Restoring Function in Veterans With Complex Chronic Pain
Pain Programs
In a review of 4 interdisciplinary pain programs (Mayo Clinic Pain Rehabilitation Center, the Brooks Rehabilitation Pain Rehabilitation Program, the Rehabilitation Institute of Chicago Center for Pain Management, and the Cleveland Clinic Foundation Chronic Pain Rehabilitation Program), Stanos found that the compositions of the staff were similar.12 In general, staff consisted of pain management physicians, pain psychologists, physical and occupational therapists, and nurse coordinators. The Mayo Clinic had more personnel, including a clinical pharmacist, the Brooks program had an additional biofeedback specialist, and the Cleveland Clinic had a tai chi instructor. The programs ranged from 3 to 5 weeks of daily programming. The duration of services provided were dependent on the payers. Stanos concluded that functional status, as measured by the Pain Disability Index, improved on discharge, 6 months, and 1 year after treatment at the Cleveland Clinic.
Cosio and Lin described their experience in a multidisciplinary outpatient pain clinic at Jesse Brown VAMC in Chicago.13 Their study noted that the number of veterans in their multidisciplinary pain clinic on chronic opioids significantly decreased, the degree of pain relief increased, and veterans reported improvements in mobility and ability to complete activities of daily living (ADLs). Overall veteran satisfaction with this pain program was reportedly high.
Cosio and Lin also published a study of the effect of complementary alternative medicine (CAM) utilization at a VAMC, which included a 12-week pain education school that was offered to all veterans and families.14 They noted that veterans began using at least 1 more CAM modality before the completion of the pain education program. However, it is unclear from the 2 studies whether the pain education program was incorporated into their multidisciplinary pain clinic.
Outpatient Functional Restoration Program
Given the challenges of addressing chronic pain and at the same time fostering an interdisciplinary approach to management, the VA Puget Sound Health Care System (VAPSHCS) team initiated a program development and quality improvement process for addressing pain and restoring function for veteran patients.
The VA Northwest Health Network (VISN 20) offers health care services for veterans located in the states of Alaska, Idaho, Oregon, Washington, and parts of California and Montana. VISN 20 has 8 parent facilities, which include the Seattle and American Lake divisions of the VAPSHCS. The VAPSHCS has established a comprehensive, interdisciplinary functional restoration pain program that integrates medical, psychosocial, and complementary alternative medicine.
The Outpatient Functional Restoration Program (OFRPP) pain team consists of a chief who is board certified in pain medicine and addiction medicine; a board-certified pain medicine physician; 2 physician assistants, one of whom has formal training in acupuncture and another who is trained in tai chi, qigong, hypnosis, and mindfulness; nurse care coordinators; a pain psychologist with training in acceptance and commitment therapy, cognitive behavioral therapy, yoga nidra, and hypnosis; a second pain psychologist who has a background in rehabilitation psychology; a physical therapist; and a pain clinical pharmacy specialist.
Prior to participation in OFRPP, veterans were required to attend 4 weekly pain education classes for 4 consecutive weeks. The classes educate veterans and their families on the complexity of managing chronic pain. Topics cover medical, pharmacologic and nonpharmacologic approaches to pain, including CAM and psychological modalities (Table 1). The pain orientation classes introduce veterans to available treatment options, and in some cases, veterans decide committing to a more intensive pain rehabilitation program is a good fit.
The program is based on the biopsychosocial model of pain care and Commission on Accreditation for Rehabilitation Facilities (CARF) interdisciplinary pain rehabilitation program standards. The length of the program was determined after reviewing data from existing VA outpatient pain rehabilitation programs; Pain Clinic staff availability, training and experience; and survey responses from veterans completing the 4-week education. This survey asked veterans whether they would be interested in an outpatient pain rehabilitation program and their preference for length of the program and treatment modalities.
Since its inception, OFRPP has earned a 3-year CARF accreditation. Veterans participate in VAPSHCS American Lake division OFRPP education twice weekly for 4 hours for a total of 8 weeks (Table 2). Each week of programming includes 2 hours of physical therapy didactics, 2 hours of physical therapy (eg, paced cardio exercise, stretching, and core strength and conditioning), 2 hours of mind-body medicine (eg, mantram repetition and neuroplasticity education), and 2 hours of psychology education (behavioral interventions and psychological strategies for pain self-management of pain).
There is also 1 hour of pharmacotherapy education regarding commonly prescribed pain medications and how to take medications safely to avoid common adverse events. The nurse is responsible for care coordination and analysis of outcome measures, data collection, and quality improvement.
