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FUNCTIONAL RESTORATION PROGRAMS FOR THE TREATMENT OF INJURED WORKERS

FUNCTIONAL RESTORATION PROGRAMS FOR THE TREATMENT OF INJURED WORKERS. KEVIN J. BIANCHINI, PHD, FACPN. 1. Association Between Compensation Status and Outcome After Surgery A Meta-analysis Harris, I., et al. Journal of American Medicine 2005 ; 293(13):1644-1652. 2.

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FUNCTIONAL RESTORATION PROGRAMS FOR THE TREATMENT OF INJURED WORKERS

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  1. FUNCTIONAL RESTORATION PROGRAMS FOR THE TREATMENT OF INJURED WORKERS KEVIN J. BIANCHINI, PHD, FACPN 1

  2. Association Between Compensation Status and Outcome After SurgeryA Meta-analysisHarris, I., et al.Journal of American Medicine2005;293(13):1644-1652 2

  3. 211 studies satisfied the inclusion criteria Of these, 175 stated that the presence of compensation (worker’s compensation with or without litigation) was associated with a worse outcome 35 found no difference or did not describe a difference 1 described a benefit associated with compensation 3

  4. A meta-analysis of129 studies withavailable data(n = 20, 498 patients)revealed the summary odds ratio for unsatisfactory outcome in compensated patients to be3.79 (95% confidence interval, 3.28-4.37 by random-effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all subgroups. 4

  5. Comprehensive Pain Programs • Multidisciplinary Pain Programs • Interdisciplinary Pain Programs • Functional Restoration Programs

  6. OWC PAIN MEDICAL TREATMENT GUIDELINES

  7. CHAPTER 21, PAGE 18 (a). Interdisciplinary Pain Rehabilitation: An Interdisciplinary Pain Rehabilitation Program provides outcomes-focused, coordinated, goal-oriented interdisciplinary team services to measure and improve the functioning of persons with pain and encourage their appropriate use of health care system and services. The program can benefit persons who have limitations that interfere with their physical, psychological, social, and/or vocational functioning. The program shares information about the scope of the services and the outcomes achieved with patients, authorized providers, and insurers.

  8. FUNCTIONAL RESTORATION 8 8 8

  9. Functional restoration is both a rehabilitation treatment approach and also a wider conceptualization of the problem, its diagnoses and management.

  10. More comprehensive gathering of information in addition to clinical symptoms and problems:

  11. Risk Factors • Comorbidities • Measures of Physical Capacity and Effort

  12. Objectives are more than simply trying to alter pain complaints and reduce medication.

  13. An important focus is on restoring function and activity, including return to work.

  14. Critical Elements of Functional Restoration are: Formal, repeated quantification of physical deficits to guide, individualize, and monitor physical training progress. Psychosocial & socioeconomic assessment to guide, individualize, and monitor disability behavior-oriented interventions & outcomes. 14 14 14

  15. Multimodal disability management programs using cognitive-behavioral approaches. Psychopharmacological interventions for detoxification and psychological management. Interdisciplinary, medically directed team approach with formal staffings and frequent team conferences. Ongoing outcome assessment using standardized objective outcome criteria. 15 15 15

  16. Effective for Pain reduction and reduced disability • More effective than usual care • More effective for “High Risk Patients” • The results are maintained for years after program ends • The outcomes (reduced pain, reduced medical costs, reduced disability) justify the expense of the program: i.e., are cost effective

  17. Effective For Pain Reduction And Reduced Disability 17

  18. Evidence-Based Scientific Data Documenting the Treatment & Cost-Effectiveness of Comprehensive Pain Programs for Chronic Nonmalignant Pain.Gatchel, R. & Okifuji, A.The Journal of Pain2006:Vol 7, No 11 18 18 18

  19. Comprehensive pain programs (CPPs) offer the most efficacious & cost-effective treatment for persons with chronic pain, relative to a host of widely used conventional medical treatment. 19 19 19

  20. Multidisciplinary team approaches for the treatment of chronic low back pain. Guzman, J., Esmail, R., Malmivaara, A., Karjalainen, K. Irvin, E., Bombardier, C. Cochrane Database Syst Rev 1998;(2):CD00963 20

  21. Systematic literature review assessed the effectiveness of biopsychosocial rehabilitation on outcomes in patients with low back pain There was strong evidence that intensive biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient treatments 21 21

  22. Also moderate evidence that intensive rehabilitation reduces pain when compared with outpatient, non-multidisciplinary rehabilitation, or usual care The reviewed trials are evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with low back pain. 22 22

  23. A 5-year-follow-up evaluation of the health and economic consequences of an early cognitive behavioral intervention for back pain: A randomized, controlled trial. Linton, SJ., Nordin, E. Spine 31:853-858,2006 23 23

  24. A randomized trial, acute low back patients seen in primary setting were assigned to either standardized treatment or cognitive behavioral treatment and physical therapy The standard treatment had greater numbers of days off work for back pain during 12 month follow up than the other groups Risk for developing long-term disability leave more than 5 foldhigher in standard treatment than the other two groups 24 24

  25. MORE EFFECTIVE THANUSUAL CARE

  26. 26

  27. PERSISTENT LOW BACK PAIN Caragee, E.J. New England Journal of Medicine 2005:352:1891-1989 27

  28. This study concluded that CPPs that focus on functional improvements produce the best outcomes. 28 28 28

  29. More Effective For “High Risk Patients” 29

  30. Treatment-and-cost-effectiveness of early intervention for acute low back pain patients: A one-year prospective study. Gatchel, R. J., et al. Journal of Occupational Rehabilitation 2003; 13:1-9 30

  31. In a randomized, controlled study, patients with acute low back pain who were identified as “high risk” for developing chronic back pain disability were randomly assigned to an early functional restoration group or a treatment-as-usual group. 31 31 31

  32. The functional restoration group displayed significantly fewer indices of chronic pain disability at 1-year follow up on a wide range of work, healthcare utilization, medicaiton use, and self reported pain variables 32 32 32

  33. The functional restoration group was: Less likely to be taking narcotic analgesics Less likely to be taking psychotropic medications The treatment-as-usual-group was less likely than the functional restoration group to have returned to work The treatment-as-usual-group cost twice as much as the functional restoration group over 1-year 33 33 33

  34. The Results Are Maintained For Years After Program Ends

  35. Long Term effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain Friedrich, M., Gittler, G. , Arendasy, M. Friedrich, K.M. Spine;2005: 30:995-1000 35 35 35

  36. 93 patients with chronic and recurrent low back pain were randomly assigned to either a control group (standard exercise program) or a CPP. 36 36 36

  37. Follow up assessments at 3.5 weeks, 4 months, 12 months, and 5 years demonstrated the greater long-term efficacy (up to 5 years) of the CPP group in terms of decreased disability & pain intensity scores, as well as increased working ability. 37 37 37

  38. Long-term return to work after a functional restoration program for chronic low-back pain patients: a prospective studyCécile Poulain,1Solen Kernéis,2,3Sylvie Rozenberg,1Bruno Fautrel,1Pierre Bourgeois,1 and Violaine Foltz1European Spine Journal2010 July; 19(7): 1153–1161. 38 38

  39. 105 chronic LBP patients with over 1 month of work absenteeism were included in an FRP. Pain, professional status, quality of life, functional disability, psychological impact, and fear and avoidance beliefs were evaluated at baseline, after 1 year and at the end of follow-up. 39 39

  40. Main effectiveness criterion was return to work. 55%of patients returned to work after mean follow-up time of 3.5 years, compared with9% of thepatients at work at baseline. Quality of life, functional disability, psychological factors, and fear and avoidance beliefs were all significantly improved. 40

  41. Return to work of 87 severely impaired low back pain patients two years after a program of intensive functional rehabilitation.Bontoux, L., Dubus, V., et al.Annual of Physical Rehabilitation Medicine2009 Feb;52(1):17-29. doi: 10.1016/j.rehab.2008.12.005. 41 41

  42. Open Prospective Study:Population: 87 chronic LBP patients. Intervention: multidisciplinary functional restoration program. Ergonomic advice on the workplace was performed for 53 patients. Outcome: work status and number of sick leaves due to LBP. 42 42

  43. The characteristics of the 26 patients lost to follow-up did not differ significantly from the rest of the population before the program. In the 61 remaining patients, 48 (78%) were at work at 2 years, 43 full-time and 22 at the same job. Nineteen worked in a different environment. Sick leaves were reduced by 60% compared to the 2 years prior to the program: 128 days (+/-200 days) versus 329 days (+/-179 days); p<0.005. 43

  44. The Outcomes (Reduced Pain, Reduced Medical Costs, Reduced Disability) Justify The Expense Of The Program: I.E., Are Cost Effective 44

  45. Annual medical therapy costs, including medications for back pain, are estimated to be $12,900 to $19,823Annual medical costs following a CPP arereduced by 68%. 45 45 45

  46. Using 45 as the average age at CPP and the life-expectancy age of 77, the lifetime healthcare cost per patient can be calculated as: 46 46 46

  47. CPP: $8,100 + ($12,99 - $19,823) x (100%-68%) x 32 years =$149, 190 - $211,087Conventional: ($12,900 - $19,823) X 32 years = $412,800 - $634,366 47 47 47

  48. Lifetime saving = Conventional – CCP =$272,610 - $423,279 48 48 48

  49. 49 49 49

  50. CONCLUSION: 50 50 50

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