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Focusing on Function: A New
Approach to the Treatment of
Chronic Pain
By Kathleen Matthews
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Kathleen Matthews has a Bachelor of
Science in Kinesiology. She visited a Bay Area functional restoration
program established by Steven Feinberg, M.D., a frequent contributor
to getMedLegal Magazine, and reports here on how his clinic treats
chronic pain.
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The Pain Problem
It is estimated that at least 116 million adults in the United States
are suffering from chronic pain conditions (Tsang et al. 2008). Chronic
pain is defined as pain that continues past the expected time of
healing. Common chronic pain conditions include headache, spine pain,
arthritis and other musculoskeletal pain. Chronic pain results in
a decreased ability to function and can ultimately lead to disability.
It is the leading culprit in delayed recovery. Chronic pain problems
also account for significant costs within the workers’ compensation
system. Functional restoration is a non-traditional method of treating
chronic pain that involves a multidisciplinary approach. Research
has shown that functional restoration can improve overall functional
capacity, decrease pain medication intake, and increase occupational
ability in individuals afflicted with chronic pain (MTUS, 2009).
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| Chronic pain is pain that continues
past the expected time of healing. |
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What is Functional
Restoration?
Explaining functional restoration begins with evaluating the differences between
the biomedical and biopsychosocial models in how they relate to the treatment
of chronic pain. American physicians are taught to treat pain in accordance with
the biomedical model. This model defines health as the freedom from disease,
pain, or defect. When a patient complains of pain, the doctor utilizes diagnostic
tools in an attempt to find the pathological source of the pain and provides
the patient with an appropriate treatment for that pathology. In most cases,
particularly with acute pain, the patient is well served by this process. Issues
with this approach arise when medicine and surgery fail to alleviate the patient’s
pain. Such is the case with chronic pain sufferers because their pain cannot
be completely explained by a specific pathology (MTUS, 2009). In many cases patients
are given pain medications that decrease their pain, but at the cost of living
with side effects that diminish their ability to function. Over time the patient
will develop a tolerance to these medications and require increased dosages.
Some of these patients even undergo additional surgeries with minimal benefit.
The end result is a patient who is not functioning at their pre-injury level
and accumulating costly medical bills (S. Feinberg, personal communication, October
4, 2011).
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In
many cases patients are given pain medications that decrease their
pain, but at the cost of living with side effects that diminish
their ability to function.
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The biopsychosocial approach is the foundation of functional restoration.
Put simply, the biopsychosocial approach differs from the biomedical
model by considering the mind-body connection. According to this
model, an individual’s biology, psychological status, and
social influences are all major factors in that person’s
ability to function when ill or injured. Functional restoration
embraces the biopsychosocial model by utilizing a multi-disciplinary
approach to treat chronic pain. Comprehensive treatment programs
include medical services, physical therapy, and psychological counseling.
These disciplines work together to focus on increases in function
rather than decreases in pain (Committee on Advancing Pain Research,
2011). |
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The biopsychosocial approach,
which considers the mind-body connection, is the foundation of functional
restoration.
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Current Medical
Treatment Guidelines for Chronic Pain
The current medical treatment guidelines recognize that psychosocial variables
play a role in how acute pain becomes chronic pain. The guidelines suggest that
if a patient is not responding to traditional treatments, a coordinated, multidisciplinary
treatment should be put in place. Simple screening questionnaires are recommended
early in treatment to determine if the patient is at risk for delayed recovery.
Risk factors include job loss, work absenteeism, a lack of response to treatments
suitable to their pathology, negative psychosocial influences, history of delayed
recovery, and unsupportive, unaccommodating employers (MTUS, 2009).
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The chronic pain guidelines are
set forth in § 9792.24.2 of Title 8, California Code of Regulations.
The chronic pain guidelines (May 2009) consist of two parts and one
appendix.
• Chronic
pain medical treatment guidelines
• Appendix
D contains the
scientific literature references used in the chronic pain medical
treatment guidelines
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Not all functional restoration programs
are the same. Suggested program components are vocational and rehabilitation
training, physical therapy, medical care and supervision, psychological
and behavioral counseling, psychosocial care, and education. The
Chronic Pain Medical Treatment Guidelines recommend chronic pain
programs, including functional restoration programs. They suggest
that patients only enroll in programs that have proven successful
outcomes (MTUS, 2009).
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An FRP should feature vocational
and rehabilitation training, physical treatment, medical care and
supervision, psychological and behavioral care, psychosocial care,
and education.
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Feinberg Medical Group
Feinberg Medical Group, lead by Steven Feinberg, M.D., specializes
in early intervention and functional restoration. Feinberg Medical
Group (FMG) offers patients an in depth medical evaluation, medical
treatment, physical therapy, and psychological care. The three top
pain conditions treated at FMG are spine pain, repetitive use syndromes,
and Complex Regional Pain Syndrome. Successful patients have seen
a decrease in the severity of their depression from moderately severe
to mild or no depression. The average FMG patient is able to reduce
opiate and benzodiazepine medication costs by 85% or more. The goal
is to have the chronic pain sufferer see dramatic improvements in
their ability to function and their overall quality of life (Feinberg
Medical Group, 2011).
The overarching theme during treatment at FMG
is that the patients are active members in their own health. Traditionally,
patients often feel that the physician is in control of their health.
At FMG the physician and the treatment team function as an ally of
the patient, in helping the person obtain maximal function (S. Feinberg,
personal communication, October 4, 2011).
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The overarching theme during
treatment at FMG is that the patients are active members in their
own health.
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Treatment at FMG begins with a Multi-Disciplinary
Evaluation. During the evaluation, a physician, psychologist, and
physical therapist assess the patient. The physician evaluates the
patient to determine the correct diagnosis. The multi-disciplinary
team then decides if the patient is suitable for the Functional Restoration
Program (FRP). Factors considered in their decision include the patient’s
motivation, barriers to recovery and likely prognosis. If the patient
is appropriate, the team prescribes a multi-disciplinary treatment
plan that may include individual physical therapy or psychological
services at FMG or in their home community or a full time or modified
FRP, including detoxification if necessary. According to FMG, only
30% of the patients who were evaluated in 2010 were deemed appropriate
for the FRP.
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Treatment starts with a multi-disciplinary
evaluation with a physician, psychologist, and physical therapist.
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Information
from Pain Specialists
Steven Feinberg, M.D., Board-certified pain specialist, offered his
advice and experiences in treating chronic pain. According to Dr.
Feinberg, a healthy attitude about pain is “living a good life
in spite of having pain.” He finds that a lot of the time a
patient’s experience of pain is being colored by how they are
treated in the work place and at home. Treatment at FMG recognizes
the importance of educating the family and a smooth transition in
return to work. Dr. Feinberg advises that employers be accommodating
and bring their employees back to modified duty as early as possible.
He encourages patients to talk less about their pain and finds just
by doing this, patients see a decrease in their pain. Dr. Feinberg,
who has chronic pain himself, encourages pain sufferers to focus
on living well and enjoying their lives (S. Feinberg, personal communication,
October 4, 2011).
Rachel Feinberg, a Doctor of Physical Therapy who
practices at FMG, emphasizes the importance of recognizing that the
pain of chronic pain sufferers is real, even if all of their pain
cannot be explained by a specific pathology. Patients who come to
her are physically deconditioned because they are often too afraid
of pain and reinjury to participate in regular exercise. She spends
a lot of time educating patients on pain versus harm, improving their
tolerance to activities of daily living and teaching them ways to
safely move their bodies. Rachel finds that by teaching them in a
controlled setting, managing their flare-ups, and increasing activities
slowly, she is able to help patients overcome their fear and successfully
meet their functional goals (R. Feinberg, personal communication,
October, 2011).
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A healthy attitude about pain
is “living a good life in spite of having pain.”
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Success Stories
at FMG
Patient success stories are a testament to the efficacy of quality
functional restoration programs. One of those success stories belongs
to a thirty-year-old firefighter who was injured on the job when
he fell off a ladder and suffered multiple compression fractures
in his spine. He was put him on opiates by his treating physician
and told to rest. He was also told that he would never be a firefighter
again. Firefighting was this man’s passion and a family legacy.
He became depressed, dysfunctional, and developed an intense fear
of re-injury. He enrolled in the functional restoration program at
FMG for 6 weeks. Dr. Feinberg and his associate Dr. Wedemeyer discontinued
the opiates that were limiting the patient’s functioning. The
psychologist, physical therapist and physician collaborated to help
the firefighter cope with his fear of re-injury and his fear of pain.
He left treatment on a Friday and went back to work that Saturday
as a firefighter. The patient did not get better because his compression
fractures healed. He got better because he was treated according
to the biopsychosocial model. The multi-disciplinary treatment at
FMG allowed this man to go back to work and live his passion again
(S. Feinberg, personal communication, October 4, 2011).
Another success
story belongs to a nurse in her late thirties who chose FMG’s
FRP over spine surgery. The nurse’s previous physician had
recommended surgery on her lumbar spine. She declined the surgery
and was put on pain medication. She became physically inactive because
of her pain problem. After a four-week program at FMG, she was able
to return to work as a nurse. A few months later, she was training
for a triathlon (S. Feinberg, personal communication, October 4,
2011).
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Summary
Functional Restoration offers chronic pain sufferers a tool kit for
improving their quality of life. It benefits the employer by getting
the injured worker back on the job and ultimately reducing their
medical costs. Research shows that the earlier the chronic pain suffer
is treated according to the biopsychosocial model, the better the
outcome (Theodore, 2009).
References
Committee on Advancing Pain Research, Care,
and Education; Institute of Medicine (2011). Relieving
Pain in America: A Blueprint for Transforming Prevention, Care, Education,
and Research.
The National Academies Press.
Engel, G. L. (1997). The need for a new medical model: a
challenge for biomedicine.
Science, 196, 129-136.
Feinberg Medical Group. (2011). The difference is FMG: The next step for your
chronic pain patients.
Medical Treatment Utilization Schedule. (2009). Chronic
Pain Medical Treatment Guidelines [Data file]. http://www.dir.ca.gov/dwc/DWCPropRegs/MTUS_Regulations/
MTUS_ChronicPainMedicalTreatmentGuidelines.pdf
Tsang, A., Von Korff, M., Lee, S. Alonso, J., Karam, E., Angermeyer, M. C., Guimaraes
Borges, G. L., Bromet, E. J., Girolamo, G., Graaf, R., Gureje, O., Lepine, J.
P., Haro, J. M., Levinson, D., Oakley Browne, M. A., Posada-Villa, J., Seedat,
S., Watanabe, M. (2008). Common chronic pain conditions in developed and developing
countries: gender and age differences and comborbidity with depression-anxiety
disorders. The Journal of Pain, 9(10), 883-891.
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Functional Restoration offers
chronic pain sufferers a tool kit for improving their quality of
life.
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