St. Louis VA Medical Center

Jefferson Barracks Division

July 1, 2014

James Toombs, MD
 

Section 3K – an IPR program “provides 

outcomes-focused, coordinated, goaloriented interdisciplinary team services.”

Must address the following domains: 

Behavioral, Functional, Medical, Physical, 

Psychological, Social, Vocational.
 The person served / family 

 Pain Team Physician

 Pain Team Psychologist

 At least one other healthcare 

professional (but probably many more)
1) No cookie cutters

2) Outcomes help massage your IPR 

program format 

3) Dynamic over dogmatic
1) Two Ears

2) Four Legs

3) One Tail

Build what your facility needs...


Prior to the establishment of the Interdisciplinary Pain 

Rehabilitation Program, the St. Louis VAMC’s chronic pain 

management services were spread across a number of independent 

specialty clinics including Psychology, Anesthesiology, Chiropractic, 

Physical Therapy, and Neurology.

In 2006-2008, the Medical Center worked to establish a 

multidisciplinary pain service, increasing the amount of space 

devoted to clinical care, securing equipment to support 

interventional procedures, and hiring a full time physician 

(fellowship trained and boarded), psychologist , nurse coordinator, 

physical therapist, and program manager. 
In 2009, Dr. James Toombs joined the St. Louis VAMC as the Pain 

Clinic Director and Adam Bank, PhD joined as the Pain 

Psychologist. The Pain Rehabilitation Center began offering 

comprehensive pain management in March 2009.

Planning for the Interdisciplinary Rehabilitation Program 

began immediately with a visit to the Pain Program at the 

Tampa VAMC (Inpatient) and teleconferencing with the San 

Juan VA (Outpatient). 

In August 2009, the Interdisciplinary Pain Rehabilitation program 

began offering services.
 In August 2009, the IPR program admitted the first 

patients to the nascent program, initially set up as an 

8-week program with visits twice per week.

 Of the two patients admitted to the program at 

inception, one dropped out within the first week.

 

 The second patient attended four appointments, then 

no-showed or cancelled the next six. . . and then 

dropped out as well.

 Back to the drawing board . . .
 The second iteration was an every-other-week 

program lasting 6 months. It reduced 

commitment but maintained our current 

drop-out and no-show rates.

 Strike Two.

 Back to the drawing board . . .again.
The current IPR program meets once per week for 

14 weeks, with each visit involving 3-4 hours of 

treatment. 
St. Louis VA (outpatient)

We’ll give you all our policies & 

procedures via CD

We welcome on-site visits
o Physical therapy

o Chiropractic treatments

o Group psychotherapy (family and individual therapy 

as needed)

o Gym-based physical exercise /Aqua-therapy

o Nutrition education

o Education about pain medications from a pharmacist

o Follow-up visits with the Pain Physician

o Extensive homework with documentation
 To maximize day-to-day function

 Improve quality of life

 Decrease emotional distress and negative thinking 

 Minimize reliance on medications

 Decrease pain intensity
The focus is not on pain elimination, but rather on 

improving the persons served ability to cope with pain, 

increasing overall activity levels, and decreasing use of 

healthcare resources.
 James Toombs, MD

Pain Physician

 Carey Keys, DPT

Physical Therapist

 Pamela Wakefield, DC

Chiropractic Physician

 David Jansen, PharmD

Pharmacist

 Amelia Mitchell, PsyD

Staff Psychologist

 Angela Brock, ANP-BC 

Nurse Practitioner

 Takisha Lovelace, MA

Program Manager

 Jackie Caskanett, RN, MSN

Nurse Coordinator
 Timothy Simmons, RT

Recreational Therapist

 Jacqueline Henderson, RD, 

LD

Dietician

 Robert Collingwood

Chaplain
 Ability to provide a structured environment for care

 Provide participants education on self-management of their pain

 Provide participants a foundation to regain control of their lives 

and cope with pain more effectively

 A dedicated interdisciplinary pain rehabilitation team that is 

knowledgeable and skilled in the latest, evidence-based 

treatments for chronic pain conditions. 

 
• Experiencing chronic pain despite operative, interventional 

therapies; 

• Able to participate fully in the program and follow program rules; 

• Free of active substance abuse, including alcohol for at least four 

consecutive weeks, as shown on lab testing; and 

• Psychiatrically stable, such that they can actively participate in an 

outpatient program. 
 Initial Consult Review (Toombs, Mitchell, Brock)

 Orientation (Group Screening-Mitchell)

 Interdisciplinary Intake (Core Team)

 14 Week Outpatient Program

 Interdisciplinary Pain Team meetings 

 Discharge Assessment and planned Follow-up

In reality, the program never ends...

 Booster Sessions

 Support Groups
 Interdisciplinary Care Plan Refresher

◦ Patient or PCP request

 Repeat IPR Program?

◦ When clinically indicated
 8:00 am – 9:00 am – Pool therapy or gym exercise (45 to 60 minutes)

 9:15 am – 11:00 am – Chiropractic (Dr. Wakefield) and Physical Therapy (Dr. 

Keys) and Pain Physician (Dr. Toombs, three visits)

 11:00 am – 12:00 pm – Group Psychotherapy (Dr. Mitchell)

Daily walking, stretching, TENS unit use, Physical Therapy and Chiropractic 

exercises and relaxation exercises are assigned as routine homework.
 Based on Kabat-Zinn’s Meditation Stress Reduction 

Program (with the addition of some CB coping 

strategies) 

 1) Orientation to IPR program; Nutrition

 2) The Biological Aspects of Pain; Introduction to 

Diaphragmatic Breathing

 3) Pain and Stress

 4) Problem Solving

 5) Acceptance (co-facilitated by chaplain)

 6) Introduction to Body-Scan Meditation; Habit 

Formation
 7) Body-Scan Meditation Practice; Cognitive 

Reframing

 8) Body-Scan Meditation Practice; 

 The Impact of Emotion

 9) Body-Scan Meditation Practice; Pleasant and 

Paced Activities

 10) Substance Abuse, Medications &Opioids, 

facilitated by Pharmacist

 11) Introduction to Sitting Meditation
 12) Sitting Meditation Practice; 

 Pain’s Impact on Relationships

 13) Sitting Meditation Practice; 

 Sleep Hygiene

 14) Relapse Prevention; Discharge
Orientation

(344)

Intake

(186)

Admission 

(75)

Completed

(48)

14%
Overall, 75 persons were admitted to the IPR program. Only 2 were 

involuntarily discharged. 25 patients who began the IPR program 

dropped out.

 
Why patients decline or drop out:

◦ childcare issues

◦ acute illness

◦ disagreed with opioid taper

◦ moved too far from VA facility

◦ wanted to continue on their own

◦ care for ill family members

◦ discontinued interest

◦ enrolled in school full-time so schedule no longer allowed for IPR 

program

◦ family conflicts with the program

◦ transportation issues

◦ upcoming surgery
Orientation

(344)

Intake

(260)

Admission 

(100)

Completed

(70)

20%
 From 2011-2013, 48 veterans with chronic pain 

completed our comprehensive outpatient pain 

rehabilitation:

 The average age of our veterans was 52 years old

(the range of ages was 28 to 73)

 24% of veterans worked full-time or part-time.

 
 Our veterans reflected the following demographics

63% Male/ 37% Female

55% Caucasian/ 45% African-American
 Our veterans had the following types of pain:

47% had Back Pain

25% had Other impairments (e.g. Osteoarthritis)

14% had Head Pain

7% had Fibromyalgia/Soft Tissue Pain

7% had Neck Pain

The average length of time since onset of chronic pain 

17.1 years. 
 What are the Targets of Treatment?

 Pain Intensity (QVAS)

 Depressive symptoms (PHQ-9)

 Catastrophic Thinking (PCS)

 Pain-Related Fear and Anxiety (PASS-20)

 Functional Status and Psychosocial Functioning 

(PDQ)
Among those who completed the IPR program, overall improvement 

rates (defined as clinically significant improvement from baseline to 

discharge) were as follows:

◦ Pain-related Fear and Anxiety – 67% improved

◦ Catastrophic Thinking – 74% improved

◦ Functional status and psychosocial functioning –77% improved

◦ Depression – 67% improved

◦ Average Pain Intensity in the past week – 42% improved
At 3-month follow-up, results were available for 39 veterans:

◦ Pain-related Fear and Anxiety – 53% improved

◦ Catastrophic Thinking – 78% improved

◦ Functional status and psychosocial functioning – 70% improved

◦ Depression – 60% improved

◦ Average Pain Intensity in the past week – 40% improved
 Marine Corp combat veteran, late 60s

 Chronic pain in low back, both hips, shoulders, 

knees, wrists and hands; onset years ago, increasing 

in last 2 yrs.

 50% SC, chronic depression, PTSD

 “Looking for a way to deal with chronic pain, 

anxiety and depression that I’ve suffered with for so 

many years.”

 Previously engaged in psychology/ psychiatry tx 
 Domain Baseline Post –Tx 4-Month F/U

 PHQ-9 19 4 4

 PCS 28 1 0

 PASS-20 40 8 4

 PDQ 90 42 37

 QVAS 4-5 6 3

 Dramatic improvement during treatment in all domains, 

even during pain flare at discharge. Continued to 

practice meditation and other self-management 

strategies and maintained or improved gains at 4-month 

follow-up.
 Post-treatment, veteran wrote:

“I was in a really dark state and I felt like I was going to 

have a nervous breakdown at any moment. During the 

14-week program, I began to learn various coping 

skills... including the most important aspect (at least for 

me), mindfulness meditation. Living in the now is how I 

like to think about it. I am incredibly grateful you shared 

this with me.”
The White House Office of National Drug Control Policy (ONDCP) 

asked the Institute of Medicine (IOM) to conduct a review of the 

scientific evidence to assess the potential health benefits and risks of 

marijuana. Their conclusion was that there is not enough research.

For the first 2 years of the program, the use of marijuana precluded 

admission and we did not admit a number of persons who might have 

benefited from our services.

We have relaxed this requirement and, now, only condition admission on 

the ability to participate in the program. At the same time, we are 

positioning ourselves to complete a formal study (R&D).
Dr. Bank accepted a position at the West Palm Beach VA. And 

it took a while to find Dr. Mitchell.

Our Physical Therapist expanded her family.

Our Pain Physician was deployed (twice).

Backup plans and cross training

Scaled back admissions

Fully disclosed to CARF
New Full-Time Pain Physician

◦ Starting soon...

Chiropractic Residency Program

◦ Additional 1.0 FTE Chiropractor

◦ Additional 1.0 FTE Chiropractic Resident
 Interventional Suite-Building 1 CY 14

 Move to Building 55 (2016)

◦ Dedicated space

 Lodger Program

 In-Patient Program-CY 14

◦ Building 53

 Export training to VISN facilities
Contact info:

Takisha.Lovelace@va.gov