S1E0 - The Chronic Pain Journey: Discovery, Treatment, and Maintenance | Care Beyond the Pain
Summary
In this episode, Dr. Jason Siefferman outlines the three distinct phases of the chronic pain journey: Discovery, Treatment, and Maintenance. The process begins with broad evaluation to determine why the pain persists, using conditions such as lumbar disc herniation to show how downstream symptoms often stem from upstream hip or spine issues. Interventions then test the clinical hypothesis, serving as diagnostic confirmation or signaling a need to re-evaluate when results differ from expectations. Once the driver is addressed, the final phase shifts control to the patient to manage daily care while processing emotional impact.
Conditions and treatments discussed
- Lumbar disc herniation. A disc herniation can develop slowly over time due to underlying biomechanical stress from the hip or spine.
- Discovery Phase. This phase focuses on identifying the underlying mechanism, cause, and drivers of persistent pain rather than assigning a simple diagnostic label.
- Treatment Phase. Interventions serve as diagnostic tests to confirm or re-evaluate the initial clinical hypothesis based on patient response.
What this shows about Manhattan Pain Medicine
In this video, Dr. Siefferman illustrates the practice framework described by Manhattan Pain Medicine, which structures care into Discovery, Treatment, and Maintenance. Manhattan Pain Medicine emphasizes diagnostic reconsideration by investigating the mechanical causes of structural issues, such as evaluating hip instability as a driver for disc herniation. The practice reports using initial treatments as diagnostic tests to confirm hypotheses, re-evaluating the plan if expected responses do not occur. This approach reflects the practice model of treating underlying drivers rather than relying solely on symptom relief or isolated labels.
Full transcript (607 words)
Hi, I'm Dr. Jason Siefferman, and welcome to Care Beyond the Pain. This is a podcast for those affected by chronic pain directly or indirectly. As a physiatrist and interventional pain specialist, I came to understand that very few patients and even providers fully grasp all aspects of living with chronic pain or providing care for those with chronic pain. The chronic pain journey is different for everyone, but certain key elements are universal. Most basically, there are three phases: discovery, treatment, and maintenance.
Discovery involves diagnosis, but not just finding a label. Diagnosis, truly meaningful diagnosis, requires an understanding of the how, what, and why of the pain. Not just what hurts, but why it hurts. How did it come to hurt? Why does it keep hurting? What's keeping it from healing? Without an accurate and thorough understanding of the pain's persistence, we have very little chance at healing it. Let me offer an example, a lumbar disc herniation. If it wasn't related to a trauma, it was likely slowly developing over time until there was a straw that broke the camel's back moment.
For those with physical jobs, this can be an obvious source, but for others, it's not always so clear. Sometimes there's a slippage of the bones in the spine. Other times there's a primary hip joint issue. And if the reason for the stress on the disc is not identified and treated, no treatment of the disc itself, even surgery, will be durable. The discovery phase requires that we begin with a broad approach and have an idea about what went wrong, how, and why.
Treatment begins when we have a reasonable hypothesis for why the pain exists and persists, and we're ready to test it. The initial part of the treatment phase really is an extension of the discovery because it's only through the response to the treatment that we actually have confirmation of whether or not the presumed diagnosis was correct. If we don't see the expected response to treatment, we must then reconsider our diagnosis. It's this iterative nature of the pain journey that is too often the most frustrating for patients.
It can be long, depending on how complex the pain has become. It can be painful as flares happen. And sometimes treating one aspect of the pain unmasks another. And then we must fold this new information into our larger understanding of the pain process in that person. It can also be emotionally and financially exhausting. The maintenance phase begins when we have a thorough understanding of what was generating pain, have found a treatment that addresses the underlying causes, and the patient is able to manage their own care.
The provider is still available for guidance and setbacks, but there is no more navigating involved except for the psychological aspect of pain. This is often when patients have to consider what they've been through, how this journey has affected their life, and address all of the emotions that had been bottled up while they were at war. The pain psychologist is essential at this phase. Care Beyond the Pain is here to share conversations between us, revealing different perspectives on this journey. Each week I will sit down with another provider, patient, or supporter, and our conversation will cover specific pain topics, care delivery, aspects of the pain journey, and in general expose our approaches to diagnosis, treatment, and maintenance.
The pain journey is rarely a straight line. To learn more about it and how to navigate it, you may visit our website manhattanpainmedicine.com or read our book Pain Answered, found on Amazon. Until next time.