A Physiatric Approach to Chronic Pain Management

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As a doctor of Physical Medicine and Rehabilitation (Physiatrist), many of the patients that I see in my clinic have some kind of chronic pain complaint.

Joint pain, myofascial pain/fibromyalgia, nerve pain, neck pain, low-back pain – any, all, or a combination of these, even in the same patient, is not uncommon.

Rarely am I the first physician that a particular patient has seen for their chronic pain.

As such, they often present with an extensive treatment history. Some treatments are ongoing while others have been tried and failed. Some patients have undergone surgery. Sorting out this history is time consuming but important.

In the eyes of these patients, and as soon as I introduce myself, I become their new “Pain Doctor.” Patient expectations are high because, unlike all the other physicians they have seen in the past for their pain, they seem to think that I have the “magic wand” that will make it all better.

Often times, there are emotional and psychosocial influences that significantly weigh upon the physical manifestation of a person’s pain. For some patients, this emotional “baggage” may have been present before the onset of the physical pain. For other patients, it has come to the surface since, or because of, the pain. Either way, this mind-body relationship cannot be ignored and as a result, it is pointless to attempt to treat, or even understand, chronic physical pain without delving into a patient’s “person.” It is no doubt easier and much less time consuming, but this approach is incomplete and ultimately less successful. You just need to open up that “can of worms.”

In the end, an effective, sometimes only marginally effective treatment plan usually requires a combination of treatment modalities, such as: physical therapy, exercise, injections, psychotherapy, and topical and oral medications. The risks and benefits of any treatment “ingredient” need to be considered.

Although complete resolution of a patient’s pain would appear to be the goal of “pain management,” more times than not, and the more chronic the pain becomes, this is unrealistic. Remember, these are patients who have been symptomatic for years despite having been involved in “pain management.”

Rather than an unrealistic goal of pain elimination, or even a significant reduction in pain, a more appropriate and potentially achievable goal in the management of patients with chronic pain is to try to optimize physical functioning, despite pain.

This goal re-setting, however, requires time, the development of a sound doctor-patient relationship, patient education, and a shift in the mindset of the patient who may still believe that becoming “pain free” is likely. It requires the patient to come to terms with a new paradigm that states that optimal, as good as possible, physical functioning – at home and at work and during community and recreational activities – is now at the center of the treatment plan. The complete elimination of pain is no longer the ultimate goal. Function is now the focus. The patient’s pain, as a result, simply becomes one of the many potential variables that can influence how a person is able to function. That is not to say that the level of a patient’s pain is not addressed, monitored, and treated. It is, but for the sake of functional goals, the treatment of pain is a means to a functional end.

From a physiatric and functional standpoint, patients with chronic pain are not unlike patients who have suffered a spinal cord injury, stroke, or amputation. Patients who suffer from chronic pain are also impaired and disabled. However, and similar to those patients whose lives are altered by other neuromusculoskelatal injuries, a chronic pain patient’s impairment and disability does not need to result in a handicap. Remember, a handicap is the limitation of the fulfillment of a role that is normal for a person. A handicap keeps a person from accomplishing life’s basic activities.

Patients with chronic pain do not need to be handicapped.