Interdisciplinary Rehabilitation: Information for Pain Practitioners
According to the International Association for the Study of Pain, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of tissue damage, or both.”1 This definition is the culmination of centuries of ideas and work that have explored the concept of pain.
Pain can be classified as acute (last a moment to weeks or longer, and is typically associated with tissue injury or disease) or chronic (pain signals remain active in the nervous system beyond the normal time of healing and does not respond to a simple or immediate treatment).
Unfortunately, the medical education system lags behind with regards to teaching future general practitioners the differences between treating acute versus chronic pain, or persistent, non-cancer pain.2 Understanding these differences and employing an interdisciplinary approach to pain management can help improve treatment and alleviate suffering.
When working with a patient who suffers from chronic pain, it is helpful for practitioners to outline treatment expectations, consider an array of evidence-based therapies that include non-opioid medications, physical therapy, behavioral programs (such as cognitive-behavioral therapy), and procedures such as nerve blocks.3 This also promotes a collaborative relationship between the patient and the practitioner. Empirically validated complementary and integrative therapies (such as spinal manipulation, massage, yoga, and acupuncture) should also be considered at this time.4
Only after other treatment options have been exhausted and a careful risk-benefit analysis has been completed should an opioid trial be considered.5 If it is determined that the risk outweighs the benefit, a referral to a pain specialist, or an interdisciplinary rehabilitation program, is indicated.
What is Interdisciplinary Rehabilitation?
Interdisciplinary rehabilitation programs are the embodiment of the biopsychosocial model of care for patients with chronic pain with providers focusing on the total person.6 It has long been recognized that the complexities of chronic pain require collaborative expertise of multiple disciplines, including pain specialists (anesthesiologists, pain physicians), osteopathic physicians, physiatrists, psychologists, pharmacists, and registered nurses and physician assistants (although the professional staff may vary from one practice setting to another).
A pain specialty physician is usually the director of the program. The patient also is considered an integral member of the team, and is responsible for self management, which may include the use of heat/ice, stretching, walking, repositioning, etc. (Table 1).
In an ideal setting, the treatment team would practice at the same location to maximize the common goal of improving the patient’s function and enhancing quality of life. For any given patient, the treatment goals of interdisciplinary rehabilitation programs include reducing (not eliminating) the patient’s pain, defining distinct goals for the patient, increasing the patient’s activity and decreasing the time they spend resting during the day, allowing the patient to return to work or vocational training, reducing their dependence on pain medications (opioids, etc), reducing their depression and anxiety and improving their coping mechanisms, and providing pain education. Interventional approaches to pain reduction also can be an important component of interdisciplinary rehabilitation program.
What are Interventional Approaches?
Interventional approaches are advanced medical procedures that often are performed through penetration of the skin, including trigger point injections, epidural steroid injections, nerve blocks, and neurostimulation.7
Trigger point injections are a series of local anesthetic shots administered in specific areas of the muscle that are pain generators. They often are performed in a physician’s office, usually with the patient either lying on their stomach or sitting on an exam table. The exact protocol varies by clinical practice setting. The physician performing the procedure locates the trigger point by manual palpation and marks the site. The injection site is then cleaned with alcohol or another skin cleanser. After the injection, a simple adhesive bandage may be applied.
(Editor’s note: Trigger points can also be treated via electromedical devices, such as lasers, ultrasound, and TENS machines, as well as via alternative treatments such as acupuncture and massage therapy).
Epidural Steroid Injections
Although under scrutiny recently, epidural steroid injections (ESIs) are the most widely used pain management procedure in the world.8 ESI’s deliver anti-inflammatory medication into the epidural space of the spine using X-ray guidance to alleviate chronic pain in the lower back (lumbar), mid-back (thoracic), and neck (cervical). More localized procedures, such as caudal (the sacral hiatus provides the most direct route of entry) and transforaminal (the placement of a needle within a neuroforamen) ESIs, are injected into portions of the epidural space that help reduce lower chronic back pain that radiates down the leg.
ESIs often are performed in a procedural clinic, usually with the patient lying face down on a fluoroscopy table. Numbing medicine (anesthetic) and then contrast dye are injected into the site. Using X-ray guidance, the physician then places the steroid medication into the specific epidural space. The procedure takes approximately 15 minutes, with exact timing varying by clinical practice. The patient is then observed for 20 to 30 minutes before a companion escorts them home. Although rare, patients may suffer from headaches after an ESI, which may require a blood patch.
How effective are ESIs? Studies are somewhat contradictory, showing different levels of response. Some patients get relief for years with 1 to 3 injections. On the other hand, some people only get relief that lasts a few weeks. In a patient with relatively new back pain radiating into the leg, a fairly good response is expected in approximately 70% of patients. Less robust response may be expected in people with a more complex disorder, a longer duration of symptoms, surgery to the area, or more than one spinal diagnosis.9
Side effects may include increased transient symptoms, such as blood sugar, anxiety, sleeping problems, water retention (bloating), facial flushing, infection, and suppression of the HPA axis (a system in your body that controls response to stress and regulates many body processes). Too frequent use of ESIs may cause local osteoporosis (bone thinning) and weakening of the surrounding tissues that may cause further spinal degeneration over the years.”9 Neurological complications, such as stroke and paralysis, have been associated with ESIs but are extremely rare.10