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.
TABLE 90.1 Conflicting Roles of Rehabilitation Specialist
TABLE 90.2 Historical Overview: Models of Pain
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).
TABLE 90.3 Pain Rehabilitation Goals
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 is 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. The growth of multidisciplinary pain treatment centers in the 1980s led to the need for development of standards and formal accreditation processes. A committee on standards for Pain Treatment Facilities was established by the American Pain Society in the early 1980s, and a process was subsequently developed to accredit multidisciplinary pain centers (MPCs) by the CARF. Non-CARF-accredited programs also exist. Furthermore, the International Association for the Study of Pain delineated four levels of pain programs38: MPCs, multidisciplinary pain clinics, pain clinics, and modality-oriented clinics. Multidisciplinary pain clinics and centers, many of which include an even more integrated comprehensive interdisciplinary approach, include similar basic treatment disciplines; however, the MPCs are usually associated with major health science institutions with an additional focus on pain-related research and outcomes.
TABLE 90.4 Pain Rehabilitation Levels of Care
FIGURE 90.5 Continuum of team models. The most common practice model is parallel practice in which each practitioner oversees only the problems within their isolated discipline with little or no interaction with other practitioners caring for the same patient. The most effective models for caring for those with chronic pain involve programs designed to allow for frequent, direct, and repeated interactions among the providers caring for each patient in the form of multidisciplinary and interdisciplinary treatment programs. (Redrawn from Boon H, Verhoef M, O’Hara D, et al. From parallel practice to integrative health care: a conceptual framework. BMC Health Serv Res 2004;4:15. © Boon et al; licensee BioMed Central Ltd. 2004. doi.org/10.1186/1472-6963-4-15.)
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
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