Understandably, patients want their chronic pain cured or eliminated. Unfortunately, there are presently no definitive cures for the majority of persistent pain problems, such as axial spine pain, peripheral neuropathies, fibromyalgia, etc. As is the case with all chronic medical conditions, chronic pain must be managed, not cured. In the medical model, responsibility resides primarily with the physician. The self-management approach places primary responsibility on the person with chronic pain. Currently, self-management strategies can significantly improve a patient’s function and quality of life, while reducing subjective experiences of pain. It is important to educate patients on this distinction, to avoid persistent and unrealistic expectations for an elusive cure, where none exists. This unrealistic curative view, often unwittingly fostered by healthcare providers or others, predictably leads to repeated failure, delayed recovery, and unnecessary disability and costs.
Importance of early identification
Patients not responding to initial or subacute management ( see Clinical Topics Section MTUS) or those thought to be at risk for delayed recovery should be identified as early as possible. Simple screening questionnaires may be used early in the clinical course to identify those at risk for delayed recovery. Those at risk should be aggressively managed to avoid ineffective therapeutic efforts and needless disability. Factors that help identify at-risk patients include: (1) those unresponsive to conservative therapies demonstrated to be effective for specific diagnoses; (2) significant psychosocial factors negatively impacting recovery; (3) loss of employment or prolonged absence from work; (4) previous history of delayed recovery or rehabilitation; (5) lack of employer support to accommodate patient needs; and (6) a history of childhood abuse (verbal, physical, mental). Of these factors, lost time from work has the highest value in predicting those patients who will experience delayed recovery.
Subacute Delayed Recovery Complaints of pain are the most common obstacle to return to work. Undertreatment of pain and/or unrealistic expectations may play a role in delayed recovery. However, the subacute phase is a critical time for the injured worker, as additional time away from work may result in adverse medical, familial, economic, and psychological consequences (including overtreatment, depression and/or anxiety, which can exacerbate pain complaints). When the physician recognizes that the problem is persisting beyond the anticipated time of tissue healing, the working diagnosis and treatment plan should be reconsidered, and psychosocial risk factors should be identified and addressed. Patients should be directed toward resources capable of addressing medical and psychosocial barriers to recovery.
Patients with Intractable Pain Studies have shown that the longer a patient remains out of work the less likely he/she is to return. Similarly, the longer a patient suffers from chronic pain the less likely treatment, including a comprehensive functional restoration multidisciplinary pain program, will be effective. Nevertheless, if a patient is prepared to make the effort, an evaluation for admission for treatment in a multidisciplinary treatment program should be considered.
A patient suffering from severe intractable pain who does not qualify for participation in a chronic pain program or who has failed a chronic pain program “should have access to proper treatment of his or her pain.” California Health and Safety Code section 124960
Thorough history taking is always important in clinical assessment and treatment planning for the patient with chronic pain. Clinical recovery may be dependent upon identifying and addressing previously unknown or undocumented medical and/or psychosocial issues. Diagnostic studies should be ordered in this context and not simply for screening purposes.
If a diagnostic workup is indicated and it does not reveal a clinically significant contraindication, the physician should encourage the patient to engage in an active rehabilitation program. Effective treatment of the chronic pain patient requires familiarity with patient-specific past diagnoses, treatment failures/successes, persistent complaints and confounding psychosocial variables (e.g. history of abuse, anxiety, depression, fear-based avoidance of activity, catastrophizing, self-medication with alcohol or other drugs, patient/family expectations, medical-legal/claims management issues, and employer/supervisor/worksite).
A thorough physical examination is also important for establishing reassurance and patient confidence, establishing/confirming diagnoses, and observing/understanding pain behaviors
Evaluation of Psychosocial Factors For patients with a complex presentation, psychosocial factors have proven better predictors of chronicity than clinical findings. Such variables/factors can and should be assessed.
Functional Restoration Approach to Chronic Pain Management Many injured workers require little treatment, and their pain will be self-limited. Others will have persistent pain, but can be managed with straightforward interventions and do not require complex treatment. However, for patients with more complex or refractory problems, a comprehensive multidisciplinary approach to pain management that is individualized, functionally oriented (not pain oriented), and goal-specific has been found to be the most effective treatment approach. (Flor, Fydrich et al. 1992; Guzman, Esmail et al. 2001; Gatchel and Bruga 2005)
Functional restoration is an established treatment approach that aims to minimize the residual complaints and disability resulting from acute and/or chronic medical conditions. Functional restoration can be considered if there is a delay in return to work or a prolonged period of inactivity according to ACOEM Practice Guidelines, 2nd Edition, page 92. Functional restoration is the process by which the individual acquires the skills, knowledge and behavioral change necessary to avoid preventable complications and assume or re-assume primary responsibility (“locus of control”) for his/her physical and emotional well-being post injury. The individual thereby maximizes functional independence and pursuit of vocational and avocational goals, as measured by functional improvement (see 8 CCR § 9792.20 (f)).
Independent self-management is the long-term goal of all forms of functional restoration. The process and principles of functional restoration can be applied by a physician or a well integrated interdisciplinary team to a full range of problems that include acute injuries (e.g., sports, occupational), catastrophic injuries (e.g., brain and spinal cord injury), and chronic conditions (e.g., chronic pain, multiple sclerosis, etc.) and is the basis for medical rehabilitation and disability management. The principles of functional restoration apply to all conditions in general, and are not limited to injuries or pain.
Multiple treatment modalities, (pharmacologic, interventional, psychosocial/behavioral, cognitive, and physical/occupational therapies) are most effectively used when undertaken within a coordinated, goal-oriented, functional restoration approach (see Part 2).
Using medications in the treatment of pain requires a thorough understanding of the mechanism underlying the pain as well as to identify comorbidities that might predict an adverse outcome. As stated on page 47 of the ACOEM Practice Guidelines, “[c]onsideration of comorbid conditions, side effects, cost, and efficacy of medication versus physical methods and provider and patient preferences should guide the physician’s choice of recommendations.” Choice of pharmacotherapy must be based on the type of pain to be treated and there may be more than one pain mechanism involved. When effective, medications provide a degree of analgesia that permits the patients to engage in rehabilitation, improvement of activities of daily living, or return to work. There are no drugs that have been proven to reverse, cure, or “heal” chronic pain or neuropathic. Periodic review of the ongoing chronic pain treatment plan for the injured worker is essential according to the Medical Board of California Pain Guidelines for controlled substances.
When choosing an invasive procedure to treat a specific chronic pain problem, a complex judgment is necessary to make sure that the desired and expected outcome is worth the risk involved, depending on the procedure and individual risk factors.
Please refer to Part 2 to find specific guidelines on chronic pain treatments that include pharmacotherapy, invasive pain procedures, psychological and behavioral therapies, physical and occupational therapies, and other approaches. Whether the treatment is provided by an individual provider, a multidisciplinary group of providers, or tightly integrated interdisciplinary pain program, it is important to design a treatment plan that explains the purpose of each component of the treatment. Furthermore, demonstration of functional improvement is necessary at various milestones in the functional restoration program in order to justify continued treatment.
Pain Outcomes and Endpoints Pain is subjective. It cannot be readily validated or objectively measured (AMA Guides, 5th Edition, page 566). Furthermore subjective reports of pain severity may not correlate well with its functional impact. Thus, it is essential to understand the extent that function is impeded by pain (AMA Guides, 5th Edition, page 578). Moreover, “[t]he desired end point in pain management is return to function rather than complete or immediate cessation of pain.” (ACOEM Practice Guidelines, 2nd Edition, p. 116)
Physicians treating in the workers’ compensation system must be aware that just because an injured worker has reached a permanent and stationary status or maximal medical improvement does not mean that they are no longer entitled to future medical care.