Each week, the Rehabilitation Institute of Washington (RIW) pain management team hears patients graduating from its program, say, “Why didn’t I do this years ago?”
That’s because many of them, after battling chronic pain for years, have overcome its physical limitations and are doing things they thought they’d never do again.
“We see many patients who have completely lost hope that they can improve,” said James Moore, PhD, RIW’s co-founder. “Within a week in our program, they’re more active than they have been in years. This is what keeps us doing what we do.”
For more than two decades, RIW’s dedicated team has used an interdisciplinary functional rehabilitation approach to help people with chronic pain restore the physical, emotional, occupational, recreational and social aspects of their lives.
“Our experience has been that functional rehabilitation yields better and more lasting changes because patients learn to manage pain and maintain active lifestyles,” Dr. Moore said.
Because of its success in treating chronic pain, the Seattle-based, 2011 American Pain Society Clinical Center of Excellence award winner also has become an established Washington State resource on pain and its treatments. Members of the RIW team actively train other physicians, chiropractors, physical therapists (PTs), occupational therapists (OTs), vocational rehabilitation counselors and psychologists, as well as residents, medical students and therapists at the University of Washington and other educational institutions, on how to treat chronic pain. Additionally, they serve on medical advisory committees for Washington State’s Department of Labor and Industries regarding best practices for managing pain. RIW helped design the state’s pain rehabilitation guidelines and collaborated on developing treatment protocols for complex regional pain syndrome, the use of opioids and detoxifying opioid-dependent patients.
Striking Out on Its Own
RIW originally was part of a large academic medical center in Seattle. According to Heather Kroll, MD, RIW’s other co-founder, the medical center “looked at its finances and goals and what kind of services it wanted to provide, and decided it didn’t want to provide this service.”
With encouragement from referring physicians and patients, RIW struck out on its own in 2005, becoming a freestanding pain management clinic and eventually moving into its current location in the uptown, “Lower Queen Anne” section of Seattle. Since then, RIW has nearly tripled its business to almost 700 patients annually.
The move proved that the old business axiom about “location, location, location” is true. “The neighborhood we’re in now is less intimidating to patients than the heart of downtown, where the medical center is located,” explained Dr. Moore. “We have plenty of parking and are very accessible to public transportation. Since many patients come from elsewhere in the state, as well as other states, we’ve acquired a nearby apartment building to house patients.”
RIW’s current facility is nearly 26,000 square feet, and incorporates an open floor plan. It has three gymnasiums, the most modern exercise and therapy equipment, the latest computer capabilities and a variety of occupational workstations.
“Our new space is not only larger than our old space,” Dr. Kroll said, “but it is laid out in a more efficient way that really maximizes all aspects of patient care.”
RIW patients perform job-specific tasks in the institute’s new “work-hardening” program, which simulates the kinds of work activities they might do in their jobs.
Becoming an independent clinic also has given RIW much more control over its program. “As part of a large medical center, we had multiple layers of administration, and [the administration] held the decision-making power,” said Dr. Moore. “As a freestanding clinic, we’ve been able to expand (three expansions in seven years), design the space to better suit our needs, acquire new equipment, develop new programs, and control the number and composition of our staff. We’ve also given team members more control and decision-making power, which in turn has improved morale and provided a sense of ownership of the program.”
Getting People Back to Work
The bulk of RIW’s patients are injured workers referred for treatment through the state’s workers’ compensation system. “Private health insurance typically doesn’t pay for comprehensive rehabilitation for complex chronic pain problems,” Dr. Moore explained. “Workers’ compensation insurance covers effective treatment because, otherwise, it will end up paying disability for years.”
Dealing with Washington’s workers’ compensation system can be challenging, but RIW has learned to navigate it effectively.
“We have patient coordinators who take care of getting authorization for treatments and, if necessary, housing and transportation for the workers,” said Dr. Kroll. “Our vocational counselors provide one-on-one counseling on workers’ compensation regulations and help injured workers understand the services to which they are entitled. Our physicians also deal directly with state case managers on the medical issues. It works smoothly because we all have the same priority—getting a person back on the job as quickly as possible.”
RIW focuses on active, exercise-based physical therapy to improve strength, endurance, flexibility, posture and body mechanics. Additionally, the program stresses occupational therapy to advance physical activity and daily function; psychological counseling to promote coping strategies and the emotional sequelae of pain; medical management to educate patients about pain and minimize the use of harmful or dependence-causing medications; and vocational counseling to help patients return to productive employment. The institute also provides nutrition counseling and drug detoxification services.
RIW has three gyms with the most modern exercise and therapy equipment to provide active, exercise-based physical therapies to improve strength, endurance, flexibility, posture and body mechanics.
A patient arriving at RIW will undergo an intensive half-day evaluation with a physician, pain psychologist and vocational rehabilitation counselor. On entering RIW’s program, patients spend the next 20 days, Monday through Friday, from 9 a.m. to 4 p.m., working with rehabilitation specialists to restore function, improve cardiovascular health and learn proper body mechanics and coping strategies.
Physical therapy may include gait training, flexibility exercises, spinal stabilization exercises, postural exercises, neuromuscular retraining, strength training, cardiovascular exercise and more.
Occupational therapy focuses on job-specific work, home or leisure activities, such as how to sit and stand comfortably, lift and carry things, walk, climb stairs, and use arms and hands.
The program puts a strong emphasis on the nonphysical or psychological aspects of the pain experience.
“The core psychological focus is to help patients understand that their pain might not be dangerous, and it should not affect daily activities,” said David Fordyce, PhD, an RIW psychologist. “We also deal with the myth that seeing a psychologist means their pain is imaginary. It is a worry many patients carry. We try to make them understand that their pain is absolutely real.”
Dr. Fordyce estimated that nearly 80% of RIW’s patients are dealing with psychological issues. Their biggest concern: fear of their pain and an almost phobic anxiety that it will get worse, or they will reinjure themselves if they try to do something.
RIW physical therapists help patients become stronger, more flexible and more confident so they can resume daily activities.
To help patients overcome these fears, RIW’s pain psychologists not only offer cognitive and behavioral coping skills for managing fear, depression, anger and other emotional consequences of pain, but they help patients understand the very nature of chronic pain and how it affects them and their families.
Dr. Fordyce pointed out that the psychological component of the program does not act independently of the physical and occupational rehabilitation, but rather is complementary.
“The psychology is kind of the icing on a cake that supports our physical rehab,” he said. “Our PTs and OTs are often our strongest psychologists, because their job is to stand next to a patient who is very fearful, anxious and frustrated at being asked to do something physical in the face of his or her pain. So, from the moment a person walks in the door, the PTs and OTs tell them they know it will be difficult and scary, but they are going to support the patients in slowly moving their bodies. It will be OK.”
Although the PTs and OTs spend the most one-on-one time with patients, RIW’s physicians and psychologists are frequently in the gyms, helping patients overcome any anxiety about what’s happening to their bodies.
According to Dr. Kroll, this kind of teamwork and concern for patients, along with the experience the team has acquired over the years, makes the program successful.
“Many of our patients have had lots of physical therapy, and it hasn’t helped,” she said. “Our staff reassures them it is safe to move, and [explains to them the] kind of symptoms they should pay attention to and which ones to ignore. Our team is very good at handling questions and negotiating a patient’s fear.”
Since becoming a freestanding pain clinic, RIW has posted impressive outcomes. For example, for patients who completed the program in 2010, more than 72% returned to work by one-year follow-up, and another 12% were in retraining.
Patients improved in all measures—reported pain, pain worry, fear avoidance beliefs, depression, self-reported function and objective measures of function. Patients also had reduced use of opiates, sedatives, alcohol and tobacco. Additionally, patients reported that after leaving the program, their newly learned coping strategies keep them more active and independent at home.
RIW’s newest initiative is its “work-hardening” facility, where patients can simulate the kind of work they might do in a job, such as moving freight, running power tools or climbing ladders.
“We hope to grow this program to help injured workers return to jobs that require the performance of specific work tasks and high levels of fitness and endurance,” said Dr. Moore.
The institute strives to help physicians understand that its program is effective for treating anyone with chronic pain, excessive medication use and prolonged disability.
“We’d like to be able to treat patients sooner, before they undergo unnecessary surgery, become dependent on medications, or become depressed and hopeless about returning to work,” Dr. Moore continued. “We have an evidence-based treatment approach that is as effective as more invasive treatments, but less costly and less likely to result in medical complications. We hope to educate physicians about the availability of this approach, and thus provide effective care to a larger group of people with chronic pain.”