By Liz Finch
Working Toward Wellness Successful, accredited chronic pain management and rehabilitation programs are a dying breed. The number of both inpatient and intensive outpatient chronic pain management programs has declined in recent years, for reasons related more to reimbursement issues than to the failure of methods used. Many programs thus turn to heavy dependence on opioids or surgical implants to remain viable in the marketplace. Interdisciplinary outpatient programs in particular, while shown to be very effective, have a difficult time surviving in this atmosphere.1 While it may have its difficulties in a reimbursement climate designed to support prescribing muscle relaxants instead of using biofeedback to educate patients, the Rehabilitation Institute of Chicago (RIC) Chronic Pain Care Center is nonetheless surviving. Robert G. Addison, MD, founded the interdisciplinary center within RIC 26 years ago, making it the first such program in the Midwest. And according to current director Norman Harden, MD, the center is still one of the few interdisciplinary outpatient clinics in operation nationwide. The center’s focus is on taking patients off medication and empowering them to regain control over their lives by learning pain management skills. To accomplish this goal, the program incorporates a range of medical management avenues: from TENS, to psychology, to biofeedback and various rehabilitative therapies. The center’s treatment team includes physicians, nurses, psychologists, biofeedback technicians, physical and occupational therapists, vocational rehabilitation specialists, and therapeutic recreation specialists. Consultations with other clinical or medical specialists, such as anesthesiologists, osteopaths, and chiropractors, occur as needed. Deborah Darr, PT, who has been working at the center for 7 years, recently added Feldenkrais Awareness Through Movement to her program because of its benefit in helping people change the habits of movement that perpetuate their pain complaints. Patient Makeup About 30% of the center’s patients are seeking relief from back pain, while the rest of the population is split fairly evenly between those suffering from neuropathic pain, complex regional pain syndrome, and musculoskeletal problems such as myofascial syndrome or fibromyalgia. Approximately 16 to 20 patients are active in the various programs at any one time, and though most referrals are from the Chicago area, the center treats patients from all over the world. “Usually patients are recommended to the center through other physicians,” Darr says. “Typically, patients have been in chronic pain for 6 months to a year, and the physician has realized they can go no further with the normal prescribed procedures.” Patient admission is coordinated with the referring physician so that diagnostic tests do not have to be repeated, and the center’s half-day multidisciplinary evaluation is combined with existing patient records to define an effective course of treatment. Length of outpatient treatment is generally 4 weeks of 5- to 8-hour days, and each treatment plan incorporates group and individualized activities. Darr teaches Feldenkrais every Tuesday and Thursday, and all patients are scheduled for those classes. In addition, each patient is scheduled for aerobics/strengthening/stretching classes every Monday, Wednesday, and Friday mornings where they each do their own individualized programs. At these sessions, Darr may incorporate deep tissue or trigger point massage. Patients also participate in aquatic therapy three times a week. The properties of the water greatly facilitate increased movement while minimizing the effects of pain. “Once a week the patients also attend a group focused on increasing activity levels that may be precluding work or household tasks,” says Melanie Swan, OTR/L, who joined the chronic pain program staff in December 2000. “Patients with chronic pain often exhibit decreased ability to tolerate sitting or standing, so we do some work simulation activities and focus on increasing endurance. For instance, we may use a leisure time activity, like woodworking or an art project, as a work focuser or a distraction to increase endurance. “We want patients working on something enjoyable,” she continues. “If the patient is looking to return to work, then we incorporate an activity similar to what they would be going back to, like clerical tasks. Repeating the task, using techniques of pacing and changing position, can increase standing power. I also focus on their alignment and weight distribution.” In addition to the weekly occupational therapy tolerance group, Swan sees patients individually to address limitations in performance of activities of daily living, work, and leisure tasks. Individual sessions frequently involve education on postural alignment and body mechanics; stretches and exercises to facilitate proper movement patterns and efficiency of movement; instruction on energy conservation and work simplification; and pacing techniques to improve balance. The combined use of physical therapy, occupational therapy, and vocational rehabilitation helps patients recover their ability to perform daily activities and occupational tasks, resolve the emotional and psychological consequences of coping with chronic pain, and develop long-term strategies for pain management, health maintenance, and a balanced lifestyle. During this time, patients focus on becoming more aware of their body’s response to pain and learn to manage it through pacing, relaxation, stretching, and increases in activity and exercise. As most patients have made postural adjustments to compensate for the pain, they usually need to relearn appropriate body mechanics. A substantial amount of nursing education is incorporated in treatment protocols as well, and the center has a large patient education library. “These programs work very well hand-in-hand,” Swan says, “and though we tend to focus on different areas, we also overlap some so it’s easy for patients to understand why these various therapies are important. It’s about a balance of lifestyle. In that respect the center is different than other outpatient occupational therapy settings in many ways. Occupational therapy is very holistic in nature, but here it is especially important to be holistic in helping patients achieve their many goals.” Those patients have to be the right type to benefit from the center’s approach, however. “For those who want instant gratification, this form of treatment does not work,” Harden says. “Patients have to be willing to accept their conditions as chronic and get on with their lives. Patients who are looking for a pill or surgery to fix them will always be disappointed, and we don’t want to be part of that disappointment. “The center is very patient-oriented; the patient is captain of the ship,” Harden says. “I may be the navigator, and I may tell the captain where to go, but he has to take the ship there. This is opposed to the old-fashioned way of rehabilitation where the patriarchal doctor calls the shots and tells everyone what to do.” In fact, a hallmark of the center is its flexibility. According to Swan, the biggest benefit to having an outpatient program is that it allows the patients an opportunity to test out what they have learned, and thus allows the therapists to adjust their program as necessary. “At the end of the day patients go back to their real lives and have a chance to implement the techniques they learned,” Swan says. “The weekend is the biggest challenge, because they have a couple of days in a row when they have to do household chores and other normal daily life tasks. But it also gives us an opportunity the following week to see what we can increase in that respect so they can pace themselves and not burn out.” The Research Component The center’s programs are also constantly updated by findings from its research arm.“When I joined the program 8 1¼2 years ago, it was almost entirely clinical,” Harden says. “I brought a research component to make ours a true center for pain studies.” Since then, research has become an integral part of the center. On May 16, the center installed the Robert G. Addison Chair for Pain Studies, making it only the third such honorary chair in pain management in the country. The center always has an array of research projects under way; Harden says there are currently about 15 projects ongoing, including pharmaceutical trials and research on diagnostic sensitivity and specificity. “We are trying to understand how to improve diagnoses in different pain areas,” he says. “The research involves both pharmaceutical and nonpharmacologic interventions in a number of syndromes, such as complex regional pain syndrome, fibromyalgia, and pain in spinal cord injury patients and amputees. “Another research project involves looking at aerobic conditioning in fibromyalgia patients,” he continues. “The studies so far have proven that such activity decreases pain, improves function, and is critical to recovery. Therefore, we have changed our treatment to emphasize aerobic exercise for those patients.” As one of the relatively few successful outpatient programs in operation, the center is naturally a role model for others looking to duplicate its methods. “People want to try to recreate this center, and I always tell them that it is very difficult to make this kind of program profitable,” Harden says. “Right now, insurance companies are trying to save a buck, usually at the expense of patients. I find it very interesting that insurers will pay for surgery that often doesn’t work, but they will not approve interdisciplinary care that is supported by a vast research base. “There is not a lot of money in an interdisciplinary program, but it is the only thing out there that reliably works,” he says. “This is the only thing that is effective and low-tech, that stresses self-management, and that is untrendy as opposed to all the glitzy high-tech stuff that is so very expensive. If other rehab clinics want to do the right thing, we are happy to help them.” Liz Finch is a contributing writer for Rehab Management. Reference Sanders S. Chronic pain rehabilitation: lost in a sea of drugs and procedures? American Pain Society Bulletin. 2000;10(3). Available at: www.ampainsoc.org/pub/bulletin/may00/clin1.htm. Accessed May 15, 2001.
