1. Augmented Paradigms. There has been increasing interest in augmented paradigms. In many cases this represents a shift away from pure biomechanical assessments toward focusing on functional movement systems. “This shift builds on decades of paying close attention to identifying and treating specific pain generators,” says Dr. Williams. “We were looking for the disc, joint or nerve root that generated the pain. Now there is more attention paid to the functional movement systems and figuring out whether an individual patient’s pain and dysfunction is a result of that focal structure or if they have a more holistic problem related to function or movement.”
In many cases, assessing posture and movement is appropriate when patients are suffering from chronic pain. This focus continues to evolve and specialists are now moving away from pure spinal mechanics to assessing the neuromyofascial web and how the different parts are connected and work together. “Rather than talking about or approaching the pain from pure anatomic lesion/focal pathology standpoint, we are thinking about how plasticity in the nervous system relates to ongoing and chronic pain,” says Dr. Williams.
2. New trends and technology for interventions. There are a growing number of papers published about the best and safest approaches for targeting structures that need testing and/or treatment. Pain physicians have traditionally used fluoroscopy, but now are increasingly bringing ultrasound into their practice. The ultrasound technology can identify targets for injection and targets in the potential path of your needle that are meant to be avoided. Also, ultrasound uses no radiation, Dr. Williams says. “We are focused on using emerging technology to improve accuracy, improve safety, and reduce risks,” he says.
Neuromodulation, rather than ablation is also a developing trend in pain management, says Dr. Williams. Avoiding potential side effects and complications related to ablative therapies (such as damage to surrounding structures, increased neuropathic pain and development of deafferrentation pain) are examples of the benefits of modulation over ablation. In many cases, physicians are able to perform less invasive interventions, causing less tissue damage and improving recovery time.
3. Practicing evidence-based medicine. Spine pain specialists can use evidence-based medicine approaches to evaluating and managing patients. “I think evidence-based medicine is a significant and important part of pain management,” says Dr. Williams. “Some specialists believe in an algorithmic approach, to performing interventions and treatments that we know are safe and effective for patients. They guide patients through an algorithm based on the signs and distribution of symptoms. The logical progression through the algorithm from one step to the next is based on individual response to a particular treatment.”
Physicians can also use evidence-based medicine data for shared medical decision making. “The patient needs to buy-in and agree to the interventions that are recommended to them,” he says. “They need to be educated in order to have enough insight to choose which option they want to use.” Patients might arrive at the office with stories about treatments that worked for their friends, and they want to know whether it would work for them. It’s the physician’s responsibility to answer that question from an evidence-based standpoint, says Dr. Williams. However, physicians also need to realize that the guidelines aren’t strict recipes for success because each patient is different and responds differently to treatment.
4. Educating the patient can produce better outcomes. Ensuring that patients are educated on the possible treatment for their care, and allowing them to participate in the decision-making process, often promotes a better overall experience and outcome. First, however, physicians must have the latest and most accurate information before relaying it to their patients. “It takes an informed physician to produce an informed patient,” says Dr. Williams. “The patient should perceive extreme value from interaction with a pain specialist as part of spine pain treatment. If this is done, they will have improved outcomes, cost and safety.”
5. Fitting into the spine continuum of care. Spine pain management is an integral part of every level of spine care, from the initial diagnosis to the decision for surgical treatment. In some cases, a patient might be prescribed pain medication or referred to another specialist before they see a pain management specialist, and by that time it could be too late. “Because of what we know about plasticity in the nervous system, as frequency and duration of pain increases, it’s harder to overcome the pain and treat it effectively,” says Dr. Williams. “Pain management should be part of the treatment early on, not just when patients fail to respond to other non-surgical and surgical interventions.”
Working with pain management specialists during the beginning stages of treatment is economically sound because the interventions may help the patient avoid a chronic condition. “It’s my belief that judicious use of interventions, such as education, rationale polypharmacy and interventional procedures early in the spine pain process can prevent chronic conditions in many cases,” he says. “We need to work with the primary care physicians, orthopedic surgeons, neurosurgeons, chiropractors, physical therapists and other specialists early on. There should be a team approach from the beginning.”
Learn more about Dr. Vernon Williams.
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