The World Health Organization (WHO) developed a comprehensive model of disablement, the International Classification of Functioning, Disability and Health (ICF) 2009; this classification is depicted in Table 13.1. The ICF framework is intended to describe and measure health and disability at both the individual and population levels and consists of three key components:
Table 13.1
Pain rehabilitation goals
1. Functional improvement |
2. Improvement in activities of daily living |
3. Relevant psychosocial improvement |
4. Rational pharmacologic management (analgesia, mood, and sleep) |
5. Return to leisure, sport, work, or other productive activity |
1.
Body functions and body structures: physiological functions and body parts, respectively; these can vary from the normal state, in terms of loss or deviations, which are referred to as impairments.
2.
Activity: task executions by the individual and activity limitations are difficulties the individual may experience while carrying out such activities.
3.
Participation: involvement in life situations and participation restrictions are barriers to experiencing such involvement. These components comprise functioning and disability in the model. In turn, they are related interactively to an individual with a given health condition, disorder, or disease and to environmental factors and personal factors of each specific case.
A patient-centered, “whole-person” approach is necessary to effectively address these important individual concepts. A team-centered treatment approach is utilized, focusing on helping patients achieve individual goals, which enable them to improve physical and psychosocial function, decrease pain, and improve quality of life. By working together, the chronic pain rehabilitation team helps patients achieve better outcomes than those achieved by an individual practitioner or interventions (i.e., surgeries, injections, pharmacotherapy, and psychological therapies) in isolation. Basic treatment goals of early and chronic pain rehabilitation programs focus on functional improvement, improved abilities in performing activities of daily living (ADLs), returning to leisure, sport, and vocational activities and improved pharmacologic management of pain and related affective distress (see Table 13.1).
History of Pain Rehabilitation
Early evidence of a rehabilitation approach to the injured person or worker dates back to the Egyptians under Ramses II, in 1,500 B.C. [5]. Further advances in treating pain seemed to be delayed until many years later, with the birth of the field of anesthesia in the 1840s, the isolation and synthesis of morphine by Serturner in 1806, and the discovery of salicylates in willow bark in the late 1800s [6]. Modern advancements in understanding health and health psychology in the 1950s also shaped a more comprehensive view of the complexities of an individual’s pain experience. This led to the view that the experience of pain is a complex phenomenon and multiple models have evolved over time to explain it. Traditionally, the biomedical model explains pain through etiologic factors (e.g., injury) or disease whose pathophysiology results in pain. Over time, it became clear this classic biomedical approach to understanding and treating pain was incomplete. Its exclusive application often resulted in unrealistic expectations on the part of the physician and patient, inadequate pain relief, and excessive disability in those with pain that persists well after the original injury has healed.
George Engel [7] developed a novel theory of health care in which the various areas impacting an individual’s disease process are taken into consideration. When developing a health-care plan, Engel posited that there were several factors affecting each individual and his/her disease processes. These factors include (1) biological, (2) sociological, (3) environmental, (4) cultural, and (5) psychological. This became known as the biopsychosocial model [8]. This biopsychosocial model was subsequently successfully applied to the assessment and treatment of chronic pain [9, 10]. In contradiction to the biomedical model, this model recognizes pain is ultimately the result of the pathophysiology, plus the psychological state, cultural background/belief system, and relationship/interactions individuals have with their environment (workplace, home, disability system, and health-care providers). To put it more simply, to treat the pain and the illness, the whole person needs attention.
The modern rehabilitation model evolved after World Wars I and II, with the founding of the fields of physical and occupational therapy as a method to rehabilitate returning soldiers who had been injured in performance of service to their country [11]. The practice of pain rehabilitation increasingly developed during the twentieth century by evolving medical specialties of physical medicine and rehabilitation, anesthesia, psychiatry, and occupational medicine. John Bonica, one of the fathers of pain medicine, championed a more comprehensive biopsychosocial multidisciplinary approach in the United States in 1947. This approach expanded to include a team of clinicians at the University of Washington in the 1960s [12]. Bonica’s collaboration with Wilbert Fordyce, a psychologist, incorporated operant conditioning and other behavioral approaches with more specialized, structured, and inpatient multi-week programs. In the 1980s, John Loeser formalized a more at structured program the University of Washington. This 3-week long, daily program became a model for interdisciplinary treatment.
An increasingly biopsychosocial approach to pain rehabilitation, facilitated by the merging of behavioral and cognitive fields and subsequent cognitive-behavioral approaches to the assessment and treatment of pain, developed in the 1980s and 1990s [13]. A proliferation of pain treatment facilities was seen between 1980 and 1995. These facilities included the advancement of interventional procedures as treatment for chronic pain [14]. A more recent conceptualization by Sullivan [15], the biopsychomotor model, focuses on behaviors within the pain system incorporating three independent behavioral subsystems: (1) communicative, (2) protective, and (3) social response behaviors. In this model, a pain system is assumed to be only adaptive. The sensory component of the pain system is accompanied by behaviors designed to act on the source, or cause of injury or illness. This may help to explain the wide variability observed in pain behaviors seen across different patients, despite relatively similar levels of reported pain intensity and objective tissue pathology. In this model, a more sensory-based model of pain extends to include behavioral factors: communicative behaviors (i.e., grimacing), protective behaviors (i.e., withdrawing a body part from fire), and social responses (i.e., empathy and solicitous behavior from others). This model, as in the biopsychosocial model, emphasizes dysfunction developing in behavioral systems separate from pain sensation. Subsequent treatments targeting pain behavior likely lead to better clinical outcomes and provide a more pragmatic and inclusive model for the spectrum of pain rehabilitation (see Fig. 13.2).
Applying a Biopsychosocial Model to Pain Rehabilitation
The biopsychosocial model of diagnosis and treatment operates on the idea that illness and disability is the result of, and influences, diverse areas of an individual’s life, including the biological, psychological, social, environmental, and cultural components of their existence. In individuals with chronic pain conditions, the pain continues past the time the initial injury has healed. There are numerous challenges and issues that the patient faces and that must be addressed. These include guarding of the injured area, fear of movement and reinjury, adoption of the sick role along with cultural beliefs about pain, the loss of productivity, a decrease in beneficial leisure activities, the loss of income, and change in the role and responsibilities within the family and the community at large.
There are several factors identifying those individuals at risk for transitioning from an acute pain episode to a chronic pain condition. These factors are (1) unresponsiveness to traditional therapies normally effective for that particular diagnosis, (2) considerable psychosocial factors which negatively influence recovery, (3) unemployment or lengthy absence from work, (4) history of prior delayed recovery or rehabilitation, (5) the employer is not supportive or accommodative of the needs of the individual, and (6) history of childhood abuse: verbal, physical, or mental. Of the previous factors, lost time from work is most predictive of those at risk of encountering delayed recovery [16].
Chronic pain usually starts with an acute pain episode although, in some cases, there is no acute event, but rather the recognition of a pain problem. When a delayed recovery is recognized, the diagnosis and treatment approach should be reconsidered. At this time, psychosocial risk factors should be identified and the patient either treated by the attending physician or specialist using a biopsychosocial approach, or when appropriate, referred to an FR chronic pain program. A treatment plan addressing the presenting symptoms and attendant risk factors delaying recovery can then be developed and implemented. With a diagnosis of delayed recovery, a program focusing on the individual’s biomedical condition, not addressing the complex requirements inherent in delayed recovery, will not be efficacious [9].
Individuals at risk of developing chronic pain conditions, as evidenced by lack of progress toward healing and a return to normalcy, are benefited by a multidisciplinary FR program. Physical and psychological interventions can be employed before disability becomes chronic. Early intervention minimizes long-term treatment costs and the negative physical, psychological, and sociological effects of disability, restoring the individual to an optimal level of functioning [16]. Many times, a purely biomedical model continues to be applied, with a narrow focus on reversing or eliminating nociception, or the “pain generator,” and is more focused on a cure than on effective management. The biomedical model ignores or minimizes psychosocial factors, as well as the more complex central changes in the nervous system (i.e., sensitization of tissue, pathways, and neurochemical changes related to affective distress),that, not surprisingly, results in treatment failure (see Table 13.2).
Table 13.2
The biomedical versus the biopsychosocial model of pain
Biomedical model | Biopsychosocial model |
|---|---|
Suitable for acute pain management | Suitable for chronic pain management |
Concentrates on physical disease mechanisms | Illness behaviors incur[prating cognitive and emotional responses to pain are acknowledged |
Accentuates peripheral perception of pain (nociception) | Understands the role central physiological mechanisms play in the modulation of peripheral nociception or the generation of pain experience in the absence of nociception |
Approach to understanding/treating pain is reductionistic | Understanding and treating pain is approached with a multidisciplinary systems perspective |
Relies on medical management approaches | Utilizes self-management approaches |
History of Functional Restoration and Work Rehabilitation
Historically, FR is a term that was initially used for a variety of pain rehabilitation programs characterized by objective measure of physical function, intensive graded exercise, and multimodal pain/disability management, with both psychosocial and case management features. The concept of functional restoration was first described in the mid-1980s. Functional restoration programs for chronic pain have strong support in the medical literature going back to the early 1990s. The term “functional restoration” has in recent years become increasing popular with evidence-based medicine support, and it has been adopted as the treatment paradigm of choice for chronic conditions and particularly chronic pain states. Indeed, the effectiveness of functional restoration programs has been independently replicated throughout the world [17]. For patients with more complex or refractory problems, a comprehensive multidisciplinary approach to pain management that is individualized, functionally oriented (not pain-oriented), and goal specific has been found to be the most effective treatment approach [10, 18, 19].
Functional restoration (FR) programs, which are based on a return to work model, evolved along with advancements in occupational medicine, beginning in the 1970s. Prior to this, in the 1920s, programs of habit training, focused on restoring workers affected by disease or injury and later, in 1923, by the incorporation of vocational rehabilitation, were mandated at the federal level by the Vocational Rehabilitation Act. In the 1950s, more objective measures were used to track progress and measure outcomes and served as the starting point for more formal work conditioning and work hardening programs. These innovative programs were championed by Lillian Wegg and Florence Cromwell [20]. Subsequently, in the 1970s, work hardening emerged as a formal industrial management service [21], adopting a similar multidisciplinary approach that was used in the management of chronic pain and disability. Standardized work simulation equipment, assessment, and treatment protocols were incorporated into standard practice in the 1980s, leading to formal accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) in the late 1980s and early 1990s.
Recent evidence-based guidelines strongly support the use of interdisciplinary functional restoration-based programs for the treatment of chronic pain, including low back pain [19]. For the treatment of chronic nonradicular low back pain, interdisciplinary functional restoration treatment, including cognitive-behavioral interventions, is supported by high-quality evidence. Within these same evidence-based guidelines, shared decision making for potential surgical intervention for low back pain should include a discussion of interdisciplinary treatment, since interdisciplinary therapy was found to be equally effective in long-term outcome studies [22].
Applying Functional Restoration Approach: Multi- and Interdisciplinary Treatment
Functional restoration is an evidence-based, empirically proven component of multi- and interdisciplinary pain management programs, emphasizing physical activity and psychosocial therapy and anticipating an individual’s gradual progression to a normal lifestyle. FR programs emphasize a multidisciplinary, biopsychosocial approach in which physicians, psychologists, occupational and physical therapists, and therapists specializing in other relaxation techniques all work in concert with each other. The ultimate goal is the development and implementation of treatment plans individualized to fit each patient’s unique needs. These programs are regarded as the treatment of choice for chronic conditions, particularly chronic pain conditions [23]. Such programs are both therapeutically and cost-effective in treating chronic pain conditions and restoring a patient to a productive lifestyle. Moreover, while FR programs are effective for chronic pain conditions, many believe this type of program would be both cost-effective and efficacious for other chronic conditions as well [24].
Gatchel et al. [25] have delineated the described critical elements of a functional restoration approach, which serves as the foundation for most multi- and interdisciplinary rehabilitation-based programs. These elements include quantification of physical deficits on an ongoing basis; psychosocial and socioeconomic assessment used to individualize and monitor progress; an emphasis on reconditioning of the injured area or body part; generic simulation of work or activity; disability management with cognitive-behavioral approaches; psychopharmacologic management focusing on improving analgesia, sleep, and affective distress; and, in some cases, detoxifying patients from medications (i.e., opioids or benzodiazepines). Individually tailored, these programs initially emphasize moderate physical interventions (i.e., stretching, strengthening, conditioning) and gradually progressing to more active, strenuous therapies with the goal of obtaining maximum rehabilitation and normalization in all facets of a person’s lifestyle. This includes return to work, improved socioeconomic factors and self-esteem, and cognitive behavior therapy (CBT) addressing beliefs about pain, the resulting dysfunction, and environmental and socioeconomic factors. Research shows that a chronic pain patient’s treatment needs are best addressed by such a multidisciplinary treatment program [26]. However, a biopsychosocial model of health care is not only efficacious in the treatment of chronic pain. Patients presenting with other disease processes are likely to benefit from this type of treatment concept.
Major Components of Functional Restoration
Some confusion has developed with the mixing of terms such as multi- and interdisciplinary models [10]. In the multidisciplinary model, patient care is planned and managed by a team leader, usually a pain specialist (anesthesiologist, physiatrist, neurologist, psychiatrist, or primary care provider), or a psychologist, and often hierarchical, with one or two individuals directing the services of a range of team members, many with individual goals. Treatment may be delivered at different facilities or centers where individual patient progress is not regularly shared between distinct disciplines. In contrast, the more collaborative interdisciplinary model involves team members working together “under one roof” toward a common goal. Team members are able to communicate and consult with other team members on an ongoing basis, facilitated by regular, face-to-face meetings. The interdisciplinary model provides practical strategies for assessing and treating pain-related deconditioning, psychosocial distress, and socioeconomic factors related to disability. An interdisciplinary team model is characterized by team members working together for a common goal, making collective therapeutic decisions, having face-to-face meetings and patient team conferences, and facilitating communication and consultation. Interdisciplinary teams may be led by a physician (medical director), psychologist, or nurse, and it includes comprehensive assessment incorporating pain medicine, pain psychology, physical functional restoration, and vocational rehabilitation. Physical and occupational therapy assessments are also included in the formal assessment. Interdisciplinary programs are usually housed in one facility, with group goal setting, periodic interdisciplinary team meetings assessing and adjusting treatment progress, program coordination, and discharge planning. The physical aspects of these programs focus primarily on restoring joint mobility, muscle strength, endurance, conditioning, and cardiovascular fitness. The psychological aspects focus on cognitive behavioral strategies for pain management. The coordination of vocational and therapeutic recreation services is an important aspect of care, focusing on aiding patients in their return to work, improving behavioral factors (i.e., coping, catastrophizing, and problem solving) in the workplace, clarifying return to work level of functioning, and, in many cases, providing individual therapy.
In general, formal interdisciplinary programs usually last 3–8 weeks, 4–8 h/day, with tailored group and individual therapies provided in an outpatient setting. Program schedules include individual and group-based therapies. Most importantly, regularly scheduled team conferences help to facilitate progress, troubleshoot patient problems, build consensus, improve communication regarding progress (i.e., complete conference notes and communicate to case managers and referring physicians), adjust goals of therapy, and plan for discharge. Long-term follow-up studies of interdisciplinary treatment programs demonstrate improved return to work rates, pain reduction, and quality of life. In special situations, inpatient functional restoration programs may be indicated. Inpatient pain rehabilitation programs typically consist of more intensive functional rehabilitation and medical care than their outpatient counterparts. They may be appropriate for patients who (1) do not have the minimal functional capacity to participate effectively in an outpatient program, (2) have medical conditions that require more intensive oversight, (3) are receiving large amounts of medications necessitating medication weaning or detoxification, or (4) have complex medical or psychosocial diagnoses that benefit from more intensive observation and/or additional consultation during the rehabilitation process. As with outpatient pain rehabilitation programs, the most effective programs combine intensive, daily biopsychosocial rehabilitation with a functional restoration approach. To again summarize, the fundamental elements of a functional restoration approach include assessment of the person’s dynamic physical, functional, cultural, and psychosocial status. This includes assessment of strength, sensation, range of motion, aerobic capacity, and endurance, as well as measures of what the individual can and cannot do in terms of general activities of daily living, recreational, and work-related activities. Psychosocial strengths and stressors are assessed, including an analysis of the individual’s support system, any history of childhood dysfunction or abuse, evidence of mood disorders or psychiatric comorbidity, assessment of education and skills, medication use, any history of substance abuse, presence of litigation, and work incapacity [24]. We will now review the various issues addressed in a comprehensive FR program.
Normalization of Function
Normalization of function is described as the reestablishment of independence and function, while understanding that some physical limitations may be unavoidable. Functional restoration empowers the individual to achieve maximal functional independence, the capacity to regain or maximize activities of daily living, and return to vocational and avocational activities. Depending on the current functional level of the patient, reaching their maximum level of function may take as long as 6 months to a year as they incorporate both a progressive exercise program and active pain management skills into their lifestyle. For physical limitations that are unavoidable, patients should be instructed on assistive devices and modifications for the home, and/or the workplace to allow them to achieve the highest level of function possible.
Education
At the beginning of any treatment, the patient’s understanding and belief system of his or her prognosis and treatment must be ascertained. Information from multiple providers can often be misunderstood. Patients are often informed that nothing else can be done for them. Some are given lifting restrictions of no lifting or carrying greater than 10 lb postsurgically, and they continue to adhere to these restrictions for years after the necessity has lapsed. The treating physician and/or physical or occupational therapists, treating in an acute care model, may have informed the patient not to use the body part if it were painful. All of these can leave the patient with incorrect directions on how to best manage chronic pain.
Before the patient considers participating in a functional restoration program, he or she should be informed regarding the differences between functional restoration and other treatment methods. It is not uncommon for the patient to have seen multiple doctors and therapists without any benefit or with a worsening of symptoms. The patient may have little confidence that a functional restoration approach will be more effective than any of the other treatments that they have tried. Therefore, education about diagnosis, prognosis, and expectations concerning treatment and outcome should begin as soon as possible. Explanation of the changes to the patient’s body, his or her personal experience, and how this translates to the symptoms they are experiencing is a connection that the provider must make for the patient. The patient must be provided with a confirmation that variability of symptoms and emotions are normal to their condition. The expectations concerning patient effort in the restoration process are emphasized. The active participation of the patient in the setting of treatment goals, his or her personal control of the process, and the success of the treatment are all important aspects contributing to the likelihood of successful completion of the restoration and a return to normalcy. The patient must understand that treatment will provoke discomfort and may be perceived as painful, that they will receive help with managing these symptoms, and that the outcome will be significant improvement in their overall functional level. Education regarding goals based on function, not only pain changes, is important to assist the patient in feeling successful and attaining their goals, as many patients believe that the focus of treatment is to simply reduce their pain level. Finally, the patient must be educated about the negative consequences of inactivity and resting. A significant loss of flexibility, strength, and secondary injury from guarding and abnormal movement are all possible, harmful consequences if the patient does not remain active after functional restoration therapy is complete.
Fear of Reinjury or Movement
Kinesiophobia (the fear of movement and reinjury) commonly obstructs the individual’s return to work, a normal home life, and leisure activities after an injury has occurred. Fear related to pain, and subsequent avoidance of activities, has been empirically validated as an important factor in determining the patient’s activity levels at 6–12 month post-injury [27]. Typically, patients will push themselves to increase social and physical activities in an attempt to confront and overcome the pain and disability of an injury. This may increase the pain, which increases the fear that an as-yet undiagnosed injury or illness is present. This fear may lead to a maladaptive avoidance response, which leads to lack of exercise and a physical deconditioning; this, in turn, leads to lack of muscle strength and flexibility and an increase in pain and infirmity. The patient must then be reexposed to previously avoided activities and assume a participatory role in the recovery process. Crombez et al. [28] found that “over prediction of pain,” a construct closely related to fear-avoidance, was reduced by a gradual, paced, and repeated exposure to the activity individualized to the patient’s own fear. Studies have suggested that back pain disability for some patients may be determined more by the fear of pain rather than intensity or other biomedical factors [29]. Treatment to overcome fear-avoidance includes patient education, repeated exposure to activities that have been avoided, and taking responsibility in an active role to recovery. Patients are educated on how their beliefs and behaviors can lead to a vicious cycle involving catastrophic thoughts, fear, avoidance, disability, and pain. The patient learns the difference between pain and damage, safe positioning, safe activity, and slow progression of exercise. The activity program consists of the fearful activities initially introduced at low levels and then progressed on an individual basis.
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