Multi- and Interdisciplinary Approach to Chronic Pain Management Steven Stanos, DO

Multi- and Interdisciplinary Approach to Chronic Pain Management

Steven Stanos, DO

www.ric.orgwww.ric.org

Working Together- Critical for Success


Criteria for Success

Society

Individual

Workers Comp

Return to Work

MCOHealth Care Utilization

Functional, Emotional improvements

Health Care Provider

Satisfaction, Low Adverse events

Pain Relief

Gatchel and Okifuji, J Pain 2006:7(11)


Chronic Pain Interrupts

• Behavior• Function• Identity• Cognition

(Harris et al., Pain: 105, 2003)


The PAIN Patient

• Demoralized by continued quest for relief

• Cascade of ongoing stressors• In a state of “medical limbo”• Inactivity leads to preoccupation

with “the body in pain”• Change from active to more

passive coping with the pain

www.ric.orgwww.ric.orgPincus T. Morley S. Psychological Bulletin. 2001;127(5)

Enmeshment and Pain

Pain Illness

Self

Healthy-normal enmeshment

www.ric.orgwww.ric.orgPincus T. Morley S. Psychological Bulletin. 2001;127(5)

Enmeshment and Pain

Pain Illness

Self

Enmeshment resulting in distress


Symptom Magnifiers (Matheson)

“refugee”

“game player”

“identified patient”

Matheson LN. Symptom Magnification Syndrome. Aspen Publ. 1988.


Gate Control Theory

Melzack R. Neural Blockade in Clinical Anesthesia & Management of Pain, 1998.


Gatchel’s 3-Stage Model

• Stage I: Normal emotional reaction during acute phase• Stage II: Behavioral and psychological reactions and problems• Stage III: Acceptance or habituation to “sick role”

Gatchel RJ, 1991

www.ric.orgwww.ric.orgCassano eta l, J of Psychosom Research, 2002

Depression: Behavioral & Physical Symptoms

Behavioral• Interpersonal friction• Anger• Avoidance• Reduced productivity• Substance use/abuse• Victimization• Social withdrawal

Physical• Fatigue• Insomnia/hypersomnia• Appetite changes• Pains and aches• Muscle tension• Gastrointestinal upset

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Predictors of Depression in Chronic Pain

• Pain intensity• Frequency severe pain experienced• Number of painful areas• Psychosocial factors

– low self efficacy– poor coping– poor problem solving

• Functional disability

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Pain Symptoms More Resistant

EmotionalDepressive Symptoms

Positive Well-being

PhysicalNon-Pain Somatic

Pain Somatic

Months1 63 9

Greco T, et al. J Gen Intern Med. 2004;19:813-18.


Interference

Life Control

Pain Depression.07

.47** .27*

-.28* -.44**

Cognitive-Behavioral Mediation Model

Turk et al. Pain, 61, 1995

www.ric.org16

Psychological Aspects of Persistent Pain


Anger1

1. Okifuji Turk Curran 19982. Sullivan M, 2008.

Perceived Injustice2


ANGER: Agent and Action

Injury/IllnessHealth care providersLegal systemInsurance companies/Social security systemEmployerSignificant othersGodSelfThe world

Chronic painDx ambiguity, failureAdversarial disputeInadequate compensationLose job, job retrainingLack of supportIll fateDisablementAlienation


ACCEPTANCE“Living with pain without reaction, disapproval, or attempts to reduce or avoid it . . .

A disengagement from struggling with pain.”

McCracken LM, Pain; 1998.

McCracken LM, J Back Musculoskel Rehab; 1999.

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Typical Patient Referral Characteristics

• Preoccupation with pain• Strong needs for dependency

and nurturance• Feelings of loneliness and

isolation• Self-defeating behavior patterns• Anger and hostility

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Facilitators Obstacles

Motivational factors Motivational factors

Adheres to program Motivated to return to work

Does not believe in program Has other plans than RTW

Capacities Capacities

Good cognitive capacities Good coping strategies Good interpersonal skills

Low cognitive capacities Coping difficulties Poor interpersonal skills

Personality-related factors Personality-related factors

Positive realistic attitude Proactive, extroverted Genuine

Pessimistic, “victim” Demanding, introverted Opposed to physical activation Lack of sincerityLoisel P, et al. J Occ Rehab 2005;15:581-

90

Worker Factors to Consider

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Insurer’s Actions/ Attitudes

Facilitators ObstaclesTowards Team Towards Team

Refers appropriate workers Authorizes requests Understands program Trusts the team Reacts promptly Flexible

Does not understand program Delays communications Withholds information Poor knowledge of case Impatient Doubts team’s competence

Towards Worker Towards Worker

Informs worker of rights Knowledge of case

Does not inform worker Easily influenced by worker Splitting team and worker Too much bureaucracy

Liosel P, et al. J Occ Rehab 2005;15:581-90

www.ric.orgwww.ric.orgDersh, Polatin, Leeman. J Occ Rehab 2004;14.

Secondary Gain

Internal• Gratification pre-existing unresolved dependency

& revengeful strivings• Attempt to elicit care-giving• Ability withdraw from unpleasant or unsatisfactory

life roles• Adoption of “sick role”• Convert socially unacceptable disability to a

socially acceptable one


Secondary Gain

External• Financial awards

– Wage replacement– Settlement– Debt protection

• Protection from legal and other obligations

• Job manipulation• Vocational retraining and skill upgrade


Tertiary gains and losses

Gains1. Gratification of altruistic

needs2. Change in role3. Decrease family tension4. Resolve marital difficulties

Losses1. Increased responsibilities2. Emotional effect3. Disturbance within the

relationship4. Guilt created by the ill

individual5. Financial hardship

Dersh, Polatin, Leeman. J Occ Rehab 2004;14.


Psycho-

Neurophysiology, Physical Dysfunction,

Tissue Trauma ?

Illness Behavior, Beliefs, Coping, Emotions,

Distress

Culture, Social interactions, Sick role

Bio-

Social-

Impairments

Activity limitations,

Personal factors

Environmental, participation

Waddell, Burton, Best Practice Res Clin Rheum 2005;19(4).

Classifications of Pain


Continuum of Team Models

Boon H, et al. BMC Health Services Research. 2004;4:15.

Coordinated Interdisciplinary

Collaborative Multidisciplinary Integrative

Parallel Practice

Continuum of Team Models

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Multidisciplinary Team Network

Psych

RN

Psychiatrist

OTPT

Family

Addiction Medicine

Vocational

Pain Physician

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Interdisciplinary Team Approach

Psych

RN Physician

OT

PT

RT

SW

Voc

PATIENT


Pain Program Goals

• Decrease pain intensity• Increase physical activity• Improve pain medication regimen• Improve psychosocial functioning• Return to leisure pursuits and work• Reduce utilization of health care

services


Commonalities of Treatment

• Re-conceptualize patients’ pain• Foster optimism and combat

demoralization• Active patient participation and

responsibility• Specific training in specific skills• Encourage feelings of success, self-

control and self-efficacy


“Yellow Flags”

• Maladaptive beliefs• Expectations and pain behavior• Reinforcement of pain• Heightened emotional activity• Job dissatisfaction• Poor social support• Compensation

Cairns MC, Spine 2003; 28(9):953-59


Interdisciplinary Team Approach

Loeser JD, Turk DC. Multidisciplinary pain management. In: Loeser JD, Butler SH, Chapman CR, Turk DC, eds. Bonica’s Management of Pain. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:2069-2079.

John Bonica, MDBen Crue, MD

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RIC’S CPM Program Components

• Physical therapy• Occupational therapy• Recreation Therapy• Psychology (CBT)• Relaxation Training• Nurse Education• Vocational Therapy• Mind Body Treatment/

Feldenkrais

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Monday Tuesday Wednesday Thursday Friday

8aWeekend

reviewGym Gym Relax (G) Gym

9Nursing lecture

OT Tolerance Psych Biofeedback MD visit

10 PT OT tolerance MD visit Voc OT

11 MD visit Video Feldenkrais

12 Relax (G) Feldenkrais PT

1 OT (G) PT BiofeedbackTherapeuticrecreation

Psych (G)

2 Biofeedback OTTherapeutic recreation

Relax (G) Relax (G)

3 Nursing Psych

4 Pool Wii Group Pool Family meeting (G) Pool

Sample: Full Pain Program Schedule


Phases of Treatment

• Educational• Skills training• Application and relapse

prevention


Physical Therapy

• Comprehensive assessment

• “Active” vs “Passive”• Movement based• Strengthening• Aerobic conditioning• Home exercise plan

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Sit to Stand

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Occupational Therapy

• Positioning • Pacing

Techniques/Implementation • Stress Loading Techniques • Strength/Endurance Training • Activity Tolerance


Role of Pain Psychology

• WEEK I– Classes: Vicious cycles of chronic pain and Gate-control theory of pain– Individual: Acceptance of chronicity vs. continuing search for cure,

Rationale for techniques/tools to manage the pain Active self-management vs. passive medical treatment Focus on functional restoration as well as pain management



• WEEK II – Classes: Pain management tools (i.e. distraction, relaxation)

– Stress – Pain connection– Stress management– Identifying negative thoughts– Catastrophic pain thoughts (re-injury)– Depression thoughts (i.e.“Why bother?”)– Challenging negative thoughts

– Individual: Cognitive – behavioral intervention– Challenging negative and self-defeating thoughts– Encouraging re-activation (rather than “if it hurts, don’t do it”)– Encouraging behavioral flexibility (rather than “I’ve always done it this way”)



• WEEK III– Classes: Stress management– Skills Training

Communication Assertiveness Problem solving

– Individual: Cognitive – behavioral intervention Continued pain intervention Patient’s individual stressors Identifying stressful situations Developing attitudes & skills to cope more effectively



• WEEK IV– Classes:

Stress management tools Relapse prevention: Identifying high risk situations Developing a plan to prevent relapse

– Individual: Cognitive – behavioral intervention Anxiety management Return to work or vocational rehabilitation Identifying patient’s strengths and resources Increase confidence and self-efficacy

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Relaxation Training/ Biofeedback

• Deep Breathing• Imagery and Visualization• Progressive Muscle

Relaxation (PMR)• Biofeedback


Vocational Rehabilitation

• Identify• Educate• Incorporate

• Return to Work• FCE• MMI• Closure


The 12-C Approach

1. Communication2. Cooperation3. Cohesiveness4. Commitment5. Collaboration6. Confront problems

7. Coordination of efforts8. Conflict management9. Consensus10. Caring (patient-centered)11. Consistency12. Contribution

Heinemann GD, Zeiss. New York, 2002.

www.ric.org ©2003 Rehabilitation Institute of Chicago

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Summary

• Multi- and Inter-disciplinary approach incorporates a biopsychosocial approach

• Depression, anxiety, anger, poor self efficacy, catastrophizing are important psychological factors that need to be identified and focused on for improved outcomes

• Pain management focuses on improving function, psychosocial well being, and making patients more active participants

Documents

Multi- and Interdisciplinary Approach to Chronic Pain Management Steven Stanos, DO