Why Multidisciplinary Evaluations (MDEs) Get No Respect

We all know the story. The injured worker is recommended for a Multidisciplinary Evaluation (MDE), often within the same medical practice, and then they are USUALLY appropriate for that practice’s Functional Restoration Program (FRP). Many on the payer/defense side feel that we have gotten to a point where getting an MDE is synonymous with a recommendation for an FRP. But that shouldn’t be the case.

Let’s start with what an MDE is supposed to be.

An MDE is an evaluation from the medical, psychological and physical therapy disciplines followed up with a team conference. The multidisciplinary approach allows the patient to be evaluated as a whole person from a biopsychosocial perspective and not just looking at diagnoses and body parts. Multiple factors across disciplines are examined to determine the most appropriate treatment plan for the patient, to assess barriers to recovery and to define treatment goals. Each clinician has a different evaluative role and the team as a whole is responsible for bringing all of the findings together in an attempt to get the best understanding of the patient and their needs.

This sounds simple enough, so what is going wrong?

One of the biggest problems is that injured workers are not being sent for an MDE early enough. If the involved parties wait to use the MDE as a last resort or until the patient is a ‘train wreck’, then there is typically a need for a change in the treatment course which may include an intensive functional restoration program (assuming it is not too late and that the patient is amendable to such an approach). Early intervention has been talked about a lot and early identification of delayed recovery factors is key. There are excellent screening tools that can identify patients who are at high risk for developing a chronic pain syndrome. Everyone who comes in contact with the patient needs to be looking for factors including, but not limited to: distress, depression and anxiety, excessive pain/disability behavior, fear-avoidance/maladaptive beliefs and Adverse Childhood Experiences (A.C.E.). If the right (biopsychosocial) treatment is offered earlier, we can avoid the downward spiral effect towards a chronic pain syndrome and the patient will require less intensive (and less costly) treatment and have a better outcome.

Another factor is that while clinicians want to help people, it should be recognized that not every patient can be helped with an FRP. Many clinicians want to give the injured worker the opportunity to be in an FRP because they know that the path that the injured worker is on will only lead to further decline. After all, don’t they deserve a chance?!?! Unfortunately, that chance can lead to a bad outcome for everyone. The patient feels like a failure when they do not do well in the program, the payer can view the FRP as a waste of money and the clinicians can become burned out. An MDE should serve as a gatekeeper, only recommending an FRP for those patients that have a high likelihood of success.

Why is a MDE so important?

The MDE provides an evaluation of the individual as a whole person, recognizing that chronic pain is best treated from a biopsychosocial perspective. It allows for the different specialties to explore differing opinions and different treatment options and decide on the best treatment plan for the patient.

Part of the MDE includes identifying multiple factors, including red and yellow flags. Here are a few:

1. To determine that the patient is committed and motivated to make a change.
2. To confirm that the pain is chronic and there is no undiagnosed or undertreated condition and that there is an absence of a serious treatable underlying disease process.
3. To determine a medication optimization plan if appropriate which may include detoxification.
4. To determine psychological stability or distress: pre-existing and concurrent (depression, anxiety, poor sleep, childhood and adult trauma, PTSD, etc.).
5. To identify if the patient has passive attitudes toward rehabilitation and to determine if they can be shifted to an active mode.
6. To assess the patient’s physical level, including baseline functional testing.
7. To identify barriers to progress including a fear of re-injury or fear of movement, a “sinister” belief regarding their pain, anger toward employer or insurance carrier, and deconditioning.
8. If the patient is an FRP candidate, to identify if the MTUS guidelines criteria for admission to a FRP have been met.

The MDE can assist patients that in the past had been resistant to further rehabilitation. Often times, the MDE uncovers that the patient is actually highly fearful of re-injuring themself and has high anxiety regarding his or her ability to participate in further therapy and be successful. Once the individual is educated regarding the process and goals of treatment, he or she will become fully onboard and motivated to participate.

The MDE is also an educational process. The individual learns about their pain and any barriers to progress along with other treatment options while being given hope that they can learn how to manage their pain.

In conclusion, the MDE has an important role in evaluation and treatment planning. It should not be an automatic entrance into an FRP. The individual deserves to have possible conservative treatment options presented to them as soon as delayed recovery is identified. They also deserve an evaluation that educates them with options and recommendations to achieve increased function and better pain management.

Fear and the Role of Physical Therapy

From the Desk of Rachel Feinberg, P.T., D.P.T.


Fear and The Role of Physical Therapy

Fear of re-injury, fear of movement (kinesiophobia) and avoidance due to increased pain levels is a common barrier in returning to normal life, work or recreational activities after an injury. Research suggests that an individual's pain related fear and avoidance are important factors in determining activity level 6-12 months after an injury.

Fear, avoidance and the effect that this has on recovery continues to be widely researched. There are measures that can provide the clinician with the knowledge that fear or avoidance may be a barrier to recovery. Two of the most common measures include the Tampa Scale of Kinesiophobia (TSK) and the Fear Avoidance Beliefs Questionnaires (FABQ). Despite the ability to measure fear and avoidance, there is limited evidence-based or clinical based information that suggests how to treat this barrier from a physical therapy perspective.

With chronic pain, the patient and often the provider, do not understand the heightened pain response. The continued pain, when it is chronic, increases underlying fear and worry of continued damage or further injury that has not been identified. Driven by fear of further pain or the threat of further damage, many people with chronic pain increasingly restrict activities and begin to exhibit a maladaptive avoidance response. For patients that do have serious pathology, it can be confusing as to how to differentiate pain that could be damaging and pain that is likely not damaging. Unfortunately, this fear can be further propagated by healthcare providers as they instruct the patient to avoid painful movements or attempt to explain a patient’s diagnosis. Messages like “slipped disc”, “the spine is out of alignment” and “the back of an 80 year old” can lead the patient to higher levels of fear and disability.

When treating a person with chronic pain, the different aspects of fear and avoidance must first be determined. In many of the questionnaires and in the research, fear of re-injury, fear of increased pain level and avoidance due to other factors are grouped together, when in fact they are quite different. The clinician should spend the time to understand the concerns of the patient so that education can be directed towards addressing the aspect of fear that is limiting rehabilitation and recovery.

Treatment for over-coming fear of re-injury includes the patient understanding their diagnosis, the anatomy involved with this diagnosis, the physiology of why movement is not damaging and understanding the difference between pain and damage. This may include topics such as the role of hypersensitivity and changes in the spinal cord and brain with chronic pain.

A fear of increased pain levels with movement can be another barrier to recovery. In this case, the patient may understand that the pain is not damaging to them, but he or she does not want to suffer through high levels of pain and is fearful of being unable to control the increased pain level. Treatment focuses on education on the detrimental effects of avoidance or guarding and the importance of movement. Further treatment includes education and instruction on flare management skills such as relaxation breathing, pacing, meditation skills and appropriate activity progression. Identifying short and long term goals can be helpful in helping the patient stay focused on why they are pushing through pain. 

Another aspect of treating fear and avoidance is recognizing that mal-adaptive thinking styles can lead to higher levels of disability. Many people with chronic pain deal with anxiety, a lack of feeling in control, catastrophizing, disappointment from only being able to perform at a low physical level, and many other emotions and thinking styles. The Fear-Avoidance Model of Musculoskeletal Pain (FAM) encourages a psychological approach to deal with these thinking styles, however the physical therapist must be able to recognize if this could be contributing to a lack of progress. Most importantly, the physical therapist must be able to recognize when assisting the patient in over-coming their fear due to mal-adaptive thinking styles is out of their clinical capacity. A referral to a pain psychologist may be necessary.

Overall, with any type of fear, treatment includes education, repeated exposure to activities that have been avoided, instruction on active pain management techniques and taking an active role in recovery. The patient begins at a level of activity that is just above their comfort level and is encouraged to slowly, but consistently push that level further. The physical therapist plays a large role in this treatment plan and should work closely with the patient to provide the necessary education and guidance.