12.08.10

Reduction of Over Utilization – Passive Care Dependency – Chronic Pain Syndrome – Decondition Syndrome

Posted in Guidelines for Treatment at 9:04 PM by Dr. Greathouse

Talking Points
Can we predict poor outcome and if so what can be done about it?Whether it be contrived or due to extenuating circumstances beyond case management & patient control, there will be cases that even with the best care & management that will fall into the chronic pain quagmire. However, health-care providers  (HCP) should systematically and diplomatically avoid allowing passive care dependency to develop.
Because two-thirds of work injury monetary loss is derived from lost wages, prediction of probability outcome is important.  The potential for early prediction lies in finding appropriate treatment early in the course of care and eliminating ongoing ineffectual (over utilization) care.  Currently, few valid prediction instruments are available, the studies that exist are varied and many times contradictory.  However, there are multiple poor outcome indicators with potential and they do offer clues that enable the HCP to be more prudent and adroit about avoiding over utilization mistakes and making better management decisions.  These sentinel indicators should be in place as standards of care for work related injuries.
Prediction of outcome not only benefits the third party system, it benefits the patient as well. Although some believe secondary gain is an issue and that patients are looking for secondary gain, the true consensus is that these patients represent only a small fraction. So, potentially identifying poor outcome probability and appropriately addressing the issue early, actually benefits all concerned. Those who oppose this assessment system may have some valid concerns, but both sides of the issue have their own agenda and a balance must be kept.
The balance comes with maintaining the focus of the true goals, which are returning the patient to as near normal function as possible, empowering the patient with independent skills and reducing or averting ineffectual care that fosters the tendency toward disability. The check & balance system should be centered on the physician following good standards of care. Standards that require accountability, proof of efficacy, medical necessity and adherence to reasonable end points of care based on the natural history of the disease or malady.

Is passive care dependency fostered?The literature is replete with “fostered care dependency”. I’m sure that any health expert in their respective specialty would agree that fostered care dependency exists.
Caveat: First and foremost, differentially diagnose the patient.  Even bona fide hypochondriacs develop serious illness and disease.  Management should remain adroit and prudent.

Actual Physiologic Time Frame for Soft-tissue Healing

All soft tissue injuries go through three basic stages of healing within a relatively standard physiologic time frame, regardless of most complicating issues. The literature supports the following;·      Acute Inflammatory Phase: 3 to 5 days.·      Fibroblastic Repair Phase: 3 to 8 weeks.·     Remodeling Phase: Up to one year.·      Inflammatory response is still detectable at 12 weeks.This should be used as a fairly standard template for treatment time frames.
Management should be algorithmic in progression. These algorithms are already established.

Identify Complicating Issues

Complicating issues should be identified and factored into the management equation.  This might include pre-existing degenerative arthritis, more severe injury, structural/anatomical anomalies, smokers, overweight, and other medical conditions such as diabetes.  These issues factored in will help the third party component as well as and more importantly, the patient, to understand the potential for protracted care and recovery.  Nonetheless, it is to be understood that returning the patient to full or as near full function and independence remains paramount as the end goal.

Transition Is the Key

Transitioning the patient from pain modulating modalities and medication to more active forms of care is a critical key to avoiding fostered, passive care dependency and potential chronic pain. Many physicians do not do this, which is like Russian roulette when it comes to exposing that low percentage of people who may be predisposed to becoming chronic pain patients. By not transitioning to active therapy, even in its simplest forms, the patient can become predisposed, a precursor if you will, to developing activity aversion which leads to activity intolerance, which is the first step in the chronic pain cascade. Patients can experience, to varying degrees, delayed maturation of collagen, muscle atrophy, joint lubrication deficits, ligament atrophy and even bone loss due to too lack of activity. In turn this leads to decline in muscle endurance, tone, cardiovascular aerobic capacity and decreased mobility.  With decreased mobility one develops proprioception, agility and coordination deficits.
With the above scenario of decreased physical capacity and abnormal overload feedback mechanisms, a vicious cycle of recurrent pain and/or re-injury may occur, as is commonly experienced by chronic pain syndrome sufferers.
A Proposed Standard of Care To Avoid Passive Care Dependency and Over Utilization
·      A four-week trial probationary period of care should be adhered to.·      By four weeks with the exception of up to six weeks with more severe injuries such as disc herniation, the attending physician should be able to demonstrate objective & subjective improvement.·      Objectively this might include reduced muscle spasm, increased gross passive range of motion, increased active range of motion, reduced straight leg raise or nerve root tension signs as well as other initially positive orthopedic signs/tests.·      Subjectively the patient should demonstrate decreased intensity, frequency and duration of pain or symptoms.  This should be quantified by grading the pain on a 0 to 10 scale and percentage improved as rated by the patient or some other valid symptom or pain rating scale. ·      Additionally, standard subjective outcome assessment questionnaires shouldbe utilized, demonstrating clear progress, including functional improvement as well. Use of subjective outcome assessment tools are now becoming a more accepted standard of care and should be expected by the third parties (insurance companies) as part of justifying continued care.
·      If the HCP cannot demonstrate that the patient is progressing with the treatment program within the trial probationary period, a second medical opinion and discharge of the patient is in order.  This should be considered a pivotal point in the management process. Beyond this point continued care providing only short-term palliative relief, without demonstrable remedial therapeutic efficacy, should be considered inappropriate and without clinical merit.
This may seem an overstatement of the obvious but on many if not most independent medical reviews or exams, subjective and objective progress is not reflected in the notes, long after treatment should have been stopped or changed.
·      If the patient is progressing, a transition should be seen from passive to active care and should be clearly indicated in the treatment plan.  Passive treatment should reduce in frequency.
·      Active care in the form of rehabilitation should be specific and based on a valid physical capacity assessment, directed specifically at the individual’s deficits. Generic exercise programs should be avoided, as they may subterfuge care with contraindicated or inappropriate procedures. Tear sheet exercise handouts are not acceptable standards of care.. ·      All patients partaking in exercise should be appropriately screened for potential risk factors associated with exercise and trained in proper protocol and execution of the exercises.
·      As a rule, passive care is remedially therapeutic through 6 to 8 weeks, thus the active care component should begin by at least 6 to 8 weeks.
·      Most patients will not require ongoing attendance by a trainer/therapist or extensive rehabilitation.
·      Most patients do require some level of rehabilitation and without this vital component the risk of chronicity and or recurrence remains higher. It’s penny wise and dollar foolish for third parties to deny this component of care.
·      As with treatment, if rehabilitation is indicated, the same burden of proof of medical necessity and efficacy of treatment should be required by the healthcare practitioner.

Board Certified in Rehabilitation by the American Chiropractic Association ACRB

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