In many ways a chronic pain management program for a potential spine surgery candidate is similar to that for any other chronic pain condition. The program is multidisciplinary in nature, aimed at improving function, reducing or eliminating use of painkillers, providing emotional stabilization, and teaching cognitive behavioral techniques for coping with pain as well as reducing maladaptive thinking. However, patients with identified spinal pathology have some particular concerns that need to be recognized and addressed in order to make the chronic pain management treatment as effective as possible.
Chronic Pain Patient Education and Support
There are two aspects that are critical to successful outcomes for patients who are good candidates for chronic pain management: the quality and magnitude of patient education provided by the physician, and the physician’s support for the patient.
More patient education about chronic pain management
Many people with chronic back pain opt for spine surgery because they feel it is the quickest and most effective solution to their pain, although they generally do not have comprehensive information about the pros and cons of surgery, and have not studied or given alternative, non-surgical approaches a good chance to succeed. One of the foundations of chronic pain management, therefore, is to help the patient view pain outside of the traditional medical model - i.e., the belief that pain can only be eliminated by a physician removing or ameliorating the underlying physical pathology. This alternative model posits that a cure for chronic pain is often not possible, but that it is up to each patient to gradually improve functional ability and pain control to maximally recover from their injury. Treatment, then, becomes a matter of learning pain management techniques through guidance by the staff and even by other patients.
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Research9 demonstrates that patients given more information about back surgery are more realistic about its potential benefits and risks. In one study 393 patients with herniated discs, spinal stenosis or other specific diagnoses were given either an interactive video with a booklet about their surgery, or the booklet alone. The percentage of patients with herniated discs who elected to undergo surgery was lower in the group that had watched the video (p<.08) compared to those given the booklet. Patients in the interactive video group reported that they felt better informed than those who received the booklet only.
Since it has been established that certain groups of patients will fare better through interdisciplinary pain management, such patients should be educated about their alternatives. For example, patients can be informed that they are more likely to obtain poor surgery results if they:
- Have high levels of psychosocial distress
- Are undergoing a second or third spine surgery
- Exhibit dependence on pain medication
Such knowledge can help patients make a better informed choice about back surgery versus rehabilitation through a chronic pain management program.
Physician’s support for the chronic pain patient
Because a chronic pain management program requires the patient to make behavioral changes rather than rely on the surgeon’s skill, it is important for the physician to play a supportive, active role in advocating a chronic pain management program so that patients see the program as truly in their best interest and a collaborative health-enhancing endeavor. The physician/surgeon plays the critical role in establishing this patient mindset.
Research on social control — the theory that individuals will conform their conduct to those with whom they have strong social bonds — shows that individuals’ health-related behavior can be strongly influenced by others. When patients feel positive and supported by their doctor in the choice they make, they are more likely to engage in the health behaviors suggested or modeled by their physicians. Conversely, when an individual feels negatively about the other’s attempt to change health-related behaviors (e.g., feels the other is nagging, or attempting to induce guilt) then the individual is likely to either ignore their suggestions or even hide unhealthy behaviors. The implication is that the patient must see the physician as a supportive advocate, who encourages functional improvements and reduction in medication through an active rehabilitation process, rather than advocating for a surgical procedure.10
Benefits of Chronic Pain ManagementThere are several reasons patients should be cautious about choosing back surgery over interdisciplinary chronic pain management. First, there is no universally-accepted standard for the treatment of most back problems. Second, back surgery, while often effective at correcting the pathology (such as the disc herniation), does not address psychosocial factors such as fear or unrealistic expectations can greatly influence the outcome of back surgery, no matter how perfectly the surgery is performed. Chronic pain management is designed to avoid these potential problems, while providing patients with a viable, productive way of improving functionality and managing pain.
- Deyo, Cherkin, Weinstein, Howe, Ciol and Mulley (2000)
- Tucker, Orlando, Elliott & Klein (2006)