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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.

 
 
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).
 
Chronic pain is pain that continues past the expected time of healing.
 
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).
 
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.
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).
 
The biopsychosocial approach, which considers the mind-body connection, is the foundation of functional restoration.
 
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).
 
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).
 
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).
 
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.
 
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).
 
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.

 
Functional Restoration offers chronic pain sufferers a tool kit for improving their quality of life.
 
Kathleen Matthews can be reached at
KathleenMMatthews@yahoo.com