A Rural Practice Helps Fill the Need for Multidisciplinary Care of Chronic Pain Patients

In the small town of Watertown, South Dakota, Dr. Patrick Retterath saw the need for a better approach to pain management for patients in his rural community. A native South Dakotan, Retterath had gradually become involved in the field of chronic pain over the course of his career as a licensed anesthesiologist—and had worked for a number of years at a clinic that focused solely on interventional treatment rather than on holistic care. “It was not a fulfilling practice for me,” he says. “I wanted to be able to address the whole of a patient’s pain experience by serving in a multidisciplinary clinic—but in this region, there were no such clinics. So I decided to create one.”

Established by Retterath in 2004, the Innovative Pain Center sees pain patients who are referred by surgeons and primary care physicians for a variety of treatments, including trigger point injections, epidurals, radio frequency therapy, spinal cord stimulators, intrathecal pumps and narcotics management.

One of Retterath’s first steps in setting up the center was to recruit Dr. Robert Buri, a clinical psychologist who provides services at the facility two days a week. The healthcare team also includes a physical therapist, nurses who are specially trained in pain management care and a physician’s assistant. Serving patients in a 150-mile radius, the clinic has grown rapidly and is currently seeking additional medical staff.

Looking for new approaches to effective pain management

As the name implies, the Innovative Pain Center is dedicated to staying abreast of the latest tools and techniques for helping patients achieve positive outcomes. To that end, Retterath has corresponded with pain management practitioners in England, Germany, France, India and other places around the world to learn about their procedures. He also has traveled to Europe to meet with professional colleagues and train on new methods—such as ozone nucleosis, which is currently in trials at Temple University.

Closer to home, Retterath and his colleagues have discovered an innovative tool that has served his practice well: the BBHI™ 2 (Brief Battery for Health Improvement 2) test. “When we researched what was available in the way of a psychological assessment to use with our patients, we didn’t find another tool that offered us what the BBHI 2 test does,” says Buri. “This instrument helps us quickly gain a picture of the patient’s total pain experience by evaluating factors such as the patient’s level of pain, where the pain is located, whether the patient is reporting excessive pain and what the individual’s coping skills are. It’s a comprehensive test that also measures for a number of other important issues, including somatization, functional complaints, anxiety and depression.”

In the past, Retterath had used other pain inventories. “But now we only use the BBHI 2 test for initial assessment,”

he says, “because it gives us more of the biopsychosocial information that we need.” He also observes that the BBHI 2 test has helped the care team build relationships with patients. “The Midwest is a very conservative area. Patients tend to be resistant to a multidisciplinary approach—they don’t want to feel they are being given psychological labels,” he says. “The BBHI 2 test provides a good bridge with our patients. The range of questions that it covers lets patients know we are interested in caring for them holistically, rather than simply focusing on interventional pain treatment.”

Getting quick, accessible results

The clinic gives the BBHI 2 test to all new patients at intake via the PAD, a handheld electronic device. “The assessment is so easy to administer,” says Buri. “The patient takes the test on the PAD, then we place the device in the docking station—and we get a report instantly. There’s no keying in of data or scanning or faxing in tests to be scored. With our busy practice, the quick turnaround on results is really a benefit.”

On the days that Buri is in the office, he is the first to see the test results, which he reviews before meeting with the patient. The report serves as a platform for his discussion with the patient during the clinical interview as well for as his consultation with Retterath. When Buri is not in the office, Retterath is the first to look at the BBHI 2 results. “The reports are easy for me to use because they are written with medical professionals in mind,” says Retterath.

With patients who have failed more conservative pain treatments such as medication and epidural steroid injections, Buri conducts a more in-depth evaluation three to six months after intake. For this assessment, he usually administers the MMPI-2™ (Minnesota Multiphasic Personality Inventory-2™) and MBMD™ (Millon™ Behavioral Medicine Diagnostic) tests. Normed on patients with chronic medical conditions, the MBMD test provides a wide range of information about coping styles, stress indicators and the patient’s overall assets and liabilities, helping to structure practical treatment plans.

Identifying underlying factors

Both Buri and Retterath find the BBHI 2 test very helpful in pinpointing issues that may not emerge in their discussions with patients. “During our conversation, the patient may focus entirely on one topic,” says Retterath. “A patient may tell me only about having pain in his arms, for example; then I look at the BBHI 2 results and see that he also has pain in his legs. Or the test results might show that the patient has trouble sleeping or coping with a family situation, which she didn’t talk about to me. These are all issues that we need to pay attention to—and the BBHI 2 test helps bring them to light.”

Buri concurs. “Sometimes when I ask patients general diagnostic questions about whether they are depressed or anxious, they tend to deny it,” he says. “The BBHI 2 test gives them a means of reporting their feelings—through a vehicle that may make them feel less vulnerable than a face-to-face interview. And, when I show them that their test results indicate an elevated score for depression or anxiety and let them know that research shows 60 to 80 percent of people in chronic pain have some problem with these issues, they seem to be more willing to acknowledge having these feelings.”

Retterath cites the case of a quiet 35-year-old female who presented with pain complaints and was reticent to share information about herself in the clinical interview. The results of her BBHI 2 test showed elevations in anxiety, depression, somatization and functional pain complaints, along with sleep disorder and PTSD.

“When we talked about the test results with the patient, we learned that she had suffered abuse in the past—and that she had undergone several pain interventions, all of which had made her pain worse, not better,” Retterath says. “The pieces of the puzzle began to fit together, because we knew from experience that a history of abuse can impair a patient’s ability to respond well to interventional treatment. The BBHI 2 test helped us get to the underlying information, leading us to determine that the patient would not be a good candidate for an interventional procedure at that time—and enabling us to formulate an appropriate treatment plan, which included psychological counseling.”

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