The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
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
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.
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.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
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.
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
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
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.
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.
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.
Financial Support
PMP interventions require access to a range of health professionals and a space (virtual or in-person) to deliver them.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
