interdisciplinary pain management & functional restoration
DESCRIPTION
INTERDISCIPLINARY PAIN MANAGEMENT & FUNCTIONAL RESTORATION. JAMES W. ATCHISON, DO Medical Director, Center for Pain Management Professor of PM&R Northwestern Feinberg School of Medicine. Disclosures. - PowerPoint PPT PresentationTRANSCRIPT
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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
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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
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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?
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THE TRIAD: PAIN, SLEEP, AND MOOD
Pain
Sleepdisturbances
Depression /anxiety
Functional impairment
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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.
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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
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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
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SELECTION CRITERIA
WHAT DOES A FUNCTIONAL RESTORATION PROGRAM CHANGE?
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Very Much Worse
Very Much Improved
No Change
RIC Full Program Completers 2013
No Change
No Change
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REVIEW OF CASE ISSUES
OK THIS WORKS! HE HAS
ILL DEFINED PAIN POOR SLEEP DEPRESSION AND
ANXIETY FAILED PROCEDURES INEFFECTIVE
MEDICATIONS
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COMMON RESPONSES
WHAT DO PATIENTS THINK?
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PAIN REGIONS/AREAS ARE EXPANDING
DOCTOR SAYS!
• GOOD NEWS,
LIKELY MYOFASCIAL
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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?”
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FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED NEEDED
DOCTOR SAYS!
• GOOD NEWS,
PAIN PROGRAM INCLUDEs PT, OT,
BIOFEEDBACK, & PSYCHOLOGY!
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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
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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.
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THE TRIAD: PAIN, SLEEP, AND MOOD
Pain
Sleepdisturbances
Depression /anxiety
Functional impairment
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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?
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MEDICATIONS NEED TO BE CHANGED
DOCTOR SAYS!
• TREAT SLEEP TCA OR TRAZODONE
• TREAT MOOD – SNRI DULOXETINE OR
VENLEFEXINE
• REDUCE THE USE OF OPIOIDS
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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”
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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.
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OK, LET’S GET STARTED!
PROGRAM STRATEGIES• ACTIVE APPROACH
• MEDICATION TAPERING OR DETOX PROGRAM
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RIC’S CPM PROGRAM COMPONENTS
Nurse Education Physical therapy Occupational therapy
• Recreation Therapy
Psychology (CBT) Relaxation Training Mind Body Treatment/
Feldenkrais/ Mindfulness
Vocational Therapy
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PHASES OF TREATMENT
Educational Skills training Application and
relapse prevention
Individual Goal Setting
Monitor Reassess &
Readjust
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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)
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PAIN PSYCHOLOGY
• Mind-Body Connection
• Coping Skills Training • Emotion Regulation • Cognitive
Restructuring • Stress Management • Mindfulness• Family Education
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RELAXATION TRAINING/ BIOFEEDBACK
• Deep Breathing• Imagery and
Visualization• Progressive Muscle
Relaxation (PMR)• Biofeedback
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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
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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
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INITIAL MEDICATION ADJUSTMENTS
TRANSITION FROM ESCITALOPRAM TO DULOXETINE
INITIATE GABAPENTIN
ADDING NORTRIPTYLINE AT HS
ADDING CLONIDINE AT HS
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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
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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
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OUTCOMES
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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
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Very Much Worse
Very Much Improved
No Change
All Full Program Completers 2013
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Very Much Worse
Very Much Improved
No Change
Patients with WC
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Very Much Worse
Very Much Improved
No Change
Patients with WC versus Patients without WC
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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
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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%
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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)
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INDIVIDUAL RESULTS
FUNCTIONAL CAPACITY EVALUATION (FCE)• VALID• LIGHT-MEDIUM
MAXIMAL MEDICAL IMPROVEMENT
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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
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THANK YOU!