With millions of sufferers, chronic pain gets increasing attention.
by Kathy McKimmie

About 116 million adults in this country experience chronic pain, which costs between $560 billion and $635 billion annually in medical expenses and associated economic costs including lost wages and productivity, according to a report issued in June by the Institute of Medicine of the National Academies, sponsored by the National Institutes of Health. The study, mandated by Congress as part of recent health-care legislation, shows a dramatic increase over previous estimates.

The first stop for individuals in pain is typically the family doctor, and the Institute's report said the majority of care and management should take place through primary care providers and patient self-management, with specialty care services reserved for more complex cases.

For those more difficult cases, however, there are several resources available in Northwest Indiana to tackle chronic pain, nearly all using minimally invasive procedures.

“Most people don't even know there are such things as pain specialists,” says Dr. Heather Nath of Lakeshore Bone & Joint Institute, Chesterton, but they've been around for about 20 years. She is board-certified in both anesthesiology and pain medicine, with a dozen years practice in the latter.

At Lakeshore, she works closely with workers' compensation insurers, adjustors and occupational health providers to treat primarily workplace injuries.

“If you would have told me that my office would be between a Walmart and a cornfield, I wouldn't have believed you,” Nath says, who spent most of her career at Rush Medical Center in Chicago and has lectured at Harvard. “But it's nice to be able to provide that kind of care here — you don't have to go to Chicago.”

“The people that come to me are those who generally fail the first round of treatment,” says Nath. That sometimes leads to frustration, financial stress and fear of reinjury, all of which need to be dealt with. It's up to her to discover why the first treatment didn't work. The individual may have been seen initially onsite at an occupational health center at a steel mill or by an orthopedic surgeon. “We work in a coordinated effort to get the proper diagnosis and treatment,” she says.

“As a pain specialist, I treat people with all different types of pain,” Nath says, “but I treat a lot of back injuries, that's the most common.” And the most common procedure she performs to alleviate back pain it is an epidural steroid injection that is done under X-ray guidance.

“I saw hundreds of injured workers last year and most get better,” she says. The treatments are sometimes combined with physical therapy or other measures to achieve success. “The best approach is prevention,” she adds, but that doesn't always get considered.

Prevention is also a key word for Dr. Shaun Kondamuri, director, Midwest Interventional Spine Specialists, based in Munster with locations in six other Northwest Indiana cities. Like Nath, he is board-certified in both pain medicine and anesthesiology, with the additional area of internal medicine. He practices interventional pain management full-time.

Fifty percent of injuries in non-Medicare adults happen in the workplace, says Kondamuri. That's why ergonomics, proper lifting techniques, and strengthening core muscles are stressed to prevent injuries. Most patients he sees are from 35 to 50 years old and some arthritis is developing; they have stiffness in the joints if regular exercise is not the norm.

When injuries occur they could be caused by heavy lifting, but just as often by bending and twisting, “life's usual events” as he calls them, putting greater stress on the spine and disks, the most common cause of back injury and pain.

Anti-inflammatories, analgesics and physical therapy are recommended and in appropriate cases Kondamuri will use steroid injections into the specific location causing the pain. In those cases, about 90 percent of patients return to work in about a week if the employer allows light-duty work. He doesn't want to have his patients at home developing “chronic pain tendencies.” More than half his patients will be back to work at full duty within a month and very few will need surgery.

The use of steroid injections has been shown to be as effective as surgery, Kondamuri says, and at much less expense than a spinal fusion. In addition, the patient frequently expects a quick result with surgery and takes a passive approach to recovery. Kondamuri says he tries to avoid prescribing opiates and muscle relaxants because they interfere with fine motor skills and shouldn't be taken while on the job.

Dr. Ramesh Kanuru, medical director, Kanuru Interventional Spine & Pain Institute, with offices in Highland, Valparaiso and at Pinnacle Hospital in Crown Point, may be the longest-practicing pain specialist in Northwest Indiana. He started in 1981 at St. Margaret's in Hammond.

He remembers introducing the pushbutton patient pain device for use after surgery in the hospital, and he has added other innovations as they have come along, like steroid injections, neurostimulation with the use of a spinal cord stimulator (implanted in the body similar to a cardiac pacemaker) that blocks the nerves going to the brain, and radio frequency ablation, which causes a burning of a nerve in the neck or back to stop pain.

Despite high-tech treatments, however, he says he remains conservative in his practice and touts a decidedly low-tech advancement that has aided pain control. It's the “fifth vital sign,” he says – asking patients to describe their pain on a scale of one to 10, with no pain being zero. It was adopted by the Joint Commission 10 years ago. “It made professionals and non-professionals aware of the importance of pain and the need to treat pain.”

About 70 percent of patients Kanuru sees have been injured at work. If he finds the majority of the patient's pain is coming from muscles, he refers to a physical therapist first. If that doesn't do the trick he will typically have them come back for an injection. In most cases the injection is a one-time thing.

Treatments are often complemented by physical therapy, stress management techniques, yoga and meditation. Conditioning strategies are emphasized with patients and employers to prevent injuries. Unfortunately, Kanuru says, employers rarely provide exercise or wellness programs. “They don't mind paying out hundreds of thousands on the other end by paying for workers' compensation, hospitals and surgeries.”

Occupational medicine plays a role
The medical staff, physical therapists and ergonomists at Memorial Center for Occupational Health, South Bend, have worked with some 2,300 companies in northern Indiana, Michigan and Illinois to help get injured workers back on the job as soon as possible and provide a safer work environment.

“Over the last few years there's been a 40 percent increase in the number reporting chronic pain in the workplace,” says its medical director, Dr. Eric P. Wohlrab. “It's now one in four employees. Half of those admit it decreases their ability to do the job.” That leads to absenteeism, but also presenteeism — showing up but only going through the motions without the normal productivity.

“Our approach to pain is: do a good job evaluating what's causing it and go about ameliorating it,” Wohlrab says. If it's tennis elbow, for instance, do minimal activity, take anti-inflammatories, do stretches, use ice and heat and limit repetitive motion. He subscribes to the old joke: “Doc, it hurts when I do this.” “Then don't do it.”

“In three to four weeks most work-related musculoskeletal injuries will get better on their own, regardless of what you do.”

For more serious cases, Wohlrab says treatment may involve more bells and whistles, such as cortisone shots, but he is adamant that prescription pain medications such as Vicodin are overused. If they are used, they need to be discontinued when significant progress is made, certainly before a return to work.

“All medications have side effects. In a safety-sensitive situation you're putting yourself and others at risk.” It is his job to report to supervisors that the employee is “fit for duty.”
“I'm more interested in the functional capacity, more so than the pain,” he says. “As we've all found, you can have pain day-to-day.

“With chronic pain, I like to take a holistic approach,” Wohlrab says. That means making referrals to alternative types of health-care treatments when appropriate, such as chiropractic, yoga and biofeedback.

Chiropractic care
“About 85 out of 100 people will suffer with an incapacitating lower-back situation in their lifetime,” says Robert Hall, DC, Broadway Plaza Pain Relief Center, Merrillville. So naturally, that's the most common problem he has treated in more than 20 years of practice, but all parts of the body can be involved.

For working adults, most problems arise from repetitive tasks or overuse, says Hall. “Of course, we also see the plain old traumatic injury,” where a person bent over to pick something up and an injury results. Those injuries are typically caused by deconditioning, he says, when you do something 90 percent of the time and then switch to something you do infrequently and the injury occurs — maybe from one little twist.

“We use conservative measures aimed at correcting whatever the problem is that is causing the discomfort, as opposed to treating with medications,” Hall says. “Is there a muscle shortened and tightened over time? Can we stretch it? Is it weak? Can we strengthen it?”

One treatment Hall added a few years ago is spinal decompression. “It's a revisitation of traction,” he says, that has come in and out of style. It's helpful in people with spinal stenosis and disc disease. When a nerve is compressed, causing pain, it is decompressed using computerized programmed patterns of stretching and release. “It's the treatment of choice if we're trying to avoid surgery.”

Like Hall, the majority of patients seen by Jose Cordova, DC, Community Chiropractic Clinic, Munster, have back injuries. Ninety percent have pain coming from the base of the skull to the tailbone, he says, with the rest typically having problems with knees, hips, feet and wrists.

Carpal tunnel syndrome is a common condition found in the wrist from overuse and is treated with stretches as well as splints, frequently used at night when the pain can get worse.

Cordova's ultimate goal is to get the pressure off and get the tissue to recover. In most cases that involves spinal manipulation – adjusting and mobilizing the spine to regain normal movement. Adjunctive therapies are also used, such as electrical stimulation, cold therapy, heat therapy and ultrasound therapy to reduce swelling.

Most of Cordova's clients have chronic pain caused by arthritis and degenerative problems caused by repetitive work, such as hairdressers, assembly line workers and truck drivers. Not surprisingly, many problems start in middle age when people tend to get out of shape. Even sitting behind desk for long periods of time causes problems, he says, because there is no exchange of fluid within the cartilage.

“Movement promotes fluid exchange,” he says. The treatment plan for these individuals may last eight to 12 weeks, compared to a couple weeks for younger workers where there is no degenerative problem or arthritis. After treatment, patients are counseled on how to do stretches and exercises to avoid reinjury. Even so, Cordova says patients with chronic conditions return every couple years.

Allowing the tissue to heal is key to Cordova's success and treatment depends on a good diagnosis. Not all patients are good candidates for his treatment. If the condition is acute enough, he will present the patient with options, including referral to a physician.

Insurance coverage for chiropractors is limited in Indiana because the state has no “any willing provider” provision in its insurance law, Hall says, which would allow a patient to more easily choose a chiropractor for care. As a result, “it's an unlevel playing field for chiropractors.” Where injured workers have a choice, like in Illinois, he said, “chiropractic flourishes.”