Multidisciplinary rehabilitation for chronic pain

by Dr Nathan Johns

Chronic or persistent pain is described as a daily pain that has lasted for longer than 3 months. People with chronic pain need to be treated individually due to the differences in the person, the site of pain and how the pain interferes with function, mood and participation in life’s activities. Some people are able to live life to the fullest despite their pain whilst others can be housebound.

Low back pain is one of the commonest sites of chronic pain and it is Australia’s and the world’s leading cause of years lived with disability (an inability to perform activity) (1). Neck pain and osteoarthritis are also in the top 10 conditions leading to disability.

Chronic pain affects 1 in 5 adult Australians and this increases to 2 in 5 after the age of 65 (2). In people with moderate to severe levels of pain, 30-40% report that their pain moderately to severely interferes with activities such as work and daily life (3). Chronic pain has been estimated to cost the Australian economy $34.3 billion dollars a year (4) due to health care costs, lost productivity and burden of disease. These costs even outweigh the cost of cancer care in Australia. 

Rehabilitation Medicine is the primary medical specialty treating people with disability. 

So with such a large percentage of the population affected by chronic pain, a change in treatment approach is required to help manage it. Thankfully, neuroscience research has helped deliver an improved understanding of chronic pain over the past 20 years. Chronic pain is now understood as a complex whole person condition affecting body tissues, the peripheral nerves and the central nervous system (brain and spinal cord) in a process known as central sensitization (5). As pain involves multiple body systems and affects the whole person, it is best managed with an holistic biopsychosocial model of treatment rather than with a purely biomedical (local tissue damaged) model.

Biopsychosocial pain rehabilitation encompasses the whole person affected by pain including tissue changes (such as muscle and posture), central sensitization changes (changes to the peripheral and central nervous systems), the impact of pain on function and ability, the impact of pain on work and relationships, the psychological consequences of pain as well as the biological, psychological and social barriers to recovery.

Underpinning successful treatment is the concept that, despite adequate tissue healing, pain is still experienced due to a combination of neuroplasticity of the central nervous system (5), changes in movements (6) (7) and changes in a person’s thoughts and beliefs (8). These changes affect each person with chronic pain to a different degree and skilled assessment is required to design an appropriate treatment intervention. Treatment of the whole person is enhanced by a multidisciplinary goal orientated team of clinicians including physician, psychologist and physiotherapist.


Multidisciplinary pain rehabilitation combines multiple treatments and therapies to achieve successful outcomes (9).

This includes education for the person experiencing pain to help them improve their understanding of their condition and what they can do themselves to reduce pain and improve function (10) (11). Education also helps to enhance the person’s self-management skills and this has been shown to reduce pain, reduce disability and improve mood (12).

Medical therapy is aimed at maximising benefit from medication use whilst minimising harms and long-term risks (13) (14). Lifestyle and other risk factors for pain are evaluated. Any other co-existing medical illnesses such as heart disease, neurological disease, diabetes, kidney disease and lung disease need to be assessed and managed to allow for participation in educational and exercise therapy.

Physical exercise therapy is directed by a trained physiotherapist with the aim of improving biomechanics such as posture, muscle strength and movements across a range of functional tasks (15). Exercise is also aimed at improving fitness to reduce secondary complications of pain resulting from poor activity levels (16).

Psychological interventions such as cognitive behavioural therapy (17) and mindfulness (18) can improve sleep, mood and pain. These psychological treatments also aim to reconceptualize pain and change negative thought patterns and beliefs about pain.

Not everyone with chronic pain will need all of these multidisciplinary interventions - the art of pain rehabilitation is in using neuroscience and clinical acumen to prescribe the best treatments at the right time for the right person.

References

1. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163-96.

2. Fiona M. Blyth LMM, Alan J.M. Brnabic, Louisa R. Jorm, Margaret Williamson, Michael J. Cousins. Chronic pain in Australia: a prevalence study. PAIN. 2001;89(2):127-34.

3. Australian bureau of Statistics. Characteristics of bodily pain in Australia. 2012.

4. Access Economics. The high price of pain: the economic impact of persistent pain in Australia. 2007.

5. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2-15.

6. Dankaerts W, O'Sullivan P, Burnett A, Straker L, Davey P, Gupta R. Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model. Spine (Phila Pa 1976). 2009;34(15):1610-8.

7. Geisser ME, Haig AJ, Wallbom AS, Wiggert EA. Pain-related fear, lumbar flexion, and dynamic EMG among persons with chronic musculoskeletal low back pain. Clin J Pain. 2004;20(2):61-9.

8. Sturgeon JA. Psychological therapies for the management of chronic pain. Psychol Res Behav Manag. 2014;7:115-24.

9. Kamper SJ AA, Chiarotto A, Smeets RJ, Ostelo RWJG, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review). The Cochrane Collaboration. 2014.

10. Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: systematic review and meta-analysis. Manual therapy. 2011;16(6):544-9.

11. Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-56.

12. Blyth FM, March LM, Nicholas MK, Cousins MJ. Self-management of chronic pain: a population-based study. Pain. 2005;113(3):285-92.

13. Rutjes N, E; Husni, E; Welch, V; Juni, P. Oral or transdermal opioids for osteoarthritis of the knee or hip (Review). The Cochrane Library. 2010.

14. Roelofs PD, RA; Koes, BW; Scholten, RJPM; van Tulder, MW. Non-steroidal anti-inflammatory drugs for low back pain: Cochrane Database of Systematic Reviews; 2008.

15. Vibe Fersum K, O'Sullivan P, Skouen JS, Smith A, Kvale A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. European journal of pain. 2013;17(6):916-28.

16. Lee DC, Sui X, Artero EG, Lee IM, Church TS, McAuley PA, et al. Long-term effects of changes in cardiorespiratory fitness and body mass index on all-cause and cardiovascular disease mortality in men: the Aerobics Center Longitudinal Study. Circulation. 2011;124(23):2483-90.

17. Bernardy K KP, Busch AJ, Choy EHS, Häuser W. Cognitive behavioural therapy for fibromyalgia. Cochrane Database of Systematic Reviews. 2013(9).

18. Morone NE, Greco CM, Weiner DK. Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study. Pain. 2008;134(3):310-9.  

  • Dr Nathan Johns is a Rehabilitation Medicine Physician providing chronic pain and rehabilitation management at The Rehabilitation Medicine Group in Moorabbin, Victoria, Australia. These thoughts are his own and there are no conflicts of interest to report.

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