Pain management changes give doctors more options

Expert offers guide to best practices

A lot has changed in pain management in the past two years since the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) of Oakbrook Terrace, IL, recommended that pain assessments be a part of every clinical exam.

For one thing, pain specialists no longer use the term "pain management," having switched to the descriptor "pain medicine."

Secondly, there continue to be new treatments and approaches championed each year, and rehab providers often adjust their practices to reflect the latest developments.

And, in 2000, physiatrists were invited to sit for the first board certification exam in pain medicine.

"In the next few years, if you don’t have a fellowship, you won’t be able to sit through the exam for physical medicine and rehabilitation," says Marc R. Gerber, MD, a partner with Florida Spine Care Center in Orlando. Gerber spoke about pain management at the 63rd Annual Assembly & Technical Exhibition of the Chicago-based American Academy of Physical Medicine & Rehabilitation, held Nov. 21-24 in Orlando.

All of these changes are necessary and timely as pain medicine becomes a bigger focus of rehabilitation care and general medicine due to the aging of the U.S. population, Gerber says.

"With the population aging and all of the musculoskeletal problems out there, physiatrists are in an excellent position to be leaders in musculoskeletal treatment, as well as pain management," Gerber says.

"There are opportunities to take over this area," Gerber adds. "It’s a growing field, and as more and more patients are treated outside the acute care hospital, there’s going to be a growing demand and more treatments for pain management with proper rehabilitative care and intervention."

Gerber and other physiatrists are seeing an increase in new pain medicine patients, including chronic back pain patients and patients whom other clinicians have given up on. This accentuates the need for a comprehensive approach to their treatment, Gerber says.

"I think it’s important for doctors to use a comprehensive approach to pain management, using occupational and physical therapists, epidurals, selective spinal procedures, psychiatric intervention, and selections from an arsenal of 50 different medications," Gerber says.

Gerber offers these guidelines for physiatrist and rehab treatment of pain patients:

Occupational therapy: Occupational therapists (OTs) can help patients with upper extremity pain, such as carpal tunnel syndrome, particularly if a patient has had surgery for the disorder and needs help afterward, Gerber says.

For typical carpal tunnel syndrome cases, a physiatrist might order wrist splints and let the patient continue to work, but when OT referral is necessary, it can be helpful to have an OT teach patients stretching exercises.

OTs may also help patients who have problems with shoulder impingement, rotator cuff problems, and injuries to the shoulder that don’t require surgery but that impose functional limitations, Gerber says.

Physical therapy: Patients who have neck pain, a herniated disk, or who were injured in a car accident often will benefit from treatment by a physical therapist (PT), Gerber says.

"I try to gear patients more toward an active approach and have them try exercises rather than just lie on a table and get a massage," Gerber says. "We try to get patients to do the exercises themselves because having a massage and ultrasound is good, but it’s only good for short-term improvement."

PTs can teach patients home stretching programs and encourage them to become involved in wellness and exercise programs.

Epidurals: When patients have neck and lower back pain with radiating symptoms to arms and legs, they often will respond well to epidural injections using fluoroscopic guidance, Gerber says.

"That’s where we use an X-ray camera that gives a live image to make sure the medication is delivered to the proper location," Gerber explains. "Years ago, they didn’t use fluoroscopic guidance, and the medications would be delivered inappropriately and miss the right spots."

The injections can be done at an outpatient surgical center, taking less than an hour. Depending on the patient’s response, one to three injections will provide patients with relief for several months or longer, Gerber says.

"It also will alleviate acute pain that occurs when people have disk or nerve root pathology," Gerber says.

Selective spinal procedures: This involves facet injections, which are injections into the bony joint that stabilizes the spine. This is used in patients who have degenerative conditions that produce pain.

"We inject steroids and anesthetics in there," Gerber says. "Many physicians also will use other types of treatments, such as radio frequency, to burn the nerves using cryoablation or radio frequency to treat these kinds of conditions."

A new procedure, intradiscal electrothermoplasty, involves inserting a coil into the disk and heating the coil so that it burns disk fibers.

All of these techniques are controversial; some clinicians will swear by them, and others will call them bunk, Gerber notes.

"I use the nerve root injections, sacroiliac steroid injections, for back pain," Gerber says. "I will do hip injections for degenerative hips, and patients will derive several months of benefit from hip injections of steroids using fluoroscopic guidance."

These are alternative treatments for patients who are either waiting for surgery or who do not want to have surgery, Gerber says.

Psychiatric consultation: Because an estimated 50% of patients with chronic back pain have clinical depression, clinicians also will need to treat their psychiatric symptoms, or else the outcomes will be less positive, Gerber says.

"Treat all aspects of pain, and not just the organic problem," Gerber advises.

Typically, a physiatrist will send such a patient to a psychiatric consultation or will prescribe antidepressants. Physiatrists also may work with psychologists to provide stress management and coping interventions, Gerber says.

Three goals of pain management are to decrease pain, improve the patient’s quality of life, and increase the patient’s function, Gerber says. "The fourth goal is to use treatments and approaches that minimize side effects, but the goal mostly isn’t to cure pain or the problem, because someone with four back surgeries is not going to be cured of back pain."

Physiatrists mainly want to help patients not to be miserable all the time, Gerber says. "Many times, doctors don’t want to take time to sit down and figure that out."

Use polypharmacy for pain management

Medications: Most patients will do better on more than one class of medication, so clinicians need to use polypharmacy, Gerber says.

"These can be combinations of anti-inflammatories, muscle relaxers, antidepressants, and pain medications," Gerber says. "We have non-opioid pain medications with some anti-inflammatory pain properties, or we have opioid pain medications, including short- and long-acting medications."

Clinicians will prescribe certain medications for episodic pain that requires treatment occasionally, and then there are long-acting opioid medications that will alleviate pain in patients for whom the pain never subsides, Gerber notes.

"In our practice, when we put patients on long-term pain management with opioids, we have them sign an opioid agreement, like a contract, that lets us be the primary providers," Gerber says. "Patients agree to follow our rules and recommendations, and they know that any deviation from our rules will result in our no longer prescribing those medications."

Because of strict regulatory oversight of opioids, clinicians need to be fully aware of all state and local laws regarding controlled substances, but that doesn’t mean physicians should be afraid to prescribe these drugs, Gerber says.

Clinicians simply need to be alert to the minority of patients who will abuse these drugs, and set up policies preventing this kind of abuse, Gerber adds.

"We don’t prescribe refills and changes after hours or over the weekend," Gerber says. "Patients are given a monthly supply, and they have to adhere to the schedule, including seeing us routinely every three to four months for a follow-up." 

Need More Information?

  • Marc R. Gerber, MD, Partner, Florida Spine Care Center, 25 W. Kaley St., Orlando, FL 32806. Telephone: (407) 481-2244.