The Interdisciplinary Treatment Approach for Chronic Pain Management: The Key Components for Success

Fig. 20.1

The biopsychosocial model of pain

Given that there are multiple factors at play, it is not surprising that treatment in only one domain (e.g., opioid medications for the “biological” domain) may not consistently provide full relief for patients. Rather, an approach that incorporates professional interventions across the full range of potential factors is better suited to address the often complex experience of pain. It is from this perspective that interdisciplinary chronic pain management programs were developed. Consideration of traditional pain factors is still relevant, but previously neglected aspects of pain may be incorporated into treatment considerations.

Interdisciplinary Chronic Pain Management

Program Framework

The primary components for interdisciplinary care include a common philosophy of rehabilitation shared by providers, coordinated communication among on-site healthcare professionals, integration of services between providers, and active patient involvement in the program. Collett, Cordle, and Stewart (2000) highlight the importance of having the team of providers working together in a common location in order to facilitate communication and collaboration. Most important is the integration of healthcare professionals from sufficiently diverse disciplines to cover each aspect of the biopsychosocial model of pain. It should be noted that there has been some confusion in the literature regarding the distinction between “interdisciplinary” and “multidisciplinary” pain management. Multidisciplinary approaches feature the involvement of several healthcare providers, but there is no communication or collaboration between providers within multidisciplinary treatment, and they are unlikely to be located in the same facility. Even when they are co-located, there remains a disconnected perception of patient goals and treatment directions. By contrast, interdisciplinary care requires frequent communication between healthcare providers and highlights the importance of having them all work at the same location. The International Association for the Study of Pain (IASP) developed a task force to help establish a uniform guideline for interdisciplinary pain centers (Loeser, Boureay, & Brooks, 1990).

The model of interdisciplinary pain management described in this chapter should be considered a general guide, which may be tailored to fit the individual demands of a particular clinic. There are essential features of interdisciplinary care, with room for some flexibility in the form and function of the programs. Some components of interdisciplinary care are essential. For instance, the healthcare professionals on the treatment team must include one or more physicians, a clinical psychologist, and a physical therapist. Nurses, vocational specialists, occupational therapists, and other healthcare providers are determined by the particular needs of pain populations served by a center, and other support personnel may be included as well. Support personnel may include outcome database managers, nutritionists, chaplain services, and case managers (Noe & Williams, 2012). This collective group of healthcare providers, housed in one location and working collaboratively with a common philosophy of patient rehabilitation, provides the nucleus of the interdisciplinary approach to pain management.

It is important that the support personnel communicate their roles or interventions, as well as a patient’s response or performance, to the rest of the interdisciplinary team. For example, patients may interact with nutritional specialists in order to evaluate and establish a proper nutritional regimen that should be communicated to the other interdisciplinary providers. A vocational rehabilitation counselor should provide the patient’s identified occupational challenges, progress, and areas of limitations or strengths. Chaplain services may highlight the role of spiritual and religious beliefs or practices that are relevant to the patient’s pain condition. There are clear implications here for patients with belief systems that are not fully compatible with effective interdisciplinary care. Take, for example, a patient who was referred to an interdisciplinary program but believes that meditation alone should be sufficient to eliminate the pain problem. This person is less likely to fully adhere to all of the interdisciplinary program’s components, and the chaplain service can be useful in helping other providers consider the impact of the person’s spiritual beliefs on their current treatment.

In terms of other support staff, database managers can provide information regarding health and functional outcomes of the interdisciplinary program participants. These data uncover trends within a particular clinic’s interdisciplinary program and inform clinic directors about areas that need to be improved. Clinical data collection provides the evidence of positive outcomes. Tracking patient progress, reporting these data to the interdisciplinary team, and contributing to the literature on treatment efficacy will empirically strengthen evidence-based care and document the clinical effectiveness of the particular treatment facility. Occupational therapists are yet another provider type that may be included in the interdisciplinary program. These therapists serve the function of evaluating and treating patient concerns in the area of independent activities of daily living. As a discipline related to physiotherapy, these therapists convey important functional disability data, which is useful to the physical therapist (as well as the other treatment-team providers). Additionally, they implement the task-related treatment of upper extremity disorders.

As shown in Fig. 20.2, each type of provider plays a unique but interrelated role in the interdisciplinary team. Physicians provide the core evaluative and diagnostic formulation of the particular pathophysiological mechanisms of pain, just as they do in their more traditional role in pain management. Additionally, they are responsible for medication management of the patient. This sometimes, but not always, includes narcotic treatment considerations. Physicians constitute the most familiar form of pain treatment (i.e., biomedical interventions) and typically represent the primary referral source, as well as entry point, into interdisciplinary chronic pain management programs. While physicians within interdisciplinary pain management clinics may also specialize in biomedical interventions for pain management, they must promote the conceptualization of patient pain experience and treatment using the biopsychosocial model.

Fig. 20.2

Outline of interdisciplinary pain management program

Clinical psychologists are adept at exploring how psychosocial factors influence the exacerbation and maintenance of chronic pain. They perform this function by means of diagnostic interviews and testing prior to interdisciplinary treatment. It is critical to assess previous and current functional abilities and limitations so as to determine the overall impact of chronic pain on the patient’s life. Occupational limitations are particularly relevant: Does the pain limit the patient’s ability to perform the physical functions of his or her job position? Has the depression associated with chronic pain affected motivation, attendance, and productivity at work? These are some of the types of questions that a psychologist consider when conducting their comprehensive evaluations.

Another function of psychologists in the interdisciplinary approach is to provide therapy. There are a broad range of therapeutic interventions and orientations, but cognitive-behavioral therapy strategies have been found to be the most efficacious in confronting the myriad of problems experienced by chronic pain patients (Gatchel & Turk, 1999). In particular, multimodal cognitive-behavioral methods of pain management have been demonstrated to be effective in helping to manage chronic pain. This includes such things as relaxation training, biofeedback, stress management, and positively enforced coping skills.

The physical therapist is crucial in conducting the pretreatment evaluation of physical functioning. This typically includes assessment of gross motor skills, coordination, range of motion, and muscle strength. Proper pretreatment evaluation of a patient’s physical functioning helps to inform treatment goals and establish a baseline of functional ability. Additionally, it provides the physical therapist with an opportunity to provide some initial information to the patient regarding the interconnected nature of physical functioning and pain-related disability. In the context of workplace disability, physical therapists can help the patient address pain-related physical limitations in work-site performance. The overall physical therapy goals are to help guide the physical rehabilitation and to encourage patients to reassert control over their physical abilities and handle pain in a more effective manner.

Finally, within interdisciplinary rehabilitation, patients themselves have an important role by investing time and energy in active participation in their therapy, as a part of the treatment team. Decision making is collaborative, and patients are encouraged to actively participate in each treatment modality, communicate openly with treatment providers, and mutually support other patients in the interdisciplinary program within group therapy. Patients are encouraged to communicate their treatment goals to the various providers on the team, which facilitates discussion and formulation of an individualized plan within which some disciplines may be utilized more than others. For example, if a patient demonstrates a minimal need for nutritional consultation, this component may be altered or eliminated, although other program participants may choose nutritional intervention as part of their treatment plan.

Interdisciplinary Program Structure

Prior to admission, interdisciplinary pain program patients must go through a pretreatment screening process. The patient will initially meet with a staff physician, who will evaluate the patient’s presenting pain complaints. Additional assessments by a psychologist and physical therapist may be recommended to determine appropriateness for program inclusion. It is important to assess all relevant biopsychosocial factors that may be relevant to the patient’s clinical presentation. Formal assessment instruments may include the Minnesota Multiphasic Personality Inventory II, the Beck Depression Inventory II, the Pain Disability Questionnaire, the Roland-Morris Disability Questionnaire, and the Oswestry Disability Index. Appropriate evaluation facilitates a more systematic conceptualization of factors that need to be addressed in therapy and ensures success in overcoming specific patient barriers to functional recovery.

An individualized treatment plan that considers the individual needs of the patient is derived from the intake assessment, and it includes the specific goals identified by the patient. If vocational abilities are disrupted, for example, functional restoration may be the interdisciplinary treatment of choice. Any significant barriers to treatment, within the context of the biopsychosocial model, should be identified, and methods for managing these issues incorporated into the treatment plan (Gatchel et al., 2002). Physicians, psychologists, and physical therapists each have a role in identifying and evaluating potential barriers and then communicating them to other members of the interdisciplinary team. Vocational counselors must assess return-to-work barriers. Most injured workers who present for interdisciplinary rehabilitation are temporarily or totally disabled from work. Those who are still working, but having difficulty performing their job tasks, may be required to request time off from work in order to complete the interdisciplinary program.

Not all patients may be good candidates for an ID program. Exclusionary criteria may include severe mobility problems, psychotic disorders that have not been stabilized, or the patient’s unwillingness to commit to the requirements of the program. In some cases, other treatment modalities may be indicated to address the specific treatment needs of the patient. If an interdisciplinary program is recommended, the patient is presented with a proposed program-start date. Some clinics offer “rolling” start dates, while others prefer to have specifically circumscribed start and end dates, with a consistent program cohort across the duration of the program. Most interdisciplinary programs last a minimum of 4 weeks. Sanders, Harden, and Vicente (2005) suggest a time-limited model that is capped at 20 session days. Once the program begins, research data collection may continue during the program, as well as for a period of time after it has been completed.

Central to most interdisciplinary programs are physician visits, individual cognitive-behavioral therapy, group therapy, and physical therapy. Physician visits focus on medical evaluation, monitoring, medication management, and medically based pain-relieving procedures, such as injections (e.g., lumbar epidural steroid injections), spinal cord stimulation, radiofrequency ablation, and transcutaneous electrical nerve stimulation (Harrington, Dopf, & Chalgren, 2001). Pain-relieving transdermal patches, as well as topical solutions like pain relief creams, may also be prescribed. Medication management may include opiates, anticonvulsants (Jensen, 2012), and antidepressants. There is a high comorbidity of chronic pain with psychiatric disorders, particularly depression. If there is a staff psychiatrist, he/she will offer psychiatric evaluation and psychotropic medication prescriptions to interdisciplinary program patients. Of course, the availability of these interventions varies by clinic and physician specialty and training.

At the conclusion of the interdisciplinary program, the patient’s final scheduled appointment is with the staff physician. This is a “checkout” to review progress achieved, answer remaining patient questions, and establish a plan for follow-up. If the patient has not attended sufficient sessions to complete the program, the patient and physician will meet to discuss the problems that led to limited compliance. A new plan might then be formulated to include alternative treatment options or program completion. Otherwise, the patient may be discharged as “noncompliant.”

Returning to the program itself, in addition to physician visits, patients are also scheduled to participate in individual cognitive-behavioral therapy, provided by the program psychologist, at regular intervals during the program. While not every patient in an interdisciplinary program necessarily has a comorbid psychiatric “disorder,” the interplay between a patient’s chronic pain and psychosocial functioning is critical to recognize and address, using cognitive-behavioral therapy and/or medication. The pretreatment psychosocial evaluation will help to inform individual treatment goals. Psychosocial distress (with particular emphasis on the impact of the patient’s pain) will be discussed between the patient and therapist in order to collaboratively establish goals and expectations for treatment. Psychologists must be mindful of the time-limited model of interdisciplinary programs and subsequently confirm that the proposed goals can be accomplished within the established time frame, or whether treatment may be continued with the same psychologist following the conclusion of the program. Again, a cognitive-behavioral treatment (CBT) approach is most effective, and the goals that are established should be consistent with the overall philosophy of interdisciplinary treatment.

Typically, CBT sessions last between 50 min and 1 h, adjusted to fit the needs of the patient and to accommodate the daily schedule of the program. Some programs include daily individual CBT sessions, while others limit them to one to two times per week. Most interdisciplinary programs contain between 10 and 16 total individual sessions (Gatchel & Turk, 1999). Although the timing and structure may demonstrate some variation, the essential components of CBT interventions are to encourage patients to develop better coping strategies in dealing with chronic pain (McCracken & Turk, 2002). Relaxation training, guided imagery, diaphragmatic breathing techniques, and biofeedback are used to help the patient cope with pain-related processes more effectively. CBT helps the patient to identify problematic thinking patterns such as catastrophizing that contribute to emotional distress or functional impairment.

Group therapy sessions are scheduled at least one to two times per week. Each group session is led by a clinician, usually a psychologist, and lasts between 1.5 and 2 h. The timing and duration depends on the particular clinic’s established program schedule. Group therapy includes a psycho-educational component (i.e., informational material regarding cognitive, emotional, and behavioral aspects of the pain experience). An interactive “pain school” curriculum is also often used. The group leader educates participants about pain issues such as coping, pacing, and stress. The patients may be presented with material outlining and describing the biopsychosocial model to facilitate awareness of these factors. Using the didactic opportunities presented in group therapy, group members may then discuss the information with each other and with the group leader. Members of the group are encouraged to share personal experiences and apply them to the provided psycho-educational material. This serves to reinforce the educational lessons by personalizing the material and facilitating consideration of the impact of pain on each participant’s own quality of life.

Group therapy also allows patients the opportunity to interact with others experiencing pain-related conditions. Appropriate feedback from group members can be a powerful tool in helping patients identify and address concerns about pain, function, treatment, and psychosocial issues, such as sex, childcare, or return to work. Mutual problem solving is facilitated by the group leader. Practical solutions elucidated during group therapy often provide participants with new ideas with which to address problems or open up discussion of previously unconsidered problems.

Within an interdisciplinary program, both group and individual therapy may facilitate other program-based treatments. For instance, patients may express notable fears about particular medical procedures recommended by the staff physician. By recognizing and exploring this fear in therapy, the patient’s hesitation to participate in the recommended treatment can be addressed. Group therapy serves a similar purpose, in that other group members may offer practical and creative solutions that have been helpful for them. It offers a chance for group members to acknowledge their treatment-related concerns, as well as a forum for stress reduction and problem solving.

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