A Team Approach to Pain Management - A conversation with Demaceo
Howard, M.D. and W. Keith Barnhill, Ph.D.
The practice of pain management dates back thousands of years. Primitive pain
management tools at this time ranged from opiate use to the application of
electric fish to apply current to a painful body part. Ancient Middle East
drawings depict a physician using heated metal rods to cauterize spinal
structures. And by the turn of the 20th century, two men in Germany allegedly
gave each other spinal injections with cocaine, using bamboo shoots.
Today, the medical specialty of pain management (PM) has evolved into a team
approach that brings together the skills and insights of myriad professionals to
benefit patients. Demaceo Howard, M.D., medical director of the Methodist Pain
Management Clinic and director of Advanced Pain Management Institute (APMI),
explained the ideology that arose about 25 years ago. "We have a
multi-disciplinary approach to pain management. Rather than just predominantly
looking at physical issues with a pain patient, we try to look at everything. We
use the biopsychosocial model, which incorporates physical complaints and injury
and how they affect behavior."
Doctor Howard said the team approach to controlling pain uses the expertise
of pharmacists, nurses, psychologists and psychiatrists, physical and
occupational therapists, neurologists, orthopedists, chiropractors, and
registered dieticians. "We're a clinic without walls."
Doctor Howard who is accredited by the American Board of Pain Medicine,
became interested in the Department of Anesthesia at the University of Chicago.
He said he decided to dedicate his medical practice to pain management because
"in any specialty, such as pain management, the practitioner's clinical skills
are directly proportional to the amount of time dedicated to the specialty."
Because Dr. Howard devotes 100% of his practice to PM, this has allowed him to
hone his skills and develop better quality of care for his patients.
EARLY DIAGNOSIS AND PATIENT EDUCATION
W. Keith Barnhill, Ph.D., CRNA (Certified Registered Nurse Anesthetist), and
Diplomat of the American Academy of Pain Management, works with Dr. Howard at
both Methodist and APMI. He emphasized that the first steps in pain treatment
are diagnosis and patient education. "When patients come to us, they're going to
learn what they have, what pathology (abnormality) is going on, and they will be
educated on the process (of what is causing the pain)." Most conditions seen at
the offices involve spine-related pathology that cause low back pain, neck pain,
and pain in the extremities.
Dr. Howard said that when a patient comes in for a first visit with a
diagnosis of back pain, the individual might know only that the pain is caused
by a herniated disc. He and Barnhill help the patient understand the process of
what is generating the pain, explain that the bulging disc is rubbing against
spinal nerves, causing inflammation, and present cortisone injections as one way
to reduce the inflammation and disc swelling. "Sometimes, if people understand
the process, it actually helps them resolve (the problem)," Dr. Howard said.
Barnhill agreed, "Once a person learns what's going on with their back, they
will make a choice whether or not to do injections. They will know there are
other options besides injections."
Early diagnosis is crucial for successful outcome and return to work, which
in turn reduce a patient's chances of developing depression, Dr. Howard
explained. In the biopsychosocial model of pain management, the social aspect
includes returning to work, Barnhill added.
PATIENT ASSESSMENT AND TREATMENT OPTIONS
The first step in addressing a patient's needs comes in the form of a
questionnaire mailed out before the first appointment, that includes sections on
past medical history, pain assessment, current medications, and psychosocial
issues. Howard and Barnhill said they review the answers on the questionnaire
before the appointment, saving the patient valuable time. After a physical exam,
"We will sit down and talk about what the patient's pain generator is. There may
be a few different issues intertwined," Doctor Howard said. Treatment options
are explained, and the patient can decide the same day or sometime later which
option to choose.
Communication between the clinicians and their patients is key because pain
is a very subjective experience, Dr. Howard pointed out. "if you have a broken
leg, we can measure how much it is displaced (with an x-ray exam), but we can
never measure how much pain it's causing." Listen to what the patient says,
then, is the only way to assess pain, Barnhill added.
After assessment, many treatment options are available to pain patients,
including anti-inflammatory steroid injections given under fluoroscopic
(specialized x-ray) guidance. The focus of the practice is treatment of the
spine, Howard said, because "most of the science in the field of pain management
in the last 25 years has gone into understanding spinal anatomy and pain
generated from the spine." Early intervention to reduce inflammation to injured
nerves is crucial, he added, because injured nerves heal very slowly.
Interventional options include nerve blocks, neuroablative (surgical removal of
nerves) procedures, spinal drug pumps, and the "growing, effective, and
minimally invasive" procedure called spinal cord stimulation.
In addition to interventional therapies, Dr. Howard never loses sight of the
multi-disciplinary approach to pain management. Other treatment options include
physical therapy, medications, weight loss, diet and exercise, limited alcohol
consumption (alcohol is an inflammatory agent), and smoking cessation (smoking
reduces blood flow to spinal disc, slowing the healing process).
FOLLOW-UP WITH PATIENTS
After a patient receives a successful outcome from a treatment, the care he
or she receives does not end. When Howard and Barnhill follow up with a patient,
they assess improvement in pain level, ability to sleep, improvement in
activities of daily living (ADL), and reduced reliance on medications. "Most
people we encounter would prefer not to take pain medicine if they can avoid
it," Dr. Howard added.
Patients are given instructions for long-term pain management because they
have a "condition," Howard explained. "They're not cured. Once you have a back
injury, you're more likely to develop another injury." Exercises that strengthen
back, abdominal, and lower extremity muscles, as well as aquatic therapy, can
increase the chance of long-term relief from pain and prevent recurring
injuries.
Patient motivation to work toward goals is another important aspect of
long-term pain control, Dr. Howard said. "What would you do different if you
didn't have this pain?" is a vital question he asks each patient before
treatment. Some common answers he gets from patients include, "I'd walk more,"
"I'd be more involved with my grandkids," and "I'd go back to work." After
treatment, the desire to resume and maintain these activities can keep a patient
on the road to a healthier lifestyle (e.g., smoking cessation, regular
exercise), resulting in positive long-range outcomes.
A TEAM APPROACH
In the quest to improve patients' quality of life and daily function, Howard
and Barnhill again emphasized their use of the multi-disciplinary approach to
pain management. The specialists listed earlier, including registered nurses
with "decades of experience" in pain management, Howard said, work together as a
team for the good of their patients.
Barnhill offered an amusing, yet poignant, analogy to describe the
multi-disciplinary model he and Howard embrace. He told a story about three
blind East Indian men who were holding different parts of an elephant, and each
man was asked to describe the animal. "One was holding the elephant's trunk, one
was holding a leg, and the third man was holding the tail. They're going to
describe the elephant three different ways because they have three different
parts. In the multi-disciplinary approach, we all see pain with a different
eye."
By; Sarah Storey Smiles
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