Functional Restoration and Complex Regional Pain Syndrome
Complex Regional Pain Syndrome (CRPS) is poorly understood by patients, their families, and healthcare professionals.1 In some cases the condition is mild, in some it is moderate, and in others it is severe. CRPS remains an enigma and is difficult to treat, often leaving the physician frustrated and the patient severely compromised—physically and emotionally.
The tools in the physician’s armamentarium are many including a host of treatments including pharmacological, interventional, passive and active physical and occupational therapies, along with cognitive/psychosocial/behavioral approaches.
This article discusses active, functional restoration approaches and is not directed to various pharmacological, interventional, or other passive treatment approaches. The emphasis in this article on functional restoration is not meant to diminish the importance of other treatment approaches. In fact, while these other “passive” approaches sometimes suffice alone to provide a good clinical outcome; more often than not with CRPS, they are not adequate alone, absent a “whole person” coordinated, goal-oriented, functional restoration approach.
Functional restoration has historically and empirically been considered a critical and necessary component of interdisciplinary pain management programs for CRPS. Functional restoration emphasizes physical activity (“reanimation”), desensitization and normalization of sympathetic tone in the affected limb, and involves a steady progression from the most gentle, least invasive interventions to the ideal of complete rehabilitation in all aspects of the patient’s life.2
Historically, functional restoration is a term that was initially used for a variety of pain rehabilitation programs characterized by objective measure of physical function, intensive graded exercise, and multi-modal pain/disability management with both psychological and case management features.
The concept of functional restoration was first described by Mayer and Gatchel3 in the mid 1980s and the term “functional restoration” has, in recent years, become increasing popular with evidenced-based medicine support and has been adopted as the treatment paradigm of choice for chronic conditions and particularly chronic pain states.4
Functional restoration chronic pain programs have strong support in the medical literature going back to the early 1990s and meet the criteria for evidence-based medicine (EBM).5 In 1992, Flor and colleagues published a meta-analytic review on the efficacy of multidisciplinary pain treatment centers.6
In this article, the term functional restoration is used broadly and refers to a philosophy and approach to medical care, although the term is also used for specific types of programs.
Functional restoration is based on a biopsychosocial model of medical diagnosis and care that focuses on not just the biology (injury/illness and associated pathology), but also on the individual as a whole person, including psychological and social aspects.
Most physicians have been trained and are familiar with the biomedical model7 which has traditionally viewed pain resulting from injury or illness in the context of those etiologic factors that resulted in the painful condition. The biomedical model assumes there is a causal relationship between a specific pathophysiology and the presence and extent of a particular symptom. While this biomedical model has served the medical community well in the treatment and cure of certain diseases, it often fails in the treatment of chronic pain and especially with CRPS.
In recent years, there has been an evolution in our understanding of pain as a biopsychosocial disease that can persist and grow—even well after the original injury has healed. We now recognize that pain causes structural and functional changes in the central nervous system that serve to amplify and maintain the experience and disability of pain.8 This pain is then modified by many additional factors that are addressed in the biopsychosocial approach.
In the traditional biomedical model, complete relief of pain is clearly an endpoint that is highly desirable especially in acute pain states, yet it is usually unattainable in chronic pain conditions. Evidence also suggests that factors other than the nature of the injury are primary determinants of disability and suggest that treating pain, even acute pain, should emphasize functional restoration in addition to relief of pain because the latter may reinforce psychological, environmental, and psychosocial factors that predispose progression to chronic pain states.
The biopsychosocial model9 of pain recognizes that pain is ultimately the sum of the individual’s biology, psychological history and state, belief system about pain, along with interactions with the environment (workplace, home, disability system, and health care providers).10 All of these factors can strongly influence symptom severity and how quickly the individual can be returned to a more functional life. In fact, the psychological and social factors can play a more significant role in disability than the biological factors.
“Functional restoration involves multiple disciplines working together in a coordinated fashion and is focused on maximizing function, returning as close as possible to pre-injury productivity... while preventing needless disability, unnecessary medical and surgical care, and avoiding iatrogenic healthcare related complications.”
While it takes more time to evaluate these non-physical psychosocial factors, they can often be crucial in helping to identify those individuals who are not responding to treatment. These patients should then be directed toward a more comprehensive evaluation and treatment program that can address these multiple factors. Without this early recognition and appropriate treatment of the at-risk patients—despite the good intentions of the treating physician—they may be subjected to many medical, interventional, and surgical procedures that serve only to worsen their pain and disability.
Functional restoration involves multiple disciplines working together in a coordinated fashion and is focused on maximizing function, returning as close as possible to pre-injury productivity (with sufficient functional capacity to avoid recurrent injuries), while preventing needless disability, unnecessary medical and surgical care, and avoiding iatrogenic healthcare related complications.
Functional restoration can be defined as the process by which an individual acquires the skills, knowledge, and behavioral changes necessary to assume or re-assume primary responsibility for his/her physical and emotional well-being. Functional restoration thereby empowers the individual to achieve maximal functional independence, the capacity to regain or maximize activities of daily living, and return to vocational and avocational activities.