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4 Articles in Volume 2, Issue #1
Effective Approaches: Multidisciplinary Pain Management
Head Pains
Managing Pediatric Pain
Mastering Medications

Effective Approaches: Multidisciplinary Pain Management

In this study, patients with severe chronic pain undergo treatment at an atypical multidisciplinary clinic.

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.

  1. Psychological assessment;
  2. Individual and group psycho therapy;
  3. Vocational assessment and counseling;
  4. Ergonomic assessment and training;
  5. Stress management;
  6. Relaxation therapy;
  7. Family counseling;
  8. Nutrition counseling;
  9. Drug counseling;
  10. Hydrotherapy (exercise in the water);
  11. EMG, EEG, and TEMP biofeed- back;
  12. Massage therapy;
  13. T’ai chi and chi kung;
  14. Yoga;
  15. Acupuncture and acupressure;
  16. Hypnosis;
  17. Medication management;
  18. 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.

Research Hypotheses

The hypotheses for this study are as follows. When pre-treatment measures are compared with post-treatment measures: 1) patients will report post-treatment decreases in pain intensity; 2) patients will report post-treatment increases in ability to cope with pain; and 3) at least 80 percent of patients will report a high level of satisfaction with the treatment program.

Methods Subjects

We selected 33 consecutive patients who volunteered to participate in the study, and who were available for testing. All patients attended the 20-day, multidisciplinary outpatient pain program from October 1999 through March 2000, because conventional biomedical treatment had failed to significantly relieve their pain. The participants were 61 percent male and 39 percent female. Of the sample, 36 percent were white, 24 percent black, and 39 perent Latino. Patients ranged in age from 29 to 58, with a mean age of 44. Most subjects had suffered job injuries and reported chronic back pain, but some reported neck, arm, shoulder, or lower extremity pain.

Eighty-seven percent of participants had a high school education or less, and 46 percent worked in semi-skilled blue collar or unskilled/laborer jobs. All subjects were experiencing at least two of the following psychosocial stressors, which contributed to the persistence of their chronic pain: depression, anxiety/worry, poor childhood experiences (e.g., abuse), financial difficulties, marital/ family problems, limited social support/ social isolation, lack of coping skills, other stressors (see Table 1).

Instruments

The subjective and variable nature of pain presents important challenges for measurement. Because pain is a complex phenomenon, no universally accepted means of measuring it have been developed.16,17 The numerous current methods of assessing pain can be grouped into three basic categories: self-report measures, measures of pain behaviors, and measures of physiological concomitants of pain, such as overall physiological arousal or associated muscle tension.17

As discussed above, pain is a subjective experience affected by psychosocial factors, and it demonstrates a highly variable association with tissue damage, physiological abnormalities, and overt behavior.1,15,16 Thus, the best measure of pain still appears to be a patient’s self-report.1 In general, pain instruments can be classified as measuring the categories of intensity, frequency, and duration, but some researchers have classified pain instruments as assessing intensity, affect, and distribution of pain in the body.17,18

For several reasons, we wanted to assess subjects with short, easily understood questionnaires. First, because most subjects had a high school education or less, we were concerned about the reading level of questions. Also, English was the secondary language for some of the Latino participants. Second, most subjects reflected the severest types of chronic pain, so their attention level might have waned if they were asked to complete lengthy questionnaires.

Therefore, because we were concerned about the reading level and length of many available pain instruments, we developed our own instruments with which to assess subjects. Using mostly numeric rating scales, we designed several brief, readable instruments that provide a global assessment of subjects’ status. This was accomplished in the spirit of the Global Assessment of Functioning Scale (GAF) found in the DSM IV. The GAF is a highly useful way of summarizing a subject’s global level of functioning.

Similarly, our goal was to compare subjects’ global status before and after treatment in the areas of pain intensity, pain frequency, coping ability, satisfaction with the treatment program, cost of physician visits for pain complaints, and work status. So, we developed the PPM Pre-Treatment Questionnaire (a subjective measure of pain intensity, pain frequency, coping ability, and work status); the PPM Post-Treatment Questionnaire (a subjective measure of pain intensity, pain frequency, coping ability, satisfaction with the treatment program, and work status); the PPM Telephone Follow-Up Questionnaire (a subjective measure of pain intensity, pain frequency, coping ability, and work status); and the Patient Health Care Utilization for Pain and Work Status Inventory (an objective measure of the cost of physician visits for pain complaints and work status).

Table 1. Subjects’ Demographic Characteristics
Total Number of Subjects 33
Gender  
Male 61%
Female 39%
Race/Ethnicity  
White 36%
Black 24%
Latino 39%
Mean Age 44
Mean Years of Education 10.69
Occupation  
Unskilled or Laborer 23%
Semi-Skilled Blue Collar 23%
Skilled Blue Collar 32%
Clerical 13%
Professional 10%
Mean Number of Years with Chronic Pain 2.78
Mean Number of Years Since Subjects Last Worked 2.70
Subjects Reporting Two or More Psychosocial Stressors 100%

Procedures

The present study has a one-group pretest-posttest, mixed factorial, quasi-experimental design. The PPM Pre-Treatment Questionnaire was completed by subjects on the first day of the program, before they underwent any treatment. The PPM Post-Treatment Questionnaire was administered on the 20th and final day of the program, just before subjects were discharged, and the PPM Telephone Follow-Up Questionnaire was administered by investigators over the phone at an average of 50 days post-treatment. A second follow-up questionnaire was administered to a subset of 14 subjects at an average of 102 days post-treatment. We had hoped to complete the Patient Health Care Utilization for Pain and Work Status Inventory to determine patients’ work status and cost of physician visits for pain complaints for up to three months pre- and post-treatment. Clinic staff was to telephone patients’ insurance companies and employers to obtain this data.

However, the subjects had been out of work for an average of 2.7 years, and most had not had adequate time to find a new job after completing the pain program. Thus, we did not assess work status in this subject sample, but did measure current work status in a separate random sample of 50 subjects who had completed the pain program between summer, 1997 and summer, 1999. In addition, insurance companies refused to release information concerning subjects’ cost of physician visits for pain complaints.

Results

All three research hypotheses were confirmed. ANOVA revealed significant overall decreases in pain when pain levels as measured on the post-treatment and first follow-up questionnaire were compared with baseline, pre-treatment pain levels (p

When compared with baseline, pre-treatment pain levels, 52 percent of subjects reported less pain on the post-treatment questionnaire, 45 percent continued to report less pain on the first follow-up questionnaire, and 50 percent still reported less pain on the second follow-up questionnaire.

A significant difference was found between ability to cope with pain as measured on the pre-treatment questionnaire and ability to cope as measured on the post-treatment questionnaire (p

On a scale of 0-10, with 10 being “complete satisfaction” and 0 being “no satisfaction,” 83 percent of subjects rated the 20-day program as a 7 or above; the mean rating was 8.1.

In a separate random sample of 50 patients who completed the 20-day program between summer, 1997 and summer, 1999, 34 percent currently were employed.

Discussion

Overall, results from this study are encouraging, because many multidisciplinary pain programs have difficulty attaining treatment success with extremely chronic pain populations. Moreover, biomedical interventions alone usually fail, because they ignore the numerous psychosocial contributors to long-term, persistent pain.

Subjects in the present study reflected the most extreme types of chronic pain and psychosocial characteristics. On average, they had experienced chronic pain and had been out of work for almost three years, they had less than 11 years of formal education, and 46 percent worked in semi-skilled or unskilled/laborer jobs. Also, 100 percent of subjects reported two or more significant psychosocial stressors, including 27 percent who reported poor childhood experiences such as abuse or an alcoholic parent. Research indicates that chronic diseases, including chronic pain, are significantly more prevalent among people of lower socioeconomic status, especially persons who have not completed high school, adjusted for race, gender, age, and access to medical care.7 A low level of formal education may make people more vulnerable to psychological and behavioral risk factors that predispose them to development of chronic disease and poor outcomes. Contributory psychological and behavioral risk factors include smoking, diet, compliance and efficiency in utilizing medical services, life stress, lack of education about lifestyle contributions to disease and stress development, and coping resources, including adaptability, problem-solving capacity, and ability to cope with stress.7 A large percentage of these patients need to be treated over a period of months (instead of a period of weeks), and systematically taught adaptive coping skills that parents and educators failed to teach them when they were children and adolescents.

Racial differences in pain perception are not a novel finding. Other studies have found that blacks have lower pain perception and reaction thresholds than some other racial/ethnic groups.16

The finding that ability to cope with pain was higher on the follow-up questionnaires than on the post-treatment questionnaire was an intriguing result. Perhaps information learned in the 20-day program was cumulative and took time to incorporate into daily living. Thus, as subjects began to incorporate more pain information and coping skills into their daily routines, their coping ability increased over time.

The discovery that 34 percent of former patients sampled were employed was a dramatic finding, considering that after 12 weeks off work following development of pain, the probability of returning to work may be as low as five percent.19 The patients in this random sample had been off work for a minimum of 24 weeks when they attended the 20-day chronic pain program.

Finally, we were surprised that subjects’ insurance companies refused to release information concerning cost of physician visits for pain complaints, even though they already released other confidential information about the subjects. For years, some insurance companies have complained that there is a paucity of data supporting the cost-effectiveness of multidisciplinary chronic pain programs. Yet, when subjects’ insurance companies were contacted to provide data that would support or refute the contention that our pain program is cost-effective, they refused. In the future, we will have to rely on data provided by referring physicians (which they send to insurance companies for reimbursement) concerning patients’ cost of physician visits for pain complaints.

Last updated on: January 28, 2012
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