Edgar L. Ross, MD
There are many reasons why patients come to see their doctors, and pain is certainly the most common complaint. It can run the gamut from an acute strain or sprain that the person may find significant enough to go see their doctor to some other kinds of more significant problems because of some disease state that they have. The most common reason why people go to see their doctor is both acute and chronic back pain and that probably represents fully one third of the pain complaints that a primary care doctor may see.
The most important features of chronic pain versus acute pain is that chronic pain is less likely to go away, requires a completely different treatment approach than acute pain. Chronic pain requires a state of the art pain management center, a team approach, requires the person to be part of the active treatment plan. Acute pain often requires an intervention by a health care professional where the person is likely to be a passive recipient.
The current approach to pain management is based on essentially three principles. There is management of nociception. This is the pain sensation as well as the impact of pain throughout the body and up to the central nervous system to the brain. There are many different targets that we can use to treat someone, including medications, implants or nerve blocks.
The second component is a psychological component which is equally important. Many of our patients have symptoms because of the chronicity of their pain, just like anyone else that has a chronic problem that they have to deal with and impacts them greatly from day to day. Depression and anxiety are very important problems that we see in our population. A person who has poorly managed depression has significant anxiety and will just perceive more pain as well.
And then the third is the rehabilitation component. Patients who have chronic pain tend to be much less active, often we see patients who have not been active at all, they spend their days in the house, on the couch, in bed. They’re using an acute model for treating their chronic pain. A person hurts themselves, sprains their ankle you stay off of it for a few days. Well imagine staying off an ankle because it hurts for years. And the implications that might occur, that you’re not using the leg, you’re hopping around. So we have to retrain patients for improved outcomes.
And so combining the three, particularly in patients who have very significant longstanding disability, from their chronic pain is vital and extremely important to make any kind of progress in restoring your life.
Brigham and Women’s Hospital has a long history of having an interdisciplinary pain management center. We have more specialties involved as a team approach than probably almost any other pain center in the country. We have experts in psychiatry, psychology, neurology, physiatry, anesthesiology, all involved and present in our clinic all the time. So patients can come to our clinic and have all that therapy at once. In addition, we also have complementary and alternative medicine therapies, acupuncture, we have physical medicine, we have physical therapists in our center who have dedicated themselves to the management of chronic pain and all nurses and nurse practitioners are certified in chronic pain management or pain management as well.
We also have an active clinical trials program for the development of new medications. One of our psychologists is exploring the risk factors that could be prospectively found in patients who are undergoing surgery for total knee and total hip replacement, finding the twenty percent of the patients that may not do well. And we can proactively work with them so their successes are more likely than they are now.
We also have a very important NIH sponsored trial on fibromyalgia. Cognitive behavioral therapy is considered to be a very important component of patient’s with fibromyalgia, which is musculoskeletal pain that’s widespread. And so we’re using functional MRI before and after the treatment. Functional MRI is an MRI scan of a person and the brain’s reaction to pain. And we can watch the pain reactions change as the person improves. So that promises to be an extremely informative study as well.
And it’s clear that many of our patients have very complex medical problems, some of which are the result of the pain or causing them to have chronic pain. My interest has been for a long time on how do we connect with those patients, how do we insure that their treatment persists outside, improving compliance, outside of the Pain Center and outside of the doctor’s visit. So we have developed a phone app and that phone app will track the patient and provide them hints on how to manage their pain outside of the pain center in a contextual, specific time frame.
So opiates are often a problem and one of the biggest concerns that physicians have is am I treating the patient with opiates and pain medication and are they using it for the right reasons. So what we’ve developed in our pain center, that’s now widely used, are risk assessment tools that can identify the patient who might have a problem with the use of prescription pain medications. And we can do that, not to deny them pain relief, but we can do that to prospectively monitor them much more closely than we would if these people weren’t identified. And so those are psychological screening tools that were developed in at Brigham and Women’s Pain Management Center and are now widely used all across the world.
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