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Payers https://www.instituteforchronicpain.org Sun, 05 Feb 2023 13:56:25 +0000 Joomla! - Open Source Content Management en-gb Minnesota Leads Nation in Developing New Payment Model for Pain Rehab Programs https://www.instituteforchronicpain.org/blog/item/209-minnesota-leads-nation-in-developing-new-payment-model-for-pain-rehab-programs https://www.instituteforchronicpain.org/blog/item/209-minnesota-leads-nation-in-developing-new-payment-model-for-pain-rehab-programs

This past summer, Minnesota Governor Mark Dayton signed into law an omnibus health and human services budget bill and in so doing he marked a significant milestone in the recent history of chronic pain management. The bill contained language, introduced by State Representative Deb Kiel and State Senator Jim Abler, authorizing the trial of a new payment arrangement through Medical Assistance, which makes it possible for state recipients of the public health insurance to receive care within an interdisciplinary chronic pain rehabilitation program.

The increasingly pressing need for effective alternatives to prescription opioid medications for the management of pain fueled the passage of the provision.

In over a three year effort, a number of additional organizations and individuals pooled resources to ensure passage of the bill, including: the Minnesota Department of Human Services’ Health Services Minnesota State Capitol 1Advisory Council, led by Jeff Schiff, MD, and Ellie Garret, JD, which authorized the state to seek to increase use of non-pharmacological, non-invasive pain therapies among Medical Assistance recipients; the Institute for Chronic Pain; Courage Kenny Rehabilitation Institute; State Representatives Matt Dean, Dave Baker, Mike Freiberg, and State Senator Chris Eaton. To our knowledge, with the passage of the bill, Minnesota became the first state in the nation in recent history to pay for an interdisciplinary chronic pain rehabilitation program in a viable manner through Medical Assistance.

The problem until now

Interdisciplinary chronic pain rehabilitation programs are a traditional, empirically-supported treatment for people with chronic pain conditions. The focus of the care is to assist patients in acquiring the abilities to successfully self-manage pain without the use of opioid medications and return to work or other meaningful, regular activity. Multiple physical and psychological therapies performed on a daily basis for three to four weeks constitute typical chronic pain rehabilitation programs. An interdisciplinary staff of pain physicians, pain psychologists, physical therapists, nurses, social workers and others deliver the different therapies. Research over the last four decades has shown that such programs are highly effective (Gatchel & Okifuji, 2006). Indeed, in 2014, the American Academy of Pain Medicine dubbed such programs the “gold standard” of care for those with chronic pain.

Despite the long-standing research base supporting its effectiveness, interdisciplinary chronic pain rehabilitation programs have historically faced obstacles to obtain adequate insurance reimbursement (Gatchel, McGreary, McGreary, & Lippe, 2014). Component therapies within such programs, when billed on a per therapy basis, are commonly reimbursed at below cost or not reimbursed at all. These low rates of reimbursement make it unviable for chronic pain rehabilitation programs to survive if they accept such reimbursement.

Historically, chronic pain rehabilitation programs have gotten around this problem by repetitively proving their superior outcomes through research and using this research to negotiate “bundled” payment arrangements with individual insurers within each state. The bundled payment is typically one fee for all the services delivered over an agreed upon time frame (usually, as indicated, for three to four weeks). Worker’s compensation and most commercial insurers pay for chronic pain rehabilitation programs in this manner.

State Medical Assistance programs over the last few decades have refrained from negotiating such bundled payment arrangements, due to lack of legislative authority to provide such arrangements. As a result, they’ve pursued more customary reimbursement practices. As indicated, though, such customary reimbursement effectively makes accepting the public health insurance unviable for interdisciplinary chronic pain rehabilitation programs. As a result, recipients of Medical Assistance were cut off from being able to receive this effective form of chronic pain management for many years.

During this time, society has also witnessed the onset of alarming epidemics of opioid-related addiction and death (CDC, 2017; SAMHSA, 2016). It is generally accepted that the impetus for these epidemics has been the large-scale adoption of the practice of prescribing opioid medications for acute and chronic, benign pain that began late last century and continues to this day.

These epidemics have led to increasing societal demand for safe, effective non-opioid options for the management of pain.

With the passage of the Minnesota bill, patients who have state-funded Medical Assistance insurance within Minnesota can now obtain chronic pain management that effectively helps them eliminate the need for opioid medications and return to work or other valued life activities, such as returning to school, job re-training or volunteering.

Not just a local problem

The importance of Minnesota’s legislative action to develop and trial a new payment arrangement for an interdisciplinary chronic pain rehabilitation program is highlighted by the fact that it’s a solution to a problem that is long-standing and widespread. This problem is not isolated, in other words, to the time and place of Minnesota in the year 2017. In other states throughout the nation, chronic pain rehabilitation programs face the problem of telling patients who would benefit that their insurance will not cover the cost of the program and as such would have to pay out of pocket if they attend. To be sure, most patients in this predicament choose to forego the therapy and resort to continuing their use of opioid medications for the management of their pain.

State-funded Medical Assistance programs are not the only insurer that has failed to cover interdisciplinary chronic pain rehabilitation programs. Medicare and some large commercial plans in the nation either do not cover such programs or only do so in a cost prohibitive way. As such, chronic pain rehabilitation programs and many would-be patients face the dilemma of being unable to access a therapy that could go a long way to resolving the epidemics of addiction and death associated with the opioid management of pain.

This problematic insurance reimbursement for interdisciplinary chronic pain rehabilitation programs has had significant consequences for the availability of such programs nation-wide. Because different insurers over the years have not covered chronic pain rehabilitation in a viable manner, many programs have struggled to remain open. While estimates vary, the number of interdisciplinary chronic pain rehabilitation programs in operation has dropped precipitously over the last two decades (Gatchel, McGreary, McGreary, & Lippe, 2014; Schatman, 2012).

This problem of reimbursement is both ironic and tragic at the same time. For the last two decades, we as a society have had a safe and effective alternative to the use of opioids for chronic pain and yet many people cannot access them because state-funded Medical Assistance programs, or Medicare, or some commercial insurance do not reimburse for them. All these insurers readily pay for opioid medication management, with all its adverse consequences, but not for chronic pain rehabilitation programs that show patients how to manage pain without the use of opioids. This irony becomes all the more tragic considering how many lives could have been saved from addiction and accidental death had people been allowed to access chronic pain rehabilitation programs as a substitute to opioid management.

Not yet a permanent solution

The bill, as passed, provides authorization of a two-year trial of a bundled payment arrangement for a chronic pain rehabilitation program within the state of Minnesota. Its intent is to provide demonstration of the effectiveness of both this type of treatment and its corresponding type of insurance reimbursement. In turn, this subsequent data will provide lawmakers with further justification to make it a permanent benefit within Medical Assistance. The long-term goal would be to bring Medical Assistance in Minnesota into alignment with the current reimbursement practices of most commercial and worker’s compensation insurers in the state.

References

Centers for Disease Control and Prevention (CDC). (2017). Understanding the epidemic: Drug overdose deaths in the United States continues to increase in 2015. Last updated August 30, 2017.

Gatchel, R. J., McGreary, D. D., McGreary, C. A., & Lippe, B. (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychologist, 69(2), 119-130.

Gatchel R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic malignant pain. The Journal of Pain, 7(11), 779-793.

Schatman, M. E. (2012). Interdisciplinary chronic pain management: International perspectives. Pain Clinical Updates, 20(7), 1-5.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). Opioids. Last updated February 23, 2016.

Date of publication: September 24, 2017

Date of last modification: September 24, 2017

About the author: Dr. Murray J. McAllister is the editor at the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported and to make that empirically-supported pain management more publicly acessible. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Programs Sun, 24 Sep 2017 01:45:58 +0000
Chronic Pain Rehabilitation https://www.instituteforchronicpain.org/blog/item/165-68chronic-pain-rehabilitation https://www.instituteforchronicpain.org/blog/item/165-68chronic-pain-rehabilitation Chronic Pain Rehabilitation

A central tenet of chronic pain rehabilitation is that what initially caused your pain is often not now the only thing that's maintaining your pain on a chronic course. Let’s unpack this important statement. It’s no accident that healthcare providers commonly refer to chronic pain syndromes as complex chronic pain or complicated chronic pain.

It’s because pain, of course, typically starts with an acute injury or illness, but it isn’t typically maintained on a chronic course by the initial injury or illness. For after all, injuries and illnesses tend to heal. Rather, something else takes over to maintain pain long past the healing of the initial injury or illness that started it all. In most cases, this transition from pain of an acute injury or illness to chronic pain involves the development of central sensitization.

Central sensitization is a condition of the nervous system in which the nervous system becomes stuck in a heightened state of reactivity so that the threshold for stimuli to cause pain becomes lowered. As a result, light amounts of stimuli to the nerves, which typically aren’t painful, become painful. In normal circumstances, it takes a high level of stimuli – like a slug in the arm – to cause pain, but in chronic pain states any little thing might be enough to cause pain. Simple movements hurt, even such movements as sitting down or getting up from a chair or walking. The amount of stimuli to, say, the low back that is associated with these movements shouldn’t be painful, but they are because the nerves in the low back have become increasingly sensitive -- so sensitive, in fact, that any amount of stimuli to them is enough to cause pain.

This condition of central sensitization explains why not only simple movements can hurt, but also why light amounts of tactile pressure can hurt. Patients with chronic pain often have had a healthcare provider ask them, “Does this hurt?” when lightly touching or pressing the painful area of their body during an examination. This light amount of pressure is often enough to send the patient through the roof. In other circumstances, you might notice that a hug or massage, which typically should feel good, is enough to cause pain. It’s all because the nerves in the painful area of the body have become so reactive that any little thing sets them off.

Other forms of stimuli, beyond that which is associated with movement and touch, can also become painful once the transition from acute pain to chronic pain occurs. As most anyone with chronic pain knows, stress can cause pain too. The stress of a bad night’s sleep or the stress of work or family problems shouldn’t typically cause pain, but it does once the nerves become stuck in the highly reactive state of central sensitization. It may also be why changes in weather can cause pain. Emotional stress or changes in temperature or barometric pressure shouldn’t typically be enough stimuli to cause pain but they do once pain occurs as a result of central sensitization.

Sensitive nerves are normal in acute injuries or illnesses

The sensitivity of the nervous system is normal in acute pain. Say, for example, you step on a nail. We often think that the resulting tissue damage from the injury (in this case the puncture wound from the nail) is the only thing that matters when it comes to pain. However, even in cases where there is demonstrable tissue damage, we also need a nervous system to have pain. Without nerves and a brain, we would never be able to feel the tissue damage associated with an injury.

In our example, the nerves in the foot detect the tissue damage and send messages along a highway of nerves from the foot, up the leg and to the spinal cord. From the spinal cord, the messages travel up to the brain, where the messages are processed by different parts of the brain. The result of this processing is the production of pain. In other words, the brain produces pain in the foot. The brain and spinal cord (i.e., the central nervous system) produces pain in response from messages sent from nerves in the foot (i.e., the peripheral nervous system).

In this process, the brain and the rest of the nervous system team up with the endocrine (hormonal) system and the immune system. With the help of hormones and neurotransmitters, the brain tells the immune system to flood the area around the injury with inflammation. Inflammation is white blood cells and certain chemicals that assist in fighting infection and repair of the tissue damage. While engaged in these activities, inflammation also makes the nerves in the area around the injury super sensitive, which, again, is why the area of the body around an injury becomes so painful to touch or pressure. In most cases, the injury heals and the brain tells the immune system that inflammation is no longer needed and so the inflammation subsides. As a result, the pain of the injury also subsides upon healing because without the inflammation the nerves return to their normal level of sensitivity. So, they stop sending messages to the brain when normal levels of stimuli to the foot occur, such as when walking on the foot.

However, sometimes, the nervous system remains stuck in a vicious cycle once the tissue damage associated with the acute injury heals. The brain, in a sense, continues to call for inflammation even after the tissue damage is repaired. With the continued presence of inflammation, the nerves in the area of the initial injury remain sensitive so that any stimuli to them, even if they wouldn’t typically be painful, continue to produce pain. The continued pain thereby keeps the brain calling for more inflammation, thus eliciting continued sensitivity of the nerves to normal stimuli and subsequently more pain.

When this process continues past the point of healing of the initial injury, it’s called central sensitization, as we’ve discussed.

Complex or complicated chronic pain

Once central sensitization occurs, any number of things can reinforce it. Just think of all the stressful problems that occur or can occur as a result of having chronic pain. Loss of work and subsequent disability can cause loss of income and significant financial hardship. The loss of work is often a blow to one’s sense of self-worth and self esteem. Chronic boredom or social isolation can also set in. Pain often produces insomnia, which further wears on the nerves. Because pain is also emotionally alarming, people with chronic pain also commonly become fear-avoidant of different activities that are associated with pain. Such distress lends itself to becoming persistently focused on pain so that life becomes predominated by pain and its associated difficulties. Anxiety and depression can secondarily occur.

All of these problems are stressful. The stress associated with these problems affects the nervous system. It makes an already reactive nervous system more reactive. The threshold that the nervous system has for producing pain becomes lower and lower. As a result, the pain of chronic pain tends to become worse and more widespread.

Notice, though, that the initial injury or illness associated with the onset of pain isn’t getting worse. It may not even be a factor at all anymore, for as we’ve discussed, most injuries and illnesses heal (e.g., lumbar strains). Sometimes, of course, the initial condition associated with onset of pain continues (e.g., rheumatoid arthritis). However, in either case, the nervous system is now also playing a role in the cause of pain. The nervous system is now maintaining pain on a chronic course. Any number of stressful problems that occur as a result of the pain can then play a further exacerbating role in the long-term maintenance of chronic pain.

So, a central tenet of chronic pain rehabilitation is that, commonly, what initially caused your pain is not now the only thing that is maintaining your pain on a chronic course.

What to do about chronic pain?

The public and even some healthcare providers commonly don’t take into account the role that the nervous system plays in maintaining chronic pain. Instead, the focus of care tends to remain on looking for evidence of any lingering tissue damage or disease associated with the initial injury or illness, respectively. The presumption is that pain must be caused by either tissue damage or disease and so the initial condition that started the pain must remain unhealed. The possibility never gets considered that the nervous system has changed so that the threshold for stimuli to cause pain has lowered.

This type of thinking leads to a lot of repetitive interventional and surgical procedures. In a pain clinic, it is not uncommon to see patients who have had numerous epidural steroid injections, neuroablation procedures or spine surgeries, repeated at the same site of the initial injury. The presumption is that the tissue damage associated with the initial injury remains unhealed and so is therefore the “pain generator”. However, repetitive attempts to rectify the tissue damage associated with the initial injury often remain ineffective because the pain is no longer due (or predominantly due) to tissue damage associated with the initial injury. Rather, the pain has transitioned from acute pain to chronic pain and as such it is due to the nervous system having lowered its threshold for producing pain. Simple movements and light touch hurt – not because the tissue damage is so great – but because the central nervous system maintains the peripheral nerves in a highly sensitive state.

From here we can see why the afore-mentioned central tenet is so important to chronic pain rehabilitation. In contrast to the typical interventional and surgical forms of pain management, chronic pain rehabilitation focuses its interdisciplinary therapies on the nervous system. Chronic pain rehabilitation aims to down-regulate the nervous system so that the nervous system is not so reactive and more approximates a normal threshold for producing pain. In other words, the goal is to get to a state of the nervous system in which it again requires the force of a slug in the arm to cause pain, and not just a simple movement like walking or sitting or a light touch.

Chronic pain rehabilitation is an empirically effective form of pain management – meaning, numerous scientific studies over the last four decades have shown that interdisciplinary chronic pain rehabilitation helps people to reduce pain, get off narcotic pain medications, and return to work in some capacity.

The key components of interdisciplinary chronic pain rehabilitation are the following:

  • Cognitive-behavioral based pain coping skills training
  • Mild aerobic exercise
  • Use of antidepressants and anti-epileptics for pain
  • Relaxation therapies
  • Exposure-based milieu therapies

All of these therapies are pursued in a coordinated fashion on a daily basis over a number of weeks. Patients learn them and become adept at independently pursuing them. As a result, patients continue to engage in them on an independent basis over the lifetime.

The target of all these therapies is the nervous system, particularly the central nervous system (i.e., the brain and spinal cord). They improve the health of the nervous system and in doing so they reduce the sensitivity of the overall nervous system and thereby reduce pain. In other words, interdisciplinary chronic pain rehabilitation focuses care on what’s now maintaining your pain and not on what initially started it way back when.

Date of last modification: 2-14-2016

Author: Murray J. McAllister, PsyD 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Programs Sun, 14 Feb 2016 14:45:59 +0000
Pain Centers https://www.instituteforchronicpain.org/treating-common-pain/pain-centers https://www.instituteforchronicpain.org/treating-common-pain/pain-centers

When going to a pain clinic, there is one thing that patients should always keep in mind: It’s that not all pain clinics are alike.

More often than not, patients are referred to one or another type of clinic, without knowing that there are different types of pain centers with different ways of treating chronic pain -- even when it comes to the same conditions. Moreover, the different types of clinics are not all similarly effective. Research on the effectiveness of different types of common treatments for chronic pain show wide variations in how effective they are.

Patients typically find it helpful to know something about these different types of clinics, their different types of treatments, and their relative degree of effectiveness.

By most conventional healthcare standards, there are generally four types of clinics that treat pain:

  • Clinics that focus on surgical procedures, such as spinal fusions and laminectomies
  • Clinics that focus on interventional procedures, such as epidural steroid injections, nerve blocks, and implantable devices
  • Clinics that focus on long-term opioid (i.e., narcotic) medication management
  • Clinics that focus on chronic pain rehabilitation programs

Sometimes, clinics combine these approaches. For instance, interventional pain clinics commonly combine their focus on interventional procedures with long-term opioid management. Other times, surgeons and interventional pain physicians combine their efforts and have clinics that provide both surgeries and interventional procedures. Nonetheless, it is conventional to think of clinics that treat pain along these four categories – surgeries, interventional procedures, long-term opioid medications, and chronic pain rehabilitation programs.

The fact that there are different types of pain clinics is indicative of another important fact that patients should know. It’s that the healthcare field doesn’t agree on how best to treat people with chronic pain.

Surgery clinics

Patients with chronic neck or back pain often seek care at spine surgery clinics. While spinal surgeries have been performed for about a century for conditions like fractures of the vertebrae or other forms of spinal instability, spinal surgeries for the purpose of chronic pain management began about forty years ago.1, 2 Typical spine surgeries are laminectomies, discectomies, and fusions. A laminectomy is a surgical procedure that removes part of the vertebral bone. A discectomy is a surgical procedure that removes disc material, usually after the disc has herniated. A fusion is a surgical procedure that joins one or more vertebrae together with the use of bone taken from another area of the body or with metallic rods and screws.

Patients often think of spine surgery as a cure for chronic neck or back pain. While acknowledging that spine surgeries can be helpful for some patients, a good spine surgeon should correct this misunderstanding and state that spine surgeries are not cures for chronic spine-related pain. In most cases of chronic back or neck pain, the goal for surgery is to either stabilize the spine or reduce pain, but not get rid of it altogether for the rest of one's life.

Patients are commonly surprised to learn that there are few studies on the effectiveness of back surgeries for chronic spine-related pain.

Mirza and Deyo3 reviewed five published, randomized clinical trials for fusion surgery. Two had significant methodological problems, which prevented them from drawing any conclusions. One of the remaining three showed that fusion surgery was superior to conservative care. The other two compared fusion surgery to a very limited version of group-based cognitive behavioral therapy. These two studies found no differences between the surgical and psychological interventions at one and two year follow-up periods.

In a large clinical trial, Weinstein, et al.,4 compared patients who received surgery with patients who did not receive surgery and found on average no difference. They followed up with the patients two years later and again found no difference between the groups. However, in a later article, they showed that the surgical patients had less pain on average at a four year follow-up period.5

Surgery for sciatica in the first few months after onset has been shown to provide more rapid relief than conservative approaches. However, by one-year follow-up, the differences will no longer be apparent and the degree of pain that patients have is the same – whether they had surgery or not.6

Reviews of all the research conclude that there is only minimal evidence that lumbar surgeries are effective in reducing low back painand there is no evidence to suggest that cervical surgeries are effective in reducing neck pain.8

Interventional pain clinics

Interventional pain clinics are the newest type of pain clinic, coming to be quite common in the 1990’s. Interventional pain physicians are typically anesthesiologists or physiatrists who have received added training in a variety of interventional pain management procedures, including epidural steroid injections, different types of nerve blocks, radiofrequency neuroablations, and implantable pain control devices, such as spinal cord stimulators and intrathecal drug delivery devices.

Research on the outcomes of epidural steroid injections consistently shows that they are no more effective on average than injections filled with placebo.9, 10, 11, 12 

There are two published clinical trials of radiofrequency neuroablations and both found that the procedure was no better than a sham procedure, which is a feigned procedure that is essentially the procedural equivalent of a placebo.13, 14 

A spinal cord stimulator is a device that is surgically implanted into the body and typically used to reduce pain of a limb. Research on the effectiveness of spinal cord stimulators suffer from poor quality. A number of reviews of this research conclude that there is limited evidence to support their effectiveness.15, 16, 17 

Intrathecal drug delivery systems (aka “pain pumps”) are also implanted devices that deliver medications directly into the spinal fluid. Research on the effectiveness of these devices also suffer from poor quality. In their review, Turner, Sears, & Loeser18 found that intrathecal drug delivery systems were modestly helpful in reducing pain. However, because all studies are observational in nature, support for this conclusion is limited.19 

Long-term opioid management clinics

Another type of pain clinic is one that focuses primarily on prescribing opioid, or narcotic, pain medications on a long-term basis. The practice of long-term opioid management for chronic, non-cancer pain began in earnest a little more than twenty years ago. This practice is controversial because the medications are addictive. There is by no means agreement among healthcare providers that it should be provided as commonly as it is.20, 21

Advocates for long-term opioid therapies highlight the pain relieving properties of such medications, but research demonstrating their long-term effectiveness is limited.22, 23 

Addiction,24 tolerance, opioid-induced hyperalgeisa,25 hormonal changes,26 and mental cloudiness27 are factors that make the use of long-term opioid therapies controversial.

Chronic pain rehabilitation programs

Chronic pain rehabilitation programs are another type of pain clinic and they focus on teaching patients how to manage pain and return to work – and to do so without the use of opioid medications. They have an interdisciplinary staff of psychologists, physicians, physical therapists, nurses, and oftentimes occupational therapists and vocational rehabilitation counselors.

The therapeutic interventions of interdisciplinary chronic pain rehabilitation programs consist of cognitive behavioral therapy, mild aerobic exercise and other types of physical therapy, and non-narcotic pain medication management. The goals of such programs are reducing pain, returning to work or other life activities, reducing the use of opioid pain medications, and reducing the need for obtaining healthcare services.

Chronic pain rehabilitation programs are the oldest type of pain clinic, having been developed in the 1960’s and 1970’s.28 

Multiple reviews of the research highlight that there is moderate quality evidence demonstrating that these programs are moderately to substantially effective.29, 30 

In his review of the research, Turk31 found that patients in chronic pain rehabilitation programs reduce pain on average by approximately 35%, even after reducing opioid pain medications.

Multiple studies show rates of returning to work from 29-86% for patients completing a chronic pain rehabilitation program.30 These rates of returning to work are higher than any other treatment for chronic pain.

Additionally, a number of studies report significant reductions in utilizing healthcare services following completion of a chronic pain rehabilitation program. For example, Gatchel & Okifuji30 reviewed multiple studies showing that 60-90% of program completers do not seek additional healthcare services for their chronic pain, even at one year follow-up.

For more information

Please also see What to Keep in Mind when Referred to a Pain Clinic and Does Your Pain Clinic Teach Coping? and Your Doctor Says that You have Chronic Pain: What does that Mean?

References

1. Knoeller, S. M., Seifried, C. (2000). Historical perspective: History of spinal surgery. Spine, 25, 2838-2843.

2. McDonnell, D. E. (2004). History of spinal surgery: One neurosurgeon’s perspective. Neurosurgical Focus, 16, 1-5.

3. Mirza, S. K., & Deyo, R. A. (2007). Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine, 32, 816-823.

4. Weinstein, J. N., Tosteson, T. D., Lurie, J. D., et al. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The spine patient outcomes research trial (SPORT). Journal of the American Medical Association, 296, 2441-2450.

5. Weinstein, J. N., Lurie, J. D., Tosteson, T. D., et al. (2008). Surgical vs. nonoperative treatment for lumbar disc herniation: Four-year results for the spine patient outcomes research trial (SPORT). Spine, 33, 2789-2800.

6. Peul, W. C., et al. (2007). Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine, 356, 2245-2256.

7. Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. [Cochrane Review]. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience.

8. Nikolaidis I., Fouyas, I. P., Sandercock, P. A., & Statham, P. F. (Updated December 14, 2008). Surgery for cervical radiculopathy or myelopathy. [Cochrane Review]. In Cochrane Database of Systematic Reviews, 2010 (1). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience.

9. Arden, N. K., Price, C., Reading, I., Stubbing, J., Hazelgrove, J., Dunne, C., Michel, M., Rogers, P., & Cooper C. (2005). A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology, 44, 1399-1406.

10. Ng, L., Chaudhary, N., & Sell, P. (2005). The efficacy of corticosteroids in periradicular infiltration in chronic radicular pain: A randomized, double-blind, controlled trial. Spine, 30, 857-862.

11. Staal, J. B., de Bie, R., de Vet, H. C., Hildebrandt, J., & Nelemans, P. (Updated March 30, 2007). Injection therapy for subacute and chronic low back pain. In Cochrane Database of Systematic Reviews, 2008 (3). Retrieved April 22, 2012.

12. van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

13. van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344.

14. Leclaire, R., Fortin, L., Lambert. R., Bergeron, Y. M., & Rosignol, M. (2001). Radiofrequency facet joint denervation in the treatment of low back pain: A placebo-controlled clinical trial to assess efficacy. Spine, 26, 1411-1416.

15. Chou, R., Atlas, S. J., Stanos, S. P., & Rosenquist, R. W. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for the American Pain Society clinical practice guideline. Spine, 34, 1078-1093.

16. Taylor, R. S., Van Buyten, J., & Buchser, E. (2005). Spinal cord stimulation for chronic back and leg pain and failed back surgery syndrome: A systematic review and analysis of prognostic factors. Spine, 30, 152-160.

17. Turner, J. A., Loeser, J. D., Deyo, R. A., & Sanders, S. B. (2004). Spinal cord stimulation for patients with failed back syndrome or complex regional pain syndrome: A systematic review of effectiveness and complications. Pain, 108, 137-147.

18. Turner, J. A., Sears, J. M., & Loeser, J. D. (2007). Programmable intrathecal opioid delivery systems for chronic noncancer pain: A systematic review of effectiveness and complications. Clinical Journal of Pain, 23, 180-195.

19. Patel, V. B., Manchikanti, L., Singh, V., Schultz, D. M., Hayek, S. M., & Smith, H. S. (2009). Systematic review of intrathecal infusion systems for long-term management of chronic non-cancer pain. Pain Physician, 12, 345-360.

20. Passik, S. D., Heit, H., & Kirsch, K. L. (2006). Reality and responsibility: A commentary on the treatment of pain and suffering in a drug-using society. Journal of Opioid Management, 2, 123-127.

21. Von Korff, M., Kolodny, A., Deyo, R. A., & Chou, R. (2012). Long-term opioid therapy reconsidered. Annals of Internal Medicine, 155, 325-328.

22. Chou, R., Ballantyne, J. C., Fanciullo, G. J., Fine, P. G., & Miaskowski, C. (2009). Research gaps on use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. Journal of Pain, 10, 147-159.

23. Ballantyne, J. C. & Shin, N. S. (2008). Efficacy of opioids for chronic pain: A review of the evidence. Clinical Journal of Pain, 24, 469-478.

24. Martell, B. A., O’Connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., Fiellin. D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127.

25. Angst, M. & Clark, J. (2006). Opioid-induced hyperalgesia: A quantitative systematic review. Anesthesiology, 104, 570-587.

26. Vuong., C., Van Uum, S. H., O’Dell, L. E., Lutfy, K., Friedman, T. C. (2010). The effects of opioids and opioid analogs on animal and human endocrine systems. Endocrine Review, 31, 98-132.

27. Kamboj, S. K., Tookman, A., Jones, L. & Curran, H. V. (2005). The effect of immediate-release morphine on cognitive functioning in patients receiving chronic opioid therapy in palliative care. Pain, 117, 388-395.

28. Chen, J. J. (2006). Outpatient pain rehabilitation programs. Iowa Orthopaedic Journal, 26, 102-106.

29. Flor, H., Fydrich, T. & Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.

30. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

31. Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clinical Journal of Pain, 18, 355-365.

Date of publication: April 27, 2012

Date of last modification: October 12, 2018

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Treating Chronic Pain Fri, 27 Apr 2012 14:03:11 +0000
What is a Chronic Pain Rehabilitation Program? https://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/chronic-pain-rehabilitation https://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/chronic-pain-rehabilitation

What is a chronic pain rehabilitation program?

Chronic pain rehabilitation programs are a traditional type of chronic pain management. Sometimes also called functional restration programs, they have long been used to help patients with chronic pain live a normal life. People who most benefit from chronic pain rehabilitation programs are those with moderate-to-severe persistent pain who have come to accept that their pain is truly chronic and cannot be cured. So, they want to be able to engage in meaningful life activities despite having chronic pain.

Chronic pain rehabilitation programs have five goals:

  • Reduce pain
  • Return to work or some other regular, meaningful activity
  • Overcome problems that occur as a result of living with pain, like anxiety, irritability, depression, sleep disturbance, stressed relationships
  • Reduce reliance on the use of narcotic pain medications, if taking them
  • Reduce reliance on the healthcare system generally

Chronic pain rehabilitation programs focus on what the patient can do to manage pain. While there is often a time and place for relying on care from specialists who perform therapies and procedures, there also comes a time for patients to focus on what they can do to reduce pain and reduce the degree to which it impairs daily life. 

This focus on what the patient can do is called self-management. In general, self-management is a two-pronged approach to managing any kind of chronic health condition. The two prongs are healthy lifestyle changes and increasing the ability to cope with the condition so that the condition itself is no longer as problematic as it used to be. With regard to self-managing chronic pain, the two prongs are:

Chronic pain rehabilitation programs are interdisciplinary. Program staff consists of psychologists, physical therapists, physicians, and nurses. Sometimes, such programs may also have occupational therapists and vocational rehabilitation specialists.

Chronic pain rehabilitation programs typically occur on a daily basis over three to four weeks. Some programs are done on an outpatient basis.
Other programs are done on an inpatient basis, with patients going home on the weekends.

A chronic pain rehabilitation program is like a chronic pain school. Patients learn everything they need to know in order to live well despite having chronic pain. The staff are like teachers. In a supportive environment, they coach patients on how to do it.

Chronic pain rehabilitation programs have nine core component therapies:Image by Anupam Mahapatra courtesy of Unsplash

Most of these components therapies are done in a small group format. All patients in the group have some form of chronic pain.

Because they have been around for decades, chronic pain rehabilitation programs have a lot of research showing that they are effective.1, 2, 3 On average, patients achieve a 40% reduction in pain by participating in a program. On top of that, most patients taper from narcotic pain medication use. So, they make up for the pain reduction that the pain medications would have produced and still reduce their pain by another 40%.

Additionally, 50% of patients who participate in a chronic pain rehabilitation program go back to work. For sake of comparison, 20-36% of patients go back to work after spine surgery.2, 4 

Because of all this research, many experts agree that chronic pain rehabilitation programs are the most effective treatment for patients with chronic pain.

When hearing about chronic pain rehabilitation programs for the first time, patients often say that they would never be able to do it. They say that they are too disabled to do anything everyday for a number of weeks. However, the typical patient who succeeds in a chronic pain rehabilitation program is a person who has had moderate-to-severe, chronic pain for years. The typical patient has been unable to work for years. In addition, the typical patient is one who struggles to do daily chores and may have difficulty doing even the basics of life, like getting dressed or taking a shower. Emotionally, the typical patient is irritable, anxious and depressed. The typical patient has poor sleep and his or her relationships are quite stressed. Many are also taking opioids to manage their pain. As such, chronic pain rehabilitation programs are set up to help the most disabled and distressed people with chronic pain. And they succeed in doing so.

References

1. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

2. Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & van Tulder, M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ, 350. doi: http://dx.doi.org/10.1136/bmj.h444

3. Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

4. Juratli, S. M., Franklin, G. M., Mirza, S. K., Wickizer, T. M., & Fulton-Kehoe, D. (2006). Lumbar fusion outcomes in Washington State worker's compensation. Spine, 31, 2715-2723.

Date of publication: April 27, 2012

Date of last modification: August 28, 2022

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Fri, 27 Apr 2012 14:01:09 +0000