Multidisciplinary Care in Pain Management

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Severe chronic noncancer pain is a considerable health issue, profoundly affecting not only the quality of patients' social and working lives but also impacting on healthcare providers and society as a whole. Marked changes in sleep patterns, coping mechanisms and ability to exercise, undertake normal daily tasks, and attend work and social activities are associated with chronic pain, leading to a reduction in the physical, psychological and social wellbeing of the patient. The impact of chronic pain on the individual patient is also exacerbated further by an increase in prevalence of comorbidities such as anxiety, depression and decreased physical and mental functioning.

Patients with chronic noncancer pain often require long-term care with frequent reassessment and adjustment of therapy. Usually, the situation is further complicated by the coexistence of several types of chronic pain in an individual patient, the multidimensionality of chronic pain and the fact that the pain is often therapy resistant. The biopsychosocial model of chronic pain recognises these conditions as a combination of physical disfunction, beliefs and coping strategies, distress, illness behaviour and social interactions. Since the introduction of the biopsychosocial model, treatment for chronic pain has become multimodal and multidisciplinary, with emphasis on a range of strategies aimed at maximising pain reduction, improving health-related quality of life, independence and mobility, enhancing psychological wellbeing and preventing secondary disfunction.

In order to achieve these goals, successful long-term management requires the use a range of specialist treatment that is tailored to the individual patient needs. 

Pharmacotherapy	Psychological approaches	Physical approaches	Practical approaches	Interventional procedures
paracetamol NSAIDs opioids antidepressants anticonvulsants topical treatements and others	psychological counselling    CBT self-help strategies behavioral medicine	exercise physiotherapy / physical therapy spa therapy electrotherapy using TENS and rehabilitation	patient education vocational counselling patient support groups	nerve blocks advanced technologies (e.g.,implantable intrathecal pumps, drug administration systems and spinal cord stimulation systems / neurostimulation) surgical procedures

Table 1. Multimodal treatment approaches for chronic noncancer pain

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Patients who are in chronic pain may take an active part in their own referral and treatment.

True multidisciplinary management of chronic noncancer pain requires a core team of healthcare professionals. Together, the core members should be capable of assessing and managing the medical, physical, psychological, vocational and social aspects of chronic pain. The primary care physician usually plays a central key role in this team as a gatekeeper and coordinator of the treatment strategy. He or she is responsible for the long-term management and care of the patient with chronic according to the treatment plan, and refers the patient for further treatments and assessment as necessary.

The core members of the team also vary according but typically include members from three or more medical specialities (e.g.,anaesthesiology, neurology, rheumatology, orthopaedics, neurosurgery, clinical psychology/psychiatry, nursing, rehabilitation and physiotherapy/physical therapy). In many countries, in practice, the core team consists of three physicians (primary care physicians, anaesthesiologists and psychiatrists) and nonphysicians (psychologists, physiotherapists and nurses).

According to the International Association for the Study of Pain (IASP) guidlines, if one of the physicians is not psychiatrist, physicians from two medical specialities and a clinical psychologist are the minimum required.

Within the multidisciplinary team, a coordinated approach is crucial to facilitate ongoing and effective regular comunication between all team members and consistency of message. 

Primary Care Physician: usually plays a central key rol as a gatekeeper and coordinator of the treatment strategy provided by the muslidisciplinary team. 

Anaesthesiologist/anaesthetist: uses his/her expertise to recomended and implement advanced pain management procedures ranging from peripheral or central nerve blocks to radiofrequency procedures, device implantation and other neurodestruction techniques. Anaesthesiologists have much experience using potent analgesic drugs as well as surgical or neural blockade and, in some countries, for example the UK, anaesthesia is the only specialty that incorporates advanced pain management within its training programme. 

Anaesthetists, therefore, play a central role in the assessment of pain and formulation of management plans for patients.

Orthopaedist: may be able to offer a patient corrective surgery to alleviate their chronic pain, although surgeons, other than those specialising in orthopaedics, may also be able to undertake this role. An orthopaedist may also be responsible for performing a functional examination of the patient.

Rheumatologists: are experienced in managing patients with chronic pain associated with inflammatory disease of the musculoskeletal system and connective tissue, degenerative disease of the joint and spine, and soft tissue disorders. They are also able to investigate patient for rheumatological processes. 

Neurologist: undertakes a comprehensive neurological examination of the patient and recommends appropriate therapeutic pain management options. 

Neurosurgeon: may perform spine surgery for discogenic pain treatment. 

Clinical nurse specialist: performs ongoing assessments of the patient's pain and helps to establish treatment plans and assists in interventional procedures. He/she also answers patient's questions and provides ongoing patient education by phone or e-mail and may assist in the titration of medications.

Clinical phychologist: responsible for a day-to-day psychosocial care of the patient. Implementation of cognitive behavioral therapy and psychological therapies, such as autosuggestion, biofeedback techniques and hypnosis, can also be used to help patients manage their negative  feelings due to pain in some diseases, to reduce the pain level and improve physical and emotional functioning.

Psychiatrists: play an important role in the management of patients with chronic pain who may also have a variety of recognised psychiatric disorders, including depression, analgesic overuse and addiction, and post-traumatic stress disorder. Psychiatrists may also have a role in supporting other member of the team should this be needed.

Physiotherapist/physical therapist: helps to design a treatment recovery plan incorporating a programme of activities to treat the musculoskeletal conditions that are the cause of or the result of pain. The physiotherapist may also teach the patient how to reduce the severity of pain through the use of appropriate body mechanics and exercise pacing. The ultimate goal is to maintain or improve the mobility of joints and strengthen weakened muscles.

Rehabilitation doctor: uses a behavioral therapy approach to help restore physical activities and improve the quality of life for people who have chronic pain conditions by encouraging them to learn how to manage their pain and any disability on a day-to-day basis. A rehabilitation doctor often gives advice regarding rehabilitation techniques that may be implemented to reduce pain and improve mobility of affected parts of the body. These techniques include laserotherapy, magnetic field therapy, general or local heat or cold application, iontophoresis and others.

In addition to the core members described above, a gynecologist, urologist or paediatrician may be included in the core team for the management of patients with pelvic and paediatric pain, respectively, and other approriate specialists may be included when patients with other types of chronic pain present.

Similar to the core multidisciplinary team, the wider team for the management of chronic pain coud include representatives from a number of key medical and non-medical specialities, many of whom work in the community since chronic pain affects not only somatic aspects, but also social functioning, causing a marked loss of workdays or even inability to work. Members of the wider team should be specialists in supporting the patient with chronic pain in various aspects of daily living, ensuring the ongoing management of their treatment and rehabilitation. Their services may be requested on an ad hoc consultative basis.

Pharmacist: may consult with the patient and their primary care physician to either implement or recommend a medication management plan for patients with complex medication needs to avoid any drug-drug interactions, drug misuse or an overdose risk. This may reduce the risk of side effects and improve patients' satisfaction with pharmacotherapy.

Occupational therapist: is involved in both the physical and vocational aspects of the patient+s rehabilitation. Many patients with chronic pain are unable to work and therefore the occupational therapist may help with vocational retraining and aid a smooth transition back to work.

Medical social worker: provides community support and helps with the management of stress between patients with chronic pain and their immediate family and friends.

Complementary therapist: can provide a range of therapies including acupuncture, chiropracty, hypnotherapy, massage, reflexology, aromatherapy and herbal medicine.

Deticians: can offer advice on nutrition and provide dietetic support as chronic pain can cause an appetite disturbances and limit the mobility of patients, resulting in obesity, which, in many cases, is a cause of chronic pain, especially back pain.

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Benefits of the multidisciplinary team for the patient
Comprehensive multidisciplinary management of chronic noncancer pain (multimodal and multidisciplinary management with an emphasis on a range of strategies and specialist treatments administered by a multidisciplinary team) is a clinically effective and cost-efficient approach when compared with non-multidisciplinary treatment or usual care.
Patients reffered for a multidisciplinary care are more likely to benefit from early diagnosis and treatment, and early and accurate diagnosis - to enable the early initiation of treatment - is essential for a number of underlying conditions associated with chronic pain (e.g.,rheumatoid arthritis).
Advantages of a multidisciplinary team:
- Allows a multidimensional diagnosis of chronic pain
- Avoids duplication of investigation
- Facilitates early and accurate diagnosis (if waiting times are short)
- Aids rapid initiation of treatment of treatment following diagnosis
- Ensures the availability of a wide array of treatment options ( pharmacological and nonpharmacological)
- Treatment plans are individualised
- Care is delivered in a programmed and coordinated manner
- Provides continuity of interaction and care
- Treatment offered is up-to-date, evidence based and safe
- Treatment failure can be recognised early on
- Potential for improvement in patient's quality of life, patient optimism and mood state
- Faster return to work
- Patients can have greater confidence in their treatment plan knowing that it has been developed by collaboration between different specialities
- Patients have the opportunity to discuss treatment options and ask questions of the different specialists involved in their care
- Opportunity for access to clinical trials and research programmes within the pain clinic
- Improved interdisciplinary knowledge

The IASO recommends that members of a multidisciplinary team communicate with each other on a regular basis, both about specific patients and overall development. In so doing, continuity of interaction and care is ensured, care can be delivered in a programmed and coordinated manner, avoiding duplication of investigations, and instances of treatment failure can be identified early on in the care pathway.
They are able to deal with a wide range of chronic pain types and that the treatment delivered is up-to-date, evidence based and safe.
All patients whose diagnosis is in doubt should be referred to an appropriate hospital specialist, while patients with pain that is likely to deteriorate should be considered for early referral rather than late.
Importance of adequate pain assessment
The main objectives of chronic pain management are maximising pain reduction, improving health-related quality of life, independence and mobility, enhancing psychological wellbeing and preventing secondary dysfunction.
Existing standardised methods for the assessment of pain (e.g.,Visual Analogue Scale and Numerical Rating Scale) are typically based on a subjective assessmment of pain severity and often lead to a mismatch between the physician's and patient's rating of pain severity, most notably an underestimation of pain on the part of the physician. In addition, the assessment of quality of life involves the use of questionnaires, which are very time-consuming for primary care physicians.
Not every patient with chronic noncancer pain requires complex multidisciplinary evaluation and treatment and most clinic or in-patient programmes are likely to treat patients who have pain as one of their underlying problems. However, if a patient has failed on conventional therapy and has an uncertain diagnosis despite multiple medical evaluations and treatment, they should be referred.

It is not possible for every chronic pain patient to be managed in a multidisciplinary way as the numbers are too high and healthcare resources may not always be available; therefore, it is imperative to identify which patients will benefit from this multidisciplinary approach to care. Patients who have not responded to initial therapy, and with an uncertain diagnosis despite detailed medical evaluation, should be referred to and managed by a multidisciplinary team. 

Importantly, a multidisciplinary approach to pain management provides benefits to patients, healthcare providers and society as a whole. The integration of multiple treatment modalities, including behavioral modification therapy, has resulted in considerable improvements for patients suffering from chronic pain in terms of a reduction in the use of medications, improved functional ability, increased likelihood of returning to work, improved quality of patient care and patient satisfaction, as well as reducing healthcare costs.

The Tool Kit is available online at www.paintoolkit.org and also on www.change.pain.com.

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