The original concept that nerve root compression from a herniated disc produces pain was challenged decades ago when Rosomoff ⁷ presented a series of observations together with clinical and experimental evidence that supported the contention that alternative nonsurgical methods will provide successful treatment even for manifest disc herniations or lumbar stenosis. Physiologic studies demonstrated that, except for a transient painful impulse when the nerve is first impacted, sustained nerve root compression or ‘pinching’ does not produce pain.⁸ There could be numbness or loss of function, but this is not a painful event.

From inspection of human anatomy, it is inescapably clear that all low back injuries must have associated soft tissue abnormalities. Even if the forces causing the injury reach sufficient magnitude to herniate or rupture an intervertebral disc, the force must be transmitted first through the surrounding soft tissue that binds the spine together as a functional unit. These tissues, when injured, undergo a breakdown of the cell membranes to arachidonic acid, from which biosynthesis of prostaglandins and associated products ensues. One important issue in this process is the induction of a state of hyperalgesia, following which a pain signal will evolve when excessive mechanical stimulation occurs or when compounds of reaction to injury, such as histamine or bradykinin, are produced.⁹ The nerve itself does not originate the pain signal; nociceptors are stimulated to initiate the transmission of the signal.

It is our thesis that the disordered musculoskeletal system is responsible for initiating these phenomena.^3,^7,¹⁰ These structures are in the surrounding paraspinal muscles, buttocks, hips, and legs. These peripheral sites are treatable by alternative medical approaches. Treatment will restore function and alleviate pain, often without the need for correcting intraspinal abnormalities that have traditionally been designated as the pain generator. Further, a study carried out in 45 000 patients with low back pain indicated that only 1 in 200 of patients may actually need surgical intervention;¹¹ in our experience the number of patients is 1 in 500.

Muscular and fascial abnormalities are called myofascial syndromes. They have been well described by Travell and Simons.¹² Abnormal movements of the back, restricted ranges of motion in the hips or legs, or the presence of muscle tenderness and/or trigger points, are seen with myofascial syndromes. These can perpetuate mechanical dysfunction, continued strain, muscle fatigue, and pain.

ALGORITHM FOR PAIN REHABILITATION

Although it can be described in discrete phases, rehabilitation is a continuous process of evaluation, treatment, conditioning, and reevaluations. The intensity and duration of each process depends on a variety of parameters including patient’s response, rate of progress, the presence of comorbidities, and the number and type of objectives to be met. The algorithm is depicted in Figure 110.1 and the elements are described below.

Fig. 110.1 Algorithm for pain rehabilitation.

Admission criteria

To enter the system, the patient undergoes evaluation over a 3-day period. The rehabilitation team attempts to identify the medical, behavioral, vocational, financial, social, and other significant problems. The approach is comprehensive and holistic. Patient selection criteria are broad. The patient must have the ability to understand and carry out instructions, must be compliant and cooperative, and must not have aggressive or disruptive behavior that would disturb the milieu. Patients with schizophrenia, manic-depression, or other major psychiatric disorders are not precluded as long as they are receiving treatment which renders them stable. The patient, the family, and significant others, such as the lawyer, the employer, and the insurer must be accepting of vthe program. Worker compensation, liability cases, multiple surgeries, long histories of invalidism, or drug abuse are not exclusionary conditions. Although integral, the financial, legal, and administrative aspects of patient admission are beyond the scope of this chapter.

Upon entry, patients are oriented to the program and are made aware of rules, policies, and expectations. Evaluations and observations are made by the various disciplines in order to:

1. Decide if the patient meets the criteria for inclusion into the program;

2. Determine the appropriate diagnosis based on previous medical records and the additional medical, physical, and psychological assessments;

3. Establish a baseline of abilities, limitations, and goals; and

4. Medication intake, dependence, and use must be determined, particularly as it pertains to narcotics.

The multidisciplinary team consists of physicians, psychologists, occupational and physical therapists, massage therapists, ergonomists, nurses, vocational counselors, and biofeedback therapists. Assessment of the injured individual by these disciplines considers not just the injury history but also the patient’s physical and behavioral status and vocational issues, if applicable.

The outcome of the exhaustive assessment is a constructed, formalized care plan detailing problem areas, treatment strategies, and expected outcomes. Due to the large number of possible findings upon initial assessment, a set of ‘key indicators’ is used to monitor progress towards the final goals. Key indicators may include (1) pain level; (2) number of hours of sleep; (3) pain medications; (4) lifting, carrying, sitting, standing, walking tolerances; (5) ranges of motion of the neck and trunk; (6) straight leg raise; (7) composite hip range of motion; (8) posture; (9) strength; (10) gait; (11) and key behavioral and vocational problems. These indicators are updated on a weekly basis.

Phase I may take 2–3 days for interviews and/or evaluations. A team meeting is then held, findings are discussed, and team recommendations are presented to the Medical Director. In a multidisciplinary conference, the Medical Director discusses the findings with the patient and significant other. Team recommendations, clarification of medical concerns, and diagnosis are addressed. Patient questions, misconceptions, and expectations are also discussed. Admission to the program is contingent upon the patient’s full consent to participate in the process, including tapering from narcotics or other dependence-producing substances.

Activation and physical restoration

During this phase, treatment is initiated. A variety of therapeutic approaches are used to restore ranges of motion, resolve trigger points, taper off narcotic medications, and begin the process of education and relearning. Stretching, physical agent modalities, body mechanics training, and behavioral interventions are used to guide the patients through what is probably the most difficult phase of the program. Patients must surmount hurdles of fear, anger, mistrust, and past misconceptions about diagnosis in order to proceed with confidence and acceptance. Education includes topics such as myofascial pain syndrome, relaxation, stress management, and healthy lifestyles. Simultaneously, the patient’s medication is reviewed and a rigorous management program is initiated and monitored, including tapering from narcotics or other dependence-producing drugs. The use of ice and other modalities to alleviate pain are introduced.

A daily treatment schedule is designed to accommodate the various treatments and disciplines. A typical treatment schedule for one patient is shown in Table 110.1. The contents of each patient’s schedule vary on a daily basis depending on the stage (week) in treatment, level of activation, and progress.

Table 110.1 Typical daily treatment schedule

Patient name___________________
Time	Activity
8:00–8:30	Movement therapy, warm up, low-impact aerobics
8:30–10:00	Physical therapy, stretching, modalities, back exercises, functional electrical stimulation, active exercises, gait training, flare-up procedures
10:00–11:30	Occupational therapy, body mechanics training, biofeedback, functional circuits, pacing, walking, climbing, lifting, carrying, pushing/pulling, reaching, safety, joint protection, ADL training
11:30–12:00	Psychological counseling, family counseling, stress management, breathing exercises, hypnosis, vocational counseling, vocational preparation, case management
12:00–1:00	Lunch break
1:00–1:30	Strength and cardiovascular training
1:30–2:00	Neuromuscular massage therapy
2:00–3:00	Occupational therapy, upper extremity activities exercises, educational activities, work simulation
3:00–4:00	Group activity, educational sessions
4:00	Evening activities, recreational activities

Treatment is provided on a daily basis including Saturdays. At nighttime, patients are assigned ‘homework’; i.e. evening self-paced exercises determined by the treating therapist and monitored by nursing staff.

A very effective tool in this phase is the concept of daily goals, final goal setting, and self-monitoring. Computerized modeling is used to determine optimal pathways a patient should follow during rehabilitation. The model utilizes statistical projection methods, which take into consideration the patient’s initial performance level and the desired goals.¹³ This nonlinear model derives its coefficients from retrospective data collected from over 1000 patients with chronic pain who successfully completed the 4-week rehabilitation and functional restoration program, and who have returned to a productive lifestyle. Once initial levels of performance have been measured and treatment goals have been determined, the daily goals are assigned to provide a personalized print-out of the expected ‘daily’ performance. The daily goals program provides daily increments for the patient’s therapeutic activities. The optimal progression print-out from initial tolerances to final goals is used by the patient and the treating staff to determine effects needed to achieve the desired daily performance throughout treatment.

On a weekly basis or sooner, if necessary, a team conference reviews the patient’s progress and level of participation; and the team determines if the program should be continued, modified, or terminated. Behavioral issues are addressed early. The patient must be in agreement with the treatment plan. The building blocks for the postdischarge maintenance program also start during this phase.

Rehabilitation for lifestyle and work restoration

Job simulation is an important concept with respect to return to work. In conjunction with the vocational counselor, job tasks are reviewed with the patient to determine which must be simulated if there is to be a successful return to work. Conferences with the employer and job site visits may be necessary to form the plan. Once the simulation demands are determined, the patient is taught to perform tasks safely to restore confidence and prevent reinjury. This allows the treating physician to certify that the patient can safely handle the job.

If a patient’s care plan does not include return to work, functional circuits and realistic lifestyle simulations are utilized to return the patient to those functional levels that will allow comfort and safety.

EVALUATION OF FUNCTIONAL DISABILITY

Objective measurements are utilized to determine physical condition, functional abilities, behavioral health, vocational parameters, and other patient attributes relevant to the rehabilitation process. Methods of measuring functional capacity fall under three main categories: (1) patient’s self-report of functional levels, which provides information about the perception of how much the patient believes he can or cannot do; (2) medical examination to provide an estimate of medical impairment; and (3) assessment of abilities or limitations producing quantifiable measures reflecting the level of performance, in comparison with performance levels of healthy subjects (e.g. norms) or the match to job/task demands.

Physician evaluation

The entry to evaluation and treatment is through the physician. The physician must obtain a detailed, accurate history. The mechanism of injury and the precise location of the pain at onset are critical. A neurologic examination evaluates reflexes, muscle strength, and sensory status to document the presence or absence of neurologic deficits.¹⁴ Although neurologic screening is essential, it is most often not significantly positive. In fact, only 1% of individuals have neurologic dysfunction which is reversible usually and, therefore, should not be considered as a pathological deficit. The soft tissue examination must be sophisticated and thorough.¹⁵ All musculoskeletal and myofascial abnormalities must be identified. This is particularly important, since myofascial syndromes may simulate neurological syndromes, particularly radiculopathies. The straight leg raising (SLR) test may produce leg pain considered to be indicative of irritated nerve roots, but this occurs even more regularly with myofascial syndromes. Contractures of the hip musculature, particularly the hip rotators, are common and disabling with standing or walking, so that restricted ranges of motion about the hips are not necessarily an indicator of articular disease. Palpable soft tissue tenderness by itself, again, is thought by some to be less specific or reliable, but, to reiterate, tender/trigger points and restricted ranges of motion are the hallmark of myofascial syndromes and must be sought so they can be identified and treated. They are, in fact, objective findings.

Simple laboratory tests, including blood count and erythrocyte sedimentation rate, are sufficiently inexpensive and efficacious for use as initial tests when there is suspicion of back-related pathology, such as tumor or infection. Lastly, special tests such as radiographs, imaging techniques, electrodiagnostics, thermography, and discography should be reviewed or recommended, if deemed necessary, but should be interpreted with extreme caution.¹⁰

Motor dysfunction evaluation

This is a method developed to identify and effectively treat ‘motor’ dysfunction in patients with chronic pain conditions.¹⁶ This innovative testing utilizes on-line computerized electromyographic (EMG) methods to study recruitment of muscles involved in a chain of motor activities.¹⁷ This method may detect functional muscular abnormalities that cannot be identified by clinical examination, even by experienced observers. The EMG signals of the various muscles are examined for baseline activity, symmetry, magnitude, frequency contents, synchrony, timing, and patterns. Patients’ behaviors are also observed. Motor dysfunction evaluation (MDE) findings are then compared to relevant clinical findings. Patient-specific, as well as condition-specific, multidisciplinary approaches are then generated to deal with the problems during daily treatment. The overall objective is to improve function and accelerate restoration. This is accomplished through using EMG and other electrically assisted methods to increase sensory perception of muscles and joints; increase neuromuscular recruitment; increase strength and endurance; and reestablish synchrony, symmetry, pattern, and synergy of muscle activity, thereby increasing functional capacities and reduction of pain.

Physical therapy evaluation

This type of evaluation emphasizes the different aspects of the soft tissues and the musculoskeletal system such as muscle tone and strength, ranges of motion, gait, spasm, swelling, pain pattern, etc. Physical examination in this category evaluates muscle strength, which is reported on a scale from 0 (no strength) to 5 (normal strength). While yielding numerical data, these measurements are to some degree subjective. Recently, new technology has enabled the introduction of testing equipment such as electronic goniometers and muscle testing machines that permit quantitative measurement of human functions.

Occupational therapy evaluation

Occupational therapy evaluation determines functional levels, such as sitting, standing and walking tolerances; posture, balance and coordination; risk of falling; stair climbing; carrying and lifting, pushing and pulling; self-care, especially activities of daily living, socialization, driving, and other vocational and leisure activities. Descriptive information about the degree of independence, physical tolerances, endurance, speed, and attitude of the patient are established. The assessment of proper body mechanics is key.

Behavioral therapy/psychological evaluation

This examination reveals a great deal about the patient’s mental state, behaviors, coping styles, and the effects of pain or injury on personality. Behavioral analysis considers compliance, achievement level before injury, activity level after injury, functional capacities, anxiety, depression, personality disorders, marital status, role reversal, and family dysfunctional states. There are psychological tests designed to elicit responses which can be translated into numerical values and compared with the performance of other persons, such as the Minnesota Multiphasic Personality Inventory and the Millon Behavioral Health Inventory Assessment. These instruments test psychogenic attitudes, such as chronic tension, recent stress, premorbid pessimism, future despair, social alienation, and somatic anxiety. They are not a predictor of outcome, nor should they be used for that purpose. We no longer use these instruments, but depend heavily on individual interview assessments.¹⁸ If utilized, it should be for the purpose of finding out how the treating staff can interact with the individual in an effective manner to allow the patient to accept the rehabilitation plan. The patient has to be a partner in the rehabilitative process; otherwise, the effort will fail.

Psychological services offer biofeedback, relaxation training, coping skills training, assertiveness, stress management, and self-hypnosis. Group and family therapy deal with social interactions, return to environment, employment, and disability versus wellness with an emphasis on function, not pain. Psychological evaluations are tailored to document these issues. They work with the vocational counselors concerning return to work issues.

Vocational evaluation

The objectives of vocational evaluations are:

1. Assessment of education level, training and work history, vocational abilities, transferable skills, job satisfaction, interests, goals, and interpersonal relations at work;

2. Identification of vocational goals and motivation to return to work, same job, modified job, different job and job seeking skills; and

3. Establishment of the role of the significant other, family, employer, attorney as it pertains to return to work issues.^1,¹⁹

COMPONENTS OF PAIN REHABILITATION (INTERVENTIONS)

Pain rehabilitation programs utilize a multimodal, cognitive–behavioral, goal-oriented aggressive physical approach within a supportive environment in which patients learn pain management techniques and work toward clear and achievable goals. Within such a complex paradigm, customization, individualization, communication, collaboration, planning, and flexibility become important characteristics.

The program is carried out by experts in pain management and rehabilitation from different specialties. Pain physicians coordinate and oversee the program, including the prescription of medication. Physical medicine and rehabilitation directs the application of all physical medicine modalities and treatments. Nurses trained in rehabilitation and behavior monitor patient progress and education, and reinforce the teachings of all disciplines, provide direct nursing care and medication, manage tapering from narcotics, and serve as case managers. The behavioral division is headed by a psychiatrist; doctorate-level psychologists are assigned to each patient. They do individual and group counseling, administer biofeedback, behavioral modification, stress management, time management, coping methods, self-hypnosis, or other applicable techniques. The vocational rehabilitation division evaluates and directs job readiness, goal setting for job placement, and return to work. The ergonomic division simulates the job and adapts the patient and/or work site while computing daily achievement goals. Functional capacities are measured regularly.

The average program will last 4 weeks on an inpatient or outpatient basis or a combination thereof. Inpatient status is preferred for the medically and behaviorally difficult, complicated case, but it is not always possible, as the healthcare reimbursement system may dictate the circumstances of treatment. In a tertiary referral center, few ‘simple,’ early primary care-type patients are seen. Our program receives the most complex, ‘court of last resort,’ salvage cases.

Medication/narcotics

Narcotics have been the first line of treatment for intractable pain since time immemorial. These agents are not particularly effective with chronic pain, even when pursued vigorously as has happened during the past decade. If this statement were not true, then why would patients come to our center, in pain, having been given escalating doses of analgesics, to the daily equivalent of 12 000 mg of morphine? This would seem almost unbelievable, if it were not for the fact this experience has been repeated at our center on numerous occasions.

Drug therapy is the primary mode of management for both acute and chronic pain, and conventionally can be classified into three categories: (a) nonopioid analgesics, (b) opioid analgesics, and (c) coanalgesics. Nonopioid analgesics such as salicylates, acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs) are indicated for pain involving inflammation, although acetaminophen lacks clinically useful peripheral antiinflammatory activity. NSAIDs are both analgesic and antiinflammatory and, therefore, are useful also for the treatment of pain not involving inflammation. NSAIDs differ from morphine-type analgesics in that there is an analgesic dose ceiling above which adverse effects increase, but additional analgesia does not result; NSAIDs do not produce physical or psychological dependence; NSAIDs are antipyretic. The primary mechanism of NSAID action is inhibition of the enzyme cyclooxygenase, inhibiting the formation of prostaglandins which sensitize peripheral nerves and central sensory neurons to painful stimuli. These time-honored agents have been used extensively, but do require caution in that they may produce gastrointestinal side effects such as ulceration or bleeding. Drugs such as ibuprofen, naproxen, ketoprofen, indometacin, ketorolac and others in this group which have their advocates will actually serve good purpose but, in chronic pain, may not produce total relief. The more recent COX-2 group were thought to be more effective, but currently are under scrutiny and have even been banned because of complicating features such as cardiac disease in addition to adverse hematological effects, renal effects, and even occasional central nervous system dysfunction.

The opioid analgesics have shown increased use throughout the later decades because of the continuing quest for pain relief in contradistinction to pain control. There have been, and continue to be, opposing views on how these drugs should be used. There are those who take the more standard approach of following the PDR recommendations. Others believe that pain is such an intolerable condition that whatever is required to produce control should be prescribed. Unfortunately, if one carries that thesis to conclusion, it will often turn out that the escalating high-level dose approach will also result in an inability to function because of sedation or other physical side effects and, therefore, prove useless, at least for the noncancer patient. It has always been the philosophy of our center that every effort should be made to taper and discontinue narcotic analgesics in favor of pain rehabilitation. So much of the disability is mechanical in origin as compared to chemical. In fact, throughout the years, there have been very few patients in whom successful tapering and cessation of narcotic use cannot be effected, to the betterment of their physical and psychological status. It would be rare for us to complete our rehabilitation program and prescribe ‘maintenance narcotic.’ This may represent a minority view, but it has been our experience, and it remains our philosophy, unchanged throughout three decades of pain management.

The coanalgesic group of drugs may be used to enhance the effect of opioids or NSAIDs, have independent analgesic activity in certain situations, or counteract the side effects of analgesics. Neuropathic pain represents 30–40% of this treatment group. This is pain which has a burning, prickling quality which has been called dysesthetic pain as compared to the sharp, toothache-like pain managed with standard analgesics. Included in this group would be the tricyclic antidepressants, the antiepileptic drugs, local anesthetics, glucocorticoids, skeletal muscle relaxants, antispasmodial agents, antihistamines, benzodiazepines, caffeine, phenothiazines, and topical agents.

Physical therapy restoration

Physical medicine has the goal of restoring body function to normal or its closest equivalent. Because myofascial contracture is the common denominator in the low back disorders, the first phase of management is muscle stretching and restoration of full range of motion in the joints of the hips, back, and lower extremities. This therapy includes gait retraining because of acquired maladaptive patterns, postural adjustment, proper use of effective modalities, elimination of adaptive equipment when possible, and strength and endurance conditioning with instruction of flare-up management.

Modalities, when evaluated as unimodal therapy, may not show clear-cut evidence of effectiveness. However, they appear to be useful in combination which, unfortunately, makes statistical evaluation more difficult. Nonetheless, scientific rationale exists for some. Ice application with lowering of temperature is known to decrease nerve conduction to the point of anesthesia, and the inflammatory reaction is contained with a reduction of chronic changes.^20,²¹ To be effective, the body part must be packed in ice for periods in excess of 30 minutes. Trigger point desensitization is indicated. Liberal use of ice is the preferred method of treatment. Heat does seem to soften muscle preparatory to stretching. An adjunct vapocoolant helps to block the stretch reflex and makes lengthening easier.

Mechanical traction is useful for certain specific indications. Conceptually, we apply traction to stretch muscle groups, not to distract the spine or to release nerve entrapment. We do not believe that distraction can be effected with the weights that are used, and the principle of entrapment is not tenable. Therefore, traditional pelvic or leg traction is not employed. Gravity traction is applied for iliopsoas contractures in the patient with a spinal flexion deformity and/or failure to extend the back. Autotraction is an important technique, which allows three-dimensional placement of the spine by rotating, flexing, or extending the unit as the patient imposes his or her own body force by pushing and pulling. The self-applied force of autotraction will not exceed that which could be potentially injurious, but it will release tight paraspinal muscles. Autotraction does not decompress the nerve root, as was the concept of its originators.^22,²³ Most stretching is manual and labor intensive, since it is important that the therapist feels the tissue during treatment.

Massage also is used as adjunct treatment to enhance muscle lengthening and supple movement. There are over 200 forms of massage and bodywork. Swedish, shiatsu, rolfing, cranio-sacral release, Alexander technique, sports massage, neuromuscular therapy, seated massage, and Thai massage are several examples. For the purpose of functional restoration and pain reduction, neuromuscular therapy uses advanced concepts in pressure therapy to break the stress–tension–pain cycle. It aims to relax muscle so that the body will return to normal neuromuscular integrity and balance. Neuromuscular massage is essential to resolve trigger points. But trigger point resolution by massage may not be sustained unless progress is made towards restoring normal ranges of motion, flexibility, and mobility.

Transcutaneous electrical neural stimulation (TENS) is used infrequently and only with patients who are TENS responders and who can be assisted with a difficult drug taper for which TENS may give short-term relief as the drugs are withdrawn. TENS will not be given to the patient beyond this period of time; it has no role in long-term therapy. Conceptually, it is to be emphasized that we are aiming for resolution of the painful disorder by physical restitution, not by an attempt at distraction, masking the pain, or at coping by ‘learning to live with pain.’

Passive, then active ranging of motion is essential, especially about the hips and, in particular, the hip rotators. Hamstring lengthening is another mandate, because hamstring tightness will affect back movement. Full ranges of back motion are the ultimate goal, so flexion and extension exercises are instituted without prejudice for the proponents of either type. Both flexion and extension exercises are needed.

A full compendium of exercises is employed, as described in any standard physical therapy textbook, to establish full ranges of motion throughout the lower body with supple muscles and fluid movement. As this is being achieved, muscle strengthening and endurance/cardiovascular conditioning are added to the regimen with monitoring of those patients who have associated medical problems. Movement (dance) therapy is an interesting adjunct, because patients with pain will often perform effortlessly to music when, seemingly, without music, pain will be a limiting factor. It helps to diminish the fear of moving/activation.

Functional electrical stimulation

When a specific muscle group is weak, functional electrical neuromuscular stimulation and muscle reeducation are implemented.^24,²⁵ This technique can produce rapid and dramatic increases in muscle recruitment patterns and muscle strength; footdrop braces can be discarded. Functional electric stimulation (FES) is used when minimal muscle recruitment or reduced voluntary control are detected upon muscle testing. With FES, muscles can be strengthened ‘passively’ without placing excessive demands on the patient, especially in the presence of pain. FES is the process of applying an external electrical stimulus to a muscle or muscle groups in order to induce muscle contraction. We also use FES successfully to treat conversion-disorders-type paralysis, for electric testing of motor responses, and as a motor dysfunction treatment method. FES allows the induction of maximal muscular contraction without any voluntary effort on the part of the treated individual. This latter aspect is of value for patients with chronic pain whose pain is often aggravated through exercise or who are unable to initiate voluntary effort necessary for muscular conditioning due to disuse. Studies on FES indicate that this passive intervention strategy can be quite effective.²⁵ It should be emphasized here that FES is not a substitute for regular exercise. FES is used to ‘jump start’ the neuromuscular system. Once the patient has gained sufficient power to initiate voluntary movement comfortably, the patient engages in active resistive exercises for strengthening and endurance training.

Motor dysfunction treatment

Strategies for treating motor dysfunctions identified upon evaluation (see MDE above) are patient specific, as well as condition specific. The overall objective is to improve functional capabilities.

Motor dysfunction treatment (MDT) is incorporated into regular patient treatment to address problems such as depressed muscle activity, increased muscle tension (hyperactivity), significant EMG asymmetry or asynchrony, and nondistinctive EMG activity patterns (work versus rest cycles). For example, in order to restore function to muscle with depressed EMG activity, the MDT protocol will consist of monitoring the target muscle while the patient performs selected therapeutic maneuvers designed to recruit that muscle compared to its contralateral partner. If EMG recruitment is found to be minimal, functional electrical stimulation is used to increase strength and power of the affected muscle. As soon as the patient demonstrates ability to recruit the muscle(s) voluntarily, active EMG interventions using methods of muscle reeducation and biofeedback commence.

Motor dysfunction treatment also involves educating the patient as to muscle compensation/isolation, and improving strength, endurance, and muscle tone through progressive resistive training and massage. It also involves increasing kinesthetic awareness in order to reestablish proper motor recruitment patterns. Establishment of proper recruitment patterns becomes essential in order for the patient to perform with proper body mechanics during functional activities and work simulations.

Occupational therapy restoration

Occupational therapy concentrates on body mechanics, activities of work and daily living, and on functional circuits. Sitting, standing, walking, lifting, climbing, and reaching tolerances are established and brought to normal levels of function. Pacing of activity and energy-saving techniques are taught. Adaptive equipment is used infrequently and only on specific indication. Posture and gait are corrected, as most patients are found to have poor posture and maladaptive gaits.

Proper motor vehicle entry, seating, transfers, and luggage management are taught. Recreational activities are reviewed and eye/hand/leg coordination and tolerances are established. Vocational goals are set in conjunction with the vocational counselor and ergonomist for job simulation.

Postural correction

Awkward postures cause fatigue, strain, and eventually pain; they need to be corrected. Poor postures will result in pain, loss of stability, and falls.²⁶ Faulty posture and poor body alignment develop slowly and may not be apparent to the individual. Poor posture is found with obesity, leading to weakened muscles, emotional tension, and poor body attitudes in the workplace. The incidence of pain increases in predominantly sitting work activities, especially with the use of computers. Ideally, patients do best when they can alternate activities among walking, standing, and sitting.²⁷

It is recognized that when the body is not in correct alignment, static loading on muscles and joints results in awkward positions that are not healthy.²⁶ Prolonged forward bending of the head and trunk, stooped postures, forced postures, and postures causing constant deviation from neutral alignment are but a few examples of poor postures. Even sleeping postures must be assessed.²⁸

Programs must address the factors contributing to poor postures from both the physical as well as the engineering perspective. On the physical level, deficiencies in human structural capabilities can be considered in the design and selection of products and tools. Patients are taught, through practice and the use of biofeedback, to choose proper equipment, to modify their working environment thus encouraging good postural habits, and to alternate activities to avoid postural fatigue.

Body mechanics interventions

Proper body mechanics provides the basis for the safest way to perform daily tasks. Corrective training to alleviate and prevent mechanical stressors and improper habits for sitting, standing, walking, lifting, carrying etc. is provided. Biofeedback may be a helpful adjunct. It is important that body mechanics techniques are taught with sufficient generalization to allow patients to accommodate specific body mechanics technique in the presence of conditions other than pain and as the task demands change. Modification of proper body mechanics must be taught if the task does not lend itself to ideal technique.

Job simulation and work readiness

This is the ultimate goal of achievement for the working-aged group, but it does not exclude students or elderly persons, who also require instruction for their needs. The physician, the occupational and physical therapists team with vocational counselors and ergonomists to develop the treatment plan. It is essential that the patient advise the job simulation team of the job activities which provoke the pain. Physical and occupational treatments are highly structured, task-focused to the job requirements, goal oriented, individualized, and multidisciplinary in nature. Patients should not begin this phase of treatment until they possess the necessary tools, such as increased awareness of posture and body mechanics; increased flexibility and mobility; adequate strength and endurance; good stress management skills; good pain control and safety techniques; and positive attitude towards employment, and return to work.

Ergonomic restoration

The thrust of the ergonomic approach to injury management and pain rehabilitation is ‘to design effective intervention strategies for the restoration of functional abilities, control of pain, and immediate return to work and productive lifestyle.’ Another objective is to avert further aggravation of an existing condition or injury. This philosophy was adopted by the University of Miami Comprehensive Pain and Rehabilitation Center as early as 1982 when ergonomics was first introduced into a multidisciplinary pain management team. This marked the beginning of a new era for ergonomics research and application in healthcare systems and pain treatment.

Workplace design

This type of ergonomic intervention aims at assessing the relationship between human characteristics (e.g. posture, body mechanics) and musculoskeletal stresses with emphasis on work issues.²⁹ The task of the ergonomist is to assist the patient or employer to design or modify the workstation to insure proper engineering design and good body mechanics when performing job tasks.

The process of workplace design within a functional restoration program consists of the following components:

1. The patient’s job description, the employee’s job description, and a description of a ‘typical’ work day;

2. Evaluation of essential job tasks is to identify tasks that are potentially stressful/painful. Analysis of video graphic data is used to isolate the critical risk factors; and

3. Intervention phase. Interventions specific to reducing or resolving the risk factors are developed. Ergonomic analysis aims at adjusting, modifying, changing, and/or replacing current heights, layout, equipment, tools, and design characteristics. It is not always necessary to recommend new equipment or adaptive technologies (e.g. cushions, ergonomic chairs, etc.). In most cases, workplaces can be reasonably accommodated to meet ergonomic needs. The patient’s set-up may not be an ‘ideally correct’ setup. It is the responsibility of the ergonomist to teach patient methods of improving safety and comfort without need for expensive adjustments or equipment.

A tool which we have used in the process of analyzing and recommending workplace adjustments and modifications is Sitting Workplace Analysis and Design (SWAD).³⁰ SWAD is a computer program resembling artificial intelligence. The inputs to the program are workplace user demographics, 16 anthropometric dimensions, workplace dimensions, work tools, and the priority and frequency of use of each work element. SWAD then combines this information with a ‘knowledge base’ of ergonomic principles and guidelines and a set of inference procedures. The output of SWAD is the recommended workplace dimensions, heights, reaches, footrest, chair parameters, VDT parameters, and optimal placement of all work tools. It enables customization of workstation adjustment without trial and error.

Electromyogram biofeedback

A carefully processed EMG signal can be a useful tool in the quantitative measurement of muscular performance, for reeducation and in the evaluation of patient’s response to specific treatments.¹⁷ Biofeedback is the process of using specialized instruments to give people information about their biological systems (temperature, heart rate, muscle activity, etc.). It is a set of training techniques used to increase awareness and voluntary control of biological conditions and relate them to human physical and emotional well-being. Biofeedback (BF) is useful in the relief of stress, tension, headaches, muscular dysfunction, and for the reduction of muscle tension, which correlates well with a reduction in pain and improvement of muscle strength.^31,³²

Using EMG biofeedback, patients perform therapeutic maneuvers while affected muscles are monitored. The information is used to facilitate patient awareness of muscular performance. These methods can then be used to improve the patient’s ability to coordinate muscle activity, reestablish proper reciprocal inhibition, reestablish functional synergy including appropriate force couples and sequential contractions, decrease the need for inappropriate muscular or postural compensations, and achieve recruitment levels beyond baseline activity.

Vocational rehabilitation

A vocational rehabilitation professional counsels the patient throughout the program to address all vocational issues. The vocational professional will work with the psychologist and ergonomist, and share essential information with the treating team. The vocational counselor is the liaison to outside parties such as case managers, insurers, and employers. The vocational professional addresses the traditional activities such as skills, obstacles to return to work, transferable skills, job readiness, and all skills needed to return to employment. The vocational goal is full functional activity and return to previous employment, when possible. Even the heaviest physical activity capacities have been achievable in most patients. If limitations are inevitable, the counselor works with the patient on possible transferable skills.

Behavioral modification

Behavioral management is a key issue. Nearly 20% of Americans suffer one or more emotional disorders, so at the least patients with low back injury may have these disturbances as a preexistent condition.

Patients with chronic pain perceive their pain as a disability limiting their functional status. The perception of pain as a disability is such a national problem that the Social Security Administration Commission on the Evaluation of Pain recommended the development of a listing ‘impairment due primarily to pain.’³³

An abnormal psychological profile is inherited by the treatment team, insurer, and all others concerned. Our study of pain-population patients found 62.5% to have anxiety disorders and 56.2% to have current depression.³⁴ These conditions were comingled with other less prevalent disorders. Only 5.3% of 283 patients were found to have no psychiatric diagnosis. Pure psychogenic pain is probably rare when presented as mental events giving rise to pain. However, all pain, as perceived by the patient, is real, regardless of cause. Most bodily pain is a combination of factors, e.g. physical stimuli and mental events. Abnormal mental and emotional states may arise from a background of past personal experiences with pain, or from personality characteristics. A history of physical abuse is not uncommon in patients with chronic pain.

Individual counseling is given when needed, including sexual counseling. Every patient has an assigned doctoral-level psychologist, who monitors daily progress and reinforces the goal of physical restoration. Relaxation training includes coping approaches, muscle reeducation, meditation and distraction, guided imagery, autosuggestion, especially to be used with physical activity, and tape supplements, which enhance ‘live’ therapy. Stress management is incorporated into the behavioral sessions. Hypnotherapy is utilized on selected cases.

Weekly family groups explore the goals of the patient with the spouse and/or other family members. How to respond to pain without fear is discussed as well as how to gain control over pain and their lives. Effective communication is an important subject. The roles of the various family members are defined, both as to distribution and as to responsibility. Experiences and frustrations are shared. These sessions facilitate the return to home, hopefully to an environment which will now foster wellness, not disability.

The behavioral staff address the ‘fall out’ and behavioral responses to tapering from narcotics. Intense activation will produce endorphin release that helps ameliorate withdrawal.³⁵ Most important of all, we do not teach people how to live or cope with their pain. Our goal is reduction or elimination of pain, and for the patient, to control any painful flare-ups. The pain is thereby no longer catastrophic; hence, it does not control the patient’s life.

Role of psychiatry

Patients with chronic pain being treated at pain centers have been reported to suffer a wide range of psychiatric conditions. These include depression, anxiety, drug dependence/abuse, irritability and/or anger, physical or sexual abuse, suicidal or homicidal ideation, and memory or concentration problems. These data are supported by epidemiological community studies, which indicate a strong relationship between chronic pain and depression.³⁶^–³⁹

Depression is not only a potential target for treatment, but coping strategies may differ in depressed patients with chronic pain. Patients with chronic pain may over-rely on passive avoidance coping activities in response to life’s stresses, including pain; these coping activities may be a function of depressed mood.⁴⁰

Severe depression is an indication for pain treatment facility referral. A facility with on-site psychiatric treatment should be chosen, since levels of anxiety, depression, etc. change rapidly during the treatment program. This necessitates an immediate response.

Drug abuse, dependence, and addiction are reported in the range of 3.2–18.9%.⁴¹ These diagnoses are reported in a significant percentage of chronic pain patients, but evidence of addictive behaviors is not common. The dependence occurs as a result of the pain, not addiction. At issue is whether patients with physician-perceived drug problems are best treated at a pain treatment facility or at a substance abuse facility. Detoxification in pain treatment facilities where simultaneous pain treatment is available appears to be the better route.³⁷ Detoxification is not realistic unless pain alleviation occurs simultaneously. Management of pain medications and controlled substances should parallel physical and functional restoration.

Role of nursing

Nurses are an integral part of the multidisciplinary team. Nurses are involved at every level as programs director, nurse manager, admissions liaison, admitting nurses and staff nurses who work in therapy areas with the patients and team throughout the treatment day. They support the physicians, do crisis management, medication management, monitor underlying medical problems, and provide 24-hour continuity of care when in the inpatient unit. They teach, counsel patients, families and case managers, and are involved with discharge planning. They supervise evening exercises assigned by the therapists.

HEADACHES AND PAIN REHABILITATION

Headache is a frequent comorbid condition in patients with chronic pain. These headaches are mostly classified as migraines. However, a considerable number of patients with chronic pain present with injury-related headaches. In one study,⁴² 10.5% of the chronic pain patients had headache interfering with function. Of these, 55.8% related their headaches to an injury and 83.7% had neck pain. Migraine headache was most common (90.3%) with cervicogenic being second (33.8%). Of the total, 44.2% had more than one headache diagnosis. The most frequent headache precipitants were mental stress, neck positions, and physical activity utilizing the neck muscles. Of the total group, 74.6% had a neck tender point. Discriminate analysis found the following symptoms as the most common predictors of headache: (1) onset of severe headache beginning at the neck tender point and numbness in arms and legs; (2) headache brought on by neck positions and arms overhead; and (3) cervical pain with a tender point in the neck. Taut muscle bands and cervical tender/trigger points perpetuate head and neck pain. Successful rehabilitation efforts must address both the headache component through effective medications and physical medicine management of the cervical abnormality.

GERIATRIC PAIN REHABILITATION

While generally thought of as a worker compensation injury-related model, the concept of pain rehabilitation applies to patients of all age groups. As American workers age, the number of expected disabled workers is also expected to increase. Older workers and those who do become disabled can respond well to well-designed, customized programs tailored to their levels, goals, and expectations.⁴³ Many studies have reported significant improvement in functional abilities of patients with pain irrespective of their age group.^30,^44,⁴⁵ Even when the outcome of return to work in older patients was not achieved (e.g. Mayer and Gatchel⁴), the consensus is that older patients should not be denied access to pain rehabilitation after onset of injury.³⁰

OUTCOME EVALUATION OF THE PAIN REHABILITATION MODEL

Are multidisciplinary pain centers effective? The answer is ‘yes,’ by virtue of increase in functional activity, return to work, decreased use of the healthcare system, elimination of opioid medication, closure of disability claims, pain reduction, and proved cost-effectiveness.⁴⁶ Evidence from well-designed outcome studies indicates that: (1) multidisciplinary pain facilities do return patients with chronic pain to work; (2) the increased rates of return to work are due to treatment; and (3) the benefits of treatment are not temporary.^2,⁴⁷^–⁴⁹

In one study, our center reported that 86% of all patients treated returned to full activity, with 70% fully employed and another 16% who were physically capable of full employment but could not return to work because jobs were not available.⁵⁰ Among the 86% who were fully active, there was no clear-cut difference between compensation and noncompensation class cases.¹⁴ In a more recent study, the return rate to full function and work was again 86%, albeit the patients had some residual discomfort that eventually remitted or was controlled at a low level of intensity.² The 14% who failed to return to full function were highly complex patients with major behavioral problems.

Treatment at multidisciplinary pain clinics, based on a meta-analysis of 3080 patients, found savings in medical expenditures equal to US$9 548 000, savings in indemnity expenditures equal to US$175 225 000, with a total savings of US$184 772 050! Our data showed a 92% improvement in functional status, a 66% reduction in pain, and a 62% return to employment or a work-ready state. A 93% patient satisfaction rate with treatment is strong testimony to the effectiveness of multidisciplinary pain center treatment.

Despite the perceived high cost, multidisciplinary pain rehabilitation programs are cost-effective by reducing long-term utilization of medical services and by returning patients early to employment or previous lifestyle.