The Role of Nonpharmacological Approaches to Pain Management Proceedings of a Workshop (2019) / Chapter Skim
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4 Emerging Models of Care
4 Emerging Models of Care
Pages 25-40
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From page 25... ...
. • Treating complex and high-impact chronic pain may involve non pharmacological interventions, particularly when pain is exacer bated by modifiable risk factors such as catastrophizing (Edwards)
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From page 26... ...
To address these challenges, the National Pain Strategy promoted the concept of integrated, patient-centered, evidence-based, multimodal, inter disciplinary care, with systematic coordination of medical, psy chological, and social aspects of care delivered by primary care, mental health, and sometimes specialty care providers. Various models of care may provide integrated care, said Kerns, including stepped care, risk stratification, matched care, collaborative care, care 1For more information about the National Pain Strategy, see https://iprcc.nih.gov/ National-Pain-Strategy/Overview (accessed February 6, 2019)
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From page 27... ...
The first of these -- collaborative care delivered in five primary care clinics at one Department of Veterans Affairs (VA) Medical Center -- showed significant improvements compared with usual treatment with an intervention that included "clinician education, patient assessment, education and activation, symptom monitoring, feedback and recommendations, and facilitation of specialty care" (Dobscha et al., 2009)
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Lynn DeBar, senior scientist at the Kaiser Permanente Washington Health Research Institute, commented that among the biggest challenges encountered in a study aimed at bringing interdisciplinary care to patients on chronic opioid therapy were (1) getting patients interested enough in the kinds of treatments being offered, and (2)
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From page 29... ...
However, for the treatment of acute and subacute back pain, the steppedcare model may make it difficult to start nonpharmacological treatments early, he said. The model presumes that it takes time to establish psychological and other kinds of treatment approaches and ignores the fact that psychosocial risk factors can be assessed in a patient within hours of back pain onset.
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From page 30... ...
The disadvantage of this approach is that it may be difficult to assign people to risk categories with this simple questionnaire. Shaw and colleagues proposed a matched-care model that uses a more detailed questionnaire to assess the nature of risk based on specific types of risk factors, such as mood problems, functional limitations, or workplace issues.
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Fritz's research suggests that patients are willing to choose a physical therapist visit as the first of line care if they can be ensured that their health care providers are working together as a team and if their concerns are appropriately addressed. CARE FOR PATIENTS WITH COMPLEX AND HIGH-IMPACT CHRONIC PAIN Nonpharmacological interventions have shown promise in treating patients with complex and high-impact chronic pain, said Edwards.
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From page 32... ...
. Catastrophizing also appears to contribute to the maladaptive network connectivity that is observed in patients experiencing chronic pain.
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, who demonstrated that the symptom cluster of sleep disturbance, pain, anxiety, depression, and low energy and fatigue -- the SPADE pentad -- correlated with functional outcomes in a stepped-care intervention program. Complementary and integrative health modalities have also been studied in more partitioned ways, disconnected from conventional care, said DeBar.
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From page 34... ...
Currently, many randomized controlled trials of chronic pain treatments, including CIH interventions, exclude older adults, especially the oldest old and those who are institutionalized, she said, noting that CIH interventions may need to be modified for these populations. Sherman also recommended: • Conducting studies on implementing and disseminating various mind–body and self-care therapies, which can increase self-efficacy, but often are unreimbursed and require sustained, consistent practice.
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From page 35... ...
To improve the quality of evidence, researchers have recommended conducting more randomized controlled trials with fewer single-arm studies, reducing variability across studies to enable comparability, and focusing on interventions with a theoretical basis, said Heapy (McGuire et al., 2017; Sundararaman et al., 2017; Wethington et al., 2018)
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From page 36... ...
Education and marketing are also needed to explain to patients how and why nonpharmacological approaches such as CBT may help, and to providers why early referral is important, she said. Heapy added that partnerships will be needed between investigators and commercial entities to address these concerns and develop a consensus, and that integrated health systems like the VA, the military health system, and Kaiser Permanente have an important role to play because they have the infrastructure, electronic health records, and large expert workforces capable of developing, testing, and implementing novel treatments into care.
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NEUROMODULATION Neuromodulation -- the alteration of nerve activity through targeted delivery of a stimulus to a specific neurologic site -- represents another nonpharmacological approach to the treatment of pain, said Richard Wilson, associate professor of physical medicine and rehabilitation at Case Western Reserve University and director of the Division of Neurological Rehabilitation at the MetroHealth Rehabilitation Institute of Ohio. The stimulus may be electric current or chemical and can be delivered either invasively or non-invasively, he said, with the goal to reduce pain and improve function and quality of life.
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From page 38... ...
, a coil placed outside the skull generates a current within brain tissue that can alter brain activity. Among invasive neuromodulatory approaches, deep brain stimulation requires neurosurgery to plant an electrode within brain tissue to deliver more precise stimulation.
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From page 39... ...
. Wilson mentioned one other example of multimodal research: a study comparing mirror therapy compared to tDCS for phantom limb pain (Pinto et al., 2016)
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