Pain patients who are candidates for surgical implants – whether a spinal cord stimulator or intrathecal pump – suffer chronic moderate to severe pain and have not benefited from conservative or less-invasive treatment methods which include, but are not limited to, oral medications including opioids, physical therapy, injections, psychological therapy, holistic treatments acupuncture, massage, cranial sacral), etc. In such instances, the use of such implants may be helpful to the management and reduction of pain and is often a last resort in the spectrum of treatment options.
It is common practice for patients to have a psychological pre-implant evaluation by a qualified licensed psychologist in their home state before implantation. It is important to fully understand the significance of this psycho-educational-evaluative role as it relates to patient satisfaction and aiding in the selection of optimum preventative treatments. These assessments are not considered forensic evaluations, but ones that are both evaluative and educational in nature. The patient’s response to these interactions is important in determining their readiness for being active participants in the aspects of both pain management self-care skills and for the management of issues that may arise from their implant.
Psychologists and Pre-Implant Evaluations
Psychologists have a long history of involvement in the scientific research, assessment and treatment of various types of health care interventions. These range from assessing and improving the effectiveness of working with diabetic patients to the more present-day concern of the obesity epidemic[1]. Psychology also has a history of providing scientific research within the health care arena of biological, neurological, and behavioral medicine. Additionally, psychology has focused on issues faced by medical professionals and third-party payers who are concerned with utilization and over-utilization of health care. Physicians and surgeons are commonly coordinating care with psychologists to offer a unique perspective to complex health care concerns and work with pain patients issues in chronic pain clinics. Psychology has a central leading role as an adjunct to medical care [2].
Behavioral medicine/health psychologists who work with chronic pain patients seeking surgical implants have an obligation to assess and understand the impact of these interventions on patients to improve pre- and post-surgery outcomes. Therefore, Behavioral Health Psychologists have an obligation to understand the bio-psycho-social issues that impact the medical environment. They help to facilitate communication and education between all parties [3], in addition to providing cognitive behavioral pain management therapy to improve the patient’s ability to become active participants in active self-care techniques. Real pain management is a great deal more than just administering a particular type of medical intervention ranging from medications to surgical interventions. Due to the gravity of surgical implantation, it is expected that the psychologist conducting a pre-implant evaluation have a Doctorate in Psychology, is licensed in his or her state, and has a background working with chronic pain patients. They would also do well to have professional affiliations with pain organizations and have a background working with neurosurgery, neurology, or other pain related specialties [4].
The Goal of Pre-Implant Evaluations
When a surgical implant of a pain management device – such as a spinal cord stimulator or intrathecal pump – is indicated, important questions need to be answered. Besides looking to see if alternative approaches have first been tried, it is also important to select those patients who have the best chance of successfully responding to the surgical implant. We are all aware that some patients may not have the best results from surgery, even when all the physical findings are present to suggest the need for it.
The goal of a pre-implant evaluation is to determine which patients will have the best chance of a successful outcome and follow-up rehabilitation. Some patients will be poor responders to surgical intervention regardless of how successful the procedure may be. Others may have a better outcome if they have first received appropriate behavioral medicine treatments which make them more proactive in their recovery and subsequent rehabilitation. Some patients may first need help in identifying and eliminating issues in their lives that will interfere with their recovery.
It is important to note that the pre-implant psychological evaluation is not necessarily designed to eliminate candidates from surgical implantation. Rather it is designed to assist the surgeon, the patient, and the family in making appropriate decisions and treatment choices, depending on the particular needs of the patient. It focuses on the patient, personality style response patterns, personal life issues, issues that might result in setbacks, and other factors that are important to improved outcomes. Many medical patients are exhausted, confused, overwhelmed, not coping well, and need help in emotional stabilization prior to having any chance of using the medical interventions in an appropriate cost-effective manner.
At times, the evaluation may recommend surgical implantation, but with very specific recommendations for post-surgical rehabilitation and recovery interventions that will enhance the chance of the patient responding in a positive manner and quickly returning to a functional capacity. As such, the pre-implant psychological evaluation is a bio-psycho-social educational approach to helping patients make better use of the variety of treatment choices/options available. Many patients do not feel that they have more than a brief overview of what the entire process is all about. Therefore, education and information are a key focus of these evaluations.
Implant Evaluation Issues
Implant evaluation is part of a behavioral pain management approach to care. Evaluating patients for implants considers a number of factors including the patient’s:
- degree of understanding of the procedure;
- degree of understanding the need to be active in self-care;
- degree of understanding the need to make changes in usual methods of approaching life that may exacerbate pain problems;
- degree of understanding life-style changes that are required as part of participating in this procedure; and
- the ability to respond to this behavioral pain management evaluation in a manner that improves knowledge, skills, and active-skills
Those individuals who have been involved in any type of behavioral pain management treatment have the advantage of knowing many of the active self-care management techniques that must be employed on a regular daily basis in their lives. Their response to behavioral medicine treatment provides a great deal of information on how they can respond to long-term rehabilitation and management issues subsequent to an implant procedure for which they are being considered. Observed behavioral actions are always more reliable in any evaluation procedure. In this sense, part of the evaluation relies on the patient’s response to pre-implant treatment interventions.
Objectives
In health care, the final determination of whether or not a surgical procedure will be of help should be decided by the patient. The patient may sometimes be the neglected aspect in the provision of health care services and treated as secondary to the physician in the health care paradigm [5]. The health care model being proposed through this research study is based more on quality of care as measured by the patient. In psychological services, patients establish goals and then later report their level of attainment. Within the health psychology arena, the patient’s involvement should also be paramount [6].
Part 2:
In part 2 of this series, the results of a follow-up study of those patients who completed a pre-implant psychological evaluation and subsequently had an implant of a pain management device is covered.
Terri A. Lechnyr, Ph.D.
Practical Pain Management is a monthly journal that contains tutorial articles designed to help diagnose and treat various aspects of pain. This publication is sent free of charge to medical practitioners in the United States.
Material adapted (with permission) by CFisher from:
Lechnyr, T.A., (2009). Pre-implant psychological evaluations. Practical Pain Management, 9(1).
References
1. Blackburn G and Kanders B. Obesity Pathophysiology Psychology and Treatment. Chapman Hall. New York. 1992.
2. Sanders D. Counseling for psychosomatic problems. Sage. London. 1996.
3. Williams D. Cognitive behavioral therapy: A strategy to assist in the management of fibromyalgia. Fibromyalgia Aware. 2003. 3: 22-27.
4. Hale G. Pre-surgical psychological evaluations for implantable device. 2002. http://www.iwci.org /Clues02/June2002.htm Accessed 10/19/06.
5. Lechnyr R J and Lechnyr TA. Psychological Dimensions of Pain Management. Practical Pain Management Journal. 2003. 3(4): 10-18.
6. Baker T and Green C. Inter-race differences among black and white Americans presenting for chronic pain management: The influence of age, physical health, and psychosocial factors. Pain Medicine. 2005. 6: 29-38.
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