The Future and Chronic Spinal Pain Management
Written by Editor   
Wednesday, October 11, 2017 07:52 AM

In discussions with patients from pain management groups, consumers (patients) experiencing chronic, persistent spinal pain each have a unique story, their experiences and perceived causes of their pain differed, yet the quality of life in all these consumers was markedly reduced.  This was the only clear similarity.  It confirms that there may be some similarities in the pain experience, but it is often more unique and individual. These consumers’ criticisms of care services were consistent, however, with dissatisfaction with their access to care, overall management of their pain, and noteworthy variations in the treatment they received.

These criticisms are commonplace. The problems associated with care delivery are confounded by a number of patient/consumer factors, such as lifestyle habits, nutrition, body weight, depression, health literacy, geographical isolation and poor socioeconomic conditions, making the management of persistent pain even more complicated.  In the future, matching the care service and treatment with the individual patient will become an essential component of care services.

To achieve the best possible outcomes, health care practitioners involved in the triage and management of patients with persistent spinal pain will need to become more vigilant about individualizing and coordinating care for each patient. For example research has concluded that patients with chronic (persistent) lower back pain related disability predicts a “nonresponse” to standard physiotherapy, but not to spinal manipulation.  This implies that spinal manipulation should be considered as a first-line conservative treatment. Indeed, spinal manipulation is now suggested as the first-line intervention by current research since not a single study examined in a recent systematic review found that spinal manipulation was less effective than conventional care. Conversely, however, high pain intensity may be an important treatment effect modifier for patients with chronic low back pain receiving Mckenzie therapy (a treatment frequently used by physiotherapists). These examples demonstrate the importance of matching treatments with the characteristics of the patient.

This report suggests that the sequence of interventions for chronic spinal pain management first involves patient assessment (history, examination, investigations, screening questionnaires, information from previous health care professionals), from which follows pain options that are relevant and available to the individual patient, which results in a pain management plan that is agreed and understood by both the patient (and their significant others) and treating practitioner and communicated to the other health care professionals (coaches). If a person in pain does not currently have a well-organized team providing evidence-based care, then their medical service will need to offer suggestions and coordinate local available options to form a virtual health care pain team.

The team will also need to be aware of novel interventions for a variety of new interventions including behavioral changes such as non-sweating movements, retraining multifidus and transversus abdominis, daily walking and mindfulness may all play a role in reducing fear, anxiety and threat. Increasing patient control and reducing threat, thereby reduces the threat value of pain, and can reduce the “other changeable pain.” 

Also, understanding the glial activation in pain pathways may well be key to reducing persistent pain.  Palmitoylethanolamide (PEA) is an endogenouslipid modulator in animals and human beings and has been evaluated since the 1970s as an anti-inflammatory and analgesic drug, emerging evidence is of interest as no drug interactions or troublesome side effects have been described so far.

And the emerging biology of pulsed radiofrequency neurotomies is unique in that it provides pain relief without causing significant damage to nervous tissue, with animal studies demonstrating modulation of pain transmission in the spinal nerves and spinal cord by a range of mechanisms including modulating gene expression and microglial neurotransmitters. These emerging concepts in the literature start to provide biological mechanisms to the use of pulsed radio frequency modalities for people with spinal pain.

Decades worth of research outcomes suggests that knowledge and guidelines related to both acute and chronic spinal pain are now available certainly enough to inform practice and the implementation of evidence-informed care services for persistent spinal pain. New policy documents have emerged along with published recommendations from recent systematic reviews. For example, exercise, tai chi, yoga, mindfulness-based stress reduction and other psychological therapies, spinal manipulation and massage, acupuncture, nonsteroidal anti-inflammatory drugs (NSAIDs; although less effective than previously reported), duloxetine, tramadol and skeletal muscle relaxants (short-term relief only) seem to have a positive role. Yet, commonly encountered treatments, such as passive physical therapies opioids paracetamol, benzodiazepines, systemic corticosteroids, tricyclic and selective serotonin reuptake inhibitor (SSRI) antidepressants, do not seem to contribute much to outcomes.

The future of persistent pain management is less about doing more research and producing more guidelines, although research continues to be important, but rather about implementation of existing care frameworks and models of care with a view to obtaining better outcomes for patients at a reasonable cost. It is very likely, indeed desirable, that care frameworks and models of care will evolve and be updated every 5–6 years, so stakeholders should keep an eye out and keep themselves informed as to how care services are changing.

The health care literature convincingly reports that coordinated, multidisciplinary and multimodal care, at the right level, is desired to achieve the best possible outcomes for patients and is very likely to be cost-effective. The challenge now is to have persistent spinal pain fully acknowledged as a legitimate chronic condition by both health care providers and policy makers/payers and have evidence-informed, cost-efficient care delivered in the manner described in published frameworks and models of care. Despite the complexity of spinal pain and its management, as with most chronic diseases, the potential workforce and services can and must be made available with appropriate attention, planning and leadership, with a view to improving accessibility to appropriate care early in the development of the spinal pain condition. The consequences are a large population of chronic pain sufferers, worsened by age-related comorbidities, which will be a tremendous burden and cost to the health care system, not to mention the personal suffering of the individual and their carers.

Getting access to the right care at the right time is critical, but the right multidisciplinary team is currently the elusive goal of contemporary spinal pain management. The proposed approach and management for pain are eloquently summarized in numerous papers directed at health care practitioners, yet most doctors are dissatisfied with outcomes and uncomfortable managing chronic pain. Clearly, there is a gap in care service which appears not to be related to examination, diagnosis or analgesic prescribing, but due to “something else,” which we believe is related to proper triage of persons with pain, which would include questionnaires and assessment, and the access of these persons to the appropriate level of multidisciplinary care at the soonest opportunity.

How may pain services be delivered in the future to comply with models of care and frameworks while reconciling the challenges of a complex pain service, including that of funding? The idea, of course, is to create a sustainable, comprehensive service with sufficient incentive and reward for the participating workforce. There is likely to be a mixed business model incorporating both the private and public sectors, but on a more community and patient-centric basis, with funds returned to front-line service delivery for integrated interprofessional pain services. This approach would reduce middle management (reducing management costs) and be subject to far less politics, as has been encountered with the poly- or super-clinic concept, while still being able to collaborate with relevant local and state government and nongovernment organizations.

The “third way” ideology for the management of complex spinal pain may have relevance, particularly when it comes to the funding/payment for services. In theory, the “third-way” ideology attempts to graft the traditional concerns about quality and social justice into an economic system based on free markets, thereby implying a mix of public and private health care models. That implies the use of both public and private funding to cover the expenses for care services, where there are government funding or rebates for care services, but the patient themselves also pays a portion of the costs. 

Future research should focus on exploring, creating and testing pain care service approaches and methods, to determine those that fulfill the criteria of modern evidence-based practice, these principles being:

1)   the use of the best available research evidence,
2)   clinical and business experience/expertise,
3)   stakeholder/consumer preference and access to care and, importantly,

4)   the available resources and funding.

Item 4 is an essential component of evidence-based practice often omitted in care frameworks and practice guidelines. There are significant barriers to multidisciplinary, collaborative working, such as professional “turf wars,” limited incentive and problems with funding, but despite the difficulties, it can be performed and needs to be performed, for the benefit of patients and also to more efficiently manage the burden of chronic spinal pain.

The characteristics of good care are accessibility, quality care, safety, timely care and coordinated care. The complexity in chronic spinal pain management, as with other chronic conditions, is not only about the appropriate implementation of the individual parts of care but also ensuring that the triage, coordination of care and the multidisciplinary approach works well. This takes planning, commitment and leadership. For example, the colocation of health care practitioners in the same building does not guarantee multidisciplinary or integrated teamcare – there needs to be explicit consideration of human dynamics and the team process for teamwork to succeed. Sound leadership provided by a champion of the service would facilitate this teamwork approach.

The process starts with motivated, energetic health care practitioners with an interest in chronic pain management to take the reins and begin planning for such community-based, primary care services. These motivated persons would draw upon their own practice experience and obtain advice/support from local health care organizations to develop a business case and feasibility of a local pain service.

Community-based pain services are likely to develop through private funding or pain practitioners developing their own private practices that offer a broader range of services than currently offered. But guard against getting caught up in health care politics, where the attempt at integrating community-based care services can be negatively confounded by political influences.

There is already sufficient research evidence and recommendations documented in published guidelines, frameworks and models of care to inform clinical practice and the care of chronic spinal pain worldwide. The overt gap in care services is not the availability of prescription medication or allied health services, but rather the coordinated, multidisciplinary provision of care services by health care practitioners with an interest and skill in pain management. The challenge of our time is ensuring early access of patients with chronic spinal pain to care, coordinated practitioner teamwork and the application of the correct level of care individualized to the patient. From here on, health care funders and medical insurers need to be persuaded that the model of care provision for chronic spinal pain is cost-efficient and cheaper than the current approaches.