NS2 taps services of pain psychologist as part of its practice for best outcomes

When Angela “Jeannie” Koestler, PhD, returned to Jackson in 1986 after completing a residency in health psychology and behavioral medicine at the University of Tennessee  Health Science Center, College of Medicine, she co-founded The Pain Clinic, Mississippi’s first interdisciplinary pain program, with a local physician. (See related story below.)

In 1993, Koestler began consulting with Rahul Vohra, MD, a physical medicine and rehabilitation physician and others who shared the true continuum of care philosophy. When Vohra’s physical medicine and rehabilitation group merged with two spine surgery groups and a pain management group to form NewSouth NeuroSpine (NS2), Koestler continued providing psychological/pain services, working in space located between neurosurgeons’ offices and the physical medicine and rehabilitation department on the second floor of the medical practice’s new building in Flowood.

“We wanted to work closely with a pain psychologist for patients who have chronic pain and are also dealing with depression and anxiety issues that can become quite overwhelming,” said Vohra. “Very few practices have access to a pain psychologist, and none that I know have access to one full time. We made the decision to go this route because it became very clear to us that pain management for patients often isn’t enough. Surgery, medication and therapy are very useful treatments but often you have to go above and beyond and treat the underlying psychological or psychiatric issues that are sometimes present in patients with chronic pain. We agreed long ago that it’s important to treat the whole person to achieve the best outcomes for patients.”

The dynamic interaction of biological, psychological and social variables affect an individual’s response to treatment, said Koestler.

“It’s important to address all of those factors,” she said, “to achieve the most optimal outcome for the patient.”

When evaluating patients, Koestler has a checklist of issues to consider:

• Longstanding depression/anxiety versus situational depression/anxiety,
• Symptom magnification,
• Level of compliance with medical treatment regimens/recommendations,
• Patient expectations regarding medical treatment and outcome,
• Coping behaviors,
• Assumption of self-care responsibilities versus level of dependence on the healthcare system,
• Compliance with medication regimens,
• History of chemical abuse/dependence,
• Work history and current job status,
• Patient expectation for return to work/premorbid activities
• Patient perception of disability,
• Perception of pain (0-10 point scale),
• Social and family support systems,
• Prior surgical and medical history,
• Activity level, and the
• Patient’s understanding of medical diagnoses and recommended medical procedure.

Koestler emphasized that studies show nearly half of all patients with chronic pain also suffer from depression.

“Some healthcare providers believe that depression precedes the pain, but in the majority of these cases, the depression appears to be the patient’s reaction to their plight,” she said. “Let’s say a patient with an acute low back injury is diagnosed with a herniated disk and begins treatment, and in the process of treatment, this patient is unable to work. As treatment progresses, their employer terminates them. This individual – the head of the household – begins to suffer financial difficulties because of the pain and injury, which may contribute to the development of psychological issues. Not only do the results of the injury affect the development of depression and anxiety, but we also know that depression and anxiety can affect a patient’s physical condition.”

Another example: patients with a pain problem will sometimes avoid activities because they fear further injury or the possibility of increased pain.

“Avoidance of activity may lead to the patient becoming physically deconditioned and may actually contribute to an increase in pain sensations,” she said. “We provide the patient with pain education and help clarify the patient’s role in their medical treatment process.”

Koestler helps patients understand the differences between acute and chronic pain conditions.

“One of the issues is that we all grow up with the expectation that if we fall down and get hurt or have some physical injury, we’re going to the doctor to get fixed,” she said.  Patients typically believe they’ll find someone who can provide them with a cure. “Usually, with a chronic pain condition, there is no fix or cure. We have the technology to significantly ease pain and help patients improve the quality of their lives. It’s very important to provide patients with pain education so they can develop realistic expectations regarding medical treatment outcomes and understand the importance of assuming self-care responsibility and taking an active role in their medical treatment process. The patient becomes one of the most important persons on the treatment team.  For example, if physical therapy and a home exercise program are prescribed but the patient doesn’t maintain the program, those factors will affect medical treatment outcomes.”

Koestler’s role is so important, she often sits in on weekly lunchtime surgical conferences with all 12 NS2 physicians.

Neurosurgeon Jack Moriarity, MD, one of NS2’s leaders, said Koestler’s input helps him recognize ahead of time a patient who has a significant psychological issue that might impair their recovery or response to surgery.

“We’ll routinely send patients to Dr. Koestler that are undergoing certain neurological modulation procedures such as a spinal cord stimulator, or a procedure for pain like lumbar fusion,” said Moriarity. “Frequently, she’ll identify an issue we might not have picked up because she takes a much deeper look at the patient’s psychological makeup, self image, and how they’re viewing their role in their care.”

Koestler’s role helping patients develop a better understanding of their relationship between neurosurgical and psychological problems helps “keep them in separate bins so they don’t blend into a huge blur after surgery,” he said.

“If a patient has a psychological issue, the worst time to first discuss it with them is after surgery if they’re still hurting, because invariably the patient will hear, ‘oh no, my surgery failed, and now he’s saying it’s all in my head.’ It’s almost impossible to gracefully unravel that discussion without the patient taking it the wrong way. You cannot dissuade them of that notion. If you have the discussion in a calmer, less acute environment prior to surgery, it’s much better than doing it when the patient is crying in the hospital on post-op day 2.”

The diagnosis and treatment method also serves as a screening tool, said Moriarity.

“Dr. Koestler can tell us when patients aren’t ready to handle the burden of a large surgery,” he explained. “We may need to have them on anti-depressants or have them through a few more therapy sessions to get them tuned up. It’s similar to sending a patient to a cardiologist who says ‘I want to get their blood pressure better controlled or catheterize first and then stent.’ It’s the same thing, but not as tangible or easy for us to understand.”

 About Angela “Jeannie” Koestler, PhD

After graduating from the University of Southern Mississippi, Koestler completed her psychology residency at the Memphis Clinical Psychology Internship Consortium, University of Tennessee Health Science Center, College of Medicine, where she trained in an interdisciplinary inpatient and outpatient pain program under the Department of Anesthesiology. She co-founded the first interdisciplinary pain clinic in Mississippi in 1987.

A fellow and past president of the Mississippi Psychological Association, past president and founding board member of the Mississippi Pain Society, and past president of the Southern Pain Society, Koestler chaired the Mississippi Licensure Board of Psychology from 2003-2005, and was reappointed to the Board in 2008.

The author of Understanding Chronic Pain and co-author of various book chapters and publications, Koestler has received the Mississippi Psychological Association’s Distinguished Practitioner Award and the Southern Pain Society’s President’s Distinguished Service Award and Award for Excellence in Pain Treatment and Research. She owns Nordal Clinic with offices in Jackson and Vicksburg.

Tags:

Related:

Bookmark:

Digg

Facebook

Technorati

Newsvine

Google