Multidisciplinary Pain Management Programmes for Chronic Pain
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- Show only programmes known to have been implemented in Scotland
Intervention Summary
Multidisciplinary Pain Management interventions for chronic pain involves the delivery of multimodal and multidisciplinary specialist treatments for long-term pain management. This approach is founded on the biopsychosocial model which recognises the dynamic influences of physical, psychological and social factors on chronic pain. Core components of these interventions, often called Pain Management Programmes (PMP), can include physical rehabilitation, psychological therapy, vocational approaches, patient education, medical care and pharmacological treatment. Core multidisciplinary team members can vary but typically include professionals from at least two specialities, e.g., anaesthesiology, neurology, rheumatology, orthopaedics, clinical psychology, psychiatry, nursing, rehabilitation, occupational therapy and physiotherapy. Patients who benefit from this approach to care can include those without response to initial treatment, with unclear diagnosis following medical evaluation, and/ or presenting with physiological and psychosocial impacts on functioning. PMP interventions for chronic pain can be delivered to children, young people, and adults, and are associated with significant improvements across several outcomes that include pain intensity, disability and depression.
PMP interventions are delivered in a number of Scottish health boards and across the UK.
Usability - Rating: 4
4 - Usable
The intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components
Core Components
PMP interventions for pain involves the delivery of multimodal and multidisciplinary specialist treatments for long-term pain management. PMP approaches to chronic pain management recognises the physical pathology of chronic pain, but also identifies the influences of psychological and social factors on chronic pain. PMP interventions therefore involve a comprehensive, coordinated approach adopted by a multi-disciplinary team of health care professionals (including physiotherapists, psychologists, psychiatrists, rehabilitation doctors, anaesthesiologists, and nurses). These practitioners deliver a range of strategies and specialist treatments to manage complex, chronic pain in patients, with the goal of managing their pain, re-establishing independence, promoting psychological wellbeing, and improving overall quality of life.
PMP interventions are most often delivered as group-based interventions to groups of up to ten patients, however, the elements can also be delivered to one individual. Components of PMP interventions can include;
- Physical reconditioning: e.g., exercise, physiotherapy, rehabilitation
- Practical approaches: e.g., peer support groups, occupational retraining, education/ training
- Psychological therapy: e.g., Cognitive behavioural therapy, Acceptance and commitment therapy, applied relaxation, psychological counselling, self-management strategies. The psychological component can make the PMP approach particularly beneficial to individuals who present with underlying psychological and behavioural characteristics that can impede their response to other components of the treatment
- Pharmacological therapy: (e.g., paracetamol, NSAIDs, opioids, antidepressants) Prescribed by medical professional to individual patients if needed as part of their treatment
Fidelity
Fidelity to treatment will involve adhering to the validated protocols of the therapies that constitute the multidisciplinary treatments. PMPs are often accompanied by a manual to guide delivery. The interventions should be delivered by competent practitioners, with ongoing supervision where required. There is no individual fidelity measure. Treatment adherence and practitioner competence can be monitored and evaluated using approaches such as recording or observation of PMP sessions.
Modifiable Components
Components of PMP interventions can vary as they are tailored to suit patients’ needs. Hence, the exact medical, physical, psychological, and education offered to patients can vary with their physical and psychosocial needs. An example would be PMP packages for people with Rheumatoid Arthritis, where additional education around joint protection may be included. PMP interventions can vary in their scope and focus, and in the number of healthcare professionals delivering care.
PMP interventions can be delivered in in-patient and out-patient settings that can include specialised pain centres (within hospitals) or pain clinics (e.g. in hospital clinic or non-hospital settings). Components of PMP intervention can be offered in different delivery modes that include face-to-face, teleconferencing, and/or internet-based sessions. Number of sessions included in research trials typically vary for 6-13 sessions, lasting 1.5-3 hours. The shorter PMP interventions (around 6 sessions) have been evaluated for delivery as a brief multidisciplinary intervention with impact on physical functioning. Longer group durations (standard delivery 8 -12 weeks) are associated with larger improvements in psychological functioning1. Intensive programme delivery may be associated with daily delivery or in-patient stays (Scottish programme details available here https://www.snrpmp.scot.nhs.uk/).
Children and Young People - Rating: 4
Usable - this intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components.
Adult - Rating: 4
Usable - this intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components.
Supports - Rating: 4
4 - Supported
Some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention
Support for Organisation / Practice
Implementation Support
The British Pain Society has guidelines for implementing pain management programmes. There is additional support available from the Pain Framework, National Steering Group, and from staff working within Pain management services. Many pain management programmes are supported by a manual which covers the content of the intervention.
Start-up Costs
There are no formal start-up costs, but consideration should be given to costs of securing an adequately sized venue to conduct multidisciplinary evaluations and deliver therapies to patient groups.
Building Staff Competency
Qualifications Required
Pain management programmes typically have a psychology lead given the psychological models underpinning the interventions. Core multidisciplinary team members can vary but typically include professionals representing physical, psychological and medical domains. The wider multidisciplinary team can include specialist pharmacists, occupational therapists, complementary therapist, educational therapists, medical social worker, and dietician.
Training Requirements
There is no formal training required to deliver a PMP beyond expertise in those professional disciplines. The psychologists involved in PMPs are typically trained in Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT). Further information on these interventions are available on this site. Staff are generally inducted into delivering PMPs through shadowing other professionals.
Supervision Requirements
It is recommended practice in Scotland that the psychologists involved in PMPs are in receipt of regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). It is also recommended that the team of professionals involved in the PMP have opportunities for reflective practice sessions to support the delivery of this intervention.
Children and Young People - Rating: 4
Supported - some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention.
Adult - Rating: 4
Supported - some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
The multidisciplinary approach to chronic pain management is founded on the biopsychosocial model. This model recognises the multiple dynamic interactions that exist between physical dysfunction, beliefs and coping strategies, distress, illness behaviour and social interactions, and that maintain and exacerbate the pain experience.
PMP approach therefore facilitates the delivery of a range of therapies (often drawing upon CBT and/or ACT and mindfulness models) that comprehensively target the underlying physiological, psychological, and social factors, for the purpose of managing pain, re-establishing independence, promoting psychological wellbeing, and improving overall quality of life.
Children and Young People - Rating: 5
Research Design & Number of Studies - Child and Young People (CYP) Evidence
Some of the best available evidence for multidisciplinary interventions for chronic pain management in CYP include four meta-analytic studies. These are described below;
One recent meta-analysis was conducted to determine the effectiveness of intensive interdisciplinary pain treatment for children and adolescents with chronic noncancer pain2. The review included 13 studies that involved CYP (n=2174), aged between 7 and 21 years, and who presented with severe and disabling chronic noncancer pain. The study was conducted in inpatient or day hospital settings.
Another recent meta-analysis was conducted to determine the effectiveness of intensive interdisciplinary pain treatment (IIPT) on parent mental health, cognitions and behaviours in parents of youth attending IIPT with their child3. The review included 7 studies involving 1757 participants. Participants were parents to CYP (aged 9–22 years) with non-malignant chronic pain. IIPT included coordinated interventions involving at least three disciplines, and that were delivered in inpatient or day hospital settings.
One meta-analytic study was conducted to evaluate the effectiveness of interdisciplinary interventions in the management of paediatric chronic pain4. Four studies (n=194) were included in the evaluation of the primary outcome (i.e. pain intensity). Participants were aged no more than 22 years and presented with chronic pain. Interventions were coordinated by at least two healthcare professionals of different disciplines, and delivered in inpatient or outpatient settings.
Lastly, a meta-analytic study was also conducted to determine the effectiveness of intensive interdisciplinary pain treatment in patients (aged 22 years or less) who were presenting with debilitating chronic pain5. The review included ten studies consisting of 1 RCT and 9 non-randomised studies, and involved 1020 participants with an average age of 13.9 years. Interventions were delivered by at least 3 health professionals in inpatient or day hospital settings.
Outcomes Achieved – Children & Young People
Child Outcomes
Compared to placebo, waiting-list, single disciplinary intervention, or in pre-post analysis, the following outcomes were observed;
- Significantly reduced pain intensity at post-intervention2,4 at short-term follow-up (i.e. 2-6 months)5 and long-term follow-up2
- Significantly improved disability at post-treatment2,5 short-term follow-up (i.e. 2-6 months)5, and long-term follow-up2
- Significantly reduced depression symptoms at post-treatment and at short-term follow-up (i.e. 2-6 months)5
Parent Outcomes
Compared to pre-intervention, the following outcomes were observed;
- Significantly better general mental health and psychological flexibility at postintervention, maintained at 3-months follow-up3
- Significantly reduced anxiety, depression, and parental stress at post-intervention, maintained at 3- and 6-months follow-up3
- Significantly reduced catastrophising at post-treatment and at 6-months follow-up3
Adults - Rating: 5
Research Design & Number of Studies - Adult
Some of the best available evidence for multidisciplinary interventions for chronic pain management in adults include three meta-analytic studies. These are described below;
One meta-analytic study was conducted to evaluate the effectiveness of multidisciplinary-based rehabilitation in adults with chronic pain6. The review included 27 RCTs that involved participants aged 18 years or over, and who presented with chronic noncancer pain (defined as pain persisting for a minimum of 3 months). Rehabilitation in this review included a physical component and at least one other element (e.g. psychological, social, or occupational), delivered by a team of at least 2 clinicians from different professional backgrounds.
A comparative meta-analysis was conducted to compare the effectiveness of unidisciplinary to interdisciplinary therapy in adults with chronic pain7. The unidisciplinary interventions were Acceptance Commitment Therapy (ACT) based, and the interdisciplinary interventions were founded on the ACT model. The review included 29 studies that involved participants with an average age of 50.3 years. Most participants in the included studies presented with mixed pain conditions or pain locations.
One comprehensive meta-analytic study was conducted to evaluate the long-term effects (i.e. 12 months or more) of multidisciplinary biopsychosocial rehabilitation programmes for patients with chronic low back pain8. The review included 41 RCTs that involved 6858 participants who presented with back pain for at least 3 months, and who had not responded to previous treatment. Studies were included in the review if the multidisciplinary intervention included a physical component, a psychological component and/ or a social work targeted component. Interventions were delivered by healthcare professionals from different backgrounds, and there were no requirements for professionals from specific backgrounds. The interventions were delivered in inpatient and outpatient settings, and were not limited by intensity or rehabilitation approach.
Outcomes Achieved - Adult
Adult Outcomes
Compared to usual care, physical treatment, or unidisciplinary therapy, the following outcomes were observed;
- Significantly reduced pain intensity in the short-term (i.e. ≤ 3 months after treatment)6 and at long-term follow-up (i.e. ≥12 months after treatment)6,8
- Significantly greater reduction in disability at post-intervention7, in the short-term (i.e. ≤ 3 months after treatment)6, and at long-term follow-up (i.e. ≥12 months after treatment)6-8
- Significantly greater reduction in depression at post-intervention, maintained at up to 1-year follow-up7
- Significantly greater psychosocial impact at post-intervention, maintained at up to 1-year follow-up7
- Significantly improved odds of being at work one-year post-treatment8
Fit
Values
PMPs involve the delivery of multimodal and multidisciplinary specialist treatments for chronic pain management. This approach is founded on the biopsychosocial model which recognises the dynamic influences of physical, psychological and social factors on chronic pain. There is a focus on increasing quality of life and function rather than on pain reduction.
- Does this focus align with the requirements of your organisation?
Priorities
The multidisciplinary approach to chronic pain management focuses on the multiple dynamic interactions that maintain and exacerbate the pain experience. PMP approach therefore facilitates the delivery of a range of therapies that comprehensively target the underlying physiological, psychological, and social factors, for the purpose of managing patient’s pain, re-establishing independence, promoting psychological wellbeing, and improving overall quality of life. Patients who may benefit from this approach to care can include those without response to initial treatment, patients with unclear diagnosis following medical evaluation, and/ or patients presenting with physiological and psychosocial dysfunction
- In what patient groups will the PMP approach be considered?
Existing Initiatives
- Does your service currently deliver interventions to manage chronic pain?
- Are existing initiatives practicable and effective?
- Do existing initiatives fit current and anticipated requirements?
Capacity
Workforce
Pain management programmes typically have a psychology lead given the underlying psychological models being presented. Core multidisciplinary team members can vary but typically include professionals representing physical, psychological and medical domains.
- Does your service have qualified practitioners who are available and interested in learning and delivering PMPs?
- Is there capacity to support its delivery?
Technology Support
Components of PMP intervention can be delivered without access to technology but access to video platforms for remote delivery (e.g. via teleconferencing, and/or internet-based sessions) can be useful as is access to methods of recording sessions for fidelity monitoring.
- Will PMP interventions be delivered in-person or remotely?
- Does your service have the technology to support remote delivery?
- Can your practitioners access technology to record sessions for supervision?
Administrative Support
PMP interventions can be delivered in in-patient and out-patient settings that can include specialised pain centres (within hospitals) or pain clinics (e.g. in hospital clinic or non-hospital settings). Group PMP delivery will require an adequately sized venue for multidisciplinary evaluations and therapies.
- In what setting will the PMP interventions be delivered?
- Does your service have a venue to deliver group therapy sessions?
- Can administrative supports be provided to deliver the multiple PMP components?
Financial Support
PMP interventions require access to a range of health professionals and a space (virtual or in-person) to deliver them.
- Does your organisation have the financial support to deliver a PMP intervention?
Need
Comparable Population
Patients who may benefit from this approach to care can include those without response to initial treatment, patients with unclear diagnosis following medical evaluation, and/ or patients presenting with physiological and psychosocial dysfunction. PMP interventions have been delivered to children, adolescents and adults with chronic pain (i.e. lasting at least 3 months) of mixed conditions and locations.
- Is this comparable to the population your service would like to serve?
Desired Outcome
PMP interventions for chronic pain are associated with significant improvements across several outcomes that include pain intensity, disability and depression. Improvements at post-intervention have been sustained at up to 12 months follow-up.
- Is delivering PMP interventions for chronic pain management in patient groups who may benefit from this approach a priority for your organisation?
- Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?
Key References
1. Romm MJ, Ahn S, Fiebert IPT, Cahalin LPPT. A Meta-Analysis of Group-Based Pain Management Programs: Overall Effect on Quality of Life and Other Chronic Pain Outcome Measures, with an Exploration into Moderator Variables that Influence the Efficacy of Such Interventions. Pain Medicine 2021 23 Feb;22(2):407-429.
2. Claus BB, Stahlschmidt L, Dunford E, Major J, Harbeck-Weber C, Bhandari RP, et al. Intensive interdisciplinary pain treatment for children and adolescents with chronic noncancer pain: a preregistered systematic review and individual patient data meta-analysis. Pain 2022 -12-01;163(12):2281-2301.
3. HarbeckWeber C, Sim L, Morrow AS, Murad MH. What about parents? A systematic review of paediatric intensive interdisciplinary pain treatment on parent outcomes. European Journal of Pain 2022 31 May;26(7):1424-1436.
4. Liossi C, Johnstone L, Lilley S, Caes L, Williams G, Schoth DE. Effectiveness of interdisciplinary interventions in paediatric chronic pain management: a systematic review and subset meta-analysis. Br J Anaesth 2019 August;123(2):e359-e371.
5. Hechler T, Kanstrup M, Holley AL, Simons LE, Wicksell R, Hirschfeld G, et al. Systematic Review on Intensive Interdisciplinary Pain Treatment of Children With Chronic Pain. Pediatrics 2015 Jul;136(1):115-127.
6. Casey M, Smart KM, Segurado R, Doody C. Multidisciplinary-based Rehabilitation (MBR) Compared With Active Physical Interventions for Pain and Disability in Adults With Chronic Pain: A Systematic Review and Meta-analysis. The Clinical Journal of Pain 2020 November;36(11):874.
7. Vowles KE, Pielech M, Edwards KA, McEntee ML, Bailey RW. A comparative meta-analysis of unidisciplinary psychology and interdisciplinary treatment outcomes following acceptance and commitment therapy for adults with chronic pain. The Journal of Pain 2020 May;21(5-6):529-545.
8. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJEM, Ostelo RWJG, Guzman J, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015 /02/18;350:h444.
Programme Developer Details
British Pain Society: Guidelines for Pain Management Programmes in Adults (revised 2018) https://www.britishpainsociety.org/static/uploads/resources/files/pmp2013_main_FINAL_v6.pdf