What is primary, secondary and tertiary care?

Rehabilitation of patients with Chronic Pain can generally be divided into separate phases.

Acute or primary care is the first care that the patient receives after developing

pain. It is basically the care that is provided during the first six to eight weeks following the

onset of pain and mainly focuses on alleviating symptoms, resolving the cause of pain and

maintaining function. Primary rehabilitation usually consists of nonoperative treatments

and rarely surgery.

The second phase is called subacute or secondary rehabilitation is usually carried

 out in the framework of the Kuppah. This is the medical care that occurs after the primary

treatment ends and before the patient returns to functional activity. For those still have

pain following primary care, secondary rehabilitation usually begins at eight weeks

after the start of the pain and can last for approximately four to six months after injury.

Secondary rehabilitation is usually given on an outpatient basis in using the Kuppah's

existing rehabilitation  services.

The new program in the Sheba Rehabilitation Campus Is suitable for Chronic or tertiary care Pain Rehabilitation This refers to the treatment that may continue after secondary rehabilitation ends. It is geared toward patients who are suffering from a chronic disability and is more intense than primary or secondary rehabilitation, requiring greater involvement from a coordinated team of health care providers and generally occurs in an outpatient

setting. By the time a patient enters this phase of treatment, the emphasis is on maximizing

function even if chronic pain persists. An analogy to the differences between

primary, secondary and tertiary care is the pitching staff on a baseball team. The starting

pitcher may pitch the entire game, like a physician providing Chronic Pain treatment

from onset until resolution. In some cases a relief pitcher is called in when the starter has

become ineffective, similar to moving toward secondary rehabilitation. Finally, in some

longer and tougher games a closing pitcher is called on to save the game, much like the way

that tertiary rehabilitation is the last chance to secure a future with less disability.

WHEN DOES A PATIENT NEED SECONDARY AND TERTIARY REHABILITATION?

Most patients who receive medical treatemnt for acute Chronic Pain improve satisfactorily.

Approximately 20% to 30% of patients who undergo primary care for Pain will need secondary rehabilitation. Up to Five percent of these pain patients may require tertiary care. It is normal to restrict some degree of physical activity following the onset of lower back pain. However, some people may stop performing most of the physical and social activities that they did prior to their injury for excessive periods of time in an effort to avoid pain. This period of inactivity and social separation can result in a condition known as "deconditioning

syndrome." This syndrome has both physical and psychological origins and can lead to

muscle fatigue and weakness, atrophy, a loss of the normal range of joint motion, depression and possibly permanent disability. The goal of secondary rehabilitation is to avoid this deconditioning syndrome by recognizing the warning signs and providing treatment to the patient through physical and perhaps psychological therapies to reduce anxiety and depression.

Tertiary rehabilitation may be required for patients who fail to respond to care for

four to six months and have severe physicaldeconditioning. Some of these include patients with multiple surgical sites, intolerable pain, drug dependencies and/or psychological disorders that may limit their ability to respond to previous rehabilitation attempts. The goal of tertiary rehabilitation is to avoid a total or near total  permanent disability.

What are the warning signs for deconditioning syndrome?

When, during primary care, a patient is demonstrating a continuing decrease in strength, fl exibility and range of motion during the primary or acute phase of rehabilitation,

he or she may be at risk. Physicians also assess the patient's social and work activities.

A dramatic reduction in social interaction, a lack of interest in recovery or the inability to

return to work (even on light duty) following the primary rehabilitation stage may also be a

warning sign.

HOW IS REHABILITATION PROVIDED?

The extent and intensity of secondary and tertiary rehabilitation depend on the individual's capabilities. Unlike primary rehabilitation, which focuses on the treatment of the cause and symptoms of the pain, secondary rehabilitation focuses on resuming the patient's physical and social abilities. In most cases secondary rehabilitation begins with an assessment of the patient's abilities and then may involve exercise, physical reconditioning, aerobics, education psychological + social counseling and stress and disabilities management. An important aspect of any rehabilitation program is that the program emphasizes functional exercises and activities.

Tertiary rehabilitation requires more intense medical direction and involves many different

health care workers who each bring their unique contribution to the Pain rehabilitation program. in addition to Dr Adahan, who is Accredited in Canada, Israel and the USA as a Rehabilitation Specialist With 17 years of experience in Pain Rehabilitation,

And who is also an accredited Sports Medicine Doctor in Canada

The interdisciplinary Pain Team at the Sheba Medical Center Rehabilitation Campus is also staffed by an Senior Experienced Rehabilitation Nurse as well as 3 Physiotherapist, 2 Occupational Therapists, 2 PhD Psychologists, an Art Therapist and Yoga therapist as well as a social worker with extensive CBT training.

In the Sheba Medical Center Rehabilitation campus' tertiary care Pain Rehabilitation Program, a person may undergo an extensive physical and psychological evaluation, treatment for depression, substance abuse and counseling while participating in an Intense Interdisciplinary effort to Improve their general conditioning and change counter-productive attitudes+ behaviors towards there pain. The duration of this type of program may be one to two months with of participation 3 x weekly in an Ishpuz Yom type of context with 6 monthly follow-up evaluations with Dr Adahan  to monitor treatment successes and fascilitate community re-integration after discharge.(please see attached pdf for more specifics as to the Nature and content of the Sheba Medical Center Pain Rehabilitation Program.) During this period Dr Adahan remains an available telephone resource consultant to help the primary care giver at the Kuppah re-integrate the difficult chronic pain patient back to the community and its existing resources for ongoing Maintenance.( such as supervised group exercise programs, support groups, long term pharmaco-nalgesice regfimen management etc..)

For certain patients, for example, those who wish to try a personalized Pain Rehabilitation program as an alternative to spine surgery for there acute, sub-acute or chronic pain; lighter Pain Rehabilitation programs may be as effective. These may combine Minimally Invasive Interventional Pain Management techniques, such as selective fluoroscopically guided epidural spinal nerve root blocks done every 2-3 weeks with once weekly Ishpuz Yom and Hydrotherapy 3x a week. Such programs usually result in a surgical salvage rate of about 70% and represent a safer and less expensive therapeutic alternative for many patients who would otherwise not consider a conservative route of care for there spine related pain crisis.

Director - Dr. Haim-Moshe Adahan   MDcm, CCFP, FRCP, Dip. ABPM+R, Dip. Can Sport Med     Ø      1988: Graduated McGill Medicine.   Ø      1994: Completed Residency in PM+R at the University of Ottawa.   Ø      1996-2000: Acting Assistant Professor, Department of Medicine - Division of PM+R at the University of Montreal.   Ø      1996: Winner of the AAPM+R (American Academy of Physical Medicine and Rehabilitation)-« Young Investigator Award » .-see http://www.aapmr.org/index.htm     Ø      1997: Diploma in Sports Medicine (Canadian Association of Sports Medicine).   Ø      1997: Winner of the P.A.S.S.O.R. research prize.( The Physiatric Association of Spine, Sports and Occupational Rehabilitation (PASSOR)- see http://www.aapmr.org/passor.htm     Ø      1998-99: Fellowship training in Interventional Pain Management, Université Catholique de Louvain, Brussels   Ø      1999: Winner of the Quebec Order of Radiologists Research Prize.   Ø      1999-2002:Acting  Assistant Professor of the Department of Rheumatology at McGill University .   Ø      1999-2001: Managing Editor of the eMedicine Project - division of PM+R.   Ø      1995-2001: Principal investigator of three randomized controlled trials examining the efficacy of Supra-Scapular Nerve Blocks ( VIA A NEW TECHINIQUE FOR THE BLOCK THAT I INVENTED)of which the largest is funded by the Arthritis Society of Canada.   Ø      1994: Principal investigator of a randomized controlled trial examining the relative efficiency of custom molded versus prefabricated  foot orthoses in the treatment of patellofemoral pain in athletes.   Ø      2000-2002: Physiatrist in charge of Brain Injury and Trauma Rehabilitation Program - Jewish Rehabilitation Hospital, (McGill University affiliated).   Ø      2002-2008: Medical Director of  Quebec's largest free standing private Interdisciplinary Rehabilitation Center that employed 40 clinicians and received more than 1500 visits/week.   Ø      2004-2008Founder of the HTB-ED Industry sponsored Pain Clinical Research unit which was ranked top Canadian recruiter for industry sponsored clinical research in the field of Pain.   Ø      2008-Given the task of starting and directing Israel's first Structured Interdisciplinary Interventional  Pain Rehabilitation Unit at the Haim Sheba Rehabilitation Campus     E-mail -Haim.Adahan@sheba.health.gov.il Tel - 972-3-530-3745