2007

A 2-Day Pain Rehabilitation Program Focuses on Functional Restoration

Points to Remember

• Many clinicians are challenged by the comprehensive treatment necessary for patients with chronic pain.
• Multidisciplinary approaches combine pain reduction with instruction in coping strategies that teach patients to live and work with their pain.
• In 1974, Mayo Clinic was among the first medical centers to develop a 3-week multidisciplinary comprehensive pain rehabilitation program.
• A new 2-day program focuses on functional restoration to meet the needs of an emerging group of pain patients, many of whom are working professionals.

The Challenge

Managing a patient with chronic pain is difficult and one of the most frequently encountered frustrations of primary care medicine. As these patients exhaust management options, they seek more time with their physicians and become increasingly dissatisfied, placing physicians at risk of "burn out." Many of these patients are working professionals who can benefit from short-term pain rehabilitation programs that teach them to live and work with their pain.

Patient 1
Four years after surgery for a back injury sustained in a car accident, a 56-year-old man is unable to return to his job as an accountant. He's tried all standard therapies and is beginning to lose hope that he'll ever manage his pain. He wants to know about going on permanent disability.

Patient 2
A 62-year-old grandmother has migraines that kept her from work so often she lost her job as a bank teller. Having tried all options, her physician finally prescribed narcotics. Now this patient finds herself too drowsy and fatigued to drive, make meals - even remember her children's telephone numbers.

Patient 3
A 34-year-old special education teacher contracted an unknown viral illness. Since the fever and headache cleared up, she has felt fatigue and aching and has difficulty sleeping and socializing. Recently diagnosed with fibromyalgia, she also is sad and depressed.

Figure. A goal of the 3-week pain program is discontinuation of opiods for pain while learning other cognitive-behavioral strategies to cope with persistent pain.

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A Cognitive-Behavioral Model

In 1974, Mayo Clinic became one of the first multidisciplinary medical centers to develop a 3-week program at the Mayo Clinic Comprehensive Pain Rehabilitation Center (PRC). It is an intensive outpatient program focusing on functional restoration and improving quality of life.

The program consists of a multidisciplinary team of pain specialists who guide therapy in physical reconditioning, biofeedback and relaxation training, stress management, chemical health education, and activity moderation. Cognitive restructuring to decrease the sense of catastrophic pain and anxiety related to pain is also used. The most common diagnosis is chronic back pain, occurring in 24.5% of patients, but fibromyalgia is also quite common, accounting for 20% of patients. Other frequent diagnoses are chronic headache/migraines (11%), generalized pain or pain in multiple sites (7.5%), abdominal pain (7%), and neck pain (7%). The remaining 23% of patients have various pain sites, including upper or lower extremities, jaw, pelvic area, joints, and face, as well as postmastectomy and neuropathic pain. Patients using the program range in age from 13 years old to their early 90s.

The concepts taught at PRC by physicians, psychologists, nurses, physical therapists, occupational therapists, chemical health counselors, biofeedback therapists, and pharmacists include

• Learning to differentiate acute and chronic pain
• Minimizing pain behaviors
• Using relaxation strategies
• Minimizing the use of analgesic pharmacotherapies (including narcotics as well as over-thecounter drugs)
• Engaging in daily exercise
Using moderation in all activities
• Using stress management techniques
• Coping with the emotional aspects of chronic pain

An important goal of the 3-week program is the discontinuation of opioids for pain while learning other cognitive-behavioral strategies for coping with persistent pain. This approach has proven quite effective, with 73% of patients citing a decrease in their pain and 81% reporting an improvement in vitality at discharge.

The New Approach

Building on the success of the 3-week program, the same Mayo Clinic team of multidisciplinary specialists has developed a 2-day pain rehabilitation program called PREP. The 2-day program is indicated for patients who

• Have chronic pain
• Have exhausted medical and surgical options to "cure" pain
• Are ready for a program designed to help them live with their pain

As in the 3-week program, a cognitive-behavioral model serves as the basis for the 2-day program. The Mayo Clinic team evaluates each patient to determine whether the 3-week program or the 2- day program is suitable. Mayo Clinic specialists can also help with insurance certification.