I am Jane Wilkens and am board certified in family medicine and in pain management, and I practice in a multispecialty clinic in Minnesota. The goal of my presentation is to help you understand the multimodal, individualized approach to the management of chronic pain, with an emphasis on nonpharmacologic options.

Developing a treatment plan for a patient with chronic pain begins with either a long initial visit that provides sufficient time to tease out all the information you will need to develop a treatment plan, or you may decide to spread the components of this interview over several visits. Some patients may require more frequent visits early in the process.

A treatment plan should incorporate the biopsychosocial aspects of a patient's pain; the experience of pain involves a complex interaction among biological, psychological, and social factors that often requires a multimodal approach to treatment. Realistic goals of treatment include improved function and increased self-reliance, and minimization of the pain experience. Unfortunately, elimination of pain is rarely a realistic goal. After the patient's chronic pain is under control, I typically see them once every 3-6 months.

The presence of a condition such as rheumatoid arthritis will point you in the direction of disease-specific treatments, but the majority of our pain patients have nonspecific pain arising from a structural abnormality, or pain that lacks a clear cause. Ask the patient for details of past failed treatments, and remain open to the possibility that a treatment that may have failed in the past may be worth considering again. Obtain a history of physical and mental illness, particularly chemical dependency. Sleep quality also is very important in the patient with chronic pain. In addition, I try to elicit potential barriers to managing a patient's pain, such as insurance and financial concerns.

Establishing a therapeutic relationship is, of course, key to successfully educating a patient about their chronic pain. It is important that they understand the difference between acute and chronic pain, and about the complex nature of chronic pain. Often a patient with chronic pain believes their pain to be acute, with expectations of cure, and so this education is necessary in order to set realistic goals and to accept that treatment is a process toward making pain less central to their life. I want them to learn pain self-management skills so they can manage their own pain over time.

The evidence is not strong for many of the treatments that we use in chronic pain. Some treatments are supported by fairly good evidence, while others have less evidence. Not all the drugs we use in pain have a US Food and Drug Administration indication for a pain condition, and some of the treatments we use are based on few studies, or on expert opinion.

I categorize the various treatments available to us into what I call baskets of care: physical, behavioral, interventional, alternative, and pharmacologic.

Physical methods used in chronic pain are aimed at achieving an appropriate level of daily activity. For some patients this may be running 1 mile every day, while for others it may be getting up from the couch for at least 5 minutes every hour. Regardless of my patient's initial level of activity, I encourage progressive increases. We discuss various types of exercise: endurance, strength, flexibility, aerobic activities, weight training, repetitive movement, and stretching. Here again it is important to set goals with the patient, and to start slowly. Although passive modalities such as massage or ultrasound can be useful, physical methods should emphasize and encourage active, rather than passive, modalities.

I have "three P's" that I discuss with my patients. The first P is pacing -- how quickly a patient performs an activity. A patient with low back pain, for example, who rushes through yard work to "get it over with" will likely pay a price for several days. That patient should be encouraged to go slowly, break tasks into manageable chunks, and take effective breaks that are neither too long nor short.

The second P is positioning -- using proper lifting and bending techniques, sleep positions, computer or desk work. The last P is posture; how they position their body while walking, standing, or sleeping. Good posture can be remarkably effective.

I consider the primary goal of physical therapy for a patient with chronic pain is the development of a home exercise program that incorporates appropriate stretching, strengthening, and aerobic activities.

Many of my patients have been through physical therapy more than once and often benefit from a physical therapy refresher of 1 or 2 sessions, just to fine-tune their program.

Interdisciplinary rehab programs are a foundation of chronic pain management. Teams comprised of representatives from a variety of disciplines work intensively with a patient over a few weeks of education, physical therapy, and psychological work, so that the patient emerges with skills to manage their pain. Interdisciplinary rehabilitation has among the best evidence in many types of pain, particularly nonspecific back pain.^[1] Patients who underwent such a rehabilitation program compared with patients who had surgery at 1 year had similar results.^[1] Unfortunately, these programs are costly and not always covered by insurance programs. If one is available I encourage you to use it for appropriate patients.

The second basket of care addresses the behavioral aspect of pain management. In primary care we typically treat anxiety and depression pharmacologically or refer to counseling. Such treatment should be considered also in the patient with chronic pain because depression and anxiety are often part of the pain experience. A patient's personality also may present a challenge in the treatment of any chronic medical condition, so we clinicians have to learn to manage such issues. We should always ask about a history of chemical dependency, and if we elicit an active dependency, determine whether the patient is receiving help. If not, we should refer the patient to appropriate treatment.

The evidence for use of cognitive behavioral therapy in management of chronic pain is quite strong -- particularly in chronic and subacute low back pain.^[2] Most psychologists are familiar with this technique, and I encourage you to collaborate with a psychologist in your practice.

The most important behavioral tool we have available to us in the office is empathy. We can help them know that we do understand that pain has a significant impact on their life, reassure them that we believe that their pain is not imaginary, and that the fact that they report pain means they have pain.

Encouraging the patient to have an active role in developing the treatment plan gives them an often much-needed sense of control. I give my patients as much control as is reasonable. Simply knowing that their participation is valued can in itself be helpful. I encourage patients also to work or engage in creative or volunteer activities.

Negative thoughts and emotions are very common in patients with chronic pain, and we can help them learn how to cope with those negative thoughts and move on to more positive thinking. Regular visits can help you chip away at negative thinking, for example, by focusing on the progress a patient is making, not how much pain they have. I reinforce every little positive step that a patient reports.

Deep breathing techniques and progressive muscle relaxation are among the easiest techniques to work with on a patient.

Our third basket contains invasive interventions. In general, patients should first undergo conservative methods and be carefully educated about what to expect from invasive interventions and spinal surgeries. It is suggested that some modalities are useful in certain conditions, and it is important to keep in mind that many of the studies of invasive interventions involve low back pain. I explain to patients that these methods may provide short-term pain relief measured in weeks to months -- but not years -- and that relief obtained by undergoing an intervention may diminish with repeated exposure to that intervention.

Injections, destructive techniques, spinal stimulators, and intrathecal pumps all have their advocates, and certainly some patients have found at least short-term pain relief from them. A multidisciplinary group led by Dr. Roger Chou looked at the evidence for a number of interventions and determined, for example, that epidural steroid injections are probably more useful for recent onset radicular symptoms of 2 to 6 weeks -- such as a new flare or new pain -- than in radicular pain of many months' duration.^[2] Fairly strong evidence was found for chemonucleolysis in radicular symptoms, although I don't believe it is much used today. A spinal stimulator may help in failed back syndrome -- continued radicular symptoms after surgery -- in which symptoms are severe and no other methods provide relief.

Patients must understand that surgery may not be a cure. Among the spinal surgeries, discectomy is helpful for radicular symptoms, although relief is often measured in months, not years. Spinal fusion may be helpful with spinal stenosis or nonradicular back pain with degenerative findings. Results of lumbar disk replacement are similar to results for fusion.^[2]

Nonspinal invasive interventions include joint and hyaluronic acid injections for arthritis, joint replacement or repair, nerve decompressions, and trigger point injections for myofascial pain. Botulinum toxin injections have been used for certain muscle pain and for chronic migraine.

Our fourth basket of care contains alternative methods, for which both the level of evidence and risk are low. It is likely that our patients have either tried or are undergoing one or more of these modalities, so do ask patients about their experience with these modalities. It can be helpful to know your local providers, and some insurance plans cover these alternative modalities.

Although results of studies of true acupuncture compared with sham acupuncture are mixed, I find it useful in spinal pain, fibromyalgia, neuropathy, and headache, with pain relief measured in weeks and months. I learned acupuncture during my pain management fellowship and offer this modality in my clinic as part of an overall program.

The evidence for chiropractic is strongest for acute low back pain. Yoga appears to be helpful, as long as the patient starts slowly and takes care with extension on certain positions.

The choice of pharmacologic agent depends on several factors. Is the pain inflammatory, neuropathic, or myofascial? What comorbidities are present? What other drugs are being used?

Realistic expectations for pharmacotherapy, and a realistic definition of success can be achieved by educating the patient about what is achievable with these agents, and collaborating on a trial of agents. Patients must understand that pharmacotherapy is a small part of the overall management of pain. I will tell a patient that I consider the diminishment of pain from a 10 to an 8 success, and that I will not rely on drugs to achieve greater pain relief.

Although I strive to use the least number of drugs when I am treating other medical conditions, chronic pain is a condition in which polytherapy can be useful, by attacking the pain with different mechanisms of action. Polytherapy also can allow the use of lower dosages of each individual agent, possibly minimizing side effects and risks. Likewise, if I can achieve 2 needed effects from a single agent, I will likely use it. For example, a tricyclic antidepressant may be helpful for a patient with depression and neuropathic pain. When one agent in a given class does not provide relief, I will rotate to another in the same class, and then move to another class of drugs.

I prescribe these agents on a fixed dosing schedule, rather than on an as-needed basis, because I find that dosing in response to pain generally results in the use of a higher dosage compared with dosing on a fixed schedule. I have found that this approach often allows us to use lower dosages of these drugs.

Consider the whole picture. Employ multiple types of treatment, rotating among therapies as necessary, address psychological problems and sleep issues, educate patients to manage expectations and involve them in treatment decisions.