January/February 2006

Quelling the Pain

By Dave Cater

Walton Rehabilitation Pain Center lives up to its motto: “Don’t live with pain, live your life.”

Erica Walling, PT (in the background), oversees patients participating in Rehab Plus, Walton Rehabilitation’s controlled conditioning exercise program.

Being the only physical medicine and rehabilitation hospital in Georgia’s Central Savannah River Area has become a doubled-edged sword for the staff at Walton Rehabilitation Hospital.

On the one hand, as the lone rehabilitation facility within the 13-county, 41-city area, Walton is not only the logical choice for individuals with physical disabilities, it also stands as the only choice for those needing a wide variety of physical therapy protocols. On the other hand, when Augusta area physicians have exhausted all accepted protocols, when they have run out of medications, when they have told the patient his only choice is to “live with it,” Walton Rehabilitation is the next stop on the speed dial.

Take, for example, the case of a local man who had been suffering from an increasingly painful case of shingles for almost a year. “He had been to four different doctors,” remembers Maureen Wright, RN, outpatient and wellness coordinator. “He had been on a host of medications, but they weren’t working. It was in his ears and in his eyes so bad he could not read anymore. He was miserable, yet his primary care physician told him, ‘Live with it.’ ”

That kind of attitude was neither acceptable to the Walton staff, nor within its scope of physical therapy comprehension. Living with the hopelessness that comes from unabated pain is not an option at Walton.

“Part of educating health care professionals and the public is that there are options for people out there,” notes Wright, who has been with Walton for nearly 18 years. “I tell anyone, ‘You don’t have to live with the pain.’ That’s what I told the

Walton Rehabilitation’s medical director, Pamela Salazar, MD, and acupuncturist Xiande Yi, LAc, Dipl, NACOM, are pain treatment specialists.

The familiar Walton Rehabilitation Hospital mantra, “Don’t live with pain, live your life,” has been the driving force for more than a decade behind the facility’s cutting-edge approach to the physical therapy aspect of pain management. This philosophy, which is shared by both management and staff at the one-story hospital in Augusta, begins with an understanding of each patient’s special pain treatment needs. Walton combines a unique team approach that melds pain intervention with specific physical therapy modalities to create a working model that deals with every aspect of a patient’s discomfort.

Diane Wilson, PT, has worked with the outpatient population at Walton for 17 years. Joining the center as an intern while attending the Medical College of Georgia, Wilson maintains that Walton’s across-the-board team approach has been directly responsible for its lofty standing in the rehabilitation field. Physicians and therapists are putting their titles and job descriptions aside for the greater common good—in this case what the patient needs to put his pain behind him.

Walton’s pain team—a pain intervention specialist, a physical therapist, a psychologist, and a wellness coordinator—discuss the specifics of every pain case that comes through the doors. Walton Rehabilitation Hospital averages around 40 inpatients on a daily basis and about 160 pain outpatients per month.

Hemant Yagnick, MD, a board-certified anesthesiologist who works in the pain center, contends that as a pain intervention specialist, his role is to find the reason or cause of pain in the patient and then try to lessen the severity by suggesting injections or minor surgical procedures. Patients, Yagnick adds, think he has the power to immediately eliminate pain. That is just not going to happen, he maintains.

From left is Walton’s medical team: anesthesiologist Hemant Yagnick, MD, of Walton Pain Center; physiatrist John Keel, MD, director of the Musculoskeletal Program at Walton Rehabilitation Health System; neurologist Marc Husid, MD, director of Walton Headache Center; Pamela Salazar, MD, physiatrist and medical director of Walton Rehabilitation Hospital; acupuncturist Xiande Yi, L.Ac, Dipl (NCAOM).

“There is no reasonably minded physician who can promise 100% pain relief,” insists Yagnick, who has been with Walton for 2 years. “There are patients who say that 50% pain is unacceptable. However, bringing them to a state of acceptability is one of my jobs. How can you even think of going to an internist and saying you want 100% relief from your hypertension or diabetes or pulmonary heart disease?”

What the staff at Walton strives to do is give the patient suffering from acute or chronic pain a chance to return to as normal a life as possible. Stephanie Smith, PT, who has been with Walton for 4 years, notes the first aspect of therapy is determining the patient’s current quality of life and future goals. “Unfortunately, there’s often a difference between their goals and what’s realistic,” Smith suggests. “What we try to do is manage what they already have.”

Physical therapists at Walton have a myriad of modalities from which to choose. The outpatient staff includes eight full-time PTs, two part-time physical therapist aides, two occupational therapists, and two speech therapists. Three gyms—each reserved for a specific diagnosis—are used for physical therapy.

“Everyone has been very accessible,” Wilson notes of the arrangement. “When the pain team first came together, we had two physicians’ offices plus the physical therapy department and the psychology department was mixed in with one or the other. Now, all of them are right here on campus, and if you have reached the limits in one therapy approach, more than likely there’s somebody else right here they can be directed to—just transition into a different aspect of care. Everything is so comprehensive. ”

That was not always the case at Walton Rehabilitation Hospital. Fifteen years ago, the pain protocol was much stricter and followed rigid guidelines. Regardless of the diagnosis, every patient was given identical treatment.

“We had a 4-week program where everyone got the same thing,” Wright explains. “No matter what your diagnosis, you were in this program and you had psychology and physical therapy and occupational therapy all in one. The results were not dramatic, because if you’re looking at chronic pain, there is an emotional side too. If you had pain for months and months, your personality would change too. The treatment was limiting and not always effective.

“A gradual change in philosophy occurred when physicians and therapists considered each case individually, rather than as a factor plugged into an iron-clad equation. After all, if the patient does not need occupational therapy, why should the discipline be included just because it is protocol? Who is to say the proper course of action is not an epidural injection followed by a wellness program?”

Change, though inevitable, came not without a few twisted egos. “Did some fight it? Oh, my gosh, yes,” Wright admits. “Change is always difficult, especially when it was done one way for so long. Some of those people have left because they could not change. There was a lot of resistance to it.”

Wright says the change in approach benefits both the patient and the program. Today, Walton Rehabilitation Hospital offers a wide array of standard physical therapy treatment and more vertical pain management programs. Physical therapy modalities include: electrotherapy stimulators, either a TENS unit or neuromuscular stimulators; traction; and thermal and ice ultrasound modalities. Unique programs that target specific pain issues (see sidebar below) include acupuncture; classes for patients with fibromyalgia or those who have survived breast cancer, both of which are led by instructors who have experienced the pain first hand; arthritis aquatic classes; and “Rehab Plus,” a wellness transitioning exercise regimen that help patients continue with the physical therapy routine once they are discharged. Rehab Plus patients can use the hospital’s exercise equipment and pool, and are supervised by a physical therapist.

“More people are served in a positive way if they don’t have to take 4 weeks off,” adds Wright, who markets Walton Rehabilitation Hospital throughout the community. “I think changing from a medical model to a wellness model is a mind-set. When we make people do more, they feel better if they’re doing it themselves. It changes their attitude for the better. We believe in treating the whole person, not just the body.”

Teams of physical therapists concentrate on certain aspects of pain management. For example, one team might work with low backs and cervical pain, while another team handles extremities. There also are teams for specialized needs such as amputations or cancer pain. This specific protocol ensures a continuum between therapists and patients.

But the team approach does not stop there. Informal meetings between therapists and physicians are held weekly to discuss patient care and suggested therapies.

“What is neat is that we all work together,” adds Wright, a certified rehabilitation nurse. “We all have different expertise but we share it. It’s never been territorial in nature. There is an openness here that provides an opportunity for the therapist and physician to discuss what they each think is better for the patient. There has to be a trust and you have to respect each other for your own expertise. Sometimes, with different personalities, you have to prove that.”

Wright credits Walton for giving its staff “the freedom to go out and educate themselves. They have encouraged us, been supportive, and allowed us to grow.”

It is this freedom that Walton Rehabilitation Hospital physical therapists are trying to instill in their pain patients. Some, however, are not so comfortable with the feeling.

“Some patients are going to fight returning to a life without physical therapy and some patients are going to embrace it,” explains Wilson. “Part of the art of therapy is deciding which category they are going to fall into. Sometimes you have to put your foot down and say, ‘I understand the doctor has written a prescription for 16 more visits, but it would be unethical to continue billing your insurance company.’

“More often than not,” she adds, “that’s not the case with patients. If you’ve established goals together, you know when you’re close to meeting them, so it’s not a huge surprise when the discharge time arrives. I think the people who have a problem are those who are not 100%. They have a hard time letting go.”

These are the cases that usually go to the staff psychologist, who helps patients gain strategies that give them active control over their lives. Once patients gain active control over their symptoms, Wilson notes, they can usually choose whether or not to hurt. This philosophy also is shared in other therapy cases.

“With spinal patients who continue to experience some back pain, they often don’t understand what’s going on with it,” she admits. “The therapist can teach you what you’re likely doing to aggravate it and what is likely to relieve it. When they start gaining a measure of control over it, whether from therapy or psychology, they can begin to be proactive. Then, whether or not you’ve helped the pain, I think the satisfaction level is a lot higher.”

Wright, who has organized a monthly lunch-and-learn program where area case managers and the referral base hear presentations from Walton staff, maintains the patient has to be taught to be realistic about his pain. While 100% pain reduction is always the goal, sometimes the goal has to be modified to meet the situation.

“If on a pain scale of 0-10 they come in at a 9 and a month later they are at a 5, they usually don’t think they are any better,” she relates. “But we show them how much they have improved. They always compare themselves to when they were 100%; well, 100% may not be the goal. Rather, the goal may be to become functional so you can live life on your own terms.”

Yagnick insists the goal of pain management has dramatically changed.

“There is no longer 100% or even 80% pain relief,” he maintains. “The goal is what do you want to do with your life? So, basically, we have gone from 100% pain relief to improved functionality. You might still have a little bit of pain, but the goal is to make sure you can do everything reasonably well in your daily life. When you put it across to patients that way, they are much more accepting of the outcome.”

Dave Cater is a contributing writer for Rehab Management.

LOOKING FOR EXPERT ADVICE? Experts here are available to answer all your questions! Please contact us for more information about this feature, or to become an expert.

MEDIA CENTER Interactive Media  Archives  · November 2008  · October 2008  · August/September 2008  · Fall 2008 Product Directory  · July 2008  · June 2008  · May 2008  · April 2008  · March 2008  · January/February 2008  · All Archives  Newsletter  · Rehab Today Resources Classifieds Calendar Consumer Resources Media Kit Advertiser Index EAB Reprints Submit an Article