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IMPLEMENTING A TEAM BASED
APPROACH TO MANAGING
CHRONIC PAIN
Talal Khan, MD and Jennifer Surprise, APRN
Objectives
• Review the pathophysiology of pain and the development of chronic pain.
• Understand that chronic pain is a complex biopsychosocial disease.
• Describe the interdisciplinary management philosophy for this complex patient population.
Definition of Pain
International Association for the
Study of Pain (IASP)
“An unpleasant sensory and
emotional experience associated
with actual and potential tissue
damage or described in terms of
such damage ...”
Scope of The Problem
IOM 116 million Americans suffer from chronic pain
Unrecognized and under-recognized disease
One of the leading causes of lost work time
May affect 65% - 85% of the US population at some point
in their lives
More patients afflicted with
pain than with heart disease,
diabetes and cancer combined
Cost up to $635 billion dollars in the US alone
Pain Pathways
Pain Pathways
Pain Pathways
Brain
Spinal cord
Peripheral nerve fibers
Altered “gating”Dorsal horn denervation hypersensitivity
Molecular changes
Gene expression changes
Receptive field changes
Ectopic discharges
Mechanosensitivity
Ephaptic crosstalk
Altered “gating”Molecular changes
Gene expression changes
Receptive field changes
Sympathetic fibers
Ephaptic crosstalk
Postulated Mechanisms Involved in Sustaining
Neuropathic Pain
Scope of The Problem
The Bio-Psycho-Social Axis
Changes Associated with the
Chronification of Pain
Brain Move from nociceptive to
emotional circuits
Spinal Cord Plasticity, abnormal connections
Sensitization
Nerves Neural plasticity
Brain. 2013
Do we try enough to prevent the
development of chronic pain?
• Unrecognized/underrecognized
• Mechanisms not completely understood
• Production pressure
• After thought
• Lack of clear preventive guidelines
• Treatments have side effects
• Combination treatments
• Care coordination
Mechanistic Management of Neuropathic Pain
Existing Evidence• Multimodal Analgesia for Perioperative Pain
Preoperative
• Antineuralgics
• Antiinflammatories
• Opioids
• Nerve blocks
Intraoperative
• Nerve sparing
• Muscle sparing
• Intraoperative opioids
• Nerve block
Postoperative
• Aggressive approach
• Nerve block
• Opioids
• Early mobility
• Continue NSAIDs and Antineuralgics
Team Approach
Evaluation History and Examination
Testing if Necessary
Discussion of root causes and treatment options suitable for YOU!
EDUCATION
Team discussion if necessary
Appropriate Treatments
BETTER!
Not Better
Re-evaluation
Interdisciplinary Treatment Approach
Stanton-Hicks M et al. The Clinical Journal of Pain;1998; 14:155-166.
Psychological Treatment
Pain ControlRehabilitation
Functional
Restoration
Surgical Correction
Patients with chronic pain are at increased risk for:
• emotional disorders (such as anxiety, depression,
and anger)
• maladaptive cognitions (such as catastrophizing and
poor coping skills)
• functional deficits
• physical deconditioning (due to decreased physical
activity and fear of re-injury)
• basic nociceptive dysregulation
All of these aforementioned variables, in turn, are often
interdependent so that one cannot simply treat one
to the exclusion of the others.
So what does this mean?
Evolution
• John Bonica
• University of Washington
Structure
Pain Physician
Behavioral Therapy
Physical & Occupational
Therapy
Surgery
Neurology
Rheumat
Social Worker
Interdisciplinary pain management
Embraces the fact that the comprehensive
assessment and treatment of all dimensions
(biologic, psychological, social) is needed in
order to be effective.
Such an approach has been demonstrated to
be the most therapeutic and cost-effective means of
managing the often recalcitrant chronic pain
syndromes.
Interdisciplinary vs. Multidisciplinary
Interdisciplinary
Individuals from various
disciplines
Individuals meet as a group
to provide
recommendations
Group collaborates to
achieve common goal
Improved outcomes through
communication
Multidisciplinary
Individuals from various
disciplines
Individuals provide
recommendations to the
physician, who ultimately
decides on patient
treatment
Benefits
Numerous experts working together to develop a plan to manage pain
Combined treatments are superior to single treatments
Increased return-to-work rate (Chapman, et al., 2000; Sanders, 2000)
Decrease in health care utilization
Improvement in psychological functioning (Mills, et al., 2004)
Outcomes
Outcomes
Outcomes
Goals of Interdisciplinary Pain
Management Decreased pain intensity
Increased physical function
Appropriate medication utilization
Increased sleep
Improved mood
Self-care strategies
Medications
Physical & Occupa-tional Therapy
Patient roles Provider
roles
Family/Care-giver roles
Interventional Techniques Radiofrequency ablation, anesthesia, surgery
Counseling/Support Group
Complementary and Alternative Medicine