Elizabeth Loder, Penelope Herbert, and Patricia McAlary
Like an alarm bell stuck in the “on” position . . . such is chronic benign pain.
—Bruce Smoller and Brian Schulman
I. The scope of the problem
II. General principles of chronic pain treatment III. Evaluation of the patient
1. History and examination 2. Pain intensity and impact 3. Attitudes toward pain IV. Treatment
1. Group therapy
2. Individual components of a chronic pain treatment program V. Measuring the benefits of treatment
VI. Conclusion Selected Readings
I. THE SCOPE OF THE PROBLEM
Despite steady improvements in the treatment of pain, a group of patients remains whose recovery is minimal despite concerted attempts at appropriate therapy. Unrelieved pain is associated with dramatic impairment of physical, psychological, and social wellbeing. Unemployment, reduced physical activity, and sleep disruption associated with chronic pain may lead to a downward spiral of physical inactivity, decreased socialization, altered sleep/wake cycles, and medication overuse. Once entrenched, these maladaptive behavior patterns are difficult to reverse. Secondary depression and medication overuse may develop, along with family dysfunction and poor work performance. Patients with chronic pain are five times more likely than the general population to use medical services, and 58% of patients with chronic pain have anxiety or depression that can further complicate their management.
The development of chronic pain syndrome (Table 1), in which patients develop disability out of proportion to the underlying disease, with associated behavioral abnormalities, requires multidisciplinary treatment. The treatment philosophy, which must be accepted by the patient and the family, shifts from cure to management. Medication reduction, increased “up” time and regular physical exercise, involvement in hobbies or return to work, and psychological intervention all help return the patient to some semblance of normal living, despite the persistence of pain.
Table 1. Characteristics of patients with chronic pain syndrome
Optimal management of chronic pain must address not only the initiating physical pathology but also the social and psychological sequelae that accompany the pain and contribute to poor quality of life. Specialized outpatient pain rehabilitation programs that provide coordinated, multidisciplinary care can be helpful. Inpatient treatment may be necessary for patients with impaired mobility or advanced debilitation, severe medication overuse (requiring special tapering from opioid or barbiturate drugs), or associated medical or psychiatric morbidity that precludes outpatient treatment.
The Pathologic Nature of Chronic Pain
Chronic pain differs from acute pain in that it is a pathologic state that is of no benefit to the individual, unlike acute (physiologic) pain, which arises in response to injury or inflammation and protects the individual from further injury. Acute pain is time limited and resolves as healing takes place. Chronic pain, on the other hand, is caused by changes in the nervous system that are not reversible (e.g., nerve injury, sensitization, new fiber growth, reorganization), and it is unremitting and extremely difficult to treat. Standard acute pain treatments (nonsteroidal anti-inflammatory drugs and opioids) have only limited efficacy in treating chronic pain. Moreover, the pain, muscle guarding, and decreased activity that serve a useful purpose in acute pain become counterproductive in chronic pain. Avoiding activity no longer serves the purpose of protecting healing tissues from further injury but instead leads to deconditioning. Patients tend to respond to chronic pain in the same way that they respond to acute pain, but the response is dysfunctional and paradoxically promotes worsening rather than improvement.
II. GENERAL PRINCIPLES OF CHRONIC PAIN TREATMENT
In nearly all cases, multidisciplinary treatment rather than medical treatment alone is required to reverse the complex behavior patterns that develop as a result of chronic pain. When it is not possible to eliminate pain, emphasis shifts from efforts directed solely at pain relief, whatever the cost, toward efforts to
maximize the patient's ability to function. It is important that this change in philosophy be accepted and understood by patient, physician, and family.
It is often hard for patients (or families) to reach the point at which they are ready to embrace a treatment model that emphasizes management and coping but does not promise a cure. They feel compelled to seek further medical opinions or treatment options before accepting the rehabilitation approach. Physicians may contribute to the problem when they focus only on the specialty treatments they are trained to provide. Prolonged searches for a “cure” can be counterproductive and expose the patient to further harm from aggressive surgical, medical, or alternative treatments. Tactful discussion can help make clear that rehabilitation does not mean giving up on efforts to improve the underlying problem, or simply learning to live with the pain.
III. EVALUATION OF THE PATIENT
1. History and examination
A thorough physical examination is essential to identify sources of pain and reassure the patient that the pain problem is taken seriously. A history of the pain problem and a detailed review of previous medical records documenting treatment trials, reasons for treatment failures, and the timing of interventions are helpful. Information about specific dosages and length of pharmacologic treatment trials helps to assess the adequacy of previous treatments. Whenever possible, original test results (computed tomography and magnetic resonance imaging scans) should be reviewed rather than relying on summary information in medical records. Access to
comprehensive records may be difficult to obtain, in which case patients or family members can participate by obtaining and organizing this information.
During the initial evaluation, special attention should be paid to the emotional context of the pain problem and its meaning in the patient's life. For example, pain resulting from an accident in which others were killed or injured, or from what is perceived as a botched surgical procedure, will be difficult to treat without attention to the psychologic aspects. Likewise, a history of repeated adversarial or unsatisfactory interactions with multiple health professionals should prompt consideration of the presence of personality or other psychiatric disorders that could complicate treatment. Speaking directly with previous or current caregivers can provide invaluable insight into patterns of self-defeating behavior or other reasons for treatment failure.
2. Pain intensity and impact
Patient complaints of pain, functional disability, medication use or overuse, and comorbid psychiatric and medical illnesses must be taken into account to develop an appropriate, individualized treatment plan. In the treatment of chronic pain, ratings of functional ability are more useful than conventional 0-to-10 pain rating scales in gauging the impact of pain and judging treatment. A 0-to-3 scale is often employed, with 0 indicating no impact of pain on ability to function, and 1, 2, and 3
representing minimal, moderate, and severe impairment of function by pain. The use of obsessive or overly detailed pain charts is discouraged (unless they are needed to judge specific interventions), because it encourages somatic preoccupation and attention to pain. In most chronic pain treatment plans, pain behaviors such as
grimacing, sighing, or rubbing affected body parts are discouraged because they draw the attention to the pain rather than reinforcing productive “well” behaviors (Table 2).
Table 2. Pain and well behaviors
Information should be obtained on the impact of pain and pain treatment on the patient's social, family, and occupational or school function. It helps to ask patients to describe a typical day's schedule and activities, and what would be different if they were not in pain. Disability and financial status and involvement with Worker's Compensation or the legal system are factors that can influence pain presentation and may also have a bearing on treatment. Education and work history can be important, especially if the pain results from a work-related injury.
Detailed information on sleep disturbance, alterations in sleep/wake cycles, and depression or anxiety should be obtained. Psychiatric or personality disorders exacerbate chronic pain and should be identified and treated. A family history of psychiatric illness or disability may be contributory. Finally, family beliefs about the patient's condition and the family's role in the pain problem (“enabling” or overly solicitous behavior, anger, or neglect) should be determined.
3. Attitudes toward pain
Patients who believe that they can help control or manage their pain are often referred to as having an internal locus of control. In contrast, patients who feel dependent on physicians, the healthcare system, or medications to control their pain are often referred to as having an external locus of control. Successful adaptation to chronic pain is more likely in patients with an internal locus of control. Treatment efforts should aim to reinforce a patient's belief in his or her ability to affect pain levels. Efforts to involve the patient in treatment and create a sense of control should be a part of all aspects of chronic pain treatment. Self-management strategies, such as those outlined in Table 3, help to de-emphasize the pattern of reliance on medications, procedures, and other passive treatments.
Table 3. Examples of independent pain control techniques
IV. TREATMENT
The effects of unrelieved pain are pervasive, and rehabilitation demands coordinated, multidisciplinary treatment. Patients are encouraged to set functional goals during the initial evaluation, and regular meetings of the treatment team should occur to assess progress toward these goals, to share information, and to refine treatment plans. Appropriate functional goals should be realistic, achievable, and under the control of the patient.
A specialized inpatient or outpatient treatment program provides a team of appropriately trained personnel to coordinate an intensive, synergistic treatment plan. Early targeted intervention for patients whose pain is not improving is helpful and ultimately cost effective. All too often, however, early intensive intervention for chronic pain is precluded by factors such as lack of insurance coverage, so that only the most refractory patients (whose outcomes are actually substantially poorer) receive such treatment.
1. Group therapy
A variety of topics and skills can be effectively taught to chronic pain patients in a group setting. Group meetings offer support and reinforcement of adaptive behaviors through group feedback and discussion. In all cases, the group must be carefully supervised to ensure positive educational experiences. Family education, postural reeducation and movement, stress management skills, substance abuse information, life skills training, and other topics are appropriate for group teaching. The therapeutic milieu is an essential component of both outpatient and inpatient pain programs and is helpful in reducing the isolation and lack of social understanding encountered by patients with chronic pain.
2. Individual components of a chronic pain treatment program
The following components of chronic pain treatment are useful in nearly every case. Certain patients with less complicated presentations may require only some of these interventions.
(i) Medication reduction and optimization
The use of medication in chronic pain is best viewed as one component of the patient's overall management plan. Medication alone is unlikely to be effective in dealing with the problem, and its importance should be placed in perspective. An important aspect of treatment is a thorough, thoughtful review of medications, with the dual goal of eliminating unnecessary medications and ensuring that the patient has had an adequate trial of disease-specific treatments. Since the causes of chronic pain are heterogeneous, it is important to carefully ascertain, through repeat trials of treatments if necessary, that patients have had appropriate trials of treatments known to be helpful for their particular condition.
Many medications that provide short-term relief of symptoms can cause long-term complications that interfere with successful treatment. Medications prescribed for sleep, muscle spasm, or anxiety are in this category. Their use over a prolonged period can cause sedation, poor concentration, and emotional detachment that impede the ability to function. Patients also come to rely on the sedative and psychoactive effects of medications in modulating emotional as well as physical pain. In many cases, medications are no longer helping, yet patients and physicians are reluctant to discontinue them, fearing that things might get worse if they are stopped. The decision to use long-acting or maintenance opioids must be made on an individual basis. Many patients with chronic pain show improved function and decreased pain on these medications. Unfortunately, a subset of patients do poorly, requiring increasing doses without satisfactory pain relief, deteriorating functionally, and possibly displaying drug-seeking or addictive behavior. As a general principle, chronic pain patients are offered only long-acting opioids. Short-acting opioids are more likely to produce a “high” and have a higher addictive risk. Patients who come to associate an altered sensorium with pain relief may regard alternative therapies (including long-acting opioids) as less than optimally effective. An insistence on only short-acting opioids is a marker of possible addiction.
(ii) Physical reconditioning
As a result of avoiding activities that aggravate or produce pain, nearly all patients with chronic, unrelieved pain develop some measure of physical deconditioning. This decreased activity generally results in a downward spiral of physical inactivity and reduced capacity for exercise that exacerbates, rather than improves, pain. Physical therapy supervision of a gradual program of reconditioning and therapeutic exercise is the cornerstone of successful rehabilitation. The roles and contributions of therapists in a multidisciplinary pain team vary according to the needs of the patient and the interests and expertise of the therapists. A system that allows therapists to have a flexible role and the ability to treat in conjunction with other disciplines provides optimal results.
Physical therapy is aimed at increasing patients' use of independent pain-management modalities such as self-massage, heat and cold, and transcutaneous electrical nerve stimulation (TENS). Physical therapy modalities such as massage and ultrasound, which are passive and do not foster independence, are less useful in chronic pain treatment.
An important focus of physical therapy is on improved aerobic and functional capacities. Chronic pain patients may have failed prior physical therapy regimens when they were encouraged to discontinue activity with the onset of pain. A major challenge for the physical therapist working with these patients is to educate them that hurt does not always mean harm. It is advisable to begin in small increments and to use a realistic, quota-based program that encourages a gradual increase in exercise tolerance. With this approach, patients quickly come to understand that some of their pain may be caused by previous inappropriate use of assistive devices, muscle weakness, and muscle guarding. A physical therapist with experience in the treatment of chronic pain can develop an appropriate program for chronic pain patients. Not only does exercise improve physical functioning, it also improves pain levels, has a beneficial impact on depression and feelings of self-worth, and aids in
restoration of a normal sleep/wake cycle. Exercises aimed at improving postural tension, body mechanics, and muscle imbalance can also have a beneficial impact on pain and function.
(iii) Occupational therapy
The impact of pain on daily life can be severe. Patients may be limited in their ability to perform basic self-care activities such as bathing and dressing, or find it difficult to prepare meals, perform housekeeping chores, or shop for groceries. Occupational therapists help patients incorporate effective pain control strategies into activities of everyday life. Specific strategies can include goal setting, group programs, pacing techniques, assertive communication, the use of appropriate body mechanics during everyday activities, and the use of assistive devices or environmental modifications to support independent function.
Activity levels in chronic pain patients often closely mirror pain levels; patients remain in bed or do very little on days when their pain is particularly severe, then
compensate with intense over-activity on days when their pain is better. This leads to a sense of frustration on the part of the patient and makes it difficult to participate reliably in work, social, and school activities. Occupational therapists can work with patients to identify such patterns and concentrate on pacing techniques. These emphasize avoidance of large swings in activity levels and encourage the use of frequent breaks in activity regardless of pain level. They also involve the incorporation of active pain control techniques on a regular basis to prevent pain escalation. These techniques include the development of a schedule that incorporates such things as the use of heat, ice, and relaxation strategies into the daily routine. Scheduled use of ice massage, theracanes, TENS, or hot packs can enhance the effectiveness of other therapeutic and pharmacologic interventions.
(iv) Nonpharmacologic pain control techniques
Biofeedback, self-hypnosis, and other relaxation strategies are useful adjuncts to chronic pain treatments. They often reduce, although they may not eliminate, the use of pain medication, and they improve a patient's sense of control over pain. These strategies are most effective when used preemptively on a regular basis; they work less well once pain is established. Many of these techniques are taught by psychologists, who can at the same time identify counterproductive and maladaptive behavior patterns. Patients often benefit from cognitive-behavioral therapy aimed at altering beliefs and ideas about pain and improving coping mechanisms. (v) Psychiatric and psychological intervention
Psychiatric disorders can complicate the management of chronic pain. Patients with premorbid psychiatric disorders cope less well with chronic pain, and unrelieved chronic pain can trigger the development of psychiatric disorders, particularly depression. Psychiatric evaluation is therefore essential in all patients with debilitating chronic pain. Appropriate management of identified disorders will improve the patient's ability to cope with chronic pain and to comply with treatment. Psychiatric oversite of the many psychoactive medications used in the chronic pain population is also important.
A history of prior physical, sexual, or emotional abuse or trauma is common in patients with chronic pain. Recent work suggests that early trauma may produce permanent changes in the functioning of the hypothalamic–pituitary axis and response to later painful events. The identification of a history of trauma has important treatment implications and should be sought in all patients with disabling chronic pain. Patients with a history of a traumatic childhood with unmet dependence needs, early adult responsibilities, or physical, emotional, or sexual abuse are often less able to cope with pain. These patients may have coped well prior to the onset of pain but the development of a pain problem can provide an unconscious but socially acceptable way to ask to be taken care of.
Patients with chronic pain may deny family or relationship stressors, blaming all life disruption on their pain and consciously or unconsciously using pain as a way to avoid unpleasant or unwanted obligations in many areas. For this reason, a careful review of social and family relationships is helpful. An assessment of mood and suicidal potential is also important, as chronic pain is a risk factor for both suicide attempts and completed suicide.
(vi) Family intervention
Perhaps the most neglected aspect of chronic pain is its impact on family members and other elements of a patient's social support network. Chronic pain in one member of a family commonly causes shifts in family roles and functions. Spouses or children may take over aspects of the patient's role, such as housework, shopping, or wage-earning. Family and friends may inadvertently support or encourage further disability and dependency through enabling, over-solicitous behavior.