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Management of chronic pain requires a multidisciplinary approach Sridhar V Vasudevan* speaks to Roshaine Gunawardana, Commissioning Editor: Sridhar V Vasudevan, MD is clinical professor of Physical Medicine and Rehabilitation (PM&R) at the Medical College of Wisconsin in Milwaukee, WI, USA. He is Board certified in PM&R and Pain Medicine (American Board of PM&R/American Board of Anesthesiology exam). He also has Board certification in Electro-diagnostic Medicine and Independent Medical Examination. He has been involved in the evaluation and rehabilitation of individuals with subacute and chronic pain using a whole-person multidisciplinary approach since 1977. He is Past President of the Midwest Pain Society, the American Academy of Pain Medicine, the Wisconsin Society of Physical Medicine and Rehabilitation and the Waukesha County Medical Society, as well as Founding President of the American College of Pain Medicine (now the American Board of Pain Medicine). He has presented on the topics of Pain Rehabilitation at several national meetings and international meetings in Scotland, Denmark, Peoples Republic of China, USSR, Germany, France, Turkey, South Africa, Canada, Aruba, Mexico and India. He has authored several chapters in text books on topics of a multidisciplinary approach to pain rehabilitation and evaluation of disability in individuals with pain. He is currently associated with the Center for Pain and Work Rehabilitation in Sheboygan, WI, USA, and is the Medical Director for the Center for Pain Rehabilitation at Community Memorial Hospital in Menomonee Falls, WI, USA. He also works at the Medical College of Wisconsin clinic in Menomonee Falls, WI, USA. He currently serves as a member of the Medical Examining Board of the State of Wisconsin, WI, USA. In your higher education and further studies, what contributed to your specific interest in the management of pain and related disabilities? QQ
At a personal level, at the age of 10 years, I started getting migraine headaches. My mother had this condition and it was assumed it was a familial problem. There was no treatment for this in India
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in 1960. Mired in the cultural, philoso phical and religious culture I lived in, I was taken to several preachers and temples. Several prayers were offered to the Gods, and homeopathic/Ayurveda medicines were attempted with minimal success. The migraine headaches have continued until today. However, I have much better control of the headaches with appropriate part of
*Wisconsin Rehabilitation Medicine Professionals, SC, Milwaukee, 53224, WI, USA; [email protected]
10.2217/PMT.12.33 © 2012 Future Medicine Ltd
Pain Manage. (2012) 2(4), 329–334
ISSN 1758-1869
329
NEWS & VIEWS INTERVIEW pharmacot herapy, and have learnt to minimize the potential triggers. In my teens and early 20s, while going to medical school, I was involved in several motorcycle accidents and other falls. This resulted in several fractures, as well as many soft-tissue injuries. I was left with chronic soft-tissue pains, which were unexplained. Currently, these are best understood as regional myofascial pain syndromes, pre dominantly involving the cervical and scapular muscles, and, to a lesser degree, the lumbar paraspinal muscles. These daily aches and pains have continued till today. I control them, with stretching, physical modalities (heat and home massage) and rare over-the-counter NSAIDs and muscle relaxants. Since the age of 4 years, I wanted to be a physician and I had expected to become an orthopedic surgeon, as I was always interested in the function of bones, joints and muscles. Later, my interest was also in the nervous system and its control of the musculoskeletal system. I emmigrated to the USA in 1973 after finishing my medical school in India and did a year of surgical training in Honolulu (HI, USA). However, I was extremely disappointed, as I did not find surgery as rewarding as I had anticipated. By serendipity, I met a physiatrist in 1973, who suggested I consider the field of physical medicine and rehabilitation, a field that I had never heard of. I took a residency in physical medicine and rehabili tation at the medical college of Wisconsin in Milwaukee (WI, USA). The rest is a rich and wonderful history and a fulfilling career. I became very interested in caring for individuals with a variety of musculo skeletal and neurological disabilities. However, I was drawn to understanding pain and was very fortunate to join the International Association of Study of Pain, the American Pain Society and one of its branches in Midwest Pain Society, all in the late 1970s or early 1980s. Through active participation in these organizations, I was able to work very closely with basic scientists and ‘super spe cialists and leaders of the field’, including Dr Dennis Turk, Dr Richard Chapman,
330
Pain Manage. (2012) 2(4)
Dr Wilbert Fordyce, Dr Stephen Brena and Dr John Loeser – to name a few. Soon I became very convinced that painrelated disability is indeed a treatable prob lem using the rehabilitation principles I had learnt as a physiatrist. Chronic pain – a con dition where pain lasts beyond the normal healing period, has no clear cause or cure and is associated with drug misuse, depres sion and disability – is ideally suited for the rehabilitation approach, as it requires a multidisciplinary group of professionals to address these multiple psychosocial and biologic aspects of the ‘person/individual’. In 1983, the American Academy of Pain Medicine (composed only of physi cians) was formed with an expressed inter ested in becoming a part of the American Medical Association, which is the ‘voice of medicine’ in the USA. One of the other important goals of the American Academy of Pain Medicine was to set up a ‘certifica tion process for physicians caring for indi viduals with pain’. Although there is still a goal to have ‘pain medicine’, as a distinct specialty similar to orthopedic surgery, anesthesiology or neurosurgery, that is still being worked on and it is, as usual, a slow, laborious and bureaucratic process. I became a founding member and then President of the American Academy of Pain Medicine. In addition, I was fortunate to be the founding President to the American Board of Pain Medicine, which we felt would be a prototype for the ‘specialty of pain medicine’. Further studies that I had to undertake in order to be certified by various differ ent pain medicine-related boards led me to a better understanding of the need for an interdisciplinary approach to pain management, which requires a biological, psychological, and social model of pain, to address the disability produced by pain. In this process, I became trained in the ‘dis ability processes in the United States,’ espe cially the social security disability system, workers compensation system and the per sonal injury system, and I have performed medico–legal work. Since 1977 to the present, I have been involved in a multidisciplinary approach to managing individuals with pain. For the first 10 years from 1977 to 1987, I was a
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INTERVIEW fulltime faculty/employee of the Medical College of Wisconsin in the Department of Physical Medicine Rehabilitation, even tually holding the rank of associate pro fessor, before leaving for private practice in 1987. I was eventually given the title of clinical professor of physical medicine and rehabilitation at the Medical College of Wisconsin. I continued to predominantly teach the students, and occasionally resi dents on request, with regard to issues of pain and disability. Could you briefly describe any ongoing research projects you have at present? QQ
After being involved in academic medicine for 10 years, at which time I did many of my research projects with other faculty mem bers, I have predominantly been involved in undertaking reviews and presentations, and being able to synthesize information from several sources and present it in a cogent manner, either in review articles, chapters or presentations, both nationally and internationally. At the present time, I am not involved in any specific research projects. However, as I have senior medical students who rotate 1 month of a ‘selective’ with me, I encour age them to do research reviews in topics of their choice, especially in the fields that they are entering whether it be physical medicine rehabilitation, anesthesiology, orthopedics, internal medicine, and so on, and have them try to publish these in journals when possible. You are the Medical Director of the Community Memorial Hospital Center for Pain Rehabilitation. In your opinion and experience, how important is the role of rehabilitation in the overall treatment of pain and related disabilities? QQ
In 1991, I was asked to become the medical director for the Center for Pain and Work Rehabilitation at St Nicholas Hospital and Sheboygan, Wisconsin. I am still associated with that program. In 1994, Community Memorial Hospital in Menomonee Falls (WI, USA) asked me to become the medical director for the center for pain rehabilitation, the posi tion I still hold. Both these programs in
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NEWS & VIEWS
Menomonee Falls, as well as in Sheboygan, are multidisciplinary, comprehensive and focus on a biopsychosocial and a rehabili tation approach to individuals with pain and related disability – with the goal of decreasing pain if possible, but to improve function and empower individuals (and their families) with chronic pain and return them to work and other ‘roles’ they have to play in their lives. These 35 years of my experience with individuals with chronic pain – either origi nating from failed back syndrome, fibro myalgia syndrome, complex regional pain syndrome, headaches, or other subacute neck, low back and extremity pain, have allowed me to use both my medical and rehabilitation skills. I am able to use my electrodiagnostic and clinical diagnostic skills to assess individuals to direct them to proper treatments so that chronic pain can be prevented by treating acute pain aggressively and promptly. However, when chronic pain becomes established with the features character ized by dysfunction, disuse, dramatic pain behaviors, drug misuse/abuse and disability that far exceed the physical findings, such individuals require a psychosocial emphasis with less medical emphasis – self respon sibility and empowerment of the patient become the key steps in managing such individuals. I have always viewed pain rehabilitation as a strong four-legged chair with the two rear legs holding most of the weight. These strong back legs include the behavioral/psy chosocial approach and the rehabilitation approach. The front two legs consist of phar macological approaches (which include, in part, interventional/injection therapies) and education/empowerment. The feet and rest of the structure of the chair is essentially the multidisciplinary team providing a sup portive environment for the individual to make the appropriate cognitive and behav ioral changes and increase physical activities that are required if one has to successfully ‘control and function despite the pain’. The focus in these multidisciplinary pro grams is not ‘cure’, but rather it is ‘cope’. The goal is not ‘pain relief ’, but rather ‘improved function and better quality of life’. The goal is not ‘continued dependence
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331
NEWS & VIEWS INTERVIEW on the healthcare system with medications, injections, surgeries and more imaging studies and disability’, but rather inde pendence using their own ‘mind or matter’, psychological skills, reframing their issue, finding alternative work within their appro priate physical and medical restrictions and gaining control of their pain and their life. Over the last 35 years of caring for indi viduals with pain and related disability, I have become convinced that, unless the psychological and social factors that con tribute to the pain experience are dealt with along with appropriate physical rehabilita tion, the use of only pharmacotherapy and interventional approaches are inadequate in the rehabilitation of these individuals. I have used the following three rules in dealing with any of my patients: Rule 1. Pain is real – I never question the
existence of someone else’s pain. As a phy sician, I believe it is the responsibility of physicians to make sure there is no sig nificant treatable or correctable pathology. Then, if there is no pathology, the focus should be on the person and not the pain. Rule 2. The pain is always in the brain.
This may initially sound as though the pain is imaginary. We have always believed that the brain has significant control over the body. Recent research has clearly demonstrated this, especially in individuals with fibromyalgia and other ‘sensory amplification syndromes’. The use of antidepressants and anti seizure drugs, which work in the brain and the CNS, are in general more effec tive than peripherally acting medications, especially for individuals with chronic pain. Similarly, numerous studies carried out by behavioral psychologists have shown that cognitive behavioral tech niques are far superior to many of the interventional and surgical techniques in managing many of these chronic pain issues. Rule 3. I inform the patients that they
could either stay on the road that they have been on – which includes narcotics, disability, injections, multiple surgeries and constant feeling of hopelessness – or they can chose a different road which
332
Pain Manage. (2012) 2(4)
involves significant self-responsibility and learning new skills from a team of profes sionals; for example, they can learn from physical therapists and occupational ther apists about appropriate exercises and use of their body, from psychologists about cognitive behavioral techniques, nurses to educate them about the use of medica tions, and vocational specialists who can assist them in resuming their ‘role’, even though it may not be the same one that they had prior to an injury or illness. This multimodal approach, using a biopsycho social process and a multidisciplinary rehabilitation process, in my opinion is truly the future of pain medicine. As new advances in the understanding of basic science continue, it will definitely add to the more successful rehabilitation of individuals with chronic pain. However, the basics of the biopsychosocial approach, which have been effective through centuries and practiced all over the world, have been and will always be the mainstay in manag ing chronic pain as well as other chronic illnesses. As an expert heavily involved in teaching, what would you consider to be the most important areas in which education in the field of pain management can be improved? QQ
It is remarkable to me that even when I went to medical school between 1967 and 1972, I had learned the ‘specificity theory’, which I usually describe as the ‘door-bell theory’. This theory believes that if there is pain there must be an injury or disease causing it. Get rid or treat the disease and the pain will go away. However, I was already being introduced to the ‘gate control theory’ that was proposed in 1965. I was aware of the chemical theories of pain that were being identified in the early 1970s and the behav ioral theories of pain, especially the learn ing model of pain and the Loeser model of pain that was well established, along with the need for multidisciplinary pain management by the mid-1970s. However, I am surprised and saddened by the fact that medical students that are graduating today still only know the ‘spe cificity theory’. When they hear a patient
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INTERVIEW complain of pain or see the patient dem onstrate ‘pain behavior’ they always assume there must be an underlying disease or tissue injury and continue to ‘look for a pain gen erator’. This has led to numerous imaging studies, which then results in the physicians and surgeons reading the ‘x-rays rather than the individual’. It has also led to numerous interventional techniques in order to ‘find the pain generator’ without taking into consideration the patient’s psychological makeup, their cultural background, their environment and the social milieu in which they function. There are legal work factors and social factors that are significantly more important in individuals with pain-related disability than medical factors, a fact which has been proven in numerous and elegant studies by Drs Steve Linton, Dennis Turk and Frances Keefe. I hope the future students will come up with the understanding that pain is not always explainable, is not always curable, and just because they cannot cure pain, they do not have to leave the patient hopeless and ‘feel hopeless themselves’. If the students are taught to accept the biological, psychological, social and environmental factors that may add to or accentuate the biological factors, then they will be able to manage many of these pain issues in a more comprehensive manner and improve the quality of life for their patients. Instead of repeated ‘studies to find the paingenerator’, multiple injections and interven tions to ‘eliminate or decrease the pain’, and use of opioids/narcotics rarely resolves the pain and is leading to an ‘epidemic of over- prescribing’, the future physicians will be able to ‘empower their patients’ and par ticipate in ‘shared decision-making’ – thus improving the quality of life for these individuals with chronic pain. Such an approach will also decrease the excessive expenditures of healthcare that is seen in western countries, especially in the USA. Your interests also lie in medico–legal activities. What aspects does your work in this area cover (with particular emphasis on pain management topics)? QQ
In the USA, work-related injuries are com pensated and provided with insurance
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NEWS & VIEWS
coverage relatively well, compared with other insurance programs. Many individ uals do not have insurance or have poor insurance, and so the workers compensa tion insurance is their main way to get care. This leads both the physician and the indi vidual to believe that many conditions are ‘work-related’, when there is very little of scientific validity to it. In addition, once it is considered work-related, physicians continue to treat the patient for prolonged periods of time (there is a clear differential between the amount of treatment the per son receives on a state insurance program as opposed to an individual who is covered under the workers compensation benefits). Similarly, in the USA there is a legal redress if you were injured in a motor vehi cle accident, or slipped and fell in a private or public property, due to someone else’s fault or due to a defect of a product. This, I believe, is an appropriate safeguard against unsafe products and unsafe work condi tions. However, a small percentage (10%) of individuals with work-related injuries are responsible for 80% of healthcare costs in work-related injuries. Similarly, although many motor vehicle accidents that may result in severe traumatic injuries usually resolve relatively quickly and effectively, individuals with ‘soft-tissue injuries’ are usually associated with significant claims from attorneys. Physicians, although with similar training, may disagree and may have different opinions. This leads to the medico–legal process. Individuals who had work-related inju ries or had been involved in motor vehi cle accidents made up the majority of my patient load for 30 of my 35 years. In most cases, I work with the insurance company and the employer in assisting my injured workers and my injured patients back to gainful employment with minimum focus on disability. I also perform independent medico–legal evaluations for both the insurance compa nies and/or their attorneys, as well as attor neys representing injured workers. This medico–legal thought process is different to any training provided at medical school. I have been involved in working with the American Medical Association with regard to the evaluation of permanent
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NEWS & VIEWS INTERVIEW impairment and have worked with my state organizations in the care of injured workers. Having been in practice for 35 years, what are some of the major developments you have seen in the field, and how would you like the specific field of pain rehabilitation to progress in the future? QQ
Over the past 35 years from 1977 to the present, I have seen the pendulum swing back and forth. When I entered the field of pain medicine in the early 1970s, it was moving away from prescribing opioids and using a ‘behaviorally based functional restoration and physical rehabilitation’. These approaches were paid for until the mid-1990s. The pendulum swung rather abruptly back to the biological basis of pain, leaving the psychosocial issues completely aside. This led to increase in the prescription of opioids (with associated misuse and death that we are currently seeing reported in the USA), as well as a significant increase in interventional approaches, including spinal surgeries, spinal injections, spinal cord stimulators and intrathecal pumps being placed, in the hope of relieving pain. However, there has not been a correspond ing focus on the physical rehabilitation, and especially the psychological and the social aspects of the ‘person with pain’, and not as much focus on ‘improving the function’ with most of the focus on ‘getting rid of pain’. This has not led to any significant improvement overall in any decrease in disability from pain. However, on the positive side, the basic science literature has assisted us in under standing that the ‘gate theory of pain’ pro posed in 1965 was not an electrical gate, but a chemical gate. Almost 30 years after the publication of the gate theory of pain by Melzack and Wall, Dr Allan Basbaum asked the question ‘what opens the gate?’ This has led to a much better understand ing of some of the chemical mediators in pain, and thus the increasing use of anti depressants and antiepileptic drugs. The development of duloxetine, pregabalin, gabapentin and milnacipran are examples of pharmacological agents from bench to
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bedside that have indeed improved the quality of life of many individuals with neuropathic pain. I am hopeful, with con tinued acceleration of the amine pathways, the cannabinoid pathways, in addition to the better understanding of the mecha nism of opioids and the role of glial cells will provide us with a much better under standing of the complexities of the pain phenomenon. Individuals with fibromyal gia who have previously been dismissed as ‘just complainers’ are now, at least some of them, clearly being identified as having a ‘sensory amplification syndrome’ due to the significant advances in basic science research using functional MRI and other animal models. However, my hope would be, as in the field of general rehabilitation where there has been substantial improvement in prosthetics and orthotics, that there will be much improvement in rehabilitating individuals with brain injury and stroke, a better understanding of the role of multi disciplinary pain programs again, and every individual with chronic pain and associated disability will have the benefit of receiving appropriate medical and also psychological and physical rehabilitation services that are so much in need. I wish to conclude that it is important that the current and future physicians who care for patients with chronic pain recog nize that ‘pain is always in the brain.’ Any program or process that addresses individu als with chronic pain is incomplete and will be ineffective without the availability of psychologists/counselors and physical reha bilitation approaches that focus on improv ing ‘self-efficacy through empowerment’ to increase function despite pain. Financial & competing interests disclosure The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
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Management of chronic pain requires a multidisciplinary approach Sridhar V Vasudevan* speaks to Roshaine Gunawardana, Commissioning Editor: Sridhar V Vasudevan, MD is clinical professor of Physical Medicine and Rehabilitation (PM&R) at the Medical College of Wisconsin in Milwaukee, WI, USA. He is Board certified in PM&R and Pain Medicine (American Board of PM&R/American Board of Anesthesiology exam). He also has Board certification in Electro-diagnostic Medicine and Independent Medical Examination. He has been involved in the evaluation and rehabilitation of individuals with subacute and chronic pain using a whole-person multidisciplinary approach since 1977. He is Past President of the Midwest Pain Society, the American Academy of Pain Medicine, the Wisconsin Society of Physical Medicine and Rehabilitation and the Waukesha County Medical Society, as well as Founding President of the American College of Pain Medicine (now the American Board of Pain Medicine). He has presented on the topics of Pain Rehabilitation at several national meetings and international meetings in Scotland, Denmark, Peoples Republic of China, USSR, Germany, France, Turkey, South Africa, Canada, Aruba, Mexico and India. He has authored several chapters in text books on topics of a multidisciplinary approach to pain rehabilitation and evaluation of disability in individuals with pain. He is currently associated with the Center for Pain and Work Rehabilitation in Sheboygan, WI, USA, and is the Medical Director for the Center for Pain Rehabilitation at Community Memorial Hospital in Menomonee Falls, WI, USA. He also works at the Medical College of Wisconsin clinic in Menomonee Falls, WI, USA. He currently serves as a member of the Medical Examining Board of the State of Wisconsin, WI, USA. In your higher education and further studies, what contributed to your specific interest in the management of pain and related disabilities? QQ
At a personal level, at the age of 10 years, I started getting migraine headaches. My mother had this condition and it was assumed it was a familial problem. There was no treatment for this in India
News & Views News Journal Watch Ask the Experts Interview
in 1960. Mired in the cultural, philoso phical and religious culture I lived in, I was taken to several preachers and temples. Several prayers were offered to the Gods, and homeopathic/Ayurveda medicines were attempted with minimal success. The migraine headaches have continued until today. However, I have much better control of the headaches with appropriate part of
*Wisconsin Rehabilitation Medicine Professionals, SC, Milwaukee, 53224, WI, USA; [email protected]
10.2217/PMT.12.33 © 2012 Future Medicine Ltd
Pain Manage. (2012) 2(4), 329–334
ISSN 1758-1869
329
NEWS & VIEWS INTERVIEW pharmacot herapy, and have learnt to minimize the potential triggers. In my teens and early 20s, while going to medical school, I was involved in several motorcycle accidents and other falls. This resulted in several fractures, as well as many soft-tissue injuries. I was left with chronic soft-tissue pains, which were unexplained. Currently, these are best understood as regional myofascial pain syndromes, pre dominantly involving the cervical and scapular muscles, and, to a lesser degree, the lumbar paraspinal muscles. These daily aches and pains have continued till today. I control them, with stretching, physical modalities (heat and home massage) and rare over-the-counter NSAIDs and muscle relaxants. Since the age of 4 years, I wanted to be a physician and I had expected to become an orthopedic surgeon, as I was always interested in the function of bones, joints and muscles. Later, my interest was also in the nervous system and its control of the musculoskeletal system. I emmigrated to the USA in 1973 after finishing my medical school in India and did a year of surgical training in Honolulu (HI, USA). However, I was extremely disappointed, as I did not find surgery as rewarding as I had anticipated. By serendipity, I met a physiatrist in 1973, who suggested I consider the field of physical medicine and rehabilitation, a field that I had never heard of. I took a residency in physical medicine and rehabili tation at the medical college of Wisconsin in Milwaukee (WI, USA). The rest is a rich and wonderful history and a fulfilling career. I became very interested in caring for individuals with a variety of musculo skeletal and neurological disabilities. However, I was drawn to understanding pain and was very fortunate to join the International Association of Study of Pain, the American Pain Society and one of its branches in Midwest Pain Society, all in the late 1970s or early 1980s. Through active participation in these organizations, I was able to work very closely with basic scientists and ‘super spe cialists and leaders of the field’, including Dr Dennis Turk, Dr Richard Chapman,
330
Pain Manage. (2012) 2(4)
Dr Wilbert Fordyce, Dr Stephen Brena and Dr John Loeser – to name a few. Soon I became very convinced that painrelated disability is indeed a treatable prob lem using the rehabilitation principles I had learnt as a physiatrist. Chronic pain – a con dition where pain lasts beyond the normal healing period, has no clear cause or cure and is associated with drug misuse, depres sion and disability – is ideally suited for the rehabilitation approach, as it requires a multidisciplinary group of professionals to address these multiple psychosocial and biologic aspects of the ‘person/individual’. In 1983, the American Academy of Pain Medicine (composed only of physi cians) was formed with an expressed inter ested in becoming a part of the American Medical Association, which is the ‘voice of medicine’ in the USA. One of the other important goals of the American Academy of Pain Medicine was to set up a ‘certifica tion process for physicians caring for indi viduals with pain’. Although there is still a goal to have ‘pain medicine’, as a distinct specialty similar to orthopedic surgery, anesthesiology or neurosurgery, that is still being worked on and it is, as usual, a slow, laborious and bureaucratic process. I became a founding member and then President of the American Academy of Pain Medicine. In addition, I was fortunate to be the founding President to the American Board of Pain Medicine, which we felt would be a prototype for the ‘specialty of pain medicine’. Further studies that I had to undertake in order to be certified by various differ ent pain medicine-related boards led me to a better understanding of the need for an interdisciplinary approach to pain management, which requires a biological, psychological, and social model of pain, to address the disability produced by pain. In this process, I became trained in the ‘dis ability processes in the United States,’ espe cially the social security disability system, workers compensation system and the per sonal injury system, and I have performed medico–legal work. Since 1977 to the present, I have been involved in a multidisciplinary approach to managing individuals with pain. For the first 10 years from 1977 to 1987, I was a
future science group
INTERVIEW fulltime faculty/employee of the Medical College of Wisconsin in the Department of Physical Medicine Rehabilitation, even tually holding the rank of associate pro fessor, before leaving for private practice in 1987. I was eventually given the title of clinical professor of physical medicine and rehabilitation at the Medical College of Wisconsin. I continued to predominantly teach the students, and occasionally resi dents on request, with regard to issues of pain and disability. Could you briefly describe any ongoing research projects you have at present? QQ
After being involved in academic medicine for 10 years, at which time I did many of my research projects with other faculty mem bers, I have predominantly been involved in undertaking reviews and presentations, and being able to synthesize information from several sources and present it in a cogent manner, either in review articles, chapters or presentations, both nationally and internationally. At the present time, I am not involved in any specific research projects. However, as I have senior medical students who rotate 1 month of a ‘selective’ with me, I encour age them to do research reviews in topics of their choice, especially in the fields that they are entering whether it be physical medicine rehabilitation, anesthesiology, orthopedics, internal medicine, and so on, and have them try to publish these in journals when possible. You are the Medical Director of the Community Memorial Hospital Center for Pain Rehabilitation. In your opinion and experience, how important is the role of rehabilitation in the overall treatment of pain and related disabilities? QQ
In 1991, I was asked to become the medical director for the Center for Pain and Work Rehabilitation at St Nicholas Hospital and Sheboygan, Wisconsin. I am still associated with that program. In 1994, Community Memorial Hospital in Menomonee Falls (WI, USA) asked me to become the medical director for the center for pain rehabilitation, the posi tion I still hold. Both these programs in
future science group
NEWS & VIEWS
Menomonee Falls, as well as in Sheboygan, are multidisciplinary, comprehensive and focus on a biopsychosocial and a rehabili tation approach to individuals with pain and related disability – with the goal of decreasing pain if possible, but to improve function and empower individuals (and their families) with chronic pain and return them to work and other ‘roles’ they have to play in their lives. These 35 years of my experience with individuals with chronic pain – either origi nating from failed back syndrome, fibro myalgia syndrome, complex regional pain syndrome, headaches, or other subacute neck, low back and extremity pain, have allowed me to use both my medical and rehabilitation skills. I am able to use my electrodiagnostic and clinical diagnostic skills to assess individuals to direct them to proper treatments so that chronic pain can be prevented by treating acute pain aggressively and promptly. However, when chronic pain becomes established with the features character ized by dysfunction, disuse, dramatic pain behaviors, drug misuse/abuse and disability that far exceed the physical findings, such individuals require a psychosocial emphasis with less medical emphasis – self respon sibility and empowerment of the patient become the key steps in managing such individuals. I have always viewed pain rehabilitation as a strong four-legged chair with the two rear legs holding most of the weight. These strong back legs include the behavioral/psy chosocial approach and the rehabilitation approach. The front two legs consist of phar macological approaches (which include, in part, interventional/injection therapies) and education/empowerment. The feet and rest of the structure of the chair is essentially the multidisciplinary team providing a sup portive environment for the individual to make the appropriate cognitive and behav ioral changes and increase physical activities that are required if one has to successfully ‘control and function despite the pain’. The focus in these multidisciplinary pro grams is not ‘cure’, but rather it is ‘cope’. The goal is not ‘pain relief ’, but rather ‘improved function and better quality of life’. The goal is not ‘continued dependence
www.futuremedicine.com
331
NEWS & VIEWS INTERVIEW on the healthcare system with medications, injections, surgeries and more imaging studies and disability’, but rather inde pendence using their own ‘mind or matter’, psychological skills, reframing their issue, finding alternative work within their appro priate physical and medical restrictions and gaining control of their pain and their life. Over the last 35 years of caring for indi viduals with pain and related disability, I have become convinced that, unless the psychological and social factors that con tribute to the pain experience are dealt with along with appropriate physical rehabilita tion, the use of only pharmacotherapy and interventional approaches are inadequate in the rehabilitation of these individuals. I have used the following three rules in dealing with any of my patients: Rule 1. Pain is real – I never question the
existence of someone else’s pain. As a phy sician, I believe it is the responsibility of physicians to make sure there is no sig nificant treatable or correctable pathology. Then, if there is no pathology, the focus should be on the person and not the pain. Rule 2. The pain is always in the brain.
This may initially sound as though the pain is imaginary. We have always believed that the brain has significant control over the body. Recent research has clearly demonstrated this, especially in individuals with fibromyalgia and other ‘sensory amplification syndromes’. The use of antidepressants and anti seizure drugs, which work in the brain and the CNS, are in general more effec tive than peripherally acting medications, especially for individuals with chronic pain. Similarly, numerous studies carried out by behavioral psychologists have shown that cognitive behavioral tech niques are far superior to many of the interventional and surgical techniques in managing many of these chronic pain issues. Rule 3. I inform the patients that they
could either stay on the road that they have been on – which includes narcotics, disability, injections, multiple surgeries and constant feeling of hopelessness – or they can chose a different road which
332
Pain Manage. (2012) 2(4)
involves significant self-responsibility and learning new skills from a team of profes sionals; for example, they can learn from physical therapists and occupational ther apists about appropriate exercises and use of their body, from psychologists about cognitive behavioral techniques, nurses to educate them about the use of medica tions, and vocational specialists who can assist them in resuming their ‘role’, even though it may not be the same one that they had prior to an injury or illness. This multimodal approach, using a biopsycho social process and a multidisciplinary rehabilitation process, in my opinion is truly the future of pain medicine. As new advances in the understanding of basic science continue, it will definitely add to the more successful rehabilitation of individuals with chronic pain. However, the basics of the biopsychosocial approach, which have been effective through centuries and practiced all over the world, have been and will always be the mainstay in manag ing chronic pain as well as other chronic illnesses. As an expert heavily involved in teaching, what would you consider to be the most important areas in which education in the field of pain management can be improved? QQ
It is remarkable to me that even when I went to medical school between 1967 and 1972, I had learned the ‘specificity theory’, which I usually describe as the ‘door-bell theory’. This theory believes that if there is pain there must be an injury or disease causing it. Get rid or treat the disease and the pain will go away. However, I was already being introduced to the ‘gate control theory’ that was proposed in 1965. I was aware of the chemical theories of pain that were being identified in the early 1970s and the behav ioral theories of pain, especially the learn ing model of pain and the Loeser model of pain that was well established, along with the need for multidisciplinary pain management by the mid-1970s. However, I am surprised and saddened by the fact that medical students that are graduating today still only know the ‘spe cificity theory’. When they hear a patient
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INTERVIEW complain of pain or see the patient dem onstrate ‘pain behavior’ they always assume there must be an underlying disease or tissue injury and continue to ‘look for a pain gen erator’. This has led to numerous imaging studies, which then results in the physicians and surgeons reading the ‘x-rays rather than the individual’. It has also led to numerous interventional techniques in order to ‘find the pain generator’ without taking into consideration the patient’s psychological makeup, their cultural background, their environment and the social milieu in which they function. There are legal work factors and social factors that are significantly more important in individuals with pain-related disability than medical factors, a fact which has been proven in numerous and elegant studies by Drs Steve Linton, Dennis Turk and Frances Keefe. I hope the future students will come up with the understanding that pain is not always explainable, is not always curable, and just because they cannot cure pain, they do not have to leave the patient hopeless and ‘feel hopeless themselves’. If the students are taught to accept the biological, psychological, social and environmental factors that may add to or accentuate the biological factors, then they will be able to manage many of these pain issues in a more comprehensive manner and improve the quality of life for their patients. Instead of repeated ‘studies to find the paingenerator’, multiple injections and interven tions to ‘eliminate or decrease the pain’, and use of opioids/narcotics rarely resolves the pain and is leading to an ‘epidemic of over- prescribing’, the future physicians will be able to ‘empower their patients’ and par ticipate in ‘shared decision-making’ – thus improving the quality of life for these individuals with chronic pain. Such an approach will also decrease the excessive expenditures of healthcare that is seen in western countries, especially in the USA. Your interests also lie in medico–legal activities. What aspects does your work in this area cover (with particular emphasis on pain management topics)? QQ
In the USA, work-related injuries are com pensated and provided with insurance
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coverage relatively well, compared with other insurance programs. Many individ uals do not have insurance or have poor insurance, and so the workers compensa tion insurance is their main way to get care. This leads both the physician and the indi vidual to believe that many conditions are ‘work-related’, when there is very little of scientific validity to it. In addition, once it is considered work-related, physicians continue to treat the patient for prolonged periods of time (there is a clear differential between the amount of treatment the per son receives on a state insurance program as opposed to an individual who is covered under the workers compensation benefits). Similarly, in the USA there is a legal redress if you were injured in a motor vehi cle accident, or slipped and fell in a private or public property, due to someone else’s fault or due to a defect of a product. This, I believe, is an appropriate safeguard against unsafe products and unsafe work condi tions. However, a small percentage (10%) of individuals with work-related injuries are responsible for 80% of healthcare costs in work-related injuries. Similarly, although many motor vehicle accidents that may result in severe traumatic injuries usually resolve relatively quickly and effectively, individuals with ‘soft-tissue injuries’ are usually associated with significant claims from attorneys. Physicians, although with similar training, may disagree and may have different opinions. This leads to the medico–legal process. Individuals who had work-related inju ries or had been involved in motor vehi cle accidents made up the majority of my patient load for 30 of my 35 years. In most cases, I work with the insurance company and the employer in assisting my injured workers and my injured patients back to gainful employment with minimum focus on disability. I also perform independent medico–legal evaluations for both the insurance compa nies and/or their attorneys, as well as attor neys representing injured workers. This medico–legal thought process is different to any training provided at medical school. I have been involved in working with the American Medical Association with regard to the evaluation of permanent
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NEWS & VIEWS INTERVIEW impairment and have worked with my state organizations in the care of injured workers. Having been in practice for 35 years, what are some of the major developments you have seen in the field, and how would you like the specific field of pain rehabilitation to progress in the future? QQ
Over the past 35 years from 1977 to the present, I have seen the pendulum swing back and forth. When I entered the field of pain medicine in the early 1970s, it was moving away from prescribing opioids and using a ‘behaviorally based functional restoration and physical rehabilitation’. These approaches were paid for until the mid-1990s. The pendulum swung rather abruptly back to the biological basis of pain, leaving the psychosocial issues completely aside. This led to increase in the prescription of opioids (with associated misuse and death that we are currently seeing reported in the USA), as well as a significant increase in interventional approaches, including spinal surgeries, spinal injections, spinal cord stimulators and intrathecal pumps being placed, in the hope of relieving pain. However, there has not been a correspond ing focus on the physical rehabilitation, and especially the psychological and the social aspects of the ‘person with pain’, and not as much focus on ‘improving the function’ with most of the focus on ‘getting rid of pain’. This has not led to any significant improvement overall in any decrease in disability from pain. However, on the positive side, the basic science literature has assisted us in under standing that the ‘gate theory of pain’ pro posed in 1965 was not an electrical gate, but a chemical gate. Almost 30 years after the publication of the gate theory of pain by Melzack and Wall, Dr Allan Basbaum asked the question ‘what opens the gate?’ This has led to a much better understand ing of some of the chemical mediators in pain, and thus the increasing use of anti depressants and antiepileptic drugs. The development of duloxetine, pregabalin, gabapentin and milnacipran are examples of pharmacological agents from bench to
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bedside that have indeed improved the quality of life of many individuals with neuropathic pain. I am hopeful, with con tinued acceleration of the amine pathways, the cannabinoid pathways, in addition to the better understanding of the mecha nism of opioids and the role of glial cells will provide us with a much better under standing of the complexities of the pain phenomenon. Individuals with fibromyal gia who have previously been dismissed as ‘just complainers’ are now, at least some of them, clearly being identified as having a ‘sensory amplification syndrome’ due to the significant advances in basic science research using functional MRI and other animal models. However, my hope would be, as in the field of general rehabilitation where there has been substantial improvement in prosthetics and orthotics, that there will be much improvement in rehabilitating individuals with brain injury and stroke, a better understanding of the role of multi disciplinary pain programs again, and every individual with chronic pain and associated disability will have the benefit of receiving appropriate medical and also psychological and physical rehabilitation services that are so much in need. I wish to conclude that it is important that the current and future physicians who care for patients with chronic pain recog nize that ‘pain is always in the brain.’ Any program or process that addresses individu als with chronic pain is incomplete and will be ineffective without the availability of psychologists/counselors and physical reha bilitation approaches that focus on improv ing ‘self-efficacy through empowerment’ to increase function despite pain. Financial & competing interests disclosure The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
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