Well-designed functional restoration programs can improve a chronic pain patient’s long term health and significantly lower claim costs. However, not all injured workers are the same and not all programs are comparable.

Functional restoration programs were groundbreaking the early 1990s because research showed that pain and function were able to be separated, meaning that even patients with severe pain could become fully functional. This was primarily done through therapeutic exercise, which was supported by cognitive behavioral psycho-social techniques.

Get the most out of a functional restoration program by defining the desired outcome for a particular case, selecting the program capable of delivering that result, and managing the injured worker before, during and after the program to achieve it.

Recently, Paradigm’s Senior Medical Director, Steven Moskowitz, MD, and the Medical Director for Midwest Employers Casualty Company, Fernando Branco, MD, conducted a webinar on functional restoration. The featured case study addressed how one answers four primary questions:

1. How does one identify an effective functional restoration program?
2. How does one prepare an injured worker for this type of program?
3. How can one recognize the key challenges?
4. What are the red flags within a particular case?

Functional Restoration Case Study

Evelyn, an active 30 year old female chef, fell down some steps resulting in soft tissue damage but no fracture or ligament damage. The first misstep occurred early when she was immediately diagnosed at the ER with Complex Regional Pain Syndrome (CRPS). Her problems cascaded from there.

Evelyn’s initial providers did not appreciate the importance of her medical history. She had been in two motor vehicle accidents and had three surgeries on her leg—an ACL repair and two arthroscopic knee procedures. She also had learning disabilities and a concussion as a child. All of these facts could possibly have changed her future care and how she responded to her injury.

Five years post injury, Evelyn reached the peak of her problems. By then she had multiple sympathetic blocks and a spinal cord stimulator (SCS), which was a result of the misdiagnosis. This caused over stimulation and spasms in her lower extremities. She used a wheelchair and was on several narcotics, including OxyContin, Oxycodone, Lyrica, Zanaflex and Klonopin, and was going to the ER on a regular basis, up to 11 times in one two month period. In addition, she was severely depressed, anxious and unable to sleep comfortably. A pain pump was recommended, which again sent her down the wrong path.

Making a Change in Six Steps

Upon referral to Paradigm, our care management team determined that a functional restoration program was appropriate for Evelyn due to her high dependence on the healthcare system, severe deconditioning, continued use of prescription medication and psychosocial sequelae. Once confirmed, the team followed six concurrent steps.

Evelyn’s case was an uphill battle; she and her attending physician showed a strong resistance to making meaningful changes. Step one was to set expectations and secure an agreement to participate. Cognitive behavioral techniques, such as TTM Stages of Change, may be used with the injured worker. The process also involves gaining the cooperation of the treating physician (or locating a new one), securing family involvement and addressing logistical issues, such as transportation. It took months of preparation to get Evelyn and the physician ready for action.

The second step was selecting the right program for the patient. This involves consideration of the program’s diagnosis specialization, inpatient vs outpatient setting, detoxification capabilities, the type of functional restoration offered, and the location. Evelyn needed a center that was very comfortable with CRPS diagnosis and knew how to treat the misdiagnosis, an inpatient setting, detoxification expertise and aggressive functional rehabilitation. The Rosomoff Pain Center met all of these case-specific requirements.

Step three in successful functional restoration is managing participation in the program, which means getting the injured worker to participate and stay, establishing the curriculum, defining discharge criteria, and shifting from passive to active engagement.

Evelyn arrived at Rosomoff uncooperative and angry. Her caretaker parents were very supportive, but caused Evelyn to regress and act as a child. Her legs were shaking on a regular basis and she demanded large amounts of medication. Evelyn also claimed she fell from her wheelchair twice, but as there were no witnesses it was clear she was saying this in order to leave the program.

Step four is reviewing the curriculum. The key areas to address are clarifying the diagnosis, engaging the injured worker in the detoxification process, showing the patient they can restore their function and decreasing reliance on the healthcare system. The most important element of this for Evelyn was clarifying the CRPS diagnosis as she held a deep conviction about the disease and her prescriptions. Medication was tapered after the providers built trust. One on one treatment is vital for eight hours per day. As Evelyn made gains, things began to fall back into place, such as improved sleep, mood and endurance.

Step five is keeping track of outcomes. The program should document participation, performance, behavior, functional progress and urine drug monitoring. It is important to avoid the patient leaving against medical advice, long-term opioid maintenance therapy, “relapse” to prior behavior during the program and returning to prior enablers. The reasons a patient may not be discharged include a lack of compliance, lack of progress and acute medical illness.

Evelyn began to slowly participate, but four weeks of treatment, three inpatient and one outpatient, were needed. By graduation, she discontinued all medications except Lyrica and began going to gym consistently. She was released to return to work three months after discharge.

The final, sixth step, is a transition back into the community. The patient will immediately need a new physician who will de-certify opioids for one of the biggest risks is returning to the prior physician and receiving sub-optimal care. Any case manager should routinely communicate with the program, patient and physician.

Relapses can occur, so it is important to remember that functional restoration is part of a process, only some of which happens at the facility. Though Evelyn did experience some difficulty later on that required post-discharge assessments and one and three months, she began Cognitive Behavior Therapy (CBT) and quickly became very active, running up to eight miles by her one month follow up. She eventually became pregnant and decided to stop the Lyrica. However, she did continue to use the SCS, at a reduced amount, against Rosomoff’s advice.

Measuring the Benefit

There are two ways to look at the value proposition of functional restoration: 1) the health and functional improvement of the patient and 2) the calculated savings. By avoiding the pain pump and stopping the medications, Paradigm saved $1.1 million of future medical costs on the Medicare Set Aside (MSA) alone. Overall lifetime medical exposure was reduced by $3 million.

Functional restoration is restoration of function. Utilization review guidelines are helpful, but this is a case management process. It is best when you can match the needs of an injured worker with strengths of a program, such as diagnosis clarifications, detoxification, behavior rehabilitation and structure. The return on investment can be impressive.

For a more detailed review of Evelyn’s case and other recommendations for optimizing functional restoration programs for chronic pain, listen to a replay of the March 2016 webinar, Optimizing Functional Restoration Programs for Chronic Pain.

Visit our website for a list of other upcoming and archived webinars.