Chronic Pain Rehabilitation

Elizabeth Loder

Patricia W. McAlary

Like an alarm bell stuck in the “on” position… such is chronic benign pain.

—Bruce Smoller and Brian Schulman

I. THE SCOPE OF THE PROBLEM

Despite steady improvements in the treatment of pain, there remains a group of patients whose recovery is minimal, although they have been subjected to concerted attempts at appropriate therapy. Unrelieved pain is associated with severe impairment of physical, psychological, and social well-being. Unemployment, reduced physical activity, and sleep disruption associated with chronic pain may lead to a downward spiral of physical inactivity, decreased socialization, altered sleep-wake cycles, and medication overuse. Once entrenched, these maladaptive behavior patterns are difficult to reverse. Secondary depression and medication overuse may develop, along with family dysfunction and poor work performance. Patients with chronic pain are five times more likely than the general population to use medical services, and 58% of patients with chronic pain have anxiety or depression that can further complicate their treatment.

The development of chronic pain syndrome (see Table 1), in which patients develop disability out of proportion to the underlying disease, with associated behavioral abnormalities, requires multidisciplinary treatment. The treatment philosophy, which must be accepted by the patient and family, shifts from cure to management. Medication reduction, increased “uptime” and regular physical exercise, involvement in hobbies or return to work, and psychological intervention all help the patient to return to some semblance of normal living, despite the persistence of pain.

Optimal management of chronic pain must address not only the initiating physical pathology but also the social and psychological sequelae that accompany the pain and contribute to poor quality of life. Specialized outpatient pain rehabilitation programs that
provide coordinated, multidisciplinary care can be helpful. Inpatient treatment may be necessary for patients with impaired mobility or advanced debilitation, for those whose severe medication overuse requires special tapering from opioid or barbiturate drugs, and for those with associated medical or psychiatric morbidity that precludes outpatient treatment.

Table 1. Characteristics of patients with chronic pain syndrome

Demanding, angry, skeptical (of help)
Doctor shopping (“fix me”)
Somatizing; dependency on health care system—often for multiple medical problems
Preoccupation with pain
Marked pain behavior
Passive–dependent personality traits
Caretaker—meets needs of others at own expense
Denial of emotional or family conflicts
Major disruption in multiple areas of life
Feelings of isolation and loneliness
Lack of insight into self-defeating behavior patterns
Use of pain as a symbolic means of communication
May be conscious or unconscious of secondary gain

From Aronoff GM. Psychological aspects of nonmalignant chronic pain: a multidisciplinary approach. Res Staff Physician 1984;3, with permission.

1. The Pathologic Nature of Chronic Pain

Chronic pain differs from acute pain in that the former is a pathologic state that is of no benefit to the individual, unlike acute (physiologic) pain, which arises in response to injury or inflammation and protects the individual from further injury. Acute pain is time-limited and resolves as healing takes place. Chronic pain, by contrast, is caused by changes in the nervous system that are not reversible (nerve injury, sensitization, new fiber growth, reorganization, etc.), and is unremitting and extremely difficult to treat. Standard acute pain treatments [nonsteriodal antiinflammatory drugs (NSAIDs) and opioids] have only limited efficacy in treating chronic pain. Moreover the pain, muscle guarding, and decreased activity that serve a useful purpose in acute pain become counterproductive in chronic pain. Avoiding activity no longer serves the purpose of protecting healing tissues from further injury, but instead leads to deconditioning. Patients tend to respond to chronic pain in the same way that they respond to acute pain, but the response is dysfunctional and paradoxically promotes worsening rather than improvement.

II. GENERAL PRINCIPLES OF CHRONIC PAIN TREATMENT

In nearly all cases, multidisciplinary treatment rather than medical treatment alone is required to reverse the complex behavior patterns that develop as a result of chronic pain. When it is not possible to eliminate pain, emphasis shifts from efforts directed solely at pain relief, whatever the cost,
toward efforts to maximize the patient’s ability to function despite the pain. It is important that this change in philosophy is accepted and understood by the patient, his or her family, and the physician.

It is often hard for patients (or families) to reach the point at which they are ready to embrace a treatment model that emphasizes management and coping but does not promise a cure. They feel compelled to seek additional medical opinions or treatment options before accepting the rehabilitation approach. Physicians may contribute to the problem when they focus only on the specialty treatments they are trained to provide. Prolonged searches for a “cure” can be counterproductive and can expose the patient to further harm from aggressive surgical, medical, or alternative treatments. Tactful discussion between the physician and the patients and their families can help make clear that rehabilitation does not mean giving up on efforts to improve the underlying problem or simply learning to live with the pain.

III. EVALUATION OF THE PATIENT

1. History and Examination

A thorough physical examination is essential to identify sources of pain and to reassure the patient that the pain problem is taken seriously. A history of the pain problem, as well as a detailed review of previous medical records documenting treatment trials, reasons for treatment failures, and the timing of interventions is helpful. Information on specific dosages and length of pharmacologic treatment trials helps the physician assess the adequacy of previous treatments. Whenever possible, the physician should review the original test results [e.g., computerized tomography (CT) scans and magnetic resonance imaging (MRI)] rather than relying on summary information in medical records. Access to comprehensive records may be difficult to obtain, in which case patients or family members can participate by obtaining and organizing this information.

During the initial evaluation, special attention should be paid to the emotional context of the pain problem and its meaning in the patient’s life. For example, pain resulting from an injury-causing event in which others were killed or injured, or from what is perceived as a botched surgical procedure, will be difficult to treat without paying attention to the psychologic aspects. Likewise, a history of repeated adversarial or unsatisfactory interactions with multiple health professionals should prompt consideration of the presence of personality or other psychiatric disorders that could complicate treatment. Speaking directly with previous or current caregivers can provide invaluable insight into patterns of self-defeating behavior or other reasons for treatment failure.

2. Pain Intensity and Impact

Patient complaints of pain, functional disability, medication use or overuse, and comorbid psychiatric and medical illnesses must be taken into account to develop an appropriate, individualized treatment plan. In the treatment of chronic pain, ratings of functional ability are more useful than conventional 0 to 10 pain rating scales in gauging the impact of pain and in deciding the type of treatment. A 0 to 3 scale is often employed, with 0 indicating
no impact of pain on ability to function, and 1, 2, and 3 representing minimal, moderate, and severe impairment of function by pain, respectively. The use of obsessive or overly detailed pain charts is discouraged (unless they are needed to judge specific interventions) because it encourages somatic preoccupation and attention to pain. In most chronic pain treatment plans, pain behaviors such as grimacing, sighing, or rubbing affected body parts are discouraged because they draw the attention to the pain rather than reinforcing productive “well” behaviors (see Table 2).

Information should be obtained on the impact of pain and pain treatment on the patient’s functioning in social, family, and occupational or school settings. It is helpful to ask patients to describe a typical day’s schedule and activities, and what would be different if they were not in pain. Disability and financial status and involvement with workers’ compensation or the legal system are factors that can influence pain presentation and may also have a bearing on treatment. Education and work history can be important, especially if the pain results from a work-related injury.

Detailed information on sleep disturbance, alterations in sleep–wake cycles, and depression or anxiety should be obtained. Psychiatric or personality disorders exacerbate chronic pain and should be identified and treated. A family history of psychiatric illness or disability may also contribute to the pain. Finally, family beliefs about the patient’s condition and the family’s role in the pain problem (e.g., “enabling” or overly solicitous behavior, anger, or neglect) should be determined.

Only gold members can continue reading. Log In or Register to continue