Robyn L. Walker, Ph.D., is a Clinical Research Psychologist in the Chronic Pain Rehabilitation Program at the James A. Haley VA Hospital, Tampa, Florida. Her interview brings attention to health care needs of currently returning U.S. Military Forces. This is her second PainEDU interview. Refer to the archives to read interview #1.

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Questions

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Evelyn Corsini:

Who are your prospective participants for the Chronic Pain Rehabilitation Program (CPRP) and what is the referral process?

Robyn L. Walker, Ph.D.: Prospective participants are veterans or active duty military and their dependents who are eligible for inpatient or outpatient care, and have non-cancer chronic pain of at least three to six months duration which has been refractory to standard therapy. Prior to inpatient program referral, applicants should have thorough medical workups of their pain complaints. In addition, they must be motivated for treatment and willing to terminate the use of opioid analgesics and muscle relaxants for pain control. In general, past participants in the program have had very long-standing pain, are moderately to severely disabled, have numerous concurrent medical or emotional problems, and have been heavy consumers of medical resources.

Individuals with cancer pain, unstable physical or emotional conditions, or serious concurrent physical conditions that significantly limit their ability to engage in daily activity are not accepted into the inpatient program. However, if appropriate and eligible for services, they may receive short-term outpatient care, or, alternatively, they may be referred to the PM&R bed service for a modified pain rehabilitation program that requires less physical activity. Individuals actively abusing or dependent on alcohol or street drugs, or whose history of opioid use indicates a primary substance abuse problem, must complete appropriate substance abuse treatment and attain a minimum of three months of abstinence from substances to be considered for admission.

Primary referral sources for participants are Veteran's Administration and Department of Defense medical centers and outpatient clinics throughout Florida, Puerto Rico, the Virgin Islands, and the United States. Local referrals (individuals who reside locally or within 100 miles of this facility) for chronic pain evaluation or treatment are initiated by completion of an electronic consultation request which is routed to the CPRP Coordinator. Non-local practitioners interested in referring candidates (applicants who reside outside of Florida or who do not have access to transportation from outlying areas), are directed to the referral packet downloadable from our web site (www.vachronicpain.org).

EC: What is your screening and admission assessment protocol?

RW: Our local candidates who are interested in and appear appropriate for the inpatient CPRP are evaluated in an outpatient screening clinic. Each undergoes a comprehensive individual examination by the screening team clinical psychologist and Pain Fellow, nurse practitioner, or physiatrist which provides for a medical and psychological assessment of their chronic pain complaints and rehabilitation potential. These evaluations consider physiological, psychological, situational, adaptive, and restorative factors. Client expectations regarding treatment methods and treatment outcome also are assessed during the psychological evaluation, and applicants are educated regarding program requirements, probable outcomes, and potential pain medication changes. Following the individual screenings, the screening team decides on his/her appropriateness for admission to the inpatient CPRP according to our admission criteria. Applicants may be accepted, accepted pending the outcome of additional tests or information, or not accepted.

For screening of our non-local candidates, upon receipt of their application materials and medical records, a record review is conducted by the pain fellow or by the attending physiatrist or neurologist to determine if the candidate meets CPRP admission criteria. If no medical contraindications are found, and if no additional evaluations are indicated, the Clinical Director (or designee) conducts a phone interview and record review. If no psychological contraindications are found, and if the applicant’s expectations are consistent with program outcomes, the CPRP Coordinator or CPRP nurse contacts the applicant and arranges an admission date. Applicants who do not meet admission criteria are referred back to their referring source for additional treatment.

On the day of admission a CPRP nurse completes a nursing assessment and a physical examination and history review is conducted by the Pain Fellow or covering physician. These evaluations focus on pain-related diagnoses and limitations, but include an assessment of all other significant medical factors. When conditions warrant further consultations, referrals to other medical specialties are initiated. Admission history and physical examinations conform to facility documentation policies. Participants also complete an admission psychological testing package consisting of the MMPI-2, and the Pain Outcomes Questionnaire- VA Version (POQ-VA). These instruments are used for treatment planning, treatment outcome assessment, and emotional needs identification. The POQ-VA also serves as the program evaluation package, and therefore is readministered at discharge and at 90-day and 180-day (if indicated) clinic or telephone follow-ups.

Each participant also undergoes timely evaluations by nursing, physical therapy, occupational therapy, recreation therapy, vocational rehabilitation, kinesiotherapy, and a physician. Results of these evaluations are used to individualize treatments to match specific problem areas or limitations. We purposely include overlap in the discipline-specific evaluations in order to assess the consistency of participants’ behaviors and self-report. Inconsistencies in physical evaluations or self-reports of pain-related problems may be identified as a separate problem area in certain cases.

EC: I understand you have a specific treatment protocol, can you describe it? Are patients’ families included?

RW: Chronic pain frequently is accompanied by detrimental patterns of behavior (a chronic pain syndrome) which are resistive to change and which, over time, may be maintained by a variety of factors other than pain per se. As a result, the focus of the CPRP is multifaceted, and views pain control as only one of several program goals. Treatment team members utilize a general behavioral approach to chronic pain, striving to extinguish undesirable pain behaviors and reinforce the development of alternative desirable behaviors. Compliance with program activity requirements and treatment attendance is closely monitored by means of treatment records, weekly schedules, and self-practice logs. We emphasize active pain management and control strategies to combat feelings of helplessness and hopelessness, through cognitive-behavioral techniques and a general wellness approach to pain. We also stress participant education as a means of reducing pain-related fears, promoting improved health, and understanding the rationale underlying program treatments.

The general goal of the CPRP is to teach participants to better manage their chronic pain and to reduce its impact on their daily life. Program objectives include promoting increased activity levels, reducing the emotional distress associated with chronic pain, eliminating reliance on opioid analgesics and/or muscle relaxants for pain relief, reducing participant's perceptions of pain, increasing participant’s levels of independent functioning and enhancing their wellness behaviors.

Specific treatment modalities are tailored to each individual's physical capabilities, concurrent medical problems, and risk status. Limitations or potential complicating health factors are noted during the participants' admission and treatment is altered accordingly. The majority of individuals admitted to the CPRP have maintained very low activity levels for years. Frequently, they may suffer from concurrent and multiple medical problems. In order to avoid taxing participants' limited physical resources, treatment activities are introduced gradually over a four-day period following admission.

Individuals are admitted to the CPRP undergo 18 full days of rehabilitation, averaging six to eight hours of active programming each treatment day. Although an individualized program of treatment is developed for each participant, basic components include:

Daily heated pool therapy session: The admission assessment by the exercise physiologist or kinesiotherapist (KT) results in an individualized program of pool therapy.

Daily physical therapy: The intake assessment by the physical therapist results in an individualized treatment plan emphasizing participant-initiated, active interventions which can be used in home settings. These include muscle strengthening, TENS treatment, hot/cold packs, range of motion exercises, education, and gait evaluation and training. Efforts are made to reduce an individual's reliance on external devices (e.g., wheelchairs, canes, crutches, braces) when it is determined they are not medically necessary.

Exercise sessions twice each day: Initial physical therapy and PM&R physician evaluations result in an individualized exercise program utilizing muscle stretching and muscle strengthening exercises. Individual repetition goals are assigned, with a daily increase of one repetition in each exercise for most individuals.

Relaxation training sessions twice each day: The relaxation program begins during the first week of treatment, and is based on a graduated series of relaxation exercises. Primary methods of relaxation include progressive muscle relaxation and autogenic training. Choice of which method to use depends on the presence of any risk factors (e.g., cardiac complications), individual preference, and recommendations by the team clinical psychologist based on psychological factors (e.g., degree of somatic focus, cognitive styles, etc.).

Didactic Group Lectures 2 or more hours each day: Instructors include CPRP team members, consultants, and other facility clinical staff. Topics include nutrition, effects of pain, sleep, substance abuse, body mechanics, assertiveness training, etc.

Recreational therapy daily: Participants’ use of leisure time is evaluated by recreational therapy, which informs an individualized treatment plan that focuses on concentration skills, use of leisure time, daily activities, and remotivation. Therapies may include education, recreation, or crafts.

Occupational therapy daily: Occupational therapy treatment includes instruction in compensatory techniques (body mechanics, work simplification, energy conservation, and stress management), remotivation, and education.

Walking sessions twice each day: A walking program is developed for ambulatory participants based on their physical therapy assessment and their medical status. Increases in walking time goals are planned every other day unless contraindicated by the participant’s physical status. Non-ambulatory individuals receive modified mobility programs suitable for wheelchair use.

Medication Management: Participants undergo a medication evaluation and adjustment as part of the CPRP. Individuals using opioid analgesics for relief of chronic pain are withdrawn from these medications during the first 3 to 15 days of the program unless their continuation is medically necessary in the opinion of the Pain Fellow or program Medical Director. Participants are informed of this policy prior to admission, and must agree to it to be admitted.

Vocational Rehabilitation: Each program admission's vocational status and need for services is evaluated by a vocational rehabilitation specialist (VRT) during their stay. Vocational needs are considered at the time of discharge planning, except in cases where more immediate services are indicated. In the latter case, participants may begin vocational rehabilitation or additional assessment prior to discharge.

Psychology: Each admission is assigned a psychologist to serve as primary therapist. The therapist’s role includes, at the minimum, general case management duties (monitoring of progress and compliance), family assessment and/or treatment, crisis intervention, and general support. Other interventions may include individual relaxation sessions, biofeedback, substance abuse screening or referral, neuropsychological screening, and individual therapy. During participants’ first week in the program, consent for contact with their spouse/family member/friend is requested. If consent is obtained, family members of participants receive The Family Book, a topically organized resource that focuses on common issues arising among family members of individuals with chronic pain. Initial goals are to identify any pain-related interpersonal issues that negatively impact participants’ relationships. After these issues are identified, we urge participants to discuss the problems with their spouse/family member/friend, using some of the suggestions in the book to try to resolve issues. All participants are urged to contact their psychologist if progress is difficult and help may be needed.

EC: When patients are discharged, what type of follow up care is provided to participants and their families? Are your discharged patients able to return for another admission?

RW: Graduates of the CPRP who reside in the local area receive follow-up care through the CPRP follow-up clinic at 3, 6, and 12 (if necessary) months following discharge. During their visit the pain team ARNP, with backup by a physiatrist, assesses the participants' compliance with their home rehabilitation program, their response to treatment, and their need for further evaluation or treatment. In the case of the latter, appropriate referrals or orders are written. Measures of pain-related functioning are readministered at this time, and are used to monitor the longer-term effectiveness of the program. Individuals who reside locally and evidence a need and interest in continued group or individual therapy for chronic pain-related problems are referred for mental health services. Those who do not meet current treatment eligibility requirements are referred to outside agencies or resources for continued care.

CPRP graduates who reside outside of the local region are referred back to their referring facility/provider for continuing care. Treating physicians are advised of the graduate’s progress in treatment and status at discharge by means of a CPRP progress summary letter. This letter also includes any recommendations for follow-up care of other significant problems. Follow up contact is attempted approximately three months after discharge unless the participant cannot be located.

Typically, participants who successfully complete the CPRP do not return for another admission, as the goal of the CPRP is to teach participants better self-management of their chronic pain and to reduce their reliance on medical resources. However, exceptions are made for participants who experience a new injury, a re-injury, surgery, or another circumstance that has resulted in increased pain experience despite their continued practice of the principles and exercises previously learned in the CPRP.