Ronald J. Kulich, Ph.D.
Professor, Tufts University
Lecturer, Harvard Medical School,
Department of Anesthesia, Pain Medicine
and Critical Care
Massachusetts General Hospital
History: Functional Restoration, Operant
and Classical Conditioning in Clinical Pain
Rehabilitation
Reissued
2014
Classical Conditioning
Bell
Work Tasks
Walking
Boss
Permanent
Changes?
CS
UCR
UCS
Salivation
Fear
Autonomic Arousal
Escape
Food
Pain
Nausea
Operant Conditioning
Edward L. Thorndike
(1874-1949)
 B.F. Skinner
(1904-1990)

Behavior
+R
Consequence
Figure 1
Initial Development of Chronic Pain with Pain
Contingent Activity
Tx
Tx
Tx
Tx
Tx
Tx Tx Tx Tx
Tx
Tx Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Injury
Kulich & Gottlieb, 1985
Stone & Kulich, 2015
Tx
Time
Tx
Pain
Activity
Multiple treatments
Figure 2
Development of Disability with Chronic Pain
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
pain-based
activity
reduced activity
Time
Tx
Kulich & Gottlieb, 1985
Stone & Kulich, 2015
Pain
Activity
Multiple treatments
Functional Restoration & Operant TX
(Fordyce, 1967,1968; Mayer, 1987, 1988)








Time limited
Group based
Highly selective
Focus on function v. pain
Targets RTW
Focuses on perception of
ability
Uses quota-based exercise
Outpatient
Fordyce, 1976
Fordyce, 1976
Operant Pain Rehab History






70s “Operant” Fordyce
80s “Functional Restoration: Mayer
Late 80s “Work Hardening” Mathieson
80s-90s Interdisciplinary Pain Management
and Faux Functional Restoration
Early 90s Inpatients Units Closed, then
Outpatient Programs Closed
2012 Structured programs reemerge in
Colorado, Holland
Clinician Beliefs: Who makes
patients disabled?
Lotters et al 2011, Occup. Rehab
 regardless of the severity of the pain disorder,
merely visiting a subspecialist was associated
with a failure to fully return to work.
Who makes patients disabled?
Houben et al. European J. Pain (2005)
Differentiated between physical therapists on
their biomedical vs biopsychosocial
orientations towards non-specific back pain.

Therapists with biomedical orientation
viewed daily activities as more harmful for
the back of a LBP patient
Consistent with van der Windt D, Hay E,
Jellema P, et al. 2008 on PT training with
chronic pain population
Exercise, chronic pain and other
variables
There appears to be little or no relationship
between improved physical functioning &
performance and measures of mobility, trunk
extension, trunk flexion strength, and other
related variables.
Psychologists fail as well


Few current “behavioral” treatment models
address objective function or employ operant
principles
Preliminary data from Jackson & colleagues
show <5% of 76 “mindfulness” chronic pain
studies employed objective measures of
physical functioning
A return to time limited,
quota-based exercise?
Exercise & Pain

“…exercise should be a core treatment ...
irrespective of age, comorbidity, pain severity
and disability. Exercise should include: local
muscle strengthening [and] general aerobic
fitness.”
(National Institute for Health and Care Excellence (NICE) 2014; Geneen L,
Smith B, Clarke C, Martin D, Colvin LA, Moore RA, 2014; Wieland, 2013,
Busch, 2013).
Quota-Based Exercise vs
Symptom Contingent “Pacing”
Jan 17, 2015
“Compared graded exercise therapy (GET), in which patients gradually
increase the length or intensity of a set of exercises; adaptive pacing therapy
(APT), a strategy to set modest exercise goals but to stay within an
maximum “envelope” of exertion defined by the illness; and cognitive
behavioural therapy (CBT), which aims to identify and adjust the thought
processes that lead to unhelpful behaviours.”
Adapted pacing therapy added nothing to physical
function scores
White et al., 2011, The Lancet
Screening: Who is Appropriate?











No medical contraindications for a progressive, quota-based
exercise
Objective, realistic “micro” and “macro: functional goals
No severe psychiatric disorder: Substance abuse, cognitive
deficits
Somatic focus, fear avoidance, and pain contingent activity is
present
Depression, anxiety, and “unhappy” with current status
Acceptance of the concept that pain relief will not be targeted
Acceptance of a diagnostic and pain amelioration endpoint
Non-solicitous family or option of family intervention
Absence of significant financial support for disability
Co-treating clinician cooperation
Opioids and other controlled substances ?
The “Functional Restoration” Program







Objective “Micro/Macro” Goals, excluding Pain
Relief
Identify Overt and Covert Pain Behaviors
Identify “Well” behaviors
Identify Reinforcers
Address Barriers, e.g., Fear-avoidance, belief about
opioids, solicitious family, sabotaging clinicians,
“hurt versus harm”
High frequency continues +R to intermitant +R
 Digital monitoring/self-monitoring, structured
visits, social reinforcement
Consistent Communication + Treatment Agreement
Identifying Pain Behaviors









Complains of pain
Grimacing, limping
Maladaptive thoughts, e.g., ruminations about injury,
pathophysiology, “correct” posture
Use of cane, braces, TENS units
Pain contingent medication use
Pain contingent physician visits
Pain contingent passive treatments, e.g. massage, rest,
ice, meditation
Pain severity & symptom monitoring
“Pacing” to eliminate “flares”
Chronic Pain and Disability “Flags”adapted from Main et al 2008
;
Biological
Personal and
environmental
Factors (Psychosocial)
Red flags
Stone & Kulich, 2016
 Serious pathology
 Medical & Psychiatric co-morbidity
Orange
flags
• Depression
• PTSD
• Somatoform Disorder/# sites
Yellow
flags
 Avoidant coping strategies
 Emotional distress
 Passive role
 Perceived low social support at wk
Environmental
(systemic)
Blue
flags
 Perceived unpleasant work
Black
flags
 Legislative criteria for
 Low job satisfaction
 Perception of excessive demands
compensation
 Nature of workplace (eg. heavy
work)
 Threats to financial security
Pharmacotherapy & Operant Tx
Can they mix?

The pattern of medication use or other “pain relief”
interventions are subject to the same operant
principles
Physicians reported increases and decreases in
function to be the most important measure of success
with chronic opioid therapy
…while objective functional gains for COT remain
elusive
N = 82 PCPs, 65 Pain Specialists

Nishimori, Kulich, Carwood, Okoye, Kalso, & Ballantyne (2006)
Examples: Realistic Goals w/ Fixed Dates






Increase function, e.g., walk 30 minute to grocery
store by May 20, sit through movie with wife by May
30, lift 30 pound grandchild by May 15
Improve mood and sleep habits, e.g. 10 point change
in CES-D, utilize 4 sleep hygiene skills
Reduce medical visit frequency, e.g., PCP visit 1x per
mo., ortho 1x per year
Reduce/eliminate inappropriate medications, (specific
medications and dates)
Improve relaxation/mindfulness skills
Return to volunteering by June 15
Is a Work Goal
Realistic?
Job & Supervisor Satisfac
Job Satisfaction Predicts Injury
(Bigos et al., 1991)




3000 Aircraft Employees over 4 years
The Item: “I hardly enjoy tasks involved in
my job.”
“Yes” predicts 2.5 x more likely to incur a
back injury
Consistent with Frymoyer’s later data on
reinjury after discectomy
Operant/Functional Restoration Program
Sample Treatment Plan and Agreement

Congratulations on your enrolment in the Functional
Restoration Program. The program is designed for individuals
suffering from chronic pain who desire to return to normal
levels of physical functioning in all area of life. Similar
selective programs have shown great success with motivated
individuals who often have tried a long history of other pain
treatments, physical therapy and other rehabilitation efforts in
the past. Rather than attempting to eliminate pain or
providing additional diagnostic tests, the program is designed
to assist you in improving overall function and developing the
best quality of life despite pain. Our team works closely with
you to achieve these goals.
agreement cont’d

The first step involves determining your specific goals that can
be achieved over a 6-8 week period. (See Sample Goal List).
After review with your clinician, these goals include:
Goal
Date
1
Walk to corner store (20 minutes)
Exercycle (30 Minutes)
May 1
2
Lift Grandchild (20 pounds)
Free weights floor to weights (40 pounds)
June 1
3
Improve sleep habits
Improve Mood (CES-D)
May 10
Out to movies with wife (3x)
Volunteer work contact + Visit with Mass Rehab
Commission
Eliminate cane
June 1
4
5
April 22
agreement cont’d

Achieving Your Goals: We know that goals change. With
respect to your exercises or other quality of life goals, we do
occasionally adjust these goals in an individual bases, while
goals are not changed or adjustment on more than one
occasion in the program in order to better insure a clear pain of
success. Goals and the components of your program are
closely viewed by each clinician on several occasions
throughout the day.

Schedule: The program is scheduled 2 days per week for
approximately 3-4 hours per day . You are expected to attend
all sessions, regardless of pain. Given the program’s intensity
and goals you have target, absence from two sessions results in
discharge.
agreement cont’d


Other Treatments: One goal of the program is aimed toward
minimizing unnecessary medical visits. During the period of
the program, all participants are asked to end other pain and
physical therapy related treatments.
Medication: You are expected to continue on a stable of
“fixed” dose of their medications during the program. The
medication plan of care is outlined at the beginning of the
program by your physician. These include:
1
2
3
4
Medication
Dose
Prescribed by
clonazepam.5
oxycodone 5mg
gabapentin 600 mg
fluoxetine 20mg
2x per day
3x per day
3x per day
1x per day
Jones-PCP
BPCC
BPCC
Smith-Psychiatry
agreement cont’d

Pain Behavior commonly occurs with individuals who have
persistent pain over many months or years. This can be
observed by others around you. Other “covert” behaviors
include thoughts about your pain that may get in your way of
improved functioning. “Well behavior,” physical capacity
and improved coping skills are intended to reduce pain
behavior. Current pain behaviors discussed by you and your
clinician include:
Pain Behaviors
1
2
3
4
5
Use of the case
Limping, grimacing
Increasing oxycodone
As-needed use of ice
Use of back brace
Solicitious Behavior

Family members are often important supports for
helping you return to functioning. In some cases, it’s
helpful to have them observe your exercise effort and
plan other family events together: “My family
member interested in participating is….”
_________________________
Figure 1
Initial Development of Chronic Pain with Pain
Contingent Activity
Tx
Tx
Tx
Tx
Tx
Tx Tx Tx Tx
Tx
Tx Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Injury
Stone & Kulich, 2015
Tx
Time
Tx
Pain
Activity
Multiple treatments
Figure 2
Development of Disability with Chronic Pain and
Introduction of Quota-based Activity
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
quota-based
activity increase
Tx
reduced activity
Time
Stone & Kulich, 2015
Tx
Pain
Activity
Quota-based activity
Multiple treatments
Figure 2
Development of Disability with Chronic Pain
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
Tx
pain-based
activity
reduced activity
Time
Tx
Stone & Kulich, 2015
Pain
Activity
Multiple treatments
Figure 3
Development of Disability with Chronic Pain and
Introduction of Quota-based Activity
Tx
Tx
Tx
quota-based
activity increase
reduced activity
Time
Kulich & Backstrom, in press
Tx
Pain
Activity
Quota-based activity
Fixed treatments
Electronic Activity Trackers




Glorified pedometers
“Use of pedometer is
associated with significant
increase in physical activity
and decrease in body mass
index and blood pressure.”
10-15% error, FitBit 10.1%
error
“the widespread integration
of this technology into
medical practice remains
limited.”(Appleboom, 2014)
• Bravata DM, Smith-Spangler C, Sundaram V, et al. Using Pedometers to Increase Physical Activity and Improve Health: A
Systematic Review. JAMA. 2007;298(19):2296-2304. doi:10.1001/jama.298.19.2296.
• Appelboom et al.: Smart wearable body sensors for patient self-assessment and monitoring. Archives of Public Health 2014
72:28
Kulich RJ, Berna C, Backstrom J, Mao J. APS 2015
Kulich RJ, Berna C, Backstrom J, Mao J. APS 2015
The early history of aggressive
operant approaches
Silas Weir Mitchell (1874) offered a treatise
on “a lad of 16, who, while oppressed under
certain family troubles, still contrived to
lead his class… (Then) the headache came
on…within a week so severe as to prevent
all study….”

…the pain was absent, or rare, as long as he rode
on horseback, or idled at the seashore, but the
slightest methodological use of his brain caused
him hours of pain.”

Describing a tenderness of the scalp and occipital
area pain with increasingly diffuse pain, Mitchell
also noted that the patient became progressively
irritable and depressed as his pain persisted.

He diagnosed that patient as having headache
“from over use of brain.” (Mitchell, 1874).


Mitchell suggested that the patient assume “a semibarbarous life,” shelving all academic interest, and
returning to “camp life…as an incomparable means
of cure.” He essentially instituted an intensive,
quota-based exercise regimen.
In commenting on causation for these stress induced
physical maladies, the Boston Medical and Surgical
Journal (1853) editorial noted that “many a bright
young fellow is broken down by being overwrought.” by their studies.
Follow-up






Post Treatment Assessment
FU Assessment
FU Crisis Protocol for Relapse
Work, Avocational, Independent Exercise
Family +R well behavior
FU Treatment Protocol



Individual non-prn visits
PCP + Managed Subspecialists
The correct S. Groups, Relapse Groups