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9 Articles in Volume 9, Issue #2
Acupuncture for Fibromyalgia
Brain Atrophy with Chronic Pain: A Call for Enhanced Treatment
Evaluating Function/Impairment of Low Back Pain Using SEMG
Medication-induced Xerostomia Secondary to Pain Management
Neuroscience, Neurophilosophy, and Neuroethics of Pain, Pain Care, and Policy (N3P3)
Reducing Pain and Anxiety During Reduction of a Fracture
Successful Treatment of Intractable Pain
Treating Chronic Pain by Patient Empowerment
Treatment of Scapulohumeral Periarthritis and Post-traumatic Joint Pain

Treating Chronic Pain by Patient Empowerment

When evaluating patients for chronic pain therapy, I always ask them at the initial consultation what treatment they have previously received. Many of these patients have been complaining of chronic pain for years to their physicians or other healthcare providers. Amazingly, the patients oftentimes respond simply “medications.” Incredulously, I will ask the patient, “You’ve only been taking medications?” to which they will respond, “Yes.” Patients also will occasionally say, “My doctor sent me to physical therapy for two years.” I will ask about this and find that the physical therapy had little-to-no benefit to the patient. Another favorite response of patients is, “My doctor sent me for lots of injections, including epidural steroid injections or facet injections.” I always ask if the epidural steroid injections worked and the response is almost invariably, “Not at all” or “Only for a brief while.” Unfortunately, many physicians regard pain management to consist solely of the prescribing of opiate pain medications. While I know that most pain physicians have difficulty believing this, but I think that a lot of our pain management practitioners suffer from a lack of vision that is caused by their procedure orientation. Unfortunately, I also believe that a lot of the procedural orientation that we see is driven by financial considerations.

Goals of Intractable Pain Management

In my clinic, I have as the goals of our treatment, the following:

  • Tolerable pain control most of the time, as judged by the patient and the physician with minimal or no side effects from the medication.
  • Improved function, as judged by the patient and physician.
  • Improved quality of life, as judged primarily by the patient.

Our means of accomplishing these goals can be briefly stated as:

  • Optimal utilization of opiate pain medications.
  • Optimal utilization of non-opiate medications including, but not limited to, antidepressants, anxiety-relieving medications, anticonvulsants, muscle relaxants, sleep aids, and other unique medications.
  • Learning, implementing, and utilizing pain reduction techniques.

I believe that patients definitely benefit from the utilization of medication, but I also believe that the primary goal of a pain management clinic should be to teach patients how and when to use pain reduction techniques. I also believe that it is very important that we empower our patients by providing them with the skills needed to no longer be a patient, but instead a person with chronic pain. I advocate that all of my patients join the American Chronic Pain Association (ACPA.org). The American Chronic Pain Association (ACPA) has a 10-step program that is utilized to transition a patient to a person. It is stated in their website that managing chronic pain is a journey that takes a patient to a person over time. It is noted that the isolation and fear that grows over time can overwhelm a person with chronic pain. In like manner, a return to a fuller, more rewarding life also takes time and is a journey with many phases. The ACPA describes these phases as 10 steps.

The ACPA’s 10 Steps For Moving Patient to Person

Step 1: Accept the pain. Learn all you can about your physical condition. Understand that there may be no current cure and accept that you will need to deal with the fact of pain in your life.

Step 2: Get involved. Take an active role in your own recovery. Follow your doctor’s advice and ask what you can do to move from a passive role into one of partnership in your own healthcare.

Step 3: Learn to set priorities. Look beyond your pain to the things that are important in your life. List the things that you would like to do. Setting priorities can help you find a starting point to lead you back into a more active life.

Step 4: Set realistic goals. We all walk before we run. Set goals that are within your power to accomplish or break a larger goal down into manageable steps and take time to enjoy your successes!

Step 5: Know your basic rights. We all have basic rights. Among these are the rights to be treated with respect, to say “no” without guilt, to do less than humanly possible, to make mistakes, and the ability of not having the need to justify your decisions with words or pain.

Step 6: Recognize emotions. Our bodies and minds are one. Emotions directly affect physical wellbeing. By acknowledging and dealing with your feelings, you can reduce stress and decrease the pain you feel.

Step 7: Learn to relax. Pain increases in times of stress. Relaxation exercises are one way of reclaiming control of your body. Deep breathing, visualization, and other relaxation techniques can help you to better manage the pain you live with.

Step 8: Exercise. Most people with chronic pain fear exercise. But unused muscles feel more pain than toned flexible ones. Together with your doctor, identify a modest exercise program that you can do safely. As you build strength, your pain may decrease. You will feel better about yourself, too.

Step 9: See the total picture. As you learn to set priorities, reach goals, assert your basic rights, deal with your feelings, relax, and regain control of your body, you will see that pain does not need to be the center of your life. You can choose to focus on your abilities—not your disabilities. You can grow stronger in your belief that you can live a normal life in spite of chronic pain.

Step 10: Reach out. It is estimated that one person in three suffers from some form of chronic pain. Once you have begun to find ways to manage your chronic pain problem, reach out and share what you know. Living with chronic pain is an ongoing learning experience. We can all support and learn from each other.

The most important thing about these steps, in my opinion, is that we ourselves can teach our patients how to do these things. To best do that, we must learn them ourselves and incorporate them into our own lives. I believe that it is important that the pain management physician be a role model. We must learn how to do these pain reduction techniques in our own lives and then develop programs that we can share with our patients so that they can implement them in their own lives. There are a multitude of pain reduction techniques, but the important point to remember is that there is no formula or secret to these. In my office, I have developed numerous handouts that I give to patients that answer their questions about many different aspects of managing chronic pain using methods other than the dispensing of pain medications or other pills.

Every patient who leaves my office does so with not only prescriptions, but also recommendations about websites to visit, books to read, and things to do to deal with certain aspects of their lives that are impeding their control of their chronic pain. Areas that I cover in teaching pain reduction techniques to my patients include the following:

  • Sleep
  • Exercise
  • Nutrition
  • Nutritional supplements
  • Meditation or relaxation response
  • Energy techniques such as The Emotional Freedom Technique or Holosync
  • Amino acid supplementation
  • Journaling
  • Spiritual instruction
  • Prayer
  • Financial instruction
  • Stress management
  • Music therapy
  • Relaxation therapy
  • EEG brainwave training
  • Church or support groups
  • Smoking cessation.
  • Fasting
  • TENS unit utilization
  • Alpha stimulation
  • Affirmations
  • Cognitive behavioral therapy

Case Illustration

As an example of how to empower patients, I will go over how I would manage a chronic pain patient who presents with a high depression level. In every office visit, I question my patient about their mood, anxiety, stress, and activity level. If a patient reports a high depression level, I will usually ask the patient to complete a Burns Depression Checklist. This excellent tool can be found in Dr. David Burns’ book, Feeling Good. This checklist is a 25-question test where the patient ranks his response in a graded fashion. The patient can score from zero up to 100. The significance of the score can be shown to the patient from the next page in that book and which I have readily available to show the patient. If the patient scores high on this test—indicating a moderate, severe, or extreme depression—I will discuss the possible utilization of antidepressants. In addition, I will take this opportunity to recommend that the patient go to the local bookstore and purchase Dr. Burns’ excellent book for the minimal cost of $7.99 and explain that this book will allow them to learn cognitive behavioral therapy on their own. I oftentimes will then read appropriate sections of Dr. Burns’ book. I can say that I have read this book several times myself and have implemented the information in this book in my own life. I do not know of anyone alive that would not benefit from reading this excellent book. If the patient’s depression is severe, I will oftentimes make arrangements for the patient to be seen by a psychologist and, if necessary, will call and make the appointment for the patient to see the psychologist immediately. Of course, I always question patients as to whether or not they are having problems with suicidal thoughts or planning. Obviously if a patient is planning to end his or her life, immediate intervention needs to be made and appropriate referrals made. At the next recheck, I can assess whether the patient has obtained the book and how much they have read by questioning them on various aspects of the book.

“I believe that patients definitely benefit from the utilization of medication, but I also believe that the primary goal of a pain management clinic should be to teach patients how and when to use pain reduction techniques.”

In my recheck form, I also question the patients as to their sleeping habits. If the patient is having trouble sleeping, we can discuss medical management of their sleeping, but I also provide a handout that I prepared that incorporates all the information contained at the American Sleep Association website. I also have several handouts, including a handout from Dr. Mercola’s website, www.mercola.com, titled “33 Secrets to Sleeping.” I also have recommendations regarding low cost herbal preparations that I have found to be very helpful in inducing and maintaining sleep. This technique places the responsibility clearly on the patient’s shoulders to become involved in the healing process.

The patients learn that there are many avenues of pain reduction that do not involve medications. It is my belief, and I transmit this very clearly to my patients, that the most important aspect of managing chronic pain is the patients, themselves, becoming empowered so that they become their own best advocate. Many patients complain that they are incapable of learning new techniques. For these patients, I recommend different avenues of learning such as books on tape.

Discussion

It is an axiom in chronic pain management circles that the ultimate in pain management is the multidisciplinary pain clinic. However, there are, unfortunately, very few of these facilities available and none of them are affordable to those who are self-pay patients. These clinics are also very inconvenient. I can think of very few of my patients who could afford an expensive multidisciplinary pain clinic coupled with taking 4 to 6 weeks out of their life and family. I know that I personally could not incorporate such a treatment modality into my lifestyle. Fortunately, I have to work on a daily basis in order to pay my bills. However, it is very possible to become a daily student of pain reduction techniques and there are many excellent avenues for learning these pain reduction techniques.

It is possible to emulate a multidisciplinary pain clinic by regular instruction in pain reduction techniques. It is also my considered opinion that very few patients with significant chronic pain can be improved in only a 4 to 6 week period of time. In my opinion, it oftentimes takes several years for patients to incorporate even a modicum of the pain reduction techniques that are available to them.

Another excellent example of a way of teaching a patient pain reduction techniques is by recommending that patients visit certain websites. I have frequently recommended Gary Craig’s excellent website, www.emofree.com. At this website, the patients can be given a free 84-page PDF document that instructs them very clearly in how to learn and implement the Emotional Freedom Technique. This is a technique that utilizes tapping of acupuncture points while repeating affirmations. This powerful technique can be utilized to treat not only chronic pain but also depression, anxiety, sleep disorders, poor golfing abilities, difficulties bowling, and just about any of the challenges that life might throw at us. The patients can also sign up for receiving Gary Craig’s frequent emails that provide additional instruction in this technique. Mr. Craig also has available very low cost DVDs that give excellent examples of how to treat conditions utilizing his powerful wellness tool. I have personally learned the Emotional Freedom Technique and have used this on an almost daily basis to deal with challenges that any pain physician frequently encounters.

In regard to exercise, I have found several books that I recommend and also have several handouts that I provide to patients. I have found it very helpful to recommend that the patients start a walking program in order to energize themselves, and that they obtain and use a pedometer. I myself wear one and can readily show this to patients and tell them where to obtain it. I can also tell them how I utilize this technique in helping to improve my overall health. Oftentimes, patients have been told by numerous physicians that if they hurt they should do nothing but I advise them to do the exact opposite. I advise them to make it a goal that they be able to walk at least 10,000 steps a day on a regular basis. Many patients are not capable of doing this but they can at least do the best they can and monitor their progress. You will find that the patients become very excited about this process and will oftentimes write down the exact number of steps that they have been taking.

I also recommend that patients do journaling and I, myself, keep a journal. I have this journal available so that I can show it to patients. I also recommend to my patients that they write out a “goals list” for every year, and a “gratitude list” that they carry on themselves update frequently. I have my goals for 2009 and my gratitude list on 3 x 5 cards that I carry in my wallet and that I can show my patients.

Being a pain management physician requires that the physician be authentic and develop a true relationship with their patients. We must have the wellbeing of our patients foremost in mind. We cannot tell patients to do something and then not have any idea of how to do it or not believe in it enough to incorporate it into our own lives. I believe it is also important that the pain management physician allow adequate time to see each patient. When I initially started my pain management practice, I structured it as a neurosurgeon might, with very quick rechecks, seeing 4 to 6 patients an hour. I quickly found out that this was impossible and now have 30 minute rechecks for all of my pain patients. This limits the number of patients that I am capable of seeing, but these complex and fragile patients cannot be handled in the same manner as a regular patient. I believe that we need to look at every aspect of the patient’s life and start to improve their lives bit by bit. I believe it is important to incorporate the patients into the process and have them become active participants in their recovery. When I was in my neurosurgical training, Dr. Robert Niten, Chief of Neurosurgery at Loma Linda Medical Center, cautioned me to not have so much patience that the patient becomes dependent upon me as a physician. He advocated that the patients are responsible for a great deal of their health care and that they can do better if they are largely in charge of getting themselves better. I think this will also allow for a very individualized approach. You will find that some patients move at a very fast pace while others take a very long time to move forward. Some patients are enamored with the medications and are looking for a “silver bullet” to cure their problem. Other patients realize very quickly that the medications have limited efficacy and seem to understand intuitively that they must do many more things than just take a pill in order to become a person rather than a patient.

Last updated on: January 5, 2012
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