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7 Articles in Volume 1, Issue #1
Breaking Down the Barriers of Pain: Part 1
Bringing Pain to the Forefront of Treatment
Microcurrent Electrical Therapy Mechanisms and Results
Relieving Pain with Pharmaceuticals
The Pain Relationship
The Perfect Treatment and Evaluation Tool
TMJ Repositioning

Breaking Down the Barriers of Pain: Part 1

New clinical approaches for diagnosing musculoskeletal and chronic pain conditions are discussed in part one of this series.

There is widespread recognition that musculoskeletal and chronic pain conditions are poorly diagnosed and treated, leading to chronic disability, risk for drug dependence and depression, dissatisfaction with the medical profession and epidemic costs. The reason is not a lack of sufficiently potent painkillers, nor undiagnosable or untreatable CNS pathology, but rather an over-reliance on analgesic and anesthetic palliation and a failure to make specific source-of-pain diagnoses.

Federal Guidelines

The federal AHCPR (Agency for Health Care Policy and Research) guidelines for low back pain have been the only guidelines widely publicized.1 In the Initial Assessment it is recommended to rule out fracture, tumor, infection or cauda equina syndrome. While one cannot fault such a cautious approach, it nevertheless offers no guidance in diagnosing the other 99 percent of back pain conditions. Recommendations for care for the first month include no guidelines for identifying the source of pain, but rather emphasize palliation. The recommended treatment is limited to acetaminophen or NSAIDs and/or chiropractic. During this period, opioids, muscle relaxants, anti-depressants, physical therapy, modalities and injections are proscribed. No diagnostic testing is recommended. It is implied that the majority of patients will recover in this first month, but the guidelines offer little help for the approximately one-third who are not recovering and typically have significant pain and anxiety.

Care in the second and third month addresses one additional diagnosis: root compression. For patients with sciatica, the guidelines recommend EMG. This is surprising since EMG-NCV studies are not reliable in diagnosing root pathology and cannot diagnose root compression, the proper test for that is an MRI. And yet the guidelines recommend an MRI only if the EMG is positive. Because an MRI will document whether or not there is root compression in the distribution of the patient's sciatica, this test should be performed first. If the MRI is positive, an EMG is not necessary. The guidelines state that only if both tests are positive should a surgical consultation be recommended. The EMG is often negative in radiculopathy and therefore this recommendation is too limiting.

The guidelines recommend surgery if the "patient will consider surgery to speed recovery" and "physical limitations are not lessening." These recommendations are reasonable but carry the risk of permanent residual radiculopathy from on-going nerve root compression that is not decompressed. This risk can be avoided if decompression is recommended for the two to three percent of low back patients whose MRI shows root compression consistent with the radicular symptoms and those symptoms are not diminishing over this time frame. The guidelines for persistence at three months are to "recommend comfort options," "help patient consider options" and if the patient is not "seeking information about options" then address factors why not or arrange for a psychosocial evaluation. These recommendations are reasonable but not realistic. The guideline's three-month evaluation addresses less than five percent of the possible causes of back pain–1) sciatica, 2) fracture, 3) tumor, 4) infection and 5) cauda equina syndrome. It is not likely that a patient will accept a psychiatric referral after so minimal a consideration of physical causes. The guidelines offer no assistance to the clinician as to how one should broach this recommendation with the patient. What is causing the pain? The guidelines imply that if none of the five causes addressed in the first three months are discovered then there is no peripheral source of pain. Several other common sources of pain should be addressed before postulating unproven "central" or psychological theories.

Table 1. Analysis of a claims database of 155,000 lives in a major metropolitan area over a two-year period up to October 1999.

New Approaches

New guidelines, developed by MyoPoint Medical Group, Inc., take a very different approach, based on addressing the question: Where is the pain coming from? MyoPoint is a group comprised of neurologists and occupational and physical therapists specializing in the diagnosis, treatment and management of musculoskeletal and chronic pain conditions. The group provides disease management programs to medical groups and health care insurers.

The MyoPoint program began in 1992 as the Pain Rehabilitation Service of Sharp Healthcare, a multi-hospital, multi-medical group organization, in San Diego, Calif., where MyoPoint maintains its clinic and training facility, as well as its call center and claims analysis services. MyoPoint has developed an algorithm for analyzing insurance claims databases, and a neurological approach to diagnosis, treatment and management of such conditions. The approach is based on determining the source of pain and focusing treatment and management specific to that source.

Incidence and Cost–The Insurance Claims Perspective

Although insurance claims are primarily used for billing, they can provide useful information on the incidence and costs of diagnoses and procedures in a defined population. An insurance claims database essentially groups together one or more ICD-9 (diagnosis) codes, and one or more CPT (evaluation and procedure) codes for a specific date and member (patient). Typically the provider and facility codes are also included. This type of data has significant limitations; the most obvious is it provides no clinical information other than the diagnosis and what was actually performed (or at least billed for). Another limitation is no relation between the reported ICD and the billed CPT. For example, the clinician may enter "low back pain" as the primary reason for the visit, but order tests such as urinalysis or EKG for unrelated symptoms. Thus in determining the true costs of low back pain in a database, and in the absence of asking the clinician directly, it is necessary to include only the CPT codes that are typically ordered to evaluate or monitor musculoskeletal pain conditions. Another limitation is errors in the ICD-9 coding.

Table 2. Breakdown by most costly diagnoses.

To comprehensively analyze the incidence and costs of musculoskeletal and chronic pain conditions, the search algorithm includes more than 225 ICD-9 and 195 CPT codes. The algorithm calculates incidence and costs of each diagnosis and evaluation or treatment, as well as the time course from first presentation to final outcome, and patterns of care. This data can be used to identify patients who are high-utilizers or at risk.

In a previously reported algorithm analysis it was found that pain-related costs were 9.0 percent of all claims costs, and that patients with pain-related claims accounted for 39.69 percent of all claims, demonstrating that these patients are high-utilizers in general, not only for pain-related conditions.2 Table 1 is an analysis of a claims database of 155,000 lives in a major metropolitan area over a two-year period up to October 1999.

As can be seen in Table 1, the musculoskeletal and chronic pain claims accounted for 9.5 percent of claims, virtually identical to the previous results from a different insurer's claims database. The total claims for those patients, including both pain and non-pain-relating claims, accounted for 57.1 percent of total claims, even higher than the 39.6 percent in the earlier study. Thus, patients with pain-related conditions are high-utilizes of services in general, not just for pain.

Of the 9.5 percent of paid claims for musculoskeletal and chronic pain conditions, 73.4 percent of that was for back, neck and head pain conditions. Of that, 64 percent was spent on surgery and other invasive procedures including epidurals.

Note in Table 2 that nearly 90 percent of all pain-related claims costs are for neck and back pain, with migraines accounting for only 0.2 percent of claims costs. How can this be when epidemiology studies show that as much as 30 percent of the population suffers migraine and less than five percent have disc herniations with root compression? The answer is straightforward–surgery. In fact 15.1 percent of the claims costs for disc displacement diagnoses are for post-laminectomy syndromes.

Table 3. Breakdown by most costly procedures.

Costs of medications are not included in Table 3. The percentages for spine surgeries and for physical therapy in Tables 1 and 3 do not match because Table 3 includes only procedures whose total claims costs were greater than $2,000.

Note in Table 3 that spine surgeries and spine-related anesthesia, both general and local, account for more than 50 percent of the high-cost procedures, four times the cost for office visits and consultations and nearly four times the cost for physical therapy. Chiropractic costs were only 0.7 percent.

What should one conclude from this claims-cost data? At the very least it demands a close look at how the diagnosis of surgically treatable spine disease is made.

Figure 1.

Source-of-Pain History-Taking

The history and physical examination of a pain patient should be able to distinguish the patient having disc herniation with root compression who may benefit from surgery from the vast majority who will not, and more likely will be made worse by surgery.

There are three components to obtaining a history from a pain patient that require special emphasis–1) the description of the pain complaint itself and for this a pain drawing, completed by the patient is essential, 2) whether the patient is taking habit-forming pain medications and if so how much and 3) the patient's "Chief Concerns."

Pain Pattern

When patients tell clinicians that they have pain in the low back radiating into the back of the leg, we have traditionally assumed the patients are describing disc herniation with root compression. Unfortunately we are wrong more than 97 percent of the time. Disc herniation with root compression accounts for less than three percent of all back pain. The most common cause of low back pain referring into the hip or buttock is muscle strain involving the quadratus lumborum, piriformis and/or gluteus medius muscles. This would have been clear if the patient had filled out a pain drawing.

The pain drawing is the single most useful information in determining the source of pain. Pain drawings should be a routine component of the history of any patient with a complaint of pain, because patients are unskilled at describing where in their bodies they experience pain. The patients should complete this independently, but then be questioned about it during the history taking. Frequently patients will only shade in the worst area of pain or the area they want to be addressed and thereby give an incomplete description. Therefore it is useful to ask, "Is this the only area where you have pain?"

Figure 2. Figure 3.

Muscular Pain Patterns Muscle

Painful muscles have characteristic patterns of pain and pain referral. The Travell and Simon's texts provide detailed drawings of hundreds of muscle trigger points.3 Figures 1 - 3 show the pain patterns for the most commonly affected muscles. Note that any one of them can be confused with the patterns from nerve or joint involvement especially if the patient gives only a verbal description in the absence of a pain drawing.

Non-Muscular Pain Patterns (Figure 4) Radicular (Dermatomal)

Nerve root compression or damage will produce the characteristic dermatomal patterns of pain and paresthesias, the common ones are presented. The most common is the so-called "sciatica" pattern, a misnomer since it is actually the S1 root, not the sciatic nerve. The pain radiates from the back or buttock down the back of the leg to the outside of the ankle, often seeming to skip the back of the knee. The L5 root is also common; compression or damage here causes pain to radiate down the lateral thigh, crossing over on the calf toward the medial side of the ankle.

A radicular pattern is most often confused with a muscular pattern. For instance, pain arising in the quadratus lumborum radiates pain from the back into the buttock, but not down the thigh into the foot. Pain arising in the piriformis muscle radiates pain into the hip but is sometimes associated with pain and paresthesias that radiates down the leg in an sciatic nerve pattern, which is thought to be caused by entrapment of that nerve as it pierces the piriformis muscle.

Peripheral Nerve

Peripheral polyneuropathies such as diabetic neuropathy produce the well-known stocking-glove pattern of sensory loss and distal hyperpathia, classic burning of the souls of the feet, bilaterally. This pattern is quite distinct and is rarely confused.

A median nerve neuropathy (such as occurs with carpal tunnel syndrome) produces pain and paresthesias of the palmar surface of the thumb, index, middle and half the fourth finger. An ulnar neuropathy produces pain and paresthesias of the side of the hand and fifth digit.

Joint and Tendon

Joint and tendon inflammation produces pain localized to the joint and tendon–the pain does not radiate or refer. The most common is lateral epicondylitis which causes localized pain just distal to the lateral elbow. Shoulder impingements are frequently confused with involvement of the shoulder girdle musculature but can be readily differentiated by passive and isometric maneuvers that are discussed in the Source-of-Pain Examination section (found in future continuation of this article).

Somatization

Patients with somatoform pain disorders, by definition, have pain patterns that fit no anatomic or physiological pattern. The most common such pattern is total body pain. The patient's pain drawing shows pain essentially everywhere (though the abdomen is often not shaded in). It is worth noting that this is the pattern most often seen with patients diagnosed with fibromyalgia.

Habit-Forming Medication Use

It is imperative to inquire about habit-forming medication use early in the history-taking process, as patients frequently underestimate the quantities they are taking; and often it is the dependence on these medications that drives utilization and pain behavior. If the patient is taking more than a few tablets per day of a habit-forming medication like hydrocodone then a plan will be needed and will be discussed in Drug Dependence section (found in future continuation of this article).

Chief Complaints vs. Chief Concerns

In medical school and residency, clinicians are taught to 1) look for "zebras," ruling out the rare syndromes before addressing the common ones, 2) focus on emergencies rather than preventive or long-term solutions, 3) assume that the patient is unable to understand complex medical issues and must therefore be protected from too much information, 4) depend on prescriptions, and finally 5) believe that doing anything is better than doing nothing. This training is a prescription for disaster in the management of musculoskeletal and chronic pain conditions.

In the traditional doctor-patient relationship the doctor diagnosed and prescribed and the patient followed "doctor's orders." The modern patient is more educated, less trusting, expects comprehensive information and complete understanding of his or her options, and benefits and risks. In this environment clinicians must provide sufficient information so that patients themselves can arrive at, and choose, the best treatment, and be motivated to pursue it. If the patient is just "following orders" he or she is less likely to stick to a treatment plan that may take time and patience to be effective.

Traditionally, the "chief complaint" is the patient's primary symptom or reason for the visit. In the case of musculoskeletal pain conditions, it is usually pain, numbness, tingling or weakness.

To the traditional focus on the chief complaints should be added the concept of "chief concerns." Chief concerns are defined as the typically subconscious or unspoken questions or needs that the pain patient in particular brings to the clinician visit.

Figure 4.

Chief Concern #1: "I believe I have an undiagnosed condition that hasn't been adequately evaluated." A patient will rarely voice this chief concern. The clinician is led to suspect it when efforts to be reassuring are not successful. The patient will reiterate his or her symptoms and will add new ones such as "Well, also I've been more tired recently." It is helpful to ask some leading questions such as "Do you think the pain is getting worse?" Or, "What were you told about the result of the tests you had?" Or, "Did your (previous or referring) clinician explain what was causing the problem?" This chief concern must be resolved or the patient will continue to seek answers elsewhere, have unnecessary tests and ineffective procedures, and will not participate fully in the recommended treatment plan. Sometimes it is necessary to order additional testing to resolve this concern, but care must be exercised because the test may come back negative or ambiguous, and this can actually increase the patient's concern. So the reasoning for testing must be spelled out. For example the clinician might say, "Why don't we go ahead and order the MRI just to settle it completely that there is no nerve root compression."

Chief Concern #2: "Modern medicine should be able to give me a 'quick fix.'" This is a common attitude in our culture of medications and procedures to fix anything and everything. If the recommended treatment will not produce a "quick fix" the reasons why must be explained clearly to the patient to avoid settling for a lesser treatment. For example, benzodiazepines or anti-depressants are often prescribed, not specifically for diagnosed anxiety or depression but rather as a "shot-gun" band-aid for non-specific, psychosomatic symptoms. By doing so the patient is deprived of the opportunity to receive treatment that could make a real difference.

Chief Concern #3: "I am afraid the doctor will tell me it's all in my head." Patients typically equate the statement "Everything's normal," or "The tests all came back negative," with the conclusion that their clinicians don't believe anything is wrong, that the patient is exaggerating or that his or her condition is "mental." When confronted with this concern, there is a disturbing tendency amongst clinicians to equivocate and thereby leave the concern unanswered. There are three possibilities: 1) There may be an underlying medical (anatomical or metabolic) disorder that has yet to be identified or yet to have responded to treatment, 2) the condition is psychophysiological, meaning that there is a physical condition that is aggravated and sustained by stress, tension, anxiety or other lifestyle factors and/or 3) the patient's symptoms are in fact a somatoform disorder, meaning the presenting symptoms cannot be explained anatomically or physiologically and arise out of the patient's distorted perception or biases. Strategies for dealing with these issues are suggested in the Somatoform Pain Disorders section (in future continuation).

Chief Concern #4: "I need refills on my medications." Patients are well aware that physicians are uncomfortable about prescribing large amounts of habit-forming medications. If they are going to a new doctor, this is particularly anxiety provoking. Typically the patient will not deal with his or her need for these medications directly but instead will emphasize how bad the pain is or how it is getting worse. The physician may respond by ordering additional tests in the mistaken belief that the pain condition has changed or progressed when in fact the patient is really asking for pain medications. The patient often waits until the end of the visit to request pain medications, or even asks the receptionist after the doctor visit has ended. It saves much time and aggravation to ask about the use of habit-forming medications at the beginning of the visit. Even if the patient has listed all his or her medications, he or she may not accurately record the amount they are taking. If the patient is taking more than a few opiates or benzodiazepines per day, a habit-forming medication plan should be negotiated. Not until the patient is satisfied that there is a plan in place for him or her to receive an adequate supply, will the patient be able to focus on other issues, such as what is causing the pain and what can be done to relieve that cause.

Chief Concern #5: "I need my disability status continued or changed." This issue is in many ways similar to the previous one about habit-forming medications. Again the patient often will not raise this issue until the end of the visit. It is another area that most clinicians are uncomfortable with, and the completion of forms or reports to document disability is time-consuming and typically reimbursed poorly, if at all. In general it is a good idea to schedule a separate follow-up visit just for this purpose. The disability issue also adds another dimension to the clinician-patient relationship, especially if the need for disability cannot be based on independent objective findings. This is particularly the case with pain conditions such as migraine or muscle pain.

The modern patient is more educated, less trusting, expects comprehensive information and complete understanding of his or her options, benefits and risks.

When the clinician asks about work and leisure activities, if the patient states they are not working or are home-bound, this is a good time to ask if he or she is on disability. If so, the clinician should say something like, "Is your (previous) clinician filling out disability papers for you?" If the patient states that the previous clinician wants the pain-managing clinician to take over that role, then it is a good idea to say something like, "Okay, but I will need to collect your records and we should set up a special visit to address this issue because it can be quite complicated from a medical-legal perspective." This gives you time to make an informed decision. If the disability is for pain, it is a safe assumption that the insurance carrier for that disability policy will challenge the medical necessity of it and will request additional information. This can catch the clinician between two roles–the desire to be an advocate for the patient and the need to supply objective documentation for the disability. The most difficult circumstance is when the clinician believes there is an objective pathology, such as status-post laminectomy or residual radiculopathy, but also knows that most patients with this pathology are capable of normal or nearly normal functioning. One strategy to avoid this conflict is to recommend to the insurance carrier that they obtain an independent medical evaluation. In this way the pain-managing clinician can remain in the treating and advocate role, and leave it to another clinician to determine the factors and severity of disability.

If the decision is made to continue disability, it is usually a good idea to do so for short periods of time, not more than a few months between re-evaluations. In this way, the clinician has on-going opportunities to encourage the patient to create the most productive life possible within the limitations of the condition. n

Last updated on: March 20, 2013
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