Effective Approaches: Multidisciplinary Pain Management
The purpose of this pilot study was to determine the effects of a multidisciplinary chronic pain treatment program in a group of patients who have experienced intractable chronic pain for an average of 2.8 years. This study differs from other chronic pain investigations in two ways. First, the pain clinic where this research occurred has no exclusionary criteria, so most of the patients who attend the treatment program reflect the most extreme types of chronic pain and psychosocial characteristics. When they are referred for treatment, many of these patients report severe, persistent pain despite multiple surgeries and a myriad of other biomedical interventions (e.g., nerve blocks, TENS or implanted ENS units, narcotic medication). Second, this pain program offers treatments that are not included in most other multidisciplinary pain programs. The 20-day program includes the following potential interventions.
- Psychological assessment;
- Individual and group psycho therapy;
- Vocational assessment and counseling;
- Ergonomic assessment and training;
- Stress management;
- Relaxation therapy;
- Family counseling;
- Nutrition counseling;
- Drug counseling;
- Hydrotherapy (exercise in the water);
- EMG, EEG, and TEMP biofeed- back;
- Massage therapy;
- T’ai chi and chi kung;
- Acupuncture and acupressure;
- Medication management;
- Conventional physical therapy.
Chronic Pain as a Health Care Problem
More than 50 million Americans suffer from chronic pain, resulting in an estimated 700 million lost workdays each year.1,2 Perhaps as many as 80 percent of physician visits are prompted by pain, and the financial cost for health care and lost productivity due to chronic pain has been estimated at more than $70 billion per year.1 Eisenberg3 estimates that $47 billion is expended annually for chronic back pain alone. According to Gevirtz, Hubbard, and Harpin,4 80 percent of Americans will suffer back pain at some point in their lives, and approximately 18 percent will develop chronic low back pain. Chronic back pain is one of the most expensive health problems in industrialized nations, and is the chief cause of disability in people under age 45.5 Following an initial episode of low back pain, relapses are reported in 30 to 70 percent of patients sampled.5,6
The Evolution of Chronic Pain Theory and Treatment
According to the biomedical model, which prevailed during the first seven decades of the 20th century, each disease is assumed to have a single, identifiable, physiological cause that can be assessed in clinical settings through the laboratory, a radiograph, or other high technology source.7 Because strict adherence to this model inspired development of medications that successfully treated a variety of infectious diseases (e.g., tuberculosis, polio, smallpox), many health professionals incorrectly assumed this model also could explain the etiology of chronic diseases, including chronic pain.
Based on Descartes’ 17th century dualistic perspective, the specificity theory conceives of pain as purely a physiological phenomenon, and posits that specific peripheral sensory receptors transmit pain messages from areas of injury to specific perceptual areas in the brain.8 However, by the 1960s a number of researchers realized that the specificity theory does not adequately explain the nature and manifestation of chronic pain. For example, if the specificity theory adequately accounts for pain phenomena, then procedures designed to cut or block neurons that transmit pain impulses from an area of injury to the brain should always eliminate perceived pain. However, this is not the case. Moreover, even the most advanced pharmacological and surgical interventions fail to alleviate pain consistently and permanently for many individuals. Finally, if direct transmission of pain from peripheral neurons through the spinal cord to the brain occurs, then one cannot explain how different people with the same diagnosis or objective pathology, treated with the same intervention, can exhibit variable responses.9
In 1965, Melzack and Wall proposed the gate control theory of pain, which posits that perceived pain is affected by more than just the transmission of nerve impulses from an area of injury to a specific processing area in the brain.10 This theory was a major advance in the conceptualization of pain, because it is comprehensive enough to account for the physiological aspects of pain, while also explaining how psychological factors (e.g., depression, anxiety) can mediate perceived pain. The timing of the gate control theory was ideal, because it blended well with the biopsychosocial model of disease that began gaining adherents in the 1970s.11
By the late 1970s, the gate control theory was inspiring a variety of interventions targeted at the cognitive, affective, and behavioral contributors to chronic pain such as group and individual psychotherapy, behavioral treatments (e.g., operant conditioning), and relaxation training. However, these interventions often were used unsystematically and piecemeal. Then, in the early 1980s, Turk, Meichenbaum, and Genest12 conceptualized the cognitive-behavioral approach to chronic pain treatment by synthesizing tenets of the gate control theory, evidence demonstrating the possibility of voluntary control of the autonomic and somatic nervous systems, evidence that psychological factors are capable of influencing physiological factors, and findings concerning the role of conditioning and learning factors in manifestations of pain behavior.2,10,13-15 The cognitive-behavioral perspective became the dominant paradigm for biopsychosocial pain treatment, and has remained the dominant approach until the present time.
By the late 1980s, cognitive-behavioral pain treatment was being systematically integrated with biomedical interventions (e.g., nerve blocks, TENS and implanted ENS units, narcotic medication) in multidisciplinary pain clinics. The combination of cooperating specialists varies somewhat among clinics. However, according to Gatchel and Turk,15 integration of these services and communication among the different specialists may be limited in some clinics. So, Gatchel and Turk15 began using the term “interdisciplinary” to connote an even greater level of treatment coordination in a comprehensive program with frequent communication and cooperation among health care specialists. In the 1990s, a few multidisciplinary/interdisciplinary clinics, such as the clinic where this study was completed, began offering additional interventions that once were considered untested alternative medicine modalities (e.g., acupuncture, massage therapy, t’ai chi) in the ongoing quest to provide chronic pain patients with the most effective treatment possible. Thus, the evolution of pain theory and treatment that began in the 1960s actively continues to this day.