Medical Treatment Utilization Schedule (MTUS)
Chronic Pain Medical Treatment Guidelines
8 C.C.R. §§9792.20 - 9792.26
Chronic pain has a huge impact on the individual and society as a whole. It is the primary reason for delayed recovery and costs in the workers' compensation system. Most chronic pain problems start with an acute nociceptive pain episode. Therefore, effective early care is paramount in managing chronic pain. Given the importance of pain in healthcare, it is presently the subject of intensive scientific research which in turn has generated a growing evidence base regarding the diagnosis, treatment and management of painful conditions. [MTUS, page 1]
Medical vs. Self-Management Model
Understandably, patients want their chronic pain 'cured' or eliminated. Unfortunately, there are presently no definitive cures for the majority of persistent pain problems, such as axial spine pain, peripheral neuropathies, fibromyalgia, etc. As is the case with all chronic medical conditions, chronic pain must be managed, not cured. In the medical model, responsibility resides primarily with the physician. The self-management approach places primary responsibility on the person with chronic pain. Currently, self-management strategies can significantly improve a patient's function and quality of life, while reducing subjective experiences of pain. It is important to educate patients on this distinction, to avoid persistent and unrealistic expectations for an elusive cure, where none exists. This unrealistic curative view, often unwittingly fostered by healthcare providers or others, predictably leads to repeated failures, delayed recovery, and unnecessary disability and costs. [MTUS, page 5]
Functional Restoration Approach to Chronic Pain Management
Many injured workers require little treatment, and their pain will be self-limited. Others will have persistent pain, but can be managed with straightforward interventions and do not require complex treatment. However, for patients with more complex or refractory problems, a comprehensive multidisciplinary approach to pain management that is individualized, functionally oriented (not pain oriented), and goal-specific has been found to be the most effective treatment approach. (Flor, Fydrich et al. 1992; Guzman, Esmail et al. 2001; Gatchel and Bruga 2005)
Functional restoration is an established treatment approach that aims to minimize the residual complaints and disability resulting from acute and/or chronic medical conditions. Functional restoration can be considered if there is a delay in return to work or a prolonged period of inactivity according to ACOEM Practice Guidelines, 2nd Edition, page 92. Functional restoration is the process by which the individual acquires the skills, knowledge and behavioral change necessary to avoid preventable complications and assume or re-assume primary responsibility ("locus of control") for his/her physical and emotional well-being post injury. The individual thereby maximizes functional independence and pursuit of vocational and avocational goals, as measured by functional improvement (see 8 CCR § 9792.20 (f)).
Independent self-management is the long-term goal of all forms of functional restoration. The process and principles of functional restoration can be applied by a physician or a well integrated interdisciplinary team to a full range of problems that include acute injuries (e.g., sports, occupational), catastrophic injuries (e.g., brain and spinal cord injury), and chronic conditions (e.g., chronic pain, multiple sclerosis, etc.) and is the basis for medical rehabilitation and disability management. The principles of functional restoration apply to all conditions in general, and are not limited to injuries or pain.
Multiple treatment modalities, (pharmacologic, interventional, psychosocial/behavioral, cognitive, and physical/occupational therapies) are most effectively used when undertaken within a coordinated, goal-oriented, functional restoration approach. [MTUS, page 7]
We now have an appreciation that chronic pain is associated with structural and functional changes of the peripheral and central nervous system. These changes can lead to the generation and maintenance of chronic pain conditions with its associated disability. While biologic mechanisms play a role in the perception of pain, it is also important to recognize that psychological and environmental factors are important. Recognition of these factors will allow the physician to better (1) treat the recently injured patient, (2) identify the "at risk" patient, and (3) refer the patient with intractable chronic pain to the appropriate resources. A full assessment of the patient is required to determine the best approach in any given case.
Therapy for chronic pain ranges from single modality approaches for the straightforward patient to comprehensive interdisciplinary care for the more challenging patient. Therapeutic components such as pharmacologic, interventional, psychological and physical have been found to be most effective when performed in an integrated manner. All therapies are focused on the goal of functional restoration rather than merely the elimination of pain and assessment of treatment efficacy is accomplished by reporting functional improvement. Typically, with increased function comes a perceived reduction in pain and increased perception of its control. This ultimately leads to an improvement in the patient's quality of life and a reduction of pain's impact on society. [MTUS, page 8-9]