Multidisciplinary Approach to Spine Care. Roland Kent, MD Axis Spine Center Post Falls, Idaho

Transcription

1 Multidisciplinary Approach to Spine Care Roland Kent, MD Axis Spine Center Post Falls, Idaho

2 Objectives Epidemiology of chronic pain Pain as a disease What is multidisciplinary pain management (MDPM) Discuss goals of MDPM Treatment modalities Medications Interventions Surgical procedures Pain psychology PT/OT Complimentary and alternative medicine

3 So why are you here? Primary care MD/NPs are the predominant providers managing pain in the US Little previous teaching Medical students receive on average <10 hours on pain physiology, neuroanatomy, physiology, diagnosis, management and treatment (Mezei et al, 2011) Medical students receive on average 1 hr of education on analgesics (Institute of Medicine Report, 2011) Housestaff education in pain management is not substantially better (Ogle et al, 2008) 2013 Hurley

4 Pain Epidemiology and Impact 100 million adults in the US with chronic pain(medical expediture panel, 2008) #1 cause for disability Patients with pain cost ~$4,500/year more than match no pain controls(iom, 2011) Direct medical costs - $293,000,000,000 Back Pain was 72% of these costs Approximately 150 million work days lost per year because of back pain

5 What do spine pain patients need? 80 percent of back pain sufferers benefit from conservative treatment that includes a thorough patient education program, a dedicated physical therapy program designed precisely for back pain problems Another 10 to 15 percent may need injection therapy 5 to 10 percent may need a surgical intervention.

6 Comparison to Other Diseases Direct and Indirect Costs in Billions(IOM, 2011) Pain - $635 Cardiovascular $309 Cancer - $243 Trauma/Poisoning - $209 Endocrine/metabolic - $127 Digestive System - $112 Respiratory System - $112

7 Why is proper evaluation and treatment of chronic pain important? Chronic pain itself is a disease Anatomical changes Physiological changes Pharmacological changes Psychological changes Altered responsiveness to medications

8 Chronic Pain State Cortical thinning in CLBP compared to controls Reversal of cortical thinning with treatment of pain Reversal of cortical thinning with treatment Seminowizc, 2011, J Neurosci

9 Development of chronic pain Pain that remains after the expected healing from an injury Pain that is NOT exclusively peripherally driven Central Nervous System amplifies and distorts the painful response so that it no longer is directly related to the peripheral input or stimulus An uncoupling of the expected stimulusresponse relationship

10 Chicken or the egg? Are the differences pre-existing? Do they predispose patients to chronic pain Do they result from chronic medication exposure? Are they the result of anxiety, depression, decreased physical activity, reduced social and intellectual stimulation?

11 What is a Multidisciplinary approach? Multiple Providers of various specialties who work together to assess and develop a comprehensive treatment plan for a patient Often includes Medicine, psychology, & PT/OT May also include alternative medicine Massage Acupuncture Chiropractic

12 Why MDPM? Because many Chronic Pain Disorders are disease states Many Pain states coexist with depression & anxiety We can t treat all of these changes with one modality We are in the midst of an opioid addiction epidemic

13 Evidence for multidisciplinary approach Selecting the most cost-effective therapies (instead of the cheapest) contributes not only to long-term cost savings but also to vast improvements in healthrelated quality of life for the patient (O Connor, 2009) Interdisciplinary treatment has been shown to contribute to significant decreases in medication use, health care utilization, and surgeries, with the potential to save tens of thousands of dollars in direct care outcomes and hundreds of thousands of dollars in indirect costs associated with long-term disability Phillips & Clauw. 2011

14 The key major barrier to the wider authorization and use of interdisciplinary pain management programs has been third-party insurance payers, who refuse to cover such programs as a means of cost containment

15 Goals in Multidisciplinary Approach to the Spine Improve or Maintain physical functioning Facilitate Re-engagement in typical activities Maintain or return to employment Perform ADLs Ability to participate in leisure activities Making Removal of Pain as a primary goal can be counter productive

16 Engaging patients in their treatment plans Discuss risk/benefits for all interventions Offer options Provide realistic, incremental goals UTILIZE PAIN PSYCHOLOGY!!

17 Medications Focus on non-opioid options Membrane stabilizers NSAIDs Topicals Antidepressants Wean current opioid regimen

18 Results of Opioid Weaning Harden et al. Pain Medicine 2015

19 Interventions Done under fluoroscopy or ultrasound Epidural steroid injections Joint injections Nerve ablations Sympathetic blocks Spinal cord stimulators IT pumps

20 Surgical Procedures Decompression Fusion Sacroiliac joint fusion

21 Pain Psychology 18-85% of patients with chronic pain have a comorbid psychiatric condition (Doan, Neural Plasticity, 2015) 35% with Chronic back/neck pain have depression or anxiety disorder (Katz, Spine. 1997,1999) Correlation between severity of pain and degree of depression (Fishbain, CJ of Pain, 1997) Cognitive approaches include CBT, biofeedback, hypnosis

22 PT/OT Physical Therapist/Occupation Therapist Educate on physiological basis of pain Teaches body mechanics, pacing Role in physical rehabilitation Address vocational issues Techniques for managing pain on the job Gatchel, Am Psychologist. 2014

23 Physical Therapy Active Treatment (better evidence) Gait Training Core Strengthening and stability Postural re-education Passive Treatment (less evidence) TENS Heat/ Cold Ultrasound

24 CAM Therapies Acupuncture Improvement in Pain, but not long lasting (Furlan 2010) Massage Little Evidence to support use (Furlan. Cochrane 2015) Manipulation Better than placebo at improving pain, function (Furlan 2010) Yoga and tai chi

25 Prolonged duration of Pain Worsens Outcomes Facet RF: Cohen et al. CJP 2007 Spine surgery: Quigley Surg Neurol 1998, Jacobs Eur Spine J 2011 Epidural steroids: Kwon et al. Skel Radiol 2007, Benzon Pain 1984 Pharmacotherapy for CRPS: Perez et al. Pain 2003 IA injections for knee OA: Tanaka et al. Rheum Int 2002 Physical therapy for DJD: Jansen et al. Eur J Phys Rehabil Med 2010 Vertebroplasty: Ryu & Park J Korean Neurosurg Soc 2009 TAKE HOME MESSAGE.SEND PATIENTS EARLY.