Dr. Thomas Williamson-Kirkland M.D.

Transcription

1 1 Presents Dr. Thomas Williamson-Kirkland M.D. Treatment of Chronic Pain Patients Pain Management Programs Work Conditioning and Work Hardening

2 2 Treatment of Chronic Pain Patients: Pain Management Programs, Work Conditioning and Work Hardening I. Introduction A. In the work comp system patients who seem to fail to heal normally cause a great deal of expense and lost work. About 10% of the patients result in 80% of the cost. B. This group of patients we sometimes call Chronic Pain Patients because they complain chronically that Pain stops them from functioning and working. C. This monograph will discuss the phenomenon of pain, define these patients and discuss methods of treatment. II. III. Pain Transmission A. Is pain the signal from damaged tissue or is it the suffering we experience? B. Nocioception is the term we use for the signal from damaged tissues. This seems as though it would be very simple but is quite complex. C. All of us need pain to learn to protect ourselves from harm. Those who do not have pain damage themselves at an early age. D. Nocioception is carried on special dedicated nerves. When those pain nerves are damaged they send signals to the spinal cord. E. In the spinal cord large Transmission cells that act as a gate receive the signals. The T cell sends signals on to the brain depending on many variables. F. All the other special sensory nerves also send signals to the T cells. These include the senses of Temperature, Touch, Proprioception (joint movement), Pressure, Muscle use, and Vibration. The more signals they send the less the T cell transmits pain. Thus normal activity decreases our feelings of pain. G. The brain also affects the T cell. It can be flooded with endorphins and send on little pain responses or it can be sensitized by depression, fear and lack of sleep and send on more than the normal amount of signals. Many drugs such as narcotics, anticonvulsants and antidepressants will also decrease transmission. H. Thus after the acute injury is healed the amount of pain we experience may be very different depending on many variables. The more we can get back to normal function the less we will hurt. Chronic Pain Patients, Who are they? A. These patients who do not appear to follow normal healing are a very diverse group. They are all not the same and should not be treated the same.

3 3 i. Healing is a body process that happens whenever there is blood or extra fluid in tissue after acute trauma. White blood cells attract macrophages, which attract fibroblast, which build scar tissue. ii. This happens quite quickly and is mostly complete in 2-6 weeks with excessive or contracted scar causing tightness and pain. iii. Exceptions to the healing process time line include areas of the body with poor blood supply or unattached segments. This includes ruptured tendons or ligaments and cartilage damage. The healing process happens but cannot heal the ends together if they are not attached. Adequate healing can only occur with approximations of the ends. iv. Partial exceptions include Lumbar Disc ruptures where healing occurs but cannot heal the disc adequately to tolerate the same amount of pressure as previously. Nerve injuries heal slowly and may not heal for 3 months to 1.5 years. If at all. v. Scar healing is never quite as good as the original and not as elastic. B. Chronic Pain Patients come from many different causes, here is a partial list i. Failure of diagnosis. Examples would be not finding a Rotator Cuff Tear for months or labeling a buttocks pain as a SI joint problem instead of referred from the low back. ii. Chronic accumulation of diseases such as degenerative lumbar discs, arthritis, chronic tendonitis, carpel tunnel compression. These happen especially in year olds who may have to change jobs as these processes progress. Many of these patients will be very resistive to returning to work at a lesser paying job. iii. Psychological illness before or after injury on the job. Most chronic pain patients have or develop significant psychological reactions to disability that prevent recovery the longer they are out of work or function. iv. Family dysfunction. Many families are quite stressed with two parents working. When one is injured and the home life functions better it may be hard to return to work. v. Drug overuse. This includes pre-morbid hidden drug addiction and dependence created by the physician and patient. Drug dependent patients have a very difficult time making it back to work successfully. vi. Vocational unhappiness. Unhappy workers are less likely to return to work when injured. vii. Excessive passive treatment. Passive treatments are anything practitioners do to the patient. This includes surgery, injections, manipulations, mobilizations, ultrasound, electrical stimulation, and acupuncture. Active treatment is what the patient performs such as stretching, strengthening, endurance exercise, and

4 4 movement. Some passive treatment such as surgery and some injections set the patient up to heal appropriately but most other passive treatments do not help the healing process and if prolonged will be harmful. 1. Prolonged passive treatment makes the patient dependant and frequently convinces them that more is wrong with them than is actually true. 2. Passive treatment is very rewarding to the practitioner so is very hard to stop. 3. Passive treatments are only appropriate the first few weeks after injury and then should be an adjunct to active treatment as the patient heals. By the time the patient is mostly healed (2-6 weeks), the tissue should be at normal length and muscles at normal strength. viii. Chronic pain patients have no worse injuries or diseases than anyone else but have more dramatic pain responses. There is no way to know if they are actually hurting or to what degree. IV. Chronic Pain Behavior A. Pain behavior is what we see or hear from the patient that tells us they are hurting. This includes groaning, moaning, limping, immobilization and just talking about pain. Normally as healing progresses, nocioception decreases and pain behavior decreases. In chronic pain patients the pain behavior tends to increase as time goes by. The patient learns that the behavior of pain is in some way reinforcing. It may get them out of work, obtain medications, and attract a lot of attention at home or work and change social interactions positively. B. Excessive pain behavior is what defines chronic pain patients and cannot be equated with nocioception or even suffering. V. The Treatment of Chronic Pain Patients A. Prevention is of course the first choice. So identify early, obtain the right diagnosis and start active treatment early. Treat psych issues early and recognize the need for vocational change early. B. Match the level of treatment to the level of pathology. C. With more disability the more intense and multidisciplinary the treatment needs to be. D. Work conditioning programs consist of 2 hours a day of intense exercise and activity, usually one hour of Physical Therapy working on flexibility, strength and endurance and one hour of Occupational Therapy to focus on work activities with good body mechanics, posture, relaxation and job endurance. When there are no significant drug problems, no psych problems, a good attitude and a job to go back to these programs can be very successful. Usually patients have not been out of work more than 6 months. Most patients should be able to recondition in 4-6 weeks and

5 5 should be doing a home program or gym program also. The main problem with these programs is poor choice of patient and poor physician followup. When there is increased pain, who decides whether to continue treatment or not? Who decides to adjust the program and how much? The best programs have physician-therapist team conferences on a weekly basis for better decision-making. E. Work Hardening programs mimic work for increasing lengths of time. These programs are for those who have a job and just can t seem to get up to full-time work. Again picking the right patient is key to success along with good physician communication. F. Pain Management programs are multidisciplinary programs designed to treat the most difficult patient with multiple problems. Individual practitioners cannot treat patients with physical problems and depression, drug problems and vocational problems all at once. These programs include physiatrist, psychologist, vocational counselors, occupational therapists and physical therapists. The programs are daily, 6 hours of actual treatment with lots of education, psychological groups and counseling along with a double dose of work conditioning exercises. The therapists who work in these programs have to be specially trained and learn to handle pain complaints and behaviors. The physicians and psychologist also need special training and personalities to tolerate the stress of excessive pain behaviors. These programs usually last 4 weeks but may need to last 5-6 weeks for the most successful outcomes. G. The most difficult patients are those with drug problems, serious vocational problems, pre-morbid psych problems and excessive pain behavioral such as limping or non-use of an extremity. V. Summary A. The experience of pain is very complex. The longer a worker goes before returning to function, the more likely he/she will begin to complain of increasing pain and disability whether there is nocioception or not. B. Active treatment is necessary early to make the quickest recovery. C. When the patient s recovery does not follow the normal healing process, problems need to be identified early. Once identified the level of treatment needs to follow the level of disability.