In April 2004, the Governor of California signed a new legislative reform package, Senate Bill 899, into Law that overhauled California’s workers’ compensation system. One of the key provisions in the new legislation requires that all medical treatment be consistent with American College of Occupational and Environmental Medicine (ACOEM) guidelines. This legislation strengthened prior reforms (AB749) by utilizing these guidelines for defining appropriate medical treatment.
ACOEM defines appropriate treatment, for an injured worker to stay at or return successfully to work following an injury. Their definition relative to this status is one in which the injured worker “must be physically able to perform some necessary job duties. This does not necessarily mean that the worker has fully recovered from the injury, or is pain‑free; it means that the worker has sufficient capacity to safely perform some job duties. Known as functional recovery, this concept defines the point at which the worker has regained specific physical functions necessary for re‑employment”. Patients who do not recover as expected usually have several interrelated causes of delayed functional recovery. Cases of delayed functional recovery require close management rather than simple care “chapter 5”
Utilization of the ACOEM guidelines can be somewhat confusing, especially in the first weeks as treatments are geared to acute pain. ACOEM defines chronic pain as pain which has not responded to treatment and exists greater than 3 months (90 days) and indicate that pain is chronic and there are factors preventing recovery) ACEOM page 108. The guidelines utilize the algorithm concept as to treatment flow and suggested response. If the course of recovery does not coordinate with the recommendations of algorithm, that after a specific time period a pain assessment is required. Referral may be appropriate if the practitioner is uncomfortable with the line of inquiry outlined above, with treating a particular cause of delayed recovery (such as substance abuse) or has difficulty obtaining information or agreement to a treatment plan. Depending on the issue involved, it often is helpful to “position” a behavioral health evaluation as a return‑to‑work evaluation. The goal of such an evaluation is, in fact, functional recovery and return to work” ACOEM chapter 5
ACOEM directs the provider to Chapter 5 and Chapter 6, if the pain assessment is indicative of delayed factors of recovery. When pain becomes chronic, greater than 3 months, a more intensive tertiary care or interdisciplinary treatment approach is required because of significant effects of physical deconditioning and chronic disability.
This is where problems begin to occur. ACOEM recognized the fact: 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” ACOEM page 114. If you have not been involved in the physical medicine field with pain management the concept is difficult to understand.
What is multidisciplinary care ?
Why all the professionals involved?
Why the need for such close communication- don’t reports fulfill this requirement?
The issue becomes cloudy, why is such treatment necessary and beneficial. ACOEM does not explain this fact To PM & R pain management the treatment that is being recommended, treatment is the gold standard of the philosophy of PM&R, pain management. This treatment has similarity to overall rehabilitation treatment following a CVA, Head Trauma, and Amputation. It is treating the WHOLE person.
At the outset, one should beware of the differences among primary, secondary, and tertiary care. The care of acute pain problems is considered primary usually consisting of control of the pain symptoms.
Primary care usually lasts between 0 and 12 weeks following the occurrence of a painful episodes and includes (but is not restricted to) passive treatment modalities.
Secondary care refers to the first stage of reactivation during the transition from primary care to return-to-work or normal activities of daily living. The secondary care phase usually occurs 2 to 6 months after the initial pain occurrence and is designed for patients not responding to initial primary treatment, in order to facilitate a return to productivity before progressive deconditioning and psychosocial economic barriers become firmly entrenched. Secondary care is, meant to avoid the occurrence of chronic disability by preventing physical deconditioning and potential negative psychosocial reactions as well as social habilitation to disability.
Tertiary care refers to rehabilitation directed at preventing or ameliorating permanent disability for the patient who already suffers the effects of disability and physical deconditioning. It is the tertiary care or rehabilitation that requires an interdisciplinary approach to accurately assess the various interrelated factors of chronic disability or pain, which then must be liked to the careful administration of a multifaceted pain management program to affect recovery and reduce permanent disability. This form of tertiary care is quite different from secondary care because the intensity of the services requires, duration of disability, treatment program protocol, more specificity of physical and psychosocial assessment, and a greater level of coordination among health care professionals.
INTERVENTIONAL PAIN CENTER VS FUNCTIONAL RESTORATION PAIN CENTER
Previous to ACOEM guidelines, and utilization review, patients were off work for extended periods of time 2, 3, 4, years. Patients had received passive and costly treatment without improvement. In fact patient s had become increasing disabled. There now was avoidance of activity for fear of pain. This became a major barrier to the initiation and maintenance of chronic pain. This was fear reinforcement due to at least three major barriers to improvement, traditionally, which individually or in combination with each other have restricted the pain sufferer's ability to achieve optimal recovery, given a specific injury or condition: (1) overemphasis on passive treatment models, (2) underemphasize on early 'proactive' intervention, (3) lack of a cohesive team approach to assessment and treatment.,
As a last resort, these patients were referred for pain management. Many of these referrals were to Interventional pain center. (Secondary Care) These proved to be very costly and did not provide the functional gains of tertiary care, for a return to work. Referring resources found pain centers not to be beneficial in their minds, mainly because there was an assumption that Pain Center meant injections and medications, fast, easy treatment. Once again these interventional pain center usually had an underemphasize on proactive intervention.
ACOEM has now brought to light that there exist two types of pain centers. The Intervention Pain Center (Secondary care) as described above, and the Functional Recovery Pain Center (Tertiary care). Interventional pain centers were usually directed by an anesthesiologist and were procedure oriented, where Functional Recovery was directed by a Physical Medicine and Rehab physician (or other gate keeper certified in pain management) and functional gains were the basis of treatment, with relatively little concern for pain levels.
In the past, when a referral was finally made to a multidisplinary pain program there had already been significant devastating damage emotionally to the patient. They had experienced several years of pain, disability with psychological overlay, and it was thought that the pain program was going to be the “Cure”. The multidisciplinary program was going to wave a magic wand and in 4 to 6 weeks they were going to undo all the damage from the preceding years, eliminate the pain, and return the patient to work. Strange, if this is the goal, and Functional Restoration Centers are believed to eradicate pain, then why are they not called Pain Eradication Center.
Belief of end product of functional restoration pain centers became distorted and misunderstood. Patients rebelled when informed of the commitment of 6-8 hours a day of treatment, 5 days a week lasing for 4-8 weeks, especially when informed there would not be 100% improvement to no pain. Referring resources did not understand the need behind the multidisciplinary treatment, or the time commitments from the patient. They had no concept that within a true functional restoration program there is a integrated intense physical and ergonomic training, psychological (behavioral) therapy, patient education, and instruction in social and work-related issues. , Their first comment was at the bottom line “expensive”. They want to utilize the OFMS with its time limits for 1 hour relative to increasing tolerance and endurance to 6-8 hours per day. How do you do this with one hour of treatment, with a cascade? OMFS is for primary acute care not Tertiary care which requires increased time with one to one treatment. They further did not understand the concept of the cost savings of cost of program, reduces future costs and disability, and within usually 6 months following treatment the cost of the program is offset with return to work, reduction in hospital visits, reduced utilization of the health care system.
Expectations were of the nature, that the success of the program depended on elimination of subjective pain report. This may have been true of Interventional pain management, for a short period of time, but not so of functional restoration. Why is it baseball players when they are hurt continue to play, using a sports medicine approach. This approach is one in which the complaint of pain is essentially disregarded, and management instead focuses on improving the patient's capacity for movement and for tasks specific to their occupation.
First studies related to functional restoration were from PRIDE program, by Mayer and colleagues1, in Texas. The first results of Functional Restoration were sufficiently impressive to attract the 1985 Volvo Award for back pain research1. The program achieved an 86% return to work, and a reduction in surgery rates and consumption of health-care. A two-year follow-up confirmed that 86% of patients had remained at work2. These results were subsequently replicated by independent investigators3, 4, and Functional Restoration has attracted considerable endorsement, at least in the United States5.
When pain becomes chronic, greater than 3 months, a more intensive tertiary care or interdisciplinary treatment approach is required because of significant effects of physical deconditioning and chronic disability.
FUNCTIONAL RESTORATION PROGRAM as Recommended ACOEM
ACOEM in Chapter 6 page 114 discusses Functional Restoration, (Tertiary care), the recommended description of the treatment is Tertiary, yet they utilize the time guidelines and goals of Secondary Care. What ACOEM appears to recommend is a modified Tertiary program, earlier in treatment to avoid the potential levels of permanent disability and reduce costs. Further ACOEM guidelines (page 114) are indicative of multidisciplinary interdisciplinary care which is Tertiary Care more so than Secondary care. Multidisciplinary care (usually secondary care) connotes the involvement of several health care providers. The integration of these services, as well as communication among providers may be limited. Interdisciplinary in concept of functional restoration, involves greater coordination of services in a comprehensive program, and frequent (at least once a week) communication among the health care professionals providing the care
ACOEM’s recommendations of Functional Restoration appear to be in between secondary and Tertiary. “Typically the treatment indicated would involve ongoing medical care or supervision, exercise or specific physical therapy intervention, psychosocial intervention, and occupational therapy or other services related to daily functioning and/or vocational rehabilitation “ With functional restoration the primary goal for the patient is attainment of maximum functioning, not only medically, but psychologically, vocationally, and socially as well.
To attain this level of treatment thru a modified Tertiary program, treatment commonly occurs in three phases. First, the patient begins an overall conditioning program consisting of aerobic, stretching and strengthening exercises, which often lead to a temporary worsening of Myofascial pain. Acupuncture and deep tissue massage are given frequently for pain relief, as an aid to deal with the increased pain the patient usually experiences in the beginning with the increased activity. These passive treatments are time limited and are eliminated once the patient has begun to demonstrate adequate utilization of coping skills. Medication management is initiated. Introductory pain management classes are offered. Behavioral sessions introduce the patient to new coping skills and other self-management techniques. This phase commonly lasts one to 2 weeks- 10 session days
The next step of treatment begins when exercise-induced worsening of pain diminishes. The use of passive modalities is reduced and/ or eliminated. The intensity of cardiovascular, stretching, and strengthening exercises increases and the patient is expected to become more independent with exercise. Other aspects of treatment continue. Hopefully, during this phase the patient has virtually eliminated undesirable medications and is beginning to achieve therapeutic doses of desirable medications. They are beginning to experience the benefit of these medication changes. Specific work hardening and conditioning tasks are introduced; they should be involved in work simulation activities of 2-2.5 hours per day, 5 days per week. This phase often lasts approximately 1-2 weeks 5-10 session days.
The third phase begins when the patient has achieved sufficient fitness, strength, and range of motion to be able to engage safely in intensive work hardening and work conditioning, 3 hours per day or greater until 6 hours obtained. Note that the degree of fitness required to minimize the risk of injury is at least that of the average, unimpaired individual. Other aspects of the program are de-emphasized as the patient is prepared to return to work at the appropriate level. Patients who are uncertain which job they'll return to (or are planning on retiring) are prepared for work at the semi sedentary level. This final phase of treatment typically lasts 2-3 weeks, 10-15 session days.
The length of treatment estimates just cited are necessarily approximations. In fact, treatment duration varies a good deal. Patients with little emotional overlay or who are physically fit can often complete treatment in four weeks. (20 treatment session days). Those requiring the longest duration of care may have generalized myofascial pain, their disability duration is greater than 11 months, and they are particularly depressed, passive, angry, and/or severely fatigued. These individuals usually require 6 weeks, (30 treatment session days)
Patients with covert yet active, severe chemical dependency or secondary gains inhibiting their desire to return to work often reveal their lack of motivation and compliance within 2-4 weeks of treatment
FUNCTIONAL RESTORATION CENTERS
Although it is recognized that clinics may vary considerably in the program delivery, the content and staffing, 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 will have developed a degree of commonality across the professionals involved. What is delivered is more important than who delivers it. Most of the programs would 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 appear to be fundamental to success. There is importance in addressing maintenance of change and the management of flare-ups.
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
A structured program is an intensive full day of treatment. It usually starts at 8 am and continues until 4 pm. The program is structured in the same manner as a job. There are set breaks and lunches. The family and significant others are included in the plan. The program usually spans over 18-30 treatments session days (depends on diagnosis and duration of time after injury). There potential advantages of treatment in this manner are:
Opportunity for patients to practice recommended exercises and skills in their naturalistic environment and report back to staff on results.
Opportunity for the family/significant others to report observations of patients responses to treatment.
With the program there is opportunity to observe effects of treatment interventions over longer periods of time and day to day development of coping skills.
The greatest effectiveness of treatment is when treatment gradually tapered from greater to lesser intensity/supervision/passive treatment in the individuals' treatment vs. independent work hardening. When patients begin the program they require intense supervision while acquiring new skills, behaviors, attitudes and an opportunity to practice and carryover these skills at home. As they work through the program the intensity of supervision decreases with an increase in independence. It is important to monitor or follow up closely with the patient to enhance independence and control costs while preventing relapse. Once a patient leaves the program they enter a maintenance program where they utilize the skills taught in continual management of their pain and function.
Each patient has a program manager/pain nurse assigned, to ensure the coordination of all aspects of the patient's treatment amoug professionals and between professionals and patients.
All professionals meet on average a minimum of once a week in a rehabilitation team conference to discuss and coordinate treatment. The patient is in these sessions at the beginning and each two weeks of treatment thereafter. The patient’s input is always requested as an active Participant in these conferences. At the conferences the goals and treatment are reevaluated and modified as necessary.
Reasonable outcomes include:
vMaximization of physical function and activity levels within physical limitation
vReeducation, not eradication of subjective pain intensity.
vMaximizing and maintaining physical activity.
vReducing subjective pain complaints.
vImprove self-management of pain and related problems so as to reduce reliance on health care system.
vReducing / eliminating the abuse of healthcare services, medications and invasive medical procedures relative to the primary pain complaint.
v Improve emotional function so as to reduce depression, anxiety, chronic anger, and other harmful emotional states associated with pain.
v Returning the patient to employment, training or educational pursuit.
Within a functional restoration program it is essential that all those involved in program must have several years’ experience within their own profession. They must have an in-depth knowledge of their own subject. They should not only have the basic qualifications required for their profession but a further qualification within their field. If a referral is required outside of the team, it is important that the pain management team should speak directly with the providers of the other treatments to gain a full understanding of the provider’s inclusion/exclusion criteria and the expected outcomes. The provider of the intermediate treatment must have a good understanding of what the pain management team requires of them. The system referral should be put in place to reduce delays and prevent the patient being lost in the system, being inappropriately reinvestigated and perhaps being offered completely different treatment from that originally intended. Referrals outside the team, lead to lead back to a medical model in which subjective complaints become addressed, when the goal of the team is not to cure the pain, but to improve function.
Team members not only need a good background in their own field but must have an understanding of the “core subjects: in the management of pain. This is outlined in the International Association for the Study of Pain’s core curriculum.
When treating patients with severe physical problems, the physiatrist (or other similarly experienced medical physician) serves as the leader of an interdisciplinary team. The team may include medical professionals such as neurologists, psychiatrists, orthopedic surgeons, and urologists, and non-physician health professionals such as physical therapists, occupational therapists, acupuncturists, aquatic therapists, massage therapists, speech pathologists, vocational counselors, psychologists and social workers. The team is different for each Patient and the team s composition changes during treatment to match the patient s shifting needs. Quality of life has long been the goal of functional restoration. They strive to achieve that goal by looking at the multiple problems of patients, minimizing those problems and optimizing function."
The treatment team is both coordinated and integrated. Mutual goals are set for each patient and are worked on individually by the professionals as well as in concert with the patient in joint treatment sessions utilizing a combination of professionals. This makes the program goal oriented, coordinated, interdisciplinary and inclusive.
It is important not to overmedicalise the program. The Doctors role in the program should be supportive of the psychologist and physiotherapists. There should be a small number of sessions in which the doctor may participate with other team members present. The reason is to reinforce that “hurt does not equal harm” message and act as a resource to answer any remaining medical questions that may arise. The physician may be required at any time during the program to evaluate any new problems that may arise.
The primary focus of the Physicians' role is:
Medical approval of patients admitted to ensure that admission is appropriate
Acquisition of appropriate diagnostic tests
Assumption medical management of patients admitted, provides prescriptions and physicians orders
Communication with referring physicians
Explanation of treatment protocols and rationale for specific therapies to patient, communication of the diagnosis and prognosis to the patient
Procedural of appropriate consultation
Direction and participation in regular staffing conferences
Assumption medical management of patients admitted, provides prescriptions and physicians orders.
It is essential to gain more objective information, or at least the patient’s perspective of their problem, before that are allocated to an assessment. Questionnaires are an essential part of the triage system. They are sent to the patient’s home with an invitation to return them. The pain questionnaire will gather further information about nature and site of pain problem. Patient questions enquire about the patient’s expectations of treatment and major concerns abut their pain. Pain questions assist in assessing the level of psychological distress, physical and social functioning. They enquire about socioeconomic impact of pain and associated disability.
Assessment of the psychological features associated with chronic pain is an essential, and possibly the most import aspect of clinical decision making whether with a view to individualize psychological therapy or to a comprehensive pain management program. The effects of prolonged disability can be profound not only on individuals in terms of personal well-being, but also on their family and ability to work. Roles within families can change, and “over protectiveness” may become a significant hindrance to recovery. In consideration to recognize such factors as potential obstacles to rehabilitation and assess their significant in the context of clinical decision making.
Primary focus of behavioral team:
Evaluate behaviors and cognitions of patient and relationships as they affect pain and related problems.
Conduct group education topics
Groups that are didactic
Groups in which active discussion of behaviors, feeling, and reactions to such issues as the presence of pain, changes in function and relationships and response to treatment individual and family therapies to work more intensively on emotions, behaviors, cognitions, and relationship.
Teach relaxation methods
Self hypnosis training
Rehabilitation (Physical and Occupational Therapy)
Physical activity is perhaps the most powerful component in pain management. Limited physical capacity and lowered pain tolerance restrict function in chronic pain patients. Engaging in activity may exacerbate the pain immediately or some time after the activity has finished. Some patients avoid activity to such an extent that they do not progress and do not achieve improvement. Increasing fitness is important not only in reversing the disuse syndrome, but in giving a powerful signal to patients that they are beginning to regain a degree of control over their musculoskeletal system.
The key aims of the physical activity program
Overcome the effects of physical deconditioning
Challenge and reduce patient’s fear of engaging in physical activity
Reduce physical impairment and capitalize on recoverable function
Provide a safe and graded approach to the rein engagement in physical activity
Help patients accept responsibility for increasing their functional capacity
Promote a positive view of physical activity
Introduce physically challenging, functional activities to rehab. Teach and demonstrate exercises to increase strength and range of motion so as to enhance physical fun
Teach appropriate body mechanics
Teach proper conditioning and engage patients in appropriate aerobic activity
Educate patients about modalities for pain relief and to use them appropriately.
Energy conservation, proper activity management
The purpose of pacing and goal setting is to regulate daily activities and to structure an increase in activity through the gradual pacing of the activity. Activity is paced up by timing activity or by the introduction of quotas of exercise interspersed by periods of rest and change in activity. Pacing activity requires the patients to break down activities into both activity and rest periods and to subdivide tasks into sections that enable rests to be taken. The patients must learn also to identify activities that they find stressful and pain provoking this is supervised treatment activity which requires individual care as well as time- 3-6 hours per day. This is one of the reasons the OMFS does not correlate with this treatment, it does not provide the coding requiring, this is tertiary care and OMFS is Primary care. Primary care allows one hour with cascade, and tertiary treatment requires intensified time that cannot be completed within these time frames and cannot be cascaded due to intensity requires of staff.
Nutritionist: For proper diet and weight loss
Learn to identify foods that increase pain levels, depression
Acupuncture: For temporary pain relief during Initial phases to enhance patient participation
Yoga/ Tai Chi: Stretching, balance, breathing reduce bracing, tension, posture
Return to Work Specialists:
Other professionals who support the case and program goals.
Work with physical therapist to establish functional capacity with particular reference to cognitive skills, including intelligence and knowledge and psychomotor and interpersonal skills.
Evaluate re-employment potential.
Identify and work on obstacles including physical, financial, social, psychological, and attitudinal.