Here are key strategies for chronic pain programs

Focus on psychological, spiritual, and physical

Starting a chronic pain program requires a commitment to creating a multidisciplinary team and an exploration of various types of cognitive and alternative therapies. Rehab Continuum Report asked rehab pain specialists at three different facilities to explain how their programs work. Here are the strategies they outlined for managing a chronic pain program:

o Create separate inpatient and outpatient programs.

Northridge (CA) Hospital Medical Center has standard pain management programs for both inpatient and outpatient care. In the outpatient program, patients visit the facility for eight weeks, five days each week, and three to six hours each day. Their weekly schedules typically include three educational group sessions with a physical therapist, three with an occupational therapist, and one with a recreational therapist, says Laura Schneeweis, MS, OTR, pain program manager.

The programs also include two sessions of pool therapy, including a relaxation class in the pool, biofeedback, and several educational classes and support groups run by a psychologist, says Heidi Race, MA, OTR, occupational therapist.

"The emphasis in all the therapies is on having patients learn how to manage their pain," Race says. "We teach patients exercises and stretches they can do when discharged from the program so they don’t need us anymore."

For example, an occupational therapist might teach patients how to open the refrigerator, how to make a bed, and how to lift items off of a counter in away that doesn’t exacerbate back pain.

"We teach proper body mechanics: posture, energy conservation, goal-setting, and assertiveness training, with a goal of carrying on with activities of daily life," Race explains.

A pain program physiatrist will see patients about every other week to monitor medication management and therapeutic intervention, Schneeweis says. "Patients also participate in psychology groups throughout the week and are seen one time a week for individual psychotherapy with a psychologist," she adds.

The inpatient program is for patients who need more structure and therapy, including individual therapy, Schneeweis says. "Patients who don’t have the physical tolerance to drive themselves to and from their homes may be recommended for the inpatient program. They may have medication issues, such as some are highly addicted to the meds, and our goal is to detox and make them less dependent, and that’s done on an inpatient basis."

Also, patients who have been in an outpatient program but failed to progress to independence may be recommended for the inpatient program.

o Teach patients to eliminate pain behaviors.

People who experience chronic pain often have fallen into the habit of indirectly expressing their discomfort through what are called "pain behaviors." These could include moaning, groaning, rubbing painful areas, facial grimacing, and wearing a brace or other support when it’s no longer necessary physically.

Pain behaviors also include bracing behaviors, where a patient stands or sits in unnatural postures to avoid pain. But in the long run these only maintain their painful condition, says Ralph Bruno, PhD, rehabilitation psychologist at Walton Rehabilitation Hospital in Augusta, GA.

As a psychologist, Bruno shows patients how to study their pain behaviors and attitudes. "This is where the person’s life is focused on pain and what they talk about are treatments that failed and physicians who didn’t give them something they needed and all various aspects of pain, as it consumes their lives."

Occupational therapists and physical therapists at Northridge point out pain behaviors to patients, but not in an obtrusive way, Race says. For instance, Northridge therapists will keep a mirror nearby, so when patients begin to exhibit a pain behavior, therapists can pull out the mirror and show them their facial expressions. Thera pists also will point out any of the other physical pain behaviors patients express.

The rationale is that people with chronic pain tend to isolate themselves socially by complaining about their pain and exhibiting pain behaviors. "For example, if you want to go to dinner with a friend and you have two friends to choose from, are you going to pick the friend who complains, My back hurts,’ throughout the dinner, or will you choose the friend who doesn’t talk about it?" Schneeweis asks.

The chronic pain team acknowledges patients’ pain, but team members discourage any talk of it during the program. "People by nature complain about everything, and, yes, they complain about their pain," Schneeweis says. "A lot of them have been in pain for a long time, and it’s difficult for them to let go of it."

o Use psychological interventions.

Walton Rehabilitation Hospital’s chronic pain program teaches patients self-regulation skills for pain. These help distract patients from their pain, giving them new coping skills, Bruno says. "Distraction helps a person focus on something else so the pain goes into the background. The relaxation training helps a person reduce the autonomic hyperarousal, which accompanies most chronically painful states," he adds. "And it helps to turn down all the symptoms associated with distress, which includes increased muscle tension, heart rate, and blood pressure."

The Walton program also teaches patients how to reduce their fear and anxiety, because those emotions can exacerbate pain symptoms, Bruno says. "A lot of times, having the fear of increased pain is what keeps people from being active, and one main symptom of chronic pain is the disuse syndrome, in which a person has been inactive for so long that the body is starting to decline, with muscle loss, strength loss, and organ decline."

A facility that helps set goals

Marianjoy RehabLink in Wheaton, IL, has a program that covers psychological losses that are related to chronic pain. For instance, a patient may have lost his or her ability to work full time, says Jevelyn Verbic, RN, clinical nurse coordinator at Marianjoy RehabLink.

Chronic pain patients often lack adequate physical, social, and mental stimulation because they’ve isolated themselves. They have spiritual crises, prompted by the "Why me?" question, and their identities are in flux. "Most of the people who come into this program can’t be what they used to be, such as a nurse or doctor or construction worker," Verbic says. "We encourage patients to set their own goals and look at themselves physically, spiritually, and emotionally."

The Marianjoy RehabLink program lasts five weeks, a total of 21 days, so patients are asked to write goals for what they want to be doing differently in five weeks.

o Help patients change their focus.

Walton Rehab’s program teaches patients to shift their concentration and attention to the other aspects of their daily lives, as a way of helping them become re-engaged with routines other than those involving pain. The Walton team includes nurses and physicians who provide medical management of pain. "Patients know their pain is being taken care of, but their mental focus has been swallowed by dealing with pain, so we gradually get them to focus on the routine and pleasurable aspects of life with friends and family rather than to just talk about their pain," Bruno says.

For example, the hospital had one elderly patient whose children met with the pain team at discharge and said, "We want to thank you for giving our mother back to us. Before, when we called her up, she’d only talk about how this medicine doesn’t help and about her pain and all the people who hadn’t helped her."

The woman hadn’t realized that she allowed her pain to consume her life to the point that she couldn’t relate to people anymore, including her own children.

"With coaxing and practice, we helped her understand there was a certain amount of pain she needed to live with," Bruno says. "And we helped her focus on the positive aspects of her life, and so after the program she’d call and talk with her children about their families and the different activities she was doing."

o Develop a physical reactivity program.

Physical therapists can develop a "physical reactivity" program in which they start patients at the level they can best handle when they enter the program and gradually increase their activity level to above their beginning pain threshold, Bruno says. "They also work on posture and body mechanics and gait, so patients can walk more evenly."

Occupational therapists will work on the patient’s physical capabilities during functional tasks, including cooking, placing pots and pans in cupboards, and working at one’s job without a pain flare-up. Therapists might even visit a patient’s job site and make recommendations for modifications and adaptive behaviors one could use while performing a job; or therapists might provide patients with work simulation tasks that build strength and endurance, Bruno suggests.

o Provide a pain support group.

"Many of the people we work with are going to have lifelong problems with their pain, and this provides them with a way in which they can be reminded of their techniques if they backslide or don’t apply what they learn," Bruno says.

Support groups also give patients encouragement when they maintain or reach their goals. At Walton Rehab, the support group is run by graduates of the chronic pain program, with a nurse as a facilitator.

"Sometimes it’s just a matter of giving a person some encouragement and reminding them to not dwell on their pain," Bruno says. "Other times a person feels like he can’t drive here and there and do things, and someone will say, I was in your shape three months ago, and now I go where I want to, and here’s how I do it.’"

Support groups also might help patients work on assertiveness. Patients can prevent injuries or strains that may cause pain flare-ups by asking for help in an assertive manner, Verbic says. For example, when chronic pain patients go to the grocery store, they should ask store employees to take the groceries to their cars without fearing they are bothering the employees. They also should be able to ask for that help without going into detail about their injury and pain. "You need to say, I need my groceries taken out to the car,’" she explains.

o Obtain reimbursement for the program.

Marianjoy RehabLink typically has no trouble obtaining reimbursement for its program from private insurers and workers’ compensation cases, Verbic says. "We work with the payer source to see what we could provide them in insurance coverage, and we try to sell the program as a package."

Northridge obtains a preauthorization from payers, including Medicare, for all patients who are referred to the program; unless patients have adequate reimbursement, they are not enrolled, Schneeweis says.

Walton Rehab has a case manager who works with insurance carriers to make sure all visits are covered and all services approved, Bruno says. "Different payers have been receptive, and others are not receptive to having patients rehabilitated for pain," he adds. "We try to lay out the best case possible in our evaluation, and then we demonstrate through our program that we’re effective by keeping data on the progress patients make."

o Use alternative treatments when needed.

Walton Rehab’s program uses no acupuncture, herbal remedies, or magnets. It does incorporate biofeedback equipment to monitor the level of arousal patients have and to show them how they can physiologically alter themselves through relaxation and mental-focusing procedures. "The equipment gives them a sense of self-control because so many of them have lost themselves to their pain," Bruno says.

Northridge uses biofeedback, heat and cold therapies, and ultrasound treatment at the acute stages of pain but offers no acupuncture, says Schneeweis.

"Ultrasound is used for patients who might never have had any exposure to it before, but the emphasis is on fitness, flexibility, and creating a home program they can take away with them," Race says.

Marianjoy RehabLink might refer patients to acupuncture treatment if physicians and patients feel there will be a benefit. The facility also uses biofeedback to teach patients how to relax.

"They hook it up to the area of injury, and they measure the muscle activity, because the more muscle activity, the more pain," Verbic says. "Then the biofeedback technician tries to find a relaxation tool that helps to bring that muscle activity down and bring the pain down." The tool might be a 15-minute relaxation tape.

Marianjoy RehabLink also is developing a wellness center in which patients would have access to a variety of alternative treatments, including massage therapy, chiropractic medicine, T’ai chi, and other options.

Need More Information?

American Geriatrics Society, 770 Lexington Ave., Suite 300, New York, NY 10021. Phone: (212) 308-1414. Fax: (212) 832-8646. E-mail: info.amger@americangeriatrics.org. For patient resources, including a chronic pain guidelines brochure: (888) 432-PAIN.

Ralph Bruno, PhD, Rehabilitation Psychologist, Walton Rehabilitation Hospital, 1355 Indepen dence Drive, Augusta, GA 30901-1037. Phone: (706) 724-7746.

Heidi Race, MA, OTR, Occupational Therapist, Northridge Hospital Medical Center, 18300 Roscoe Blvd., Northridge, CA 91328. Phone: (818) 885-8500.

Laura Schneeweis, MS, OTR, Pain Program Manager, Northridge Hospital Medical Center, 18300 Roscoe Blvd., Northridge, CA 91328. Phone: (818) 700-5648. Fax: (818) 700-5695.

Jevelyn Verbic, RN, Clinical Nurse Coordinator, Marianjoy RehabLink, 26 W. 171 Roosevelt Road, P.O. Box 795, Wheaton, IL 60185. Phone: (630) 588-7998.