Functional Restoration Program
There has also been a recent paradigm shift from the curative medical model of pain in which symptoms are expected to resolve once the underlying pathologic process is treated medically or surgically to a model which emphasizes patient autonomy, symptom management, and functional restoration. This volume addresses this new model of chronic pain in those specific conditions where applicable. It also explores the conceptually distinct rehabilitation model, in which it is recognized that the underlying pathology may be incurable or untreatable. The goals now involve minimizing the adverse effects of the pain and maximizing function and quality of life.
Physical and occupational therapies form the basis of rehabilitation from the adverse effects of CRPS. Once again, there are few data regarding the most effective modality or combination. Harden et al.3 reports a functional restoration algorithm using four stages (Table 27.4). Although this is not strictly an algorithm, it is a useful addition to the CRPS armamentarium. Patients can enter the process at whatever stage they are in the severity spectrum and progress to subsequent levels according to functional recovery. Table 27.4 Functional restoration algorithm physical occupational therapy physiatry.
There are several aspects to the psychiatrist's role in the care of patients undergoing any of the aforementioned interventions. By spanning preinter-vention to postintervention (see Table 7-7), the psychiatrist can be helpful in ensuring that the patient is prepared for the intervention and continues to participate in functional restoration measures postintervention.
In the absence of a cure or treatable cause, the major goal of care for children with chronic and recurrent pain conditions is to restore health and function through interdisciplinary rehabilitative (biopsychosocial) programs. Although most patients' priority is relief from pain, healthcare providers are presented with challenges of biological, psychological, and social difficulties in children with chronic pain. The biopsychosocial model addresses the multidimensional dynamic interplay of psychophy-siological antecedents and consequences of pain, and facilitates functional restoration to activities of daily living through modulation of cognitive, emotional, and physical status, which often occurs before the patient perceives pain reduction.
Although trials to determine the best time for treatment initiation are lacking, from the pathophysiologic concerns, it is of the utmost importance that treatment in CRPS should be immediate and most importantly directed toward restoration of full function of the extremity. This view is derived from the evidence in pain research that the duration of pain leads to ongoing changes in the peripheral and central nervous system underlying chronic pain syndromes and possibly predicts less treatment response in the later course of the disease. To achieve a favorable outcome, a comprehensive interdisciplinary setting with particular emphasis on pain management and functional restoration is thought to be best 161, 162 .
CRPS represents a very complicated pathophysiological disturbance, further complicated by its biopsychosocial complications.38 The pain is disproportionate to the initiating stimulus, and the consequences are likewise disproportionate. The specific initiating factor is often unknown, and the specific pathophysiological changes are also unknown. Prevention is therefore difficult or impossible.39 Specific therapy is therefore not possible, so generalized functional restoration must occur. This is itself a difficult concept, as there are few studies that have been able to define the active modality or combination in overall successful comprehensive pain rehabilitation programs. General principles are necessarily espoused on reasonable empiric bases which sound logical.40 III If there is acceptance by both practitioner and patient, then positive results might occur. If one or both do not subscribe to the treatment premise, then no improvement will occur, or the situation might become even...
When evaluating a patient to find out whether he she is an appropriate candidate for a functional restoration rehabilitative program, we need to determine if that patient is physically, mentally, and emotionally suited to participate. For example, the patient's cardiopulmonary status will affect the level intensity of such treatment. If a patient presents with depressed mood or emotional distress, this will adversely affect the outcome of the rehabilitative program. Hence, it is vital in such a case scenario, especially when dealing with chronic pain, to obtain a psychological history. In many instances, this might require a referral to a pain psychologist for appropriate evaluation and treatment. Another example is a patient who presents for his physical therapy following a head on collision with bodily injury. In many such cases the ensuing traumatic brain injury is underdiagnosed but will come to attention when the patient presents with cognitive impairments and or learning...