Pain Rehabilitation



Pain Rehabilitation


Steven P. Stanos

Wilson J. Chang




“Rehabilitation is a continuous process.”1

Rehabilitation may be described as a “return to ability … the return to the fullest physical, mental, social, vocational, and economic usefulness that is possible for the individual.”2

The focus is placed more on one’s abilities rather than their disabilities.2


Historical Overview: Pain Rehabilitation and Functional Restoration

In 2016, in response to the Institute of Medicine’s (IOM)3,4 recommendations to improve the scope and breath of pain management, the National Pain Strategy (NPS), a call to develop a comprehensive population health level strategy to address pain prevention, care, education, and research, was released. Included in the plan is a need to focus on biopsychosocial-based self-management and more formal multidisciplinary team-based models of care. NPS defined “high-impact pain” as pain associated with “substantial restriction of participation in work, social, and self-care activities.” This chapter is a foundation to apply a “rehabilitation model” to address the critical needs facing those patients suffering with the debilitating effects of chronic pain, including high-impact chronic pain. In this approach, “function” and “restoration” of previous activity remains the focus of providers in the rehabilitation team.


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 1500 BC where organized treatments of injured workers, fees for treatment, and compensation for injury were established.5 The development of more expertise and a more rational treatment and management approach of pain was delayed until the birth of the field of anesthesia in the 1840s and the isolation and synthesis of morphine by Serturner in 1806 and salicylates from willow bark in the late 1800s.6 The modern development of a rehabilitation model evolved only after World War I and World War II with the birth of the fields of physical and occupational therapy as a means to “rehabilitate” injured returning soldiers.7 Pain rehabilitation developed in the context of evolution of the medical specialties of physical medicine and rehabilitation, anesthesia, psychiatry, and occupational medicine during the 20th century. John Bonica championed a more comprehensive “multidisciplinary” approach in the United States in 1947 and later at the University of Washington in 1960.8 Wilbert Fordyce, a psychologist and collaborator of Bonica, incorporated operant conditioning and other behavioral approaches with more specialized 8-week inpatient programs in the late 1960s. In 1982, John Loeser formalized a more “structured program” at the University of Washington, a 3-week daily program, which has become a model for “interdisciplinary” treatment. A more biopsychosocial approach to pain rehabilitation has also been facilitated by the merging of behavioral and cognitive fields and the subsequent cognitive-behavioral approach to the assessment and treatment of pain in the 1980s and 1990s.9,10,11 A proliferation of pain treatment facilities was seen between 1980 and 1995 and included the advancement of interventional procedures.12 A more recent conceptualization of pain focuses on behaviors within the pain system, a biopsychomotor model of pain, which incorporates three interdependent behavioral subsystems: (1) communicative, (2) protective, and (3) social response behaviors.13 This model assumes that a pain system can only be adaptive if 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. The biopsychomotor model of pain can be extended to include behavioral factors such as communicative behavior (grimacing), protective behaviors (i.e., withdrawing a limb from the fire), and behaviors designed to elicit social responses (i.e., empathy and solicitous behavior from others). This model, like the biopsychosocial one, emphasizes that dysfunction may develop in behavioral systems separate from pain sensation, and subsequent treatments targeting pain behavior would more likely lead to greater clinical outcomes and provide a more pragmatic and inclusive model for the spectrum of pain rehabilitation (Fig. 90.1).






FIGURE 90.1 Biopsychomotor response to pain. (Redrawn from Sullivan MJ. Toward a biopsychomotor conceptualization of pain. Clin J Pain 2008;24[4]: 281-290, with permission.)



HISTORY OF FUNCTIONAL RESTORATION AND WORK REHABILITATION

Functional restoration (FR) programs, based on a return-towork model, evolved along with advancements in occupational medicine beginning in the 1970s. Prior to this, programs of “habit training” focused on restoring workers affected by disease or injury in the 1920s and later by the incorporation of vocational rehabilitation mandated at the federal level in 1923 and 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 championed by Lillian Wegg and Florence Cromwell.14,15 In the 1970s, work hardening emerged as a formal industrial management service16 and adopted a similar multidisciplinary approach used in the management of chronic pain and disability. Standardized work stimulation equipment, assessment, and treatment protocols were incorporated into standard practice in the 1980s and led to formal accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) in the late 1980s and early 1990s.17,18,19

Gatchel et al.20 described eight classic critical elements of an FR approach which serves as the foundation for most multiand interdisciplinary rehabilitation-based programs. Elements include quantification of physical deficits on an ongoing basis, psychosocial and socioeconomic assessment used to individualize and monitor progress, and an emphasis on reconditioning of the injured area or body part. The team-centered FR approach also includes generic simulation of work or activity, disability management with cognitive-behavioral approaches, psychopharmacologic management focusing on improving analgesia, sleep, and affective distress, many times detoxifying patients from medications (i.e., opioids or benzodiazepines).20


WHAT IS PAIN REHABILITATION?

A pain rehabilitation model can be applied to the entire spectrum of pain conditions, from acute musculoskeletal injuries, to subacute and recurrent injuries aggravated by poor ergonomics and/or physical impairments, to more complex chronic pain conditions where interplay of biologic, psychologic, and social influences is more apparent. Pain rehabilitation is based on a structured, individualized approach. The formal assessment identifies specific problems and needs most relevant to the patient and relates the problem to impairments and psychosocial factors, selecting appropriate measures to monitor progress and treatment. The rehabilitation program includes planning and coordinating various interventions with a focus on treating the specific impairments by restoring function and identifying compensatory strategies. Additionally, addressing activity limitations by addressing environmental and personal factors may help in restoring patients to previous levels of functioning and preventing or limiting disability.1

A traditional definition of rehabilitation, based on a biomedical model, places the concept of rehabilitation as a secondary intervention, used to restore patients to their previous level of (residual) physical, psychologic, and social functioning, and, if possible, return them to (modified) work.21 Waddell and Burton22 question this assumption in that the biomedical definition assumes that disability is a “matter of permanent impairment,” that sickness and disability imply an incapacity to work, that rehabilitation focuses on “irremediable permanent impairment,” and that rehabilitation is a second-stage process following acute medical management and only is carried out after treatment ceases. Waddell and Burton22 have implied this may be inappropriate in that in many chronic pain conditions (i.e., low back pain), objective factors (pathology and impairment) accounts for a small part of the incapacity. These chronic conditions are characterized more by “symptoms and distress” than tissue abnormality.22 A number of biopsychosocial risk factors (i.e., lower level of education, higher preoperative pain, low work satisfaction, longer duration of sick leave, somatic complaints, and passive avoidance coping) have been identified as predictors of poor outcomes after surgical interventions contributing to loss of function, increased disability, and persistent elevated levels of subjective reports of pain.23,24 These biopsychosocial risk factors may serve as important potential targets for pain rehabilitation.


STAKEHOLDERS IN REHABILITATION

Pain rehabilitation also involves the coordination of a number of important stakeholders involved in the care of the individual patient or worker. Stakeholders may include various health care providers, managed care organizations and insurers, the workers’ compensation carrier, society, the individual patient, and family members. This complex health care process and related list of stakeholders involved may sometimes add, as described by Shultz et al.25 and Gatchel et al.,20 a political dimension to the individual patient’s assessment and treatment process. Success in treatment may vary depending on stakeholder and may indirectly lead to antagonistic, confrontational, and misinterpreted feelings by the patient suffering with pain. Criteria of success may vary significantly depending on whether it is assessed by the patient or by society in general (Fig. 90.2). Many times, contrary to what is seen in other areas of clinical medicine, the pain rehabilitation clinician may find himself or herself in a potentially conflicting role in the treatment of patients with chronic pain (Table 90.1). The focus of care should remain on providing appropriate clinical services, serving as a patient advocate or adjudicator, without crossing ethical boundaries resulting in harm to the client.26

This chapter focuses on an overview of assessment and treatment strategies included in a pain rehabilitation-based approach to acute and chronic pain conditions. As part of the clinical continuum, the more comprehensive and integrated treatment approaches commonly referred to as multidisciplinary, interdisciplinary, and/or FR27 will be examined. Important psychological factors related to chronic pain and disability, the continuum of treatment models from more acute to integrative approaches, specific responsibilities of members of a pain rehabilitation team (i.e., physical and occupational
therapist, psychologist, relaxation therapist, and vocational specialist), and an overview of more specific work rehabilitation approaches including work conditioning, work hardening, and functional capacity testing will be reviewed.






FIGURE 90.2 Criteria for success in comprehensive pain programs. (Redrawn from Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain 2006;7[11]:779-793. Copyright © 2006 American Pain Society. With permission.)








TABLE 90.1 Conflicting Roles of Rehabilitation Specialist









  1. Clinical service provider working to reduce the client’s suffering



  2. Client’s advocate working to protect the client in conflicts with an insurer



  3. An adjudicator working to help the insurer detect evidence of client’s fraudulent behavior


From Sullivan MJL, Main C. Service, advocacy and adjudication: balancing the ethical challenges of multiple stakeholder agendas in the rehabilitation of chronic pain. Disabil Rehabil 2007;29(20-21):1596-1603. Reprinted by permission of Taylor & Francis Ltd. www.tandfonline.com.



Models of Rehabilitation

Conceptual models of pain rehabilitation are based on historical advances that initially described pain as a purely sensory phenomenon evolving to include a more mind-body approach to understanding disability and function (Table 90.2). Hippocrates and Galen (c. 150 AD) described an imbalance of bodily “humors” as a means of developing chronic pain and distress as a model for understanding suffering.28 In the 1600s, a dualistic mechanistic model emerged. René Descartes (1596-1650) theorized damage to the body would stimulate specific neural pathways, giving rise to the sensation of pain.28 Through the mid-19th century, medicine focused on the individual’s unique manifestations of the disease process. In the mid-1800s, the expanding understanding of pathologic anatomy shifted the focus to a more biomedical model. In 1965, Melzack and Wall29 proposed the gate control theory of pain which proposed that pain experience was determined by physical, motivational, cognitive, and emotional factors, and transmission of nerve impulses could be modulated by spinal gating mechanisms at the level of the dorsal horn. Melzack30 elaborated on this more dynamic role of pain networks further with the “neuromatrix” model, arguing that the brain and central nervous system play a dominant role in the pain experience.


BIOPSYCHOSOCIAL APPROACH VERSUS BIOMEDICAL MODEL FOR PAIN MANAGEMENT

The biomedical model assumes a causal relationship between a specific physical pathology and the presence or intensity of pain symptoms. It emphasizes the importance of eliminating pain by restoring normal function in the organ or body part from which pain is thought to emanate. Although the more disease-based biomedical model enabled the medical sciences to flourish and improved our ability to treat infection and other disease processes, its fundamentally limited scope led to less profound success and relative treatment resistance in the treatment of many chronic pain states. A biomedical model may be more advantageous in treating more acute pain states, where interventional procedures, pharmacotherapy, and surgical interventions may lead to recovery of pain or hasten time to recovery. But the biomedical model poorly addresses related mental health issues and frequently relies on dualistic decision pattern, whereby if the patient does not respond to an intervention, then the pain may be not be “real” or just “in their heads.”31 Many more complex pain conditions remain resistant to a purely biomedical approach (i.e., chronic low back pain, neuropathic pain, and fibromyalgia).32 George Engel33 helped to shift the thinking from a purely biomedical model of disease management to a more comprehensive biopsychosocial model of illness. Recently, the World Health Organization34 has embraced a biopsychosocial model of disability (Fig. 90.3), which incorporates a dynamic interaction between the individual health condition and contextual factors.








TABLE 90.2 Historical Overview: Models of Pain
























Hippocrates and Galen28


Bodily humors


Descartes28


Dualistic theory


Melzack and Wall29


Gate control theory


Engel30


Biopsychosocial approach in medicine


Melzack and Wall30


Neuromatrix model


Turk and Gatchel9


Biopsychosocial approach


Sullivan13


Biopsychomotor approach







FIGURE 90.3 Domains of the biopsychosocial approach to pain rehabilitation. (Redrawn from Waddell G, Burton AK. Concepts of rehabilitation for the management of low back pain. Best Pract Res Clin Rheum 2005;19[4]:655-670. Copyright © 2005 Elsevier. With permission.)

The pain rehabilitation approach is based on a fundamental understanding of the individual’s unique condition as it relates to (1) impairment, (2) disability, and (3) functional limitation. Impairment is the loss of normality psychologically, physically, or functionally at the level of the organs and body systems.35 Examples of physiologic impairments include muscle weakness, loss of range of motion, and pain. Disability is a restriction or lack of ability to perform activities due to related impairments such as inability to function in a specific vocation, as a spouse, student, or parent. Functioning has been described as an umbrella term for body functions, body structures, activities, and participation, denoting a positive interaction between the individual or patient and contextual factors (i.e., background of the individual’s life and current situation). Functional limitation is a deviation from the normal behavior of performing activities of daily living (ADLs) and may include problems with transfers, standing, ambulation, running, and stair climbing.35 A formal model proposed by the International Classification of Functioning, Disability and Health integrates the individual components into a biopsychosocial-based model where a “health condition” is substituted by “chronic pain” (Fig. 90.4). Chronic pain is affected by body function, activities, and participation as well as influences from the environment and personal factors.

A patient-centered approach is necessary if one is to effectively address these important individual concepts. A teamcentered approach focuses on helping patients to achieve individual goals, which enable them to improve physical and psychosocial function, decrease pain, and improve quality of life. By working together, the rehabilitation team is able to help patients achieve better outcomes than could be achieved
by an individual practitioner or intervention (i.e., surgical procedure, injection, pharmacotherapy). Basic treatment goals of both acute and chronic pain rehabilitation programs focus on functional improvement; improved abilities to perform ADLs, return to leisure, sport, or vocational activities; and improved pharmacologic management of pain and related affective distress (Table 90.3).






FIGURE 90.4 A formal model demonstrating the relationship among individual components that affect an individual’s function was proposed by the International Classification of Functioning, Disability and Health. This model was proposed for any “health condition,” and here, we have substituted “chronic pain” for the more generic term. (Redrawn from Weigl M, Cieza A, Cantista P, et al. Physical disability due to musculoskeletal conditions. Best Pract Res Clin Rheum 2007;21[1]:167-190. Copyright © 2006 Elsevier. With permission.)


TREATMENT APPROACHES: PAIN REHABILITATION

A pain rehabilitation approach encompasses a wide range of treatment options including more directed therapies for acute pain conditions to more comprehensive and collaborative multi- and interdisciplinary approaches (Table 90.4).


Acute Rehabilitation

An approach to managing acute pain conditions relies on a more focused understanding of causative and aggravating factors, changes to affected tissues and related overload stresses, and includes three important phases: (1) acute, (2) recovery, and (3) functional. Within each phase, specific treatment focuses are applied by the therapist or clinician, and tools or skills are taught by the treating therapist with a goal of ongoing self-management and practice. Acute management may involve relative rest, passive modalities (ice, heat, ultrasound), interventional procedures (i.e., trigger point injections, epidural, and facet injections), and oral and topical analgesics. Recovery phases focus on more advanced stretching and strengthening, increasing endurance, and assessing and treating postural changes that may be contributing to chronic pain.36


More Comprehensive Team Models: A Pain Continuum

Rehabilitation treatment models include a continuum of care based on patient severity and needs with increasing complexity of treatment philosophies, a need for greater communication, and decreasing individual team member autonomy.37 Each of these models occupies a position along a continuum of care based on increasing levels of coordination, diversity of philosophies, and decreased hierarchical structure and practitioner autonomy. The left side of the treatment continuum (Fig. 90.5) shows the least collaborative model, parallel practice, where health care providers function quite independently. As one moves to the right, services become more coordinated with decreasing level of autonomy and increasing diversity of philosophies. From a structure standpoint, moving left to right increases the complexity of care, whereas reliance on hierarchy and clearly defined roles decreases. Complexity and diversity of outcomes increases while, from a process perspective, communication, participants, synergy, and importance of consensus building increases. Multi- and interdisciplinary treatment is even more structured, usually involving a number of specialties with less evidence of practitioner autonomy.








TABLE 90.3 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


With parallel practice, independent health care practitioners are working within their defined scope of practice such as in an emergency room setting or an acute cardiac unit (i.e., nurse, phlebotomist, physician, radiology technician) where the goal is rapid assessment and treatment in the most efficient manner. Consultation may include a pain physician referring a patient to an addiction specialist or surgeon for recommendations and shared treatment responsibilities. Collaborative practice may include the use of a case manager to help coordinate treatment between the patient and physical therapist. In a collaborative approach, information is shared on an ad hoc basis; practitioners normally practice independently sharing information regarding a particular patient. In coordinated treatment, patient records are shared among clinicians providing treatment for a specific therapy where the case coordinator or case manager is responsible for ensuring information is transferred to all team members. Differentiating between multi- and interdisciplinary treatment will be reviewed in greater detail in the following text. Although commonly used interchangeably, the terms interdisciplinary and multidisciplinary have important distinguishing features.




Outcomes of Multi- and Interdisciplinary Treatment Programs

An early prospective trial documented high rates of return-to-work versus control subjects with improved physical capacities, self-reported disability, depression, and pain scores.42 Maintained posttreatment improvements in pain, perceived health, and psychological and physical function have been demonstrated in long-term studies (6 months and 5 years).43,44 The interdisciplinary treatment approach is supported by evidence suggesting these programs are more cost-effective and provide at least equal or greater efficacy than other pain treatments (i.e., spinal cord stimulation and implantable devices, conservative care, and surgery).45 Additional evidence-based studies have demonstrated outcomes and treatment cost-effectiveness data supporting FR treatment which included multidisciplinary and interdisciplinary treatment programs.46,47,48 A recent analysis examined the cost utility of interdisciplinary treatment of chronic spinal pain.49 Cost utility involved the calculation of cost of the specific treatment relative to desired treatment goal (increased functioning and decreased pain) relative to pharmacologic treatment with or without anesthetic interventions. Interdisciplinary treatment was associated with better cost utility supporting interdisciplinary treatment as both less costly and more effective.49 Patients undergoing complex lumbar spine surgeries have also demonstrated improvements in pain and function.50 Although early intervention and referral for pain rehabilitation treatment should intuitively favor greater outcomes as compared to referrals late in the treatment process, studies have demonstrated that patients with long-term disability, many of whom have a greater incidence of pretreatment surgery, may still benefit from comprehensive treatment with similar improved return-to-work rates and decreased lost time rates.51 Rehabilitation-based multidisciplinary treatment
has demonstrated high cost-benefit with regard to decreasing treatment costs and increasing workplace return to work.52,53 Sustained improvement in pain, mood, function, and opioid reduction or discontinuation was demonstrated in a large cohort of patients enrolled in a structured FR program. Patients entering treatment on opioids retained similar benefits regardless of opioid dose (i.e., high or low daily morphine equivalent doses).54


Team Building and Stakeholder Coordination



APPLYING TEAM VALUES

Decision making in pain rehabilitation has been found to incorporate common decision values shared by the team members, worker, and stakeholders. Shared “general values,” as described by Loisel et al.,60 are those that stress work is therapeutic, pain is multidimensional, and interventions should be graded. These values should in turn be shared by the team members, the worker, and stakeholders facilitated by reassurance and the delivering of a single message as a way of more successfully returning a patient to work or previous level of function.60 These same values can be applied to the many barriers presented to the individual patient and stakeholder (Table 90.5).


Assessment, Goal Setting, and Progression through Treatment


PAIN REHABILITATION PRINCIPLES

Assessment of patients prior to entering a rehabilitation program is based on a comprehensive examination of physical, psychological, and social or relevant vocational factors. Also, the evaluating clinician must work to develop trust and rapport with the patient in order to understand barriers to recovery (i.e., contentious relationships involving family, employer, case manager, and/or the legal system) that may potentially lead to a delay or reduction of clinical improvement. Many times, the success of developing that relationship starts at the initial evaluation. Understandably, patients undergoing a rehabilitation program are often asked to make significant changes in the ways they cope with pain and function. Readiness to make such important changes has been found to be associated with treatment success,61,62 and readiness to self-manage pain increases from pre- to post-MPC treatment.63 Based on the transtheoretical model of behavior change, individuals are seen to progress through a number of stages involving decisions about change and include precontemplation, contemplation, action, maintenance, and acceptance phases.64 These basic concepts are important for the physician to explore during the evaluation and often become a focus of discussion between other potential treatment disciplines (i.e., pain psychologist, physician, and vocational counselor) when deciding whether the patient is an appropriate candidate for treatment. The pain rehabilitation clinician must be consistent and clear in promoting exercise and activity as essential, safe, and effective for the correction of functional impairments. The clinician must also be aware of various fears, negative attitudes, financial, and vocational stressors many chronic pain working and nonworking patients
are sometimes struggling with and be able to confront the patients on these issues in an open and understanding manner (Table 90.6).65








TABLE 90.5 Strategies Applied by the Rehabilitation to Overcome Barriers to Collaboration




















Stakeholders


Strategies Applied


Worker


Pain management


Relaxation


Education


Confrontation


Rational polypharmacy: analgesia, sleep, mood


Employer


Education


Asking for employer’s opinion on the TRW setting


Sensitizing the employer to its support role in relation to the worker


Asking the insurer to use its authority to exert influence on the employer


Insurer


Education


Sensitize to the issues involved in the intervention


Clarification of the roles and objectives


Meeting with the insurer’s case worker before meeting the worker or the employer to ensure consistency in information delivered


Acting without interfering


Choosing convincing information


Asking for the case worker’s support for the intervention


Physician


Inform the physician about the rehabilitation process


Convincing him or her to take action to facilitate return to work


Recommendation that worker find another physician if too great a hindrance to the TRW process


TRW, therapeutic return to work.


Adapted by permission from Springer: Loisel P, Durand M, Baril J, et al. Interorganizational collaboration in occupational rehabilitation: perceptions of an interdisciplinary rehabilitation team. J Occup Rehab 2005;15(4):581-590. Copyright © 2005 Springer Science + Business Media, Inc.


Sep 21, 2020 | Posted by in PAIN MEDICINE | Comments Off on Pain Rehabilitation
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