interdisciplinary pain management & functional restoration james w. atchison, do medical...

INTERDISCIPLINARY PAIN MANAGEMENT

& FUNCTIONAL

RESTORATIONJAMES W. ATCHISON, DO

Medical Director, Center for Pain Management

Professor of PM&R

Northwestern Feinberg School of Medicine

DISCLOSURES

Principle Investigator for RIC participation in multicenter research project for Paraxel/Pfizer.

Principle Investigator for RIC participation in multicenter research project for INC/Grunenthal.

Advisory Board for Mallinkrodft

Advisory Board for Janssen

REVIEW OF CASE ISSUES

CONTINUED PAIN w/ POOR SLEEP • SPREADING PAIN PATTERN

INCREASED DEPRESSION AND ANXIETY FAILED MULTIPLE PROCEDURES MEDICATIONS INEFFECTIVE

• LONG ACTING OPIOID – OXYCONTIN 40 MG TID 180 MEQ MS PER DAY

• SHORT ACTING OPIOID – NORCO 10/325, 8 PER DAY 80 MEQ MS PER DAY

• BENZODIAZEPINE – TID (2 AT NIGHT)• ?MUSCLE RELAXANT AND SSRI?

THE TRIAD: PAIN, SLEEP, AND MOOD

Pain

Sleepdisturbances

Depression /anxiety

Functional impairment

PSYCHOSOCIAL “YELLOW FLAGS”

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

New Zealand Accident Comp Corp. 1997;23-66.Cairns MC, Spine 2003; 28(9):953-59.

PHYSICAL “YELLOW FLAGS”

Pain moves from local to regional Guarding of the injured area Fear of movement Fear of re-injury Decrease in proper movement

patterns

INTERDISCIPLINARY FUNCTIONAL RESTORATION, FEINBERG, GATCHEL, STANOS ET AL; CH. 82 IN COMPREHENSIVE TREATMENT OF CHRONIC PAIN BY MEDICAL, INTERVENTIONAL AND INTEGRATIVE APPROACHES,

DEER ET AL, 2013, AMERICAN ACADEMY OF PAIN MEDICINE

MEDICATION “YELLOW FLAGS”

Continued use of meds w/o pain reduction or improved function• Despite continuation of side effects• Beyond the natural history of recovery

Escalating doses w/o benefit Multiple opioids Early use of long acting opioids Use of opioids w/ benzodiazepines Intolerance of PT w/ medications

SELECTION CRITERIA

WHAT DOES A FUNCTIONAL RESTORATION PROGRAM CHANGE?

Very Much Worse

Very Much Improved

No Change

RIC Full Program Completers 2013

No Change

No Change

REVIEW OF CASE ISSUES

OK THIS WORKS! HE HAS

ILL DEFINED PAIN POOR SLEEP DEPRESSION AND

ANXIETY FAILED PROCEDURES INEFFECTIVE

MEDICATIONS

COMMON RESPONSES

WHAT DO PATIENTS THINK?

PAIN REGIONS/AREAS ARE EXPANDING

DOCTOR SAYS!

• GOOD NEWS,

LIKELY MYOFASCIAL

PAIN REGIONS/AREAS ARE EXPANDING

PT SAYS!

• “IT HURTS TOO MUCH TO BE THE MUSCLES”

• “SHOULDN’T WE DO ANOTHER MRI?”

• “WON’T SURGERY OR MORE INJECTIONS TAKE AWAY THE PAIN?”

FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED NEEDED

DOCTOR SAYS!

• GOOD NEWS,

PAIN PROGRAM INCLUDEs PT, OT,

BIOFEEDBACK, & PSYCHOLOGY!

FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED

PT SAYS!

• “SO YOU THINK IT IS ALL IN MY HEAD?”

• “I’M NOT DEPRESSED!” JUST FRUSTRATED

AND/OR IRRITABLE

PROCESSING OF PAIN IN THE BRAIN OCCURS IN SEVERAL REGIONS

Anterior cingulate cortex

Prefrontal cortex

Hippocampus

Amygdala

Insular cortex

Thalamus

Somatosensory cortex

Pain + emotion

Pain only

Adapted from Apkarian AV, et al. Eur J Pain. 2005;9:463-484. Image courtesy of Apollo Marcom.

THE TRIAD: PAIN, SLEEP, AND MOOD

Pain

Sleepdisturbances

Depression /anxiety

Functional impairment

FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED

MR. CARR SAYS!

• I HAVE TO DO THE WORK?

“I’VE ALREADY DONE PT!”

• “MY PAIN IS NEVER GOING AWAY?

MEDICATIONS NEED TO BE CHANGED

DOCTOR SAYS!

• TREAT SLEEP TCA OR TRAZODONE

• TREAT MOOD – SNRI DULOXETINE OR

VENLEFEXINE

• REDUCE THE USE OF OPIOIDS

MEDICATIONS NEED TO BE CHANGED

PT SAYS!

• “I NEED MORE PAIN MEDICATION”

• “I CAN’T DO IT WITHOUT PAIN MEDS”

• “IT WORKS BETTER WHEN I TAKE IT WITH THE ALPRAZOLAM”

DOCTOR SAYS: “YOU CAN DO IT WITHOUT OPIOIDS!”

OPIOID CESSATION AND MULTIDIMENSIONAL OUTCOMES AFTER INTERDISCIPLINARY CHRONIC PAIN TREATMENT• MURPHY ET AL, CLIN J PAIN 2013;29:109-117.

LACK OF CORRELATION BETWEEN OPIOID DOSE ADJUSTMENT AND PAIN SCORE CHANGE IN A GROUP OF CHRONIC PAIN PATIENTS• CHEN ET AL, J PAIN 2013 APR; 14(4): 384-92.

LOW PAIN INTENSITY AFTER OPIOID WITHDRAWAL AS A FIRST STEP OF A COMPREHENSIVE PAIN REHABILITATION PROGRAM PREDICTS LONG-TERM NONUSE OF OPIOD IN CHRONIC NONCANCER PAIN• KRUMOVA ET AL, CLIN J PAIN 2013; 29: 760-769.

OK, LET’S GET STARTED!

PROGRAM STRATEGIES• ACTIVE APPROACH

• MEDICATION TAPERING OR DETOX PROGRAM

RIC’S CPM PROGRAM COMPONENTS

Nurse Education Physical therapy Occupational therapy

• Recreation Therapy

Psychology (CBT) Relaxation Training Mind Body Treatment/

Feldenkrais/ Mindfulness

Vocational Therapy

PHASES OF TREATMENT

Educational Skills training Application and

relapse prevention

Individual Goal Setting

Monitor Reassess &

Readjust

PHYSICAL THERAPY OCCUPATIONAL THERAPY

• Comprehensive assessment

• “Active” instead of “Passive”

• Movement based• Strengthening• Aerobic conditioning• Home exercise plan

• Positioning/Posture • Pacing Techniques• Body mechanics • Stress Loading• Desensitization• Graded Motor Imagery

(Left/Right discrimination; Mirror Therapy)

• Graded Activity Exposure• Functional Capacity

Evaluation (FCE)

PAIN PSYCHOLOGY

• Mind-Body Connection

• Coping Skills Training • Emotion Regulation • Cognitive

Restructuring • Stress Management • Mindfulness• Family Education

RELAXATION TRAINING/ BIOFEEDBACK

• Deep Breathing• Imagery and

Visualization• Progressive Muscle

Relaxation (PMR)• Biofeedback

Monday Tuesday Wednesday Thursday Friday

8aWeekend

reviewGym Feldenkrais Relax (G) Psych

9Nursing lecture

OT Tolerance

Psych Biofeedback MD visit

10 PT OT toleranceConditioning/

GymVoc OT

11 MD visit Video PoolConditioning/

GymPT

12 Lunch Feldenkrais Lunch Pool Lunch

1 OT (G) Lunch Biofeedback OT (G) Psych (G)

2 Biofeedback OT OT (G) Relax (G) Relax (G)

3 Nursing Psych OT (G) OT (G)

4 Relax (G) Wii Group Mindfulness (G)Family meeting

(G)OT (G)

FULL DAY PROGRAM SCHEDULE

MEDICAL MANAGEMENT

• Team lead by a physiatrist, pain medicine specialist

• Nursing monitoring and education• Inpatient or outpatient detoxification

incorporated into program as needed• Medication adjustments

• Sleep Assistance• Nerve Pain• Myofascial Pain

INITIAL MEDICATION ADJUSTMENTS

TRANSITION FROM ESCITALOPRAM TO DULOXETINE

INITIATE GABAPENTIN

ADDING NORTRIPTYLINE AT HS

ADDING CLONIDINE AT HS

DETOX AT 2 WEEKS

OPIOID USE AT 260 MEQ PER DAY• TOO LARGE TO TAPER IN PROGRAM

25-33% REDUCTION WEEKLY

• TRANSITION TO BUPRENORPHINE/ NALTREXONE FILMS

BEGINNING SLOW TAPER OF ALPRAZOLAM

PT REPORT AT F-U VISIT AFTER DETOX

RTC ON BUPRENORPHINE FILM AT 1 MG SL BID• REDUCTION EVERY 2-5 DAYS

3/8 FILM BID ¼ FILM BID 1/8 FILM BID DC

• MOOD GOOD• SLEEP IMPROVED

PROGRAM COMPLETED

OUTCOMES

FULL DAY INTERDISCIPLINARY PROGRAM OUTCOME DATA 2013

COMPLETEDOVERALL

COMPLETEDWC

INCOMPLETEOVERALL

INCOMPLETE WC

# PATIENTS 150/193 (77.72%)

48/65(73.8%)

43/193 (22.27%)

17/65 (26.15%)

MEAN # DAYS TX(MAX=20)

18.55 18.42 9.59 9.29

MEAN # UNITS TX(MAX=560)

414.4 407.33 185.5 196.17

MEAN # HOURS TX(MAX=140)

103.6 101.83 46.38 49.04

Very Much Worse

Very Much Improved

No Change

All Full Program Completers 2013

Very Much Worse

Very Much Improved

No Change

Patients with WC

Very Much Worse

Very Much Improved

No Change

Patients with WC versus Patients without WC

AT DC TEAM CONFERENCE

PAIN 4/10; MOVEMENT MUCH BETTER

“I’M SO HAPPY TO BE OFF THE MEDS.” • “I WOKE UP”

“PAIN IS NOT GOING TO KILL ME,” • “DON’T HAVE TO HAVE DRUGS TO FIX IT!”

TEARFUL AND THANKFUL

INTERDISCIPLINARY PROGRAM OUTCOME DATA 2013

wcCOMPLETED

wcINCOMPLETE

PAIN DURATION 35.5 MONTHS 33.7 MONTHS

MMI 88.2% (95.7%) 27.8%

RELEASED TO WORK 80.4% (97.6%) 29.4%

RELEASE STATUS FULL: 90.2%GRADUAL: 2.4%

FULL: 100%

FCE 84.3% 55.6%

FCE VALID 58.1% 80%

INTERDISCIPLINARY PROGRAM OUTCOME DATA 2013

FCE STRENGTHwcCOMPLETED

wcINCOMPLETE

SEDENTARY 7% 20%

SEDENTARY-LIGHT 2.3%

LIGHT 39.5% 40%

LIGHT-MEDIUM 18.6%

MEDIUM 14% 40%

MEDIUM-HEAVY 7%

HEAVY 4.7%

MISSING 7% (n=3)

INDIVIDUAL RESULTS

FUNCTIONAL CAPACITY EVALUATION (FCE)• VALID• LIGHT-MEDIUM

MAXIMAL MEDICAL IMPROVEMENT

4 WEEK FOLLOW-UP

AFTERCARE• HEP

CORE & PRONE EXERCISE MANEUVERS

• COGNITIVE TREATMENTS IMAGERY DEEP BREATHING

MEDICATIONS STABLE• OFF BUPRENORPHINE AND CYMBALTA• CONTINUES GABAPENTIN AND NORTRIPTYLINE• TIZANIDINE PRN w/ FLARES

WORKING FULLTIME @ STAPLES• INCORPORATES PACING & BODY MECHANICS

THANK YOU!

QUESTIONS

jatchison@ric.org