Cochrane reviews withdrew a review on rehab programs that questioned any validity to programs that do not have full multidisciplinary approaches. One wonders if this was pressure from Functional restoration business – who would not like that presented
Cochrane Database of Systematic Reviews 2008 Issue 1 Status: Withdrawn
update of:
Cochrane Database Syst Rev. 2002;(1):CD000963.
WITHDRAWN: Multidisciplinary bio-psycho-social rehabilitation for chronic low-back pain.Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C.
Institute for Work & Health, 481 University Avenue, Suite 800, Toronto, Ontario, Canada, M5G 2E9. jguzman@iwh.on.ca
BACKGROUND: Chronic low back pain is, in many countries, the main cause of long term disability in middle age. Patients with chronic low back pain are often referred for multidisciplinary treatment. Previous published systematic reviews on this topic included no randomised controlled trials and pooled together controlled and non-controlled studies. OBJECTIVES: To assess the effect of multidisciplinary bio-psycho-social rehabilitation on pain, function, employment, quality of life and global assessment outcomes in subjects with chronic disabling low back pain. SEARCH STRATEGY: We searched MEDLINE, EMBASE, PsychLIT, CINAHL, Health STAR, and The Cochrane Library from the beginning of the database to June 1998 using the comprehensive search strategy recommended by the Back Review Group of the Cochrane Collaboration. Intervention specific key words for this review were: patient care team, patient care management, multidisciplinary, interdisciplinary, multiprofessional, multimodal, pain clinic and functional restoration. We also reviewed reference lists and consulted the editors of the Back Review Group of the Cochrane Collaboration. SELECTION CRITERIA: Design: randomised controlled trials comparing multidisciplinary bio-psycho-social rehabilitation with a non-multidisciplinary control intervention.Population: Adults with disabling low back pain of more than three months in duration.Intervention: Patients had to be assessed and treated by qualified professionals according to a plan that addresses physical and at least one of psychological, or social/occupational dimensions.Outcomes: Only trials which reported treatment effect in at least one of pain, function, employment status, quality of life or global improvement.Exclusion: Pure educational interventions (back schools) and pure physical interventions were excluded. DATA COLLECTION AND ANALYSIS: Selection, data extraction and quality grading of studies was done by two independent authors using pre-tested data forms. Study quality was assessed according to the scheme recommended by the Back Review Group of the Cochrane Collaboration. Trials with internal validity scores of five or more in a ten point scale were considered high quality. Discrepancies between authors were resolved by consensus or by a third author. Given the marked heterogeneity in study settings, interventions and control groups we decided not to pool trial results in a meta-analysis. Instead, we summarized findings by strength of evidence and nature of intervention and control treatments. The evidence was judged to be strong when multiple high quality trials produced generally consistent findings. It was judged to be moderate when multiple low quality or one high quality and one or more low quality trials produced generally consistent findings. Evidence was considered to be limited when only one randomised trial existed or if findings of existing trials were inconsistent. MAIN RESULTS: Ten trials (12 randomised comparisons) were included. They randomised a total of 1964 patients with chronic low back pain. There was strong evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved function when compared with inpatient or outpatient non-multidisciplinary treatments. There was moderate evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved pain when compared with outpatient non-multidisciplinary rehabilitation or usual care. There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary bio-psycho-social intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psycho-physical treatments did not improve pain, function or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. Few trials reported effects on quality of life or global assessments. AUTHORS’ CONCLUSIONS: The reviewed trials provide evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves pain and function. Less intensive interventions did not show improvements in clinically relevant outcomes.
- In this province WCB and our auto insurer, SGI, have a conditioning program. It would be hard to have a psychosocial program when clients are frequently threatened with termination of coverage. Yet this review stated ” Less intensive interventions did not show improvements in clinically relevant outcomes.”
- The idea that an insurer can terminate converage following completion of one of these “rehab” programs is also not true – “There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary bio-psycho-social intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psycho-physical treatments did not improve pain, function or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care.”
- The idea that one is ready for work just because they completed a rehab program is a tactic used by insurer. It is a form of what I had called a “Shakedown”. This is a new usage. It means cut someone off coverage and see what happens. They can get away with doing that because “of course” the client/victim will be ready for work after a rehab program. This is sometimes a crock and this above article delineates that well.
- Most chronic pain patient in a pain clinics will admit they might be able to work if they had to – the suffering might be immense, but what else could they do? Early on, some US rehab programs reported they were having success getting people back to work. Then Danish studies came out not being able to replicate their results. The latter studies complained that there was success in the US studies merely because the subjects/vicitms were not given enough money to live on and had to go back to work. The shakedown in operation.
- I was always taught there was no point in strengthening muscles in spasm. Yet back exercise programs without neutralizing vigorous Psoas spasms, seems to regularly occur.
Comment – I am uncomfortable with the tractic that exercise programs by itself makes pain patients employable and hence coverage can be terminated following completion of a rehab program. The Canadian Supreme court case in Nova Scotia 2001 made that illegal. Prior, chronic pain subjects of undetermined origin (and only them) were cut off funding after a 5 week rehab; this was considered a human rights violation.
In this province they say they handle things on a case by case basis, yet this frees them to violate human rights on a case by case basis; all they need is one biased professional to stipulate that a patient is employable.
The WCB act stipulates that the patient be given the benefit of the doubt. Given that, letters of termination of coverage should read “Beyond any reasonable doubt you are employable”; not we want to try a shakedown and see what will happen. I would suggest that if anyone receives a termination of coverage s/he send back the letter and demand that by law they have to state “beyond any reasonable doubt” in that termination and so have them modify the termination letter to say so. This statement is often not defensible; beyond a reasonable doubt does not mean one biased WCB paid professional or the fact a conditioning AKA “rehab” program has been completed.
How often is it happening now? A talk with one psychologist who has some doctors as clients, has made it clear that angst over how patients are being treated by insurers is a cause of doctor burnout.
Do people have suggestions of how to deal with this?
There needs to be professionals that will give a proper view. I have taken training in IME (NOT certified) and am amazed at how biased the organization(s) seems to be against chronic pain of undetermined origin. I had to mention to one instructor that to treat such a patient in Canada like such would be a human rights violation (which did seem to have some impact). Many IME’s make their bread and butter off insurers and demand “objective findings” to be taken at all seriously. This has resulted in discussions by the Canadian Pain Society in their journal Pain Research and Management:
Viewpoint Spring 2001, Volume 6 Issue 1: 9-10
Toward making “IMEs” independent
GV Rossie, RD Gretzinger
Commentary Spring 2001, PRM, Volume 6 Issue 1: 13-14,
Toward making IMEs independent: Balancing the source of work
” The complaint that ‘independent medical examinations’ (IMEs) initiated by insurance companies are unfair or biased appears to be universal. Many claimants and their medical providers believe, perhaps with good reason, that insurance adjustors send claimants to examiners who can be counted on to issue reports that favour the insurer’s position. Doctors who routinely side with insurers can expect appreciable income flow from the potentially unlimited supply of referrals.”
Commentary PMR Spring 2001, Volume 6 Issue 1: 11-12
Medical examiners: Independent or ignorant?
EN Thompson
The medicolegal conditions in Colorado before the changes introduced in 1997, as described in the article by Rossie and Gretzinger in this issue of Pain Research & Management (pages 9-10), still exist in Canada and elsewhere. So-called independent medical examiners (IMEs) paid by the insurance companies repeatedly testify that injured motorists complaining of persistent pain and dysfunction have no real organic basis for their complaints and that they are fit to return to work. These experts are from various specialties but are frequently orthopedic surgeons, neurosurgeons, neurologists, physiatrists and psychiatrists. Psychologists and some manual therapists are also involved. Most appear genuine in their beliefs that there is nothing wrong with these patients. This is not surprising because actual knowledge about the pathophysiology of chronic pain is not a requirement to qualify as an expert in these matters.
Commentary PRM Spring 2001, Volume 6 Issue 1: 13-14
Toward making IMEs independent: Balancing the source of work
FE Hayman
“It has been said many times that ‘money is what makes the world go around’. The article ‘Toward making “IMEs” Independent’ (pages 9-10) certainly reinforces this phenomenon in the insurance context, highlighting the economic forces at work in independent medical examinations (IMEs).”
Do people know of any neutral “specialists” who will give a reasonable appraisal?
In this province, I have personally seen 60 year old men. Some with hip replacements from work place falls forced through 12 week rehab programs and sent back to work. Many with little restrictions. It was my own experience that “rehab” programs are a bussiness just like all others. Selling a product to insurers, and therefore must maintain customer satisfaction. A high rate of “clients” successfully completing these programs and declareing them fit for work.
I found your blog via Google while searching for global life insurance and your post regarding Exercise Rehab Programs by Themselves Worthless? – Evidence Snuffed?? and How does One Get an Unbiased Appraisal of Disability? looks very interesting to me. I could not believe the amount of quality material on this site. The site is extremely eyecatching and pulls the reader straight it, the articles are great quality and are very professionally written. I have seen too many of these sites where it looks like they pay an 8 year old to do the writing – Not this one. Your site is easily the best that I have seen in a long while.
You got master mind on Exercise Rehab Programs by Themselves Worthless? – Evidence Snuffed?? and How does One Get an Unbiased Appraisal of Disability?, that’s why you could able to write a article like this, hats off mate – keep up the good work.
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Rehab will fix anything? So WCB placed me in rehab only to be overcome in severe pain; The physiotherapist then requested help from a pain specialist and WCB DENIED me help once again;
I have had the same miserable claims adjudicator from WCB and she has negligently denied me help requested from a physician; Returned me to work with LIES; Stated good luck in my future all the while knowing I would be injured further;
Saskatchewan Sask Party has announced that they are conducting a workers compensation service review; BUT WON”T LET ME SEND MY CLAIM FILE TO BE REVIEWED;
Mr. Wall and Mr. Norris you are about to be named in a lawsuit for NOT DOING YOUR JOBS;
The Saskatchewan PEOPLE whose lives were placed in DANGER will finally have PROOF that WORKERS COMPENSATION IS A FRAUD;
I am filing a LAWSUIT ASAP:
Workers Compensation is legalized fraud / racketeering, they take employers money and then when a worker is injured DENY them medical help; I have multiple injuries and WCB claims adjudicator LIED and DENIED me the doctors requests or wishes and warnings, BILL 45 should result in charges being laid;
They were not laid due to the corruption that is allowed to exist in workers compensation.
BEWARE SASKATCHEWAN CITIZENS, WORKERS COMPENSATION IS A FRAUDULENT ORGANIZATION THAT COULD CAUSE YOUR DEATH: