![]() Multidisciplinary chronic pain management in a rural Canadian setting Robert Burnham, MSc, MD, FRCPC
Introduction: Chronic pain is prevalent, complex and most effectively treated by a multidisciplinary team, particularly if psychosocial issues are dominant. The limited access to and high costs of such services are often prohibitive for the rural patient. We describe the development and 18-month outcomes of a small multidisciplinary chronic pain management program run out of a physician’s office in rural Alberta. Methods: The multidisciplinary team consisted of a family physician, physiatrist, psychologist, physical therapist, kinesiologist, nurse and dietician. The allied health professionals were involved on a part-time basis. The team triaged referral information and patients underwent either a spine or medical care assessment. Based on the findings of the assessment, the team managed the care of patients using 1 of 4 methods: consultation only, interventional spine care, supervised medication management or full multidisciplinary management. We prospectively and serially recorded self-reported measures of pain and disability for the supervised medication management and full multidisciplinary components of the program. Results: Patients achieved clinically and statistically significant improvements in pain and disability. Conclusion: Successful multidisciplinary chronic pain management services can be provided in a rural setting. Introduction : La douleur chronique est un problème fréquent et complexe qui répond mieux à une approche pluridisciplinaire, surtout en présence de composantes psychosociales importantes. L’accès limité à de tels services et leur coût élevé empêchent souvent leur application chez les patients en milieu rural. Nous décrivons ici la mise en oeuvre et les résultats à 18 mois d’un petit programme de prise en charge pluridisciplinaire de la douleur chronique dans un cabinet de médecine albertain en milieu rural. Méthodes : L’équipe pluridisciplinaire réunissait les éléments suivants : médecin de famille, physiatre, psychologue, physiothérapeute, kinésithérapeute, personnel infirmier et diététiste. Les professions paramédicales participaient à temps partiel. L’équipe a procédé au triage à partir des renseignements figurant dans les demandes de consultation et les patients ont subi un examen de la colonne vertébrale ou une évaluation de leurs soins médicaux. Selon les résultats de l’examen, l’équipe prenait les patients en charge selon l’une de quatre méthodes, soit consultation seulement, intervention pour la colonne vertébrale, pharmacothérapie supervisée ou prise en charge pluridisciplinaire complète. Pour les volets pharmacothérapie supervisée et approche pluridisciplinaire complète du programme, nous avons consigné de façon prospective des séries d’automesures de la douleur et de l’invalidité. Résultats : Les patients ont connu une amélioration cliniquement et statistiquement significative de leur douleur et de leur invalidité. Conclusion : Il est tout à fait possible de prendre efficacement en charge la douleur chronique avec une équipe pluridisciplinaire en milieu rural. INTRODUCTION Rural practitioners are frequently called upon to manage complex chronic pain problems. It is estimated that 21.5% of patients who see their primary care physician suffer from persistent pain.1 In adult populations, epidemiological studies have estimated the prevalence of chronic pain to be between 2% and 40%.2 In Alberta, it is estimated that about 11% of residents have chronic pain and about one-quarter of them classify their pain as severe.3 For the solo rural practitioner, the care of the patient with complex chronic pain is challenging and burdensome. Research has confirmed that the most clinically and cost effective treatment for complex chronic pain is through a coordinated multidisciplinary team. Interestingly, the best outcomes have been recorded when individual treatment is in excess of 100 hours.4,5 Unfortunately, access to such programs is limited, particularly for the rural chronic pain sufferer. Such programs are labour-intensive, expensive and, to be affordable, often require third-party funding. They typically are located in large urban settings. Establishment of rural multidisciplinary pain management programs is uncommon, which is possibly related to the lack of qualified and accessible team members, financial and infrastructure issues, and the lack of a functional, proven rural model. The purpose of this report is to describe the development and results of a multidisciplinary chronic pain management program over its first 18 months of operation, which was established in a rural setting in central Alberta. METHODS Finding and funding the team The David Thompson Health Region is located in rural central Alberta and has a population of about 300 000 people. In 2006, the health region administration provided partial funding for the development of a multidisciplinary chronic pain management program (Central Alberta Pain and Rehabilitation Institute [CAPRI]). The program philosophy and mandate were to provide pain management services to patients in the public health care system (patients in the private health system often had funding available for the large urban programs) that involved active participation and personal responsibility on the part of the patient, using evidence-based techniques in a practical and cost-effective manner. The clinic was located in Lacombe, Alta., a rural community of about 12 000 people. A physiatrist and 2–3 physiotherapists were already practising musculoskeletal pain management in the community. At that time, the existing pain management services included fluoroscopically guided spinal injections and nerve ablations, which were performed in the local hospital. To complement those services, a primary care physician was recruited, who was involved in the CAPRI program 4 days per week. His role was to coordinate medication management and assist with intake assessments. A part-time psychologist, nurse, dietician and kinesiologist were also recruited and were involved 1–2 days per week. Alberta Health and Wellness accredited the assembled team as a multidisciplinary chronic pain management program, which allowed the physicians to bill for their services on a timed basis and to be reimbursed for team and patient conferences. This was imperative, as most patients required lengthy comprehensive medical evaluations and there were frequent team conferences. The health region provided remuneration of the other team members through an annual budget of about $130 000. A one-time startup grant of $62 000 from the pharmaceutical industry also supplemented the initial funding. It was used primarily for staff and patient education. The CAPRI program care path Figure 1 outlines the CAPRI program care path. Referral documentation review Patients accessed the CAPRI program by physician referral. The CAPRI program director triaged referral information and assigned patients to 1 of 2 initial assessment paths: spinal or medical. During the first 18 months of the program, the team accepted 1905 patient referrals. Initial assessment
Regardless of the care path, each patient received in the mail a questionnaire that they completed within 1 week of the initial consultation. The questionnaire included questions regarding patient demographics; pain character, including onset, intensity, frequency, exacerbating/remitting factors and a pain diagram; general family history and medical functional inquiry, including sleep quality; red flags (symptoms suggestive of sinister disease); yellow flags (psychosocial factors associated with pain and disability chronicity); opioid risk assessment; previous investigations; previous and current treatments and their effects; perceived disability (Patient-Specific Functional Scale6); and depression (Beck Depression Inventory short form7). Assignment to the initial assessment paths did not preclude secondary assessment by the alternate path. Treatment Following initial assessment, the team selected 1 of 4 treatment modes:
Over the following 2 hours, each patient had a one-on-one consultation with each of the individual CAPRI team members. Each team member was housed in a separate examining room of the clinic. During the individual consultation time, the team member reviewed the patient’s progress, treatment program adherence, concerns and goal attainment pertinent to his or her area of expertise. Team members made modifications and upgrades to the patient’s treatment plan and home program, and established new clearly defined goals for the upcoming week. Once the patient completed the consultation, each rotated to the next room and visited with the next health professional. Following the consultations, patients took a nutrition break/rest while the CAPRI team conferenced together to discuss the progress and plans for each patient. Then, each patient individually met with one of the team members to summarize the progress and reinforce the updated home program for the upcoming week. At the end of the day, patients had the opportunity for additional services, as required, such as individual psychotherapy or an individualized exercise session. The number of weeks each patient was in the full multidisciplinary program depended on his or her individual progress. The mean duration of involvement was 2–3 months. Patients were discharged when the goals of the patient and the team were met, progress plateaued or the patient was noncompliant. Analysis Outcome measures for patients treated by consultation only are not available. The outcomes for interventional spine management have been published elsewhere.11,12 We compared demographic data of the supervised medication management and full multidisciplinary program groups using unpaired t test for all variables except the educational level which we analyzed using χ2 analysis. We used 2-way repeated-measures analysis of variance to analyze initial, midprogram and discharge pain intensity and interference scores. We quantified pain intensity using a numerical rating scale of 0–10, where 0 indicates no pain and 10 indicates worst imaginable pain. Using the Pain Interference Questionnaire, patients quantified their perception of how much pain interfered in 7 separate domains (0/10 = no interference at all; 10/10 = complete interference). The domains were general activity, mood, walking ability, normal work, relations with others, sleep and life enjoyment. RESULTS
DISCUSSION The purpose of this report was to describe the development and results of a multidisciplinary chronic pain management program that was established in a rural setting during its first 18 months of operation. The CAPRI program has generally been considered a success by the staff, health region and patients. Our experience suggests it is feasible to establish a rural multidisciplinary chronic pain management program, but it is not without challenges. Attracting interested and qualified staff to a rural area can be a challenge. We acknowledge it is unusual to have a physiatrist with expertise in interventional spinal pain management in a rural setting. However, as demonstrated by the success of the care paths of the program that did not involve spinal intervention services, significant improvements in pain and disability can still be achieved. Primary medical care, nursing, dietary and physiotherapy are often available in rural communities. Psychology services may be less available. If not, social work or occupational therapy may be available to provide similar services. The challenge is to pull the available services together as a functioning team. For example, the CAPRI program had staffing problems during the inaugural 18 months in that there were periods when the team did not include a nurse or physical therapist. Team flexibility and innovation are necessary. We concede that working with these patients is labour-intensive. Physicians are often working under significant time constraints. It is helpful to use the allied health professionals as physician extenders as much as possible. For example, the CAPRI program has now added a pharmacist to help the physician with day-to-day medication management issues, thus leaving the physician more time for medical consultations. Our experience has been that the integrated multidisciplinary team model is an attractive working environment for the allied health professionals and has been a selling point in their recruitment. The biggest challenge is funding their services. Without the support of the health region, and in the absence of third-party funding, establishing a multidisciplinary pain management program would be virtually impossible. The other big challenge our team has encountered is trying to keep up with the demand for service. As the program has become more widely known, the referral base and wait list have also expanded. We are now exploring the feasibility of offering off-site full multidisciplinary and medication management services via telemedicine. Preliminary work in this area suggests it is feasible and acceptable to both the service provider and recipient.14,15 It remains to be seen if it is equally effective. Telemedicine has the potential advantage of providing a greater number of services to patients who may not otherwise be able to access them, at a lower cost both in terms of time and dollars. Another challenge has been how to decide which care path a patient should be allotted. For example, the only guideline we gave our team for enrolment in the full multidisciplinary program was that patients were to be able to benefit from the services of each discipline represented on the treatment team and patients needed to be able to comply with the program. This treatment mode is the most expensive and labour-intensive. Pain reduction achieved in the full multidisciplinary program was comparable to the less expensive supervised medication management care mode; however, the disability reduction was greater. Interestingly, it appears that the team naturally selected a different cohort of patients to enter into the full multidisciplinary program. Specifically, they were a more highly educated group and scored higher on the intake Beck Depression Inventory Questionnaire. The latter factor suggests a higher level of psychosocial complication. Accordingly, it was appropriate that they be treated by the entire team, which included psychology. The difference in education level is interesting and may reflect the team’s perception that a patient with higher education would be more adept at learning the skills taught in the full multidisciplinary program. CONCLUSION We have presented our experience of establishing a rural multidisciplinary pain management program and are of the opinion that, with the proper support and staff, such programs can function in a rural setting and offer a useful service. Robert Burnham, MSc, MD, FRCPC, Central Alberta Pain and Rehabilitation Institute, Alberta Health Services, Lacombe, Alta., and the Division of Physical Medicine and Rehabilitation, University of Alberta, Calgary, Alta.; Jeremiah Day, MD, CCFP, Centennial Centre for Mental Health and Brain Injury, Ponoka, Alta.; Wallace Dudley, PhD, Central Alberta Pain and Rehabilitation Institute, Alberta Health Services, Lacombe, Alta. This article has been peer reviewed. Competing interests: None declared. Correspondence to: Dr. Robert Burnham, 1, 6220-Highway 2A, Lacombe AB T4L 2G5; rburnham@telusplanet.net References
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