The article discusses chronic pain rehabilitation and describes its components and some of the core operating principles. Outcomes in chronic pain are best when multiple treatment strategies with a focus on functional restoration are employed, and this is often best done in an interdisciplinary pain rehabilitation program.
Key points
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Pain is a multidimensional experience that has an impact on a person’s ability to function.
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Functional restoration is the cornerstone of a good chronic pain management strategy.
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Interdisciplinary treatment has been well established in the literature as the most effective approach, with improvements in pain, mood, and function.
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Opioid discontinuation undertaken as a part of an interdisciplinary treatment approach often leads to improvement in pain mood and function.
Introduction
Pain is a multidimensional experience that often expresses itself as reduced quality of life and functional ability. The biopsychosocial model of the assessment and management is increasingly considered to be the best model. Interdisciplinary pain rehabilitation programs have been shown to be very effective in improving pain mood and function in patients with chronic pain. A meta-analysis of 65 studies of multidisciplinary pain rehabilitation showed significant improvement in function. Another study of 27 randomized controlled trials (RCTs) demonstrated greater effectiveness of this approach compared with no treatment, standard treatments, or nonmultidisciplinary treatment.
This improvement has been shown to persist for up to 13 years.
Although these programs are more resource intensive initially, interdisciplinary pain rehabilitation programs (IPRPs) have been shown to be effective in reducing the use of pharmacologic treatment, surgeries, implantable pain devices, and physical therapy. Among all pain-related treatments, this is the only approach that has consistently been shown to be associated with return to work, reduction in hospitalizations over a 10-year period, and meaningful, sustained improvement in pain and function.
This article will discuss the approach and principles of chronic pain rehabilitation in an inter- or multidisciplinary environment. It will also highlight the common practices across some of the chronic pain rehabilitation programs in the United States.
Introduction
Pain is a multidimensional experience that often expresses itself as reduced quality of life and functional ability. The biopsychosocial model of the assessment and management is increasingly considered to be the best model. Interdisciplinary pain rehabilitation programs have been shown to be very effective in improving pain mood and function in patients with chronic pain. A meta-analysis of 65 studies of multidisciplinary pain rehabilitation showed significant improvement in function. Another study of 27 randomized controlled trials (RCTs) demonstrated greater effectiveness of this approach compared with no treatment, standard treatments, or nonmultidisciplinary treatment.
This improvement has been shown to persist for up to 13 years.
Although these programs are more resource intensive initially, interdisciplinary pain rehabilitation programs (IPRPs) have been shown to be effective in reducing the use of pharmacologic treatment, surgeries, implantable pain devices, and physical therapy. Among all pain-related treatments, this is the only approach that has consistently been shown to be associated with return to work, reduction in hospitalizations over a 10-year period, and meaningful, sustained improvement in pain and function.
This article will discuss the approach and principles of chronic pain rehabilitation in an inter- or multidisciplinary environment. It will also highlight the common practices across some of the chronic pain rehabilitation programs in the United States.
Components of IPRPs
There is no consensus about what constitutes IPRPs. The terms interdisciplinary and multidisciplinary may be used interchangeably. Generally, these programs consists of providers from multiple backgrounds, including pain medicine, other medical backgrounds, psychologists, physical therapists, occupational therapists, addiction counselors, vocational rehabilitation specialists, and others, working together on a common treatment plan for every patient. This coordination and common treatment goal setting differentiate these programs from routine fragmented or unimodality care. The duration of programming can vary. Although patients in some programs are in rehabilitation 8 to 9 hours a day for 3 to 4 weeks, in others, patients attend 3 to 4 hours, a few days a week, for a few months. Often, patients are treated in groups.
The primary approach is addressing the factors that lead to disability and suffering. Pain behaviors are discouraged, and wellness behaviors are encouraged. Patients are usually in a stage of acceptance of their pain. The treatment is based on the physical and psychological needs of the individual patient. The flavor of the program can vary depending on the expertise of the providers. Although some providers may be pharmacologically biased, others may lean more toward psychological or physical therapy techniques. Nevertheless, the presence of all of these approaches in a coordinated fashion is common to all such programs.
Psychological factors that affect pain
Pain Catastrophizing
Multiple studies have shown that catastrophization leads to a heightened pain experience and is associated with poorer treatment outcomes. Catapstophizing is considered to be attribution of magnified negative meaning to the experience of pain. For example: “my nerves are being pulled,” or “my back was broken” may be used to describe sciatica or back pain, respectively. Catastrophization can be contagious. Catastrophization by family members has been associated with the same in adults and children.
Mood and Affect States
Like depression, anxiety and anger have been shown to impact the pain experience and treatment outcomes. Thirty percent to 60% of patients with chronic pain have comorbid depression or anxiety.
Acceptance is an important part of chronic pain rehabilitation. Patients entering these programs do better when they accept their pain and are looking to work on managing their lives better, reducing its effect on their function and moving away from a sick role to take on more appropriate role with their families, work, and friends. Patients who are looking for more tests and surgeries to cure their pain may not be appropriate candidates for treatment in this environment.
Interestingly, the only imaging correlate with poor outcome was moderate-to-severe Modic changes of the vertebral end plate, which were weakly associated with an adverse outcome.
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