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Beyond the device solution: a neurologist explains how devices are only one part of the spectrum with diagnosing and treating back pain.

In any given issue of Orthopedic Design & Technology, the topics covered ordinarily include the latest manufacturing processes, innovative product development, risk management or the latest merger and acquisition. Rarely--though not necessarily by design--is the patient care side explored with much depth beyond how physicians use the latest hip implants or how clinical trial results may affect product clearance by the FDA.

As part of our preview of the upcoming Orthopedic Design & Technology Conference and Exhibition on Oct. 2931 (see page 50 for more details), we're examining the physician perspective with one of the event's keynote speakers: Brian Hainline, MD, chief of the Division of Neurology and Integrative Pain Medicine at ProHEALTH Care Associates in Lake Success, NY. He also currently serves as the chief medical officer of the US Open Tennis Championship and is clinical associate professor of neurology at the New York University School of Medicine.

At ProHEALTH, where he's practiced for 10 years, Hainline has developed a comprehensive, multidisciplinary approach to patient care that embraces rigorous scientific methodology with compassionate holistic medicine. His daily medical practice served as the springboard for his new book, titled Back Pain Understood: A Cutting-Edge Approach to Healing Your Back.

Hainline recently discussed his views with ODT about the nature of pain, his approach to treatment and how physicians and patients should reevaluate the nature and source of severe and chronic back pain when determining the best options for treatment-because, as he explains, there's very seldom a quick or easy fix.

Following are excerpts from that interview:

Orthopedic Design & Technology: How do you approach care for patients with spinal pain?

Brian Hainline, MD: You can look at orthopedic surgery as being focused on the skeletal structure and basic biomechanics, while neurology is about the brain, spinal chord and peripheral nerves, and the physiology of the nervous system. But when you look at the spine and analyze back or spinal pain, it's never just a matter of pure biomechanics or pure skeletal structure. And it's also never just a matter of whether the nerve is functioning properly or not. It has to do with function--integrating biomechanics and the nervous system together. But even more importantly, it gets to anther part of what really allows function to happen--the thinking person, the emotional person. That's really where all my work has taken me, especially when it comes to something such as chronic back pain. Such pain doesn't fit neatly into orthopedic surgery or neurology. It's something where one must delve deeper.

The majority of my patients are chronic pain patients, and the majority of chronic pain patients have chronic back pain of one sort or another. And many have gone through innumerable orthotic devices and implantable devices--such as spinal cord stimulators or a morphine pump; they've had hardware for spinal fusion, artificial discs, and then they've worn the TLSO braces. In evaluating patients with chronic back pain, I come to see these devices from the point of view where some of them work, but also where some have led to clinical--and patient--failure. My practice specializes in refractory pain. And the refractory pain patients have gone through everything, so one important lesson, which in part led to me writing the book, is how to best choose the patient for any device or procedure.

ODT: So it's a matter of defining pain?

BH: Yes. Pain is not always a black and white issue. Is it anatomically generated? Is it primarily physiologically generated? Usually, it is a combination of the two, but you want to find out what the biggest contributors is. If someone has a fractured vertebra and they're in severe pain, the source is obvious. The other extreme would be someone who has severe chronic back pain and no matter what they do-whether sitting, lying down, standing, walking--they experience constant. burning pain. This type of pain is generated physiologically; it is not coming from a disc, a pinched nerve or an unstable spine but is, rather, generated from the brain. How do we tell when pain is primarily generated from the brain? Ultimately, all pain is mediated by brain circuitry. However, some chronic pain is primarily the result of altered or dysfunctional brain circuitry, and in such a case, the underlying anatomy is less relevant. In such patients, surgical interventions addressing spinal anatomy are doomed for failure.


The hardest part of medicine is trying to figure out what makes that person tick. In patients whose pain is more physiologically driven, they have often suffered multiple injuries, or one very serious injury that was life altering, or they've had a pattern in their life in which they've been victimized repeatedly. Such trauma can kindle brain circuitry that can generate neuropathic pain signals. Getting to know and understand the patient is the foundation for treating chronic pain patients. Ultimately, taking time to understand the patient while employing good, old-fashioned clinical skill is the best method for differentiating back pain that is really mechanical versus back pain that is physiologically, or brain generated. However, as physicians, we too often want to make a quick diagnosis, and then recommend a quick and easy drug or device.

ODT: But that's the nature of patient care in this country. How do you change that?

BH: There are a couple of ways. I am actually part of a company--we are about 120 physicians, and I am partner in the company. When I negotiated coming here, I negotiated a salary and said I would spend one hour with every new patient. I told the company that although I personally would not be profitable, my division would be profitable through its multidisciplinary approach, which includes surgical procedures, therapeutic injections and implantable devices. Thus, multi-disciplinary centers, or specialty centers, allow some practitioners to spend considerable time with patients, while assuring complete care, ranging from psychological to surgical.

The reimbursement incentives in medicine need an overhaul. For example, I can spend an hour during an initial consultation, and I can devise a comprehensive treatment plan. Part of the treatment plan may be a therapeutic injection, and my colleague can be reimbursed as much--or much more--for a 10-minute injection as for my one-hour consultation. Because of such reimbursement, doctors who rely primarily on cognitive skills will spend less time with patients, thereby seeing several per hour. This is a shame.

My practice tries a multidisciplinary approach. We have spine surgeons, pain anesthesiologists, physical therapists, psychologists, massage therapists and group practice facilitators. With chronic pain patients, you need to try a broad, multi-disciplinary approach. For example, if someone has chronic pain and is depressed, you will never treat the pain successfully as long as the depression persists. Sometimes antidepressants help, but more often, it is the long-term trust relationship, with different practitioners trying to help multiple layers of dysfunction, which ultimately helps the depression of the chronic pain patient.

We also try to help patients help themselves, and we stress the importance of listening to your body's needs. For example, if you have chronic back pain because you're working 14 hours a day, sitting most of the time while feeling completely stressed out, your pain is caused by core muscle insufficiency as well as chronic myofascial-emotional stress. However, in such a case, if you simply come into the office and complain of back pain, and no time is spent in reviewing your daily schedule, then treatment will be short-sighted and, in the long run, unsuccessful.

ODT: What was the motivation behind your book?

BH: Previously I wrote three medical textbooks. During the past few years, many of my patients have encouraged me to write a book that is a reflection of my treatment philosophy. Then, a new publishing house (Medicus Press) approached me about writing just such a book. Back Pain Understood is the first in a series of patient education books from Medicus Press. The book serves as a guide for patients, physicians and other healthcare providers. The book begins by defining the nature and meaning of pain, while providing a broad overview of multi-disciplinary treatment options for back pain. The second part of the book discusses many specific back conditions in more detail. In each chapter, I try to help the reader understand that there is always a mind-body continuum in back pain. In essence, anatomy and physiology perception intertwine at every level of pain. Not all pain can be fixed with an injection or a device.

ODT: Do you have experience with some of the newer spinal devices, such as artificial discs?

BH: Yes. I have treated many patients who have undergone lumbar disc replacement surgery. For patients in whom pain is primarily the result of a faulty, degenerated disc, such surgery can lead to great clinical outcomes. However, many patients have had this surgery because they have chronic back pain and degenerative discs on imaging studies, but the pain is not primarily generated from the degenerated disc. In these patients, the clinical outcome is poor, even if the surgery is flawless. So, just as with any device or procedure, it is the pre-device or pre-surgery clinical picture that determines clinical outcome, much more so than the technical success of the surgery itself.



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Author:Delporte, Christopher
Publication:Orthopedic Design & Technology
Article Type:Excerpt
Geographic Code:1USA
Date:Sep 1, 2007
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