Research Support for Functional Restoration
The EBFR program is based on decades of medical research that supports the effectiveness of functional restoration type rehabilitation treatment. The California Workers’ Compensation Chronic Pain Medical Treatment Guidelines (July 18, 2009 revision) recommends multidisciplinary functional restoration programs on pages 30 – 33, for appropriately selected patients. The following is a selection of abstracts from scientifically based, peer-reviewed, nationally recognized research on functional restoration.
Please click “Patient Outcomes” to review the results of patients participating in our program.
Jacob Rosenberg, M.D., EBFR Co-Medical Director, Howard Rome, Ph.D., EBFR Program Director
A PROSPECTIVE ONE-YEAR OUTCOME STUDY OF INTERDISCIPLINARY CHRONIC PAIN MANAGEMENT: COMPROMISING ITS EFFICACY BY MANAGED CARE POLICIES
AUTHORS: Heather Robbins, Ph.D., Robert J. Gatchel, Ph.D., Carl Noe, M.D., Noor Gajraj, M.D., Peter Polatin, M.D., Martin Deschner, Ph.D., Akshay Vakharia, M.D., and Laura Adams, Ph.D.
CITATION: Anesthesia and Analgesia, 2003, 97:156-62; copyright 2003 by the International Anesthesia Research Society 0003-2999/03
INTRODUCTION: Although interdisciplinary pain management programs are both therapeutically effective as well as cost-effective, they are currently being underutilized because of managed care policies. We used this prospective comparison trial, with 1-yr follow-up of chronic pain patients, to demonstrate the short-and long-term efficacy of an interdisciplinary pain management program, and evaluate the impact of managed care’s physical therapy “carved out” practices on these treatment outcomes. Consecutive chronic pain patients (n = 201) were evaluated, some of whom had their physical therapy “carved out” from this integrated program. Results revealed that successful completion of interdisciplinary pain management was therapeutically effective. Most importantly physical therapy “carved out” practices had a negative impact on both the short-term and 1-year follow-up outcome measures. Thus, interdisciplinary pain management is effective in treating the major health problem of chronic pain. However, insurance carrier policies of contracting treatment “carve-outs” significantly compromise the efficacy of this evidence-based, best standard of medical treatment. This raises important medico-legal and ethical issues.
DISCUSSION: Our results clearly show that patients who completed interdisciplinary pain management demonstrated significant improvements on the majority of outcome measures, and maintained these gains at one-year follow-up relative to treatment dropouts. This was true for measures of both physical and psychosocial functioning, suggesting that the treatment program had a significant effect on all aspects of the experience of chronic pain… Differences in vocational status were also found. Treatment dropouts were less likely to be working one year after they discontinued to program, relative to those who completed, and the original injury or pain was more likely to be the cause of not returning to work…
MULTIDISCIPLINARY REHABILITATION FOR CHRONIC LOW BACK PAIN: Systematic Review
AUTHORS: Jaime Guzmán, research fellow, a Rosmin Esmail, Cochrane Collaboration coordinator, a Kaija Karjalainen, research fellow, b Antti Malmivaara, assistant chief physician, b Emma Irvin, manager, information systems, a Claire Bombardier, senior scientist.
a Institute for Work and Health, Toronto, Canada M4W 1E6,
b Finnish Institute of Occupational Health, Helsinki, Finland 00250
Correspondence to: J Guzmán, University of Manitoba Faculty of Medicine, S112-750 Bannatyne Avenue, Winnipeg MB, Canada R3E 0W3
CITATION: British Medical Journal (BMJ), Volume 322, 23 June 2001 www.bmj.com
ABSTRACT: Objective: To assess how effect of multidisciplinary biopsychosocial rehabilitation on clinically relevant outcomes in patients with chronic low back pain.
Design: systematic literature review of randomized controlled trials.
Participants: A total of 1964 patients with disabling low back pain for more than three months.
Main outcome measures: Pain, function, employment, quality of life and global assessments.
Results: Ten trials reported on a total of 12 randomized comparisons of multidisciplinary treatment and a control condition. There was strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary rehabilitation or usual care. There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary biopsychosocial intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psychophysical treatments did not improve pain, function or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. Few trials reported effects on quality of life or global assessments.
CONCLUSIONS: The reviewed trials provide evidence that the intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with chronic low back pain. Less intensive interventions did not show improvements in clinically relevant outcomes.
DOES NONSURGICAL PAIN CENTER TREATMENT OF CHRONIC PAIN RETURN PATIENTS TO WORK? A Review and Meta-Analysis of the Literature
AUTHORS: Robert B. Cutler, PhD, David A. Fishbain, MSc, MD, FAPA, Hubert L. Rosomoff, MD, DedSc, Elsayed Abdel-Moty, PhD, Tarek M. Khalil, PhD, PE and Renee Steele Rosomoff, BSN, MBA, CRC, CIRS, CRRN
CITATION: SPINE, Volume 19, Number 6, pp 643-652, copyright 1994, J.B. Lippincott Company
ABSTRACT: Evidence in the literature relating to return to work as an outcome variable for nonsurgical treatment for chronic pain was examined. Study selection criteria were as follows: a detailed definition of patient work status, delineation of work status pre-treatment and at follow-up, and documentation of the proportion of patients employed at follow-up. Of 171 studies reviewed, 37 fulfilled these selection criteria. Because the data were objective in nature, they were abstracted by the senior author only. For the coded variables of time to follow-up, proportion of patients working pre-treatment and at follow-up and number of patients, descriptive statistics and correlations were calculated. Change in employment status at follow-up was significant (P < .001.) The mean difference in employment at follow-up for treated patients versus those not treated was approximately 50%. The proportion of patients working increased from 20% to 54% post chronic pain nonsurgical treatment. Correlation analyses did not find a significant trend in percent employed with time to follow-up.
CONCLUSIONS: The results indicate that (1) chronic pain nonsurgical treatment does return patients to work; (2) increased rates of return to work are due to treatment, and (3) benefits of return to work are not temporary.
SOCIOECONOMIC OUTCOMES OF COMBINED SPINE SURGERY AND FUNCTIONAL RESTORATION IN WORKERS COMPENSATION SPINAL DISORDERS WITH MATCHED CONTROLS [Functional Restoration]
AUTHORS: Tom Mayer, MD; Margaret J. McMahon, Ph.D.; Robert J. Gatchel, Ph.D.; Brett Sparks, MA; Anna Wright, Ph.D.; Pauline Pegues, RN
CITATION: SPINE, Volume 23(5). March 1, 1998.598-605
ABSTRACT: Study Design. A longitudinal study (n = 448) comparing functionally restored discectomy (n = 123) and fusion (n = 101) workers’ compensation patients to matched, unoperated control patients (n = 123 and n = 101, respectively).
Objectives. To determine successful treatment outcomes uniquely important in a workers’ compensation environment when spine surgery is combined with comprehensive tertiary rehabilitation, to optimize anatomic and social sequelae.
CONCLUSIONS: Discectomy patients had work, health care utilization, and recurrent injury outcomes comparable with those for unoperated patients. Fusion patient had better outcomes of work retention, reoperation, and healthcare use compared with the unoperated control patients and even with the discectomy patients, in spite of more cases of previous surgery and greater duration of disability.The discectomy and fusion cohorts of operated chronic spinal disorder compensation patients with subsequent functional restoration had the best documented outcomes found in the literature for this population. In spite of the common assumption that spine patients fare poorly in a workers’ compensation environment, these results demonstrate that such patients can show remarkably successful objective outcomes if accompanied by effective rehabilitation, documenting efficacy and clinical utility.A new clinical approach is required to evaluate prospectively the combination of surgery and rehabilitation in chronic pain/disability workers’ compensation patients, in which the surgical role is to correct an anatomical lesion, but the socioeconomic outcomes either occur spontaneously or are affected through some form of rehabilitation.
EFFICACY OF MULTIDISCIPLINARY PAIN TREATMENT CENTERS: A META-ANALYTIC VIEW
AUTHORS: Herta Flor, Thomas Fydrich and Dennis Turk
CITATION: Pain, 49 (1992) 221-230. 1992 Elsevier Science Publishers, B.V. All rights reserved.
SUMMARY: Sixty-five studies that evaluated the efficacy of multidisciplinary treatments for chronic back pain were included in a meta-analysis. Within- and between-group effect sizes revealed that multidisciplinary treatments for chronic back pain are superior to no treatment, waiting list, as well as single-discipline treatment such as medical treatment of physical therapy. Moreover, the effects appear to be stable over time. The beneficial effects of multidisciplinary treatment were not limited to improvements in pain, mood and interference but also extended to behavioral variables such as return to work or use of the health care system. These results tend to support the efficacy of multidisciplinary pain treatment; however, these results must be interpreted cautiously as the quality of study designs and study descriptions is marginal. Suggestions for improvement in research designs as well as appropriate reports of research completed are provided. …
DISCUSSION: Overall the results of this meta-analysis provide support for the conclusion that multidisciplinary pain clinics are efficacious. Even at long-term follow-up, patients who are treated in such as setting are functioning better that 75% of a sample that is either untreated or has been treated by conventional, unimodal treatment approaches…
Conventional physical therapy is somewhat better than no treatment or medical treatment but inferior to multidisciplinary approaches (commonly a combination of medical, physical therapy, and psychological approaches.)…
Despite the limitations noted, several conclusions can be drawn from this meta-analytic study. First, multidisciplinary pain treatments are superior to unimodal treatments and no treatment. Second, the beneficial effects from pain clinics are maintained over an extended period of time. Importantly, the improvements documented are not only reflected on subjective ratings of pain but also more objective measures such as return to work and use of the health care system. These results are quite impressive and add credence to the relative and incremental validity of multidisciplinary pain clinic treatment.