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- ~
Rehabilitation
Approaches and
Issues in Chronic Pain
As documented throughout this report, the inten-
sity and disabling e£ects of chronic pain are
highly variable and unpredictable. Among the problems faced by
persons with such pain are disruptions in the physical, psychological,
social, and economic aspects of their lives. 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") for re-
habilitation. Such programs have proliferated rapidly in the last 20
years. Although they vary greatly in terms of staging, specific treat-
ment orientation, and criteria for accepting patients into their pro-
grams, these pain clinics are specialized rehabilitation facilities whose
approach is consistent with the basic philosophy and approach of
rehabilitation medicine.
THE REHABILITATION APPROACH
Rehabilitation medicine differs from other types of medical practice
in a number of ways. A major focus is on preserving residual function and
preventing secondary complications (physical, physiological, behavioral,
or social) that lead to increased disability. Rehabilitation is geared to the
needs of people with multifaceted problems and, therefore, tends to take
a multidisciplinary approach to treatment in which experts from a
232
OCR for page 233
REHABlLITATlON APPROACHES ED ISSUES 233
number of pertinent disciplines work together to design and implement
treatment plans. This conscious, focused meshing of the skills and
knowledge of professionals from many fields into a multifaceted, tightly
coordinated treatment approach sets rehabilitation medicine apart from
the other areas of practice that deal with pain patients.
In order for a rehabilitation team to function successfully, it is
believed that each member must share responsibility for addressing
the patient's problems and achieving the goals established. In addi-
tion, clinicians generally find that the rehabilitation process is more
successful if it includes the active participation of the patient and his
or her family and if the goals are set by mutual agreement among the
patient, family, and team members. The goals may include a resump-
tion of physical and psychological well-being through increased mobil-
ity, self-care, communication, emotional and social adjustment, and
return to work. Unlike some other areas of medicine that concentrate
primarily on the causes and direct consequences of a specific disease or
disorder, rehabilitation is directed toward an optimal resumption of
performance in all aspects of daily living.
This chapter describes pain management programs and the tech-
niques 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. In addition, it raises a number of issues about rehabilitation
for pain claimants in the context of the Social Security disability
system.
PAIN MANAGEMENT PROGRAMS: AN OVERVIEW
Specialized facilities for the treatment of chronic pain have origi-
nated within the past 20 years and are associated with the emergence
of a medical specialty known as aIgology or dolorology. This specialty
is devoted to the study of pain, and includes a shift in the medical
conceptualization of pain as a symptom of disease to chronic pain as an
independent clinical entity. It is estimated that there are more than
1,200 organized multidisciplinary pain clinics in existence today
(Ho~zman and Turk, 1986), as well as many other small, single-
discipline practices calling themselves pain treatment facilities.
Chronic pain management programs exist in a variety of organiza-
tional settings and facilities. Many programs are university-based,
operated by departments of various medical specialties. As such, they
are situated in medical centers, community hospitals, rehabilitation
hospitals, and the rehabilitation units of hospitals. Some are free-
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234 ASSESSED TREATING PINED DYSFUNCTION
standing specialized pain centers that focus exclusively or primarily on
chronic pain. Programs can be voluntary (nonprofit), government-run
(state or federal), or proprietary (either as an individual profit-making
entity or as part of a regional or national chain).
The philosophy of most pain management programs is to Took at the
broad aspects of a patient's life, not just at the medical factors.
Treatment is oriented toward the patient and family as a unit and
concentrates on restoring functional capacity and limiting disability in
all spheres of living; in doing so, this approach Reemphasizes disease
processes and diagnostic categories. Although pain reduction is a goal,
the total alleviation of pain is less important than enabling the patient
to function effectively with whatever residual pain exists.
Common criteria for admission to pain management programs
include the presence of pain for at least 6 months, that the pain is
not due to an active disease process for which other medical or
psychiatric treatments are deemed more appropriate, and the
patient's agreement to participate actively in the program and to
involve his or her family members in the treatment. These programs
usually design individualized patient assessments, treatments, and
follow-up plans. Medication reduction, psychological treatment (di-
rected particularly at depression and anxiety), family counseling,
socialization skills, and educational or vocational counseling are
emphasized. Physical treatment methods (e.g., transcutaneous electri-
cal stimulation [TENS] and nerve blocks) and physical reactivation
methods (e.g., exercise, strengthening, conditioning, postural improve-
ment, and physical stress-reduction techniques) often are integral
components of the treatment plan (Fey and Fordyce, 1983; Roberts and
Reinhardt, 19801. Even pain management centers oriented to one
primary treatment method tend to use supporting approaches as well.
Thus, for example, in a program that espouses a "purely" behavioral
approach, one is likely also to find occupational and physical therapy
. . .
activities.
Despite their similar underlying philosophy, chronic pain manage-
ment programs or pain clinics vary considerably. They can be roughly
classified into three types, each of which may provide inpatient andJor
outpatient care. (1) Comprehensive pain centers are multimodal
chronic pain management programs with an integrated multidiscipli-
nary rehabilitation approach that screen patients prior to admission
and routinely include psychological assessment and patient follow-ups;
(2) syndrome-oriented pain centers deal with discrete problems (e.g.,
headache, low back pain, or cancer pain) and may be uni- or multidis-
ciplinary; (3) modality-oriented pain centers rely on a particular
treatment (e.g., nerve blocks, psychotherapy, transcutaneous stimula-
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RENABlLITATION APPROACHES ED ISSUES 235
tion) and tend not to include extensive evaluative procedures (Csordas
and Clark, 19861.
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 accred-
ited programs by mid-1986) (Whitacre, 1986~. As is true of health care
facility accreditation in general, accreditation for rehabilitation facil-
ities is based on the availability of particular health care professionals
and services, not on the quality of treatment. These standards do
require individualized treatment programs, but actual performance
criteria are lacking. Performance standards could help to deal with the
following three issues.
1. The variation among pain treatment facilities is a substantial
problem for the patient who may be inclined to consult the first pain
center recommended, assuming that they are all the same. This is
especially pertinent because these centers are typically the last resort
for sufferers who feel they have tried everything else. The diversity of
centers also poses a major challenge for research on the comparative
effectiveness of pain treatment facilities.
2. As discussed in Chapter 10, health care professionals tend not to
be adequately trained to manage patients with chronic pain. Thus,
some pain programs are run by well-intentioned physicians or other
health care professionals who nevertheless lack specific training and
experience in the management of patients with chronic pain. Further-
more, there is concern that some programs are headed by untrained
individuals who see the current interest in chronic pain treatment as
a way to make money (Bonica, 19811. There is no easy way for either
the pain sufferer or the referring physician to differentiate between the
good and bad programs.
3. Properly carried out interdisciplinary rehabilitation for chronic
pain can be expensive. The cost must be balanced against the patient's
needs and resources, the payor of the services, the rehabilitation
facility, and the overall system of health care delivery, as well as the
potential economic benefit to both the patient and to society of
returning an individual to work.
Establishing agreed-upon standards could help resolve all three
of these issues. Patients and their health care providers must be able
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236 ASSESSING ED TREATING PEN ED DYSFUNCTION
to decide on the basis of clear, generally accepted criteria which
programs are reputable, how the programs differ from one another,
and what may be the most appropriate and cost-effective treatment
program for a given individual. The committee cautions against the
Social Security Administration (SSA) taking any action that could
lead to the further proliferation of pain clinics or centers without first
setting proper performance standards.
REHABILITATION TECHNIQUES FOR PATIENTS WITH
CHRONIC PAIN
The chronic pain patient of primary concern to the SSA is one in
whom no organic or psychological cause has been identified that is
sufficient to account for the pain. By the time the patient has been
frustrated by the inability of numerous providers to identify the cause
of the pain and resolve it, practitioners, employers, family members,
and friends may increasingly question the "genuineness" of the pain.
Even if the pain initially had a single treatable cause, with time it
becomes enmeshed in a complex web of emotional, behavioral, and
social interactions that defy simple solutions. The patient suffers not
only from the inescapable pain, but also from the uncertainty as to
what causes the pain. He or she sees frightful visions of what this
unknown threat may portend for the future. 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. One approach reassures the patient that the pain will not
harm them. Because most practitioners do not truly understand the
pain's cause, efforts to convince the patient that the pain is harmless
can be difficult and can strain the patient's credulity. The other
approach encourages the patient to increase his or her activity and
thus discover that this additional activity does not increase their pain.
Patients are likely to become more functional as they refocus their
attention toward productive and rewarding activities and away from
the pain. This strategy mirrors rheumatologists' treatment for pa-
tients diagnosed as having fibrositis (Bennett, 1981, 1984) or fibromy-
aIgia (Yunus et al., 1982), diagnoses that have no commonly agreed-
upon or well-understood etiology (Wolfe and Cathey, 19851.
The following sections summarize seven treatment modalities used
by rehabilitation programs for patients suffering from chronic pain:
physical modalities, behavior modification, patient education, psycho-
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REHABILITATION APPROACHES ID ISSUES 23 7
social rehabilitation, stress management, pain control, and vocational
rehabilitation.
Physical Modalities
Nearly all chronic pain treatment programs include some form of
physical treatment or an activities program administered by a physi-
cal therapist, occupational therapist, activity therapist, or specially
trained nursing staff (Tyre and Anderson, 19811. These interventions
are designed to alleviate pain and to increase physical functioning. A
few reports simply identify physical therapy as one treatment ap-
proach without giving further details; others specify the physical
modalities used. The 72 responses to a survey of the 263 U.S. centers
listed in the 1979 Pain Clinic Directory of the American Society of
Anesthesiologists revealed that the treatments most commonly used
by physical therapists were (1) an individualized exercise program, (2)
instruction in body mechanics, (3) relaxation training, (4) TENS, (~)
biofeedback, and (6) group exercise (Doliber, 19841.
Nearly every chronic pain rehabilitation program incorporates
some form of exercise designed to increase the patient's activity
tolerance and range of motion. The exercise program may include
stretching, conditioning, strengthening, relaxation, or some combina-
tion of these. Many exercises are incorporated into the patient's daily
routine in the hope that the patient will continue the exercise at home
after completing the program.
TENS is used, at least occasionally, in most programs. It is nonin-
vasive, relatively inexpensive, harmless, and not likely to interfere
with other treatments. Although TENS helps some chronic pain
patients, how any individual patient will respond is unpredictable, and
its benefit for pain relief is likely to fade with time. Comparing the
efficacy of vibration with that of TENS in 267 patients with chronic
pain, Lundeberg (1984) concluded that TENS was generally compara-
ble with but not quite as effective as vibration.
Joint mobilization or manipulation is commonly practiced by phys-
ical therapists, chiropractors, some osteopaths, and a few physicians.
According to patient reports, chiropractic manipulation alone for
chronic back pain rarely provides more than temporary relief. Manip-
ulation is more useful as part of a total program than as an isolated
treatment approach (Klein and Sobel, 19851.
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. Other treatment methods
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238 ASSESSING kD TREATING PEN ED DYSFUNCTION
such as ultrasound, traction, and electrical stimulation were used less
frequently.
Chronic pain programs usually use the various methods just men-
tioned in conjunction with an exercise program. Clinical experience
suggests that exercise is a critical element of treatment and that the
combination of exercise and other physical modalities is more effective
than any single modality. In addition, there is no evidence that any
one physical modality alone is totally effective in the treatment of
· .
c Come pam.
Behavior Modification
The reconceptualization of chronic pain from a disease model to a
behavioral mode] was primarily the work of Fordyce and his colleagues
(Fordyce et al., 19681. According to this model, regardless of its source,
pain eventually develops a life of its own by interacting with environ-
mental factors that reinforce pain behavior. Behavioral treatment
methods attempt to improve functioning by helping patients rework
and unlearn pain behaviors and by helping family members alter their
responses to the patient in order to encourage better functioning. A
primary goal of treatment is to demonstrate to patients that they can
increase their activity levels and decrease excessive drug use without
increased pain (Fordyce et al., 19851. 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),
or some combination of behavioral strategies, sometimes including
physical interventions (Lipton, 19861. One recent study (Heinrich et
al., 1985) confirmed experimentally the general impression that pro-
grams integrating physical and behavioral rehabilitation are more
effective than any one approach alone.
Most behavior modification programs for pain include the following
seven components, with variable emphasis from program to program.
1. The patient and health care team work together to establish goals
and agree on a treatment plan. Baselines of drug usage, function, and
reported pain levels are recorded.
2. "Well behaviors" (e.g., recreational exercise, hobbies, social in-
teractions, and vocational planning) are reinforced. "Sick behaviors"
(e.g., inactivity and pain complaints) are discouraged by disregarding
them. Attention is paid primarily to what the patient does rather than
to what the patient says.
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RENABlLITATION APPROACHES ED ISSUES 239
3. Patients suffering from drug intoxication are gradually with-
drawn from nonessential pain medications, including narcotics, non-
narcotic analgesics, antidepressants, muscle relaxants, tranquilizers,
and sleep medications either through a "pain cocktail" or controlled
decreasing dosage.
4. Daily activity quotas are established and graphed so as to increase
activity levels gradually. Quotas are revised regularly to encourage
progress and avoid failure. Daily graphic feedback of the activity level is
considered essential to the behavior modification process.
5. A spouse, family member, roommate, or coworker is taught
about pain behavior and the behavior modification approach. This
person is also taught how to help replace the pain behavior with well
behavior.
6. Patients are taught to generalize their well behavior by transfer-
ring it from the therapeutic setting to the patient's home and voca-
tional setting.
7. Because of the possibility of having overlooked organic pathology
that will be exacerbated by- the exercise and activity program, or of
ignoring a new illness, patients and physicians learn to distinguish
"new' from "old" symptoms. New symptoms are investigated promptly.
The patient is helped to live with old symptoms.
Patient Education
Patient education takes many forms and is included in some form in
most programs. It may include audiovisual presentations, literature,
and discussion about such topics as the contribution of psycho-
physiological stress to chronic pain, the neurophysiology and anatomy
of pain, the role of nutrition and being overweight, the proper use of
pain medication, energy conservation, body mechanics, and postural
awareness (Gottlieb et al., 1977; Graff-Radford et al., in press). Patient
education is as varied as the differences among individual chronic pain
patients and the emphasis of individual pain programs.
Psychosocial Rehabilitation
Some chronic pain programs emphasize psychosocial rehabilitation
to help the patient function better despite his or her pain. Such
approaches include the following points.
· Training in coping skills to teach patients to solve problems and
meet responsibilities rather than avoid them.
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240 ASSESSING ED TREATING PEN ED DYSFUNCTION
· Family retraining to facilitate important interpersonal responses
in the modification of pain behavior. A key person is identified through
whom the contribution of important others is implemented.
· Social rehabilitation to encourage and reinforce increased num-
bers of social contacts and activities in the therapeutic milieu and offer
the completion of therapy.
~ Psychotherapy is an integral component of most treatment re-
gimes. Individual, family, and group psychotherapy may be used. The
manner in which this therapy is introduced to patients as well as the
patients' perceptions about its potential usefulness are usually critical
to its success (Coriey and Zlutnick, 19811.
Stress Management
Stress management is a common component of chronic pain rehabil-
itation programs. It may include relaxation training, biofeedback, and
hypnosis. Relaxation training was used in most of the physical therapy
programs Doliber (1984) surveyed. Doliber also noted that biofeedback
is commonly used by psychologists and physical therapists. Biofeed-
back for reduction of muscle tension has been found helpful for upper
back, neck, and shoulder pain; for tension headaches; and for jaw pain
associated with teeth clenching. It is rarely helpful for low back pain
(Fordyce, 19811.
Medical Interventions for Pain Control
Most of the treatment strategies discussed previously focus primar-
ily on the improvement of function. 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 pe-
ripheral nerve blocks or epidural steroid injections (see Chapters 9 and
10).
Attention to Myofascial Trigger Points
As discussed in Chapter 10, there is still considerable controversy
among physicians about the existence and treatment of myofascial
trigger points. Nonetheless, some studies report that trigger points are
common in chronic pain patients. Doliber (1984) found that physical
therapists in 90 percent of 72 chronic pain treatment programs
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REHABlLITATION4PROACHES ED ISSUES 241
reported seeing patients with myofascial syndromes, but that only 56
percent reported seeing them frequently. At the pair treatment center
in Miami, 85 percent of a consecutive series of almost 400 patients
were found to have myofascial trigger points (Fishbain et al., 19861.
There is a growing literature reporting that recognizing and dealing
with the factors that perpetuate myofascial trigger points contribute to
overall treatment electiveness (Graff-Radford et al., in press).
Use of Drugs
As discussed ire Chapters 9 and 10, many different kinds of drugs are
commonly prescribed for pain patients. Over time, many patients
become involved in polypharmacy with multiple providers, which may
produce untoward side effects. Most rehabilitation programs for
chronic pain emphasize detoxification and withdrawal from non-
narcotic and antidepressant drugs; a few programs introduce drugs as
a part of their treatment program. The more powerful analgesics and
muscle relaxants may interfere so seriously with function that their
side effects outweigh their benefits for some patients with Tong-stand-
ing chronic pain. Nonsteroidal anti-inflammatory (Irugs are considered
useful in patients with primary fibromyalgia (Yunus et al., 1982;
Bengtsson, 1986; Bennett, 1984), whereas myofascial pain from trigger
points is rarely alleviated by these drugs (Travel! and Simons, 19831.
Nerve Blocks and Epidural Steroid Injections
Peripheral nerve blocks are commonly used by anesthesiologists
diagnostically to localize the source of pain. Occasionally, a temporary
diagnostic block proves therapeutic. In a controlled study, epidural
steroid injections were found to relieve low back pain in twice as many
of the treated patients as in controls, with a statistically significant
advantage in the treatment groups at a 3-month follow-up (Dilke et al.,
1973~. However, these injections are rarely included as a regular part
of chronic pain programs.
Vocational Rehabilitation
One essential aspect of rehabilitation is vocational rehabilitation
Vocational rehabilitation is a specialized practice that focuses on
occupational or work function. Generally, vocational retraining starts
in the later stages of a rehabilitation program, and builds on the gains
in function achieved in the restorative program. The issue of optimum
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242 ASSESSING ED TREATING PEN ED DYSFUNCTION
timing for vocational counseling and training is raised frequently. It is
generally believed that earlier and stronger emphasis on vocational
factors, particularly on an early return to work, is likely to result in
better outcomes (Goldberg, 1982; Gottlieb et al., 19771.
OUTCOMES OF PAIN MANAGEMENT PROGRAMS
The general message from the literature on pain management
programs is that they almost universally show good effects on the basis
of a variety of outcome criteria. Improvement is observed in pain
self-reports, measures of physical activity level, employment status,
and medication use. There are, however, some important caveats
regarding the design and methodology of many of these studies,
especially those conducted before about 1982 (see Aronoff et al., 1983;
Fey and Fordyce, 1983; Goldberg, 1982; and I~inton, 19821. Some of the
specific problems follow:
· Admission criteria. 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. Therefore, there is no way of
knowing how representative of the entire pain population those
persons are who participated. Generally, the patient selection criteria
are not well-enough described to enable comparisons among studies.
Standardized admission protocols and comparable physical, demo-
graphic, laboratory, and psychological data would be useful.
· Types of patients. Patients suffering from different types of chronic
pain are often reported on within the same study without proper
differentiation. It is not clear whether the conclusions drawn for some
groups apply to others or whether treatments effective for one type of
pain will be as effective for others. This lack of differentiation further
impedes comparisons between studies.
· Control groups. Many studies lack control groups, and in other
studies the groups are not truly comparable. Appropriate patients for
such comparison groups are those who are untreated although eligible,
or those who are treated only with drugs anchor surgery rather than in
a multifaceted rehabilitation program.
~ Treatment ejects. The various components of treatment packages
are not well-enough identified to allow an evaluation of their individ-
ual components. Thus, it is not known whether the observed outcomes
are attributable to particular treatment modalities or to the ~nterac-
tive effects of multiple treatments.
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250 ASSESSING ED TREATING PEN ED DYSFUNCTION
ment as much as those not receiving compensation. Major design
problems marred this study, primarily in that the two groups were not
comparable on sex or initial diagnosis, and improvement was measured
only in terms of the discontinuation of pain complaints and the subse-
quent resumption of normal activities, including work. In addition,
because this study was done wholly through retrospective chart review,
data may be tainted by the caregiver's subjective interpretations.
Hammonds, Brena, and Unike] (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. Patients receiving compensation were
less likely to merit a block than were those not receiving compensa-
tion. Further, although not statistically significant, noncompensation
patients decreased their semantic index of pain verbalization after
they improved functionally, whereas that of compensation patients
increased after treatment. The authors concluded that pain behavior is
reinforced by conditioning and that financial compensation operates as
a reward for the learned pain behavior. Brena, Chapman, Stegall, and
Chayette (1979) drew a similar conclusion from a study of 101 patients,
all of whom had pending disability cases. (Later studies by this group,
however, found no significant relation between compensation and
rehabilitation outcomes.)
Trief and Stein (1985) evaluated the erects of pending litigation for
compensation on treatment outcomes in patients with chronic low back
pain who participated in a 6-week behavioral treatment program. The
patients were differentiated according to whether they had unsettled
legal claims for compensation. Although both groups improved signif-
icantly as a result of treatment, there were some differences on specific
measures between the two groups. Patients without pending litigation
obtained significantly greater reduction on the hypochondriasis and
hysteria scales of the Minnesota Multiphasic Personality Inventory
(M~D, any achieved "relatively greater," although not significantly
different statistically, improvement on two out of three physical mobility
behavior measures.
Block et al. (1980) reported on a study of patients divided on the
basis of referral source. Patients referred from a disability program
(Workers' Compensation or other), although significantly improved
after a behavioral treatment program, did less well than those referred
by physician specialists. In a 1981 article, more valuable for its descrip-
tion of on approach to the management of pain than for its research
method, Herman and Baptiste found work incentive, employment, and
the absence of litigation or Workers' Compensation claims to be signifi-
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REHABILITATION APPROACHES ID ISSUES 251
cant in differentiating successes from failures. They concluded that the
greatest deterrent to work was the "secondary gain" received or elected
from Workers' Compensation and pending litigation.
In an exploratory study using discrim~nant analyses, Guck et al.
(1986) found that age, compensation status, and education level, taken
together, were significant predictors of treatment outcome. In addition,
successfully treated patients tended to be younger and less likely to be
. . .
receiving compensation.
Studies Suggesting Little or No Negative Effect of Compensation
A number of studies show little difference in outcome between patients
who claim compensation and those who do not when their psychological
or physical states are assessed. Chapman, Brena, and Bradford (1981)
found that pending or current disability claims are "not necessarily" an
indication of likely treatment failure. Treatment in this study combined
an operant conditioning approach emphasizing patient education and
counseling in an attempt to refine internal coping mechanisms and
abilities to adopt healthy life behaviors despite pain. Chapman and his
colleagues (1981) studied 100 patients, at an average of 21 months
posttreatment, divided into three categories of Usability status: currently
receiving long-tenn disability payments, baring a pending claim for
compensation, and not currently receiving or seeking compensation. They
found that changes from pretreatment to foBow-up were not significantly
different among the three groups. Commenting that a significantly
higher percentage of patients with pending disability claims returned to
work compared with those currently receiving disability compensation,
the authors suggest that granting open-ended disability be done cau-
tiously so as to avoid establishing a permanent sick role. Similar findings
are reported by Brena, Chapman, and Decker (19811.
Meizack et al. (1985) examined patients suffering from low back pain
or other musculoskeletal pain. All were tested on the McGill Pain
Assessment Questionnaire (MPQ) and the MMPI. Compensation and
noncompensation patients had nearly identical pain scores and pain
descriptor patterns. The groups were also similar on the MMPI pain
triad (depression, hysteria, and hypochondriasis) and on several other
personal variables. 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.
Rosomoff et al. (1981) looked at low back pain patients who presented
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252 ASSESSING ED TREATING PEN ED DYSPUNCTION
at a clinic as totally disabled; the majority were in unskilled and
semiskilled jobs requiring heavy labor. At the outset, 59 percent were
receiving compensation and 41 percent were not. At follow-up (an
average of 11 months after the end of treatment), 86 percent of the total
group and 88 percent of the compensation patients reported fiall levels of
function. Also at follow-up, 70 percent of the entire group and 65 percent
of the compensation group were "effectively and appropriately occupied,"
having returned to work or school or resumed their usual activities. The
authors found no difference between groups and concluded that compen-
sation status in and of itself does not affect the final outcome of patient
functioning. They attribute success to early and aggressive job planning
and placement as a central component of treatment.
Peiz and Merskey (1982) examined the social adjustment and psy-
chological characteristics thought to be representative of a pain clinic
population. They examined the effects on personal and social life,
spontaneous descriptions of pain, the frequency of depression, and the
personal characteristics of chronic pain patients. Interviewers admin-
istered the Hopkins Symptom Check List-90 and the Levine-Pilowsky
Depression Questionnaire. Patients receiving compensation differed
from others only in their higher somatization scores, a difference the
authors suggest could have been an artifact of sampling resulting from
the unequal sex ratios in the two groups.
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 rehabili-
tation 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.
Another reason was that the arrangement was thought to be cost
elective. Between 1954 and 1965, legislative amendments provided
both a carrot and a stick to foster rehabilitation. In 1954, when an
earnings freeze for disabled workers was passed, the law required the
referral of disabled workers to state vocational rehabilitation agencies.
When cash benefits were introduced in 1956, a similar referral provi-
sion was included with the additional specification that benefits could
be withheld or reduced if the disabled beneficiary refused rehabilita-
tion services without good cause. The creation of a trial work period
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REHABILITATION APPROACHES ID ISSUES 253
was also intended to foster rehabilitation. Despite these measures, the
number of beneficiaries who were rehabilitated was small (Treitel,
1979).
In an attempt to improve SSA's performance in rehabilitating
beneficiaries, Congress established the Beneficiary Rehabilitation Pro-
gram (BRP) as part of the 1965 Social Security amendments. Previ-
ously, the federal government had provided 80 percent of the voca-
tional rehabilitation funds, while the remaining 20 percent came from
the states. Under the BRP, the federal government provided 100
percent of the rehabilitation funds; the goal was to stimulate the states
to greater rehabilitation activity. Clients had to meet four eligibility
requirements, the most important of which was that the predicted
period of productive work should be long enough so that the benefits
saved would offset the cost of the rehabilitation services. Initially, the
maximum amount of SSDI trust funds allocated among the states was
fixed at 1 percent of the year's total SSDI payments. In response to the
program's encouraging start, the maximum was increased to 1.25
percent in 1973 and 1.5 percent in 1974.
The BRP ultimately failed for a number of reasons. Some observers
felt that funds had been poured into the state programs faster than
they could be wisely spent. The allotment for 1972 was $40.5 million;
by 1976 the amount had reached $102.6 million. Questions were raised
about the effectiveness of the program, and a number of cost-benefit
analyses were conducted, with equivocal results. It was difficult to tell
whether all of the clients who had been accepted into the program
actually met the eligibility requirements and it was more difficult still
to tell whether the recovery of the clients could be attributed to the
services received. The program's objective was not to restore the client
to maximum effectiveness but to enable him or her to engage in
"substantial gainful activity" and hence leave the benefit rolls. In
1981, Congress effectively abandoned the BRP program; since then,
state vocational rehabilitation agencies have been reimbursed only for
services to federal disability beneficiaries who have been able to return
to work for 9 consecutive months (Berkowitz and Fox, 1986~. Less than
$1 million per year is currently appropriated to the states for this
program.
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-
OCR for page 254
254 ASSESSING ED TREATING PEN ED DYSFUNCTION
suring pain (see Chapters 7 and 11~. One solution that has been
proposed is to focus on the functional limitation caused by the pain
that prevents the person from carrying out a fully active life. Func-
tional limitation is more precisely describable than pain, and certain
key elements of it can be measured with acceptable validity and
reliability. For example, it is possible to verifier alterations in the
performance of the activities of daily life. Communication, self-care
performance, mobility status, and social activity inside and outside the
home or in the workplace could all be used to assess the disabling
consequences of chronic pain.
Thus, one realistic approach in determining eligibility for the
various benefits available is to define that eligibility by a more precise
measurement of the components of dysfunction and disability and to
use functional assessment as a surrogate for the measurement of pain.
Disability level, as demonstrated by properly designed functional
tests, may be the most objective and appropriate evidence of the
inability to work caused by pain.
The Question of Mandatory Rehabilitation
There appears to be a trend toward viewing rehabilitation (as
defined in this chapter) 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. This commit-
tee, too, feels that there would be critical problems with such a
recommendation. As has been reiterated throughout this report, it is
not known how many people have chronic pain or how many of them
have conditions that are due to treatable but undiagnosed conditions.
Further, not enough is known about existing chronic pain rehabilita-
tion facilities in teens of their adequacy, their comparative effective-
ness, or their ability to meet either strict standards or a requirement
for accreditation. We do know that the number of high-quaTity pro-
grams with experienced stab and a focus on the Social Security
population is limited and that some of the most successful programs
accept only 30 to 40 percent of those referred for pain rehabilitation.
We also know that combinations of treatment modalities appear to be
elective, but there are insufficient data available to recommend one
type of rehabilitative program over another.
Quite apart from the practical considerations, there are serious
ethical problems in mandating treatment or rehabilitation in order
for pain claimants to get benefits. Such a requirement would raise
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REHABILITATION APPROACHES ID ISSUES 255
questions of fairness and equity: Would it be fair for pain claimants to
have to meet requirements that no other claimants must meet?
Conversely, would it be fair for pain claimants to receive a benefit
(automatic access to rehabilitation programs) that no other claimant
receives? In addition, mandatory treatment would compromise the
claimants' autonomy and voluntariness, both of which are key ele-
ments in the doctrine of informed consent. Finally, the inception of
mandatory rehabilitation would risk promoting a rapid proliferation of
pain centers of poor quality because of the sudden availability of funds
to pay for such rehabilitation efforts. For all of these reasons, the
committee cannot recommend a mandatory rehabilitation require-
ment for SSA pain claimants.
Research and Demonstration Projects
The pain management programs reviewed earlier in this chapter
are restorative in their orientation and rehabilitative in their treat-
ment approach. Despite methodological shortcomings in study
designs, an increasing body of literature supports the view that
comprehensive multidisciplinary rehabilitation, provided in special-
ized clinics, is useful in reducing the disability and dysfunction
associated with chronic pain. Because the programs vary so much in
the specific techniques used to rehabilitate pain patients, little is
known about which treatment or set of treatments is responsible
for the observed improvements. It appears that a multimodality,
multidisciplinary approach Is critical, but much more research is
needed.
Specifically, a major research and demonstration effort is needed
to assess the efficacy of comprehensive rehabilitative management
services for chronic pain patients. The design should focus on clinical
factors and on issues of social and economic policy. The clinical aspect
should include research into the process and outcome of rehabilita-
tive treatment studied at selected demonstration sites. The study
centers should have a comprehensive interdisciplinary approach to
chronic pain rehabilitation and a clear definition of the elements of
the treatment process. Sites should be chosen that offer differing
combinations of treatment approaches to allow a comparison of
these various approaches. Common admission and outcome criteria
and uniform follow-up evaluation protocols should be used at all
sites.
The companion policy research effort should include attention to the
possibilities that follow.
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256 ASSESSING kD TREATING PMN ED DYSFUNCTION
1. Earner Identification and Entry into the System
Under SSA rules, a claimant cannot receive benefits until at least 5
months after the onset of a disabling condition. 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.
A well-designed, well-evaluated demonstration project to determine
the feasibility of early identification and the effects of early rehabili-
tation would add significantly to our current knowledge of the predic-
tion of long-term disability, the optimal timing and content of reha-
bilitation, and the relative costs and benefits of early versus late
intervention. In designing such a project, several difficult questions
emerge.
· How does one identify people earlier?
· Who should identify them?
· What kinds of people are being sought? Can "high-risk" categories
be identified?
· Who will be responsible for providing rehabilitation services and
for the costs of such services?
2. Expansion of the Initial Assessment of Pain Claimants to Incor-
porate a More Functional Approach
Medical criteria are used as a basis for presuming or establishing the
inability to work. Disability in excess of objective medical evidence, as
is often the case with chronic pain claimants, leads to denial of benefits
and to possibly unnecessary reviews and appeals. Pain claimants
should be able to proceed to the stage of the evaluation process in
which the ability to function in working and in performing basic
activities is assessed. Such an evaluation is then directly relevant to
questions about the possibility of rehabilitation for chronic pain
claimants.
3. Disentangling the Current Requirements for Proof of Work
Disability and the Requirements for Acceptance into Vocational
Rehabilitation
The SSA's definition of disability requires the total inability to work.
To be eligible for state or federal vocational rehabilitation, however,
claimants must be able to demonstrate a future likelihood of employ-
ment. This is an inconsistency that must be resolved if claimant
rehabilitation is to be achieved.
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RENABlLITATION APPROACHES AND ISSUES 257
4. Coordination of Disability Benefits Programs and Rehabilita-
tion Services
As discussed previously, although state vocational rehabilitation
agencies are linked to the SSA, they treat relatively few SSDI or
Supplemental Security Income beneficiaries. If rehabilitation is to be
an integral part of the federal disability program, the administration
and funding of these activities must be better coordinated.
5. Emphasis on Existing Incentives
Currently, the Social Security disability programs include provisions
designed to encourage people to try to work, such as a trial work period
during which disability and medical benefits continue. These features
seem to be used very infrequently, at least partly because physicians,
lawyers, and beneficiaries are unaware of them. A concerted educational/
information campaign should be undertaken to highlight these provisions
and to encourage beneficiaries to take advantage of these opportunities.
REFERENCES
Aronoff, G.M., and Evans, W.O. The prediction of treatment outcomes at a multidiscipli-
nary pain center. Pain 14:67-73, 1982.
Aronoff, G.M., Evans, W.O., and Enders, P.L. A review of follow-up studies of multidis-
ciplina~r pain units. Pain 16:1-11, 1983.
Bengtsson, A.. Primary fibromyalgia: a clinical and laboratory study. Linkoping,
Sweden. Linkoping University Medical Dissertations No. 224, 1986.
Bennett, R.M. Fibrositis: misnomer for a common rheumatic disorder. Western Journal
of Medicine 134:40~13, 1981.
Bennett, R.M. Fibrositis: does it exist and can it be treated. Journal of Musculoskeletal
Medicine 1(7):57-72, 1984.
Berkowitz, E., and Fox, D. The Struggle for Compromise: Social Security Disability
Insurance, 193~1986. Background paper prepared for the Institute of Medicine
Committee for a Study of Pain, Disability, and Chronic Illness Behavior, 1986.
Block, A.R., Kremer, E., and Gaylor, M. Behavioral treatment of chronic pain: variables
affecting treatment efficacy. Pain 8:367~75, 1980.
Bonica, J.J. Preface. NIDA Research Monograph 36, Rockville, MD, pp. vii-x, 1981.
Brena, S.F., Chapman, S.L., and Decker, R. Chronic pain as a learned experience: Emory
University Pain Control Center. NIDA Research Monograph 36, Rockville, MD, pp.
7~83, 1981.
Brena, S.F., Chapman, S.L., Stegall, P.G., and Chayette, S.B. Chronic pain states: their
relationship to impairment and disability. Archives of Physical Medicine and Reha-
bilitatzon 60:387~89, 1979.
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. Pain 21:77-89, 1985.
Catchlove, R., and Cohen, K. Effects of a directive return to work approach in the
treatment of workmen's compensation patients with chronic pain. Pain 14:181-191,
1982.
OCR for page 258
258 ASSESSING AND TREATING PAIN AND DYSFUNCTION
Chapman, S.L., Brena, S.F., and Bradford, L.A. Treatment outcome in a chronic pain
rehabilitation program. Pain 11:25~268, 1981.
Cinciripini, P.M., and Floreen, A. An evaluation of a behavioral program for chronic
pain. Journal of Behavioral Medicine 5:37~389, 1982.
Corley, M.J., and Zlutnick, S. A model for inpatient liaison-consultation with chronic
pain patients. In: The Comprehensive Handbook of Behavioral Medicine (Fergeson,
J.H., and Taylor,C.B., eds.). Jamaica, NY: Spectrum Publications, 1981.
Csordas, T.J., and Clark, J.A. Survey of pain care facilities: preliminary summary of
findings. Unpublished paper. Boston: Harvard Medical School, 1986.
Dilke, T.F.W., Burry, H.C., and Grahame, R. Extradural corticosteroid injection in
management of lumbar nerve root compression. British Joz~rrzal of Medicine
2:635-637, 1973.
Doliber, C.M. Role of the physical therapist at pain treatment centers: a survey. Physical
Therapy 64:90~909, 1984.
Dworkin, R.H., Handlin, D.S., Richlin, D.M., Brand, L., and Vannucci, C. Unraveling
the erects of compensation, litigation, and employment on treatment response in
chronic pain. Pain 23:49-59, 1985.
Fey, S.G., and Fordyce, W.E. Behavioral rehabilitation of the chronic pain patient.
Annual Review of Rehabilitation 3:32-63, 1983.
Finneson, B.E. Psychosocial considerations in low back pain: the 'cause' and 'cure' of
industry related low back pain. Orthopedic Clinics of [forth America 8:2~26, 1977.
Fishbain, MA., Goldberg, M., Meagher, B.R., Steele, R., and Rosomoff, H. Male and
female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria.
Pain 26:181 - 198, 1986.
Fordyce, W.E. Back pain, compensation, and public policy. In: Prevention in Health
Psychology (Rosen, J.C., and Solomon, L.J., eds.). Hanover, NH: University Press of
New England, 1985.
Fordyce, W.E. Chronic pain. In: Handbook of Severe Disability (Stolov, W.C., and
Clowers, M.R., eds.). Washington, DC: U.S. Department of Education, Rehabilitation
Services Administration, 1981.
Fordyce, W.E., Fowler, R.S., Jr., and Delateur, B. An application of behavior modidca-
tion technique to a problem of chronic pain. Behavior Research and Therapy
6:10~107, 1968.
Fordyce, W.E., Roberts, A.H., and Sternbach, R.A. The behavioral management of
chronic pain: a response to critics. Pain 22:113-125, 1985.
Goldberg, R.T. The social and vocational rehabilitation of persons with chronic pain: a
critical evaluation. Rehabilitation Literature 43:27~283, 1982.
Gottlieb, H., Strite, L.C., Koller, R., Modorsky, A., Hockersmith, V., Kleeman, M., and
Wagner, J. Comprehensive rehabilitation of patients having chronic low back pain.
Archives of Physical Medicine and Rehabilitation 58:101-108, 1977.
Graff-Radford, S.B., Reeves, J.L., and Jaeger, B. Management of chronic head and neck
pain: the electiveness of altering factors perpetuating myofascial pain. Journal of
Head and Face Pain, in press.
Guck, T.P., Skultely, F.M., Meilman, P.N., and Dowd, E.T. Prediction of long term
outcome of multidisciplinary pain treatment. Archives of Physical Medicine and
Rehabilitation 67:29~296, 1986.
Guck, T.P., Skultely, F.M., Meilman, P.N., and Dowd, E.T. Multidisciplinary pain center
follow-up study: evaluation with a no-treatment control group. Pain 21:295~06,
1985.
Hammonds, W., Brena, S.3?., and Unikel, I.P. Compensation for work-related injuries
OCR for page 259
REHABILITATION APPROACHES AND ISSUES 259
and rehabilitation of patients with chronic pain. Southern Medical Journal
71:6644666, 1978.
Heinrich, R.L., Cohen, M.J., Naliboff, B.D., Collins, G.A., and Bonekkar, A.D. Compar-
ing physical and behavior therapy for chronic low back pain on physical abilities,
psychological distress, and patients' perceptions. Journal of Behavioral Medicine
8:61-79, 1985.
Herman, E., and Baptiste, S. Pain control: mastery through group experience. Pain
10:79~6, 1981.
fIolzman, A.D., and Turk, D.C. Pain Management: A Handbook of Psychological
Treatment Approaches. New York: Pergamon Press, 1986.
Keefe, F.J., and Gil, K. Recent advances in the behavioral assessment and treatment of
chronic pain. Annals of Behavioral Medicine 7:11-16, 1985.
Klein, A.C.? and Sobel, D. Backache Relief. New York: Random House, 1985.
Krusen, E.M., and Ford, D.E. Compensation factor in low back injuries. Journal of thee
American Medical Association 66:112~1133, 1958.
Leavitt, F., Carron, D.C., McNeill, T.W., and Whisler, W.W. Organic status, psycholog-
ical disturbance, and pain report characteristics in low-back-pain patients on com-
pensation. Spine 7:398~02, 1982.
Linton, S.J. Behavioral remediation of chronic pain: a status report. Pain 24:12~141,
1986.
Linton, S.J. A critical review of behavioral treatments for chronic benign pain other
than headache. British Journal of Psychology 21:321~37, 1982.
Lundeberg, T. Long-term results of vibratory stimulation as a pain relieving measure for
chronic pain. Pain 20:1~23, 1984.
Melzack, R., Katz, J. and Jeans, M.J. The role of compensation in chronic pain: analysis
using a new method of scoring the McGill Pain Questionnaire. Pain 23:101-112, 1985.
Mendelson, G. Compensation, pain complaints, and psychological disturbance. Pain
20:169~177, 1984.
Newman, R.I., Seres, J.L., Yospe, L.P., and Garlington, B. Multidisciplinary treatment
of chronic pain: long-term follow-up of low back patients. Pain 4:28~292, 1978.
Painter, J.R., Seres, J.L., and Newman, R.I. Assessing benefits of the pain center: why
some patients regress. Pain 8:101-113, 1980.
Pelz, M., and Merskey, H. A description of the psychological erects of chronic painful
lesions. Pain 14:293~01, 1982.
Roberts, A.H., and Reinhardt, L. The behavioral management of chronic pain: long-term
follow-up with comparison groups. Pain 8:151-162, 1980.
Rosomoff, H.L., Green, C., Silbert, M., and Steele, R. Pain and low back rehabilitation at
the University of Miami School of Medicine. NIDA Research Monograph 36,
Rockville, MD, pp. 9~111, 1981.
Seres, J., Painter, J.R., and Newman, R.T. Multidisciplinary treatment of chronic pal
at the Northwest Pain Center. NIDA Research Monograph 36, Rockville, MD, pp.
41~5, 1981.
Tarsh, M.J., and Royston, C. A follow-up study of accident neurosis. British Journal of
Psychiatry 146:1~25, 1985.
Travell, J.G., and Simons, D.G. Myofascial Pain and Dysfunction: The Trigger Point
Manual. Baltimore, MD: Williams & Wilkins, 1983.
Treitel, R. Disability beneficiary recovery. Social Security Once of Research and
Statistics Working Paper No. 2, 1979.
Trief, P., and Stein, A. Pending litigation and rehabilitation outcome of chronic back
pain. Archives of Physical Medicine and Rehabilitation 66:9~99, 1985.
OCR for page 260
260 ASSESSING AND TREATING PAIN AND DYSFUNCTION
Tyre, T.E., and Anderson, D.L. Inpatient management of the chronic pain patient: a
one-year follow-up study. Journal of Family Practice 12:819-827, 1981.
Weighill, V.E. Compensation neurosis: a review of the literature. Journal of Psychoso-
matic Research 27:97-104, 1983.
Whitacre, L.G. Personal communication. Commission on Accreditation of Rehabilitation
Facilities, 1986.
Wolfe, F., and Cathey, M.A. The epidemiology of tender points: a prospective study of
1,520 patients. Journal of Rheumatology 12:116~1168, 1985.
Yunus, M., Masi, A.T., Calabro, J.J., and Shah, I.K. Primary fibromyalgia. American
Family Physician 25:11~121, 1982.
Representative terms from entire chapter:
pain patients
