An example of the importance of a multi-disciplinary approach to persistent pain is the patient with Kinesiophobia (fear of movement associated with anxiety related to an injury). Just as stress and anxiety can make pain worse, kinesiophobia can prevent a patient from recovering to their full extent and achieving relief from muscle pain.
An example….
Consider the case of a 50-year-old woman who was visiting the Norman Marcus Pain Institute for the treatment of her foot and ankle pain. The pain started two weeks after a fall, and had plagued her for five months. Because she felt that she was unable to walk without support, she used a walker or a cane. She complained of pain in her heel and ankle and in her Achilles tendon. Her foot was cold and clammy. Attempting to move her foot up and down and applying pressure to the painful areas caused the pain to become much worse.
She was overwhelmed with her pain and fearful that she would never get better. With her continued pain, tenderness, stiffness, and cold and clammy feet, her doctor told her she had RSD and needed to see a pain doctor for medications and possibly nerve block injections.
When she came in to consult with Dr. Marcus, he wanted to see if he could help increase the range of motion in her ankle. He used Ethyl Chloride spray to briefly make the area cold and numb. She moved her ankle and her pain was gone! Once she felt relief from her original pain, Dr. Marcus asked her to stand. However, she couldn’t because she was too weak. Five months without walking had weakened her muscles and made her unable to walk. She needed strengthening exercises, so she was referred to a physical therapist that helped her re-learn her walking technique while strengthening her muscles. She is now without pain because she no longer holds her ankle stiffly.
Kinesiophobia created more problems than necessary
Her fear of pain and her belief that not walking or moving her ankle would protect her caused her to become disabled, relying on her walker or cane. This could have easily been mistaken for RSD and lead to unnecessary, expensive and painful treatments. She had kinesiophobia, or fear of movement. This is an important factor when a patient is trying to overcome the effects of a painful injury.
Tagged with: foot pain • kinesiophobia • pain relief • relief from pain
Filed under: leg pain posts • pain management
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Unfortunately, for every patient having the good fortune to receive a multidisciplinary treatment program involving Dr Marcus there are FAR too many involved in expensive and ineffective multiD programs. They move from surgeon to neurologist to physiatrist to physical therapist to chiropractor and, in a typical pain management program, anesthesiologist. While struggling to navigate this ‘system’ they will likely begin psychotherapy to help them cope with the pain that they fear may never abate. Each specialist has his or her bag of tools, but they too often rarely find the correct one. Most pain mgt programs are comprehensive, and often hospital-affiliated; yet their outcomes are often sub-optimal at best. In my long experience in both clinical and workplace settings, I have regularly found that the main flaw of these programs is that they do not address, and in fact cannot address, the muscle problem that underlies much of the chronic pain. So in far too many of these cases, the multiD is one of the most important perpetuating factors in the pain. Clinicians need to undergo a fundamental re-training in a very different model of muscle physiology, and then be willing to build teams of like-minded members to change (ie, correct) the plan. However difficult this goal will be to attain, it is a worthwhile one indeed.
Tom, I agree that non-integrated multidisciplinary programs will frequently not achieve optimal outcomes. We both believe that more appropriate cost effective treatment could occur if the understanding of the pathophysiology of muscle pain and its treatment were a standard part of the clinical educational system. In addition, when the chronic pain movement began in earnest in the early 1970’s, functional restoration was the prime objective. Pain reduction without improvement in function, was not considered a success. Physical therapy needs to be coordinated with somatic and psychological interventions. An integrated multi-disciplinary team requires costly team meetings which many centers may find difficult to afford. Clinicians can reasonably only provide treatment for which they are paid. The tail wags the dog. The reimbursement model should cover team meetings, at least for the difficult chronic back pain patients, because it appears to be one of the only approaches, according to Cochrane, that consistently works.