The guidelines provided by the New York State Workers Compensation Board offer general principles for Interdisciplinary Pain Rehabilitation Programs. These directives aim to assist healthcare professionals in determining appropriate strategies for implementing comprehensive rehabilitation programs that address pain from multiple perspectives.
Healthcare practitioners specializing in Interdisciplinary Pain Rehabilitation Programs can depend on the guidance from the Workers Compensation Board to make well-informed decisions about the most suitable approaches for managing pain in their patients through a collaborative and multidisciplinary framework.
It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the implementation of Interdisciplinary Pain Rehabilitation Programs should involve collaboration between the patient and their healthcare provider.
Tertiary Pain Programs: Interdisciplinary Pain Rehabilitation Programs, Multidisciplinary Rehabilitation Programs, Chronic Pain Management Programs, and Functional Restoration Programs
Indications: The decision to enroll a patient in a tertiary pain program should be based on the following criteria:
- Patients are either completely off work or on modified duty for at least 90 days and are progressing toward a significantly slow and prolonged functional recovery.
- There is a known cause for the chronic pain disorder or a specific clinical condition, including physical injury or illness.
- Other appropriate medical and/or invasive interventions have been attempted and proven insufficient to restore functional status.
- The patient has the potential for effective rehabilitation (i.e., they are deemed capable of benefiting significantly from the program).
- The patient has not responded to other interventions, including quality non-invasive therapy programs.
- The patient exhibits at least some behavioral or psychosocial issues impacting their recovery. For workers without additional associated problems and solely a physical gap between current abilities and future work requirements, work conditioning/work hardening programs are generally more suitable and cost-effective.7.The patient experiences significant disparities between current physical abilities and actual or anticipated occupational demands.8.There are no known contraindications to the treatment program, such as certain unstable medical conditions, primary substance abuse disorder, or mental impairment that would hinder effective learning.
9.The patient is committed to the recovery process.
Frequency/Dose/Duration: Moderate physical activity, incorporating exercises aimed at transitioning the patient toward a home fitness maintenance program and a gradual increase in residential and occupational functional tasks.
Tertiary pain program treatment typically involves five full days a week. The duration of treatment programs is not fixed by the severity of deficits, rate of progress, interruption of healing and therefore is personalized. Standard durations are four to five weeks.
Complicating factors such as coordination with temporary work, transportation, childcare, severe physical deficits, high-dose narcotics, or limitations imposed by comorbid conditions are considerations that might necessitate a more gradual approach to program maintenance and a longer treatment duration.
Treatment Objectives which must be consistently surveyed and recorded:
Practical improvement: This should emphasize addressing the physical limitations that have been identified as “pain-restricted.” While general or aerobic conditioning is suitable for most patients, there should be evidence of progress in areas where dysfunction or deficiencies have been observed.
Improvement in activities of daily living: These activities are unique to each patient, and goals should also be relevant to activities restricted by pain.
Significant psychosocial improvements: There should be measurable progress in accepting psychosocial functioning.
Withdrawal from opioids, opioid-hypnotic, and muscle relaxant medications: This is a requirement unless there are specific indications. A history of satisfactory functional improvement associated with opioid medications alone would not lead to a referral to a tertiary pain program unless excessively high doses of medications are being used with related physical and mental dysfunction.
Clinical management: All other medications should be regularly assessed and adjusted as needed.
Return to work or other functional activity: Appropriate assessment, counseling, planning, and skill development should commence early in the program, with efforts focused on determining if it is reasonable for the patient to return to work.
Inpatient Care: Almost all patients can be treated on an outpatient basis. In the rare instances where hospitalization is necessary, it should be guided by or closely coordinated with a tertiary pain program physician. Indications for continued care include any of the following:
1. Detoxification on a short-term basis might pose an unacceptable clinical risk.
2. Clinical instability.
3. Evaluation suggests that treatment may worsen pain/disease behavior to the extent that there is a risk of injury or results in florid symptoms of significant mental confusion.
4. 24-hour nursing care is required.
5. Extreme pain behavior and dysfunction that renders short-term care impractical, and there is reasonable evidence presented by the evaluating pain team that a brief continued stay will facilitate transition to a short-term tertiary pain program.
Other Functional Restoration: Patients may occasionally require functional rehabilitation but find that there is either no formal program available or that it is unsuitable due to social or medical challenges.
If the patient needs treatment for specific clinical indications with the services to be delivered, functional restoration may be possible in these situations. Physical or occupational therapy, behavioral/psychological treatment, and at least one additional discipline focused on rehabilitation should all be indicated, at the very least.
A physician who is appropriately qualified and skilled to administer and supervise rehabilitation treatments or functional restoration must oversee the patient’s care. Such services should be provided under the following conditions:
1. Meeting the criteria for composing functional restoration care as appropriate to the case.
2. A level of disability or dysfunction that does not require treatment in a formal program.
3. No medication dependence or significant opioid usage, and
4. A medical condition for which return to work can be anticipated upon completion of the services.
Follow-up – After being successfully discharged from a tertiary pain program, regular or rigorous formal therapy is typically not required. It is crucial that patients who learned physical restorative and psychological pain management techniques during the tertiary pain program continue their own self-directed home programs.
A long-term care plan should be prepared to simplify management by the treating physician, and routine follow-up should be provided to assess the durability of the functional restoration obtained.
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