In the previous article, Professor Michael Nicholas discusses promising findings from his early intervention program that may reduce the risk of chronic pain. The present article will consider best practice when acute-care options fail and chronic pain develops. Best practice for this purpose remains an Intensive Interdisciplinary Group Chronic Pain Program (IPP).
Let’s consider the chalky subject through the eyes of Nathan, a typical presentation.
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Nathan: A case vignette
Nathan H, a tradesman, lifted a box of parts onto the tray of his work-truck – something he has done many times. He felt a sharp pain in his lower back. He stopped working. After a few days off work he returned to normal duties only to reignite his pain. Over the next few months his GP increased his medications and finally referred him to a neurosurgeon who has offered surgery. He developed pins and needles, numbing and weird sensations in various parts of his body. Nathan has lost confidence, stopped fishing, and his close friends have stopped dropping by. His sleep is disturbed due to pain. Now, five years later, Nathan has endured assessments, scans, several medical interventions including surgery and lots of pills. His pain is different but remains disabling. He is fed up. He has small children, relationship and financial stress. Now Nathan has been referred to an intensive pain program. |
Nathan has become triggered by words such as injury, chronic pain and disability, and preoccupied with opiates, surgery, and work. He is poorly adjusted and shows strong catastrophic thoughts and fear of movement. While these factors suggest that Nathan would be an appropriate referral for an IPP, he may not benefit from IPP (see NSW Agency for Clinical Innovation clinical guidelines for more information about inclusion criteria – www.aci.health.nsw.gov.au/resources/clinical-guidelines). So what do we know about who is likely to benefit from an IPP, and what are the chances that Nathan will benefit?
Potted history
Intensive pain programs can be traced back to post World War II. John Bonica, the son of the local Mayor and an amateur wrestler ‘The Masked Marvel’, noticed the poor association between somatic pain and medical pathology (Bonica & Loeser, 2001). He graduated from medical school in 1942 and joined the army. Throughout his service, he witnessed many painful injuries and unexplained outcomes. As a result of his military experience, he learned the importance of working with a team when managing pain. However, it was not until 1990 that he was able to establish a Multidisciplinary Pain Clinic. In the following years, a range of pain programs were developed and Guzman et al. (2001), after years of work in the provision of IPPs, published their review. They concluded definitively that “intensive (>100 hours) group pain programs provide significant benefits over less intensive or individual treatments for chronic lower back pain” (p. 322).
Interdisciplinary versus multidisciplinary
Within pain programs, differences have been identified between interdisciplinary versus multidisciplinary approaches – with interdisciplinary teams thought to be more effective. Therefore it would be misleading to consider, as many have done, that these terms are interchangeable. There are important differences:
- A multidisciplinary team can be merely the engagement of different health professionals in a care plan, such as when a GP refers a patient to a physiotherapist.
- An interdisciplinary team implies that the team coordinates care through regular communication.
Interdisciplinary teams are therefore usually housed together in the same premises to enable a high level of clinical communication. An interdisciplinary team includes medical, physical, psychological and vocational/rehabilitation components. Therefore an interdisciplinary team is necessary for the evidence-based delivery of an IPP.
IPP treatment components
The content of most IPP programs is similar with common treatment components including modules on:
- Self-management
- Pain education
- Relaxation training
- Cognitive-behavioural therapy incorporating mindfulness training
- Medication rationalisation
- Sleep hygiene
- Goal setting (including vocational goal-setting)
- Physical activities
- Pacing (a structured approach to activity)
- Functional upgrading (progressive increases in functional capacity)
- Relationships and communication
Effectiveness
Anecdotally, I see patients that have attended single- or dual-discipline (physiotherapy and education) programs for the treatment of chronic pain without improvement. A review by Scascighini (2008) concluded that multidisciplinary comprehensive treatments work while monodisciplinary approaches fail
Scascighini also concluded that more work needs to look at subgroup based on person factors, to determine who is most likely to benefit from IPPs. Education is often thought to be a key factor however it may not work for everyone. A recent meta-analysis by Geneen et al. (2015) reported that there is little evidence for education alone, with the exception of a small effect from targeted neuropsychology education within the context of a multidisciplinary treatment program.
So we have a best-practice standard and a history to draw on. However, not all participants will benefit even if they are deemed appropriate. At Innervate, we run 104-hour IPPs several times a year. These comply with best-practice standards for intensive programs. We have collected data over 11 years, 630 participants and 76 groups. The data, to be presented at the International Congress for Behavioural Medicine later this year, shows that about 70 per cent of appropriate participants report benefits across a variety of functional and psychological outcomes at the one month follow-up. While this is encouraging, approximately 30 per cent do not show benefit. Our team constantly consider who benefits and why.
Who benefits?
Identifying who is most likely to benefit from participation in an IPP is not an easy question to answer. Indeed, there are multiple complexities in conducting research on IPPs (see Nicholas, 2004). However, there are a few studies which have attempted to shed light on who might benefit. Hildebrandt et al. (1997) sought to identify a causal relationship between person-level factors and benefit from an IPP in his study of 82 IPP patients, and found that improved perceived disability was the best predictor above physical, psychological or medical factors, of return to work and perceived-pain outcomes. In another study, Dip Kei Luk et al. (2010) studied 57 participants in an IPP and found that work status, absence from work and patient age were significant predictors of physical/vocational functioning. In Scascighini’s (2008) review, fibromyalgia and chronic back pain patients tended to benefit more from an IPP than patients with diverse origins of their chronic pain diagnoses.
In addition to these findings, the NSW Agency for Clinical Innovation (ACI) has published guidelines that offer criteria for inclusion in an intensive pain program. These criteria include meeting a disability threshold (>8) for the Roland Morris Disability Questionnaire (RMDQ), moderate depressive symptoms (>15) on the Depression Anxiety Stress Scales (DASS), low pain self-efficacy (<25) as measured by the Pain Self-Efficacy Questionnaire (PSEQ), and high catastrophising (>25) on the Pain Catastrophising Scale (PCS). Other criteria include such things as a person’s reliance on medication or their use of passive strategies (e.g., medications and massage), or where there are multiple areas of dysfunction (sleep, relationship and work problems etc.)1.
Unfortunately, eligibility criteria do not ensure a beneficial outcome. This brings us to the shaky ground of anecdotal or clinical experience. Ask any experienced pain clinician and my bet is that they have no algorithm for predicting who can benefit and who will not. It’s a horserace. Clinically, we have seen participants benefit most when during or just before participating in a program, they experience significant change such as their claim ends, or their relationship ends or they are retrenched from work. So, in the case of Nathan, if he learned that his insured claim will finish (payout or ceased weekly payments), clinical experience would suggest that he would be more likely to apply, participate and benefit from the IPP. The idea that a resolution of external stress during an IPP is related to greater benefit for the person receiving treatment fits reasonably well with the stages of change model by Prochaska & DiClemente (1982) which has been considered in pain management.
In summary, IPPs are not one-size-fits-all. Measures of fear of movement, confidence to manage pain, mood and psychosocial risk are currently the gold standard for determining suitability. With IPPs clearly the stand-out in terms of best practice for the treatment of chronic pain, rather than focusing our research on new non-medical treatments, it may be more prudent to focus our attention on targeting who would benefit most from IPPs. Recent research on the old stages of change model, and clinical experience, suggest that readiness to change or low resistance to change may be a frontrunner in predicting beneficial outcomes.
The first author can be contacted at [email protected]
- See www.aci.health.nsw.gov.au/resources/clinical-guidelines for additional details on best-practice guidelines.