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16.1 Know Your Provider

There are several types of providers who offer pain management in our society.

  • Traditional Chinese medicine providers

  • Naturopathic physicians

  • Chiropractors

  • Osteopathic and allopathic physicians

Traditional Chinese medicine (TCM) providers utilize several approaches including, but not limited to, acupuncture, tai chi, and herbal products to help improve quality of life and treat some pain conditions. TCM has evolved over thousands of years. A TCM provider WITHOUT a recognized medical degree (DO, MD) can become a Doctor of Acupuncture and Oriental Medicine by obtaining an advanced clinical doctorate which requires 2 years of additional study beyond a master’s degree. There are also a number of intensive training programs a provider can complete to earn a Doctor of Traditional Chinese Medicine which typically includes acupuncture training. TCM providers are not considered medical physicians in the United States.

According to the NIH National Center for Complementary and Integrative Medicine, “Chiropractic is a licensed health care profession that emphasizes the body’s ability to heal itself. Treatment typically involves manual therapy, often including spinal manipulation. Other forms of treatment, such as exercise and nutritional counseling, may be used as well.” (https://www.nccih.nih.gov/health/chiropractic-in-depth) Chronic low back pain or neck pain are common reasons why a patient may seek treatment from a chiropractor. Chiropractors may also treat other musculoskeletal related pains. In order to practice chiropractic in the United States, chiropractors must complete a Doctor of Chiropractic degree, pass a board examination, and have a state license.

According to the Association of Accredited Naturopathic Medical Colleges, established in 2001, “Naturopathic medicine is a distinct health care profession that combines the wisdom of nature with the rigors of modern science. Naturopathic physicians (NDs) are trained as primary care providers who diagnose, treat and manage patients with acute and chronic conditions, while addressing disease and dysfunction at the level of body, mind and spirit.”(https://aanmc.org/naturopathic-medicine/) Naturopathic physicians focus on wellness through promotion of health and prevention of disease using natural means, if possible. Licensed naturopathic physicians complete a 4-year graduate-level degree in naturopathic medicine.

Osteopathic and allopathic physicians are licensed medical physicians who have completed extensive education and training in their chosen specialties. This typically includes a 4-year undergraduate degree, a 4-year medical degree, 3–5 years of training through a residency program, followed by an additional 1–3 years post-residency fellowship focused on specialty training, that is, pain management. There are slight differences in philosophy and training between osteopathic and allopathic physicians. For instance, osteopathic physicians are trained in osteopathic manipulation (OMM) which is excluded from allopathic training programs. Many medical physicians obtain additional training in acupuncture and other complimentary medical techniques that can be used to treat pain.

When you are searching for a provider to address your pain management needs, you must first determine what approach you personally feel comfortable with and can have confidence in. It is important to understand that while some conditions can be treated with natural or holistic methods, many conditions do require the advances of medical science and should be addressed by a medical physician. No matter what route you decide to take, you must make sure that the provider you choose to establish a clinical relationship with is well educated, adequately trained, and board certified if applicable. The task of searching for a medical physician can seem daunting. Online search engines can provide you with a plethora of information about any given provider. However, the accuracy of the information can come into question. There are numerous online sources that allow individuals to submit reviews about providers that they may or may not have actually interacted with. Just like online voting for a friend’s pet for a contest, often times the value of a provider’s rating can be skewed and be misleading. A patient who may not have agreed with what the provider has offered as treatment options or a patient who is angry because the provider would not prescribe inappropriate medications that the patient desired may provide a bad review on one of these review sites. That same patient can ask their friends and family to also submit bad reviews to the same review site in order to purposely reduce the overall rating of that provider. Therefore, it is not recommended to utilize these sources as your primary source of information regarding a potential provider.

Every state has a state board of medicine which has a publicly accessible website. You can search for a particular provider to determine if they are board certified. It is not required that a physician is board certified to practice medicine in the United States. However, having board certification means that the physician has met all of the expert requirements of their specialty and continues to meet the requirements for continued medical education and training needed to keep them up to date with advanced knowledge in their particular field of medicine. You can also determine if there have been any complaints filed against that provider or if there has been any disciplinary action taken against the provider.

Another reliable source of information regarding a potential provider is the official website of the healthcare system or practice where the provider is employed. Many of these websites provide a professional summary of each provider and what specific conditions the physician treats. There is also usually a section containing patient reviews, including comments. Even with all of these various resources available, none can be considered to be 100% accurate and you ultimately have to combine all of the information you have gathered and determine your confidence in that provider’s ability to address your needs.

16.2 Know Your Diagnosis

Once you have seen your physician about your condition, you may be given a diagnosis or a differential diagnosis. What is a differential diagnosis? It is the process that your physician goes through to differentiate between conditions that share similar signs or symptoms. More testing or diagnostic procedures may need to be done before a specific diagnosis can be provided. If this is your situation, you may be given a list of additional tests or procedures that your provider wants you to do which will aid them in determining what the source of your pain is and how to manage it optimally. Even if your physician explains in detail what they are ordering or why they are ordering it, you still may have questions when you walk out the door. Where can you find additional information about these tests and procedures that are accurate? The Internet is the most common and utilized source for information in today’s world. While there are countless sites you can refer to, below are just a few examples of resources with the highest standards of reliability and accuracy. It is important to know that most major healthcare systems in the United States have publicly available information regarding specific tests and procedures.

https://medlineplus.gov/: MedlinePlus is a service of the National Library of Medicine (NLM), the world’s largest medical library, which is part of the National Institutes of Health (NIH). Our mission is to present high-quality, relevant health and wellness information that is trusted, easy to understand, and free of advertising, in both English and Spanish. Anywhere, anytime, on any device—for free.(https://medlineplus.gov/about/)

16.3 Know Your Treatment Options and Participate in Formulating Your Treatment Plan

Once your physician has determined your diagnosis, treatment options will be offered to you. It is important for you to work with your physician as a team to develop a plan of care. However, it is vital that you keep an open mind and listen to all of the treatment options that the provider offers to you. There may be options offered to you that you have tried in the past that were not successful or you know of someone who has had that treatment before and it didn’t work for them. You should not dismiss these options immediately. You are unique and your body and symptoms do change with time. Therefore, something that may not have worked before may help at this stage in your life. Also, everyone responds to treatments differently. Your response to a treatment will not be the exact same as a friend who has had the same treatment. It is equally important for your physician to understand your priorities and goals for treatment of your condition. What may be the physician’s priority in your treatment plan may not be your priority, so you want to make sure both of you are in alignment with the overall treatment plan.

16.4 Know Your Specific Treatment Modalities

There are many modalities for treating pain. Most pain management providers consider a multimodal approach to treatment.

  • Physical therapy and aqua therapy

  • Acupuncture or other complimentary medical techniques

  • Pharmacologic agents

  • Interventional pain procedures (injections, minimally invasive surgeries)

  • Psychology based treatments (cognitive behavioral feedback, biofeedback)

Physical therapy is a modality that utilizes methods such as massage, heat, and stretches and exercise to help reduce pain by improving flexibility, mobility, strength, and dynamic function of the body. Treatments are individualized for each patient after a physical therapist has evaluated you. The stretches, exercises, and techniques learned during your physical therapy exercises should be performed on a consistent basis even after you have completed your course of therapy in order to maintain the improvements your body has achieved. It is important to understand that change takes time with improvements in function of our bodies and sometimes training our bodies to do different things than what it is used to can create some increased pain.

There are a number of complimentary medical techniques available that can be integrated as part of a multidisciplinary treatment plan. Acupuncture, frequency specific microcurrent treatment, Reiki, and electromagnetic therapy are several examples. Most providers who offer these complimentary techniques have completed additional training to become adept at these techniques. You should confirm with the provider that they do have adequate training if offered on of these treatment options.

There are many different pharmacologic agents that have been utilized for the treatment of different types of pain. Opioid medications had long been used widely to treat all types of pain. However, with new knowledge of how these medications work in the human body, the use of these medications for the treatment of chronic non-cancer pain has fallen out of favor. There are medications that treat inflammatory pain like arthritis. There are medications that treat nerve related pain like diabetic neuropathy. There are medications that treat pain from muscle spasms. Your physician may prescribe a combination of different categories of medications depending on the complexity and the origin of your pain complaints.

With advances in medical science and technology, there are many different interventional treatments that can be utilized to treat pain. It is very important to keep in mind that an injection is just one type of treatment for specific types of pain. There is not an injection that will help with every type of pain. Injections do not take the place of other categories of treatment. Not every patient with the same diagnosis is an appropriate candidate for the same injection. Just because you know someone who had an injection that worked for them does not mean that the same injection will work for you. Each individual patient is unique with unique considerations that your physician will account for when developing your unique treatment plan.

Psychology-based treatments have become more acceptable forms of treatment as society has overcome a lot of the stigma surrounding psychological disorders. It is widely accepted that a person’s biology, psychological state, and social environment all contribute to an individual’s chronic pain experiences. There is a great deal of complexity related to the psychology of chronic pain and several different psychology-based treatment modalities have been developed and proven very successful in the treatment of the psychological aspects of chronic pain (Psychol Res Behav Manag, 2014).

16.5 Know How to Monitor Your Treatment Responses

Once a treatment plan has been implemented, it is important to monitor your body for any type of response to treatment—good or bad. It may be helpful to you to start a journal to record your daily pain experiences in order to be able to notice subtle improvement trends or any unwanted side effects of a given treatment. Be careful not to overanalyze, however, because excessive attention to your pain can actually cause your pain to worsen (pain catastrophizing) (Schutze et al., 2020). Review your journal before each follow-up appointment so that you are able to provide your physician with accurate recall of any changes in your condition. This will help your physician to adjust your treatment plan as necessary.

16.6 Know How to Report and Mitigate Side Effects and Adverse Events

If you do notice side effects that can be confidently related to a specific treatment, it is important to inform your physician as soon as possible. When reporting the side effect(s), provide detailed and specific information that can help your physician determine any other appropriate alternative treatment options that may be available to you. If you feel that the side effects that you are experiencing are serious and you are not able to reach your physician, you should present to the nearest urgent care or emergency room for an evaluation.

16.7 Know How Your Lifestyle Can Exacerbate or Mitigate Your Pain

Many lifestyle choices and habits can affect your pain. Smoking, sleep hygiene, nutrition, and ergonomics are a few examples of modifiable factors that can influence chronic pain.

Multiple epidemiological and clinical studies have suggested that the prevalence of smoking among persons in pain may be up to twice that observed in the general population. In a study looking at the relationship between chronic pain, cigarette smoking, and nicotine dependence, it was found that “the prevalence of current smoking was: 42% among persons experiencing medically unexplained chronic pain in the past year; 35% among persons reporting medically unexplained chronic pain in their lifetime; and 30% among persons reporting past year or lifetime chronic neck or back pain. Furthermore, after adjusting for a host of highly relevant psychosocial factors (i.e., age, marital status, income, education, race, gender, and the presence of any lifetime mood, anxiety, or substance use disorder), persons who met criteria for past year nicotine dependence were almost twice as likely to report past year medically-unexplained chronic pain (OR = 1.83; 95% CI = 1.15–2.90) and past year chronic neck or back pain (OR = 1.95; 95% CI = 1.41–2.68)” (Zvolensky et al. 2009).

Some studies conducted in recent years suggest that sleep disturbances may contribute to the development and maintenance of chronic pain, including endogenous pain inhibition and joint pain (Finan et al. 2013) One study concluded that “short-term (2-month) improvements in sleep predicted long-term (9- and 18-month) improvements for multiple measures of sleep, chronic pain, and fatigue. These findings are consistent with benefits of improved sleep for chronic pain and fatigue among older persons with osteoarthritis pain and co-morbid insomnia if robust improvements in sleep are achieved and sustained” (Viteillo et al. 2014). Therefore, improving sleep hygiene could potentially result in a reduction in chronic pain complaints.

What you eat can affect how your body feels. In recent years, it has been suggested that certain foods we eat can increase chronic pain. Foods containing high-fructose corn syrup or that are high in sugar content, artificial trans fats, vegetable oils, refined carbohydrates, excessive alcohol, and processed meats are commonly thought to promote inflammation, thereby promoting chronic pain through low level inflammation throughout the body. Many practitioners will promote anti-inflammatory diets such as a “Mediterranean diet.” The American Heart Association promotes this diet because it “emphasizes vegetables, fruits, whole grains, beans and legumes; includes low-fat or fat-free dairy products, fish, poultry, non-tropical vegetable oils and nuts; and limits added sugars, sugary beverages, sodium, highly processed foods, refined carbohydrates, saturated fats, and fatty or processed meats”(https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/mediterranean-die).

Simple ergonomic corrections in your daily routine can help to mitigate chronic daily pain such as working on your posture, having good ergonomics when using a computer or reading a book, and limiting the use of handheld devices (as they can put a strain on your neck and joints of your hands).

16.8 Know How to Build and Nurture a Trusting Patient-Clinician Relationship for Best Possible Outcomes

Open and honest communication is the best way to build a trusting patient-clinician relationship which will lead to the best possible outcomes for you as well as the physician treating you. One thing to remember when interacting with your physician is that they are human just like you. Despite having very similar educational backgrounds, every physician is a unique individual with a unique personality. Every patient is a unique individual with a unique personality. Every person can have a good day or a bad day the day. I would encourage you to discuss any concerns you may have with your physician in a sincere and honest fashion. Be open minded about the information and advice your physician provides to you even if it is not what you want to hear. Do not go on the defensive immediately if their ideas are not your ideas. At the end of the day, your physician just wants to help you get better.