By Chris Wolski
Steven Stanos, DO, RIC Chronic Pain Care Center medical director (center), works with Tim Zepelak, PT, OCS, CSCS (right), to find the best therapy options for patient Ben Charrow.
But some pain never goes away. It lingers like a specter, affecting a patient's ability to work, have fun, and live. For chronic pain sufferers, the pain will remain for life. However, this does not mean that it needs to affect their ability to function. The Rehabilitation Institute of Chicago's Chronic Pain Care Center (CPCC) has been dedicated to helping patients gain control over their pain and return to their normal activities.
The center's intensive 4-week pain management course immerses patients in a full schedule of individual and group rehab activities aimed at developing strategies to control and overcome the pain that is derailing their lives.
The center's approach reflects the newer understanding of pain management, which deemphasizes the use of pharmacologic management—including opioid and nonopioid analgesics. "The medical community has been forced to refocus strategies related to medication management given recent adverse effects with a number of medication classes, including the nonsteroidal anti-inflammatories and Cox-2 inhibitors. In many cases, medications have been pulled from the market by the FDA. Physicians and consumers are beginning to understand that pain management really needs to involve a more comprehensive and active patient-centered approach" says Steven Stanos, DO, medical director of the Chronic Pain Care Center. "At the same time, there's been a number of news reports and studies concerning the misuse of opioids including problems with addiction, tolerance, and aberrant use. The pain management community has improved management and screening procedures that have helped to better select appropriate opioid candidates."
But understanding the effects of medications is not the only area of knowledge that has grown in relation to pain management. "More important, there has been a growth in understanding how depression and other psychological and social factors contribute to the development and maintenance of persistent pain and related disability," says Stanos. "Because of this, there's been a push back to more balanced and comprehensive treatment approaches and programs. Our type of interdisciplinary and multidisciplinary treatment incorporates different disciplines of health care providers working collaboratively under a rehabilitation-based approach."
The program, which was started originally as an inpatient service in the 1970s, was moved to its current North Clark Street site in 2000 and is now an outpatient program, which focuses on addressing the patient's biologic, social, and psychological needs. The 6,000-square-foot facility includes the outpatient clinic. The gym and pool space are housed in an adjoining private gym in which rehab and able-bodied exercisers use the equipment side by side. "I think this brings home the message that it's really about function and self-management with the goal that when patients finish the 4-week program, they will continue with their own individual program at home and/or at a local gym facility," says Stanos.
REHAB BOOT CAMP
Melanie Swan, OTR/L, assists patient Charrow find his optimum ergonomic alignment for computer work during an occupational therapy session.
The program is strict, not allowing absences or excuses. There are typically about 16 patients enrolled in the full program at any given time with a waiting list of patients wishing to take part. According to Stanos, about 60% to 70% of the patients' pain is related to neck and low back conditions. The balance of diagnoses include arthritis, fibromyalgia, myofascial and neuropathic pain, and amputation and spinal cord-injury related conditions. The program accepts most insurance, including workers' compensation.
Most patients have been suffering with their pain for several years. Many times, the center is the last in a long line of medication treatments and interventional failures. Though Stanos acknowledges the benefits of pain medications, he believes in coordinating their use with active therapy and psychological treatments. "Our approach involves finding a balance of medications focused on improving sleep and mood, and achieving analgesia with limiting side effects. Medication trials and adjustments are much easier since we are able to see patients 3 days a week in the program. This medication approach has more recently been referred to as rational poly-pharmacy," he says.
The physical therapy piece of the 4-week program is aimed at getting patients back to enjoying their life again, says Timothy Zepelak, PT, OCS, CSCS, a physical therapist at the center. Treatment is divided among both group and individual sessions. Individual treatments are conducted two to three times a week, and include techniques to help control pain such as joint articulation, resistance training, stretching, functional movement, and visualization techniques.
The focus of the daily group sessions is a bit different. The various therapy groups include Feldenkreis, group exercise, aquatic therapy, and creative movement class. "We really focus on trying to get the patient back to their own body, back to their own independent lifestyle, back to their life independently. So everything we do, all the techniques that we use, is all educational. It is teaching them how to do things themselves so they can get more function and participate more in their life," says Zepelak.
While the Rehabilitation Institute of Chicago's Chronic Pain Care Center treats those with the worst and longest-lasting pain, therapists in RIC's other departments are also treating pain on a daily basis, using a variety of methods ranging from the oldest and most time tested, heat and ice, to the most technologically advanced.
The therapists at the Spine and Sports Rehabilitation Center (SSRC) at the RIC use a variety of equipment to help ease their patients' pain. Among the conditions treated at SSRC are back injuries, gait disorders, musculoskeletal conditions, orthopedic conditions, osteoporosis, and pelvic pain.
Melissa Kolski, MSPT, OCS, mainly sees patients with pain stemming from spine disorders or injuries, including the neck, back, and herniated or degenerated discs; repetitive stress injuries; and sports-related injuries; as well as some postoperative or chronic pain.
Among the modalities Kolski might use to help treat pain are ultrasound, transcutaneous electrical nerve stimulation (TENS) units, and neuromuscular electrical stimulation. She uses ultrasound to heat tissues for stretching by helping the collagen relax, allowing "creep and stretch to come into the tissue," she says. "That constant heat can keep the tissue heated while I'm doing a passive stretch, taking the patient to a point where the tissue wouldn't have gotten to otherwise," she says.
Kolski uses neuromuscular electrical stimulation in postoperative situations on patients' quadriceps or anterior cruciate ligament. In her experience, TENS units appear to have better results on acute pain or flare-ups than on chronic pain. "Electrical stimulation is good in that inflammatory early phase," Kolski says. "It works on the gate control theory of pain, in the sense that it's beating out the pain fibers through sensation."
In her role at SSRC, Lauren Mermel, MPT, DPT, primarily treats patients with women's health/pelvic floor dysfunction, including pre- and post-natal patients, pelvic pain, coccygodynia, vulvodynia/vestibulitis, stress and urge urinary incontinence, SI joint dysfunction, and post-breast cancer/surgery rehabilitation. Among the modalities Mermel uses are interferential electrical stimulation, and real-time and perineal ultrasound.
Interferential electrical stimulation is used at SSRC to treat pelvic pain, coccygodynia, and occasionally sacroiliac joint dysfunction. "The interferential current often is used to help treat current pain complaints and is frequently used prior to any internal manual pelvic floor therapy. It has been suggested that interferential decreases the resting tone of the pelvic floor, [allowing] for more pain-free and effective internal manual therapy techniques," Mermel says.
The therapists use real-time ultrasound to treat low back pain and pelvic floor pain and/or dysfunction, visualizing the presence or absence of pelvic floor and deep lumbar stabilizer muscles. "The real-time ultrasound allows not only for assessment of muscular activation, but is also a useful visual biofeedback tool to instruct and ensure appropriate muscle activation for the patient's home exercise programs," Mermel says.
Perineal ultrasound is used for the treatment of postpartum painful episiotomies and occasionally to treat vulvar pain, since deep heat modalities may allow for decreased pain and increased extensibility of the perineum.
—Danielle Cohen
For Melanie Swan, OTR/L, an occupational therapist and clinical manager of the center, her focus is on improving specific functions related to work, home, and leisure. Her individual sessions emphasize posture, body mechanics, and ergonomics as related to the key areas of the patient's life. Group sessions are designed to help improve endurance and tolerance. "It's going to be a supervised therapy session, but it's also going to be an opportunity for you to take the skills you're learning in the individual sessions and start to apply them more independently in a structured group setting with the therapist there to guide you and help you, but not necessarily being there to set you up with an intensive plan of treatment," says Swan. "There are certain parts of the group therapy that are very structured by the therapist and parts that we're really encouraging the patients to structure." Group sessions may include group endurance activities, which progress in difficulty throughout the week, and then segue into an area—such as sitting for a long period of time—that the individual needs to work on.
Swan notes that much of her work is individual to the patient and is tied to their needs. "I'm definitely looking at what the patient is interested in being able to do. Obviously, as a therapist, I can evaluate a patient and I can look at activities that I think would be great for that patient to do. But if the patient isn't particularly interested in those activities, I'm going to have a tough sell," she says. "And there are some activities they are not going to be able to go back to." In this case, Swan will work with the vocational rehabilitation and psychological staff to identify strengths and skills that may get patients back to activity similar to one—either leisure or work related—that would be appropriate to their physical status.
As the patients go through their 4-week program, it becomes more intense with exercises, for instance, increasing from a minute or so to 25 minutes as the patient becomes better at controlling their pain and their overall stamina. Stanos says that the toughest part of the program is the psychological component. "If you can get them the right kind of support, you can change a lot of [the patient's] maladaptive thinking," he says. "We always try to teach them that pain does not mean harm. That's what [stops] a lot of these people. They think that, and that's why they're so limited."
Treatment does not stop on Friday afternoon. Patients are given "homework" assignments—tasks to perform and practice at home—over the weekend.
The rehab team works closely with one another, holding weekly meetings to evaluate each patient's progress and set individual goals for the patients.
The importance of psychological considerations is a function of the effect chronic pain has on patients. What makes the program unique is the recognition that the pain will not fade, but be part of the patient's life, which is different than the more traditional approach, says Zepelak.
In addition to traditional rehab, the program also evaluates and educates patients about other pain factors such as diet and sleep hygiene, says Stanos.
LEARNING ABOUT PAIN Patients and their family members spend much of the 4 weeks learning about pain and how to cope with it. And, again, much of this is part of the psychological component that is so crucial to the work Stanos and his team are trying to accomplish at the center.
Caryn Feldman, PhD, is the center's staff psychologist, and it is her job to both evaluate patients prior to coming into the program and help them adjust to the realities of chronic pain.
Like her rehab colleagues, much of Feldman's work is aimed at keeping the patient psychologically grounded. "What I try to do is help present to the people a realistic and more hopeful perspective," she says. "Most people are desperately eager to feel better."
Like the physical side of the program, the psychological includes both individual and group sessions. For Feldman, it is the group sessions that are the most useful to treatment. "There is something really magical that happens—something fantastic—when folks who feel incredibly alone and isolated, like an outcast, and misunderstood get to meet each other and see what it's like to chat with someone who gets what they're going through," she says. "I think that really helps motivate each other in a really positive way." Many of the patients who attend these three-times-a-week meetings stay in touch after the program ends, continuing the support they found during their boot camp experience. Sessions are held with family members as well.
Individual session topics vary from person to person. "It really depends on their needs and openness," says Feldman. "Typically, we'll go into more detail about individual stressors."
Like physical rehab, many of the psychological needs are individual to the patient and have to be addressed in a unique way.
Once patients graduate from the 4-week program, their work at the center is not done.
FOLLOW-UP
Francisco Malate, PT (left), leads an aqua therapy class as part of the physical therapy portion of a 4-week session at the RIC Chronic Pain Care Center.
Patients return to the clinic a month following completion of the program for a reevaluation by the entire team. They return to the clinic at the 3, 6, and 12 month marks, but meet only with a physician instead of the entire team. Patients can schedule appointments apart from the mandatory rechecks, according to Zepelak.
While the staff is focused on its day-to-day treatments, they are learning as much as the patients are. Research data is collected on patients while they are in the program. All of the treatment at the center is evidence based. The CPCC is also involved in ongoing drug studies through collaboration with the Center for Pain Studies. The center is run by Norman Harden, MD, and focuses on drug studies and clinical pain research.
The center has found a successful way to help patients deal with chronic pain, but there are still changes Stanos hopes and expects to see in the future.
THE FUTURE
RIC Chronic Pain Care Center Medical Director, Steven Stanos, DO consults with a patient on the importance of spinal alignment.
But the biggest challenge facing Stanos and his colleagues may not be a lack of space or shortening long wait lists, it may be educating primary care physicians. "Because of that, we're hopefully going to see patients referred to us sooner rather than later," he says. "Now, the average that we get patients referred to us from primary care is sometimes 2 or 3 years. I think as [the physicians] start to become better able to assess pain, those patients that have chronic pain will see us sooner."
Chris Wolski is editor of Rehab Management.
