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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.
“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

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.


“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.”

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.

 

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.

 

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.

 

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.

“Often the approach is to find a “happy medium” where activity and exercise, while possibly uncomfortable, are helpful but not harmful.”

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.

 

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.

 

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.

 

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!

 

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!

 

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.

 

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

For detailed CVs, click here for Steven Feinberg and click here for Rachel Feinberg


 

> Doctor's Office: Functional
Restoration
> People Who Made a Difference
> Pain Disorders & DFEC
> Defense Perspective: Surviving
> Chapman on Structured Settlements
> PD Pain Under SB 899
The Doctor's Office
Functional Restoration: Interview with
Steven D. Feinberg, M.D. &
Rachel M. Feinberg, PT, DPT.


In the fifth of a series featuring medical
professionals in the workers’ compensation
system, Marjory Harris interviews
Steven D. Feinberg, M.D., a board certified specialist in Physical Medicine & Rehabilitation, Pain Medicine, and Electrodiagnostic Medicine, and Rachel M. Feinberg, D.P.T., who specializes in physical therapy for chronic pain.
They work together and provide functional restoration services at the Bay Area Pain & Wellness Center in Los Gatos.