Presurgical Psychological Screening PDF

PRE-SURGICAL PSYCHOLOGICAL SCREENING: SCS Dr. Michael Lewandowski WHAT IS SCS? Contains four parts: 1. Implantable pulse generator with a battery 2. Lead with a number of electrodes 3. Extension wire that connects generat...

PRE-SURGICAL PSYCHOLOGICAL SCREENING: SCS Dr. Michael Lewandowski WHAT IS SCS? Contains four parts: 1. Implantable pulse generator with a battery 2. Lead with a number of electrodes 3. Extension wire that connects generator and lead 4. Hand-held remote that patient uses to adjust stimulation  POTENTIAL INDICATIONS CRPS (Complex Regional Pain Syndrome) Postherpetic neuralgia Peripheral vascular disease Traumatic nerve Injury Neuropathic pain Visceral pain Failed back surgery syndrome Refractory angina pectoris  CANDIDACY ISSUES Risks Who is a good candidate? Who is NOT a good candidate? Psychological characteristics play an important role in shaping individual differences in the pain experience The selection of proper candidates for implantable spinal cord stimulation is a critical factor for producing acceptable outcomes for patients suffering from severe pain. A device in the proper location with the appropriate programming will not be helpful if the patient is a poor candidate for the therapy or if the disease process does not respond to the application of spinal cord stimulation. PATIENT SELECTION CRITERIA FOR IMPLANTABLE PAIN THERAPIES Failure of more conservative therapies Further surgical intervention is not indicated Absence of serious untreated drug habituation Psychological evaluation and clearance for implantation has been obtained No contraindications to implantation exist. sepsis, coagulopathy, etc. Successful screening trial  PATI E NT- S PE C I F I C CHARACTERISTICS The patient should have no This refers to the untreated drug addiction psychological problem of problems. addiction and does not refer to a patient who is taking properly prescribed opioids under the care of a vigilant physician.  PATI E NT- S PE C I F I C CHARACTERISTICS The patient should be Many patients who are psychologically stable for the afflicted with chronic pain also planned technique. suffer from depression and anxiety. Outcome studies have shown that the presence of these problems does not adversely affect outcomes if they are treated and stable  PATI E NT- S PE C I F I C CHARACTERISTICS Suicidal or homicidal patient’s are Antisocial personality disorder is inappropriate candidates for these another worrisome problem and devices. should also be viewed with caution. The other area of concern is that of People with Body Dysmorphic personality disorders. disorder are also a concern. While several personality disorders can lead to functional disabilities, the diagnosis of borderline personality disorder should be seen as a relative contraindication to moving forward with an implant.  PATI E NT- S PE C I F I C CHARACTERISTICS The patient should have Cognitive functioning can be appropriate cognitive ability to diminished because of understand the procedure, the neurological disease, medical risks, and expectations of the illnesses, or from a baseline therapy. level of intelligence that does The patient must also not allow for implanting. understand the use of the equipment and the technical A psychologist or neurologist responsibilities of having the may be helpful in determining device implanted competence when the implanting doctor has doubts. INDICATIONS FOR PSYCHOLOGICAL CONSULT Some/Most insurance companies require a Pre-Surgical Psychological evaluation for SCS implantation Outcome of diagnostic testing, suspected pathology, signs & symptoms do not fit Markedly unusual reaction either positive or negative to medicine / treatments Suspicion of emotional “instability” “Personality” concerns Suspicion of poor / inadequate / inappropriate coping, fears, beliefs, distress, expectations, and / or attributions  KEY QUESTIONS FROM PSYCHOLOGICAL/BEHAVIORAL EVALUATION Identify patient desire to have the procedure Expectations of patient regarding pain reduction and proposed therapy Desire to reduce and/or eliminate use of oral pain medications Type and degree of social support  PRINCIPLES OF SCREENING Goals of SCS should be discussed and defined by both the physician and patient BEFORE the trial Goals are not uniform across patients – they need to be defined on a case-by-case basis SCS trial should approximate as closely as possible the conditions of long-term therapy SCS represents a SINGLE element in overall long-term pain management for a given patient OTHER ISSUES OF CONCERN Discuss location of SCS Implications of future MRI’s Some common problems (quick movement, belt line) What to do if the patient no longer wants the SCS PSYCHOLOGICAL ASSESSMENT Personality measures: (MMPI-2 RF, MBHI, MCMI-III) Pre-Surgical Psychological Screens SURGICAL EXPECTATIONS (check mark all that apply): o I think surgery will "fix" my medical problems o I accept the fact that surgery may not resolve my medical problem(s) o l am aware of the risks and benefits of surgery o I am aware that after surgery I may hurt worse even though the procedure performed was teclmically perfect o I am aware that after surgery I may experience severe muscle spasm pain around the surgical site that has formed as a result of a protective mechanism of my body o I accept the fact that at this time I have no further options other than to have surgery or learn to live with the pain o I think I have nonsurgical treatment options available to me that I have not tried and would like to do so o I am absolutely convinced that surgery to treat the presenting medical problem is my only choice even though my doctor tells me that there are available options other than surgery  AB 474 PRIMARY PATIENT RISK ASSESSMENT & PATIENT RISK OF ABUSE ASSESSMENT  PATIENT RISK ASSESSMENT _____ I have obtained and reviewed a medical history of the patient. _____ I have conducted a physical examination of the patient. _____ I have made a good faith effort to obtain and review the medical records of the patient from any other provider of health care who has provided care to the patient. _____ I have documented the efforts to obtain such medical records and the conclusions from reviewing any such medical records in the medical record of the patient. _____ I have completed an assessment of the mental health AND risk of abuse, dependency and addiction of the patient using methods supported by peer reviewed scientific research and validated by a nationally recognized organization. AB 474 Sec. 54. 1. An evaluation and risk assessment of a patient must include: (d) Assessing the mental health AND risk of abuse, dependency and addiction of the patient using methods supported by peer- reviewed scientific research and validated by a nationally recognized organization.  1. OPIOID RISK TOOL Dr. Lynn Webster developed Five questions (really 10) Estimates Risk for aberrant drug behavior  1. OPIOID RISK RISK PYRAMID ORT SCORE Opioid Risk Tool (ORT) The ORT is a self-report that is designed to predict the probability of a patient’s displaying aberrant behavior when prescribed opioids for chronic pain. Scores of 0-3 are associated with low risk, 4-7 with moderate risk, and 8 and over with high risk. The patient's risk for aberrant behaviors associated with opioids is Low Risk. Score: 1 Low Risk Areas of Concern: Age Between 16 and 45 MSQS PROFILE  WHODAS 2.0 Understanding and 1.67 Mild Communicating Getting around 4.00 Severe Self-care 2.00 Mild Getting along with 2.20 Moderate people Life activities - 3.50 Severe Household Life activities - 3.25 Severe School/Work Participation in 2.75 Moderate society General Disability 2.72 Moderate Score WHODAS % 43.06% disability GO TO PRISKA.IO