5 Points on the Role of Pain Management in Spine CareWritten by Laura Miller | May 12, 2011
With so many unknowns surrounding the healthcare environment, it remains to be seen where exactly the pain management physician will fit into the continuum of spine care in the future. Spine pain management physicians and specialists discuss five points on where spine pain management is heading.
1. Evidence-based medicine for spine pain management. Medical specialties across the board are focused on practicing evidence-based medicine, and spine pain management is no different. Spine specialists continue to conduct research on current interventions to identify efficacy and safety of different procedures, and establish treatment algorithms, but that hasn't come without challenges. "There is a paucity of high quality studies in the pain management literature currently," says Jared Greenberg, MD, an Interventional Spine specialist with the Meriter Medical Group in Madison, Wis. "We should be practicing evidence-based medicine, but there is currently a lack of evidence to support many of our treatment decisions. That does not mean our treatments are not effective — more will become known and standardized moving forward as the research advances. Furthermore, an additional challenge is that success of our treatments is measured by pain and functional improvement, yet there is no research to support that pain improvement will translate into functional improvement."
Dr. Greenberg says that as studies improve, pain management physicians will be able to develop algorithms for patient treatment and fill in the gaps where there isn't currently any research.
"We can use evidence-based medicine approaches to evaluating and managing patients, which will show the treatments we are offering are safe and provide good outcomes," says Vernon Williams, MD, a neurologist and medical director of the Kerlan-Jobe Center for Sports Neurology in Los Angeles. "We can use evidence-based medicine as guidelines, but it shouldn't be recipes. For patients with chronic spine pain, we have to go through the algorithm based on the individual's response to a particular treatment."
2. Protocol for treatment. The most recent developments in spine pain management are focused on diagnosing back pain and finding the best indications for each intervention. However, insurance companies are developing their own protocol for treatment, which means patients often need to go through several steps before undergoing pain procedures. For example, a patient with back and leg pain and an MRI showing a disc is pressing into the nerve might benefit from placing a steroid on the nerve, but the insurance company says the patient must undergo a month of physical therapy first. If the patient's condition has worsened after physical therapy, it may take an increased amount of injections to relieve the pain.
"The trend is for insurance companies to have their own protocol for treatment," says Eugene Lipov, MD, medical director of Advanced Pain Centers in Hoffman Estates, Ill. "They are trying to make medicine into a predictable, controllable machine. It doesn't work like that most of the time."
Oftentimes, the physicians who must approve or deny coverage for the patient aren't spine or pain management physicians. These physicians make decisions based on written guidelines or protocol, and when patients don't fit the description they are denied coverage. "In a perfect world, we'd all fit down a clear medical pathway," says Eli Finkelstein, MD, a physical medicine and rehabilitation specialist at Resurgens Orthopaedics in Cumming and Roswell, Ga. "But not everyone fits into set guidelines. The physicians on the insurance side must realize that they are dealing with certified and competent physicians on the other side."
3. Lowering the cost of care. The idea behind patients going through several rounds of physical therapy or chiropractic care before more aggressive interventional care is to save money on expensive treatments that might be unnecessary. This method may not be the most cost-effective way to deal with back pain, as many patients undergo physical or chiropractic therapy and still need the more costly interventions. "We can provide cost-effective treatment early on so patients don't develop chronic pain," says Dr. Williams. In some cases, waiting to long to begin aggressive care can also raise the cost of spine care because the patient's condition worsens in the meantime.
"Now, everything conservative has to fail before patients can receive interventional treatment or surgery," says Nilesh Patel, MD, a pain management physician with Advanced Pain Management in Greenfield, Wis. "But if you can get patents in early and help them, you can really mitigate the costs." There are also economic repercussions to shortening the conservative treatment period among appropriate patients. The patients who undergo interventional treatment sooner may be able to return to work quicker.
4. Comprehensive spine centers. Pain management physicians are tending to take a more collaborative approach to providing spine care than they have in the past by working with rehabilitation specialists and surgeons to bridge the continuum of care. Some pain management physicians are teaming with chiropractors, spine and neurosurgeons, physical therapists and other back pain specialists to develop a comprehensive spine center. "We are now seeing much more of a collaboration going on between the different specialties," says Richard Kaul, MD, president of New Jersey Spine & Rehabilitation. "A multidisciplinary approach to spine can be the best from a clinical and economic standpoint. Having fragmentation of care raises costs because there are often duplications of diagnoses and treatments. The different groups coming together will be able to take care of patients in an economical fashion."
Spine centers offering a variety of care can also help streamline the patient's experience. "Comprehensive spine centers standardize the patient flow," says Dr. Greenberg. "In the past, the kind of care you received depended on where you entered the system. At comprehensive centers, you go to one place and everything is managed from the ground up. The patients receive the same care based on the standards partnering physicians agree upon."
5. Working with patients on interventions. Physicians are now working more with their patients to decide on the appropriate method for treatment, instead of dictating the course of care. Patients often come into the office with a base knowledge about different treatment methods and they want the physicians to guide them down the appropriate path. "Nowadays, people come in with pain and they've done research online, so they'll ask the physician what they think about the different solutions," says Dr. Williams. "We should address these questions from an evidence-based standpoint. Their treatment should be a shared medical decision."
Related Articles on Spine Pain Management:
10 Biggest Trends in Spine Pain Management
Dr. Scott Martin: 5 Challenges Facing Spine Pain Management
4 Points on Medication Management for Back Pain
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