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The Pain Clinic  


When it comes to the non-surgical treatment of refractory pain, frequently patients are referred by their medical doctors in desperation to pain clinics.   Unfortunately, the term pain clinic is often a euphemism for needle clinic.   Most pain clinics are staffed by anesthesiologists whose treatment modalities include: epidural injections, facet blocks, sacroiliac blocks, nerve blocks, botox, trigger point injections, and opiates.  Not a very deep pool of treatment options and certainly not one that would be considered multidisciplinary.   There is a movement afoot to deepen and broaden the treatment options of pain clinics.   Organizations such as the American Academy of Pain Management promote the use of various other treatment modalities such as chiropractic, acupuncture, exercise, massage, physical therapy, feedback, electromedicine, meditation, lifestyle coping,  counseling, ergonomic training, and stress management.   The ideal pain management practice would have the resources of multiple disciplines to support patients with refractory pain.


A logical algorithm for treating refractory pain would begin with the safest treatment option available.  If that treatment is not effective, then try the next safest option, and so on until an acceptable mitigation has been reached.  Usually total pain relief is not a realistic goal in difficult cases, but reducing the pain to a point where a patient can live a normal life can be feasible.   Since pain clinics frequently treat spinal pain with epidural injections, a high-risk treatment, there is obviously a need for safer options in these clinics.   The culture of an anesthesia-based clinic is to inject, even though epidural injections have not been shown to have a significant impact on lower back pain.[1]


In addition to equivocal scientific evidence, epidural injections have some serious risks: anaphalaxis, hematomas (placing pressure on the spinal cord), infection, dural punctures, intravascular injection, and bladder dysfunction. Personally, I have seen two patients paralyzed from epidural hematomas caused by epidural injections.  This illustrates the need for a conservative pain management specialist such as a chiropractor in pain clinics.


Pain intervention is mandatory. 


The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that an intervention be implemented when patients report pain at level four or greater (using a 0-10 analog pain scale).  To most medical doctors “intervention” equates with giving a drug.  Since intervention is mandatory and injections and oral medications are inherently dangerous, treatments such as chiropractic or physical therapy are safer alternatives. It is the duty of chiropractors to provide a safe alternative or complementary treatment for patients in pain.  It would be a boon for pain patients to have more chiropractors integrated into pain clinics.  If the pain clinics in your region are resistive to having chiropractors in their clinic, the medical doctors in that region may need to be educated into their options other than an anesthesia pain clinic.


To join a pain clinic or to receive more referrals of pain patients will require more than sharing scientific validation of chiropractic.  It will require the development of relationships.  With the development of inter-professional relationships, doctors are more apt to acknowledge evidence concerning other treatment options.  When anesthesiologist-dominated pain clinics become more motivated by evidence, they will recognize that the risk/benefit ratio requires exhausting conservative treatments before using more invasive interventions such as epidural injections. To obtain a position in a progressive minded pain clinic you need to prove yourself as a sincere, ethical, educated and proficient pain professional in your community.  


Most chiropractors will not practice in a pain clinic, but they will predominantly treat pain patients.   It is our duty to manage pain patients with the least invasive and least dangerous treatment available.   It is also our duty to cultivate relations with doctors who can refer appropriate pain patients to our clinics.


[1] Nelemans PJ, de Bie RA, de Vet HCW, Sturmans F. Injection therapy for subacute and chronic benign low back pain. Cochrane Database Syst Rev 2000;(2): CD001824.[Medline]