ACOEM, Chronic Pain and Functional Restoration - 3

Saturday, December 31, 2005 | 0

This is the third and final part in an article series on functional restoration by Brenda Klass. The earlier two installments can be read by clicking on the titles in the side bar at right.

STAFF COMPOSITION OF AN INTERDISCIPLINARY FUNCTIONAL RESTORATION CENTER

Medical Director/Physician: Serves a leadership role responsible for medical issues involved in the diagnoses and management of anatomic, pathologic, and physiologic process associated with the complaint of pain.

Nurse/Case Manager: Serves as a physician extender, plays a significant role in obtaining patient histories, monitoring medications, evaluating lifestyle issues that may affect patients suffering pain and their response to treatment, and monitor progress in compliance and performance.

Psychologist: Assesses the patient's psychosocial functioning, personality characteristics, social support, motivation status, and coping resources that will help treatment planning. Provide treatments addressing these issues, and monitoring therapeutic progress. Plays a leading role in the day-to-day maintenance of the psychosocial aspects and status of the patients care.

Physical Therapist: Performs comprehensive musculoskeletal evaluation, including the examination of gait and postural abnormalities, range of motion, sensation, reflexes, and neurologic indices. This information is used to specifically tailor a therapeutic program to address any diagnosed defects. The physical therapist interacts daily with the patient regarding any physical progression issues toward recovery.

Occupational Therapist: Occupational therapist is involved in both the physical and vocation aspects of the patient's treatment. Conducts pre- and post- treatment evaluations that focus on body mechanics and energy conservation needed for activities of daily living, work, and leisure. During treatment, supervises progressive increases in the performance such as functional activities so that patients can return to a normal level of functioning as best possible. Plays an important educational role in teaching patients techniques for managing pain on the job that does not jeopardize their employment status. Also serves as the liaison between employers and injured workers, obtains job descriptions, and may aid in developing job modifications for accommodation of the injured workers. Promotes vocational and social reactivation throughout the treatment program, post program follow-up and occupational planning and sequencing with coordination of socioeconomics.

Biofeedback Therapist: Biofeedback therapist is involved in relaxation, biofeedback, and related self management treatments. Self management treatments place less emphasis on physical procedures applied to others: place more emphasis on patient involvement and personal responsibility; expand the scope of treatment to include emotional, mental, behavioral and social factors that impact pain, and seek to enable patients to cope more effectively with pain and associated symptoms. Biofeedback plays an important part in relapse prevention as patients who attribute therapy improvements to their own efforts demonstrate better long term outcome than patients who attribute improvement to the interventions of health care providers.

Acupuncture: The acupunctures assist in mediation of the pain at the start of the program. When a patient begins treatment pain levels usually increase, acupuncture is utilize in lieu of increased medications. Acupuncture needling and electrical stimulation to acupuncture points have shown to affect nociceptive, proprioceptive and autonomic nerve pathways. Both needle acupuncture and electro acupuncture increase enkephalin and dynorphin in the spine and mid-brain and raise endorphins in the pituitary-hypothalamus complex. The flow of enkephalins in mid-brain stimulates the release of monoamines, serotonin and norephineprine in the spine. It is theorized that these substances are responsible for the inhibition of pain.

IMPORTANT FACTORS THAT DETERMINE THE SUCCESS OF AN INTERDISCIPLINARY FUNCTIONAL RESTORATION PROGRAM.

* Understanding and acceptance of the philosophy of the treatment program by all the staff.
* Systematic monitoring of treatment outcomes to maximize quality assurance.
* Regular staffing to maximize frequent communication among team members and mutual reinforcement of the overall goals for each patient.
* Mutual reinforcement among team members for each other's role and efforts, as well as the communication of respect for each other's skills with the patients.

MAJOR GOALS OF AN INTERDISCIPLINARY FUNCTIONAL RESTORATION PAIN PROGRAM

* Return the patient to productivity
* Maximize function, minimizing pain
* Patient assumption of responsibility for self management and progress
* Reduction or elimination of future medical utilization
* Avoidance of recurrence of injury and maintenance of therapeutic gains
* Avoidance of medication dependence and abuse.

TREATMENT

For an injured worker to attain a level of maximum functioning, treatment should occur in three phases: First, the patient begins an overall conditioning program consisting of aerobic, stretching and strengthening exercises, which lead to a temporary worsening of Myofascial pain. Acupuncture and deep tissue massage are given frequently for pain relief; as an aid to deal with the increased pain the patient usually experiences in the beginning with the increased activity. These passive treatments are time limited and are eliminated once the patient has begun to demonstrate adequate utilization of coping skills. Medication management is initiated. Introductory pain management classes are offered. Behavioral sessions introduce the patient to new coping skills and other self-management techniques. This phase commonly lasts one to 2 weeks- 10 session days.

The next step of treatment begins when exercise-induced worsening of pain diminishes. The use of passive modalities is reduced and/ or eliminated. The intensity of cardiovascular, stretching, and strengthening exercises increases and the patient is expected to become more independent with exercise. Other aspects of treatment continue. Hopefully, during this phase the patient has virtually eliminated undesirable medications and is beginning to achieve therapeutic doses of desirable medications. They are beginning to experience the benefit of these medication changes. Specific work hardening and conditioning tasks are introduced; they should be involved in work simulation activities of 2-2.5 hours per day, 5 days per week. This phase often lasts approximately 1-2 weeks 5-10 session days.

The third phase begins when the patient has achieved sufficient fitness, strength, and range of motion to be able to engage safely in intensive work hardening and work conditioning, 3 hours per day or greater until 6 hours obtained. Note that the degree of fitness required to minimize the risk of injury is at least that of the average, unimpaired individual. Other aspects of the program are de-emphasized as the patient is prepared to return to work at the appropriate level. Patients who are uncertain which job they will return to, (or are planning on retiring), are prepared for work at the semi sedentary level. This final phase of treatment typically lasts 2-3 weeks, 10-15 session days.

The length of treatment estimates just cited is necessarily approximations. In fact, treatment duration varies a good deal. Patients with little emotional overlay or who are physically fit can often complete treatment in four weeks. (20 treatment session days). Those requiring the longest duration of care may have generalized myofascial pain, their disability duration is greater than 11 months, and they are particularly depressed, passive, angry, and/or severely fatigued. These individuals usually require 6 weeks, (30 treatment session days).

Patients with covert yet active, severe chemical dependency or secondary gains inhibiting their desire to return to work often reveal their lack of motivation and compliance within 2-4 weeks of treatment.

A structured program is an intensive full day of treatment. It usually starts at 8 am and continues until 4 pm. The program is structured in the same manner as a job. There are set breaks and lunches. The family and significant others are included in the plan. The program usually spans over 18-30 treatment session days (depends on diagnosis and duration of time after injury). The physical rehabilitation is established with daily quotas, the time duration is increased daily. The patient begins with 2-3 hours per day of physical activity, incorporated with treatments such as biofeedback, cognitive behavior individual, nutrition, education groups, group exercises, (depending on the extent of deconditioning and pain levels), acupuncture, and massage therapy may be incorporated. By the end of the four week period the physical activity component of the program has increased to 5-6 hours, acupuncture is minimal or eliminated as is massage; education continues for relapse prevention, and emotional aspect of return to work is addressed. As the physical activity increased, other modalities are decreased until the injured worker in participating in a work simulation program for 6-8 hours per day. At that point they are discharged with a recommendation for return to work.

All professionals meet on average a minimum of once a week in a rehabilitation team conference to discuss and coordinate treatment. The patient is in these sessions at the beginning and each two weeks of treatment thereafter. The patient's input is always requested as an active Participant in these conferences. At the conferences, the goals and treatment are reevaluated and modified as necessary. This form of communication serves as the hallmark of functional restoration.

There potential advantages of treatment in this manner are:

* Opportunity for patients to practice recommended exercises and skills in their naturalistic environment and report back to staff on results.

* Opportunity for the family / significant others to report observations of patients responses to treatment.

* With the program there is opportunity to observe effects of treatment interventions over longer periods of time and day to day development of coping skills.

* The greatest effectiveness of treatment is treatment gradually tapered from greater to lesser intensity/supervision/passive treatment in the individuals' treatment vs. independent work hardening. When patients begin the program they require intense supervision while acquiring new skills, behaviors, attitudes and an opportunity to practice and transfer these skills at home. As they work through the program the intensity of supervision decreases with an increase in independence. It is important to monitor or follow up closely with the patient to enhance independence and control costs while preventing relapse. Once a patient leaves the program they enter a maintenance program where they utilize the skills taught in continual management of their pain and function.

* Each patient has a program manager/ pain nurse assigned, to ensure the coordination of all aspects of the patient's treatment among professionals and between professionals and patients.

Reasonable outcomes include:

* Maximization of physical function and activity levels within physical limitation.
* Reeducation, not eradication of subjective pain intensity.
* Maximizing and maintaining physical activity.
* Reducing subjective pain complaints.
* Improve self-management of pain and related problems so as to reduce reliance on health care system.
* Reducing / eliminating the abuse of healthcare services, medications and invasive medical procedures relative to the primary pain complaint.
* Improve emotional function so as to reduce depression, anxiety, chronic anger, and other harmful emotional states associated with pain.
* Returning the patient to employment, training or educational pursuit.

Overall, it has been demonstrated that the interdisciplinary functional restoration treatment programs yielded significantly better outcomes than the other treatments on the following outcomes: medication use, health care utilization rates, functional activity levels, return to work rates, closure of disability claims as well as fewer iatrogenic consequences of adverse events.

Article by Brenda Klass, Care Center Rehab and Pain Mgmt. She can be reached at 818 784-0990, or by e-mail at BKlass@CareCtr.com.



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