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These are hybrid-type suites that are becoming increasingly common. They involve a multidisciplinary approach to the treatment of pain. Frequently, one will find neurologists, nutritionists, deep-tissue massage therapists, chiropractors, psychologists, and biofeedback technicians working together in a holistic manner to change the patient's behavior or symptoms. Some neurologists may have one or more biofeedback rooms and physical therapy massage rooms incorporated into their offices.

In recent years, anesthesiologists have become involved in pain management of persons suffering from intractable pain. Anesthesiologists who specialize in pain management are physicians who have received additional training in this area after completion of anesthesiology training. According to the American Board of Medical Specialties, certification in pain management recognizes that these physician anesthesiologists have demonstrated competence to provide a high level of care either as a primary physician or as a consultant to patients experiencing either acute or chronic pain.

Procedures Performed by Anesthesiologists

Fluoroscopic-guided injections into the epidural space can be carried out in a minor procedure room but are more commonly done in a hospital or ambulatory surgical center setting as the cost of radiographic equipment would go beyond what most physicians would want to invest in their offices. All injections, however, are not fluoroscopically guided. Sometimes a local anesthetic is injected into soft tissue, joints, and the spine. Fluoroscopy is used where the space is anatomically small and hitting the target may be difficult without the help of fluoroscopy. Often, there is a recovery area because patients can get up after the procedure and fall. How patients feel after the procedure is very important and they might be interviewed in a consultation room or exam room after recovery.

Measuring the Problem

Chronic and intractable pain is a huge problem in that it affects approximately 50 million Americans and results in considerable loss of productivity and time away from

Table 4-10. Impact and Extent of Chronic Pain

Number of Americans who have chronic pain

Adults who routinely take prescription painkillers

Number who can't do routine activities because of pain

Proportion of employees who take time off from work because of pain

Number of work days lost yearly to pain

Annual loss in productivity due to pain

Annual sales of over-the-counter analgesics

Amount Americans spend annually on pain care

Most common types of chronic pain that physicians treat

48 million 21.6 million 13.6 million 14% 4 billion $65 million $3 billion $100 billion Cancer pain, lower back pain, arthritis, headaches, fibromyalgia

Source: Wall Street Journal, October 18,1999, p. R-6; National Institutes of Health; Louis Harris & Associates Inc.

work. In the inpatient setting, only recently has pain been documented as one of the vital signs. Patients are asked to rate their level of pain, which is recorded in their chart, along with vital signs. For those with terminal illnesses, there's currently much discussion about the appropriate use of morphine and other narcotics to end suffering.

For others, chronic pain—defined as that which no longer serves a biologically useful function—is terribly debilitating and, according to researchers, can actually change the wiring in the brain, spinal cord, and nerve cells by triggering the release of proteins that cause tissue damage. Pain can actually become a disease in itself. Treating it is often a trial-and-error process in which sufferers consult numerous physicians and therapists trying to find the magical cure. Low-back pain is second only to the common cold as the most common cause of illness. Other common causes of pain are migraine headaches, fibromyalgia, arthritis, cancer pain, and that which results from traumatic injuries and degenerative disk disease. Table 4-10 shows the impact and extent of the problem caused by chronic pain.

Defining the Program

Because pain treatment providers vary so widely in their specialties, skills, and approach to pain management, the following questions may be helpful in defining the program:

1. What types of patients do you see and do you have a subspecialty in treating certain types of conditions?

2. What is the patient flow after patients have checked in?

3. Where does the initial history taking and interview take place? Who performs it?

4. What is the frequency of visits or treatments for each type of patient and/or condition?

5. Is anesthesia or conscious sedation used?

6. What do the treatments consist of?

7. What is the type of coordination with the patient's primary-care provider, neurologist, neurosurgeon, physi-

atrist (physician specializing in rehabilitation medicine), oncologist, rheumatologist?

8. What type of recovery is generally required after treatment? If required, what is the length of stay in the recovery room?

9. Is there any equipment used that requires specific or unique utilities?

10. What is the ideal type of lighting in your examination and procedure rooms? Do you require a surgical light?

The plan in Figure 4-152 was developed for an anesthesiologist. It does not accommodate a massage therapist, psychologist, chiropractors, or others who sometimes work together in a coordinated, integrated approach to pain management.

82-0"

82-0"

Equipment Used Oncologists

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