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NENA Fosters Collaboration in Pain Medicine
Michael Connelly, M.D., Division of Pain Medicine
Pain is among the most common reasons patients go to the doctor as they seek a proper diagnosis and a treatment plan that will ease their suffering.
For primary care providers and specialists, pain is both a common and difficult problem. What is the source of the pain? How can it best be treated? Has the patient developed depression or anxiety? How can an optimal outcome be achieved, even if this means pain relief is not complete? How can the patient’s level of activity and quality of life be improved?
The treatment of pain presents unique questions that require a collaborative effort among medical specialists. Knowing where to start is one challenge. Knowing when to include another specialist is another. Understanding who needs an injection, surgery, medication, physical therapy and mental health care, or some combination of these, is not only difficult, it is critical to successful treatment.
New England Neurological Associates (NENA) offers a unique setting for collaborative treatment. Pain specialists, neurologists, neurosurgeons, physiatrists, psychiatrists, and psychologists work together in one office, with interventional treatment and physical therapy in the office next door.
The most common conditions treated by our team are spine disorders including spinal stenosis, disc herniations, compression fractures, and spon-dylolisthesis. Other commonly managed conditions include cancer, neuropathy, and shingles.
The New England Neurological Associates Model
The NENA approach to pain medicine is unique, providing a multi-specialty neuroscience practice that fosters collaboration and communication amongst specialists. In the traditional practice model, care can be fragmented. A patient with pain will see a specialist in spine surgery in one practice, a pain specialist in another, neurology in a third, psychology or psychiatry in a fourth, and physiatry in yet another practice. Ideally, the patient’s care
is coordinated. Unfortunately, this can be difficult, with communication between offices left to delivery of typed notes or electronic records that are not integrated. The result is care is that is episodic and not well coordinated.
The NENA model of pain medicine provides access to a variety of specialists—each of whom has a different expertise and perspective on pain management—under one roof, in one location. Patients can see collaboration first hand. Physicians and physician assistants are commonly found hovering over films and charts discussing patients. They have learned how other specialists think, and how they can best help each other manage a wide variety of clinical problems.
Working across traditional practice lines, urgent referrals can be difficult to coordinate quickly. Working within the same practice, the situation is different. The pain medicine physician can arrange injections quickly based on the assessment of neurosurgery, and neurosurgery has confidence that a request for surgical assessment has already had optimal nonoperative treatment. The nuances of assessing pain in the context of the patient as a whole and treating relevant psychological variables such as depression are invaluably optimized. Treatment may include cognitive behavioral therapy or other approaches including medication.
Examples of Collaboration
• A patient referred for pain between the shoulder blades is seen by pain specialist Dr. Michael Connelly. Concerned with what he sees on the MRI, he asks for input from Dr. Henry Ty, a NENA neurosurgeon. As a result of this collaboration, assessment and treatment for a serious spine infection is rapidly coordinated.
• A patient with severe leg pain and a disc herniation is seen by neurosurgeon Dr. Peter Grillo. In hopes of avoiding immediate surgical treatment, he presents the case to Dr. Connelly, and an injection of steroid is arranged for the following day.
• A woman with multiple sclerosis is referred with pain “all over” from spasticity. Dr. Connelly directs her to movement disorder specialist Dr. James Whitlock for his expertise. Dr. Whitlock and neurosurgeon Dr. Ty team up in providing spinal infusion of baclofen that is often life altering in its benefit.
• A middle-aged woman with a long history of back pain was referred to NENA psychologist Dr. Robert Moverman by a pain medicine physician within the practice. The patient was experiencing a high level of stress and tended to bottle up disturbing feelings, with a corresponding “conversion” of stress into somatic complaints. Through counseling with Dr. Moverman, the patient faced a number of emotional issues and decreased her pain to the point that she no longer required intervention by the psychologist or pain medicine physician.
Approaches to Back Pain and Collaborative Pain Medicine
It is worth noting that back pain alone affects millions of Americans, and represents a clinical area that benefits from collaborative approaches to management. There may be diverse causes of back-related pain. For many patients, physical therapy directed by a NENA physiatrist is the key to relief. Patients receive guidance in stretching as well as strength and conditioning exercise for “core” muscles in the back and abdomen. With direction to independent exercise, patients often benefit from learning that they do not need to fear activity.
Pain from a herniated disc is most often managed without the need for surgery. In certain cases that do not respond to physical therapy, NENA pain specialists are able to employ x-ray- guided injection of cortisone along the painful nerve root (Figure 1). This can be very helpful in easing the pain in a majority of patients.
Figure 1—Disc herniation causing severe left leg pain.
A: S1 nerve root
B: Disc against left S1 nerve root
Another very common problem is pain related to osteoporosis resulting in spinal fractures. These “compression” fractures may be painless for some patients, and disabling for others. For painful fractures, balloon kyphoplasty is performed to stabilize the bone, relieve pain and often restore height to the collapsed spinal bone (Figure 2). A randomized trial published in May 20091 demonstrated superior outcomes for balloon kyphoplasty in pain and quality of life compared with nonoperative treatment.
Figure 2—Injection of left nerve root by a NENA pain medicine specialist provides relief.
When surgical evaluation is needed, collaboration on a treatment plan is facilitated with the neurosurgeon consulting with the neurologist, pain specialist, and physiatrist in one location. Physicians communicate about patients at the point of care, and patients have the security of knowing their doctors are working together.
Conclusion
New England Neurological Associates patients experiencing pain from back disorders and other conditions benefit from a treatment plan that is the result of collaboration among specialists in Pain Medicine, Neurology, Neurosurgery, Physiatry, Psychology, and Psychiatry. Patients experience optimal outcomes when their needs are addressed by an integrated and highly motivated team.
From conservative guidance and advice to advanced interventional therapy, the specialty of pain medicine at New England Neurological Associates offers hope and relief, and improved quality of life for many patients.
1. Wardlaw D, Cummings SR, Van Meirhaeghe J, et al. “Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial.” Lancet 2009; 373 (9668): 1016-24.
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