Chronic pain is a huge problem nationwide.
Oct. 15, 2019 Washington Post
Nearly 20 million of those people have high-impact chronic pain , which is persistent and affects a person’s ability to carry out day-to-day activities, resulting in a lower quality of life. Chronic pain is also frequently associated with a higher prevalence of mood disorders such as depression and anxiety.
Though pain is nearly universal — almost everyone will deal with a bout of serious pain in a lifetime — chronic pain can be challenging to treat. “When you look at the landscape of society, the number one reason people go to the doctor is because something hurts,” says Yury Khelemsky, an anesthesiologist and associate professor at Icahn School of Medicine at Mount Sinai. Many of these patients have “underlying issues that can be corrected,” Khelemsky says. “For instance, if you have abdominal pain and gallstones, you can take the gallbladder out, and it gets better.” That is called acute pain, and it usually resolves within six months.
Another group of people have what Khelemsky calls “vague” pain — when the source is unclear — that lasts more than six months. “Perhaps chronic muscle, joint, back or knee pain,” he says. It could be pain that continues after an illness has ended or an injury has healed, or it could involve conditions such as fibromyalgia, arthritis, neuropathy, back problems or irritable bowel syndrome. “Among this group, with some, we know what it is, and we can kind of fix it; some, we really can’t fix it, or the treatments don’t fix it a good proportion of the time. We see that much more often in our profession,” Khelemsky says. “There just isn’t a good permanent solution.”
This is chronic pain, and treating it requires more than the occasional appointment and prescription for medication or therapy. In recognition of that fact, the medical community is turning to other approaches, including increasing patient support and education and improving overall wellness, perhaps with alternative treatments.
One factor researchers are looking at is continued care outside office visits. A pilot study published in the Clinical Journal of Pain examined the impact of supportive text messages with guidance and encouragement, such as, “Make plans to spend time with a friend or family member today by phone or video chat,” or, “You are in control of your health and happiness. Don’t let the small setbacks you experience discourage you.” The researchers found these texts reduced patients’ perception of their pain and decreased the extent to which it hindered their day-to-day life.
A 2019 study of 294 chronic pain patients examined how other out-of-office treatments might improve pain symptoms, as well as mood-related conditions such as depression and anxiety. In the research, the first group of patients were put on a Web-based self-management program with modules about coping with pain, pain medications, communicating with providers, cognitive strategies and more; the patients did regular self-reporting of symptoms and got reminders to complete their modules.
The second group was treated with the Web-based self-management program, but the patients were also monitored by a nurse who would contact them to add and adjust medications for pain and facilitate mental-health referrals for depression and anxiety, according to study lead researcher Kurt Kroenke, professor of medicine at Indiana University and a research scientist at Regenstrief Institute. “The nurse had weekly care management meetings with the supervising physician to develop treatment plans for new patients as well as those who were not responding adequately to their current treatment regimens,” he says.
The results of continued care were promising. “Both groups had moderate improvement in their pain and mood symptoms, and the improvement was superior what has historically been seen in primary care studies where the control arm simply received ‘usual primary care,’ ” Kroenke says. “The patient group that additionally received telecare from the nurse-physician team had further improvement beyond that experienced by the group that only received online self-management.”
More providers and health systems are implementing digital methods of care, such as patient portals, so patients can reach their physicians to communicate progress. Using technology to bolster treatment and educate patients could prove especially helpful for those who have chronic conditions.
Kroenke says it’s critical that patients with pain receive more than a single appointment with a doctor during a busy day. “All single treatments have, on average, modest effects in reducing pain, which means that changing, adjusting or combining treatments is often necessary to optimize outcomes,” he says. That means “following up at regular intervals to monitor and adjust treatment.”
Richard W. Rosenquist, chairman of the department of pain management at the Cleveland Clinic, believes patients with chronic pain benefit from attending organized programs run by a variety of medical specialists to keep up with treatment and self-care options. “We have a program at Cleveland Clinic called Back on TREK ,” he says. “It’s a chronic back pain program with psychologists, physical therapists, spine specialists and other physicians involved. Part of chronic-pain healing is the shared experience; people with back pain find out they’re not alone in the world — there are other people with the same problem.”
Many of these programs exist across the country for other conditions. For instance, Dan Clauw, director of the Chronic Pain & Fatigue Research Clinic at the University of Michigan, holds regular seminars about living with and managing fibromyalgia.
There’s promising research that patient education may relieve pain symptoms or improve physical functioning. In a study of people with low-back pain, receiving one-on-one counseling with a physiotherapist increased their ability to do a forward bend and straight leg raise. There’s also evidence that public education on chronic pain, through means such as social media and education classes, can help people avoid risk factors and advocate for family members who are experiencing pain.
Boosting overall wellness
Another factor in managing and preventing chronic pain is overall wellness. “The first thing is to stay physically fit and physically active,” Khelemsky says. “If I could change one thing [it would be that] everyone would eat a proper diet and do some type of physical activity where you’re using your muscles. It’s not just good for the physical body, but it’s good for the emotional state, as well.”
Maintaining a healthy weight can also help long term so you are not stressing your joints. “You have to think of the downstream effect of the pain,” Khelemsky says, noting that people tend to experience more of it as they get older. “If people set themselves up to deal with pain better, disability and suffering decreases.”
There are also more doctors and hospitals with integrative programs, such as the Duke University Medical Center, the University of California at San Francisco and the Mayo Clinic. This approach considers nontraditional therapies such as yoga, acupuncture, meditation and more as part of a holistic approach to treatment.
“In our wellness institute, we have an integrative pain program that involves using tai chi, diet changes, therapy and other lifestyle changes,” Rosenquist says. “We have a Functional Medicine Center led by Dr. Mark Hyman, which focuses on improving access to care, looking at the role of psychology, the diet and exercise in treating chronic pain.
“All of these contribute to reducing overall levels of pain and are things that are actually important when looking at a long-term view,” Rosenquist says.” If you’re smoking, overweight or sedentary, the likelihood of good long-term outlook goes down. It’s important to talk about the lifestyle change.”
Functional medicine physicians may look through a different lens than your primary care physician. Yeral Patel, a family medicine physician and integrative specialist in Newport Beach, Calif., says she sees lots of patients for chronic pain syndromes, injury recovery, back and neck pain, and carpal tunnel. “Functional medicine doctors try to dig deeper and look at the root causes of the pain,” Patel says. “We try to identify the possible causes of inflammation, such as gut dysfunction, micronutrient deficiency, insulin resistance and inflammatory markers.”
After taking an extensive history and doing a battery of tests to look at smaller contributing factors that might be preventing recovery, you’ll get an integrative plan “that utilizes nutrition, exercise and diet, supplements, and mediation for stress management,” Patel says.