Are Pain Clinics Right for You?
Specialized clinics may help patients control chronic pain and reclaim their life.
NANCY MAIER’S FINGERS WERE SO STIFF FROM OSTEOARTHRITIS that friends had to cut her meat for her when she went to a restaurant. She was just 45 years old.
“They were more like sticks than fingers,” says Maier, now 48, a stay-at-home mother and former public relations writer from Hartford, Wisconsin. “I had less than 10 degrees of motion in three of the fingers on my left hand. I couldn’t turn the key of my car, unlock a door, open a can … it was maddening.”
Her hands hurt all the time, and the pain kept her up at night. Her primary care physician didn’t offer much help, so she
begged for a referral to a rheumatologist, who prescribed a nonsteroidal anti-inflammatory gel. But applying it multiple
times a day while caring for two boys (and all the hand washing that entailed) was a problem. She was determined to avoid taking pills. A counselor she’d been seeing mentioned a pain clinic not too far away. That clinic, Maier says, changed her life.
What is a pain clinic?
There are two main types of pain clinics. The first offers procedures such as injections and nerve blocks, explains Daniel Clauw, MD, professor of anesthesiology at University of Michigan. These procedures are usually performed by an anesthesiologist, most often for specific problems such as low back or neck pain. Unless you know you need one of these procedures, advises Dr. Clauw, “I would avoid a block clinic.”
The other is the type Maier went to, a one-stop shop where a team of health professionals works together to help patients
tackle their pain using a variety of evidence-based approaches.
“The good pain clinics will be interdisciplinary. They’ll have physical therapists and occupational therapists and psychologists and other health providers that can provide the sort of team-based interdisciplinary care that is now most widely recommended for treating chronic pain,” says Dr. Clauw. Patients typically attend the pain rehabilitation programs (PRPs) at these clinics all or most of the day every day for several weeks as an outpatient. “It’s kind of like pain boot camp,” says Jeannie Sperry, PhD, co-chair of addictions, transplant and pain at Mayo School of Medicine in Rochester, Minnesota. Other programs are longer in duration but more part-time. Maier attended a program in Wauwatosa, Wisconsin, from 8 a.m. to 5 p.m. daily for about three months, followed by additional “booster” sessions over six months.
Medications may or may not be part of a person’s treatment plan. In fact, some PRPs, such as Mayo’s, require that patients agree to taper off opioids. “Pain medicine in a chronic pain patient actually makes pain worse,” says Sperry. “It makes the brain more sensitive to pain, so people experience higher and higher levels.” Mayo’s PRP also tapers patients off sleep and anxiety medications and muscle relaxants. “Many medications are started to treat the side effects of opioids, like sleep disruption, sedation, agitation, nausea and sex problems, so when we taper opioids, patients often don’t need
a lot of their other medications."
A quick fix is not the goal – neither is the total elimination of pain. Rather, the clinics aim to restore function and
improve quality of life. Getting to that point involves learning pain-management skills and, perhaps most important, resetting the brain so it stops sounding the alarm that perpetuates chronic pain, something drugs can’t do. “Medications are just like sticking cotton in your ears,” says Sperry. “They initially dull the sound, but after time, your brain tries harder to hear, and the cotton doesn’t stop whatever is generating the noise.” Instead of feeling worse when coming off pain medication, she says, “People report feeling better, often within a week and even within a few days.” That’s because the body’s own endorphins start kicking in.
A multipronged approach
A day at a PRP might go something like this: an hour of physical therapy (PT), which focuses on improving movement; an hour of occupational therapy (OT), which focuses on improving the ability to perform daily activities; several hours of pain education classes that teach how chronic pain works; and an hour of relaxation and mind/body therapy.
Patients also learn techniques to manage pain, including guided imagery, breathing
training and muscle relaxation.“The intent is to train them on what’s effective for them, and then they go home and practice it on their own,” says Sperry. Maier still uses her guided imagery training. She also learned how to see her pain as a color (red for the worst pain) and to picture dialing it down to orange, then yellow, then green. “That works really well for me,” she says. Mayo and other clinics also provide cognitive behavior therapy, which teaches problem-solving skills and helps patients break the cycle of pain, stress and depression by reshaping their mental responses to pain. Even the daily routine at a clinic can be beneficial, says Sperry. “People have to be up and showered and in the door at 8, and they’re here until 5. We’re getting them into a regular schedule again and getting them moving.”
Central to the interdisciplinary approach is the fact that the practitioners work together on each case. Says Maier,
“If you had some kind of problem or something wasn’t working, then they could work on it together. I think that’s
the biggest benefit of the place.”
Getting people physically active is one of the main goals, says Sperry. “We teach patients that the less you move,
the more you hurt, and so your brain needs to unlearn the connection it has made between pain and moving.” Once
they start moving and the sky doesn’t fall, patients become less fearful. “And fear is the real enemy.” (For more on
Fear of Movement, see p. 37.)
Dr. Clauw agrees that movement is critical, especially for people with inflammatory forms of arthritis such as rheumatoid arthritis and scleroderma. If they don’t keep moving their joints, he says, they can develop contractures, the shortening and hardening of muscle and other tissues, which limit range of motion. Exercise in general and PT and OT “can be tremendously helpful from a standpoint of both pain and functional improvement,” Dr. Clauw adds. Maier, who has non-inflammatory arthritis, said the PT and OT were the most helpful parts of her treatment.
The PT “really showed me the value of exercise and fitness in helping with pain,” she says, and the OT helped her
regain use of her fingers.
Another benefit of a pain clinic is being among people who are in the same boat.
“Pain can be so isolating to people, particularly if they’re not working, going to church or going bowling because of it,” says Sperry.
At Mayo’s pain clinic, patients are with 25 other people from all walks of life who are also struggling with pain. “They immediately feel validated. People start laughing again and being in a group again. That by itself is very therapeutic,” she says.
Family members also play a part. At Mayo, family members are invited twice a week to get educated on what pain is and what’s helpful and not helpful for their loved one, like encouraging them to keep moving and not talk too much about their pain, which Sperry says makes pain worse.
When Maier arrived at her clinic, “I was ready to cut my hands off – and I was not joking around about it.” After her program ended, she says, “I felt like it was absolutely life-changing. They got me back to running, and I was able to play basketball with my kids. When I walked out of there, I had hope.”
Her hands don’t function perfectly, but “now I can touch all three fingers of my left hand to my palm,” she says. “It may not sound like much, but it’s a big deal.” Sperry says the turnarounds she sees are dramatic. “We have patients who enter in wheelchairs, and often by the end of the first week they’re using a walker. In the second week they’re using a cane, and when they leave they’re able to walk independently and they’re taking the stairs. People go back to walking and jogging.”
Typically, the results last. “We measure patients when they come in, when of them continue to have significant improvement in mood, quality of life and physical outcomes.”
Is this for you?
If your pain is managed well enough that you can work or carry out your normal activities, you probably don’t need a PRP (and you might not qualify for admission or insurance coverage). But if you can’t, despite treatment, it’s an option to consider. At Mayo’s PRP, most patients have fibromyalgia – which many rheumatologists aren’t especially well equipped
to treat, Dr. Clauw says – although the center also sees plenty of folks with osteoarthritis and rheumatoid arthritis. Often, patients have had multiple injections, joint replacements and other surgeries, and still their quality of life has continued to decline.
According to Dr. Clauw, patients with an inflammatory form of arthritis as well as fibromyalgia are among those whom PRPs might help the most. People with fibromyalgia often benefit from cognitive behavioral therapy in particular, he notes.
Finding a clinic
It may not be easy to find an interdisciplinary pain clinic near you. They are far less common than they were a few decades ago, before the era of managed care. “Those that exist don’t have wide-open doors,” says Dr. Clauw. You’ll probably need a referral, you’ll have to meet the program’s admission requirements, and your health insurance may not pay.
“It’s not a cheap date, that’s for sure,” says Maier. Even though her insurance company covered the lion’s share of the cost, she says she’ll be paying off the balance for years. Time is a factor, too, because you’ll need to devote several weeks to the program. Use caution in choosing a clinic. Opioid mills that masquerade as pain clinics are on the decline, say both Dr. Clauw and Sperry, but still, says Sperry, “Not everything that calls itself a pain clinic is something you’d want your
mother to go to.” The best PRPs tend to be associated with academic medical centers, such asthose at Mayo Clinic, Cleveland Clinic and Johns Hopkins. They can tell you the outcomes of their programs, says Sperry, and typically have providers associated with research institutions. If you apply to Mayo’s Pain Rehabilitation Center and it can’t take you, staff will help you look for another program, says Sperry.
To find a clinic near you, see if your state has a branch of the American Chronic Pain Association, which may provide leads. The American Pain Society has a list on its website of “clinic centers” that have won awards from the society.
If you get accepted to a pain rehabilitation program and can afford it, it can spell the difference between suffering
and living. “The whole process is so valuable, being around other people with problems and just learning how to cope,” says Maier. She has since gone back to her rheumatologist, who continues the anti-inflammatory medications the pain clinic prescribed. “He’s pretty shocked at the results that I got,” she says, “but he seemed happy that I regained better
and more complete use of my hands.
Learn more about pain and ways to manage it in our <a href="/images/OA-Better-Living-76x57.jpg