Functional restoration programs are recommended by the Louisiana Medical Treatment Guidelines as “the gold standard” of chronic pain treatment, and are recognized as a highly effective method by the American Academy of Pain Medicine. However, many workers’ comp system stakeholders are not aware of what functional restoration is and how early intervention utilizing such programs can provide significant return on investment for the claims dollar.
Louisiana Comp Blog reached out to the practitioners that founded Boost Rehab in Metairie – Aaron Wolfson Ph.D/Clinical Director and Kevin Bianchini Ph.D/Director of Psychology – to get their perspective on how and why functional restoration works.
Comp Blog: Starting with the basics: what is a functional restoration program? What characterizes it as such?
Wolfson: A functional restoration program is designed to do exactly what its name implies – to increase an injured person’s ability to function. So their ability to work, to enjoy life; and the industry that we’re in at Boost Rehab came out of a chronic pain management genre that came about in the 80s and 90s. It started on the West Coast, and the idea was to bring together a group of professionals to treat chronic pain.
Comp Blog: How is functional restoration different from other methods of chronic pain treatment?
Wolfson: The outcome of ordinary chronic pain treatment was to help patients feel better, to reduce suffering. The intended outcome for us is to improve functioning. If you have a reduction of pain that’s fantastic, but it isn’t the primary focus.
So the components of a true functional restoration program include: a multidisciplinary team headed up by a medical director who is usually a physiatrist. On the team you’ll usually find a psychologist and a physical therapist as well. From that base, there are any number of other specialists that are part of the program. For example, we have a yoga instructor and a nutritionist. And we can bring in any number of others depending on the patient.
Bianchini: Overall, as far as defining functional restoration, I think it’s important to remember that functional restoration programs are a type of rehabilitation program. And rehabilitation programs are always focused on not just ameliorating symptoms, but also helping people to function better, and that includes return to work.
Comp Blog: How does that return to work philosophy manifest in the initial intake of a new patient?
Bianchini: Identifying and managing behavioral and emotional risk factors from the get go is a big part of it. For example, reduced activity and prior psychiatric history are two major risk factors. Of course, that doesn’t mean that patient can’t get treated, it just means that the outcome could be poor. Smoking, obesity, anger at the employer, time since injury – all risk factors. So one of the things we try to do is actively address these issues and to help turn things around so that the outcome is positive.
Comp Blog: You mentioned time since the injury: around when do you tend to get these patients in the life of the claim?
Wolfson: The ideal time is early. To have the maximum efficacy its less than two years – preferably much less than two years. The Louisiana Medical Treatment Guidelines actually have it right here, a patient should be strongly considered for it if there’s a poor response after about six months. There is a robust body of literature dating back to the 70s that shows that this approach leads to better outcomes compared to usual care.
Comp Blog: Tell me about the history of Boost and how it was founded.
Wolfson: Dr. Bianchini and I have been partners in our practice since 2005. Our expertise in pain management – doing these evaluations of pain patients and having nowhere to send them – was really the impetus behind this. There was a noticeable lack in the treatment landscape for this type of program here in Louisiana.
Comp Blog: Do injured workers make up the bulk of your patients?
Wolfson: Right now in fact, all of our patients are workers’ comp. But we do take others.
Comp Blog: What challenges do you encounter in the workers’ comp system as providers of a program this comprehensive?
Bianchini: One of the biggest problems is that people tend to wait. The longer the person is out of work, their chances of ever returning drop. Sometimes we get patients that are 10 years out on a claim. It is much harder to rehabilitate someone that has been in disability mode for that long.
Comp Blog: Opioids are often part of the medication regimen for chronic pain patients. How do you address this at Boost?
Wolfson: One of things that we do is have our Medical Director, Dr. Michael Zeringue, calculate the morphine equivalency per day of each patient and encourage the team to brainstorm ways to reduce that while the patient is with us and then thereafter. Depending on how medicated a person is, some of it can be handled with gentle tapering. For others, it requires a more detailed approach. We have a consulting psychiatrist whose role is just to oversee that component when necessary.
Bianchini: We get mixed responses to reducing opioid medications. Some patients understand that they may be functioning less even as they’re taking more medicine, and they want help with that. But for others, it’s anxiety provoking to think about dealing with pain with less medication.
Wolfson: Our program also includes up to two psychosocial groups per day that address things like fear avoidance behavior and pain catastrophizing with coping skills. We teach them about depression and anxiety.
The incidence rate of depression among the general population, depending on what study you read, is seven to 12 percent. Among the chronic pain population, it’s from 35 to 55 percent. Imagine if 55 percent of people in the U.S. had a cold – things would shut down. So we’re dealing with a very high base rate of mental health issues and patients often don’t recognize that.
Comp Blog: After all of this intensive preparation, how do you measure patient outcomes? Do most patients finish the entire program?
Bianchini: We’ve only had one person that didn’t finish the program. The ultimate outcome variable is return to work and return to a more full life. We look at pain reduction, medication reduction, and emotional symptom improvement and sleep quality – those are the main ones.
Comp Blog: What kind of injuries are best for treatment with a functional restoration program?
Wolfson: Musculoskeletal injuries are the bread and butter. Objective findings on spinal studies like bulges, failed back syndrome, early diagnosis complex regional pain syndrome, etcetera. It’s easier to ask what conditions we can’t help. If it’s painful, we can usually do something to improve it.