Divergent Treatments for Chronic Pain
As I described in the previous post, chronic pain initially begins, appropriately, as acute pain – a biological event in response to noxious stimuli. However, as time progresses, social, psychological, and cultural factors impede and complicate recovery. These psychosocial factors become complicit in exacerbating the pain and disrupting pain management.
Unless underlying triggers are recognized and addressed early on, the treating clinician is left to treat the symptomology of the patients’ pain, often with repeated surgeries and ever escalating doses of narcotic analgesics. Such treatments may not be addressing the real pain generators. More often than we’d like, surgeries are treating MRI results. As many as 30% of these diagnostic screenings are potentially inaccurate. MRIs may return false positives that hint at physiological incongruences that are only potentially associated with the patient’s pain pathology. Often the patient’s medical file tells a treatment story of narcotic analgesics in large doses for multiple years. The present reality is that the patient is now both physically and emotionally dependent on these medications.
The question then is what to do with injured workers with complicating psychosocial factors which can range from adverse childhood events (ACE) to more recent post-traumatic stress disorder (PTSD). Selected treatments should account for a patient’s psychosocial and behavioral complications. As an industry we are faced with a myriad of options and limited guidance as to how best to choose between them. However, the focus should be on providing carefully selected interdisciplinary care and referring the injured worker for modalities that can simultaneously address a patient’s pain while building endurance and addressing the psychosocial drivers of chronic pain.
The probable starting point is to identify the goal of treatment and the disposition of the patient. It may not be possible to return the injured worker to a pre-injury state, but treatment should be geared towards restoring the patient to maximum medical improvement. The goal of this treatment should be to facilitate the worker’s return to some form of employment - even if that is at a restricted duty level.
For patients with longstanding chronic pain Motivational Interviewing (MI) is commonly a good starting point to assess the patient. It is a patient-centered treatment modality meant to engage the patient and assess ambivalence and anxiety. This also provides a screening opportunity.
You may find that understanding an injured worker’s chronic back pain, ongoing for 10 or more years, may be attributed to nothing more than age progression degenerative changes. The spine begins to lose its water content in the early 30’s which increases the risk of bulges, herniations, and even annular tears. These degenerative changes impact almost everyone, even without symptoms. Studies show disc degeneration in about 37% of all asymptomatic 20 years-olds, 80% of asymptomatic 50 year-olds, and 96% of all asymptomatic 80 year-olds.
Or you may also find as part of an initial screening of the patient, a history of a more traumatic event. Significant diagnoses such as PTSD can occur in instances such as rape, traumatic brain injury, gun point robbery, severe motor vehicle accidents, veterans returning from combat, or employees witnessing a shooting incident or murder. These individuals need to be referred to a specialist who can provide the necessary interventions recommended by the American Psychological Association issued in their “A” list included in the published 2008 guidelines.
Frequently you will find the injured worker’s status can be improved through referral to multiple modalities addressing pain, function, and comorbid conditions as well as addressing smoking and weight issues.
Choosing between Coordinated Interdisciplinary Care and a Functional Restoration Program
Without engagement, a patient chronically treated with narcotic analgesics, now likely dependent, will be resistant to change and unlikely to achieve any progress of either their pain or function. It is critical however that the delivery of care be improved. Common options include referring the patient to a Functional Restoration Program (FRP) or by coordinating analogous care by referring to multiple modalities in an integrated system, inclusive of motivational counseling such as cognitive behavioral therapy (CBT).
Functional Restoration Programs
A FRP is a rehabilitation program aimed at increasing physical functioning, improving pain-coping skills, and returning the patient to a productive lifestyle at home and at work. These treatment programs will be inclusive of multiple provider types, commonly including physical therapists, addictionologists, psychiatrists and/or psychologists, orthopedists and others. These programs excel at providing coordinated care through treatment teams that jointly assess and construct treatment plans weaving multiple modalities together.
However, FRP programs cost anywhere from about $40,000 on the low-side to upwards of $90,000 on the higher end. Unfortunately, due to their size and volume, a number of these programs do not have peer reviewed, published, prospective, randomized controlled studies to support their published claims of outcomes. While there are fantastic programs available, they come at significant cost and with refutable evidence of their program's ability to produce improved functionality, pain control, medication management, or return to work.
When considering the incredible cost of these programs, it is important to also account for patients who are poor candidates for such a program. Patients who are retired, or who will never return to work in any function, would not be good candidates for referral. Additionally patients with comorbidities that would prevent full participation in all the modalities of an FRP (e.g., suicidal ideations, unstable heart conditions, uncontrolled hypertension, asthmatics, exertional dyspnea etc.) would not be good candidates. Other poor candidates include patients who have previously failed CARF accredited programs, have unrealistic expectations of treatment such as immediate cure, or patients who are depressed or not motivated to fully participate. Those who are already dependent on narcotics with existing neurobiological changes may not recover as expected.
There is no advantage for the payer, physician, patient or anyone else to refer a patient for therapy that will not provide efficacy for that individual patient.
Cognitive Behavioral Therapy
Depending on diagnosis, CBT when used in conjunction with other treatment modalities (such as needed physician consults by orthopedist, psychiatrist, psychologists etc.) biofeedback, physical therapy (PT), aqua PT, or other PT modalities such as Alexander or McKenzie’s protocol which may help to centralize or relocate the pain, can restore patients to function in a shorter time than putting them through all the sessions of the FRP. It can often be even more beneficial as FRP programs often require the patients be housed near the campus which silos the patient away from their family and support systems.
Utilizing this integrated coordinated outpatient delivery of care, the patient can also be taught protocols to be done at home after they are mastered in the facility ,allowing the injured worker better continuity of care. Including a dietitian can also help the patient by reconstructing their diet around anti-inflammatory foods, limiting sugars, fats, sodium intake and introducing more plant-based fibrous foods into their diets. This has the added advantage of addressing other elevated medical risk-associated with raised BMI levels.
All of this can be provided for the patient while keeping them at or close to home at a much lower cost to the payer.
Evidence for Coordinated Care
When coordinate care delivery programs are utilized in a hospital facility, various specialty providers have weekly group strategy meetings focused on each patient's needs. The team sets treatment goals for each patient and each team member then coordinates their intervention to achieve the team goal.
Other team members like an addiction specialists, nutritionists and a vocational rehabilitation provider, can also be brought in as needed, to help address patient detox, weaning, medication management, and return to work. This often includes the assistance of a psychotherapist with associated lifestyle goals such as weight reduction and return to work with necessary modifications. In this setting a PM&R specialist sometimes act as the team coordinator.
In 2007 G. Roche et al., published a comparison of an FRP intervention and an active individual therapy (AIT) intervention post five-week study period(1). The included a study groups included the FRP program utilized fort 25 hrs/wk, versus active individual physical therapy group utilizing 3 hrs/wk for patients with chronic low back pain. The objective of this randomized controlled trial was to compare short term outcomes of each intervention.
The study was conducted within two Rehab Centers and private ambulatory PT facilities. There were a number of outcome measures including flexibility and endurance, daily activities, reports of work ability, resumption of sports and leisure activities. The results showed all outcome measures improved except the endurance in the active individual PT group. There was inter- group difference in pain intensity or Dallas Pain Score, daily activities or work and leisure activity scores. However, better results were observed in FRP for the other outcome measures.
Low cost ambulatory AIT is effective. The main advantage of FRP is improved endurance. They speculated that this may be linked to better self-reported work ability and more frequent resumption of sports and leisure activities. Personally, I would think being at a facility 25 hours per week as opposed to 3 hours would lend itself to more availability of other aerobic sport and leisure activities to build endurance, this can be done just as well in a community gym etc.
Treatment of chronic pain starts with careful assessment of the patient. This in turn relies strongly on an engaged treating physician and solid patient-physician relationship. When coordinating the delivery of interventional care it is critical that the right care be selected to achieve the greatest impact for the patient with the least wasted expense. Not all care is equally effective, and not all patients of similar diagnoses will be similarly impacted by identical care. Leading with a motivational assessment is a good place to start when choosing between care delivery models. While integrated and collaborative care delivery as is provided in hospital settings and intended to be provided by FRPs is the gold standard when it comes to chronic pain interventions, finding such a program close to a patient's home, with the necessary modalities, with objective outcomes, and at an acceptable cost is often an impossible task. In many cases these hindrances to care outweigh the benefits that may be obtained. Analogous, low cost care can be provided through carefully integrated and coordination for each injured worker with multiple modalities.
1. Roche G, Ponthieux A, Parot-Shinkel E, et al. Comparison of a functional restoration program with active individual physical therapy for patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88(10):1229-1235. doi:10.1016/j.apmr.2007.07.014.