J Pain Research 2017 (Aug 30); 10: 2089–2095 ~ FULL TEXT
Gregory F Parkin-Smith, Stephanie J Davies, Lyndon G Amorin-Woods
School of Health Professions,
Perth, WA, Australia;
The other day, we oversaw a seminar on pain management for a local consumer pain
group, where all consumers (patients) in attendance were experiencing chronic, persistent
spinal pain. Each person had a unique story, and their experience and perceived
cause of their pain differed. The quality of life in all these consumers was markedly
reduced, which was the only clear similarity, confirming that there may be some similarities
in the pain experience, but the pain experience was more often unique and
individual. These consumers’ criticisms of care services were consistent, however, with
dissatisfaction with their access to care and overall management of their pain. They
described variable and often difficult access, limited continuity of care, they were often
not taken seriously by health care providers, they received scant information about
chronic pain and its prognosis and there were often noteworthy variations in the treatment
We agree that these criticisms are commonplace and a frequent
gripe directed at health care practitioners about the “system.”  Moreover, the problems
associated with care delivery are confounded by a number of patient/consumer factors,
such as lifestyle habits, nutrition, body weight, depression, health literacy, geographical
isolation and poor socioeconomic conditions, making the management of persistent
pain even more complicated.  There is no doubt that, in the future, matching the care
service and treatment with the individual patient will become an essential component
of care services, as has been implied in published research. [3–6]
Health care practitioners involved in the triage and management of patients with
persistent spinal pain will need to become more vigilant about individualizing and
coordinating care for each patient, to achieve the best possible outcomes. For example,
Cecchi et al concluded that patients with chronic (persistent) lower baseline pain (LBP)-
related disability predicted “nonresponse” to standard physiotherapy, but not to spinal
manipulation (an intervention commonly employed by chiropractors [7–9]), implying that spinal manipulation should be considered as a first-line conservative treatment.  We note
that spinal manipulation is now suggested as the first-line intervention by Deyo,  since not a single study examined in a recent systematic review found that spinal manipulation
was less effective than conventional care. 
Garcia et al,  conversely, showed that
high pain intensity may be an important treatment effect modifier for patients with
chronic low back pain receiving Mckenzie therapy (a treatment frequently used by
physiotherapists). These examples demonstrate the importance of matching treatments
with the characteristics of the patient.
Similarly, identifying potential pain generators using
diagnostic low-risk interventional pain procedures by precise
anatomical instillation of local anesthetics informs the probability
of subsequent therapeutic low-risk interventional pain
procedures providing medium- to long-term pain relief for
that individual. The potential to provide a therapeutic window,
for months or years, can enable individuals to continue with
evidence-informed behavioral change to achieve the patient’s
short- and long-term goals. Interventional pain procedures
are rarely performed in isolation because the procedure is
only one part of a broader pain management plan.
The person in pain, prior to considering an interventional
pain procedure, is ideally engaged in their own “prehabilitation,”
which is the process of enhancing functional capacity
of the individual to enable him or her to recover more quickly
following a procedure.  We suggest that the sequence of
interventions first involves patient assessment (history, examination,
investigations, screening questionnaires, information
from previous health care professionals), from which follows
pain options that are relevant and available to the individual
patient, which results in a pain management plan that is
agreed and understood by both the patient (and their significant
others) and treating practitioner and communicated to
the other health care professionals (coaches). If a person in
pain does not currently have a well-organized team providing
evidence-based care, then their medical service will need to
offer suggestions and coordinate local available options to
form a virtual health care pain team.
Figure 1 flow chart, is
an example of the process of care service provision and the
patient journey for the management of chronic spinal pain.
Although interventional pain procedures have been utilized
for many decades, it is not easy to find precise definitions.
Specifically, the distinction between diagnostic and therapeutic
procedures is often opaque, and so we have provided our
definitions to reduce miscommunication between health care
professionals (definitions are listed at the end of this article).
Flow Diagram of an example
of the patient journey and service
processes for chronic pain management.
We would like to draw attention to behavioral changes
such as non-sweating movements including real-time imaging
for retraining multifidus and transversus abdominis
and daily walking, and mindfulness which may all play a
role in reducing fear, anxiety and threat. [14, 15] We postulate
increasing control and reducing threat, thereby reducing the
threat value of pain, can reduce the “other changeable pain”
called alloplastic pain for which the glial-modulated immune
response (GMIR) is key. Understanding the glial activation in
pain pathways may well be key to reducing persistent pain, 
with palmitoylethanolamide (PEA) which is an endogenous
lipid modulator in animals and human beings and has been
evaluated since the 1970s as an anti-inflammatory and analgesic
drug in more than 30 clinical trials, in a total of ~6,000 
patients, including eight clinical trials for nerve entrapment.
In one pivotal, double-blind, placebo-controlled trial in 636
sciatic pain patients, the number needed to treat (NNT) to
reach 50% pain reduction compared to baseline was NNT=1.5
after 3 weeks of treatment.  This emerging evidence is of
interest as no drug interactions or troublesome side effects
have been described so far.
In addition, the emerging biology of pulsed radiofrequency
neurotomies is unique in that it provides pain relief
without causing significant damage to nervous tissue, with
animal studies demonstrating modulation of pain transmission
in the spinal nerves and spinal cord by a range of
mechanisms including modulating gene expression  and
microglial neurotransmitters. [20–22] These emerging concepts
in the literature start to provide biological mechanisms to
the use of pulsed radiofrequency modalities for people with
Decades worth of research outcomes suggests that knowledge
and guidelines related to both acute and chronic spinal
pain are now available [22, 23] – certainly enough to inform practice
and the implementation of evidence-informed care services for
persistent spinal pain. New policy documents have emerged in
Australia, for example, the Spinal Pain Model of Care and the
Framework for Chronic Pain, [25, 26] along with published recommendations
from recent systematic reviews. For example, exercise,
tai chi, yoga, mindfulness-based stress reduction and other
psychological therapies, spinal manipulation and massage,
acupuncture, nonsteroidal anti-inflammatory drugs (NSAIDs;
although less effective than previously reported), duloxetine,
tramadol and skeletal muscle relaxants (short-term relief only)
seem to have a positive role. Yet, commonly encountered
treatments, such as passive physical therapies (interferential
therapy, short-wave diathermy, traction, ultrasound, lumbar
supports, taping, electrical muscle stimulations), opioids (the
evidence is very limited for their efficacy), paracetamol, benzodiazepines,
systemic corticosteroids, tricyclic and selective
serotonin reuptake inhibitor (SSRI) antidepressants, do not
seem to contribute much to outcomes. [27, 28]
It is fair to say that we have attended numerous seminars and
discussions (such as the working groups and forums in Western
Australia [WA] that culminated in the WA Framework for Persistent
Pain [2016–2021]),  all of which are saying much the
same things and consistently offering similar recommendations
about chronic spinal pain care. There is ample written about the
contemporary approach and context of pain management, such
as the Royal Australian College of General Practitioners’ pain
management contextual statement.  Therefore, the future of
persistent pain management is less about doing more research
and producing more guidelines, although research continues to
be important, but rather about implementation of existing care
frameworks and models of care [30–32] with a view to obtaining
better outcomes for patients at a reasonable cost. It is very likely,
indeed desirable, that care frameworks and models of care will
evolve and be updated every 5–6 years, so stakeholders should
keep an eye out and keep themselves informed as to how care
services are changing.
The health care literature convincingly reports that coordinated,
multidisciplinary and multimodal care, at the right
level, is desired to achieve the best possible outcomes for
patients and is very likely to be cost-effective.  The challenge
now is to have persistent spinal pain fully acknowledged as
a legitimate chronic condition by both health care providers
and policy makers/payers and have evidence-informed, cost-efficient
care delivered in the manner described in published
frameworks and models of care. Despite the complexity of
spinal pain and its management, as with most chronic diseases, the potential workforce and services can and must be made available with appropriate attention, planning and leadership,
with a view to improving accessibility to appropriate
care early in the development of the spinal pain condition.
The consequences are a large population of chronic pain
sufferers, worsened by age-related comorbidities, which will
be a tremendous burden and cost to the health care system,
not to mention the personal suffering of the individual and
Getting access to the right care at the right time is critical,
but the right multidisciplinary team is currently the elusive
goal of contemporary spinal pain management. In Australia,
waiting times for pain services and specialist appointment
may run into many months, if not longer, thereby missing
the opportunity for timely treatment.  The problem does
not lie with access to pain medication/analgesics per se;
these may be prescribed by general practitioners (GPs)/
family physicians, indeed already too often or too much, 
but rather with artful analgesic prescribing and coordinated
multimodal treatments within a multidisciplinary setting. We
know that spinal pain, according to various reports, such as
from the Australian BEACH (Bettering the Evaluation and
Care of Health) project, is common and that analgesics for
it are among two of the top five most commonly prescribed
medications.  Upshur et al  showed that 37.5% of adult
appointments in a typical GP’s week involved chronic pain
complaints, comprising back pain (23.6%), followed by joint
pain (17.1%), headache (12.1%), generalized pain (7.8%)
and neck pain (7.5%). Indeed, the proposed approach and
management for pain are eloquently summarized in numerous
papers directed at health care practitioners, such as by Wan 
and Goucke  yet most doctors are dissatisfied with outcomes
and uncomfortable managing chronic pain.  Clearly, there
is a gap in care service which appears not to be related to
examination, diagnosis or analgesic prescribing, but due to
“something else,” which we believe is related to proper triage
of persons with pain, which would include questionnaires and
assessment, and the access of these persons to the appropriate
level of multidisciplinary care at the soonest opportunity.
So, how may pain services be delivered in the future to
comply with models of care and frameworks while reconciling
the challenges of a complex pain service, including that of
funding? The idea, of course, is to create a sustainable, comprehensive
service with sufficient incentive and reward for
the participating workforce. To this end, the coauthors agree
that there is likely to be a mixed business model incorporating
both the private and public sectors, but on a more community
and patient-centric basis, with funds returned to front-line
service delivery for integrated interprofessional pain services.
This approach would reduce middle management (reducing
management costs) and be subject to far less politics, as has
been encountered with the poly- or super-clinic concept,
while still being able to collaborate with relevant local and
state government and nongovernment organizations.
The “third way” ideology for the management of complex spinal
pain may have relevance, particularly when it comes to the
funding/payment for services. In theory, the “third-way”
ideology attempts to graft the traditional concerns about
equality and social justice into an economic system based
on free markets, thereby implying a mix of public and private
health care models. That implies the use of both public
and private funding to cover the expenses for care services,
where there are government funding or rebates for care services,
but the patient themselves also pays a portion of the
costs. [41, 42] With a mixed-model business approach and using
contemporary models of care, future research should focus on
exploring, creating and testing pain care service approaches
and methods, to determine those that fulfill the criteria of
modern evidence-based practice, these principles being:
1) the use of the best available research evidence,
2) clinical and business experience/expertise,
3) stakeholder/consumer preference and access to care and, importantly,
4) the available resources and funding.
We strongly promote item 4 as
an essential component of evidence-based practice, often
omitted in care frameworks and practice guidelines. Research
will continue to inform clinical practice by offering evidence
from practice-based research that test packages or models
of care for spinal pain, alongside assessment of teamwork
and human dynamics encountered within service delivery.
These limitations of current care services for spinal pain
are emphasized in a recently published Model of Care for
Spinal Pain and WA Framework for Persistent Pain (2016–
2021),  where the case for patient-centered, coordinated and
collaborative approach to care provision is offered. There
are significant barriers to multidisciplinary, collaborative
working, such as professional “turf wars,” limited incentive
and problems with funding, but despite the difficulties, we
believe that it can be performed and needs to be performed,
for the benefit of patients and also to more efficiently manage
the burden of chronic spinal pain on behalf of the health care
An example of how collaborative practice is emerging
in Australia is via the patient-centered medical home (PCMH)
model, as described by Thistlethwaite  and Kellerman,  where health care practitioners are colocated and collaborate
to improve care delivery in primary care, while reducing
costs. This is not the only model of multidisciplinary working,
and there are more than one way to skin the proverbial cat,
but it does show the way health care practitioners, leadership,
training and funding of care for chronic spinal pain, and other
chronic diseases, will need to change, with the characteristics
of good care being accessibility, quality care, safety, timely
care and coordinated care. The complexity in chronic spinal
pain management, as with other chronic conditions, is not
only about the appropriate implementation of the individual
parts of care but also ensuring that the triage, coordination
of care and the multidisciplinary approach works well. This
takes planning, commitment and leadership. For example, the
colocation of health care practitioners in the same building
does not guarantee multidisciplinary or integrated team
care – there needs to be explicit consideration of human
dynamics and the team process for teamwork to succeed. 
Sound leadership provided by a champion of the service
would facilitate this teamwork approach.
So, how can colocated health care teams be set up to deliver
optimal care? We suggest that the process starts with motivated,
energetic health care practitioners with an interest in chronic
pain management to take the reins and begin planning for such
community-based, primary care services. These motivated
persons would draw upon their own practice experience and
obtain advice/support from local health care organizations, such
as Primary Health Networks  and the Patient-Centered Primary
Care Collaborative  encountered in Australia, among others, to
develop a business case and feasibility of a local pain service.
Grants or funding for community-based pain services are
vague with fluctuating commitment from government sources.
Hence, community-based pain services are likely to develop
through private funding or pain practitioners developing their
own private practices that offer a broader range of services than
currently offered. Also, organizations like the Primary Care
Networks, or even private/corporate health care organizations,
may be a source of funding or facilitation of pain services. We
do, however, caution against getting caught up in health care
politics, as witnessed with the UK Polyclinics [48, 49] and Australian
Super Clinics [44, 50] which have received a mixed reception, where
the attempt at integrating community-based care services has
been negatively confounded by political influences.
In summary, we feel that there is already sufficient
research evidence and recommendations documented in
published guidelines, frameworks and models of care to
inform clinical practice and the care of chronic spinal pain
worldwide. The overt gap in care services is not the availability
of prescription medication or allied health services,
but rather the coordinated, multidisciplinary provision of
care services by health care practitioners with an interest
and skill in pain management. The challenge of our time is
ensuring early access of patients with chronic spinal pain to
care, coordinated practitioner teamwork and the application
of the correct level of care individualized to the patient. On
a positive note, this type of integrated service is emerging in
dedicated pain centers and community-based clinics, which
will hopefully expand going into the future. From here on,
health care funders and medical insurers need to be persuaded
that the model of care provision for chronic spinal pain is
cost-efficient and cheaper than the current approaches. [8, 51]
Interventional pain procedures:
Needles, probes, catheters or stimulation leads are used to pierce the skin and body parts, to reach a precise anatomical location to deliver drugs to the targeted areas or modulate nerve transmission, for the diagnosis or treatment of pain, either as a trial or a definitive procedure. This is usually in conjunction with imaging that allows confirmation of anatomically correct positioning of the needle, confirmation with radio-opaque contrast or fluid volume effect if using ultrasound.
Diagnostic interventional pain procedures:
Diagnostic procedures require a precisely placed needle, through which local anesthetic (usually low volume) can be instilled in the anatomical structure, or over the anatomical path of the sensory nerve relevant to the proposed pain source that is being investigated. This is in conjunction with imaging that allows confirmation of anatomically correct positioning of the needle, confirmation with radio-opaque contrast or fluid volume effect if using ultrasound. This allows reproducibility if a significant reduction in pain is achieved during the local anesthetic phase. Placebo-controlled diagnostic blocks, or comparison between duration of local anesthetic action, require repeated procedures and are the gold standard. Diagnostic procedures aim to determine the relative contributions of anatomically linked pain as people can have multiple inputs from multiple structures. Co-instillation of corticosteroids and other adjuncts in some patients may prolong benefit, and in these instances the procedure can be both diagnostic and therapeutic.
Therapeutic interventional pain procedures:
probes, catheters and/or stimulation leads are used to pierce the skin and body parts, to reach a precise anatomical location to deliver drugs to the targeted areas or modulate nerve transmission, with the expectation of pain relief for weeks, months or years. This is usually in conjunction with imaging that allows confirmation of anatomically correct positioning of the needle, confirmation with radio-opaque contrast or fluid volume effect if using ultrasound.
Gregory F Parkin-Smith and Stephanie J Davies were formerly
the cochairs of Pain Health Working Group (Musculoskeletal Health Network of the WA Department of Health)
and both were major contributors to the WA Framework for
The authors report no conflicts of interest in this work.
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