It’s pretty clear that for many people with chronic pain, medications just don’t cut it (Turk, Wilson & Cahana, 2011). This leaves very few options available to the many people who fail to respond – and by and large, it means either soldiering on, or getting help from an interdisciplinary pain management programme. And while there are a hardy few who do cope well on their own (roughly 30% of those with chronic pain), there are a mighty lot who could do with a hand. The problem with this is trouble accessing suitable pain management programmes.
For some reason, interdisciplinary pain management has been gradually falling into space. There are fewer and fewer programmes around (Loeser, 2006), an d various people have argued that they’re expensive, cumbersome, people don’t like going to them (they’re not sexy and they take hard work!), and they’re hard for clinicians who work in them.
Amongst the arguments around interdisciplinary programmes are discussions about how long or intense a programme should be (the “dose”), the content and what is or isn’t necessary within them, and personnel or who should or shouldn’t be involved. I thought I’d take a little look at some of these arguments.
First of all, what should go into a programme?
Unfortunately, although there is a great deal of literature on interdisciplinary programmes, what is far less clear is the content. Content varies widely from well-documented manualised treatment protocols like some of the ACT or acceptance-based programmes, to rather loosely combined topics. Some programmes have no hands-on treatment, while others include massage, hot pools and mud packs (truth!). What is common about programmes are the following (at least from what I’ve deduced):
- information about pain mechanisms and psychology (appraisals, mood etc)
- exercise, usually focusing on graded reactivation
- activity management (how much activity, daily planning, “pacing”)
- goal setting and problem solving
Other topics may or may not be incorporated including returning to work, intimacy and relationships, communication, pain behaviour – you name it, you’ll probably find it.
I do have opinions (yes, I know I always have opinions!) about content of programmes, but at this stage I think it is truly opinion not researched evidence-based. With ongoing arguments about what “pacing” is, how it should be conducted, the purpose of it, it’s not surprising to me that there doesn’t appear to be much consistency nor consensus about the content. It surprises me, though, that in all the literature on pain management and coping that there is so little known about what “works” within a programme. It almost makes me wonder whether it’s the content that matters – perhaps there’s something else working?
The next question is whether results differ for people who are diligent about using what they’ve learned in a programme as opposed to those who don’t. Again, I think the literature is a bit murky.
If you ask Prof Mike Nicholas, he’d say that adherence was a predictor (Nicholas, Asghari, Corbett, Smeets, Wood, Overton, Perry et al, 2012). But as we know, there is an enormous difference between what people do when they’re observed and what they do when they’re on their own, and Nicholas and colleagues studies of adherence were carried out during the programme rather than estimating what people do “in the real world”.
This means there is no clear evidence that people use coping strategies in daily life after a pain management programme. In fact, Curran, Williams and Potts showed in 2009 that there was very little difference in outcome between those who self-reported adhering to strategies, and those who didn’t.
Programme Intensity or “dose”
The programmes I’ve worked on came in three main forms. The first was the “traditional” three week full day programme where a group of people (usually up to 8) attend daily from 8.30 to 4.30 for three full weeks, with a follow-up around six weeks later. The second was a six week part-time programme, where people (again a group of around 8) attended two to three half days a week for six weeks, then returned for a six week follow-up. Finally, the third variant was an “individualised” programme for roughly 12 weeks, attending alone usually once a week. This latter format became the default for most people attending the Service where I worked, and I’m not sure why.
The situation is that we don’t know how much of a treatment is needed, although there are some suspicions that the more intense a treatment (ie the more sessions, the closer together) the better the outcome, and that programmes of less than 100 hours duration are not particularly helpful.
The problem with examining “dose” is that definitions are very unclear – what might be “multimodal”, as in Waterschoot and colleagues (2014) definition can range from two types of approach to many different approaches, as long as they include medical or physical or psychological or a combination. Additionally, outcome measures differ greatly, with some programmes measuring psychological outcomes, some using “real world” outcome such as returning to work, and others incorporating physical performance measures.
Once again, I’m not sure we have any answers.
Who should facilitate programmes?
Naturally, among the discussions is the question of which health profession should be involved in facilitating such programmes. And once again the situation is pretty murky, but I think there is sufficient evidence to show that it’s not a matter of which discipline, but more about teamwork (especially maintaining a consistent team rather than changing personnel), and about using a cognitive behavioural approach. So, it’s possible to find nurses (Broderick, Keefe, Bruckenthal, Junghaenel et al, 2014); clinical psychologists, physiotherapists, rehabilitation advisors and medical pain specialists (Nicholas, Asghari, Sharpe, Brnabic, Wood, Overton et al, 2014); occupational therapists (Shannon, 2002; Persson, Andersson & Eklund, 2011; Keogh, McCracken & Eccleston, 2005) – and a whole bunch of others including social workers, psychotherapists, massage therapists, vocational counsellors and so on.
If you ask any of the professionals involved, I can bet they’ll argue for their own type of professional – but seriously, I graduated in 1983, and I think I’ve learned one or two things since then – so perhaps my original training is less influential than whether I use what the literature finds useful.
Actually, I don’t think there is any conclusion that I can draw from the literature as it stands today. I think there is so much more to learn about what works for whom, and why, and when and how chronic pain management programmes should be used. Pragmatism probably rules in most areas. If a programme is perceived to be difficult to organise, hard to staff, tiring for clinicians and expensive, I don’t think it’ll be supported – and I think that might be the case for interdisciplinary pain management programmes.
It’s high time some of the ingredients within the “black box” of interdisciplinary pain management got unpacked and sorted, lest we see more and more single discipline, usually biomedical approaches dominating – and we know that biomedicine just doesn’t address the “what it is like” to have lived with chronic pain.
Broderick, J., Keefe, F., Bruckenthal, P., Junghaenel, D., Schneider, S., Schwartz, J., Kaell, A., Caldwell, D., McKee, D., Reed, S., & Gould, E. (2014). Nurse Practitioners can effectively deliver Pain Coping Skills Training to osteoarthritis patients with chronic pain: A randomized, controlled trial PAIN® DOI: 10.1016/j.pain.2014.05.024
CURRAN, C., WILLIAMS, A. C. & POTTS, H. W. 2009. Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13, 178-188.
Kaiser, U., Deckert, S., Kopkow, C., Schmitt, J., & Sabatowski, R. (2014). Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Waterschoot et al., Pain 155 (2014) 179-189 PAIN® DOI: 10.1016/j.pain.2014.06.002
KEOGH, E., MCCRACKEN, L. M. & ECCLESTON, C. 2005. Do men and women differ in their response to interdisciplinary chronic pain management? Pain, 114, 37-46.
LOESER, J. D. 2006. Comprehensive Pain Programs Versus Other Treatments for Chronic Pain. The Journal of Pain 7, 800-801.
NICHOLAS, M., ASGHARI, A., CORBETT, M., SMEETS, R., WOOD, B., OVERTON, S., PERRY, C., TONKIN, L. & BEESTON, L. 2012. Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain? European Journal of Pain, 16, 93-104.
PERSSON, D., ANDERSSON, I. & EKLUND, M. 2011. Defying aches and revaluating daily doing: Occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18, 188-197.
SHANNON, E. 2002. Reflections on clinical practice by occupational therapists working in multidisciplinary pain management programmes in the UK and the USA. Australian Occupational Therapy Journal, 49, 48-52.
TURK, D. C., WILSON, H. D. & CAHANA, A. 2011. Pain 2: Treatment of chronic non-cancer pain. The Lancet, 377, 2226-35.
Waterschoot, F., Dijkstra, P., Hollak, N., de Vries, H., Geertzen, J., & Reneman, M. (2014). Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: A systematic review PAIN®, 155 (1), 179-189 DOI: 10.1016/j.pain.2013.10.006