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10 Articles in Volume 15, Issue #9
Differentiating Insomnia and Depression in Chronic Pain Therapy
Improving the Sex Lives of Patients With Chronic Pain
Incorporating Concierge Medicine into Pain Management
Interdisciplinary Rehabilitation: Information for Pain Practitioners
Latest Advances in the Diagnosis and Treatment of Polymyalgia Rheumatica
Letters to the Editors: Arachnoiditis, Pituitary Adenoma
Opioid Withdrawal: A New Look at Medication Options
Oral Opioids: Not for Everybody
Oxycodone Metabolism
Sexual Therapy for Patients with Chronic Pain

Interdisciplinary Rehabilitation: Information for Pain Practitioners

Understanding the role of epidurals, nerve blocks, neurostimulation, and osteopathic manipulation can help improve treatment and alleviate suffering.

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

Nerve Blocks

A nerve block is an injection directly around (not into) the nerves that serve an area of pain, such as occipital (cause headaches) and sympathetic (in extremities and abdomen) nerves.

A medial branch block (for the treatment of arthritis in joints of spine) is a diagnostic injection that temporarily interrupts the pain signal being carried from a specific facet joint. If the medial branch block proves to be successful, then a radiofrequency nerve ablation may be performed, during which radio frequency waves are used to heat up specifically identified nerves surrounding the facet joints. Prior to the procedure, patients may take their normal medications with a small amount of water, except if they are taking any blood thinners—these medications must be discontinued well before the procedure with the prescribing physician’s consent.

Nerve blocks often are performed in a procedural clinic, usually with the patient lying on his or her stomach on a fluoroscopy table. The site of the nerve block is cleaned with an antibacterial solution. Anesthetic is injected into the site, and x-ray imaging helps guide placement of the needle. After the procedure, staff members observe the patient for 30 to 45 minutes before a companion escorts them home. Complications due to nerve blocks are rare but can include infection, bleeding, or an injection into a blood vessel.11

Neurostimulation

Neurostimulation involves surgically implanting a device that uses electrical impulses to block pain. Spinal cord stimulation (SCS) is used to treat chronic and intractable pain, including failed back surgery syndrome, complex regional pain syndrome, and phantom limb pain. A simple SCS system consists of 3 parts: microelectrodes (implanted in the epidural space to deliver stimulation pulses to the spinal cord), an electrical pulse generator (implanted in the lower abdominal area or gluteal region where it is connected to the electrodes via wires), and a remote control (to adjust stimulus parameters such as pulse width and pulse rate).

Candidates for the SCS must undergo a medical and psychological evaluation, trial procedure (1 week), final implant surgery, and follow-up with a gradual decrease of medications.3 Patients with chronic pain should be encouraged to move every day when possible. Thus, interventional approaches may be coupled with a manual therapy, such as spinal, or osteopathic manipulative treatment (OMT).

Osteopathic Manipulation

A concept patients with chronic pain should embrace is that of “motion is lotion.” It is the idea that continued movement can improve or maintain function and promote health. It also is an idea rooted in the principles of osteopathic medicine, in which the movement of the body promotes health. OMT usually is performed by a Doctor of Osteopathic Medicine (DO). It is an added tool for the DO in which they use manual medicine to promote well-being.

Osteopathic medicine is based on the works of Dr. Andrew T. Still, an MD-trained physician in the mid 1800s who became disenchanted with medical practice after he lost his children to meningitis.12 Dr. Still believed that rather than treating only symptoms, a doctor should try to discover the cause of disease.13 Dr. Still once stated that the “bone is the starting point from which to ascertain the cause of pathological conditions.” He practiced medicine believing that illness could be caused through dysfunction in the musculoskeletal system, and that manual manipulation could help harness the body’s own potential for self-repair.

In 1855, Dr. Still coined the term “osteopathic medicine.”14 It is unclear when Dr. Still added manipulation to his philosophy of osteopathic medicine, but by 1879 he was known as the “lightning bonesetter.”14 It wasn’t until 1892 that the first “osteopathic school” was opened, in Kirksville, MO. There now are more than 20 accredited colleges of osteopathic medicine and about 44,000 osteopathic practitioners in the United States.15 DOs vary in their use of OMT. According to recent research, about 6% of DOs surveyed reported treating more than 50% of their patients with OMT, whereas nearly one third reported using OMT on less than 5% of their patients.16

There are 4 principles by which a DO approaches health:

  1. The human being is a dynamic unit of function;
  2. The body possesses self-regulatory mechanisms that are self healing in nature; 
  3. Structure and function are interrelated at all levels; and
  4. Treatment is based on the understanding of the previous 3 principles.17

However, a physician’s foremost principle is to “do no harm.” To apply these 4 osteopathic principles, a DO strives to restore the body’s normal structure and function, which promotes its self-healing nature. When structure is altered via the musculoskeletal system, abnormalities occur in other body systems. This, in turn, can produce restriction of motion, tenderness, tissue changes, and asymmetry. In other words, dysfunction in one area of the body, such as pain in the lower back, is believed to possibly derive from dysfunction of multiple other areas of the body, such as the mid-back or the neck. Thus, restoration of function in these areas also might help improve the symptoms and motion in an area of concern.

Some common problems treated by a DO using OMT include mid to low back pain, neck pain, muscle tightness or stiffness, hip pain, fibromyalgia, muscle injury, scoliosis, some types of headaches, and muscle spasms. In 2014, a systematic review and meta-analysis of 15 randomized controlled trials found moderate quality evidence that OMT reduces pain and improves functional status in acute and chronic nonspecific low back pain.18

The goal of OMT is to improve the natural range of motion (ROM) of the body by overcoming restrictions to normal motion. To do this, a DO will take an extensive patient history and review any relevant diagnostic tests, such as images or laboratory results. The DO also will use his or her hands to palpate the body, looking for restrictions to normal ROM while the patient remains clothed. The value of the placing of hands on a patient is universally acknowledged by health professionals. This essential component of the doctor-patient relationship has a great deal to do with the patient’s well being. Thus, when the DO examines a patient with his or her hands, the treatment has already begun.

After discussing options for treatment and understanding the patient’s comfort with the proposed therapy, a DO will use different techniques to try to improve motion. Amongst a diverse group of DO methods, the 3 most commonly used techniques include myofascial release, isometric stretches (or muscle energy), and high-velocity, low-amplitude treatment (HVLA).19

With direct myofascial release, the tissue is loaded with a constant force until release occurs. With indirect myofascial release, the dysfunctional tissues are guided along a path of least resistance until free movement is achieved. It is through the continual direct or indirect engagement of myofascial barriers, which the DO palpates, that a release of myofascial tissues occurs. For example, myofascial release may relax the myofascial tissue of the low back in a patient with chronic pain.

During isometric stretches the patient’s muscles are actively used against a comparable physician counterforce for stretch. The purpose is to restore motion, decrease muscle/tissue changes, and modify asymmetry of somatic dysfunction.

Through HVLA, more commonly known as the “thrust technique,” the DO employs a rapid and therapeutic force of short duration and short distance to restore or improve the ROM of a joint. The procedure reduces and/or completely nullifies the physical signs of somatic dysfunction tissue changes, asymmetry, restriction of motion, and tenderness. Sometimes during this treatment, a patient might feel or hear a “pop,” but success of the technique does not depend on that.

Patients may find instantaneous relief of pain symptoms with the use of OMT over time. In addition, through motions of OMT, a patient will gain confidence that motion can be safe and effective for the body. Before the conclusion of a visit with a DO, the patient and the provider will determine which OMT techniques worked best for the patient, as well as how many follow up visits a patient might need to achieve a desired level of functional improvement. Each patient is treated with this shared decision-making perspective in mind.

OMT is much like chiropractic care, allopathic care, physical therapy, and yoga in that all of these forms of treatment are trying to promote motion. However, each is distinct in its own way. The primary differences between a DO and other therapists are their levels of training and the scope of their practice (Table 2).

For example, a chiropractor (Doctor of Chiropractic) is not a licensed physician and has not completed residency training in a hospital. The scope of chiropractic practice is defined by statute and is primarily concerned with normalizing the alignment of the spine to influence the relationship between the spinal column and the nervous system. The focus in treatment for a DO goes beyond simple spinal alignment by also dealing directly with abnormal body physiology using an array of direct and indirect techniques. This also means that the DO does not prescribe months of treatment at the first visit but lets the prescription unfold as the treatment progresses.20 Regardless of which modality one explores, they are all based on the first law of motion, which states that “a body at rest stays at rest, and a body in motion stays in motion.”21

Acknowledgements
The authors wish to thank all the veterans and providers who contributed to the Pain Education School program from which this tutorial was created. The authors especially want to thank David Schaefer, DO, MPH, and Felix Angelov, MD, for their contributions in teaching about interventional approaches and osteopathic manipulation. We also would like to thank the Jesse Brown VA Medical Center’s Anesthesiology/Pain Clinic Department for their vision and ongoing support of the Pain Education School program.

 

Last updated on: November 9, 2015
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