Chronic Pain: How Did We Get Here?
Kris Beebe, MS, MPT
Chronic Pain Management in the Past…
I had the great fortune to work as a physical therapist under Hubert Rosomoff, MD, a neurosurgeon and a pioneer in pain medicine. Dr. Rosomoff believed that chronic pain was generally a nonsurgical condition that should be treated within the rehabilitation model. He did not believe in the use of invasive procedures or chronic opioid analgesic therapy. In 1975, Dr. Rosomoff and his wife, Renee, started the University of Miami Comprehensive Pain and Rehabilitation Center (now named Rosomoff Comprehensive Rehabilitation Center-Functional Restoration Program) in Miami Beach, FL. It was one of the first programs to use the multidisciplinary model approach for pain. The program consisted of a 4-week, inpatient program with a packed schedule of physical therapy and occupational therapy 2x/day, psychology, psychiatry, and physiatry. It was a collaborative space where both patients and the clinicians enjoyed a fun and engaging environment.As a young, fresh-out-of-school physical therapist, the experience with Dr. Rosomoff greatly shaped my views and practice throughout my career. During our weekly rounds meeting, he impressed upon our team that every patient mattered and deserved the very best, honest care. No patient was ever considered hopeless. Complicated cases only challenged him to dig deeper and he encouraged the whole team to do so as well. The quality of care and support was of utmost importance and a huge part of the success of the patient. Dr. Rosomoff was ahead of his time. His methods predated the biopsychosocial approach and “therapeutic alliance”. Not only did he provide great care with this program, but his systematic, multidisciplinary data collection greatly influenced our modern understanding of chronic low back pain. Specifically, this data showed the effectiveness of returning people with chronic low back pain to employment with the implementation of integrated rehabilitative care. This was something that other physicians and researchers had failed to do at that time.
What happened?
When I began working with the program in the late 1990s, there had already been a great decline in the number of such pain clinics due to declining reimbursement rates. To reduce costs, the managed care plans only reimbursed for physical therapy if it was a stand-alone service and not part of a multidisciplinary functional restoration program. As a result, there were fewer favorable outcomes. Patients still suffered with increased pain intensity and disability along with decreased function compared to those patients receiving treatment from multidisciplinary programs. Additionally, pain physicians were now being trained under the specialty of anesthesiology, with an emphasis on spinal procedure-based care. Because of financial difficulties, these changes forced many of the multidisciplinary pain treatment clinics, which had opened in the 1970s and 1980s, to close.The majority of chronic pain care was then left to primary health care providers and single-modality chronic pain treatment clinics. Unfortunately, at this same time (the late 90s), two studies were released that suggested prescription opioids had low addiction rates. In 1997 there were just 670k oxycontin prescriptions. By 2002 that number had risen to 6.2 million. These numbers advanced the opioid crisis that we struggle with today.
Where do we go now?
In 2019, with increased awareness of suicide and substance abuse disorders, preference for opioid prescription has shifted. But if opioids are not an option and multidisciplinary pain treatment centers are cost-prohibitive, primary care providers now have to create a multimodal treatment approach for each patient. This involves referring the patient out for physical, psychological, and behavioral therapies. This process is time-consuming, costly, and exhausting for patients. It ignores the accessible, collaborative healthcare approaches that have proven successful.
Barriers to treatment:
Scheduling conflicts
Time off work
Childcare costs
Transportation need and costs
Lack of practitioners in rural areas
KARUNA HOME VIRTUAL REALITY AS A SOLUTION
Karuna Home has created a digital functional restoration program for chronic pain treatment that eliminates barriers to treatment. Karuna uses evidence-based techniques from physical therapy, pain psychology, cognitive neuroscience, and functional restoration programs. Its focus is on function and improved quality of life. Karuna’s program can restore function, is fun and engaging with Virtual Embodiment Training, non-pharmacological, and is non-invasive.Pain is a very personalized experience and everyone’s pain map is different based on past experiences, emotions, and social context. Karuna uses the brain’s ability to reorganize itself by forming new neural connections and pathways. Over time, this learning process slowly returns the neurons to normal and pain diminishes. Karuna’s software uses virtual reality to create neuroplastic changes by placing the patient in an environment where they increase movement while blocking pain signals. The brain ties movement with different experiences and not to pain. This process is key to changing the perception of pain and the movement associated with it as non-threatening.Some skeptics may claim that virtual reality and its complex technology is moving us away from the personalized care promoted by Dr. Rosomoff’s methods. When compared to opioids or to the use of fragmented care with various disciplines and barriers to treatment, Karuna presents a solid solution for a complex problem. Virtual Embodiment Training brings multidisciplinary care to the patient in the comfort of their own home. The patient’s progress is tracked through the device, with pain coaches available for consultation and motivation. Patients can be proactive and take control of their own treatment. Karuna provides hope to patients that leads to lasting results and a return to a normal life. It is a solution that I am sure would have won the approval of the late Dr. Rosomoff.Source:{$excerpt:n}