Pain and Disability Clinical, Behavioral, and Public Policy Perspectives (1987) / Chapter Skim
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12. Rehabilitation Approaches and Issues in Chronic Pain
12. Rehabilitation Approaches and Issues in Chronic Pain
Pages 232-260
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From page 232... ...
In their search for relief, chronic pain patients often seek care both from several different physicians and also from nontraditional healers; in addition, they may undergo numerous treatments over a period of months or years. At some point in their quest for relief these patients may be referred to specialized pain management programs (or "pain clinics")
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This chapter describes pain management programs and the techniques they use to rehabilitate chronic pain patients. It reviews the findings from outcome studies on the effectiveness of rehabilitation and on the relation between receipt of compensation and rehabilitation success.
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From page 234... ...
(1) Comprehensive pain centers are multimodal chronic pain management programs with an integrated multidisciplinary rehabilitation approach that screen patients prior to admission and routinely include psychological assessment and patient follow-ups; (2)
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The Need for Standards Accompanying the rapid increase in the number of chronic pain treatment facilities are several problems for those suffering from pain, for health care providers, and for those who pay for such services. The Commission on Accreditation of Rehabilitation Facilities has begun accrediting chronic pain management programs (there were 50 accredited programs by mid-1986)
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From page 236... ...
The question facing pain centers is how such a patient can be rehabilitated and returned to function despite their pain. Regardless of the specific treatment modalities used, pain centers commonly use two general strategies for rehabilitating chronic pain patients.
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Physical therapists in over half of the 72 chronic pain programs surveyed by Doliber (1984) used hot or cold packs, massage, and/or hydrotherapy in their treatment programs.
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Most pain management programs use at least some behavioral therapy, including operant conditioning, relaxation methods (biofeedback and progressive relaxation) , cognitive strategies (including restructuring of thought processes or distraction)
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From page 239... ...
. Patient education is as varied as the differences among individual chronic pain patients and the emphasis of individual pain programs.
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From page 240... ...
Many medical rehabilitation approaches focus on the alleviation of pain per se. The pain control treatment approaches that may be used in rehabilitation settings include stretch and spray of muscles or injection of trigger points; vibration; nonnarcotic, analgesic, and antidepressant drugs; and peripheral nerve blocks or epidural steroid injections (see Chapters 9 and 10)
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From page 241... ...
. Use of Drugs As discussed ire Chapters 9 and 10, many different kinds of drugs are commonly prescribed for pain patients.
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Pain management programs usually are quite selective and accept only about one-third of those who are referred for evaluation. Most of the studies do not describe the characteristics of those who were denied admission.
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· Attention to vocational adjustment. There are few studies of the vocational adjustment of persons who have completed pain treatment programs (Goldberg, 19821.
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From page 244... ...
Other improvements include · increased attention to social and environmental variables that may influence behavioral responses; ~ more standard methods for evaluating antecedents that may elicit maladaptive pain behavior patterns and for evaluating the consequences of changing these behaviors; · identification of behavioral and psychological variables that may predict treatment response; and ~ comparison of behavioral approaches to other treatments routinely used in the management of chronic pain. The development of improved outpatient programs for the behavioral management of chronic pain has been described as a major advance, as these programs provide for substantial cost savings and less disruption of patients' lives (Keefe and Gil, 19851.
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From page 245... ...
In addition, given the limitations of even the most successful treatment programs, the prevention of the development of chronic pain should be an important clinical research priority. In conclusion, it now appears that although the early research efforts investigating the effectiveness of pain management programs were weak, recent work has been more scientifically rigorous.
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(1985) studied the effects of compensation, litigation, arid employment on the treatment responses of chronic pain patients.
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compared chronic low back pain patients at a pain center in the United States with those in a treatment center in New Zealand. They investigated psychosocial and economic factors that may influence disability and recovery in patients from countries with different approaches to the handling of disability compensation.
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Taken as a whole, however, the results of these studies seem to indicate that increased attention to vocational rehabilitation for chronic pain patients is warranted. The education of physicians and other treatment providers, the public, and the pain-impaired individual should focus on the possibility, desirability, and encouragement of those with pain returning to work and other activities.
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From page 249... ...
Studies examining the relation between compensation and treatment response in patients participating in multidisciplinary pain programs present conflicting evidence. Some studies report differences in outcome, with compensation and disability payment patients exhibiting less successful results (Block et al., 1980; Brena et al., 1979; Finneson, 1977; Fordyce, 1985; Hammonds et al., 1978; Herman and Baptiste, 1981; Krusen and Ford, 19581.
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(1978) focused on chronic pain patients for whom the primary treatment was the administration of sympathetic nerve blocks as a positive reinforcer for the achievement of particular behavioral goals.
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Significantly Tower affective or evaluative MPQ scores and fewer visits to health care professionals were made by compensation patients. The authors suggest that the financial security of compensation decreases anxiety, resulting in lower affective ratings but unchanged sensory or total MPQ scores.
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REHABILITATION ISSUES IMPORTANT TO THE SSA The SSA and Vocational Rehabilitation Administrators of the Social Security disability system historically have relied on the joint federal-state program of vocational rehabilitation to provide rehabilitation services; this has been an uneasy alliance. One reason for housing the disability determination services at the state level in the first place was to allow the state rehabilitation agencies to screen applicants for vocational rehabilitation services.
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From page 253... ...
Measurement and Evaluation of Pain The problem for the SSA in determining entitlement for disability benefits or remedial services for chronic pain patients appears to revolve around the difficulty—if not impossibility—of objectively mea
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From page 254... ...
as the preferred method for the treatment of patients with chronic pain. The Commission on the Evaluation of Pain subscribed to this view, although it stopped short of recommending mandatory rehabilitation for all chronic pain patients.
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Research and Demonstration Projects The pain management programs reviewed earlier in this chapter are restorative in their orientation and rehabilitative in their treatment approach. Despite methodological shortcomings in study designs, an increasing body of literature supports the view that comprehensive multidisciplinary rehabilitation, provided in specialized clinics, is useful in reducing the disability and dysfunction associated with chronic pain.
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From page 256... ...
Furthermore, the elapsed time between initial filing and granting of benefits, especially for claimants whose level of dysfunction seems disproportionate to objective medical findings, is often a year or more. Clinicians have observed that the more time that passes, the harder it is to intervene successfully with pain patients.
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From page 257... ...
Carron, H., DeGood, D.F., and Tait, R A comparison of low back pain patients in the United States and New Zealand: psychological and economic factors affecting severity of disability.
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Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria.
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From page 259... ...
Pain Management: A Handbook of Psychological Treatment Approaches. New York: Pergamon Press, 1986.
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From page 260... ...
Commission on Accreditation of Rehabilitation Facilities, 1986. Wolfe, F., and Cathey, M.A.
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