Interdisciplinary Pain Management Programs

Interdisciplinary pain management programs have been shown to be more effective than unimodal approaches. Flor, Fydrich, and Turk (1992), in a meta-analysis of outcome data from 65 studies, found that 1) combined treatments are superior to single treatments or no treatments for chronic nonmalignant pain; 2) participation in an interdisciplinary pain program increases the return-to-work rate (average, 43%) and decreases health care utilization; 3) the benefits of an interdisciplinary pain program are maintained over time; and 4) patients who benefit from treatment and those who do not are similar in terms of age, pain duration, workers' compensation status, and treatment duration.

Goals of the program

At the start of a program, each patient should identify specific goals. These may include the following:

1. Reduction of pain intensity. Although patients rarely if ever report that their pain has been eliminated, by the conclusion of the program they often report a reduction in the amount of pain. Most patients enter a pain management program because of persistent pain, but they are taught not to set pain elimination as their primary goal. Instead they are encouraged to focus on other, more attainable goals.
   
   
2. Enhancement of physical functioning. In group-based pain programs, patients are encouraged to participate regularly in exercise (including stretching, cardiovascular reconditioning, and weight training) and to increase their activity at a progressive rate under supervision. The goal is to gradually increase function without exceeding predetermined limits of pain and discomfort. Patients have been known to increase their physical strength and endurance by 50% - 100% over a three-month period.
   
   
3. Proper use of medication. Through education and daily monitoring, most patients are able to use prescription pain medication responsibly. Participants are frequently asked to monitor their medication for a week before entering a program and to report their daily medication at the end of the program.
   
   
4. Improvement of sleep, mood, and interaction with other people. Most patients report being depressed and having problems relating to other people. At the conclusion of most group-based pain programs, patients usually show evidence of improved sleep, decreased emotional distress and increased self-esteem.
   
   
5. Return to work or to normal daily activities. Patients who set as their goal an eventual return to work are often successful. Follow-up helpfulness ratings indicate that patients who have a positive experience in a pain management program tend to return to work and/or maintain an active, productive lifestyle.
   
   

Roles of a multidisciplinary team

Chronic pain involves a complex interaction of physiological and psychosocial factors, and successful intervention requires the coordinated effort of a treatment team with expertise in a variety of therapeutic disciplines. Although some pain centers offer a unimodal treatment approach, most programs use a blend of medical, psychological, vocational, and educational techniques. Generally included are medical assessment, medication management, pain-reduction treatments, didactic instruction, relaxation training, biofeedback, physical therapy, psychotherapy, and vocational counseling.

Most interdisciplinary pain treatment programs have as their core staff one or more physicians, a clinical psychologist, and a physical therapist. Other health professionals who may play important roles include clinical nurse specialists, occupational therapists, vocational rehabilitation counselors, and exercise physiologists. Physicians from specialty areas (e.g., neurology, rheumatology, orthopedic surgery, physical medicine, internal medicine) should be available for consultation. The physician's primary responsibility is to oversee the medical aspects of treatment and to prescribe medication and procedures when needed. The psychologist, psychiatrist, or social worker addresses the mental health and behavioral aspects of the patient's program. He or she may facilitate the pain management classes and group therapy sessions and may offer training in biofeedback and relaxation. The physical therapist and exercise physiologist coordinate daily group exercises and assist patients in setting up and following individual exercise programs. An interdisciplinary staff coordinates efforts to rehabilitate the patient and designs a comprehensive discharge and follow-up plan to meet each patient's short- and long-term needs. The patient's participation is strongly encouraged. Among the predictors of success in a multidisciplinary pain program are the patient's motivation to cope with pain and the patient's support system outside the program.

Program structure

Multidisciplinary pain programs are often highly structured, time limited, and organized along a specific treatment schedule. Common goals include an increase in physical, social, and emotional functioning and a decrease in pain and in reliance on health care services. The patient is expected to attend clinic sessions and to participate in all aspects of the program. These expectations must be made clear. To this end, patients frequently sign a treatment contract that spells out the general program requirements as well as individual treatment goals. In addition to helping patients understand exactly what is expected of them, such a contract is a means of identifying before treatment those patients who may lack motivation or have difficulty conforming to the structure of the program. Patients are asked to keep a daily written record of their pain intensity, medication use, and activity levels. Noncompliance may be grounds for discharge from the program.

This article was excerpted from the book Mastering Chronic Pain: A Professional's Guide to Behavioral Treatment. by BW Pain Management Center physician Dr. Robert N. Jamison, Ph.D., published by Professional Resource Press, Sarasota, FL, 1996.