המרכז החדש לשיקום כאב

1. המרכז החדש לשיקום כאב דר' חיים-משה אדהאן, מנהל המרכז לשיקום כאב המרכז הרפואי ע"ש שיבא, תל השומר www.doctoradahan.com

2. British Politician (Churchill) • I am going to tell you what I am going to tell you • Then I am going to tell you What I just told you I was going to tell you • Then I am going to tell you what I just told you

3. what I am going to tell you • PM+R is pain focused in America but net yet so in Israel • Precisely structured Interdisciplinary Pain Rehabilitation Programs Are Recommended by the AMA +APS but are not readily available in Israel • Traditional –Disease Model Focused medical and rehabilitation approaches leave most chronic pain patients wanting • Complementary Medical approaches leave most Chronic Pain Patients wanting • Precisely structured Interdisciplinary Rehabilitation Programsshine most when the traditional medical +complimentary medical approach leave most patients wanting • Think outside the box!

4. www.DoctorAdahan.com

5. Dr H.M. Adahan, - BRIEF BIOGRAPHYMDcm, CCFP, FRCP, Dip. ABPM+R, Dip. Can Sport Med • 1988: Graduated McGillMedicine. • 1994: Completed Residency in PM+R at the University of Ottawa. • 1996-2000: Acting Assistant Professor, • Department of Medicine – Division of PM+R at the University of Montreal. • 1996: Winner of the AAPM+R « Young Investigator Award ». • 1997: Diploma in Sports Medicine (Canadian Association of Sports Medicine). • 1997: Winner of the P.A.S.S.O.R.research prize. • 1998-99: Fellowship training in Interventional Pain Management, Université Catholique de Louvain, Brussels • 1999: Winner of the Quebec Order of Radiologists Research Prize. • 1999-2002: Acting Assistant Professorof the Department of Rheumatology at McGill University and Staff at Dr Melzck’s Pain Clinic • 1999-2001: Managing Editor of the eMedicine Project – division of PM+R. • 1995-2001: Principal investigator of three randomized controlled trials examining the efficacy of Supra-Scapular Nerve Blocks of which the largest is funded by the Arthritis Society of Canada. • 1994: Principal investigator of a randomized controlled trial examining the relative efficiency of custom molded versus prefabricated foot orthoses in the treatment of patellofemoral pain in athletes. • 2000-2002: Physiatrist in charge of Medical Care in the Brain Injury and Trauma Rehabilitation Program – Jewish Rehabilitation Hospital, (McGill University affiliated). • 2002-present: Medical Director of the HTB Pain and Injury Rehabilitation Center. Quebec’s largest free standing private Interdisciplinary Rehabilitation Center that employs 40 clinicians and receives more than 1700 visits/week. • 2005-2008-Founder of the HTB-ED Industry sponsored Pain Clinical Research unit which is now ranked top Canadian recruiter for industry sponsored clinical research in the field of Pain. • 2008-present: Head of the Pain Rehabilitation unit @ Sheba

6. A Multidisciplinary Pain Rehabilitation Center Over 40 healthcare professionals Over 1700 visits/week Over 1300 sq. meters healthcare facility in one location

7. Who is Dr Adahan? The crazy Canuck!

9. The Unique Contribution of American Pain Rehabilitation teams • Incorporated into the Chronic Pain Clinical Practice Guidelines of… • The IASP • The AMA • The American Pain Society • The NIH

12. The goal of treatment is an emphasis on improving function through the development of long-term self-management skills including fitness and a healthy lifestyle. • Can download guideline from my website- • www.doctoradahan.com

13. COMPOSITION OF THE INTER-SPECIALTY GROUP THAT AUTHORED THE GUIDELINE • Work Group Members: Richard Timming, MD (Work Group Leader) (HealthPartners Medical Group) (Physical Medicine and Rehabilitation); W. Michael Hooten, MD (Mayo Clinic) (Anesthesiology); Louis Saeger, MD (Midwest Spine • Institute) (Anesthesiology); Brian Bonte, DO (Hutchinson Medical Center) (Family Medicine); David von Weiss, MD (Park Nicollet Health Services) (Family Medicine); Susan Ferron, MD (Community University Health Care Center) (Internal Medicine); James Smith, MD (HealthPartners Medical Group) (Internal Medicine); Michelle Bensen, MD (Marshfield Clinic) (Internal Medicine/Addiction Medicine); Miles Belgrade, MD (Fairview Health Services) (Neurology); Patrick Rivard, RN (Gillette Children's Specialty Healthcare) (Nursing); Galina Shteyman, PharmD (Park Nicollet Health Services) (Pharmacy); Neal Walker, RPh (Fairview Range Regional Health Services) (Pharmacy); Barbara Bruce, PhD (Mayo Clinic) (Psychology); Janet Jorgenson-Rathke, PT (Institute for Clinical Systems Improvement) (Measurement/Implementation Advisor); Pam Pietruszewski, MA (Institute for Clinical Systems Improvement) (Facilitator) • Can download guideline from my website- • www.doctoradahan.com

14. A patient-centered, multi-factorial, comprehensive care plan is necessary, one that includes addressing biopsychosocial factors. Addressing spiritual and cultural issues is also important. It is important to have a multidisciplinary team approach coordinated by the primary care physician to lead a team including specialty areas of psychology and physical rehabilitation.

15. Medications are not the sole focus of treatment in managing pain and should be used when needed to meet overall goals of therapy in conjunction with other treatment modalities.

16. Plan of Care Using Biopsychosocial Model • A written plan of care is the essential tool for ensuring a comprehensive approach to treatment of a patient with chronic pain. To maximize the success of treatment, a care plan must address the whole person in all of his/her complexity, including physical and biologic factors, psychological state and beliefs, as well as the family, social, and work environment (biopsychosocial model). To do this, it is important to have a multidisciplinary team approach coordinated by the primary care physician to lead a team including specialty areas of psychology and physical rehabilitation.

17. Who are The 18 Sheba Pain Rehabilitation Team Members?

18. Interventional Pain Management Fluoroscopic Suite • Peripheral Nerve Blocks • Selective Nerve root epidural blocks • Caudal and interlaminar epidural blocks • Joint injections • Botox injections

19. The Importance of coordinating Interventional Pain management Techniques with Rehabilitation Efforts! When all you have is a hammer- Everything is a Nail!

20. 1 Nurse- “md’s Rx, Nurses Provide”

21. 4 Physiotherapists

22. 2 Occupational therapists

23. 1 Social Worker With CBT TRAINING

24. Pool Physiotherapy Team

25. Friedman Exercise Physiotherapy Facility

26. 2 Rehabilitation Psychologists with expertise in CBT

27. 1 Yoga Therapist

28. 1 Art Therapist

29. Spiritual support services available

30. Who are our patients? • 2/5 are injured soldiers with significant disability such as spinal cord injury or amputation or other major trauma • 1/5 are civilians with significant disability such as spinal cord injury , amputation, or major trauma • 2/5 are people with problematic persistant MSK or neuropathic pains such as LBP, radiculopathy, failed back surgery, CRPS etc.. • We are intitiating collaboration with the Cancer Center @ Sheba

31. גישות מקובלות לטיפול רפואי בכאב • טיפול תרופתי • זריקות • ניתוח 31

32. Persistent Pain is Inadequately Managed Physician Perceptions of Persistent Pain Management Patient Perceptions of Persistent Pain Management 64%treatment not effective 68%treatment not effective 36%treatment effective 32%treatment effective Moulin DE, et al.Pain Res Manag 2002;7(4):179-84. Morley-Forster PK, et al.Pain Res Manag 2003;8(4):189-94. .

33. Barriers for Physicians Limited training in medical schools Veterinarians get 5 times as many teaching hours in pain Lack of up to date knowledge Pain management not seen as a priority in the disease-centered model of care Lack of consultation and treatment resources Time consuming Biases and fears about use of opioid analgesics How is Israel doing?

36. How would we react if this was post-op infection rate?

37. כל הכבוד! You are the exceptional Israeli Doctors who worry about their patient’s quality of Life and attend CME events such as these!

38. International perspective on Pain management and rehabilitation We must examine other nation’s Consensus statements and ask ourselves how the Israeli standard of care measures up to them as we do in other fields Israel Must look abroad and learn

39. גישות מקובלות לטיפול בכאב • טיפול תרופתי • זריקות • ניטוח 39

40. Medications are not the sole focus of treatment in managing pain and should be used when needed to meet overall goals of therapy in conjunction with other treatment modalities.

41. יחידה חדשה לשיקום כאב במרכז הרפואי שיבאהטיפול האידיאלי לכאב כרוני בעייתי פיסי/שיקומי פסיכולוגי • רפואי • תרופתי • פולשני PNCP: persistent non-cancer pain

42. מודל כאב כולל לשיקום כאב -גישה הוליסטית גורמים מכאניים

43. Specific and measurable goals and clearly described specific treatment elements give patients a framework for restructuring a life that has often been significantly altered by chronic pain • plan of care for all patients with chronic pain should address all of the following five major elements: • Set personal goals • Improve sleep + Mood • Increase physical activity and day to day function and role fulfillement • Manage stress • Decrease pain

44. יחידה חדשה לשיקום כאב במרכז הרפואי שיבא

45. The Solution- a planned and precisely structured approach to pain management for all doctors- T.S.A.A.R.O.T. Timing Severity and Specificity Aggravating/Alleviating Factors Rx intelligently and React to response to pharmaco-analgesic response quickly Observe the patient in different situations Teach and involve the interdisciplinary team

46. T.S.A.R.O.T. • Timing

47. מרבית התרופות לשיכוך כאב מטפלות ב 3 השכבות התחתונות בפירמידה ארבע השכבות העליונות נובעות/קשורות למוגבלות ונכות ומשפיעה על איכות החיים 47

48. Movement-related pain is difficult to manage with drugs alone The doses of oral opioid required to control movement-related pain may be excessive when the pain stops the patient is too sedated. Two audits show that pain on movement is a major problem for half of those whose pain is controlled at rest. (Bandolier.com)

49. Remember that there are neurophysiologic concepts to be kept in mind when managing activity related pain which is mediated by A-delta fibres more than C-fibers . A-delta fibers are less affected by opioids at their synapse with the spinal cord. The process of central sensitization and the appearance of phenomena such as allodynia can greatly complicate the management of activity related pain.Movement-related pain is difficult to manage with drugs alone The doses of oral opioid required to control movement-related pain may be excessive when the pain stops the patient is too sedated. Two audits show that pain on movement is a major problem for half of those whose pain is controlled at rest. (Bandolier.com) With the help of an appropriate rehabilitation intervention- many patients are less disabled and handicapped despite unimproved pain severity. The pain is the same … the pain experience however- can be much less severe. Uncontrolled Movement-related pain= Disability

50. Treat the distinct dimensions of physical pain with distinct individually tailored pharmaceutical and non pharmaceutical approaches Somatic Superficial NOCICEPTIVEPAIN Deep Visceral MIXED Central Nociceptive NEUROPATHIC PAIN Peripheral Differentiation Ashby MA et al. Description of a Mechanistic Approach to Pain Management in Advanced Cancer Pain 1992 51:153-161 Sympathetic - Maintained