Taking a Second Look at Pain
Date: November 28, 2018
How chiropractic knowledge is influencing the face of non-cancer pain management
Pain has been a rising topic, and it has been proclaimed by some as one of the most misunderstood symptoms by doctors, and even more so by patients and the general public. In the area of complex pain management, there are programs that serve to address that symptom head-on, as the entry point to address its hidden (and diverse) causes.
Since 2014, Dr. Demetry Assimakopoulos has been the clinical coordinator at the University Health Network (UHN) Toronto Rehabilitation Institute, Comprehensive Integrated Pain Program (formerly at Toronto Western Hospital). This specialized program deals with very complex cases of pain and how to manage it with input from various healthcare professionals to determine what pathways are best for individual patients. The clinic has been (and continues to be) supervised under a physiatrist.
Recently, however, Dr. Assimakopoulos—a trained chiropractor, acupuncture provider, and certified exercise physiologist—has seen his role change. From the beginning, Dr. Assimakopoulos’ role has been primarily diagnostic, with the full team of integrative medicine healthcare providers on the team providing care. Here, his chiropractic expertise often comes into play: “On top of being the clinical coordinator, I am often called upon to provide my opinion on how the musculoskeletal [MSK] system is contributing to the patient’s chronic pain. If it’s MSK, they knock on my door.” What is new is an idea that changes how the clinic looks at pain—creating a pathway for patients that includes manual therapy.
In July of 2014, when Dr. Assimakopoulos joined the University Health Network, he became the first chiropractor to join as an advanced practice leader. “He had to know differential diagnosis based on the way we work as physicians through physical examination” said then clinic director Dr. Angela Mailis. With his chiropractic background, his contribution to the clinic was “absolutely unique;” Dr. Mailis explains with pride, “we did not have the manual therapy skills, and so he brought that and was cross-pollinated by the skills he got in the clinic. [It was] an absolutely ideal combination.”
The clinic itself has evolved since Dr. Assimakopoulos joined its ranks: in 2015, Dr. Mailis stepped down, and Dr. John Flannery filled her place. At that time he was running the Musculoskeletal Rehabilitation Program at the Toronto Rehabilitation Institute. When he joined the UHN Toronto Comprehensive Integrated Pain Program, the two formerly distinct programs amalgamated. The pain program was moved to the Toronto Rehabilitation Institute and currently operates under the umbrella of Musculoskeletal Rehabilitation Medicine. This amalgamation also resulted in the development of multidisciplinary chronic pain treatment programs. Dr. Assimakopoulos hopes that they will soon have a fully-functioning chronic pain treatment team, including himself.
Musculoskeletal education and clinic growth regarding manual therapy are gaining traction at the clinic. Dr. Flannery recognizes the value of having chiropractic insight on the team, particularly through Dr. Assimakopoulos’ initiatives educating his peers and new residents with respect to “physical assessment and the treatment components of a chiropractor.” Dr. Flannery adds, “He’s been a real ambassador to the field.”
There are also a number of new treatment programs which Dr. Assimakopoulos has taken part in developing. One of those is the Chronic Pain 1:1 Rehabilitation treatment programs, which started rolling out in January. Other programs which are currently in development are mindfulness meditation, pain self-management, and hydrotherapy group programs.
Chiropractic Pathway
After his initiation into the program, Dr. Assimakopoulos created an informal pathway for patients to be referred to the clinic at the Canadian Memorial Chiropractic College (CMCC), where chiropractors and interns have also begun to collect data on these pain patients. He came to the realization of this need after his extensive hours of history taking, physical examination, and reporting of complex chronic pain cases. “As time progressed, I began to notice that many of these pain patients had undiagnosed or untreated musculoskeletal issues contributing to chronicity,” he reflects. “I then developed a working relationship with the CMCC treatment clinics and began referring patients there for comprehensive, evidence-based treatment. I also treated many chronic pain patients out of my private practice.” Dr. Mailis says he opened the clinic to opportunities they didn’t know existed, and it enabled them to help a greater number of patients: “We had so many patients downtown who couldn’t afford treatment, but then connecting with the interns at the chiropractic college, all of a sudden we found a whole lot of facility to take our patients.” Dr. Flannery also sees manual therapy as part of the program’s future development. He references programs offered by other chiropractic groups, like the CMCC, and says “that’s what we’re ultimately trying to do. [It’s] something we’re looking to expand over time and are trying to set that up.”
Through the help of chiropractic professionals, he says the team has managed to help reduce not only these sufferers’ pain, but also their medication use, particularly with opioids: “I had one patient who was taking huge doses of opioids and anti-epileptic medications due to complications from multiple surgical cervical spinal fusions from cervical myelopathy. Acupuncture, SMT, soft tissue therapy, counselling, and rehabilitation helped the patient get off opioids almost completely and finally go on a vacation with his wife!”
When it comes to the work at the amalgamated Musculoskeletal Rehabilitation Program at the Toronto Rehabilitation Institute, the main objective is “to address the most complex chronic pain cases.” Dr. Assimakopoulos explains: “These are not patients that have mechanical low back pain that have been unresponsive to treatment for six months and a day; rather, the patients we see have undergone and failed various treatments, including conservative, pharmaceutical, interventional and surgical, and are looking for a solution in spite of these failed efforts.” He also explains that with the complexity of the cases, they schedule two hours for a new patient assessment.
The Assessment
With a two-hour intake assessment, the protocol is extensive, “The patient is taken to the examination room by the clinician, who observes the patient’s gait, and the presence of other organic or non-organic pain behaviours,” says Dr. Assimakopoulos. Following the physical observations (the physical examination itself comes later) is the thorough history-taking, which allows the team to “map out the evolution of the person’s pain experience. Here, we will also determine which investigations, and treatments they have undergone, which allows us to understand the etiology and evolution of one’s pain over time.”
Patients undergo physical examinations following the patient history. Dr. Assimakopoulos says they will observe “behaviour, posture and movement, screening for non-organic signs (i.e., Waddell’s tests, Hoover’s sign), range of motion, neurological examination, orthopaedic testing and palpation.” There’s more: “We do not only examine the area of pain—rather areas proximal and distal to the site of pain are examined to determine if they are contributing to the clinical presentation.”
There’s a certain beauty to the process, according to Dr. Assimakopoulos, that comes from the sensory examinations, which include pinprick, soft touch, temperature, vibration and deep stimulation. The thorough and effective attention to detail provides deep insight into the patient’s pain, “and subtle clinical signs can be discovered which can dramatically change the course of care.”
He provides the story of one patient whose exam exemplified the findings that can come from extensive sensory examination. She had suffered with bilateral foot pain for over a year, which began when she went on vacation. She had seen sports physicians and a chiropractor, but her condition had not improved in any significant measure. Through Dr. Assimakopoulos’ extensive patient history and sensory examination, he and the team came to a hypothesis: “Her history made me suspect a small fibre neuropathy. Our examination revealed stocking-like hypersensitivity in both lower extremities.” They placed the patient on a different medication, with the intention to follow-up after qualitative sensory testing. The results were astonishing: they did not end up sending her for testing. Knowing her diagnosis, the patient decided to take the condition into her own hands, “she began a desensitization and goal-oriented walking program, three times daily. Her pain levels and overall level of function significantly improved. This is a perfect example of how a properly delivered diagnosis through a multidisciplinary assessment can empower a patient to take control of their condition.”
Multidisciplinary Care
Within the Musculoskeletal Rehabilitation Program there is an imperative for multidisciplinary care. There are chronic barriers to recovery that can extend beyond his scope, and in these cases, he says, “The pain program taught me where my job begins and where it ends. […] Having other skilled therapists at my side is a blessing. Their expertise complements my own.” After history, examination, and analysis, the findings are discussed amongst the team: “Some patients have extensive psychopathology and require psychiatric or psychological treatment prior to any biophysical intervention. Others might benefit from chiropractic care, physiotherapy, injections or medication prescription,” advises Dr. Assimakopoulos. “The end goal is to improve a patient’s function—with that in mind, we decide what might be in the patient’s best interest. We then propose a management strategy and follow-up accordingly.”
Beyond the current system of referring patients out to evidence-based chiropractors in their local area, Dr. Assimakopoulos sees a role for chiropractic within the clinic in the future. Within his role as clinical coordinator, he acknowledges how much his chiropractic education has shaped him, “My chiropractic training taught me how to wisely use my hands. We at the pain program have heard many stories about clinicians who fail to touch the patient, and rely solely on diagnostic imaging,” he says. “I can think of multiple occasions where, through palpation, I was able to identify a patient’s source of ongoing pain. In these cases, we often refer the patient for manual therapy and/or an injection, which resolves or greatly improves the patient’s pain.”
His chiropractic education also changed the lens through which he views his patient examinations:
“My chiropractic education also taught me to examine a pain patient’s entire kinetic chain. For instance, in addition to identifying which loads, postures and demands increase and decrease a patient’s pain, I will more often than not, assess a low back pain patient’s thoracic spinal area and hips. Many times, treating an area adjacent to the patient’s site of pain can decrease their overall perception of pain, and allow for early self-management and mobilization.”
There is more room to position chiropractic within the field of pain management programs. The Musculoskeletal Rehabilitation Program at the Toronto Rehabilitation Institute is one opportunity to show how it can further healthcare’s understanding of pain. Patient care is paramount. Looking forward, Dr. Assimakopoulos hopes to see the program as one that can create opportunities for the chiropractic profession to work within its multidisciplinary teams and ultimately, better serve the needs of patients suffering in pain.