Treatment Goals
The treatment goals, as relevant for each case should include:
- Improvement of physical function (e.g., increase range of motion, standing, walking).
- Improvement of general functional status (e.g., increase activities of daily living (ADLs), social - recreational activities, home - domestic activities).
- Increase in self-management of the chronic non-malignant pain syndrome (CPS).
- Improvement of vocational/disability status (e.g., return to work, start job retraining, start classes to increase work options).
- Reduction/discontinuation of opiate and sedative-hypnotic medications.
- Reduction of healthcare utilization for the CPS (e.g., reduce medical procedures, inpatient admissions, outpatient office visits).
- Reduction of pain level (e.g., reduce visual analogue scale scores, verbal rating scores, verbal descriptor scores)
The current guidelines continue to emphasize increasing patients' level of function and ability to self-manage their pain and related problems. While reduction of pain level is a goal, the other goals should be actively pursued even if no reduction in pain level occurs.
Clinical Evaluation
The current guidelines recommend that CPS patients be evaluated by healthcare professionals with specialized training in chronic pain management. The initial evaluation should be performed by a qualified physician and psychologist. The content of these medical and psychological evaluations needs to include a detailed medical and psychological/behavioral history, review of all clinical records and diagnostic data, and thorough physical and behavioral psychological examinations by the appropriate professionals. Patients' working diagnoses, appropriateness for treatment, basic treatment plan, and initial goals should be set by the initial evaluation team, with input and agreement obtained from the patient before treatment begins.
For those patients that are accepted and agree to treatment, a physical function evaluation should be completed. This should include neurological, musculoskeletal, and activities of daily living functional assessments by physical and/or occupational therapists trained in these evaluations and pain rehabilitation. If CPS patients have a work related injury, a realistic goal of returning to work, or pending disability issues, an evaluation of their occupational and functional capacities should be done at the end of initial treatment.
It is recommended that the clinical treatment team meet regularly to discuss patients' response to and progress in the rehabilitation program. Likewise, ongoing treatment revisions should occur as needed to reach as many of the treatment goals as possible.
Treatment
The evidence continues to accumulate that the most effective treatment for CPS patients is found within an integrated interdisciplinary pain rehabilitation program. Services need to be provided by a coherent team of healthcare professionals with specialized training in pain rehabilitation and management, with patients receiving coordinated care across disciplines.
CPS patients should be accepted for treatment if there is indication that significant improvement in at least four treatment goals is achievable. For those patients where responsiveness is not clear, it is recommended that they be given a two to five day treatment trial, with assessment regarding initial responsiveness, compliance, motivation, and any kinds of initial treatment gains. If the initial response is promising, the remainder of the treatment plan can be implemented.
Primary Treatment Modalities
This section reviews and makes recommendations about various treatment modalities that have demonstrated evidence, as defined herein, of effectiveness either alone or in combination within an integrated interdisciplinary treatment approach. Likewise, some common and emerging modalities and technologies with insufficient evidence are reviewed. When recommended, a treatment should be available to CPS patients within an integrated pain rehabilitation program as their clinical condition warrants.
Medication Management
The research literature continues to provide increasing evidence that antidepressant medications can be beneficial for symptomatic treatment of CPS patients. Also, evidence continues to grow demonstrating that the tricyclic antidepressants and certain anticonvulsant medications can significantly reduce the subjective pain experience in neuropathic based pain. Thus, these medications are recommended for application to CPS patients, as their clinical condition would indicate. Evidence also continues to accumulate supporting certain medications with CPS patients suffering from primary migraine headache. There are useful and appropriate listings and guidelines for application of various medications for migraine headache. The evidence supports the systematic palliative or prophylactic use of non-steroidal anti-inflammatory, ergotamine, anti-emetic, serotonin receptor agonist, tricyclic antidepressant, angiotensin-converting enzyme (ACE)-inhibitor, beta-adrenergic blocker, calcium channel blocker, and anticonvulsant medications. It is recommended that when indicated these medications, as delineated in the referenced guidelines, be applied to CPS patients suffering from migraines.
Researchers are beginning to look at chronic application of oral and transdermal opioids using better controlled research designs; however, thus far, they lack the specified scientific rigor as persuasive evidence. At this time there are no randomized controlled, long-term trials or other appropriate experimental evidence demonstrating improvement in function or other objective measures associated with opioid usage in non-cancer CPS populations. In addition, without considering issues of addiction or dependency, some studies have found a significant increase in "problem drug behavior" with regular usage (e.g., dose violations, lost prescriptions, multi-sourcing). Given the continued lack of quality research and the growing concerns about the increasing frequency and abuse of opioid prescriptions, the current guidelines still do not recommend the use of opioid medications with CPS patients. Since the 1999 revision, there has also been no substantial evidence supporting the routine use of sedative-hypnotic medications with these patients either. Thus, this drug classification is also not recommended.
If opioids or sedative-hypnotics are used, it should be on a very time limited basis (10-15 days). If other published guidelines are employed for long-term use of opioid or sedative-hypnotic medication, there should be clear evidence that the patient is not demonstrating significant impairment, such medication application produces a clinically meaningful increase in function, and the benefits and any clinical problems are frequently reassessed.
The current guidelines continue to recommend that patients demonstrating primary alcohol or other substance abuse dependency on nonprescribed substances should be treated separately for these issues.
Physical and Occupational Therapy
The scientific literature continues to accumulate and support, at least for CPS low back pain patients, the need to receive active physical and/or occupational therapy. The focus of physical and occupational therapies should be on helping patients learn awareness of body mechanics and dynamic posture, initiation and activation of a long-term exercise program to gradually increase general fitness, strength, coordination, and a range of flexibility and motion, postural and muscle balance, as well as specific physical coping strategies. Passive treatment methods should be only used in a secondary supportive role. Activity and/or job specific occupational therapy interventions should be used when appropriate, along with therapeutic recreation and sleep hygiene for those patients showing impairments in these areas.
Behavioral/Psychological Therapies
The research literature continues to provide a strong evidence basis for the importance and need for behavioral/psychological treatment. If significant depression or anxiety is present, psychological/behavioral treatment is recommended, as well as appropriate pharmacological interventions for these symptoms. CPS patients should receive and have access to stress management training, relaxation training, cognitive behavioral therapy, operant therapy, and biofeedback as their condition warrants.
Vocational Rehabilitation and Disability Management
Dealing with vocational and disability issues remains important for many CPS patients. Recommendations are for a focus on optimizing function, including return to work when possible. Job site analysis, job specific reconditioning, and functional capacity assessments, should be pursued when appropriate.
Adjunctive Treatment Modalities
Trigger Point and Botox Injections, Prolotherapy, Nerve Blocks, and Acupuncture
There has been an increasing use of trigger point and botox injections, prolotherapy, nerve blocks, and acupuncture for CPS patients over the last five years. This is in spite of a lack of any convincing quality evidence that any of these techniques work for this patient population. Thus, as with earlier guidelines, these methods are not recommended for use with CPS patients.
More Invasive Medical Procedures
Implantable Infusion Pumps and Spine Stimulation Devices
Studies and systematic reviews regarding the efficacy of infusion pumps and spinal cord stimulators have increased. Given the continued absence of quality research, however, the current guidelines do not recommend using implantable infusion pumps or spinal cord stimulators with CPS patients.
Radiofrequency Denervation, Intradiscal Electrothermal Therapy (IDET), and Spine Surgery
Application of radiofrequency denervation techniques and IDET for chronic back pain is also on the rise. While there are a number of uncontrolled and single group studies, the research literature to date is of poor quality and does not support usage with CPS patients. Thus, these techniques are not recommended.
There is increasing evidence that with certain back pain patients, spine surgery is indicated and can be quite effective. However, the evidence is still very weak regarding application to CPS patients. Therefore, the current guidelines recommend that spinal surgery be avoided with CPS patients with the following exceptions: presence of a new lesion, significant neurological deficit or progression, or clinically significant spine instability.
Treatment Intensity and Timing
The literature continues to support outpatient treatment for CPS patients whenever possible, with an upper limit of 20 total primary treatment days in most cases. Obviously, this upper limit may need to be extended based upon the specific documented outcomes and goals for a given treatment program. Consistent with effective treatment outcome studies, CPS patients should be followed for at least three months after the primary clinical care has been completed. If possible, 6 to 12 month follow-up is preferable, but sometimes not feasible.
For chronic back pain patients in general, and CPS patients in particular, the research literature continues to support early intervention whenever possible.
