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HARRIS:
Dr. Feinberg, you and your daughter, Rachel, specialize
in pain management. Can you tell me about your practice,
your philosophy of treatment, and how you came to emphasize
functional restoration?
S. & R. FEINBERG:
We are frankly rather passionate about this approach to
medical care. Functional restoration is not just relevant
to chronic pain management but to all of medicine. It
is about looking at the whole person and not just focusing
on pathology. It is about empowering people to be educated
and proactive about their problem. For the person with
chronic pain it is about learning to manage pain while
still having a productive and meaningful life. |
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“Functional
restoration can be defined as the process by which an
individual acquires the skills, knowledge, and behavioral
changes necessary to assume or reassume primary responsibility
for his/her physical and emotional well-being. Functional
restoration thereby 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.”
Functional
Restoration and Complex Regional Pain Syndrome
by Steven D. Feinberg, MD and Rachel M. Feinberg, PT,
DPT
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HARRIS:
Over the years I have represented many clients with
chronic pain conditions. It seems that the insurers view
functional restoration programs as a last resort, and
avoid authorizing them as long as they can get away with.
Is this your perception of the workers’ compensation
system? Is it different in non-industrial cases?
S. FEINBERG: Both ACOEM and the new MTUS
(Medical Treatment Utilization Schedule) strongly support
functional restoration chronic pain programs. They have
been proven cost-effective. Some employers and insurers
are enlightened and are strongly supportive of what we
do while others hide behind poor utilization review and
say no to everything. What’s not to like about getting
a dysfunctional and disabled injured worker off narcotics,
functional and back to work?
I am sad to say that coverage for functional restoration
programs is extremely limited outside of workers’
compensation.
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| “Functional
restoration treatment team members act as educators, de-emphasizing
passive and/or palliative therapies, while emphasizing
independent self management… The goal is a mitigation
of suffering and return to a productive life despite having
a chronic/persistent pain problem.” |
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HARRIS: I have
observed many times how pain seems to spread from the
original trauma site and engulfs much of the body. What
causes this proliferation of pain?
S. & R. FEINBERG:
Without getting too technical, there are several reasons.
Neurologically, pain can “centralize” where
the spinal cord and brain get reprogrammed for pain. An
example would be an amputee who still has pain in the
missing limb.
Another physical reason is that once the person begins
to guard and protect their body because of the pain, they
move in what we call compensatory movement patterns. This
abnormal movement places increased stress on other body
parts that can begin to hurt as well.
Another reason is behavioral. Most of us live very delicately
balanced lives; but for the person with relentless chronic
pain who also cannot pay the bills and support the family,
pain unconsciously often takes over, spreads and becomes
a way of life.
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HARRIS:
You screen patients before recommending they undertake
the program. How do you determine who to admit? What are
the statistics for success or failure?
S. & R. FEINBERG: Each program is
different but we do an intense evaluation of each injured
worker to determine whether they are truly ready to participate
in what is often a difficult and grueling experience.
Getting off of drugs, exercising and taking back your
life is a major undertaking – it is a little like
going to boot camp! Unless the injured worker is ready,
willing and able to take up this challenge, we don’t
recommend that they come into our program. Success rate
for quality functional restoration programs is in the
60% range. Success is measured as getting off or reducing
drug intake, becoming functional, returning to work and
limiting interactions with health care providers.
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HARRIS:
Is there any way to predict at the outset who will find
relief from pain and who will continue indefinitely with
severe pain? Are there any tests that predict outcome?
S. & R. FEINBERG:
There are no tests that predict outcome. We do know that
individuals who suffered from abuse (emotional, physical,
sexual) or neglect as children statistically are more
likely to develop chronic pain problems and are more difficult
to treat. Otherwise, regarding predicting outcome, it
has been my experience over many years that chronic pain
treatment success has to start with a person ready to
make a change. Often, I will hear a patient tell me that
they just can’t keep living the way there are. Sometimes,
it is a person who is fearful of losing a spouse. It can
be a grandmother who wants to be able to play with her
grandchildren. To put it simply, we often look for a “hook”
– something important to the person with chronic
pain – to get them to buy into entering a functional
restoration chronic pain program.
The functional restoration program is not a cure for pain.
In the traditional biomedical model, complete relief of
pain is clearly an endpoint that is highly desirable especially
in acute pain states, yet it is usually unattainable in
chronic pain conditions. Treating acute or chronic pain
should emphasize functional restoration in addition to
relief of pain.
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HARRIS:
What role does physical therapy play in the treatment
of chronic pain?
R. FEINBERG: After
a person is injured, they typically avoid activities that
can aggravate their symptoms. This is often due to fear
of re-injuring themselves and/or fear of increasing their
pain level. Physical therapy assists the person in first
determining activities that are safe and then helping
the person slowly progress their physical level. This
higher level of activity can initially cause an increase
in pain and therefore we also teach tools such as relaxation,
pacing and flare management techniques.
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| “Often
the approach is to find a “happy medium” where
activity and exercise, while possibly uncomfortable, are
helpful but not harmful.” |
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HARRIS:
You use other modalities such as cognitive behavioral
therapy and relaxation therapy. What is involved with
these approaches? How do they work?
R. FEINBERG: Cognitive behavioral therapy
is a form of psychotherapy that emphasizes the important
role of thinking about how we feel and what we do. Relaxation
therapy consists of different techniques designed to teach
control over relaxing the mind and body. These approaches
assist the patient in changing their thinking and movement
patterns from ones of stress and guarding to balanced
thought and relaxed movement.
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HARRIS:
Some patients, despite diligent efforts of caring professionals,
cannot seem to escape a life of invalidism and despair.
Do they spontaneously improve over time, or do they have
shortened lives? Is there any reliable information on
what becomes of these people?
S. & R. FEINBERG: There actually is
no data on this topic. It is true though that some individuals,
for whatever reason, do not do well and go on to lead
lives of “quiet desperation.” They tend to
be over-medicated and they spend a major part of each
day resting (“downtime”). It is such a tragedy
to see this in a fellow human being. We admittedly are
very biased about functional restoration as we see and
treat so many injured workers who go from dysfunction
to being highly functional.
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HARRIS:
What role does pain medication play in your practice?
Just how dangerous is the long-term use of prescribed
pain medications?
S. FEINBERG: This is a tough question
to answer briefly. There are lots of people who use opioids
effectively and work and are productive. Frankly, these
are not the people I see in my practice though. The great
majority of patients I see are over-medicated, dysfunctional
and impaired cognitively and emotionally. We routinely
suggest detoxification and the great majority of patients
we see “wake-up” and are better off without
the large quantities of medications they come to us on.
Despite what is being “sold” to the public,
the long term use of opioids is quite worrisome. I can’t
go into details, but tolerance with dose escalation is
a big problem and there are numerous negative metabolic
problems such as endocrine disorders (sexual dysfunction),
cognitive problems and other issues.
Prescription drug misuse, abuse and diversion are bigger
problems today in this country than illicit drug use.
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HARRIS:
It seems to me that the medications given for severe chronic
pain produce an illness in and of itself, in that the
side effects can be devastating, particularly the loss
of will and the inability to concentrate or remember or
get engaged mentally in the world outside the body. How
do you deal with this?
S. FEINBERG: Very simply. We spend a lot
of time meeting with injured workers and their families
and try to convince them that they can take back their
life and be functional and whole again. We try to find
a “hook” (see prior answer) that will give
them the strength and courage to participate in a functional
restoration program. I routinely have family members tearfully
thanking us for giving them back their loved one. It may
seem counter-intuitive but detoxification usually results
in less pain and more function!
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HARRIS:
If you had the power to change the existing workers’
compensation system, what would be on your wish list?
S. FEINBERG: Wow! I would like physicians
to focus more on patients as people rather than focusing
on pathology. I would like claims people and defense attorneys
to think of every injured worker as if they were a loved
one. I would like applicant attorneys to send their clients
to doctors they would go to themselves. Am I in enough
trouble yet?
Most of all, I would like us to all work together to recognize
problem cases early on that show evidence of delayed recovery
and provide functional restoration services to avoid progression
to a chronic pain state. I would like to see no need for
chronic pain programs!
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HARRIS:
Can you give an example of a “success” with
your functional restoration approach?
S. FEINBERG: Here is a case example. Violeta
suffered a right shoulder/upper extremity injury after
a fall in 2004. She had received various medications and
physical therapy without benefit and then underwent a
failed right shoulder surgery and subsequently developed
CRPS (RSD). Despite the best efforts of her treatment
team, she was severely depressed, in chronic pain, on
large amounts of narcotics and essentially had a useless
right arm. Her family would help her with dressing and
bathing.
She went through an outpatient, interdisciplinary, functional
restoration chronic pain program in late 2006 and by the
end of treatment was off of the majority of her medications
(she was off all opioids) and had almost full use of her
arm again. She was upbeat, excited to get on with her
life and return to some type of work again. Her story
has been captured on video and is available at the following
Internet link http://tinyurl.com/Violeta.
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Both Dr. Steven and Dr. Rachel Feinberg welcome comments
and input. Please feel free to contact us as follows:
Steven Feinberg, MD
Feinberg Medical Group
1101 Welch Road, C-8
Palo Alto, CA 94304
650-724-7500
www.FeinbergMedicalGroup.com
stevenf@stanford.edu
Rachel Feinberg, DPT
Bay Area Pain & Wellness Center
15047 Los Gatos Blvd., Suite 200
Los Gatos, CA 95032
408-364-6799 x371
www.bapwc.com
rfeinberg@bapwc.com
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