Chronic Pain Programs at Hospitals

Name of Hospital has been removed. Please excuse the mess.

 

Improving Care for Patients with Chronic Pain at _______ Hospital and Clinics

Process Improvement Paper

The purpose of this process improvement paper it to develop a program intended to better meet the needs of patients with chronic pain at _____ Hospital and their network of clinics. I propose the formation of a chronic pain program consisting of an interdisciplinary team that has been trained to provide collaborative pain management interventions to patients with chronic pain.

Introduction:

Musculoskeletal pain affects between 13.5-47% of the general population, with chronic pain affecting between 11.4-24%1.  Over a million Americans have some form of persistent pain.2 Americans, who only make up of 5% of the world’s population, consumes 80% of the global opioid supply and 99% of the global hydrocone supply.3 With recent breakthroughs in pain management strategies and recent national exposure of the opioid epidemic, the stage is set to implement change.

A shift needs to take place from the tissue/biomedical model to a biopsychosocial approach in education and treatment of chronic pain conditions.  Explanations of chronic pain using the biomedical model is falling short when trying to explain someone’s pain to them.4 Shifting patient education to address the biopsychosocial factors that impact their pain state, may help them overcome their symptoms.  A recent study found that education strategies aimed at addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophizing and physical performance in patients with chronic pain5.  Not one discipline has the answer to chronic pain.  But by working together, the patient may be able to receive care that overcomes the shortcomings of each specialty. By having healthcare providers prepared to work together to help those in chronic pain, will help meet the needs of the 11-24% of people with chronic pain.

Background

_______ Hospital is located in rural California and has a two clinics nearby.  They offer orthopedic, family medicine, pediatrics and women’s health services, and are the primary healthcare provider for local city.   The hospital network consists of many different sub-specialties and works in partnerships with providers in nearby cities for advanced care. They also operate an outpatient orthopedic clinic and a family medicine clinic in close by towns.  Having smaller clinics in nearby towns has allowed for a better continuum of care to their patients along this rural region.

The current process involves patients first consulting with either their primary care provider or an orthopedic specialist for medication, imaging and/or surgery, and is often referred to physical therapy for 6-8 weeks. Although this approach is sufficient for a majority of patients with musculoskeletal pain, those with chronic pain are often not treated successful. They are forced to seek care from multiple healthcare providers and some live their lives dependent on opioids.

Plan

The development of an interdisciplinary chronic pain program will help to address the needs of patients with chronic pain.  This program will be able to filter out patients who require services beyond the standard care. When these patients are identified by their healthcare provider, they will be referred to the program and their care will be taken over by a team of specialists. Their initial evaluation will be done interdisciplinary, which may consist of 2-3 practitioners in the fields of medicine, psychology and physical therapy.  Following the initial evaluation, a plan of care will be established, which will include the appropriate services, such as mental health, physical health, nutrition and social services.  These team members will then carry out the plan of care, drawing on the resources of the community whenever necessary.

 Implementation

A planning committee must be formed in order to make the arrangements necessary for implementation of the program.  The planning committee will identify those best qualified to serve in the program and assist in finding the training required. The program will consist of existing practitioners and of local partners that specialize in mental health, nutrition and social services. It is essential that all members of the program are locally based in order to guarantee accessibility by the patients. In order for the program to be a success, patients must be able to receive care as often and for as long as they need.

As with any new program, it will face obstacles. Some foreseeable obstacles include: low attendance and referrals, lack of specialized training for practitioners, compliance, and stigma of receiving psychiatric care. Although low attendance might happen, the pitfalls of low rates can be avoided by using existing hospital practitioners so that they will be ready, but not be dependent on this program. The practitioners chosen for the program will be required to complete extra training to best prepare them for collaborative treatment, chronic pain and working with those with psychological issues.  All clinical staff will need to be trained on using the correct terminology when enrolling a patient into the program. By using a collaborative team approach, psychosocial services are provided but in a way that is seen as part of the program and not as a “psych eval”.

 In order to determine the success or set-backs of the program, a review committee must be formed and goals must be set.  This committee may consist of the same members of the planning committee, but must also include the practitioners who are participating in the program. For the first year of implementation, quarterly meetings will be required to track the progress of the program.  Objective measures will be reviewed, such as the number of patients seen, their diagnoses and objective findings resulting in their care through the program. Case studies will be presented to highlight successes and failures of the programs. After a year of implementation, the practitioners are expected to design and publish case studies in a national publication. Essential elements for this program to be successful is dedicated practitioners, continual mutual input and feedback from everyone involved, leadership and a long term commitment.

 Conclusion

As with many other rural areas in the country, the opioid epidemic seems to be right outside the door.  Without the tools necessary to help those susceptible, the system will continue to fail them.  By forming teams of multi-disciplinary healthcare providers, they will help to address the complex nature of those suffering from chronic pain and susceptible to substance abuse.  _____ Hospital is in prime position to start and implement a program of this kind. Since they are a small organization with a wide outreach in the region. Implementing this program will help _____ Hospital provide a higher level of care to those who need it the most and set an example of quality care for patients with chronic pain.

Mirror Therapy

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I made a “mirror box” for my uncle who had recently survived a stroke.  I did a quick search on the internet for directions, but was unable to find comprehensive directions.  Now, I am not sure why this was… did I just do a bad search?  Had all the directions been taken down since some companies are now selling these boxes (for $50)?  There were some excellent YouTube videos about it (“Mirror Therapy“), which gave me a good visual of what I needed to make, but did not actually give me directions on home to assemble one.

So here it is (until I am forced to take it down).

Supplies:

  1. Mirror- you can buy one at a craft store. I bought one a Pat Catan’s for $5.  It was just under 12″ x 12″
  2. Foam board- neutral color
  3. Duct Tape
  4. Double Sided Tape
  5. Velcro- mine was 2″ thick, but this ended up being a bit too heavy duty. I recommend using a 3/4″ strip.
  6. Exact-o knife & cutting supplies (cutting matt and ruler)

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Directions

  1. Cut 4 – 12″ x 12″ sections from the foam board
  • you may need to adjust these dimensions depending on the size of your mirror.

2. Cut one board in half so that it is 12″ long by 6″ in wide.

3. Align the boards so that there the 6″ one is first then the three 12″ x 12″ sections.

img_11614. place a strip of duct tape along the seams between each board so that they are all connected.

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  • consider leaving a 1/4″ space between the 3rd and 4th square to allow for folding of the “box” for storage.
  • Reinforce these seems with another strip of tape if needed.

5. Apply a strip of velcro to board # 4 (along the far edge)

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6. Fold over the 6″ board over & apply a strip of velcro along the inside edge of the 6″ board.

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7. Apply the double sided tape to board #3.

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  • I did two long strips- one across the top and one across the bottom, and then made an”X”

8. Gently press mirror so it is centered on the board

9. Fold the mirror up & see your creation!!!

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Yoga for Chronic Low Back Pain

Chronic Low Back Pain (cLBP) is a subset of back pain which may be alleviated with the practice of yoga. A study found that 85-95% of patients with LBP are diagnosed as having “nonspecific low back pain”.1 This means that the doctor doesn’t know the specific patho-anatomical cause of the pain.  A majority of patients with chronic pain fall outside the typical healing time frame.  This is one of the reasons chronic conditions have stumped the medical community for so long.   There has been a recent increase in research that looks at the central nervous system’s role in cLBP. It is widely accepted that a person’s history and beliefs about pain can influence the outcome of treatment. Recently discovered insights on central sensitization and neuroplasticity have allowed for the development of more effective treatments.

A physician may refer their patient for an MRI or radiograph to diagnose the cause of cLBP. These can be useful in identifying serious conditions, such as vertebral fractures or a spinal cord impingement.  Most often, imaging causes unnecessary stress over normal changes that occur in the spine.  A recent study found that disc degeneration was present in close to 90% of individuals 60 years of age or older.  More than 50% of asymptomatic people ages 30-39 also had degenerative change of their spine.2  Degenerative changes, such as disc degeneration disease, are part of the normal aging process and cause unnecessary anxiety when used as a diagnosis.  This counter-acts the healing process by activating the autonomic nervous system.  There are many structures in the back that can cause pain that may or may not be related to what the imagining shows. A patient’s belief about the cause of the pain and diminished sense of body awareness can play a role in managing chronic pain.

Traditional and non-traditional interventions for chronic low back care have fallen short.  A recent study found that interventions, such as manual therapy, exercise, acupuncture, and spinal injections, are not superior to one another and all have limited long-term impacts on the disorder.3  This might be due to interventions failing to address cLBP within a multidimensional framework. A multi-disciplinary approach to cLBP is one solution. Physical therapists and yoga teachers have complementary skills that can be utilized to help counteract chronic pain.

Cognitive Behavior Therapy (CBT) addresses the biopsychosocial issues that often go with chronic pain.  Biopsychosocial issues include:

  • Cognitive Factors: negative beliefs, fear avoidance behaviors, anxiety, depression, poor coping skills
  • Physical Factors: pain provocative postures and movement patterns
  • Lifestyle factors: sedentary behavior, sleep deficits11

Yoga interventions found in Mindful-based Stress Reduction (MBSR) address the same factors as CBT.  MBSR is a “mind-body approach that focuses on increasing awareness and acceptance of moment to moment experiences, including physical discomfort and difficult emotions.”4  MBSR uses meditation, pranayama, yoga and patient education to help a person cope (MBSR Protocol).  A recent study compared this approach to CBT and normal medical treatment and found MBSR had similar results as CBT.  Both had significant improvement when compared to standard medical treatment.5  There are many similarities between the two approaches.  Both have elements of body awareness, addressing movement and cognitive deficits, imagery and coping skills.  However, both practices come from different schools of thought, which becomes clear after looking at the comparative chart (Comparison Chart). Those who come to a yoga back care class will likely respond well to the MBSR approach described in this study.

 

The brain is an amazing structure of the body due to its ability to adapt to stresses placed on the body. Neuroplasticity is “the ability of the nervous system to respond to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections.”6 There are structural and functional changes in the brains of people with chronic musculoskeletal pain. These changes contribute to the development and maintenance of the chronic pain state.7 An example of these changes is central sensitization.  This is an adaption of the nervous system to noxious stimuli: stimuli that are non-painful, but are perceived to be painful.  Studies show that a person who experiences cLBP undergoes anatomical changes to the brain, including decreased cortical thickness, hippocampus (memory center) and medial prefrontal cortex (learning and memory) and increased amygdala (fear center) size.8 Changes to the cerebral cortex can cause changes to the homunculus, the “sensory map” in the brain (Noi Group).  This map of the body can change when a person experiences chronic pain.  The mind “smudges out” that body part and creates a distorted body image.  The Noi Group has developed a method called “Graded Motor Imagery.”16 This uses Left/Right Discrimination, Motor Imagery and Mirror Therapy to re-introduce the area of the body back to the brain.  Both these intervention uses neuroplasticity as a catalyst to induce change in the brain caused by chronic pain conditions.

The medical community has realized the importance of the brain’s neuroplastic ability in treating chronic pain.  Recent studies have shown that meditation used in MBSR has the ability induce neuroplasticity.  A recent study took people who had never meditated before and put them through the eight week MBSR program.  This study found that five regions of the brain experienced a change in volume after 8 weeks.  Four areas thickened: posterior cingulate (mind wandering and self-relevance), the left hippocampus (learning, cognition, memory and emotional regulation), the temporoparietal junction (perspective taking, empathy and compassion), and the pons (regulatory neurotransmitters production). One area, the amygdala, got smaller, which is the center that stores negative memories and feelings.9   This is a groundbreaking discovery for MBSR in management of chronic pain.  Yoga for chronic pain has a place at yoga studios.  Studios can offer a series that is completed over eight weeks and follows the MBSR protocol (Appendix 3).  Yoga as Therapy has research behind it to legitimize its use for treatment in the clinic, especially for chronic pain.

Bibliography

  1. Apeldoorn AT, van Helvoirt H, Meihuizen H, et al. The Influence of Centralization and Directional Preference on Spinal Control in Patients With Nonspecific Low Back Pain. J Orthop Sport Phys Ther. 2016;46(4):258-269. doi:10.2519/jospt.2016.6158.
  2. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. a, … Jarvik, J. G. (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Spine, 36(4), 811–6. http://doi.org/10.3174/ajnr.A4173
  3. Fersum,Vibe K, et al. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain (United Kingdom). 2013;17(6):916-928. doi:10.1002/j.1532-2149.2012.00252.x.
  4. Cherkin, D. C., et al. (2016). 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. Jama, 315(12), 1240. http://doi.org/10.1001/jama.2016.2323
  5. Cramer, S. C., et al. (2011). Harnessing neuroplasticity for clinical applications. Brain, 134(6), 1591–1609. http://doi.org/10.1093/brain/awr039
  6. Wand, B.M., et al. (2011). Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice. ManualTherapy, 16: 15-20
  7. Lucas, PH. Practical Application of Yoga-based Techniques in the Treatment of Chronic Pain. Power Point Presentation. CSM 2014 (Las Vegas, NV).
  8. Butler, David and Moseley, Lorimer. (2014). Explain Pain. Noigroup Publications, Adelaide, Austrailia. Pg. 76
  9. Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893-1897. doi:10.1097/01.wnr.0000186598.66243.19.