ACOEM, Chronic Pain and Functional Restoration - 2

Saturday, December 17, 2005 | 0

By Brenda Klass

WHAT IS FUNCTIONAL RESTORATION, WHY THE NEED FOR SPECIALIZATION

In Chapter 6 page 114 ACOEM opens the treatment guidelines with a direction towards Functional Restoration. Although it does not provide in-depth guidelines, it does provide a general conceptualization of the treatment. Functional restoration has a strong emphasis on the direct quantification of function used to drive a "sports medicine" philosophy of the approach. At the onset one should be aware of differences among primary, secondary, and tertiary care. The care of acute pain problems is considered as the primary care, usually addressing control of the pain symptom. Primary care within ACOEM usually lasts 2-8 weeks following the occurrence of a pain episode and includes (but not restricted to) "passive treatment modalities" such as electrical stimulation, manipulation temperature modulation methods, and analgesic medication.

Secondary care refers to the first stage of reaction during the transition form primary care to return to work or normal activities of daily living. The secondary care usually refers to week 6 to 12. This phase occurs before the patient experiences progressive physical deconditioning and psychosocial economic barriers become firmly entrenched. Secondary care is meant to avoid the occurrence of chronic disability, preventing physical deconditioning and potential negative psychosocial reactions, and social habituation.

Finally, tertiary care refers to rehabilitation directed at preventing or ameliorating permanent disability for the injured worker who already suffers the effects of disability and physical deconditioning. It is this tertiary care or rehabilitation that requires an interdisciplinary team approach to accurately assess the various interrelated factors of chronic disability and pain, which then must be linked to careful administration of a multifaceted pain management program to affect recovery and reduce permanent disability. It is this tertiary care of rehabilitation that is referenced by ACOEM. Tertiary care is quite different from secondary care because of the intensity of services required, duration of disability, and treatment program protocol. There also needs to be more specificity of physical and psychosocial assessment, and the level of coordination among health care professionals.

The goal with early tertiary invention is to avoid the potential levels of permanent disability and reduce costs associated with it. Patients who have more a more complicated presentation of chronic pain are generally harder to treat. As a form of chronic pain, chronic low back pain - secondary to a herniated or rupture disks - usually involves pain at the site of the injury as well as referred pain which involves the sciatic nerve root. *(Rosomoff & Rosomoff 1991)

Thus, patients experience a "double dose" of severe pain, which when combined with a longer duration, results in greater disability. Such disability may include (but not limited to) difficulty ambulating or poor gait, paralysis, frequent urination or, in cases of extreme nerve impingement incontinent, loss of reflex(s) sensory or proprioceptive losses, bilateral foot drop, rigid and tight muscles and loss of functional activity. Patients with ruptured disks are also more likely to under go more back surgery(s).

The experience of surgery includes fear of death, injury, postoperative pain, and helplessness. Studies of patients with chronic pain demonstrate the perception of life threat and significant physical impairment were predictors of major the development of PTSD. In being told that they will be living with a chronic painful and potentially disabling condition, individuals will initially experience shock or denial. They may attempt to deny they are having such experiences. Patients experience increased anxieties from chronic pain, and there may also be other factors that contribute to the disruption in their lives. As the situation becomes worse and the pain and disability worsen, the injured worker may attempt to try more treatments to relieve the pain. However, when their pain is not relieved, and their condition worsens, that are likely to start to feel anger. The cycle continues. It becomes a never ending spiral of difficulties. Treatment is no longer primary, secondary, it is tertiary.

Don't be confused by the term multidisciplinary and interdisciplinary. Multidisciplinary connotes the involvement of several health care providers. The integration of these services, as well as communication among providers, may be limited. Interdisciplinary, involves greater coordination of services in comprehensive program and frequent communication among health care professionals providing care. A key ingredient of interdisciplinary care is a common philosophy of rehabilitation and active patient involvement. Tertiary care is much more complex and demanding on healthcare professionals.

It is also noted that ACOEM is somewhat confusing in their application multidisciplinary and interdisciplinary; they tend to interchange the terms. They discuss interdisciplinary yet refer to is as multidisciplinary

ACOEM, guidelines on page 114: "The treatment of chronic pain requires specialized knowledge, substantial time, and access to multidisciplinary care. Judicious involvement of other professionals, including psychologists, exercise and physical therapists, and other healthcare professionals who can offer extra physical or mental therapy while the physician continues to orchestrate the whole therapeutic process can be helpful. Close communication between all participating professionals is mandatory. Research suggests that multidisciplinary care is beneficial for most persons with chronic pain, and likely should be considered the treatment of choice for persons who are at risk for, or who have, chronic pain and disability".

Pain is a complex experience that typically requires a multifaceted, multidimensional, multidisciplinary approach.

FUNCTIONAL RESTORATION CENTERS

Although it is recognized that clinics may vary considerably in the program delivery, the content and staffing, and a number of common features characterize functional restoration. The successful program blends specific professional skills into an integrated package that is consistent in terms of its overall philosophy of care and balance of emphasis. In a mature program, there is a developed a degree of commonality across the professionals involved. What is delivered is more important than who delivers it. Most programs acknowledge primarily a cognitive-behavioral emphasis, although other psychotherapeutic perspectives may be incorporated. The primary focus is on improvement of function rather than cure of pain; and, the development of personal responsibility and self-help skills are fundamental to success. There is importance in addressing maintenance of change and the management of flare-ups.

Functional restoration of injured workers involves a broader conceptualization of the entire problem, its diagnosis and management. Functional restoration involves more objective information rather than accepting current limits in "history taking" based solely on patients' self-report of pain and diagnosis through imaging technology. Objective assessment of physical capacity and effort with comparison to a normative database adds a new dimension to diagnosis. In keeping with a "sports medicine" approach permits the development of treatment programs of varied intensity, and duration aimed primarily at restoring physical functional capacity and social performance. Their objectives are more ambitious than merely attempting to alter pain complaints and decrease medications. It is assumed that improvements in quality of life will be greatly enlarged by focusing on increasing physical capacity and decreasing social problems associated with pain. Attention is given to realistic goals such as returning to work, increasing activities of daily living, and reducing the use of the medical system.

CRITICAL ELEMENTS OF A FUNCTIONAL RESTORATION PROGRAM (Gatchel et al) Formal, repeated modification of physical deficits to guide, individualize and monitor physical training

* Psychological, and socioeconomic assessment to guide, individualize, and monitor disability behavior-oriented interventions and outcomes
* Physical reconditioning of the injured functional unit
* Generic work simulation and whole body functioning
* Multi-modal disability management program using cognitive behavioral approaches
* Psychopharmacologic interventions for detoxification and psychological management
* Interdisciplinary medically directed team approach with formal staffing, frequent team conferences, and low patient-to-staff ratios
* Ongoing outcome assessment utilizing standardized objective criteria

DESIRABLE CHARACTERISTICS OF MULTIDISCIPLINARY/INTERDISCIPLINARY FUNCTIONAL RESTORATION PAIN CENTERS

* A multidisciplinary pain center (MPC) should have on its staff a variety of health care providers capable of assessing and treating physical, psychosocial, medical, vocational and social aspects of chronic pain. These can include physicians, nurses, psychologists, physical therapists, occupational therapists, vocational counselors, social workers and any other type of health care professional who make a contribution to patient diagnosis or treatment.
* At least three medical specialties should be represented on the staff of a multidisciplinary pain center. If one of the physicians is not a psychiatrist, then physicians from two specialties and a clinical psychologist are the minimum required. A multidisciplinary pain center must be able to assess and treat both the physical and the psychosocial aspects of a patient's complaints. The need for other types of health care providers should be determined on the basis of the population served by the MPC.
* The health care professionals should communicate with each other on a regular basis both about individual patients and the programs which are offered in the pain treatment facility.
* There should be a Director or Coordinator of the MPC. He or she need not be a physician, but if not, there should be a Director of Medical Services who will be responsible for monitoring of the medical services provided.
* The MPC should offer diagnostic and therapeutic services which include medication management, referral for appropriate medical consultation, review of prior medical records and diagnostic tests, physical examination, psychological assessment and treatment, physical therapy, vocational assessment and counseling and other facilities as appropriate.
* The MPC should have a designated space for its activities. The MPC should include facilities for inpatient services and outpatient services.
* The MPC should maintain records on its patients so as to be able to assess individual treatment outcomes and to evaluate overall program effectiveness.
* The MPC should have adequate support staff to carry out its activities.
* Health care providers active in a MPC should have appropriate knowledge of both the basic sciences and clinical practices relevant to chronic pain patients.
* The MPC should have a medically trained professional available to deal with patient referrals and emergencies.
* All health care providers in an MPC should be appropriately licensed in the country or state in which they practice.
* The MPC should be able to deal with a wide variety of chronic pain patients, including those with pain due to cancer and pain due to other diseases.
* An MPC should establish protocols for patient management and assess their efficacy periodically.
* An MPC should see an adequate number and variety of patients for its professional staff to maintain their skills in diagnosis and treatment.

The final part of this series will conclude the review of appropriate functional restoration compositions.

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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