Specialist Referral for Chronic Pain with Peripheral Nerve Involvement
For your patient with chronic pain, prior unsuccessful pain clinic treatment, and previous nerve conduction studies, refer to a board-certified pain medicine physician at a multidisciplinary pain center that offers interventional procedures, and concurrently refer to a neurologist with expertise in peripheral neuropathies and small fiber disorders. 1
Why Multidisciplinary Pain Center Referral is Essential
Your patient requires a comprehensive pain rehabilitation program, not just another pain clinic consultation. 1 The key distinction is that multidisciplinary pain centers integrate physicians, psychologists, physical therapists, and occupational therapists into a coordinated treatment team, whereas traditional pain clinics often provide only medication management or isolated procedures. 1
Patients with refractory chronic pain who have failed initial pain team interventions benefit most from comprehensive pain rehabilitation centers offering 3-week intensive day treatment programs combining physical reconditioning, occupational therapy, behavioral therapy, and medication optimization. 1
These programs have demonstrated sustained functional improvements in patients with severe, recalcitrant pain syndromes, including cases where patients progressed from wheelchair-bound to resuming active lifestyles. 1
The pain specialist should be board-certified in pain medicine with access to interventional options including nerve blocks, spinal cord stimulation, intrathecal drug delivery, and radiofrequency ablation for refractory cases. 2, 3, 4
Neurologist Selection Criteria
Select a neurologist who specializes in peripheral nerve disorders, particularly small fiber neuropathies, as these conditions privilege neuropathies affecting smaller fibers and generate the most intense neuropathic pain. 5
The neurologist should have expertise in electrodiagnostic testing beyond basic nerve conduction studies, including quantitative sensory testing and autonomic function testing if small fiber neuropathy is suspected. 1, 5
Look for a neurologist who collaborates actively with pain medicine specialists, as peripheral neuropathies causing chronic pain require coordinated management between neurology for disease-modifying treatment and pain medicine for symptom control. 1
The neurologist should be comfortable managing neuropathic pain pharmacologically with first-line agents (gabapentin, pregabalin, duloxetine, tricyclic antidepressants) while the pain team addresses interventional and rehabilitative aspects. 1, 6
Timing and Coordination of Referrals
Make both referrals simultaneously rather than sequentially. 1 Waiting for one specialist to complete their evaluation before referring to the other delays comprehensive care and perpetuates the fragmented approach that has already failed this patient.
Explicitly state in your referral letters that the patient has had unsuccessful prior pain clinic treatment and is seeking alternative specialists, so the new providers understand this is not a first-line referral. 7
Request that both specialists communicate directly with each other and copy you on their correspondence to ensure coordinated care planning. 1
Avoid referring to pain clinics with long waiting lists or poor communication with referring physicians, as these are common pitfalls that lead to treatment delays and fragmented care. 7
What to Communicate in Your Referral
Provide specific details about the prior pain team interventions that failed, including which medications were tried at what doses, which procedures were attempted, and why treatment was discontinued. 1 Generic statements like "unsuccessful pain management" are insufficient for specialists to plan alternative approaches.
Document the functional impact of the pain using validated tools such as the Brief Pain Inventory (BPI) or the 3-item PEG scale (Pain intensity, interference with Enjoyment of life, interference with General activity). 1
Identify comorbidities that might influence treatment selection, including cardiac disease, renal impairment, hepatic dysfunction, depression, anxiety, substance use history, and gait instability. 1, 8
Specify the patient's functional goals (e.g., return to work, resume specific activities, reduce medication burden) rather than just pain reduction, as multidisciplinary programs focus on restoring function even when complete pain elimination is not achievable. 1
Critical Pitfalls to Avoid
Do not position the pain center as a "last resort" for a hopeless case. 7 This framing undermines the patient's engagement and the specialists' ability to implement effective rehabilitation. Instead, frame it as accessing specialized expertise that was not available in the prior treatment setting.
Do not refer without preparing the patient for realistic expectations. 1 Explain that multidisciplinary pain rehabilitation aims to improve function and quality of life, not necessarily eliminate all pain, and that active patient participation in physical therapy, occupational therapy, and behavioral interventions is essential for success.
Avoid referring to single-modality pain clinics that only offer medication management or only offer procedures. 1 Your patient needs the integrated approach that only true multidisciplinary centers provide, with coordinated input from multiple disciplines working toward shared functional goals.