Pain Relief

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March 2005

By Michelle Apuzzio, MSPT

Quincy Medical Center offers a community-based treatment option

On the map, it is only nine miles from the south shore suburb of Quincy to the center of Boston, a health care mecca of cutting-edge research and treatment. But the typical procession of brake lights on the Southeast Expressway can be a real problem for those with chronic pain seeking treatment in the city. When a 15-minute trip turns into a 40-minute crawl, even a minor headache can become a major pain.

The solution? As Christine Cadegan, NP, director of the Pain Clinic at Quincy Medical Center (QMC), puts it: “We bring the Boston doctor to the community.”

For 5 years, the outpatient pain clinic at the 282-bed community hospital, through its affiliation with the 547-bed urban teaching hospital, Boston Medical Center (BMC), has done exactly that for its patients with chronic pain. “You find there’s a large percentage of elderly patients who don’t want to go into Boston,” says Cadegan. “People want to stay in their community, and that’s the beauty of having the affiliation with BMC.”

Initially, the pain clinic started small, says Cadegan. At the request of a few primary care physicians (PCPs), an anesthesiologist started performing nerve blocks, the common term for a procedure in which medicine is injected into the spine to control pain. Booking time in the operating room was difficult, and occasionally the nerve blocks would be bumped for emergencies. Cadegan, who is also director of occupational health at QMC, welcomed the appeal to move the nerve blocks to her area, which had ample space. The procedures became more regular, and QMC soon purchased a C-arm fluoroscopy system, which provides a scan of the body for more precise injections, for the burgeoning clinic.

COMMON COMPLAINT
Pain is the single most common complaint during doctor’s visits and is labeled chronic when it lasts 30 days longer than expected, says Christopher Wenger, MD, director of pain management at Anesthesia Associates of Massachusetts, which runs the clinic at QMC.

The clinic’s immediate popularity reflects the prevalence of chronic pain, but Cadegan thinks the timing was good. Pain patients require much time with consultation and follow-up, she says, and 5 years ago was around the time that PCPs began to “get squeezed time-wise.” PCPs are still the primary source of referrals, usually when their patients are not responding to conventional medication.

The QMC Pain Clinic now occupies a quiet wing past the moderately busy desk of the Occupational Health Clinic on the second floor. The clinic is serene with sparse décor and a clean, calm appearance. A check-in desk, unobtrusively a few feet high, rather than a counter sits in the center of the clinic, surrounded by physician’s offices, which are occupied by a few rotating doctors—anesthesiologists, neurologists, and a physiatrist—on Wednesdays and Thursdays, when the clinic is open.
An alcove off the check-in area is a smaller waiting area, perhaps for family and friends who accompany patients, and off of that are two additional spaces—one for performing the nerve blocks and another for patients to relax after the procedure. The rooms are airy. When the hospital converted them from standard patient rooms, walls were knocked down to double the size of each one. And because they were patient rooms, they have windows, some of which afford a spectacular view of the Boston skyline, even on a dreary New England winter day.

Roughly 2,000 adult patients fit the profile for chronic pain treatment at QMC’s clinic each year, many of them elderly people who commonly present with postherpetic neuralgia (resulting from shingles) and spinal stenosis. Wenger estimates that 40% of the people he treats have low back pain. “Orthopedic surgery can fix knees, and shoe inserts can improve many foot problems, but we just can’t help using our backs,” he says. The multidisciplinary team also treats cervical spine pain—both general and herniated discs—as well as headaches, cancer-related pain, and postoperative pain.

TRAVELING FOR RELIEF
Although the majority of patients reside in Quincy, a community of nearly 90,000 people, the appointment books are filling with patients from suburbs further down Route 3, the highway that connects Boston to Cape Cod. The clinic does not market to other communities, but Cadegan consults with several municipalities for occupational health issues. “I have a lot of healthy people in [the Occupational Health Clinic]. They get here, and then they find out we have a pain department. They’ve got a mother, sister, brother [needing those services]. And so we’re getting little offshoots from occupational health just being out there in the community,” says Cadegan. “It’s amazing, the number of people that have chronic pain.”

INDIVIDUALIZED RELIEF
But no pain is the same, and, therefore, all treatment plans vary among patients, even for those with similar diagnoses. That is where Wenger finds one of the advantages of the QMC Pain Clinic. He points out that many pain management centers are operated by anesthesiologists, neurologists, or physiatrists rather than having an interdisciplinary setup with all of those specialties plus occupational and behavioral health and physical and occupational therapies on-site. The patient must still obtain a referral from the PCP for additional services but does not have the hassle of finding another care provider.

Brenda Ebode, PT, MBA, director of rehabilitation services at QMC, says the continuum of services absolutely benefits the patient. If a person has had only partial success with physical therapy at QMC, a referral to the anesthesiologist or neurologist in the Pain Clinic gives him another resource with a much different, more aggressive focus, she explains.

While there is no gold standard for how long the therapist waits before suggesting a visit to the Pain Clinic, Ebode says that it is generally 6 weeks if there is no improvement with strengthening, stretching, and ultarsound and electrical stimulation modalities, which vary according to the plan of care. “If we see some promise, some potential, we might keep them a little bit longer,” Ebode says, adding that traditional occupational and physical therapy work for the majority of patients who come in for 30-minute sessions two or three times per week.

Of course, success is relative. “On a scale of zero to 10 with 10 being the worst intractable pain, some people say they can live with a four. Other people will say they can’t even live with a one,” says Ebode.

MAGIC SHOT
In the Pain Clinic, treatment, which is covered by insurance, may be oral or injected pain medication or a combination of the two. When an injection is appropriate, the doctor uses the C-shaped fluoroscope to obtain a continual x-ray of the patient’s spine, pinpoint the exact location of the injection, which can be epidural or in the facet joint, and watch the medicine flow to the affected area. According to Wenger, x-ray guided injections have a higher success rate—he says that 70% respond—and are safer and more comfortable for the patient. The block can be an anesthetic or a steroid in a lipid emulsion that releases slowly for a few weeks.

Christine Cadegan, NP, director of the Pain Clinic at Quincy Medical Center, consults with a staff member about a patient’s upcoming pain treatment.

If pain medication or a nerve block diminishes the pain, the patient may return to therapy for fine-tuning or be completely discharged. In many instances, the injection or medication provides a period of reduced or no pain so that the patient can work through the cause with a therapist.

If the condition does not improve, the OT or PT teaches compensatory techniques, such as pacing and using adaptive equipment, to live with that level of pain. Pacing is a “big one,” says Ebode, and therapists often coach patients to learn how to read their body signals. They also reinforce what the Pain Clinic has already instructed the patient to do. Ebode frequently sees patients who do not understand how to build up therapeutic levels of medication in their bodies or who discontinue the drugs on their own for fear of addiction or because they are feeling better. And sometimes it is just a matter of helping the patient cope with a new lifestyle. “A lot of people are so stubborn that they won’t ask for help. They’ll live with the pain,” says Ebode.

POWER OF POSITIVE THINKING
Attitude plays a big part in treatment, it seems. When a patient has already tried therapy without success, it is that much harder to persuade them that it will work the next time. Wenger occasionally comes across this situation when he tries to send patients back to therapy after injections. Yet as the patient’s pain subsides, he says, the person begins to trust his judgment. “I tell them, ‘These magic shots are going to wear off, and this is the bridge to getting better,’” he explains.

And, although it is important to diagnose and treat depression in the chronic pain population, a referral to a psychiatrist is often a harder sell to patients. “They think you’re telling them it’s all in their head if you tell them that they need to see a psychiatrist,” says Wenger.

Other patients are eager to try whatever they can find that might ease their pain, including non-Western therapies such as acupuncture and herbal medicine. Although QMC does not offer Eastern-based techniques at present, it recently secured a grant from third-party insurer Blue Cross Blue Shield to form a cultural competency task force to study other health care models and how they would fit in with treatment.

WAIT AND SEE
One of the challenges facing the staff is when patients wait a long time to address their chronic pain, something that is fairly common, they say. But it could be a lack of knowledge that these treatments exist. “People will say to us, ‘I never knew this existed and I’ve had this pain all these years,’” said Lisa McSweeney, RN, who works in the pain clinic.

When her colleague, Mary Lorman, RNC, explains that chronic pain patients “need a lot of time, compassion, and understanding.” McSweeney adds, “These are people who have been worn really thin.”

And so the staff takes the extra step to make sure that the patients know they care. One time Lorman left her home phone number on a patient’s voice mail because it was the end of her shift. When the woman called to speak with Lorman at home, the patient said she was shocked and grateful that the nurse would give up her time to talk after work. “But how can you leave somebody hanging?” shrugs Lorman.

The rehabilitation department takes the same approach. “More than any other patient, you have to treat the symptoms and you have to treat the mental component,” says Ebode. “We certainly do it for everyone, but we do it much more for the chronic pain patient.”

The clinic has not performed any outcome studies, and it would be hard to pull off any type of double-blind research because, as Wenger explains, he would have a hard time giving a placebo to someone who waited 6 weeks for an appointment. Yet many of the clinicians can recall a memorable patient.

Cadegan remembers a man with cancer who would visit the clinic for a nerve block, which relieved his pain enough that he could play golf. “It was just temporary, but he got to play golf,” she says. “You knew he was terminal, but he was going to play golf.

Michelle Apuzzio, MSPT, is a contributing writer for Rehab Management.

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