Restoration of Function: The Missing Link in Pain Medicine?

The goals of treatment for patients with chronic pain are reduction in pain, improvement in function, and restoration of psychological health. In order to meet these goals, there must be specific attention directed toward rehabilitation and restoration of function in parallel with the treatment of pain. Functional impairments have been demonstrated in patients with chronic pain in the back, neck, and extremities, and other sites, as well as in patients with fibromyalgia. Functional impairment in chronic pain can be diffuse or focal. In addition to nociceptive and neuropathic problems, there may be psychological problems including fear‐avoidance. Common fears include the fear that activity will cause more pain, the fear due to misunderstandings that pain with activity means further damage, or the fear that the pain is a symptom of serious pathology. Functional restoration requires first quantifying deficits using interviews, validated questionnaires for physical function and psychological condition, and when possible, direct measurements of focal and general function. A cognitive‐behavioral approach appears to work best. Treatment stresses education and clarification of possible misconceptions, exercise to targeted levels, and graded exposure to painful activities. Patients are taught that it is safe to exercise despite pain and that there is no risk of harm. Graded exposure requires progressive activity and exercise that emphasizes training in strength, flexibility range of motion, and endurance despite pain. Exercises are quota or goal‐directed, and not influenced by the pain. After specific deficits in muscle strength and flexibility are identified and quantified, they become the major foci of therapy. Repeated single effort strength maximums are established. Each week or twice weekly, new goals are set based on the individual's progress. Although rehabilitation concentrates on function and does not specifically address pain, quite often as function improves, there is reduction in pain and improvement in psychological health.