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Physical Medicine Pain Management Treatment Guideline
Summary of Research Proposal by Dr. Jason Mazzarella, DC, DAAPM, DCAPM
Pain Grant and Proposal Letter
Background:
Dr. Mazzarella of the North American Spine Institute says consumers and healthcare providers need to be better educated about the issue surrounding pain —both concerning its diagnosis, treatments and, importantly, its prevention. In order to more effectively treat and assess persons with chronic pain, Dr. Mazzarella became credentialed as a Diplomate with the American and Canadian Academy of Pain Management.
As part of this intensive program, Dr. Mazzarella also learned the very latest pain principles of anatomy and physiology, patient assessment, examination and observation, treatment, and outcome measure methods to better understand not only the effects of a chronic pain process, but also the various risk factors that can increase a person’s chance for developing long-term symptoms. “By understanding the unusual pathophysiology of pain, diagnostic methods and treatment need can be determined more effectively, allowing for a more individual and specific therapy regimen based on research,” said Dr. Mazzarella
Dr. Mazzarella keeps current on pain, research by reading approximately 500 new research articles a year and attending a multitude of post graduate courses, allowing him to stay in the forefront of pain management, evaluation, diagnosis, and treatment. Dr. Mazzarella also has additional training through Johns Hopkins University Medical School, University of Pennsylvania Medical School, the American Academy of Family Physicians and the American Medical Association.
Pain Grant and Proposal
Introduction and Purpose:
I have developed the CARE program. This program takes the approach of physical medicine therapy for chronic pain patients. The implementation of CARE for those suffering from chronic pain attempts to allow for a reduced dependence on medicinal intervention, facility based care and outside assistance with the emphasis of a return to normal life.
CARE stands for Chiropractic, Acupuncture, Rehabilitation and Exercise. At first these may seem like a relatively normal therapy regimen for pain. However, research has shown the affects of these types of therapies on the spinal cord and brain in helping to reduce pain. Treatment therapy is not only about the type of treatment, but also the application of that treatment. Research has shown that when treating active musculoskeletal pain, treatment must be within 1 cm of the involved pain area. If therapy is outside of this zone, inflammatory markers will not dissipate, but will continue to remain, thus leaving the provided therapy essential useless.
Pain Grant and Proposal
Why we NEED This Funding:
Currently in Ontario, the only treatment option for many Canadians suffering from chronic musculoskeletal pain is to obtain pharmacological intervention by referrals through their primary care physician or referrals to a “chronic pain program” which provides mostly pharmacological interventions through injections or prescriptions.
Though private insurance does cover some physical medicine therapies, and physiotherapy is available under OHIP to those under 19 and over 65, the majority of chronic pain patients fall in the age category between 19 and 65 and many due to their pain are no longer or unable to work (thus has no private insurance).
Lastly the implementation and development of a treatment plan in regards to physical medicine interventions is limited due to the provide education in Canada.
Currently on the Canadian Academy of Pain Management website, only 28 doctors, including Dr. Jason Mazzarella are listed as having obtained credentialed status as a Diplomates. This lack of overall provider education also plays into the current pain epidemic that Canadians are facing today.
Pain Grant and Proposal
Why we NEED This Program:
Canada’s Current Pain Epidemic
Currently in Canada an estimated 6 to 7 million people suffer from chronic persistent pain. [1] The Canadian Pain Study in 2002 report that chronic pain patients make up to 40% of the population. [1] Further to this, the prevalence of pain is reported to increase with increasing age. [1]
Additional factors to consider:
- 2/3 of physicians believe chronic pain is not well managed in Canada. [1]
- 2/3 of patients believe chronic pain is not well managed in Canada. [1]
- Primary concerns regarding pain includes lack of adequate training and lack of specialized treatment resources. [1]
- Due to the severe shortage of pain specialists and pain programs, family doctors provide the bulk of pain treatment services for patients with pain, acute and chronic. [1]
As primary care physicians provide the bulk of pain management treatment a general concern regarding therapy must be considered, especially in light of recent world events including injections infected with meningitis and new law suits occurring primarily in California involving physicians and the prescription of opioids.
Due to new medico-legal concerns regarding the prescription of opiods along with a new interest in law suits attacking medical malpractice via older drug cartel laws and new research evidence suggesting the usage of opioids over 30 days can result in permanent loss of gray matter, these primary care physicians have very little alternatives to provide meaningful helpful treatment.
1. Health Canada Meeting Re: Scheduling of Tramadol Ottawa, December 5th 2006. Roman D. Jovey MD, President Canadian Pain Society.
Pain Grant and Proposal
Pain - The Silent Epidemic
The Canadian Pain Coalition calls this current situation regarding pain a silent epidemic because Canadians in general do not yet recognize pain as a primary health priority. [1] On September 3, 2010 the International Pain Summit held in Montreal made a declaration which stated, “Access to Pain Management is a Fundamental Human Right.”
This silent pain epidemic is present and occurring in Canada. For this reason, something needs to be done to reduce pain and improve the overall health and economy of Canada.
1. The Status of Pain in Canada - moving toward a Canadian Pain Strategy Recommended by the Canadian Pain Coalition, The National Voice of People with Pain. http://www.canadianpaincoalition.ca
Pain Grant and Proposal
What is the Economic Cost of Pain in Canada:
“Pain is taking a startling toll on Canada’s economy, according to an Angus Reid national survey released today. The survey, conducted for the Canadian Pain Society, a coalition of health professionals and researchers, found that moderate-to-severe chronic pain is hitting the economy where it really hurts: in lost productivity and absenteeism. In the past three months, nearly one-third of all Canadians (32 per cent) report having suffered a loss of income, booked off sick days, experienced a reduction in workplace productivity and responsibility, or even lost their jobs as a result of their pain”
- The Canadian Pain Society
- 23% of Canadians between 18-34 report missing work days due to pain [1]
- 1 in 5 (in this group) report loss in productivity [1]
- 15% (in this group) report loss of income due to pain [1] (National Avg. 11%) [1] - Actual reported Costs of Pain
- $14,744 per affected person per year
- Direct health care costs for Canada 6 Billion plus per year [1] - Estimate cost to Canada by 2025, 10 Billion plus per year [1]
1. Canadian Pain Society - Pain Hurts Canada’s Economic Recovery PDF
Pain Grant and Proposal
Lets Understand Pain
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” [1]
Pain is either nociceptive or neuropathic.
Nociceptive pain - Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors. [1]
Neuropathic pain - Pain caused by a lesion or disease of the somatosensory nervous system.
Pain Transmission and Order: There are four steps that occur in a pain process development. First, we come in contact with a stimulus, mechanical or chemical. This results in a reception (second), where a nerve ending senses the stimulation. Thirdly, transmission occurs where the nerve sends the signal to the central nervous system. This can involve several neurons. Lastly, the brain receives the information for further processing in the Pain Reception Center.
Pain Grant and Proposal
What are we doing about PAIN now?
In general the primary course of intervention is Pharmacological. Pharmacological intervention is based on the idea of blocking these pain signals at some point along the central nervous system in order to reduce the amount of input that the pain interpretation centers of the brain receive. This allows for a temporary blockage of pain signals and thus subjective feelings of pain relief, not a resolution of the cause of the pain.
1. International Association for the Study of Pain. http://www.iasp-pain.org The difficulty with primary pharmacological intervention is that the current medicine available results in side effects requiring additional medication. And this cycle continues as presented by Dr. Walker.
In addition, research has shown that prolonged usage of opioids (which this study suggested was 30 days) results in loss of gray matter in the brain stem and somatosensory cortex. Your brain is made of white and gray matter. Gray matter controls functions such as muscle control, sensory perception (vision, hearing, memory and speech) and emotions/mood.
Thus the usage of opioids over 30 days will result in significant neurological and psychological changes which will further tax the current health system/economy, as well as lower overall quality of life, and to make matters worse, the opioid usage will not “cure” the pain in which it was prescribed to treat, only provide a temporary relief of symptoms.
Pain Grant and Proposal
Our Goal for the CARE Program:
The goal of this grant/donation request is to obtain funding to provide physical medicine services to those suffering from chronic pain in Canada.
This goal will attempt to accomplish two services.
1. Reduce overall chronic pain due to implementation of physical medicine therapy. This will attempt to both reduce subjective feelings of pain while at the same time treat the Nociceptive cause resulting in the feeling of pain. The hopes is that by treating the cause of the pain as well as the symptoms, resolution or mitigation of symptoms will occur to a significant and profound level.
2. Use clinical findings to develop a physical medicine chronic pain treatment guideline based on patient presentation and treatment results.
Pain Grant and Proposal
The physical medicine therapies will/can include the following:
- Chiropractic care (CMT-D/SOT/Activator)
- Acupuncture (Needles/Electrical/Acupressure)
- Gua Sha
- Intramuscular Stimulation / Dry Needling
- Physio-therapy Modalities (electrical stimulation, ultrasound, electrical nerve blocks, cryotherapy, thermotherapy and laser)
- Active and Passive Rehabilitation and Exercise Based Pain Management
- Nerve Mobilization
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Soft Tissue Therapy (ART/Nimmo)
- Vestibular Rehabilitation
- Nutritional Counseling
- Mechanical Traction
- Electrical Nerve Blocks
- Ergonomic and Kinematic Evaluation (Kinesiology)
- Education and Injury Prevention
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