Terminology and Subtypes

Functional restoration refers not only to a specific intervention for chronic low back pain (CLBP), but also to a wider conceptualization of the challenges facing clinicians and patients dealing with this condition. Functional restoration is based on the biopsychosocial approach to CLBP, which views pain and disability as the result of a complex and dynamic interaction among physiologic, psychological, and socioeconomic factors that can initiate, perpetuate, or exacerbate the clinical presentation.^1,2 Functional restoration is a comprehensive approach that attempts to address these multiple contributing factors by combining interventions aimed at restoring not only physical function, but also behavioral health, and any other occupational or social difficulties that may develop as a result of prolonged disability due to CLBP. Many approaches to functional restoration have been developed by various specialty spine and chronic pain clinics.

The term multidisciplinary rehabilitation is often used to designate spine programs in which patients receive concurrent or coordinated care from behavioral, functional, and medical professionals (Figure 22-1). However, that term is not strictly defined. Multidisciplinary rehabilitation can also be interpreted narrowly and used to promote spine programs in which patients who fail to obtain adequate relief after physical therapy are then referred to surgery. Similarly, this term can also be used to designate a loose collaboration between surgical and nonsurgical specialists who rely mostly on injections or other invasive approaches aimed at specific anatomic structures. Only multidisciplinary rehabilitation programs using the more comprehensive biopsychosocial approach to CLBP espoused in this chapter can be designated as functional restoration.

Figure 22-1 Functional restoration requires collaboration and open communication among health care professionals.

History and Frequency of Use

Functional restoration was developed in the 1980s by the spine surgeon Tom Mayer and psychologist Robert Gatchel through their collaboration in a Dallas clinic that specialized in managing patients with complex, severe, or debilitating CLBP that was not responsive to conventional approaches. This intervention slowly gained popularity in the 1990s as clinicians and third-party payers became increasingly frustrated with the generally poor results observed after patients with CLBP received costly and invasive interventions. The emergence of functional restoration coincided with a wider adoption of the biopsychosocial model of LBP developed by the Scottish surgeon Gordon Waddell, and was well received by those looking for alternative approaches to managing CLBP.³ Research supporting the principles of functional restoration continues to grow. Researchers recently lauded this approach and indicated that “the concepts underlying functional restoration have been found to be highly relevant to patients with chronic low back pain, medical providers, and disability systems, and continue to gain acceptance and integration into the care of patients throughout the industrialized world.”⁴

Practitioner, Setting, and Availability

Functional restoration requires a multidisciplinary team of clinicians that may include a medical director, pain management specialist, psychologist or psychiatrist, nurse, physical therapist, and occupational therapist, although not all patients with CLBP will require separate interventions from each of those providers when receiving functional restoration (Figure 22-2 and Table 22-1).^3–11 Given the number of health providers involved, effective communication among functional restoration team members is crucial (e.g., a patient’s fear of physical activity should be discussed openly to prevent it from interfering with their physical reconditioning program). This intervention is typically offered in specialty spine clinics located in larger cities and is not widely available in the United States.

Figure 22-2 Functional restoration requires a multidisciplinary approach and coordination of care.

TABLE 22-1 Health Care Providers Commonly Involved in Functional Restoration for Chronic Low Back Pain

Procedure

Functional restoration was developed to overcome the limitations inherent in traditional problem-focused management of CLBP, with medical history taking, evaluation of symptoms and physical function based solely on self-reported pain, and an anatomic diagnosis guided primarily by advanced imaging. To fully understand the nature of CLBP and its complete impact on a patient’s life, it was deemed essential to acquire additional (preferably objective) information to arrive at an appropriate diagnosis and make recommendations about multidisciplinary management. This additional information should be collected through structured interviews, quantitative measures, and objective assessment of physical capacity and compared with a normative database. Influenced by a sports medicine approach, this additional information guides the development of treatment programs tailored for each patient and aimed primarily at restoring physical functional capacity and psychosocial performance. The objectives of functional restoration are ambitious and include not only decreasing pain and medication use, but also restoring function in activities of daily living and returning to full employment, with sufficient physical capacity to avoid recurrent injury and limit future health care utilization.

Functional restoration includes the following components: (1) formal, repeated quantification of physical and functional deficits to guide physical therapists in improving “weak-link” performance of the injured area and guide occupational therapists working to improve activities of daily living; (2) psychosocial and socioeconomic assessment; (3) multimodal disability management; (4) psychopharmacologic interventions; (5) ongoing clinical outcomes assessment; and (6) interdisciplinary, medically directed team approach. The goal of repeated quantification of specific physical deficits (e.g., ability to lift 20 lb to waist level) is to guide and monitor individualized physical training programs designed to correct these deficiencies. A comprehensive psychosocial and socioeconomic assessment is conducted by a behavioral expert to guide and monitor important aspects of recovery, including pain, disability, and mental health. Multidisciplinary disability management programs integrate cognitive behavioral therapy (CBT) approaches into interventions aimed at correcting specific anatomic contributors to CLBP.

The goal of psychopharmacologic interventions is to identify and address addiction or dependence to opioid analgesics or other medications, monitor any required detoxification, and provide psychosocial management to complement pharmaceutical interventions. Medications for symptoms of depression, anxiety, sleep disturbance, or neuropathic pain are routinely provided, at least on a temporary basis, to facilitate rehabilitation and return to work goals. Standardized and validated condition-specific and general health instruments are used to collect objective data about outcomes using questionnaires and structured interviews. The multidisciplinary team critical to functional restoration requires regularly scheduled staff meetings and conferences to discuss the progress of specific patients and suggest any required changes to the current approach.

Regulatory Status

Not applicable.

Mechanism of Action

The mechanism of action involved in functional restoration for CLBP is likely complex because it is thought to not only provide the combined beneficial effects of each intervention administered individually, but also derive some synergies from their coordinated and integrated delivery in a multidisciplinary environment. Such synergies are thought to occur as a result of enhanced communication between providers, which may optimize the timing for introducing specific components of the intervention and decrease the likelihood of presenting contradictory information to the patient. This approach also offers practical advantages by combining all providers in one location, thereby facilitating patient access and compliance to what may otherwise be a disparate network of providers. By adopting a comprehensive approach to patient management and simultaneously addressing physical, psychological, and vocational impediments to returning to work, functional restoration may decrease the time necessary to recovery if individual elements were addressed sequentially.

Indication

Functional restoration is an appropriate tertiary care option for those patients with CLBP who have failed to respond to programs such as reactivation and work hardening, have not improved after surgical or other interventional methods, and have no active, objective pathophysiology requiring immediate medical or surgical care. It is well known that significant psychosocial barriers to successful recovery may develop as a patient progresses from acute to chronic pain. Although serious comorbid psychiatric disorders are often a contraindication to many interventions for CLBP, such psychopathology can be effectively managed within the context of a functional restoration program.¹² The ideal CLBP patient for functional restoration is one who is motivated to learn to manage pain more effectively, is compliant with the prescribed rehabilitation regimen, and wishes to return to work and full activities of daily living. Often, there are certain “barriers to recovery,” such as secondary gain associated with perceived financial incentives for remaining disabled. However, even these secondary gain issues can be successfully dealt with in a comprehensive functional restoration program.¹³

Assessment

Before receiving functional restoration, patients should first be assessed for LBP using an evidence-based and goal-oriented approach focused on the patient history and neurologic examination, as discussed in Chapter 3. Additional diagnostic imaging or specific diagnostic testing is generally not required before initiating this intervention for CLBP. Certain questionnaires (e.g., Tampa Scale for Kinesiophobia, Fear Avoidance Beliefs Questionnaire) may be helpful to identify subsets of patients with CLBP who may benefit from specific interventions aimed at addressing those issues (e.g., fear avoidance training, as discussed in Chapter 7). Psychological testing is also required for functional restoration to identify coexisting conditions such as depression. An evaluation of medication use and functional capacity may also be indicated to tailor specific recommendations to address any noted deficiencies.

Clinical Practice Guidelines

Six of the recent national CPGs on the management of CLBP have assessed and summarized the evidence to make specific recommendations about the efficacy of functional restoration or other multidisciplinary rehabilitation programs.

The CPG from Belgium in 2006 found high-quality evidence that intensive multidisciplinary rehabilitation programs combining education, exercise, relaxation, behavioral, and other interventions are more effective than conventional interventions alone in patients with CLBP.¹⁴ That CPG also found moderate-quality evidence that intensive multidisciplinary biopsychosocial rehabilitation with a functional restoration approach is more effective than outpatient non-multidisciplinary rehabilitation or usual care with respect to improvements in pain for CLBP. Multidisciplinary rehabilitation programs based on biopsychosocial models for the management of CLBP were recommended.

The CPG from Europe in 2004 found moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with a functional restoration approach is more effective than outpatient non–multidisciplinary rehabilitation or usual care with respect to improvements in pain for CLBP.¹⁵ That CPG also found strong evidence to support the efficacy of intensive multidisciplinary biopsychosocial rehabilitation with a functional restoration approach with respect to improvements in pain and function for CLBP. There was no evidence comparing the efficacy of multidisciplinary biopsychosocial rehabilitation with a functional restoration approach to sham procedures for CLBP.

The CPG from the United States in 2007 found evidence to support the efficacy of functional restoration with CBT with respect to improvements in work absenteeism.¹⁶

The CPG from Italy in 2007 recommended that multidisciplinary rehabilitation should include a comprehensive diagnostic assessment and both individual CBT and back exercises when used for the management of CLBP.¹⁷

The CPG from the United Kingdom in 2009 recommended that multidisciplinary rehabilitation should include CBT, exercise, and some aspect of goal setting or problem solving for CLBP.¹⁸ That CPG also recommended multidisciplinary rehabilitation for patients who continue to have high disability or psychological distress after receiving less intensive interventions, and suggested that the more extensive multidisciplinary rehabilitation approaches were indicated for those with CLBP and a poor prognosis, whereas lower intensity approaches were indicated for those with CLBP and a good prognosis. There was insufficient evidence to determine that any one particular approach to multidisciplinary rehabilitation was superior to others for CLBP.

The CPG from the United States in 2009 found good evidence to support the efficacy of multidisciplinary rehabilitation using a CBT approach in the management of CLBP.¹⁹

Findings from the above CPGs are summarized in Table 22-2.

TABLE 22-2 Clinical Practice Guideline Recommendations on Functional Restoration for Chronic Low Back Pain

Systematic Reviews

Other

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