Rehab hospital features specialized pain programs

Facility ranks No. 1 in national survey

The Rehabilitation Institute of Chicago (RIC), which was ranked the No. 1 rehabilitation hospital in the United States by U.S. News & World Report in July, probably has a specially designed program that can treat any kind of pain patients experience.

Patients with acute pain are handled by one team of physicians and therapists; patients with chronic pain are handled by another team; patients with arthritis pain may be referred to the hospital’s new Arthritis Center (see story on RIC’s Arthritis Center in the July issue of Rehab Continuum Report); and patients who have pain that is related to a sports or occupational injury could be treated for pain in a pain program and/or the Center for Spine, Sports and Occupational Rehabilitation. (See "Sports med center gets holistic makeover," in this issue.)

The hospital’s 26-year-old chronic pain program treats patients who suffer from pain related to lower- or upper-back problems, musculoskeletal pain, myofascial pain syndrome, fibromyalgia, spinal cord injury pain, amputee phantom limb pain, and headaches associated with traumatic brain injury and post-stroke pain. "Everybody on our team is full time, and this is all they do," says neurologist Norman Harden, MD, director of the Center for Pain Studies at RIC.

The team includes Harden, a physiatrist, two psychologists, physical therapists, physical therapist aides, occupational therapists, occupational therapist aides, a vocational rehabilitation specialist, a therapeutic recreation specialist, a biofeedback therapist, and nursing educators who handle all patient education.

Patients are either self-referred or referred by physicians. A patient is evaluated initially by a physician, who spends about 1.5 hours with the patient, and by a psychologist who talks with the patient for an hour. Occasionally there will be a vocational rehabilitation specialist who also will talk with the patient for an hour.

Patients must meet specific criteria

Before patients can be placed in a pain program, they need to meet the chronic pain facility’s basic criteria, which include having a diagnosis that is compatible with the center’s work. Also, patients need to be highly motivated and compliant because the program requires very hard work on the patient’s part, Harden says. "There are other criteria, like making sure there are no complicating factors such as inappropriate drug regimes that need to be modified before the patient comes in," Harden says. "For instance, high-dose opioid therapy is not consistent with the work we do."

The chronic pain team also might meet with patients initially to straighten out drug dependence and psychological issues before treatment begins, or they might refer some patients to a chemical dependency specialist. "Then we decide which of our three basic programs would be appropriate," Harden says.

The three programs are as follows:

• An every-day program requires the patient to attend the center each day for one to four weeks. The every-day program requires patients to meet with each therapist and discipline for an hour, with a break for lunch and a 15-minute consultation with the physician. This program also includes an hour of patient education. Patients do not see each team member daily, but will eventually see them all at some point within the week. Physicians see these patients at least three times during the week.

"This program has very detailed and complex scheduling that changes based on the patient’s individual needs," Harden says. "Some patients will need more psychology services, some will need more physical therapy, so it’s tailored and adapted as we go along."

• A half-day program has the patient meet the team once a week for half a day. This program is set up as a round robin; for example, patient A will see the physical therapist first while patient B sees the physician first, patient C sees the occupational therapist, patient D sees the psychologist, and patient E sees the biofeedback therapist. Then after half an hour or 45 minutes of treatment, they all switch, until each patient completes all five sessions.

Program available for less-serious cases

• A modified program for less serious cases is available in which the patient sees a physician and physical therapist, psychologist, or occupational therapist according to need. The modified program is designed by the evaluation team, but once it’s under way, the physician makes changes, taking into consideration the patient’s and team’s opinions. 

For example, the modified program for a patient might include medical care, psychology, and physical therapy. The physician, psychologist, and physical therapist would meet to talk about the patient’s progress and problems. The team would make suggestions for modifying the patient’s plan and adding other modalities as needed.

In addition to traditional services, the center offers some complementary medicine options, including acupuncture, chiropractic care, Pilates treatment performed by physical therapists, and Feldenkrais therapy, a movement therapy administered by physical therapists.

The pain center tracks outcomes by monitoring 14 different psychometrics, including general categories with subjective measures of pain, assessing the patient’s depression and anxiety levels, function tests, medication quantification scale, and other validated instruments, including some the center has designed, Harden says. "The majority of patients report some decrease in their pain, with about 67% reporting a significant decrease in their pain," Harden adds. "Most of our patients, about 95%, achieve maximum medical improvement, which means we do all of the standard-of-care things that are reasonable for the pain so the patient can decrease health care utilization."

About 35% of the center’s patients return to work, a considerable achievement in light of the fact that less than 1% of patients nationally return to work after experiencing two years of chronic pain, Harden says. The center’s payers typically fall into three categories. These include Medicare and Medicaid, which reimburse about 45 cents per dollar of pain center services; HMOs and similar plans, which cover most services (with an occasional 50% limitation for psychological services); and workers’ compensation, which covers 100% of services, as required by state law.

Some of the complementary medicine services are routinely covered by payers; others, such as biofeedback and acupuncture, are not. Patients occasionally will pay out of pocket for the services, but most of the time, the center will cover the cost of non-covered services, Harden adds. "We take what we can get and don’t bill the patient for the rest."

Need more information?

Norman Harden, MD, Director of Center for Pain Studies, Rehabilitation Institute of Chicago, 1030 North Clark St., Chicago, IL 60610. Telephone: (800) 354-7342, ext. 87878.