Key points

Interdisciplinary pain rehabilitation programs for the management of chronic pain remain underused in the United States. The reasons for their limited use are numerous, starting with restricted health care coverage for such programs. However, it is worthwhile to revisit a model that has consistently shown evidence-based benefit for patients, and that focuses on the achievable goals of improvement in both function and pain as well as decreased medical and societal costs. It is apparent that traditional medical interventions are not effectively tackling the problem of chronic nonmalignant pain. Deaths from pain-related opioid use are one concern stemming from the present approach. As the prevalence of chronic pain grows, patients increasingly require treatments to reduce their pain, suffering, and disability. Multiple analyses of the most effective ways of reducing chronic nonmalignant pain identify the need for coordinated, comprehensive care, including addressing physical and psychological complications associated with chronic pain syndrome.

An interdisciplinary treatment approach applies to the millions of patients with chronic pain generating nearly 70 million physician office visits annually, and the 130 million outpatient, hospital, and emergency room visits. There are also indirect costs, including employers dealing with absenteeism and disability costs. The US military, which faces back-related pain as the leading cause of disability, has found a use for this model with veterans. Despite the different cultural contexts of patients living with chronic pain, which are influenced in large part by the patients’ developmental, social, and psychological histories, comprehensive pain programs have shown efficacy for providing pain relief and improving physical limitations throughout the industrialized world, possibly because common human factors such as development of maladaptive coping skills, fear of movement, and mood disorders play a large role in development and perpetuation of pain disorders.

The precursor of pain rehabilitation using an interdisciplinary approach has been credited to John Bonica, M.D. He recognized the need for coordinated pain services in injured World War II soldiers who needed specialized care. Chronic pain rehabilitation programs were first formed in the United States in the 1970s, and functional restoration approaches emerged in the 1980s. The alternatives available to patients for chronic pain treatment have typically been exhausted before patients are referred to interdisciplinary programs. These treatments include opioid and analgesic medications; targeted injections; ablation procedures; surgeries; chiropractic care; massage; physical therapy; and complementary alternative treatments, including acupuncture. Many of these treatments lack long-term efficacy for chronic pain, can expose the patient to risk, and rely on passive management of pain (relief provided by biomedical or manual treatments done by providers). Although effective for acute pain conditions, these treatments do not have a curative or a significant rehabilitative effect for patients with chronic pain. In contrast, interdisciplinary pain programs are designed to decrease medical use by improving patients’ ability to independently manage their pain, improve functional and physical endurance, pain severity, quality of life, and employment capacity.

The distinction between an evidence-based interdisciplinary model and the frequently used, but less intensive, multidisciplinary approach is important. The terms are frequently used interchangeably in the literature but have distinct meanings. An interdisciplinary team is based in the same facility and works toward the same goals developed after a comprehensive evaluation. The treatment approach allows for functional recovery through musculoskeletal conditioning, cognitive-behavior therapy (CBT), relaxation techniques, and pain medication tapering. Vocational education is a component of many programs. The interdisciplinary approach stresses seamless communication between team members, daily communication, and weekly team meetings to discuss progress and barriers to recovery. It is time intensive and requires a high level of staffing for the brief period (minimum of 3 weeks) that patients participate in the program.

Multidisciplinary treatment involves multiple clinicians who are concurrently treating the patient, but often without a coordinated discussion of the treatment plan, and may not have similar treatment philosophies. There is limited opportunity for integrated communication with this approach. Multidisciplinary treatment does not tend to involve a brief, intense period of treatment, and may go on indefinitely with variable levels of treatment and support provided to the patient.

Structure of a pain management program

The core of an interdisciplinary program is a skilled team of clinicians. This team typically includes a physician educated in pain rehabilitation, a psychologist trained in CBT, counselors, case managers, and physical and occupational therapists. Additional team members can include nurses, psychiatrists, and biofeedback specialists. Vocational rehabilitation counselors, particularly for programs designed to assist with return to work following an industrial injury, are an integral part of the team. There are a small number of inpatient programs throughout the United States, but a larger number is outpatient based. Literature shows many variations of multidisciplinary or interdisciplinary care. A systematic review showed that daily intensive programs with more than 100 hours of therapy were superior in showing improvements in pain, function, and vocational outcomes compared with less intensive programs.

The typical interdisciplinary pain rehabilitation program includes 3 to 4 weeks of treatment lasting 4 to 8 h/d, 5 d/wk. Because many patients have musculoskeletal impairments and have limited ability to be fully functional, patients are guided individually or in a group setting through progressive exercises to reverse the effects of deconditioning. Using the principles of CBT to learn adaptive pain coping strategies, they are taught self-management skills to manage any concomitant mood disorders that may be present, as well as decreasing avoidant behaviors secondary to fear of pain. Decreasing dependence on habit-forming medications such as opioids and benzodiazepines is another key feature of such programs. Patients typically taper use of medications while they gain self-management skills, enhancing their confidence that they can cope with increased activity with less use and without a significant worsening of their symptoms.

The average patient usually presents to an interdisciplinary pain clinic years after being diagnosed with chronic pain. Multiple efforts at managing their pain have been attempted, including medications, surgeries, physical therapy, aquatic therapy, spinal and joint steroid injections, nerve ablation procedures, dorsal column stimulator placement, intrathecal pump placement, chiropractic care, massage therapy, and acupuncture. For many, it is the patient and the referring provider’s last effort to improve the patient’s quality of life. Understandably, the patient’s perception of disability is highly entrenched at this juncture, and represents a formidable challenge when trying to restore the patient to an improved state. Although the question of secondary gain from remaining disabled in a financial-legal setting, such as with workers compensation or personal injury, is important to consider with some patients, most have gradually slid into a level of comfort with their disabilities. This level of comfort may also have been reinforced by well-meaning providers who instruct the patient that they will always be in pain, will always need opioids, or have the back of a 70-year-old (when the patient is decades younger). More concerning is reinforcement of pain behaviors by providers who perform increasingly interventional procedures on patients targeting a pain generator but without having a clear understanding of the multiple contributors to chronic pain, which include distress, somatization, and depressed mood.

Evaluating a new patient for the program involves taking a detailed history of the pain complaints, activity tolerances, prior diagnostic work-up, medication usage, prior treatments, social history, personal and family history of substance use, and psychological history. Patients tend to give a history replete with passive attempts at managing their pain, including surgeries and procedures, but few are able to recount active self-management techniques.

An initial evaluation should include the domains of physical, emotional, cognitive, and behavioral functioning, along with assessing the patient’s individual factors, clinical history of treatment, and impact on their daily living and quality of life.

Self-assessment and validated measurement tools are used during evaluations to identify the patients’ major concerns and areas of dysfunction in their lives, including life activities such as work, recreation, and abilities for daily living. It also includes evaluating for comorbid conditions of depression, anxiety, posttraumatic stress disorder, and somatoform disorders. A history of prior medication use, including opiates, psychotropic medications, anticonvulsants, nonsteroidal antiinflammatories, muscle relaxants, and sleep medications, is obtained to identify opportunities for reducing polypharmacy, assessing safety, and determining when adjuvant medications may be useful.

Patients who are not appropriate for participation include those unable to learn for cognitive or psychopathologic reasons. Patients who are poorly motivated to participate because of a disability mindset are challenging candidates for such a program, but, if there are no objective physical or psychiatric restrictions inhibiting participation, it is reasonable to offer them the option of treatment, because empiric data indicate that they are usually able to make improvements in physical and emotional functioning.

CBT is used in interdisciplinary pain programs to bring to the forefront the maladaptive cognitions patients hold surrounding their pain, and use behaviors that augment the benefits of physical conditioning. Thoughts secondary to catastrophizing, kinesophobia, and fear of injury are challenged and restructured. Psychologists train patients in the acquisition of skills related to relaxation training and managing activities through pacing. Multiple psychosocial domains of pain respond positively to this mode of therapy, including disability and depression, cognitive coping, interference of pain on function, perceived control of pain, behavioral expression of pain, and social role functioning. The efficacy of CBT-based treatment within chronic pain programs has been shown in multiple clinical controlled trials. Compared with usual rehabilitative treatment, the expense of adding CBT is offset by fewer work days lost, and therefore lower indirect costs.

Structure of a pain management program

The core of an interdisciplinary program is a skilled team of clinicians. This team typically includes a physician educated in pain rehabilitation, a psychologist trained in CBT, counselors, case managers, and physical and occupational therapists. Additional team members can include nurses, psychiatrists, and biofeedback specialists. Vocational rehabilitation counselors, particularly for programs designed to assist with return to work following an industrial injury, are an integral part of the team. There are a small number of inpatient programs throughout the United States, but a larger number is outpatient based. Literature shows many variations of multidisciplinary or interdisciplinary care. A systematic review showed that daily intensive programs with more than 100 hours of therapy were superior in showing improvements in pain, function, and vocational outcomes compared with less intensive programs.

The typical interdisciplinary pain rehabilitation program includes 3 to 4 weeks of treatment lasting 4 to 8 h/d, 5 d/wk. Because many patients have musculoskeletal impairments and have limited ability to be fully functional, patients are guided individually or in a group setting through progressive exercises to reverse the effects of deconditioning. Using the principles of CBT to learn adaptive pain coping strategies, they are taught self-management skills to manage any concomitant mood disorders that may be present, as well as decreasing avoidant behaviors secondary to fear of pain. Decreasing dependence on habit-forming medications such as opioids and benzodiazepines is another key feature of such programs. Patients typically taper use of medications while they gain self-management skills, enhancing their confidence that they can cope with increased activity with less use and without a significant worsening of their symptoms.

The average patient usually presents to an interdisciplinary pain clinic years after being diagnosed with chronic pain. Multiple efforts at managing their pain have been attempted, including medications, surgeries, physical therapy, aquatic therapy, spinal and joint steroid injections, nerve ablation procedures, dorsal column stimulator placement, intrathecal pump placement, chiropractic care, massage therapy, and acupuncture. For many, it is the patient and the referring provider’s last effort to improve the patient’s quality of life. Understandably, the patient’s perception of disability is highly entrenched at this juncture, and represents a formidable challenge when trying to restore the patient to an improved state. Although the question of secondary gain from remaining disabled in a financial-legal setting, such as with workers compensation or personal injury, is important to consider with some patients, most have gradually slid into a level of comfort with their disabilities. This level of comfort may also have been reinforced by well-meaning providers who instruct the patient that they will always be in pain, will always need opioids, or have the back of a 70-year-old (when the patient is decades younger). More concerning is reinforcement of pain behaviors by providers who perform increasingly interventional procedures on patients targeting a pain generator but without having a clear understanding of the multiple contributors to chronic pain, which include distress, somatization, and depressed mood.

Evaluating a new patient for the program involves taking a detailed history of the pain complaints, activity tolerances, prior diagnostic work-up, medication usage, prior treatments, social history, personal and family history of substance use, and psychological history. Patients tend to give a history replete with passive attempts at managing their pain, including surgeries and procedures, but few are able to recount active self-management techniques.

An initial evaluation should include the domains of physical, emotional, cognitive, and behavioral functioning, along with assessing the patient’s individual factors, clinical history of treatment, and impact on their daily living and quality of life.

Self-assessment and validated measurement tools are used during evaluations to identify the patients’ major concerns and areas of dysfunction in their lives, including life activities such as work, recreation, and abilities for daily living. It also includes evaluating for comorbid conditions of depression, anxiety, posttraumatic stress disorder, and somatoform disorders. A history of prior medication use, including opiates, psychotropic medications, anticonvulsants, nonsteroidal antiinflammatories, muscle relaxants, and sleep medications, is obtained to identify opportunities for reducing polypharmacy, assessing safety, and determining when adjuvant medications may be useful.

Patients who are not appropriate for participation include those unable to learn for cognitive or psychopathologic reasons. Patients who are poorly motivated to participate because of a disability mindset are challenging candidates for such a program, but, if there are no objective physical or psychiatric restrictions inhibiting participation, it is reasonable to offer them the option of treatment, because empiric data indicate that they are usually able to make improvements in physical and emotional functioning.

CBT is used in interdisciplinary pain programs to bring to the forefront the maladaptive cognitions patients hold surrounding their pain, and use behaviors that augment the benefits of physical conditioning. Thoughts secondary to catastrophizing, kinesophobia, and fear of injury are challenged and restructured. Psychologists train patients in the acquisition of skills related to relaxation training and managing activities through pacing. Multiple psychosocial domains of pain respond positively to this mode of therapy, including disability and depression, cognitive coping, interference of pain on function, perceived control of pain, behavioral expression of pain, and social role functioning. The efficacy of CBT-based treatment within chronic pain programs has been shown in multiple clinical controlled trials. Compared with usual rehabilitative treatment, the expense of adding CBT is offset by fewer work days lost, and therefore lower indirect costs.