Comprehensive, Multimodal Pain Rehabilitation at AMITA Health

The definition of pain proposed by the International Association for the Study of Pain in 2020 emphasizes the biological, psychological, and social factors underlying pain perceptions1. This is reflected in modern pain medicine programs through the use of comprehensive management plans that aim to treat the complex and diverse etiologies of chronic pain.

Evidence has suggested that plans combining pharmacologic, nonpharmacologic, and interventional treatments can be effective in managing chronic pain compared with traditional approaches. Likewise, it has been proposed that pain management programs should employ a multimodal and interdisciplinary strategy that makes use of adjuvant mental health services, physical therapy, and patient neuroscience education2,3,4.

At the AMITA Health Neurosciences Institute, this approach is the cornerstone of the pain management program. Multidisciplinary teams of pain specialists, surgeons, health psychologists, physical therapists apply a wide range of interventions which include image-guided injections, personalized pharmacologic therapies, mental health services as well as cutting-edge techniques like spinal cord stimulation (SCS). Because the practice of pain medicine is constantly evolving, implementing this dynamic and evidence-based approach into the ecosystem of care ensures that patients receive the most comprehensive and effective therapies.

Interventional techniques

The number of interventional and pharmacologic treatments for chronic pain has increased in recent years5,6. Advances in image-guided glucocorticoid injection, radiofrequency nerve ablation, and nerve blocks in combination with the development of opioid-sparing pain medications have created a variety of avenues for treatment. Likewise, pain medicine specialists have increasingly been able to match pharmacologic and interventional therapies with the specific functional goals of patients.

Physicians at the AMITA Health Neurosciences Institute integrate information from the patient history, including prior surgeries and self-reported pain localization, to choose the most appropriate intervention for each case. By superimposing these data with the results of multimodal imaging studies, providers are able to administer epidural or transforaminal glucocorticoid injections, radiofrequency ablations, and nerve root blocks at the neuronal loci generating particular pain patterns.

Pharmacologic approaches

Pharmacologic management of chronic pain comprise a variety of drug choices informed by the type and nature of pain7. Though the use of opioid medications can often be a point of concern for patients, providers at the AMITA Health Neurosciences Institute work to implement opioid-sparing analgesic regimens whenever possible. When opioids are deemed appropriate, pain management specialists abide by an “opioid playbook” based on CDC guidelines. Central to this strategy is identifying valid use-cases for opioid medications, monitoring patients at risk for substance-use disorders, and frequently assessing drug dosage to ensure effective treatment.

Non-pharmacologic approaches

It has been shown that supplementing interventional and pharmacologic therapies with nonpharmacologic approaches can result in a clinically significant improvement in patient pain reduction compared with baseline8. Physicians at the Neurosciences Institute work in tandem with in-house health psychologists trained in cognitive behavioral therapy, mindfulness-based stress reduction, and patient neurophysiology education. Patients can thus receive individualized treatment for factors exacerbating or contributing to pain, such as stress, anxiety, and depression, as well as for pain itself. The addition of physical therapy to pain management regimens has also been shown to improve patient function3. Addressing the functional limitations of a patient with chronic pain can aid in reducing fear avoidance and deconditioning behaviors as well as encourage active recovery. Physicians at AMITA Health collaborate with in-house physical therapists or offsite providers to meet patient-specific goals.

Spinal cord stimulation

Spinal cord stimulation (SCS) is a potent neuromodulatory intervention for patients with chronic pain refractory to traditional interventions. SCS has been shown to be effective in a number of chronic pain etiologies including persistent upper lumbar or lower cervical radiculopathies (“failed back surgery syndrome”) as well as complex regional pain syndrome, painful peripheral vascular disease, and intractable angina. Though patients with coagulopathies or active infection may be at risk for complications, SCS has few contraindications overall9.

At the AMITA Health Neurosciences Institute, pain management physicians and spinal surgeons work closely to determine if patients are suitable candidates for SCS, employing a two-stage approach. The first stage involves a percutaneous trial period whereby an external pulse generator and temporary leads are placed at the anatomical focus of pain under fluoroscopic guidance. Patients are discharged and monitored for pain control. If significant improvements are seen, the temporary leads are removed, and patients are scheduled for surgery. The second stage involves permanent implantation of an internal pulse generator as well as the epidural placement of the leads. After this, patients are followed to review SCS settings as well as monitor surgical complications.

AMITA Health physicians work closely with referring physicians and look forward to returning patients to your care as quickly and efficiently as possible.

Mona Patel, MD
Pain Medicine
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References

  1. Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976-1982. doi:10.1097/j.pain.0000000000001939
  2. Scascighini L, Toma V, Dober-Spielmann S, Sprott H. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology (Oxford). 2008;47(5):670-678. doi:10.1093/rheumatology/ken021
  3. Skelly AC, Chou R, Dettori JR, et al. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update. Rockville (MD): Agency for Healthcare Research and Quality (US); April 2020.
  4. Nijs J, Wijma AJ, Willaert W, et al. Integrating Motivational Interviewing in Pain Neuroscience Education for People With Chronic Pain: A Practical Guide for Clinicians. Phys Ther. 2020;100(5):846-859. doi:10.1093/ptj/pzaa021
  5. Huygen F, Kallewaard JW, van Tulder M, et al. "Evidence-Based Interventional Pain Medicine According to Clinical Diagnoses": Update 2018. Pain Pract. 2019;19(6):664-675. doi:10.1111/papr.12786
  6. Manchikanti L, Boswell MV, Hirsch JA. Innovations in interventional pain management of chronic spinal pain. Expert Rev Neurother. 2016;16(9):1033-1042. doi:10.1080/14737175.2016.1194204
  7. Dale R, Stacey B. Multimodal Treatment of Chronic Pain. Med Clin North Am. 2016;100(1):55-64. doi:10.1016/j.mcna.2015.08.012
  8. Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA. 2016;315(12):1240-1249. doi:10.1001/jama.2016.2323
  9. Mekhail NA, Mathews M, Nageeb F, Guirguis M, Mekhail MN, Cheng J. Retrospective review of 707 cases of spinal cord stimulation: indications and complications. Pain Pract. 2011;11(2):148-153. doi:10.1111/j.1533-2500.2010.00407.x