Carolyn Martinez’s fibromyalgia pain was excruciating. “On a scale of 1 to 10, it was a10,” said the hotel manager from Chicago.
Barely able to work or lift one of her grandchildren, she enlisted in a Rehabilitation Institute of Chicago (RIC) Center for Pain Management (CPM) “boot camp.” As she describes it, “it was intense, like going back to high school. We had one session after another.” After undergoing the camp’s daily routine of physical and occupational therapy, psychological counseling, biofeedback and cognitive-behavioral therapy, Ms. Martinez feels like she got her life back.
“My stress level as a hotel manager is very high,” she said. “It was important for me to learn techniques to relax and control my pain, and this program gave me those techniques, which I can put into action every day.”
For more than three decades, CPM has helped people like Ms. Martinez.
“We often see people beat up by the system, demoralized because interventions by other physicians have failed,” said Steven Stanos, DO, director of the outpatient facility, which won an American Pain Society (APS) Clinical Center of Excellence Award in 2009. “We teach them active ways of fighting pain, so they can manage it on their own.”
“Up and At ’Em”
According to Judith Paice, PhD, RN, director of the cancer pain program at Northwestern University’s Feinberg School of Medicine, in Evanston, Ill., CPM takes a comprehensive approach to pain management.
“Rather than attacking a nerve using a needle or probe, this program addresses the needs of the whole person,” she said. “We know that pain is a biopsychosocial problem, affecting not only the nervous system, but an individual’s emotional state and social interactions. CPM’s team works to address all these needs.”
“Its program is most effective for addressing complex, persistent pain, offering much more than a quick fix,” she continued. “It begins patients on a lifelong path of self-learning. The only minus is that not every third-party payer is sufficiently savvy to realize the benefits of the program, so some people are being excluded due to shortsightedness.”
At the core of CPM’s program is the rehabilitative concept of functional restoration.
“We want patients to break through their fear of movement,” said Dr. Stanos. “Getting them moving helps them [restart] activities they might have stopped because of the pain.”
The rehab modus operandi is a natural evolution of CPM’s role within RIC, which since 1991 has been recognized by U.S. News and World Report as the
No. 1 rehabilitation hospital in the United States. CPM provides pain therapies to RIC’s inpatient rehabilitation hospital; sport and spine rehabilitation unit; and women’s health, arthritis and amputee centers.
“We’re unique in that we have training in treating people with complex conditions, such as cerebral palsy, spinal cord injuries, stroke and traumatic brain injury,” Dr. Stanos said. “We see how these conditions affect function and apply what we learn to chronic pain patients.”
“The rehab aspects of our training also allow us to provide a more integrated and wider approach to treating pain,” added Gadi Revivo, DO, assistant medical director of RIC’s new Pediatric and Adolescent Rehabilitation Program.
That wider approach means a minimalist view of interventional treatments and pharmacologic therapies. CPM physicians are not averse to using injections, nerve blocks, pain pumps or opioids if they help a patient, but addressing all the ways pain affects a person has produced better outcomes.
In CPM’s boot camp, patients spend eight hours a day, four days a week for four weeks working with an interdisciplinary team consisting of physical medicine and rehabilitation physicians; pain psychologists; physical, occupational and relaxation therapists; vocational rehabilitation specialists; nurses; and clinical care managers.
“The boot camp terminology originated when a TV reporter described our program that way, and it implies to patients that we will train them to battle pain, so after they’re done, they can manage it on their own,” Dr. Stanos said.
Chronic pain’s mind–body connection gets full attention. “What goes on in our heads—our moods, beliefs, thoughts—affect pain signals from the brain,” said Christine Gagnon, PhD, one of the center’s psychologists. “The more negative these things are, the more likely people will experience greater levels of pain.” CPM’s psychologists change patients’ mind-sets about pain by using various biofeedback, relaxation and stress-reducing techniques.
Attending a boot camp certainly isn’t a day at a spa. Patients might begin with an 8 a.m. Feldenkrais whole body movement class, followed by a one-on-one meeting with a psychologist, cardio conditioning exercises, a workout in the pool, lunch, a group psychology meeting, individual physical therapy, and finally, relaxation therapy.
There is a large group component to the camp, an often-forgotten element in treating pain.
“Our group structure helps patients because they’re with people who are going through the same thing,” Dr. Gagnon said. “Talking with each other, they further learn what works and doesn’t work.”
Besides full-day boot camps, CPM offers half-day programs, in which patients come to the center one or two days a week for approximately five hours a day.
Bigger and Better
In 2008, CPM opened a new, state-of-the-art, 12,000-square-foot facility, allowing it to more than double the number of patients it treats to approximately 2,500 annually.
The facility features an expanded gym for physical and occupational therapy, aerobic and functional capacity testing equipment, and dedicated space and equipment for biofeedback and relaxation training. It has expanded interdisciplinary patient treatment areas, including a fully equipped kitchen and patient lounge. Advanced multimedia capabilities allow for more educational outreach programs, Web-based team conferencing and case management, and clinical trial collaborations. The increased space allowed CPM to add the pediatric/adolescent program for children ages 8 to 18, who come to the center two half-days a week for treatment.
“Our pediatric/adolescent care uses the most current evidence-based medicine and effective treatments available,” said Dr. Revivo. “As with adults, we try to improve physical well-being, help children understand how emotions and pain are connected, and improve outlooks and coping skills. The family also becomes an important part of the treatment team, so it can promote pain relief at home.”
Understanding How Pain Works
Since its founding, CPM has endeavored to be a leader in research. Its Center for Pain Studies, which was founded in 1976, is the oldest pain research center in America, and the only freestanding research center associated with a rehabilitation facility.
According to R. Norman Harden, MD, the center’s director, the current research protocols involve clinical studies into the mechanisms of pain, as well as validating and measuring outcomes. Clinical trials include numerous multicenter drug trials of novel pharmacotherapeutic agents. Other studies focus on cervicogenic headache, complex regional pain syndrome, pain from spinal cord injuries, osteoarthritis pain and amputee/phantom limb pain.
“Our ongoing studies into post-amputation pain, spinal cord injuries and pain from traumatic brain injuries have been of great interest to the U.S. Department of Defense, because of what’s happening in Iraq and Afghanistan,” Dr. Harden pointed out.
Outcomes studies have investigated how well biofeedback and relaxation training reduce pain, and if interdisciplinary teams are the best way to treat it.
“Findings suggest biofeedback and relaxation training have a greater impact on the perceived ability to cope with pain, rather than actually decreasing it,” said Dr. Gagnon, who led the trials. “Data on interdisciplinary approaches suggest patients treated that way have higher levels of pain acceptance, as well as improved emotional functioning and ability to cope with pain.”
Outcomes like these are helping position
biopsychosocial, functional restoration–based programs into the mainstream fight against chronic pain.
“In 2009, APS guidelines, published in Spine magazine, stated that interdisciplinary management of pain, including cognitive-behavioral therapy, should be suggested to patients suffering from low back pain,” said Dr. Stanos (Spine 2009;34:1066-1077). “It’s the first time a major guideline has recommended that, meaning there is good-quality evidence that our approach helps patients.”