisciplinary programs can they begin to successfully address the complex treatment needs of chronic pain patients.
Historically, chronic pain management has been based on the emerging awareness in the '50s that acute and chronic pain are actually different entities requiring different treatment approaches. Although the mistreatment of simple, acute injuries has been shown to result in chronicity (with its attendant exorbitant expense), and must be avoided at all costs, the treatment of chronic pain was shown to respond best to a comprehensive approach fundamentally different from the traditional medical and surgical procedures used for acute pain.
In the '60s, important breakthroughs were made in the understanding of pain as a biopsychosociaL phenomenon. Chronic pain started to be conceptualized in terms of pain behaviors (complaints, grimaces, activity avoidance, and medication dependence). These behaviors do not simpLy express medical pathology but also result from reinforcement based on opérant learning principles that shape what a pain patient does for secondary gain rewards. Physician groups began to emphasize "well behavior," as opposed to "sick behavior."
About the same time, the integration of the psychological with the physiological began, and a little later, the cognitive-behavioral model, suggesting that attitudes and beliefs about illness, the ability to cope with stress, and interpersonal strengths/weaknesses would determine the patient's response to the primary pain generator, particularly after experiencing pain for a long time. It was theorized that physiological, psychological, and social components interact differently, depending on pain duration. Chronological stages of pain, as manifested by specific behaviors across time, could be compared in different patients.
In the early stages of a painful injury, a patient responded with fear and anxiety. If the pain was not appropriately treated and continued for several months, emotional distress worsened, characterized by pre-morbid personality and psychological, characteristics. Pain beyond 4 to 6 months, with accompanying emotional distress, resulted in the patient's adopting the sick role. That role excused him/her from normal functioning and frequently reinforced secondary-gain issues. At this point, there is very little motivation to recover, with both physical and psychological de-conditioning setting in; an effective treatment at this stage must aggressively address both components.
Are multidisdplinary pain programs cost effective? Steig and Turk's findings do support this view.9 They compared the average cost of treatment of $8,160 for a 3-week pain management program with the total cost (provided by the insurance carrier) of medical and disability payments for 1 year prior to and 1 year after pain treatment.10 The savings cited pointed to an average potential saving of $238,515 per patient.
Prof. Dennis Turk, PhD, University of Washington/Seattle, published a cost analysis and determined that the utilization of multidisciplinary pain centers reduces the rate of surgery by about 31% and lowers medical costs by 58%.3 Recent data strongly suggest that multidisciplinary pain management is cost effective and has succeeded in these cases where conventional treatments, such as medical or physical therapy applied independently, have failed. A meta-analysis of 65 studies found that treatment in multidisciplinary pain programs resulted in a much greater likelihood of return to work and medication reduction.2
Supporting the notion of early appropriate treatment, a recent study undertaken by Northwestern National Life Insurance Company found that return-to-work success rates are highest among workers with back and musculoskeletal disorders (60%), resulting in an average savings of $35 in disability reserves for every $1 spent on rehabilitation. This translated to a reserve savings per claim of $78,279. In the same study, it was found that for disabled workers who underwent rehabilitation and returned to the same job, an average of $96 was saved for every $1 spent on rehabilitation expenses.11
Although interdisciplinary programs can very effectively treat the acutely injured patient and stave off chronicity, chronic patients have complex needs and requirements. Although these patients represent a minority, they total a significant number of patients who have failed to benefit from a combination of spontaneous healing and short-term, symptom-focused treatment. They also have become financial burdens on their insurance carriers. These patients have been treated with varying degrees of success at other facilities, usually by single-discipline practitioners, or with the consultative assistance of other professions. They often have had repeated and extended contacts with several different physicians and other health care providers, but they have failed to experience significant pain relief. Physical and psychological de-conditioning, secondary gain, and medication addiction may complicate their presentation. This stage of treatment is much more complex and demanding of health care professionals and the pre-eminent goal should be to avoid iatrogenic chronicity.
Pain Management Specialists of Indianapolis (PMSI)-A Successful Interdisciplinary Program
Because no single professional discipline is capable of adequately addressing the complex needs of the chronic pain patient, an interdisciplinary treatment program is a necessity. Effective communication and full treatment participation require that team members be employed on site, preferably in a full-time capacity. Formally, communication takes place in the interdisciplinary case conference that occurs weekly, but the informal, daily contact with other team members, during which patient progress can be discussed, is equally important. Interdisciplinary treatment implies constant communication among treatment team members, as well as a common understanding of the overall goals of the treatment program. This means patients hear the same treatment philosophy from each member of the team. In the face of a cohesive and united therapeutic plan, unmotivated patients are much more likely to fully participate.
Pain Management Specialists of Indianapolis (PMSI) comprises a certified team of professionals, including medical physicians, chiropractic physicians, a clinical psychologist, an acupuncturist, physical therapists, exercise physiologists, and therapeutic massage therapists. In addition, an Ambulatory Surgery Center is staffed by appropriate specialty physicians to carry out recommended interventional injection procedures. Depending on the presenting case, all or components of these specialties are applied in an effort to address the problem, with the ultimate goal of improving function, decreasing pain, reducing medications, current treatment costs, and subsequent health care utilization. Patients are also encouraged to return to productivity, increase physical activity, and reinforce the ability to manage pain-related problems.
The ingredients of the PMSI model are what make for success. PMSI physicians have a strong background in providing medical rehabilitation for the types of disorders frequently encountered in both acute and chronic pain programs. Formal training varies from anesthesiology (interventionaL procedures) to physiatry, occupational medicine, rehabilitative medicine, preventive medicine, chiropractic therapeutics, psychology, and acupuncture. A medical director oversees the team and takes charge of the overall treatment of the patient, providing the team with the medical history, directing pharmacological management, and coordinating medical contributions to the patient's care.
The staff physicians must also evaluate and summarize the patient's progress at the end of treatment and relate improvements to the patient's future functioning by delineating an after-care plan and clarifying residual disability and secondary-gain issues. PMSI physicians educate patients about the distinction between impairment and disability, cure and functional restoration, and the importance of taking responsibility for self care.
Inasmuch as the PMSI model of treatment provides a multiplicity of individual treatments, the nursing staff is made up of essential team players. The nursing staff has the greatest impact on the patient as a physician-extender and educator. The nursing staff frequently maintains patient communication after hours by telephone, addressing urgent concerns that require education and reassurance. By emphasizing educational issues in the same way as other team members, the nurses are helping the patient to hear a consistent message from the treatment team, even though the message may be unacceptable in the light of preconceived notions regarding pain relief and cure.
Whereas the physicians play a major role in managing the physical status of the patient, the staff psychologist maintains the patient's mental health. Early detection of emotional, issues and psychosocial barriers impacting the overall health status of the patient proves essential for the treating clinician. We recognize that what affects the mind undeniably affects the body. Therefore, the input from this specialist is most important at the weekly case conferences, inasmuch as he or she will be responsible for the educational curriculum provided in interdisciplinary treatment. This includes such topics as:
* differentiating between acute and chronic pain;
* coping with depression, fear, and anxiety that can be associated with Living with a disabling condition; helping to ensure that medication management has not developed into medication abuse;
* helping patients to develop problem-solving skills;
* refraining negative and self-destructive thinking patterns;
* encouraging and assisting with return to gainful employment when possible; and
* assisting patients with the grieving process.
Many patients living with pain and, in particular, chronic pain, struggle with accepting the fact that there may be some things that they cannot do in exactly the same way as they could before. This requires an individual to grieve for what "was" before he/she can accept what "is", and these psychological issues invariably have a direct influence on physical pain, pain perception, and response to any treatment intervention.
Physical Medicine Department (Functional Restoration)
Overseen by our physiatrist-a physician specializing in rehabilitative and physical medicine-our physical therapists interact regularly with the patient regarding physical progression toward recovery. Psychosocial barriers will be manifested as pain sensitivity, somatization, symptom magnification, and noncompliance during participation in physical therapy, but are overcome by extending compassion and education in an effort to motivate the patient toward functional restoration. This department will provide all the treatment modalities needed to make our patients comfortable, including chiropractic manipulation, massage therapy, and acupuncture, if indicated. At the completion of treatment, our physical therapists will instruct the patient on home exercise to maintain the gains made in treatment.
The Chiropractic Ingredient - Making the Difference?
All patients with musculoskeletal compromise exhibit various patterns of functional and movement maladjustment, usually because the body attempts to adapt to post-injury effects of injury, however insignificant. Although most individuals will recover without residua, a certain group develops an adaptation that, in and of itself, becomes a pain generator-long after the initial injury has healed. These patients have chronic painful muscle and joint problems. Manual medicine, primarily practiced by chiropractic physicians and, to a lesser extent, by doctors of osteopathy, has proven to be the single ingredient, when integrated with other essential multidisciplinary treatments, that affects a successful treatment outcome.
Manual medicine emphasizes on joint movement and musde function and uses manipulation. It is an increasingly important and useful modality in the treatment of pain and dysfunction of the neuromusculoskeletal system-underlying joint misalignment and imbalance, which cause painful conditions of the nerves, muscles, and bones.
Manual therapy basically realigns and "unloads" joint surfaces by stretching surrounding joint-tissues and muscles, thereby relieving tension and pain affecting the joint, and restoring normal function. The manipulation is carried out by a trained doctor of chiropractic, through the appropriately directed thrust to the joint structure to affect alignment, flexibility, and neurologic reflexes that result in painful conditions. In many instances, manipulative therapy must be repeated a number of times with concurrent functional restorative exercise therapy, to "train" the recalcitrant joint(s) and supportstructures into a new, non-painful postural position-in effect, teaching the body new "muscle memory."
Ambulatory Surgery Center
The specialist physicians staffing the PMSI ambulatory surgery center play an important role in providing pain management through interventional procedures when necessary. In patients whose pain levels prevent our physical therapists and chiropractic physicians from accomplishing their goals, interventional injection procedures provide the window of opportunity to proceed with functional restoration.
Multidisciplinary pain centers maintain 2 fundamental assumptions about pain in general: first, that it is a compLex phenomenon involving physical, psychosocial, and behavioral factors; and second, that pain problems are best evaluated and treated by a team of health care professionals from various disciplines.
PMSI is a vertically integrated, single-site, medical treatment facility, focused on the spine-injured and musculoskeletally compromised patient, presenting with either acute or chronic pain problems. The practice incorporates all the appropriate specialties and subspecialties required to effectively and efficiently address the pain patient in a timely manner.
PMSI uses the strengths of multiple disciplines working together to address the complex issues confronting acute and chronic pain patients. This involves pharmacological management, education, stress reduction, disability management, physical reconditioning, emotional stabilization, and behavioral restructuring. The therapeutic focus is toward independence and autonomy, while acknowledging those physical limitations that cannot be overcome. Adaptation does not mean defeat, and pain patients can learn, through the combined resources of an interdisciplinary program, that it is possible to lead a successful and rewarding life in spite of discomfort.
Ultimately, the success of effective therapeutic intervention depends heavily on prompt referral for appropriate treatment to prevent acute problems from becoming chronic.
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By Peter G. Furno, DC, Medical Administrator
Dr. Furno is the medical administrator of Pain Management Spedab'sts of Indianapolis, a multi-specialty treatment medical facility incorporating chiropractic within the clinical treatment protocols. He is certified in rehabilitation.
Copyright American Chiropractic Association Oct 2004
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