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pain management practitioner

What Is It?
How Does It Work?

Health Benefits

How To Choose a Practitioner

References
Evidence Based Rating Scale

What Is It?

The specialty of pain medicine is concerned with the evaluation, diagnosis, treatment, and rehabilitation of persons with painful disorders and in some cases with the prevention of those disorders when they can be anticipated. Pain is the number one reason that patients seek healthcare. It may arise from emotional, physical, mental and/or spiritual traumas—often from a combination of these. Pain is also the number one reason that Americans utilize complementary and alternative medicine. (25) In some conditions, acute pain and its associated symptoms arise from a specific cause (such as postoperative pain or pain associated with a malignancy); in other conditions, chronic pain itself is the primary problem (such as neuropathic pain or fibromyalgia).

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recognizing the importance of adequate pain management for health and recovery, integrated pain assessment and management into their standards and intent statements in 2001. In an effort to improve pain management in US health care facilities, all JCAHO-accredited health care organizations must assure that their pain assessment and management processes meet these standards. This has led to an increasingly important role for the pain management practitioner both in and outside the hospital setting.

The ultimate goal of the pain management practitioner, working solo or with a team of specialists is to help patients manage persistent pain and resume more normal, productive lives. Some pain specialists focus on acute pain, often in hospitals and trauma centers; others deal specifically with cancer pain; still others specialize in helping those with chronic pain conditions.

A pain management practitioner can be consulted directly by a patient in need of help, or may be recommended by the patient's primary-care doctor. The practitioner may also serve as an educator and consultant to other health-care providers and participate in an interdisciplinary pain management team.

Pain centers typically have an organized team that includes medical specialists in anesthesiology, rheumatology, physiatry (a branch of medicine that specializes in rehabilitation and musculoskeletal conditions), orthopedics, neurology, neurosurgery, and podiatry. In addition, nurse practitioners, behavioral health practitioners (psychologists, social workers, and counselors), and physical and occupational therapists are typically included. Pain management practitioners working in solo or small group practices, or those in "nonmedical" disciplines (dentistry, chiropractic, mental health, and others) will typically offer referral to a local "team" of sources for pain care needs that they themselves cannot supply.

In addition to utilizing the conventional treatment methods of prescribing medications, performing pain-relieving procedures, and counseling patients and their families, pain management practitioners may also integrate proven complementary therapies in a comprehensive treatment and recovery program for their patients. These may include acupuncture, acupressure, Biofeedback, Guided imagery and hypnosis, herbal medicine, chiropractic and osteopathic manipulative therapy, homeopathy, massage , meditation, and nutritional supplements. Alternative Bodywork, somatic education, fitness training and movement work may also be used, e.g., Alexander therapy, Feldenkrais, qigong, tai chi, and yoga. (For more information on these therapies, see the individual entries in the WholeHealthMD Reference Library).

How Does It Work?

The first visit to a pain management practitioner will most likely begin with an in-depth discussion of the patient's current condition and medical history. The practitioner may ask when the pain began and for a description of the pain. The patient should also mention any past and current pain treatments.  Next, the practitioner will want to perform a physical exam by checking vital signs including heartbeat, blood pressure, and pulse and any areas of specific pain localization. The practitioner may perform a neurological exam to assess sensory (feel) and motor (function) capabilities such as reflexes and muscle tone. Additional tests such as x-rays, computed tomography (CT), or magnetic resonance imaging (MRI) may be requested.

After the tests, the practitioner will determine the cause of the pain and devise a treatment plan. In the case of acute pain, which is usually of recent onset and expected to be of short duration, e.g., pain associated with injury or surgery, the cause can be more easily identified, and a simple treatment plan for a short period of time usually reduces or eliminates the pain.  However, chronic pain—severe intermittent or persistent pain that is not responsive to routine pain control methods and lasts six months or longer—may not have an identifiable cause and often has to be managed over a long period of time. Please see the WholeHealthMD Healing Center on Chronic Pain. (1, 2)

Health Benefits

Pain management practitioners develop treatment plans using therapies to relieve, reduce, or manage pain and to help patients return to normal activities without heavy reliance on medication. Practitioners are concerned with overall quality of life and treat the whole patient—not just one part of the body. A pain management practitioner may devise a plan using medications as well as various complementary modalities for effective pain control.   

Specifically, pain management therapy may help to:

Relieve pain of strains, sprains and sports injuries. In conjunction with conventional treatments such as RICE (rest, ice, compression, elevation) and pain medication, a pain management practitioner may devise a plan that also includes alternative therapies.

One small study of 79 patients with ankle joint sprain indicated acupuncture was more beneficial than electromagnetic therapy. (3) A 2008 study of the effect of massage on muscle pain showed the therapy effectively reduced muscle pain by as much as 50%. (4) Osteopathic manipulation therapy (OMT) can effectively improve the rate of healing in muscle injuries. A 2003 study showed that OMT reduced swelling and pain in ankle injuries, and a 2007 study showed that OMT reduced inflammation in repetitive motion strain. (5, 6) Homeopathic remedies such as arnica, bryonia, ruta, and ledum may be of benefit in pain associated with bruising, movement, and ligament and tendon injuries. (7) Several studies have shown that Traumeel, a combination homeopathic medicine, is as effective as a Non-Steroidal Anti-inflammatory Drug (NSAID) in reducing symptoms of inflammation, accelerating recovery, and improving mobility after musculo-skeletal injury with fewer side effects. (24) Please see the WholeHealthMD reference library for more information about these therapies. Plans for physical therapy and for activity modification to reduce further injuries might also be included.

Reduce symptoms of heartburn. Conventional medications combined with complementary therapy work best for heartburn. One small study indicates acupuncture was more effective than doubling the dose of a proton pump inhibitor (class of medications including Prilosec, Prevacid, Nexium, etc.) in controlling heartburn. (8) Chiropractic manipulation of the spine was found to be beneficial in some patients with indigestion. (9) And a small study indicated biofeedback training helped heartburn patients control the amplitude of esophageal contractions during swallowing. (10)

Minimize pain after surgery. Pain after surgery is a normal part of the healing process. In one small study, 93 patients undergoing total joint replacement surgery were divided into two groups. The experimental group listened to a breath relaxation and guided imagery tape every day for 20 minutes, from the day before surgery to the third post-operative day, along with receiving conventional care. The control group received only conventional care. The pain severity scores on a pain and anxiety questionnaire were lower in the experimental group suggesting that guided imagery could complement analgesics in post-operative pain management. (11) In a study of 190 adults undergoing tonsillectomy, patients were given placebo or two tablets of homeopathic arnica six times on the day after surgery then twice daily for the next seven days. The arnica group reported a small decrease in pain compared to the placebo group. (12) A 2009 review of studies showed hypnosis is effective in alleviating post-surgery pain in children and adolescents. (13) In a study of 200 women undergoing breast biopsy or lumpectomy, patients were randomly selected to receive a 15-minute pre-surgery hypnosis session. After surgery, the hypnosis group reported less pain intensity and unpleasantness than the control group. (14) Also, music has been shown to reduce the use of pain medications after knee surgery. (15) At Abbott Northwestern Hospital in Minneapolis, 21 full-time staff provide complementary medicine interventions. Retrospective analysis on 1,837 cardio-vascular, medical, surgical, orthopedic, spine, rehabilitation, oncology, and women’s health patients treated between January 2008 and June 2009 demonstrated shorter lengths of stay (3.99 vs. 4.41 days) and a 55% reduction in pre/post pain scores while decreasing use of opioids. (23)

Treat various types of chronic pain. Chronic pain often has to be managed over a longer period of time because its cause is difficult to determine or the pain requires trying multiple strategies for effective control. Pain management practitioners may use many different therapies including medication, nutrition, supplements, and modification of activities to find those that are both therapeutic and well tolerated. (16) Acupuncture and homeopathy have been effective for chronic pain conditions including fibromyalgia, osteoarthritis, and migraine headaches. (17-22) Please see the WholeHealthMD Healing Center for more information on Chronic Pain as well as the entries for specific treatments.

How to Choose a Practitioner  

Today less than 1% of medical doctors are specially trained in pain relief. However, the number is growing rapidly and many hospitals have clinics specifically devoted to the treatment of chronic pain. There are also private clinics and solo practitioners specializing in pain management. Due to the interdisciplinary approach needed in pain management, practitioners in various disciplines, including anesthesia, family medicine, behavioral health, chiropractic, and physical therapy are also members of the team specializing in satisfying the needs of chronic pain patients. Look for centers that stress a team approach and track outcomes with documented success.

Keep in mind that to be effective, pain management requires more than just medical knowledge: A good practitioner must also be compassionate and sensitive to the patient's condition and ready to communicate with other practitioners on the patient's behalf. A patient should never be told, "It's all in your head . . ." or "Pain is part of growing older . . ." or "There's nothing we can do about it. . . ." If that happens, look for another practitioner. Patients should plan to take an active role in their pain management. Patients should not give up when they encounter barriers to treatment but should find ways to work through or around them to continue to pursue their goals.

When choosing a pain practitioner, consider the following:

  • If the pain is very severe and likely in need of prescription medicine, patients will need to work with either a Doctor of Medicine (M.D.) or Osteopathy (D.O.). These practitioners are licensed to prescribe medications.

  • Chronic pain that is less intense, especially involving the musculoskeletal system (chronic back pain or fibromyalgia, for example) may not always require an M.D. or D.O. In this case, patients should consider a doctor of chiropractic (D.C.), a physical therapist (P.T.), doctor of naturopathy (N.D.), licensed acupuncturist (L.Ac.), a cranio-sacral practitioner, or a behavioral health practitioner (holding a Master's or Ph.D. degree in counseling). A state government agency directory can help with locating the appropriate licensing departments for these disciplines. There you can find out if the practitioner you are considering is appropriately licensed.

  • In addition, patients should carefully check out any practice they are considering. Do they have a focus on the special needs of chronic pain patients? Do they have a practitioner who has an understanding of the need to involve multiple disciplines in patient care? The need to involve multiple disciplines in pain management may be required by the state. 

Although not required for excellence in pain management, additional certification or membership in one of the following professional organizations is a "plus":

  • Certification as a Diplomat, Fellow, or Clinical Associate in Pain Management by taking the credentialing exam given by the American Academy of Pain Management (AAPM). The Pain Management exam is interdisciplinary and open to M.D.s, D.O.s, D.C.s, L.Ac.s, D.D.S.s, and other licensed practitioners.

OR

  • Certification as a Diplomate by taking an examination in the field of Pain Medicine offered by the American Board of Pain Medicine (ABPM). This exam process is open to only licensed M.D.s and D.Os.

OR

  • Certification by the subspecialty examination in Pain Medicine by the boards for Anesthesiology, Physical Medicine and Rehabilitation, or Psychiatry and Neurology. This examination is only for those M.D.s and D.O.s who have already completed specialty training in one of these fields.

OR

  • Be a dentist (D.D.S., D.M.D.) certified by the American Board of Orofacial Pain.

To find a pain practitioner, check with a local hospital or contact one of the credentialing organizations listed above. Patients may also want to contact their insurance company to find out what aspects of pain management are covered under their policy.

Cautions

As part of a pain management program patients may be referred to alternative practitioners. Just as patients would check the credentials of a medical doctor, they should look into the credentialing of all recommended chiropractors, massage therapists, acupuncturists, or any other alternative practitioners. For more information on how to choose a practitioner specializing in a particular modality, see the specific therapies in the WholeHealthMD Reference Library.

For more on pain, see the WholeHealthMD Healing Centers for individual conditions.

References

1. The Spine Universe-Pain Management Specialist. Web page. Available at http://www.spineuniverse.com/displayarticle.php/article3337.html. Accessed January 15, 2012.
2. The Spine Universe-Chronic Pain. Web page. Available at http://www.spineuniverse.com/conditions/chronic-pain/what-chronic-pain.  Accessed January 15, 2012.
3. He XF, Xu HB. Observation on therapeutic effect of acupuncture at Yanglingquan (GB 34) on sprain of external ankle joint. Zhongguo Zhen Jiu. 2006 Aug;26(8):569-70.
4. Frey Law LA, Evans S, Knudtson J, Nus S, Scholl K, Sluka KA. Massage reduces pain perception and hyperalgesia in experimental muscle pain: a randomized, controlled trial. J Pain. 2008 Aug;9(8):714-21.
5. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003 Sep;103(9):417-21.
6. Meltzer KR, Standley PR Modeled repetitive motion strain and indirect osteopathic manipulative techniques in regulation of human fibroblast proliferation and interleukin secretion. J Am Osteopath Assoc. 2007 Dec;107(12):527-36.
7. Kreuzel T, The Homeopathic Emergency Guide. North Atlantic Books, Berkeley, CA. 1992.
8. Dickman R, Schiff E, Holland A, et al. Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Aliment Pharmacol Ther. 2007 Nov 15;26(10):1333-44.
9. Bryner P, Staerker PG. Indigestion and heartburn: a descriptive study of prevalence in persons seeking care from chiropractors. J Manipulative Physiol Ther. 1996 Jun;19(5):317-23.
10. Valori RM, Hallisey MT, Dunn J. Power of oesophageal peristalsis can be controlled voluntarily. Gut. 1991 Mar;32(3):236-9.
11. Lin PC. An evaluation of the effectiveness of relaxation therapy for patients receiving joint replacement surgery. J Clin Nurs. 2011 Feb 9. doi: 10.1111/j.1365-2702.2010.03406.x.
12. Robertson A, Suryanarayanan R, Banerjee A. Homeopathic Arnica montana for post-tonsillectomy analgesia: a randomised placebo control trial. Homeopathy. 2007 Jan;96(1):17-21.
13. Accardi MC, Milling LS. The effectiveness of hypnosis for reducing procedure-related pain in children and adolescents: a comprehensive methodological review. J Behav Med. 2009 Aug;32(4):328-39.
14. Montgomery GH, Bovbjerg DH, Schnur JB, David D, Goldfarb A, Weltz CR, Schechter C, Graff-Zivin J, Tatrow K, Price DD, Silverstein JH. A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients. J Natl Cancer Inst. 2007 Sep 5;99(17):1304-12.
15. Simcock XC, Yoon RS, Chalmers P, Geller JA, Kiernan HA, Macaulay W. Intraoperative music reduces perceived pain after total knee arthroplasty: a blinded, prospective, randomized, placebo-controlled clinical trial. J Knee Surg. 2008 Oct;21(4):275-8.
16. Sherlekar S. Pain management clinics. Clin Podiatr Med Surg. 2008 Jul;25(3):477-91;vii.
17. Wang X, Du YH, Xiong J. Survey on clinical evidence of acupuncture therapy for fibromyalgia syndrome. Zhen Ci Yan Jiu. 2011 Jun;36(3):230-5.
18. Sanders M, Grundmann O. The use of glucosamine, devil's claw (Harpagophytum procumbens), and acupuncture as complementary and alternative treatments for osteoarthritis. Altern Med Rev. 2011 Sep;16(3):228-38.
19. Yang CP, Chang MH, Liu PE, Li TC, Hsieh CL, Hwang KL, Chang HH. Acupuncture versus topiramate in chronic migraine prophylaxis: a randomized clinical trial. Cephalalgia. 2011 Nov;31(15):1510-21.
20. Davidson JR, Crawford C, Ives JA, Jonas WB. Homeopathic treatments in psychiatry: a systematic review of randomized placebo-controlled studies. J Clin Psychiatry. 2011 Jun;72(6):795-805
21. Patil CR, Rambhade AD, Jadhav RB, Patil KR, Dubey VK, Sonara BM, Toshniwal SS. Modulation of arthritis in rats by Toxicodendron pubescens and its homeopathic dilutions. Homeopathy. 2011 Jul;100(3):131-7.
22. Witt CM, Lüdtke R, Willich SN.  Homeopathic treatment of patients with migraine: a prospective observational study with a 2-year follow-up period. J Altern Complement Med. 2010 Apr;16(4):347-55
23. Dusek, et al. The impact of integrative medicine on pain management in a tertiary care hospital, J of Patient Safety, 2010;6(1)48.
24. Schneider C. Traumeel - an emerging option to nonsteroidal anti-inflammatory drugs in the management of acute musculoskeletal injuries. Int J Gen Med. 2011 Mar 25;4:225-34.
25. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. Dec 10 2008(12):1-23.

Evidence Based Rating Scale

The Evidence Based Rating Scale is a tool that helps consumers translate the findings of medical research studies with what our clinical advisors have found to be efficacious in their personal practice. This tool is meant to simplify which supplements and therapies demonstrate promise in the treatment of certain conditions. This scale does not take into account any possible interactions with any medication/ condition/ or therapy which you may be currently undertaking. It is therefore advisable to ask your doctor before starting any new treatment regimen. 

 

Condition

Rating

Explanation

 

Chronic Pain

 


Numerous studies indicate multidisciplinary pain management treatment may be beneficial in reducing many chronic pain conditions. (16-19)

 

Heartburn  
Date Published: 04/19/2005
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