Clinic Addresses Pressing Need for Multidisciplinary Pain Management Services

When Rush Foundation Hospital in Meridian, Mississippi, hired pain specialist Eric Pearson, MD, to head up their anesthesiology department in 1995, one of his first priorities was to persuade the hospital to build a pain center. Since moving to Meridian in 1992, Dr. Pearson had become keenly aware of the lack of pain management services in the region.

The hospital readily agreed to Dr. Pearson’s proposal. The initial plan called for Dr. Pearson to divide his time equally between the pain clinic and the anesthesiology department. But the demand for pain management services in the region was so great that within two weeks after the Pain Treatment Center at Rush Foundation Hospital opened its doors in January of 1996, Dr. Pearson was working full time as director at the pain clinic.

From the onset, Dr. Pearson was committed to building a multidisciplinary team to meet the biopsychosocial needs of pain patients. Early on, the clinic subcontracted with a group of psychologists in the area; by 1998, it had brought two pain specialist psychologists on staff. Over the years, the clinic has steadily expanded the care team. The current group also includes two pain specialist physicians, two professional counselors, a nurse practitioner, a physician assistant, more than 30 nurses, and a physical therapist. In addition, the clinic makes referrals to outside services, including chiropractic and massage therapy.

The clinic has built a broad referral radius, with the majority of referrals coming from physicians in the medical community. It serves many different types of pain patients, including individuals with failed back syndrome, complex regional pain syndrome, cancer pain, and neuropathic pain. About 20 percent of the clinic’s clientele are workers compensation cases.

Today, the clinic is one of the few—perhaps the only—multidisciplinary pain clinics in the region. The practice has grown so rapidly that after only nine years, the construction of a new center is underway.

Taking a lifespan approach

James Gilbert, PhD, Coordinator of Behavioral Medicine at the clinic, explains why it is so important to use a multidisciplinary model in treating pain patients. “Many of our clients have already reached the chronic stage by the time they come to us. We offer different tools to help them manage their symptoms, but these symptoms are in the context of a life; patients must learn how to manage pain on a daily basis. Through a lifespan approach, we help patients rehabilitate physically and emotionally—and we help them set realistic expectations.”

Since its founding, the clinic has focused on discovering the best techniques and tools available to address its patients’ multifaceted issues. As part of this evolutionary process, the group has used various psychological assessments to identify those that are best suited to their needs. In 2002, Dr. Gilbert introduced the use of the BHI™ 2 (Battery for Health Improvement 2) test and the shorter version of this instrument, the BBHI™ 2 (Brief Battery for Health Improvement 2) test. Both assessments have since become a standard part of the clinic’s protocol.

“The BBHI 2 and BHI 2 tests appealed to us because they are multiscale instruments that look at physical, emotional, and psychosocial aspects, giving us a better understanding of the patient’s full pain experience, which goes far beyond just physical symptoms,” says Dr. Gilbert.

“Another big plus of these tests is that they are normed on a physical injury population, making them more relevant to our patients than most of the other tests available, which are typically normed on a psychiatric population,” says James McLaughlin, PhD, one of the clinic’s psychologists. “In addition, the construction of the BBHI 2 and BHI 2 tests helps reduce the risk of overpathologizing pain patients. For example, chronic pain patients may exhibit vegetative symptoms such as sleep irregularities and appetite disturbance that are commonly associated with depression, and yet these symptoms may be mainly related to the pain and the person may not be seriously depressed. The BBHI 2 and BHI 2 tests are designed to help sort out these confounding symptoms.”

BBHI 2 test gives quick empirical view

Every patient at the clinic completes the BBHI 2 test during the initial visit while waiting to see the physician. Dr. Pearson likes the fact that the test is a brief instrument, taking less than 10 minutes for the patient to complete. “Compared to some of the other tests we have used, the BBHI 2 test provides a shorter, more efficient tool for initial assessment,” says Dr. Pearson. Within a week, Dr. Gilbert assesses the BBHI 2 results and enters a brief report on the patient’s chart.

“With this index [Pain Tolerance Index], we gain a very helpful snapshot of the patient’s perception of his/her level of disability, especially when coupled with the Functional Complaints score.”

At the first visit, the physician also reviews a pain diagram and social history checklist filled out by the patient and conducts a physical examination and clinical interview.

Based on this information, the physician develops a preliminary treatment plan. If non-invasive procedures are included in the plan, such as medication or physical therapy, these treatments are initiated immediately. While invasive surgeries are scheduled at the initial visit, they will not be performed until the team has reviewed the results of the BBHI 2 test.

Dr. Gilbert uses the BBHI 2 results to assess to what degree the behavioral medicine specialists should be involved in the patient’s care. “Some people may only need periodic follow-up to monitor progress and compliance; others may benefit from a more thorough psychological evaluation and ongoing therapy,’ he says. “The BBHI 2 test helps us determine the suitable level of assistance.”

A component of the report that Dr. Gilbert finds especially useful is the section on treatment recommendations. “This feature is very ‘clinician-friendly’ for the treating psychologist or counselor,” says Dr. Gilbert. “It offers specific suggestions about issues to address in counseling that can help ensure medical intervention will be successful for the patient.”

An aspect of the report that Dr. McLaughlin appreciates is the Pain Tolerance Index, which compares the patient’s self-reported pain level to his/her self-reported coping ability. “With this index, we gain a very helpful snapshot of the patient’s perception of his/her level of disability, especially when coupled with the Functional Complaints score,” he says.

In addition, the medical team uses the BBHI 2 results to re-evaluate the patient’s initial treatment plan and ensure that it is the most effective course. “The test yields valuable information on psychosocial factors commonly seen in pain patients, such as pain, somatic, and functional complaints—as well as psychological concerns such as depression, anxiety, and patient defensiveness,” says Dr. Pearson.

BHI 2 test provides a fuller picture

If there are significant subscale elevations on the BBHI 2 test, the behavioral medicine specialists administer the BHI 2 test as part of a more extensive evaluation to gain greater perspective on the patient’s issues. The follow-up evaluation also may include either the MMPI-2™ (Minnesota Multiphasic Personality Inventory-2™) or the MBMD™ (Millon™ Behavioral Medicine Diagnostic) test, depending on the clinician’s preference.

The clinic administers the BHI 2 test to assess all candidates for implantable devices such as drug infusion systems and spinal implants. “It is especially important to verify the candidacy of the patient when one is considering an expensive invasive surgery, such as a percutanous discectomy, that insurers are very resistant to covering,” says Dr. Pearson. “In this area, the BHI 2 test’s Symptom Dependency scale has proven very useful. We have found it to be the highest predictor of whether or not the patient is going to respond to treatment.”

The BHI 2 test also is administered to all candidates for chronic narcotics therapy. “It is not easy for us to identify patients at risk for addiction simply through a physical exam and clinical interview,” says Dr. Pearson. “Highly elevated scores on the BHI 2 test’s Defensiveness, Substance Abuse, and Doctor Dissatisfaction scales help alert us that the patient is not a likely candidate for narcotics therapy.”

In addition, the clinic gives the BHI 2 test to all workers compensation patients. “In these cases, it can be very difficult to establish whether the patient’s pain prevents them from returning to work or whether there are secondary issues at play,” says Dr. Pearson. “Physical examinations often produce inconsistent findings. The BHI 2 test provides an empirical measure to help accurately reflect the patient’s true pain experience.”

Use of both tests creates efficiencies

The care team cites several advantages to using both the BBHI 2 and the BHI 2 tests as part of their protocol. “Because the tests derive from the same base and use the same terminology, administering both of them has helped us clean up our data,” notes Dr. Pearson. “We are using fewer tests now to get the information we need.”

“When we use the BHI 2 test to conduct a follow-up evaluation,… we are able to gain in-depth information on the same specific areas that were flagged by the BBHI 2 test.”

Dr. McLaughlin points out additional benefits of using two instruments in the same test family. “When we use the BHI 2 test to conduct a follow-up evaluation, we can conduct a more focused search; we are able to gain in-depth information on the same specific areas that were flagged by the BBHI 2 test. In addition, since the two tests measure the same core items, using both of them allows us to track the patient’s status at two points in time—which helps inform our initial decisions about the patient’s care.”

Taking the vital signs

In their ongoing commitment to finding the most effective approach to patient care, the clinic has discovered that the BHI 2 and BBHI 2 tests are targeted to their needs. “These tests include specific scales that measure the emotional vital signs of the chronic pain patients we serve,” says Dr. Gilbert. “By helping us to better understand the individual experience of pain, the tests help us to structure a more efficient and successful treatment plan for each patient.”

James Gilbert, PhD, is Coordinator of Behavioral Medicine for the Pain Treatment Center at Rush Foundation Hospital in Meridian, Mississippi. A licensed professional counselor, Dr. Gilbert received his doctoral degree in health psychology from Capella University and his MSCE in counseling psychology from the University of West Alabama. His special interests include the psychological aspects of pain treatment, stress management, and working with public safety professionals.

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