Sarah Gradis’ patient was an older woman experiencing chronic pain, primarily in her back and legs. The woman was independent, lived on her own and was reluctant to ask her family for help with everyday tasks.
But she was having difficulty with things like housework, and was feeling increasingly isolated and concerned she might fall.
She began treatment with Gradis, a pain management specialist in the Portland area who holds a doctorate in physical therapy. That treatment included strength exercises.
During their appointments, they’d talk about the woman’s daily routines to get a sense for how she moved, allowing Gradis to discuss posture, body mechanics and ways to make tasks easier, and, at the same time, take stress off overworked parts of her body, thereby reducing the pain. They also discussed the woman’s fears. Though initially reluctant, she eventually began to use a four-wheeled walker.
“That was a big game-changer,” Gradis says. “She was resistant at first, but we talked about how it was safer (and) allowed her to move around more.”
Gradis’ patient was among an estimated 25 million adults with chronic pain, or pain experienced every day for the preceding three months. That figure is from a 2015 analysis of results from the 2012 National Health Interview Survey — an analysis funded by the National Institutes of Health’s (NIH) National Center for Complementary and Integrative Health.
Among older Americans, chronic pain is a growing problem. Medline Plus, a publication of the NIH and the Friends of the National Library of Medicine, reported a few years ago that 50 percent of older adults who live on their own, and 75 percent to 85 percent of elderly people in care facilities, experience chronic pain.
“Yet, pain among older adults is largely undertreated, with serious health consequences, such as depression, anxiety, decreased mobility, social isolation, poor sleep and related health risks,” the publication notes.
Gradis says it doesn’t have to be that way. She and other providers stress the importance of older adults with chronic pain talking with their doctor, setting goals and developing a personalized treatment plan.
For her part, Gradis describes herself as an investigator and guide, helping individuals understand the causes and nature of their pain and developing a plan to address it. The goal is an empowered patient, she says.
“I start where they are and ‘walk’ with them,” she says, noting that though treatment may not eliminate all pain, focusing on things such as body mechanics, exercises and stretching can chip away at the pain and accompanying stress, allowing more function and therefore reduced pain. “It really does add up,” Gradis says.
According to the NIH, a “growing body of evidence” suggests that complementary treatments — among them acupuncture, massage therapy and yoga — may help manage some painful conditions. The National Center for Complementary and Integrative Health notes that acupuncture, for one, “appears to be a reasonable option for people with chronic pain to consider,” noting that “a number of studies suggest that acupuncture may help ease types of pain that are often chronic such as low-back pain, neck pain, and osteoarthritis/knee pain. It also may help reduce the frequency of tension headaches and prevent migraine headaches.”
In addition, an NIH center-funded clinical trial in 2011 concluded massage may be useful for chronic low-back pain, while a 2009 clinical trial by the center concluded ma-sage may help with chronic neck pain.
Meanwhile, the value of physical and other therapies in the healthcare toolbox for treating chronic pain has been highlighted in recent times through a handful of major initiatives that aim to curb Americans’ dependence on opioids.
Early last year, the Centers for Disease Control and Prevention issued its guideline that provides recommendations for primary care clinicians prescribing opioids for chronic pain outside of cancer treatment, palliative care and end-of-life care.
Also, the U.S. surgeon general late last summer sent a letter to more than two million health professionals, asking them to lead a national movement to address the nation’s prescription opioid epidemic.
The letter, part of the surgeon general’s Turn the Tide Rx campaign, was accompanied by a pocket card, adapted from the CDC’s guidelines, noting that before prescribing opioids for chronic pain, providers should consider if non-opioid therapies are appropriate, including exercise, physical therapy or cognitive behavioral therapy.
Dr. Amanda Rosen, a geriatrician with Legacy Health in Vancouver, describes the CDC guidelines as an “excellent general framework” in terms of exercising caution about the risks and benefits of opioids, but stresses that treatment needs to be personalized for each patient. As adults age, the risks for side effects from any medication increase and sometimes outweigh the benefits, she says.
“As a geriatrician, you want to start low and go slow, not just with opiates but every medication class,” she says. “There can be a role (for opiates in treatment) based on an individualized plan, but I don’t believe any chronic pain management plan starts with medication, regardless of the medication.”
Rosen says understanding a patient’s unique history is critical, including what has changed about their pain that brought them to a provider and how that pain is affecting their life. That history will lead to an appropriate treatment plan.
She encourages chronic pain sufferers to reach out to a provider and talk about goals for treatment in terms of reducing pain to a manageable level and how that will impact their ability to function.
“Some people think pain is a normal part of aging,” Rosen says. “It doesn’t have to be.”
She’s seen patients respond to various treatments – from massage therapy to physical and occupational therapy – “extremely well,” depending on the cause of the pain. And there is evidence for “alternative treatment” beyond medicine or surgery, she adds.
Rosen stresses that patients should keep providers informed about alternative treatments they pursue to minimize adverse reactions to another type of treatment they’re receiving.
Like Rosen, Dr. Ben Platt, medical director of the Interventional Pain Clinic at Vancouver’s PeaceHealth Southwest Medical Center, says it comes down to developing an individualized treatment plan because “everyone’s pain is different.”
In the past, patients’ pain too often was under-treated by the medical community, Platt notes. Then came a shift, which in some cases resulted in providers overprescribing opioids.
He believes it’s important to educate patients about the limitations of pain medications, and that there is a “time and place” for pain medications following “rational and careful prescribing.”
Other treatments, such as physical therapy, have long existed, but there is more of an intention in their use now, he says.
“Some people have not pursued the basics first,” Platt says, noting one woman in her 80s found pain relief by improving her posture.
One of the keys to better health outcomes for patients with chronic pain is collaboration among providers involved in an individual’s care, Platt says, “The more teamwork, the better.”
In some respects, there is good news in terms of insurance coverage. For example, an increase in Medicaid coverage took effect last summer for non-pharmacological treatment options for back pain through the Oregon Health Authority. This allows physical therapy, chiropractic and acupuncture coverage for back pain.
The important thing is for patients to ask questions and arm themselves with knowledge, both about treatment options and what might be covered by their insurance, Gradis says.