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.

Yoga & Mechanical Diagnosis and Treatment (MDT)

Robin McKenzie, a physical therapist from New Zealand, revolutionized the treatment for LBP in the 1950s. McKenzie discovered symptom centralization by using repeated movements or sustained postured.  Mechanical Diagnosis and Treatment (MDT) is a tool for assessment, treatment and prevention of musculoskeletal disorders.  McKenzie is an advocate for independent management of a person’s own back pain.  He said,

“I believe the treatment dependency is undesirable and should be avoided where possible. Therefore, in addition to whatever treatment is necessary for present symptoms, the patient should be taught to become self-reliant and independent of the therapist in the management of future low back pain” RA McKenzie, 19811

McKenzie advocates patient education to prevent the recurrence of low back pain. It can be safe to assume that he would support the daily yoga practice as long as it is individualized to the student’s needs. MDT consists of three categories for diagnosing back pain: Postural, Dysfunction and Derangement. A specific style yoga may be the key to a person’s self-management of their back condition.  By understanding the treatment strategies of physical therapists, yoga can be applied appropriately.

Postural Syndrome

Postural Syndrome is when normal tissues are placed on end range stretch for prolonged periods of time. It is insidious in nature and can be hard to reproduce.  The yoga student with a postural syndrome will have pain or symptoms that increase throughout the day. They may have a job where they sit for long periods of time or have a medical condition that causes abnormal posture.  Postural Syndrome is from sustained poor posture.

Postural education and exercises can address any muscle strength imbalances which underlie postural dysfunctions. Postures that open up the chest and strengthen antigravity muscles will help address these deficits.  Specific yoga classes that focus on posture, such as Iyengar yoga, are appropriate.  A study completed in 2009 compared 24 weeks of Iyengar Yoga to conventional interventions for LBP. The yoga group had greater improvements in functional disability, pain, depression and a reduction in pain medication.2 A yoga teacher who understands muscle imbalance and compensatory movement patterns will help a student overcome their postural syndrome.

Dysfunction

Abnormal or dysfunctional tissues often cause low back pain.  Dysfunctional tissues cause pain when placed on end range stretch or placed under mechanical deformation (palpation). A physical therapist uses repeated movements to determine if their client has dysfunctional tissues. Symptoms will either decrease or stay the same with repeated motion into the painful direction. Muscle guarding and spasms, facet joint restrictions or adhesions in the fascia can cause dysfunction of the back. These restrictions may result from previous trauma, inflammatory or degenerative processes.3  Research agrees that compensatory strategies may develop as a result of habits formed due to previous injury4,5.  This may cause habituated abnormal movement patterns that perpetuate the dysfunctional tissues.

The repeated motion that is used to diagnose dysfunction in the clinic is also used to treat.  This can easily be applied to a yoga class, but difficulty arises when there is a mixed class of dysfunctions.  Someone may have a flexion dysfunction due to quadratus lumborum (back) spasm.  They need a gentle class consisting of forward folds and twists.  Those with tight iliopsoas (hip flexor) will enjoy erected postures, gentle extension and lunges. Most yoga asanas can be placed into a direction specific exercise group and can be used to treat specific dysfunctions (Specific Exercise PDF). Back Care, restorative and a beginner yoga class will help a majority of people with dysfunction. Themed classes, such as psoas release or stiff back classes, might help to separate people into groups based off of their dysfunction.  Class should consist of hands on assists that are massage-like and repetitive movements that flow with the breath.

Derangement

Derangements are often thought to be discogenic in nature.  Discogenic in nature implies that a nerve root is being pinched, either due to decreased vertebral disc height or a bulge or herniation.  A crucial symptom for diagnosing a derangement is the migration of pain in response to repeated motions.  Centralization occurs when a movement or position relieves the pain or causes it to move towards the spin.  If the pain centralizes with a forward fold, that means it migrates proximally.  If it peripheralizes, the pain migrates distally from the spine, down the leg or to the foot.  Directional Preference is similar to centralization, but more specific to a position in which one finds relief from pain.  Centralization with movement indicates a better prognosis than directional preference alone.6 Despite this finding, directional preference is used for exercise prescription. A study found matching directional preference with specific exercise decreased pain and medication use.7  For treatment of derangement, it first must be reduced.  This is done using either specific movements, manipulation or mobilizations by a trained professional.  Next, the patient needs to perform exercises to increase the stability of the spine and normalize posture.

Individualized yoga classes will help a person with a derangement recover faster and manage their symptoms better, although direct communication with a physical therapist is recommended.  Understanding their directional preference and what movements cause the symptoms to centralize will help the teacher tailor the practice to meet their needs.  Often, a person can go from a derangement to dysfunction.  In order to prevent this, yoga as therapy must be applied appropriately.

It is a challenge for a yoga teacher to meet the needs of every student. A partnership between the teacher and a physical therapist may help alleviate the burden.  If a studio offers back care classes, they must accept the responsibility of providing the best care possible.  An understanding of the student’s symptom behavior is necessary to determine the best class for them.  A thorough intake form may be helpful in screening a student for a serious condition and to understand the nature of the student’s symptoms (Intake Form).  Keeping classes small and offering them in a series may help reduce the unnecessary risk of exacerbating symptoms. It is possible for physical therapy and yoga to partner in providing long term care for low back patients using the principles of MDT. Understanding MDT and the terms will improve communication between yoga teachers and physical therapists.

References

  1. Moore, Jeff, DPT. Incorporating Repetitive Movement. (Power Point Presentation) Masterminds Mentorship Group. 4 November 2015.
  2. Williams, K., Abildso, C., Steinberg, L., Doyle, E., Epstein, B., Smith, D., … Cooper, L. (2009). Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine, 34(19), 2066–76. http://doi.org/10.1097/BRS.0b013e3181b315cc
  3. McKenzie and May, The Lumbar Spine, Mechanical Diagnosis and Therapy, Vol I & II, Spinal Publications Limited, P.O. Box 2, Waikanae, New Zealand, 2003.
  4. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: The role of fascia following pregnancy and delivery. J Body Move Ther. 2008;12(4):333-348. doi:10.1016/j.jbmt.2008.05.003.
  5. Moseley GL, Hodges PW. Reduced variability of postural strategy prevents normalization of motor changes induced by back pain: a risk factor for chronic trouble? Behav Neurosci. 2006;120(2):474-476. doi:10.1037/0735-7044.120.2.474.
  6. Werneke MW, Hart DL, Cutrone G, et al. Association between directional preference and centralization in patients with low back pain. J Orthop Sports Phys Ther. 2011;41(1):22-31. doi:10.2519/jospt.2011.3415.
  7. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine (Phila Pa 1976). 2004;29(23):2593-2602. doi:00007632-200412010-00002

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.