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INTERDISCIPLINARY PAIN MANAGEMENT
& FUNCTIONAL
RESTORATIONJAMES W. ATCHISON, DO
Medical Director, Center for Pain Management
Professor of PM&R
Northwestern Feinberg School of Medicine
DISCLOSURES
Principle Investigator for RIC participation in multicenter research project for Paraxel/Pfizer.
Principle Investigator for RIC participation in multicenter research project for INC/Grunenthal.
Advisory Board for Mallinkrodft
Advisory Board for Janssen
REVIEW OF CASE ISSUES
CONTINUED PAIN w/ POOR SLEEP • SPREADING PAIN PATTERN
INCREASED DEPRESSION AND ANXIETY FAILED MULTIPLE PROCEDURES MEDICATIONS INEFFECTIVE
• LONG ACTING OPIOID – OXYCONTIN 40 MG TID 180 MEQ MS PER DAY
• SHORT ACTING OPIOID – NORCO 10/325, 8 PER DAY 80 MEQ MS PER DAY
• BENZODIAZEPINE – TID (2 AT NIGHT)• ?MUSCLE RELAXANT AND SSRI?
THE TRIAD: PAIN, SLEEP, AND MOOD
Pain
Sleepdisturbances
Depression /anxiety
Functional impairment
PSYCHOSOCIAL “YELLOW FLAGS”
Expectations and pain behavior Heightened emotional activity Reinforcement of pain Maladaptive beliefs Job dissatisfaction Poor social support Compensation
New Zealand Accident Comp Corp. 1997;23-66.Cairns MC, Spine 2003; 28(9):953-59.
PHYSICAL “YELLOW FLAGS”
Pain moves from local to regional Guarding of the injured area Fear of movement Fear of re-injury Decrease in proper movement
patterns
INTERDISCIPLINARY FUNCTIONAL RESTORATION, FEINBERG, GATCHEL, STANOS ET AL; CH. 82 IN COMPREHENSIVE TREATMENT OF CHRONIC PAIN BY MEDICAL, INTERVENTIONAL AND INTEGRATIVE APPROACHES,
DEER ET AL, 2013, AMERICAN ACADEMY OF PAIN MEDICINE
MEDICATION “YELLOW FLAGS”
Continued use of meds w/o pain reduction or improved function• Despite continuation of side effects• Beyond the natural history of recovery
Escalating doses w/o benefit Multiple opioids Early use of long acting opioids Use of opioids w/ benzodiazepines Intolerance of PT w/ medications
SELECTION CRITERIA
WHAT DOES A FUNCTIONAL RESTORATION PROGRAM CHANGE?
Very Much Worse
Very Much Improved
No Change
RIC Full Program Completers 2013
No Change
No Change
REVIEW OF CASE ISSUES
OK THIS WORKS! HE HAS
ILL DEFINED PAIN POOR SLEEP DEPRESSION AND
ANXIETY FAILED PROCEDURES INEFFECTIVE
MEDICATIONS
COMMON RESPONSES
WHAT DO PATIENTS THINK?
PAIN REGIONS/AREAS ARE EXPANDING
DOCTOR SAYS!
• GOOD NEWS,
LIKELY MYOFASCIAL
PAIN REGIONS/AREAS ARE EXPANDING
PT SAYS!
• “IT HURTS TOO MUCH TO BE THE MUSCLES”
• “SHOULDN’T WE DO ANOTHER MRI?”
• “WON’T SURGERY OR MORE INJECTIONS TAKE AWAY THE PAIN?”
FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED NEEDED
DOCTOR SAYS!
• GOOD NEWS,
PAIN PROGRAM INCLUDEs PT, OT,
BIOFEEDBACK, & PSYCHOLOGY!
FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED
PT SAYS!
• “SO YOU THINK IT IS ALL IN MY HEAD?”
• “I’M NOT DEPRESSED!” JUST FRUSTRATED
AND/OR IRRITABLE
PROCESSING OF PAIN IN THE BRAIN OCCURS IN SEVERAL REGIONS
Anterior cingulate cortex
Prefrontal cortex
Hippocampus
Amygdala
Insular cortex
Thalamus
Somatosensory cortex
Pain + emotion
Pain only
Adapted from Apkarian AV, et al. Eur J Pain. 2005;9:463-484. Image courtesy of Apollo Marcom.
THE TRIAD: PAIN, SLEEP, AND MOOD
Pain
Sleepdisturbances
Depression /anxiety
Functional impairment
FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED
MR. CARR SAYS!
• I HAVE TO DO THE WORK?
“I’VE ALREADY DONE PT!”
• “MY PAIN IS NEVER GOING AWAY?
MEDICATIONS NEED TO BE CHANGED
DOCTOR SAYS!
• TREAT SLEEP TCA OR TRAZODONE
• TREAT MOOD – SNRI DULOXETINE OR
VENLEFEXINE
• REDUCE THE USE OF OPIOIDS
MEDICATIONS NEED TO BE CHANGED
PT SAYS!
• “I NEED MORE PAIN MEDICATION”
• “I CAN’T DO IT WITHOUT PAIN MEDS”
• “IT WORKS BETTER WHEN I TAKE IT WITH THE ALPRAZOLAM”
DOCTOR SAYS: “YOU CAN DO IT WITHOUT OPIOIDS!”
OPIOID CESSATION AND MULTIDIMENSIONAL OUTCOMES AFTER INTERDISCIPLINARY CHRONIC PAIN TREATMENT• MURPHY ET AL, CLIN J PAIN 2013;29:109-117.
LACK OF CORRELATION BETWEEN OPIOID DOSE ADJUSTMENT AND PAIN SCORE CHANGE IN A GROUP OF CHRONIC PAIN PATIENTS• CHEN ET AL, J PAIN 2013 APR; 14(4): 384-92.
LOW PAIN INTENSITY AFTER OPIOID WITHDRAWAL AS A FIRST STEP OF A COMPREHENSIVE PAIN REHABILITATION PROGRAM PREDICTS LONG-TERM NONUSE OF OPIOD IN CHRONIC NONCANCER PAIN• KRUMOVA ET AL, CLIN J PAIN 2013; 29: 760-769.
OK, LET’S GET STARTED!
PROGRAM STRATEGIES• ACTIVE APPROACH
• MEDICATION TAPERING OR DETOX PROGRAM
RIC’S CPM PROGRAM COMPONENTS
Nurse Education Physical therapy Occupational therapy
• Recreation Therapy
Psychology (CBT) Relaxation Training Mind Body Treatment/
Feldenkrais/ Mindfulness
Vocational Therapy
PHASES OF TREATMENT
Educational Skills training Application and
relapse prevention
Individual Goal Setting
Monitor Reassess &
Readjust
PHYSICAL THERAPY OCCUPATIONAL THERAPY
• Comprehensive assessment
• “Active” instead of “Passive”
• Movement based• Strengthening• Aerobic conditioning• Home exercise plan
• Positioning/Posture • Pacing Techniques• Body mechanics • Stress Loading• Desensitization• Graded Motor Imagery
(Left/Right discrimination; Mirror Therapy)
• Graded Activity Exposure• Functional Capacity
Evaluation (FCE)
PAIN PSYCHOLOGY
• Mind-Body Connection
• Coping Skills Training • Emotion Regulation • Cognitive
Restructuring • Stress Management • Mindfulness• Family Education
RELAXATION TRAINING/ BIOFEEDBACK
• Deep Breathing• Imagery and
Visualization• Progressive Muscle
Relaxation (PMR)• Biofeedback
Monday Tuesday Wednesday Thursday Friday
8aWeekend
reviewGym Feldenkrais Relax (G) Psych
9Nursing lecture
OT Tolerance
Psych Biofeedback MD visit
10 PT OT toleranceConditioning/
GymVoc OT
11 MD visit Video PoolConditioning/
GymPT
12 Lunch Feldenkrais Lunch Pool Lunch
1 OT (G) Lunch Biofeedback OT (G) Psych (G)
2 Biofeedback OT OT (G) Relax (G) Relax (G)
3 Nursing Psych OT (G) OT (G)
4 Relax (G) Wii Group Mindfulness (G)Family meeting
(G)OT (G)
FULL DAY PROGRAM SCHEDULE
MEDICAL MANAGEMENT
• Team lead by a physiatrist, pain medicine specialist
• Nursing monitoring and education• Inpatient or outpatient detoxification
incorporated into program as needed• Medication adjustments
• Sleep Assistance• Nerve Pain• Myofascial Pain
INITIAL MEDICATION ADJUSTMENTS
TRANSITION FROM ESCITALOPRAM TO DULOXETINE
INITIATE GABAPENTIN
ADDING NORTRIPTYLINE AT HS
ADDING CLONIDINE AT HS
DETOX AT 2 WEEKS
OPIOID USE AT 260 MEQ PER DAY• TOO LARGE TO TAPER IN PROGRAM
25-33% REDUCTION WEEKLY
• TRANSITION TO BUPRENORPHINE/ NALTREXONE FILMS
BEGINNING SLOW TAPER OF ALPRAZOLAM
PT REPORT AT F-U VISIT AFTER DETOX
RTC ON BUPRENORPHINE FILM AT 1 MG SL BID• REDUCTION EVERY 2-5 DAYS
3/8 FILM BID ¼ FILM BID 1/8 FILM BID DC
• MOOD GOOD• SLEEP IMPROVED
PROGRAM COMPLETED
OUTCOMES
FULL DAY INTERDISCIPLINARY PROGRAM OUTCOME DATA 2013
COMPLETEDOVERALL
COMPLETEDWC
INCOMPLETEOVERALL
INCOMPLETE WC
# PATIENTS 150/193 (77.72%)
48/65(73.8%)
43/193 (22.27%)
17/65 (26.15%)
MEAN # DAYS TX(MAX=20)
18.55 18.42 9.59 9.29
MEAN # UNITS TX(MAX=560)
414.4 407.33 185.5 196.17
MEAN # HOURS TX(MAX=140)
103.6 101.83 46.38 49.04
Very Much Worse
Very Much Improved
No Change
All Full Program Completers 2013
Very Much Worse
Very Much Improved
No Change
Patients with WC
Very Much Worse
Very Much Improved
No Change
Patients with WC versus Patients without WC
AT DC TEAM CONFERENCE
PAIN 4/10; MOVEMENT MUCH BETTER
“I’M SO HAPPY TO BE OFF THE MEDS.” • “I WOKE UP”
“PAIN IS NOT GOING TO KILL ME,” • “DON’T HAVE TO HAVE DRUGS TO FIX IT!”
TEARFUL AND THANKFUL
INTERDISCIPLINARY PROGRAM OUTCOME DATA 2013
wcCOMPLETED
wcINCOMPLETE
PAIN DURATION 35.5 MONTHS 33.7 MONTHS
MMI 88.2% (95.7%) 27.8%
RELEASED TO WORK 80.4% (97.6%) 29.4%
RELEASE STATUS FULL: 90.2%GRADUAL: 2.4%
FULL: 100%
FCE 84.3% 55.6%
FCE VALID 58.1% 80%
INTERDISCIPLINARY PROGRAM OUTCOME DATA 2013
FCE STRENGTHwcCOMPLETED
wcINCOMPLETE
SEDENTARY 7% 20%
SEDENTARY-LIGHT 2.3%
LIGHT 39.5% 40%
LIGHT-MEDIUM 18.6%
MEDIUM 14% 40%
MEDIUM-HEAVY 7%
HEAVY 4.7%
MISSING 7% (n=3)
INDIVIDUAL RESULTS
FUNCTIONAL CAPACITY EVALUATION (FCE)• VALID• LIGHT-MEDIUM
MAXIMAL MEDICAL IMPROVEMENT
4 WEEK FOLLOW-UP
AFTERCARE• HEP
CORE & PRONE EXERCISE MANEUVERS
• COGNITIVE TREATMENTS IMAGERY DEEP BREATHING
MEDICATIONS STABLE• OFF BUPRENORPHINE AND CYMBALTA• CONTINUES GABAPENTIN AND NORTRIPTYLINE• TIZANIDINE PRN w/ FLARES
WORKING FULLTIME @ STAPLES• INCORPORATES PACING & BODY MECHANICS
THANK YOU!