Outpatient management of chronic pain in Middle Franconia

In Middle Franconia, one of the larger Bavarian administrative division (population 1994: 1,657,101), the number of patients suffering from cancer pain, chronic headache and chronic back pain is not known. Furthermore, there are no data on interdisciplinary organization of outpatient pain management. METHODS: All physicians and psychologists involved in outpatient pain management in Middle Franconia (n=2130) were asked (questionnaires) to estimate the number of patients suffering from cancer pain, chronic (>6 months) headache and chronic (>6 months) back pain treated the last 12 months. RESULTS: 264 (12.4%) responses were analyzed; 107,346 patients had been treated in the last 12 months, 67% by a single specialist and 33% by two or more specialists. The participation of psychotherapists and anesthetists in outpatient management of pain patients was poor; 22,754 (21%) patients were thought to need multidisciplinary analgesia therapy in a pain clinic, which actually does not exist in Middle Franconia. CONCLUSION: The data presented suggest that patients suffering from chronic pain are not optimally managed in Middle Franconia. Regional institutions for multidisciplinary pain treatment have to be established close to where chronic pain patients live.     

The current status of pain clinics in Italy: a questionnaire survey

One hundred-eight questionnaires were mailed to Pain and Headache Centers evenly spread throughout Italy to evaluate the current status of pain clinics and therapy. Sixty-three centers (58.3%) responded: fifty-two (82.5%) were Pain Clinics, while eleven (17.5%) were Headache Clinics. Approximately half of the clinics were run by anesthesiologists (43.3%), followed by neurosurgeons (15%), and neurologists (10%). The Pain Team involved up to 26 members (average number: 7), with representatives from anesthesiologists (71.4%), psychologists and psychiatrists (52.4%), neurologists (36.5%), specialists in internal medicine (23.8%), and neurosurgeons (20.6%). The outpatient pain clinic made up the great majority of the respondents (80.9%), whereas the in-patient service for both emergency and elective pain treatment was available in twenty-six centers (41.3%). A total of 49.445 patients (average number: 810) were treated in a period of one year. Pain syndromes most frequently treated (mean incidence) were (a) cancer pain (39.0%); (b) chronic primary headache (37.3%); (c) non-oncologic extra-cephalic pain (37.0%); and (d) orofacial pain (17.2%). A multidisciplinary team approach was used by 65% of the respondents. Treatment modalities most frequently used were drugs (mean utilization index, MUI: 138), followed by anesthesiological methods (MUI: 70), neuroaugmentive procedures (MUI: 51), psychiatric and psychophysiological methods (MUI: 33), and neurosurgical procedures (MUI: 28). Mean percent immediate and long-term treatment successes (pain relief 50%) were the following: (a) cancer pain (74.7-63.3%): (b) non-oncologic pain (66.7-50.3%); (c) chronic primary headache (64.2-52.6%); and (d) orofacial pain (64.2-52.5%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Orofacial Pain and Headache: A Review and Look at the Commonalities

Research has shown that psychosocial factors can predict poor outcome for spinal cord stimulation (SCS) for patients with chronic pain, substantiating the need for standardized assessment techniques to incorporate psychosocial factors in patient selection. Presurgical psychological assessment is often required for SCS. Best practices include clinical interviews by psychologists and use of standardized measures of psychosocial risk factors. Psychologists should assess mental health and social risk factors, as well as an individual’s understanding of SCS and expectations for pain relief, while consulting with physicians to support a multidisciplinary based patient selection. In addition, psychologists take part in preparing patients who were initially deemed unsuitable for SCS by providing recommendations and potential access to clinical care addressing psychological issues in chronic pain. Barriers to presurgical psychological assessments include limited access to skilled psychologists and issues with feasibility and appropriateness of standardized measures, and further work is needed to improve standardized methodology.     

The psychology of pain

Emotional and evaluative issues are very important in the evaluation and treatment of pain. Treating the physical pain alone can leave these issues unresolved, and possibly exacerbate them through reinforcement. Understanding the impact of fear, expectations, and attention can help physicians deal more effectively with acute pain. Psychological issues are particularly prominent in chronic pain. Though acute care physicians may not be treating these psychological conditions, they can help by referring patients to the appropriate psychological or multidisciplinary setting.     

A review of follow-up studies of multidisciplinary pain units

Chronic pain is a major public health problem in the United States. Estimates from the National Institutes of Health put the cost of chronic pain at 40 billion dollars a year. They estimate that as many as 15 million adults suffer from low back pain with a minimum cost of 5 billion dollars in direct medical costs and 93 million work days lost every year. In an attempt to cope with this massive problem, multidisciplinary pain units have arisen which attempt to address the complex, multi-faceted aspects of a chronic pain problem. The importance of this new treatment approach is made evident by the 1981 overview of multidisciplinary pain centers published by the National Institutes of Health. In this publication, the history and success of these units since their first development by Bonica are evidenced. The purpose of the present paper is to briefly, critically summarize one small aspect of these programs, specifically follow-up analysis of the patients after discharge.     

Epidemiology of chronic pain - an investigation in 5 medical practices

BACKGROUND AND METHODS: The aim of this study was to get more information about the prevalence of chronic pain in different practices of home physicians. 900 patients of five different specialists (general medicine, internal medicine, neurology, orthopaedics, surgery) in the german town Bochum were investigated with a questionnaire about chronic pain. Chronic pain was defined as a continuous or intermittend pain of longer duration than six months. RESULTS: 36% (328 patients) of all investigated patients had chronic pain due to this definition, twice more women than men. The four most frequent localisations of chronic pain were the back, the head, the joints and the legs. 15% of the patients with chronic pain were retired or going to retire due to their chronic pain. Orthopaedics were the most frequent physicians visited in the past. Only 5% of the patients had a psychological therapy and only 1% were treated in a pain clinic. The primary treatment strategies of the chronic pain were physiotherapy and drug therapy. 30% of the patients did not have any pain relieve by the past treatment strategies. CONCLUSION: Patients with chronic pain are a frequent and important problem in practices of home physicians. The high frequency of patients with chronic pain in practices of specialists demonstrates the necessity of a special qualification also on this level of our medical system.     

Multimodale Schmerztherapie

Multimodal pain therapy describes an integrated multidisciplinary treatment in small groups with a closely coordinated therapeutical approach. Somatic and psychotherapeutic procedures cooperate with physical and psychological training programs. For chronic pain syndromes with complex somatic, psychological and social consequences, a therapeutic intensity of at least 100 hours is recommended. Under these conditions multimodal pain therapy has proven to be more effective than other kinds of treatment. If monodisciplinary and/or outpatient therapies fail, health insurance holders have a legitimate claim to this form of therapy. Medical indications are given for patients with chronic pain syndromes, but also if there is an elevated risk of chronic pain in the early stadium of the disease and aiming at delaying the process of chronification. Relative contraindications are a lack of motivation for behavioural change, severe mental disorders or psychopathologies and addiction problems. The availability of multimodal pain treatment centers in Germany is currently insufficient.     

Impact of opioid use on outcomes of functional restoration

OBJECTIVES: To examine the effect of opioid use on psychological function, physical functioning, and return-to-work outcomes of a multidisciplinary rehabilitation program (MRP) for chronic pain. METHODS: The participants were 127 patients with on-the-job injuries who had completed an MRP between 2001 and 2003. Opioid use was controlled by the patients' treating physicians (who were not affiliated with the MRP) and was assessed via patient self-report at the time of admission to the program and discharge. Other measures included pretreatment and posttreatment assessments of depression, pain severity, perceived disability, and physical ability (floor-to-waist lifting capacity). Return-to-work outcomes were obtained via follow-up phone calls approximately 6 months posttreatment. RESULTS: Significant improvements from pretreatment to posttreatment were evidenced on all psychological and physical measures for both opioid users and nonusers. Further, there were no significant posttreatment differences between opioid and nonopioid users on psychological, physical, or return-to-work outcomes. DISCUSSION: The role of opioids in the treatment of chronic pain continues to be controversial. Despite a lack of definitive data on their effectiveness, opioids continue to be prescribed, and thus patients using opioids continue to present for multidisciplinary rehabilitation. Although further exploration is warranted, results of the current study suggest that opioid use during rehabilitation does not necessarily preclude treatment success.     

Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: a practice-based feasibility study

BACKGROUND: Chronic low-back pain is a significant public health problem for which few therapies are supported by predictable outcomes. In this report, practice activities and 1-month outcomes data are presented for 93 chiropractic patients and 45 medical patients with chronic, recurrent low-back pain. DESIGN: A prospective, observational, community-based feasibility study involving chiropractors and family medicine physicians. SETTING: Forty private chiropractic clinics, the outpatient clinic of the Department of Family Medicine at Oregon Health Sciences University, and 5 other Portland area family medicine clinics. Outcomes Measures: The main outcome measures were pain severity, functional disability, sensory and affective pain quality at 1 month, and patient satisfaction assessed at 7 to 10 days and at 1 month. RESULTS: Although differences were noted in age, sex, education, and employment, the patients were closely matched at baseline with respect to frequency, severity, and type of low-back pain and the psychosocial dimensions of general health. The treatment of choice for chiropractors was spinal manipulation and physical therapy modalities; for medical physicians antiinflammatory agents were most frequently used. Chiropractic patients averaged 4 visits, and medical patients averaged 1 visit. On average, chiropractic patients showed improvement across all outcomes: 31% change in pain severity, 29% in functional disability, 36% in sensory pain quality, and 57% in affective pain quality. Medical patients showed minimal improvement in pain severity (6%) and functional disability (1%) and showed deterioration in the sensory (29%) and affective (26%) dimensions of pain quality. Satisfaction scores were higher for chiropractic patients. Outcomes for medical patients were heavily dependent on psychosocial status at baseline. CONCLUSION: Patients with chronic low-back pain treated by chiropractors show greater improvement and satisfaction at 1 month than patients treated by family physicians. Nonclinical factors may play an important role in patient progress. Findings from the Health Resources and Services Administration-funded project will include a report on the influence of practice activities, including more frequent visits by chiropractic patients, on the clinical course of low-back pain and patient outcomes. (J Manipulative Physiol Ther 2000;23:239-45).     

The assignment of orthopaedic rehabilitants to the traditional or the behaviour-medical rehabilitation approach--is it clinically relevant?

Rehabilitants with chronic orthopaedic diseases are assigned to either the traditional or the behaviour-medical rehabilitation approach by consultant physicians of the rehabilitation department within the Deutsche Rentenversicherung Bund (German pension insurance agency). The clinical relevance of this assignment was evaluated at the Rehazentrum Bad Pyrmont-Klinik Weser within a randomised controlled trial. In a sample of 363 rehabilitants the agreement of consultant physicians with the ratings of physicians and psychologists in the clinic was analyzed. We also tested whether rehabilitants treated in their assigned approach benefit more from the treatment than patients who by randomisation were not treated in their assigned approach. Results indicate that psychiatric comorbidity frequently is taken into consideration as a decision-making criterion in the assignment made by the consultant physicians. However, there is only little agreement between the assignment by consultant physicians and the ratings by treating physicians and psychologists. Further, rehabilitants treated in their assigned approach did not benefit more from the treatment than patients who due to randomisation had not been treated in their assigned approach but in the other. Therefore, the procedure applied so far for assigning rehabilitants to either the traditional or the multidisciplinary rehabilitation approach is not sufficiently valid. Concluding, implications for the modification of assignment criteria are discussed.     

Multidisciplinary treatment of chronic pain patients: its efficacy in changing patient locus of control

OBJECTIVE: To assess the efficacy of multidisciplinary treatment in altering chronic pain patient locus of control beliefs. DESIGN: A before-and-after treatment design including demographics. PARTICIPANTS: Seventy-three chronic nonmalignant pain patients who completed study questionnaires both before and after treatment. SETTING: Comprehensive, outpatient, multidisciplinary pain management program at a large Midwestern university medical center. MAIN OUTCOME MEASURES: Pain Locus of Control Scale and Survey of Pain Attitudes Control subscale. RESULTS: Patients' perceptions of personal control over pain increased from pretreatment to posttreatment, and patients' perceptions of external control over pain, such as fate or powerful others. decreased from pretreatment to posttreatment. CONCLUSIONS: This study supports the efficacy of chronic pain management centers in altering patient beliefs about pain. The ability to increase patients' self-efficacy in their control over pain and to decrease external attributions are essential to successful pain management.     

Zusatzausbildung in psychologischer Schmerztherapie durch die Deutsche Gesellschaft zum Studium des Schmerzes

Quality assurance with regard to pain treatment is a major concern of the German section of the International Association for the Study of Pain (IASP). For this reason, efforts to reach a consensus on guidelines for diagnostic and therapeutic procedures have been intensified and include educational endeavours as a basis for state-of-the-art practice. The German IASP section has implemented a postgraduate educational programme on pain treatment for psychologists. Objectives are to lay the foundation for a scientifically based assessment and treatment of chronic pain and to enable communication and cooperation among the disciplines. Admission is restricted to psychologists who have already started a course of training in psychotherapy, thus ensuring that sufficient knowledge about behaviour changes will be obtained in addition to the special programme about pain. After completion of the training in psychotherapy, a certificate will be issued if the student fulfils the following requirements: (1) attendance at 150 classes on pain syndromes, their anatomical and physiological basis, and their medical treatment, psychological methods of pain assessment and treatment, and effective ingredients of psychological treatment for pain; (2) experience in the treatment of patients with chronic pain; and (3) submission of 10 reports on assessments and treatments of chronic pain patients under supervision. To ensure training on a regular basis, the educational programme is offered to members of the IASP jointly by the German IASP and the Academy of the German Psychological Association. A sequence of eight modules covering the curriculum is repeated at least every 2 years, thus permitting entry to the programme at any time.     

Structure quality in outpatient care of chronic pain patients

BACKGROUND: Outcome quality of medical treatment depends on structure quality of the treatment facility. In the present study we tried evaluate structural parameters of outpatient treatment facilities relating to management of headache, low back pain and cancer pain. METHODS: 109 outpatient treatment facilities (104 offices, 3 outpatient departments of hospitals, 2 pain ambulances of hospitals) in middle franconia, one of the larger Bavarian administrative division (population: 1,6 Mio.), have been evaluated by questionnaires. Questions examined certain structural conditions of the treatment facility as compared to german guidelines for outpatient treatment of pain patients ("Schmerztherapievereinbarung"). RESULTS: Only one treatment facility worked within an interdisciplinary setting. Less than 25% (median) of total patients of an outpatient treatment facility suffered from acute or chronic headache, low back pain or cancer pain. 38% of physicians participated regularly on pain conferences. Established methods for diagnosis and documentation of patients suffering from chronic headache, chronic back pain and cancer pain were regularly used by 16%, 12% and 10% of physicians, respectively. Regular interdisciplinary cooperation in the management of patients with chronic headache, chronic back pain and cancer pain was indicated by 28%, 24% and 41% of physicians, respectively. However, personal discussion of patient related problems took place in less than 5% of physicians. Although a considerable number of different therapies (included as standard therapy for outpatient management of chronic pain in the "Schmerztherapievereinbarung") can be applied in each outpatient treatment facility (median:5), psychological therapy for management of chronic headache, chronic back pain and cancer pain was used regularly by 5%, 2% and 7% of physicians, respectively. Scoring of all examined structural parameters provides a measure for the quality of the parameters of a certain outpatient treatment facility as compared to that of an optimal outpatient facility for pain treatment (quality score=100%). However, 75% of examined outpatient treatment facilities reached quality scores only up to 43%. CONCLUSIONS: There are considerable structural deficits in outpatient treatment facilities involved in management of patients suffering from chronic headache, chronic back pain and cancer pain. Realisation of standards according to the "Schmerztherapievereinbarung" needs organisation of an interdisciplinary network between the different specialties necessary for pain management. Interdisciplinary cooperation should be supported by the official organization of the medical self-government in Germany--the Kassen?rztliche Vereinigung--which has to assure optimal conditions for outpatient treatments.     

Predictive factors for the outcome of multidisciplinary treatments in chronic low back pain at the first multidisciplinary pain center of Japan

[Purpose] Multidisciplinary treatments are recommended for treatment of chronic low back pain. The aim of this study was to show the associations among multidisciplinary treatment outcomes, pretreatment psychological factors, self-reported pain levels, and history of pain in chronic low back pain patients. [Subjects and Methods] A total of 221 chronic low back pain patients were chosen for the study. The pretreatment scores for the 10-cm Visual Analogue Scale, Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Short-Form McGill Pain Questionnaire, Pain Disability Assessment Scale, pain drawings, and history of pain were collected. The patients were divided into two treatment outcome groups a year later: a good outcome group and a poor outcome group. [Results] One-hundred eighteen patients were allocated to the good outcome group. The scores for the Visual Analogue Scale, Pain Disability Assessment Scale, and affective subscale of the Short-Form McGill Pain Questionnaire and number of nonorganic pain drawings in the good outcome group were significantly lower than those in the poor outcome group. Duration of pain in the good outcome group was significantly shorter than in the poor outcome group. [Conclusion] These findings help better predict the efficacy of multidisciplinary treatments in chronic low back pain patients.Key words: Chronic pain, Low back pain, Multidisciplinary treatments     

Management of Pain in Addicted/Illicit and Legal Substance Abusing Patients

Abstract:   Approximately one-third of the American population experiences chronic pain. This varies in origin and severity. It also has been documented that billions of dollars are lost yearly because of health care expenses and missed workdays for chronic pain. Addiction is a primary, chronic, neurobiological disease with genetic, psychological and environmental factors influencing its development and manifestations. Addictive disorders occur in 3% to 26% of the general population, 19% to 255 of hospitalized patients and 40% to 60% in patients who sustained major trauma. More specifically 13.9 million of people living in USA over the age of 12 years are currently using illicit drugs.
Although patients with chronic pain may be at an increased risk for addiction, the general population has demonstrated similar addiction rates. Unfortunately, patients who have chronic pain and addition will only have one of these aspects addressed.
The purpose of this article is to clarify specific definition of substance use, abuse and addiction. As well as examining the role of pain physicians in evaluating and treating the chronic pain patients who have a history of substance abuse, and lastly outline strategy for assessing patients at risks and evaluating the most practical way of dealing with their chronic pain issues.     

Patient characteristics and physicians' practice activities for patients with chronic low back pain: a practice-based study of primary care and chiropractic physicians

BACKGROUND: Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. OBJECTIVES: To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. METHODS: A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians' practice activities; and low back complaint status at 1 year. RESULTS: Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients' care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. CONCLUSIONS: Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.     

A critical review of the pain readiness to change model.

Current approaches to treating chronic pain often incorporate a multidisciplinary approach and a focus on self-management. Although many of the patients who complete this type of treatment exhibit gains, there remain a significant proportion of patients who fail to engage in or complete this type of approach or who fail to adhere to treatment recommendations. In an attempt to address these issues, the construct of readiness (or motivation) to adopt a self-management approach to chronic pain has been described and has attracted research interest in recent years. Operationalization of the construct has led to the development of the Pain Stages of Change Questionnaire and other strategies for its assessment. Considerable discussion, debate, and ongoing research have expanded our understanding of motivation in the context of chronic pain treatment and have informed the articulation of potentially important ways in which self-management treatment approaches to chronic pain might be improved. The aim of this article is to review the work in this area and discuss implications for clinical practice and further research. PERSPECTIVE: This article reviews the research to date in the area of pain readiness to change. It provides readers with an overview of the current conceptualization of readiness and discusses important implications for multidisciplinary treatment interventions with a focus on self-management.     

Predicting readiness to self-manage pain

OBJECTIVE: The goal of multidisciplinary treatment for chronic pain is to help patients actively self-manage pain. In this study, we examined predictors of 2 measures of readiness to self-manage pain, namely the Precontemplation and Action subscales of the Pain Stages of Change Questionnaire. In particular, we examined the relative importance of experiences with pain and the primary care physician and beliefs about self-efficacy and pain control in predicting intention to self-manage pain (Precontemplation) and actual use of pain self-management strategies (Action). METHOD: One hundred and two chronic pain participants, from 4 multidisciplinary rehabilitation centers, completed the Precontemplation and Action subscales. They also completed self-report questionnaires assessing pain severity, interference, depression, pain-related anxiety, perceptions of the patient-physician relationship, pain locus of control beliefs, and pain self-efficacy. RESULTS: Considerable variance in Precontemplation scores (49%) was explained by the variables studied. Beliefs about powerful others controlling pain and perceptions of low internal control were particularly salient in the prediction of Precontemplation scores. Less variance was explained in Action scores (35%). Satisfaction with information provided by the physician was uniquely related to Action scores. DISCUSSION: The results of the study are placed within the context of the Motivational Model of Pain Self-Management and provide insight into factors that are associated with motivation to self-manage pain. Future directions for research are discussed with respect to perceptions of pain control and satisfaction with information from physicians, constructs which have previously been overlooked in research on motivation to self-manage pain.     

Pain Education at the University of Washington School of Medicine

Contemporary medical education is inadequate to prepare medical students to competently assess and design care plans for patients with acute and chronic pain. The time devoted to pain education in most medical school curricula is brief and not integrated into case-based clinical experiences, and it is frequently nonexistent during clinical clerkships. Medical student pain curricula have been proposed for over 30 years and are commonly agreed upon, though rarely implemented. As a consequence of poor undergraduate pain education, postgraduate trainees and practicing physicians struggle with both competency and practice satisfaction; their patients are similarly dissatisfied. At the University of Washington School of Medicine, a committee of multidisciplinary pain experts has, between 2009 and 2011, successfully introduced a 4-year integrated pain curriculum that increases required pain education teaching time from 6 to 25 hours, and clinical elective pain courses from 177 to 318 hours. It is expected that increased didactic and case-based multidisciplinary clinical training will increase knowledge and competency in biopsychosocial measurement-based pain narrative and risk assessment, improve understanding of persistent pain as a chronic complex condition, and expand the role of patient-centered interprofessional treatment for medical students, residents, and fellows, leading to better prepared practicing physicians.PerspectiveStrategies for improving multidisciplinary pain education at the University of Washington School of Medicine are described and the preliminary results demonstrated.     

Pain management: What's the more efficient model?

ObjectivesConduct a literature review on the organization models for the chronic neuropathic pain management of spinal cord injury (SCI) patients.MethodsBibliographical research on Medline based on the following keywords: chronic neuropathic pain in spinal cord injury–comprehensive management–multidisciplinary approaches.Results and discussionNo data was found in the literature on this specific topic. We took the option to report the data from the French laws regarding chronic non-cancer pain management. Chronic pain in SCI patients needs a specific and rigorous approach, justifying the role of the physical medicine and rehabilitation (PM&R) physician within specialized pain management centers as a key referent physician and coordinator for this type of patient. Furthermore, SCI pain is a chronic pain and as such requires a global care management; engulfing its emotional, affective, cognitive and behavioral aspects. These particular aspects need to be evaluated within specialized centers dedicated to chronic pain that provide specific therapies such as behavioral and cognitive therapies.ConclusionSpecific pain management centers or hospital units remain the benchmark place for chronic pain in SCI patients. PM&R physicians play a key role in the care management of chronic SCI pain. The partnership PM&R–Pain management center aims to provide the most efficient and coordinated care for SCI patient.