Which patient for which program?

A guide for clinicians on selecting pain programs for patients.

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Published: 2023. Next review: 2028.

Multidisciplinary pain management

Multidisciplinary pain management programs are conducted by a team of trained health professionals who work together in an interdisciplinary manner.1 They aim to teach chronic pain patients self-management strategies to:

  • enhance function and independence
  • reduce reliance on formal healthcare
  • promote wellbeing.2

Group multidisciplinary pain management programs

Group pain management programs typically consist of 5-10 sessions, ideally with a physiotherapist, clinical psychologist, clinical nurse consultant/specialist and with, or in coordination with, a pain specialist.3 They need to consider the biological, psychological, social and environmental factors contributing to the patient’s pain. The program should be based on a comprehensive assessment and tailored treatment plan that addresses any identified problems and contributors.

When selecting patients, discuss their expectations and:

  • individual circumstances
  • personal goals
  • role in the program
  • mood severity
  • medication dependency
  • risk of chronicity.

It is essential that the patient agrees with the assessment results and understands how the program will help them achieve their goals. Be sure to give the patient the opportunity to discuss the program and provide informed consent before attending.2

Individual programs

It is crucial to tailor the program to an individual’s characteristics and needs, rather than adopting a one-size-fits-all approach. Evidence suggests that more intensive programs (around 50-100 hours over 3-6 weeks or longer) are best for severely depressed and disabled patients. Less intensive programs (around 20-50 hours over 4-8 weeks) are equally effective for patients with low levels of depression and disability.4-6

Individual programs have been effective in addressing fear- avoidance, using techniques such as relaxation training or desensitising.7-10, 13 Trials using home-based programs by nurses and web-based programs have also been successful.1, 11, 12, 14

Pre-assessment education

Pain services often encounter people who are not familiar with pain concepts and services. This can lead to inappropriate referrals and potential waste of resources.

To address this, pre-assessment pain education programs have been developed to assist patients to get ready to participate in a full program. These educational programs can vary in duration and depend on observational trials within the service, available resources, and initial assessment of the patient. However, patients with higher levels of disability and depression may need these comprehensive programs. This particularly applies to those who rely on opioid medication.

Pre-assessment education is a chance for patient engagement and can include:

  • explaining the ‘whole person’ approach
  • outlining the clinic process and management of expectations
  • describing the difference between acute and chronic pain
  • triaging patients for multidisciplinary assessment and/or appropriate group program
  • discussing the role of medications and other self-management strategies.
Average pre-assessment education description
Median time allocated 3 hours
Staff members allocated 2 allied health workers
Median group size 15 (including carers)  
Timing Before the multidisciplinary assessment
Patients that may need special consideration Culturally and linguistically diverse consumers, older people, people with disabilities and people who fit the criteria for priority one assessment

More information on patient suitability for group-based, pre-assessment education:

Selection of patients for different pain programs

    In the following tables, multiple problem areas refers to the patient having more than one of the following:

    • sleep problems
    • mood problems
    • avoidance of multiple activities
    • interpersonal conflict at home or work
    • poor pain coping strategies.

    Decisions about suitability for various  levels of intensity need to be flexible and assessed on a case-by-case basis. Use the criteria as a guide rather than as absolute specifications. The underlying principle is to match the type of program to the patient's needs, characteristics or presenting problems.

    Program types:

    Indicative numbers relating to scales or medication dosage are presented as a guide only, but have been derived from normative data, clinical experience and the literature, and interpreted for the clinicians designing pain program.

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    Individual patient

    Format

    • 1-10 sessions, 30-60 minutes each, 1-2 weeks apart
    • Total time: 30 minutes-10 hours

    Staff and resources

    • One or more staff: Practitioners with appropriate skills, working in a coordinated way, e.g. clinical psychologist, plus physiotherapist, plus general practitioner or specialist
    • Consulting room

    Suitable patients

    Patient questionnaire scores
    • Pain intensity: <6 on Brief Pain Inventory (BPI) intensity score
    • Pain interference: <6 on BPI interference score
    • Depression: <13 on depression item on Depressions and Stress Scale (DASS)
    • Self-efficacy: >35 on Pain Self Efficacy Questionnaire (PSEQ)
    • Catastrophising: <25 on Pain Catastrophising Scale (PCS)
    Reliance on medication
    • Low: simple analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, anxiolytics, low level anticonvulsants, sleeping tablets

    Specific problem area
    • Single area such as sleep disturbance, anger, low acceptance or poor activity pacing which can be targeted effectively in a limited number of individual sessions
    Patient not ready for group program
    • Patient unwilling or unable to participate in a group program
    • Patient needing to work up to high intensity program, e.g. undergoing supervised withdrawal from medications, extreme low level of activity, excessive bed rest or severe depression

    Low intensity group

    Format

    • 5-10 sessions, 1-3 hours each, over 4-6 weeks
    • Total time: 8-20 hours

    Staff and resources

    • Two or more staff: may include psychologist, physiotherapist, occupational therapist or nurse. Coordinated with medical management
    • Group room: exercise area, white boards and chairs

    Suitable patients

    Patient questionnaire scores
    • Pain intensity: <7 on BPI intensity score
    • Pain interference: <7 on BPI interference score
    • Depression: <13 on depression item on DASS
    • Self-efficacy: >35 on PSEQ
    • Catastrophising: <20 on PCS
    Reliance on medication
    • Low: simple analgesics, NSAIDs, antidepressants, anxiolytics, low level anticonvulsants, sleeping tablets
    Multiple problem areas
    Other responsibilities
    • Need to maintain attendance at work, school or family duties
    • Unable to attend more intensive program

    Medium intensity group

    Format

    • 2 part days of 3 hours each or 1 full day of 6 hours per week for 4-6 weeks
    • Total time: 24-36 hours

    Staff and resources

    • Two or more staff: May include psychologist, physiotherapist, occupational therapist or nurse. Coordinated with medical management
    • Group room: exercise area, white boards and chairs

    Suitable patients

    Patient questionnaire scores
    • Pain intensity: 6-8 on BPI intensity score
    • Pain interference: 6-8 on BPI interference score
    • Depression: 14-20 on depression item on DASS
    • Self-efficacy: 20-35 on PSEQ
    • Catastrophising: 20-30 on PCS
    Reliance on medication
    • Low to moderate: simple analgesics, NSAIDs, antidepressants, anxiolytics, low level anticonvulsants, sleeping tablets. Low to moderate regular opioid use: 20-50 mg morphine equivalent daily or 6-8 Panadeine Forte
    Multiple problem areas
    Functional ability
    • Reasonably functional and reasonably active, e.g. working or minding children
    Other responsibilities
    • Need to maintain attendance at work, school or family duties
    • Unable to attend more intensive program

    High intensity group

    Format

    • 3-5 days per week for 3-5 weeks with planned follow-up
    • or 5 hours per day twice per week with structured homework between sessions
    • Total time: 50-100 hours

    Staff and resources

    • Three or more staff: may include psychologist, physiotherapist, occupational therapist, nurse and psychiatry in paediatrics. Specific medical input for medication and education
    • Group activity room: exercise area, white boards, chairs and refreshments

    Suitable patients

    Patient questionnaire scores
    • Pain intensity: >7 on BPI intensity score
    • Pain interference: >7 on BPI interference score
    • Depression: >20 on depression item on DASS
    • Self-efficacy: <20 on PSEQ
    • Catastrophising: >30 on PCS
    Reliance on medication
    • Low to high: simple analgesics, NSAIDs, antidepressants, anxiolytics, low level anticonvulsants, sleeping tablets. Higher regular opioid use: >50 mg morphine equivalent.
    Multiple problem areas
    Functional ability
    • Limited physical function

    Guiding principles

    When the person has been deemed suitable to participate, these principles apply to all types of pain management program (PMP).

    1
    A person/family-centred approach should determine timing of and suitability to participate in an appropriate pain program.
    2
    Structured, time-limited interventions tailored to the individual are aimed at improving pain self-management.
    3
    Admission to a PMP should follow appropriate multidisciplinary assessment to confirm suitability and identify relevant individual goals.
    4
    Inclusion and exclusion criteria for all types of pain program should be specified with little reliance on personal opinion, e.g. making predictions.
    5
    Where relevant to participation in the program and potential benefit, inclusion and consideration of the support network, including family, carers and healthcare providers, is essential.
    6
    A PMP may be part of a series of interventions, but these should be planned to ensure effective engagement of the person and the consistent support of their treatment providers.
    7
    A pain management program is typically conducted by a multidisciplinary team that works in an interdisciplinary way.1
    8
    Broad program goals include reduced interference in daily activities due to pain (or return to normal lifestyle despite persisting pain); improved mood; improved personal relationships; and reduced use of healthcare services. Specific, person-centred goals should also be identified before admission.
    9
    Some reduction in pain severity is possible, but is not the primary goal.
    10
    Mechanisms for promoting the maintenance of gains over the long term are key features of these programs. This could include the involvement of significant others, e.g. families.
    11
    Evaluation of outcomes in terms of achievement of specific goals and common functions, such as disability, mood, pain, healthcare use is essential. For example, follow up at one, three, six or 12 months after the pain management program.
    12
    PMP require staff with appropriate skills and training. Provision must be made to ensure this is the case for all staff.
    13
    To date, the most consistent evidence is that a background understanding and knowledge of cognitive behavioural management therapies, principles and methods is appropriate for all participating staff.
    14
    Recognition that co-morbid conditions, e.g. spinal cord injuries, diabetes, post-traumatic stress disorder, major depression, personality disorders, can complicate participation in a PMP. They need to be addressed on an individual basis, e.g. with individual therapy in conjunction with PMP.

    References

    1. British Pain Society. Recommended Guidelines for Pain Management Programmes for Adults. British Pain Society, London, 2007. Available from: https://www.britishpainsociety.org/static/uploads/resources/files/book_pmp2013_participant.pdf
    2. Elbers S, Wittink H, Konings S, et al. Longitudinal outcome evaluations of Interdisciplinary Multimodal Pain Treatment programmes for patients with chronic primary musculoskeletal pain: A systematic review and meta- analysis. Eur J Pain. 2022;26:310–335. DOI: 10.1002/ejp.1875
    3. Hayes C, Hodson F. A whole person approach to persistent pain: from conceptual framework to practical application. Pain Med. 2011;12(12):1738-1749. DOI: 10.1111/j.1526-4637.2011.01267
    4. Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. Br Med J. 2001;322:1511-16. DOI: 10.1136/bmj.322.7301.1511
    5. Haldorsen E, Grasdal A, Skouen J, et al. Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. Pain. 2002;95:49-63. DOI: 10.1016/s0304-3959(01)00374-8
    6. Marhold C, Linton S, L Melin L, et al. A cognitive-behavioural return-to-work program: effects on pain patients with a history of long-term versus short-term sick leave. Pain. 2001;91:155-163. DOI: 10.1016/s0304-3959(00)00431-0
    7. de Jong J, Vlaeyen J, Onghena P, et al. Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Pain. 2005;116(3):264-75. DOI: 10.1016/j.pain.2005.04.019
    8. de Jong J, Vangronsveld K, Peters M, et al. Reduction of pain-related fear and increased function and participation in work-related upper extremity pain (WRUEP): effects of exposure in vivo. Pain. 2012;153(10):2109-18. DOI: 10.1016/j.pain.2012.07.001
    9. de Jong J, Vangronsveld K, Peters M, et al. Reduction of pain-related fear and disability in post-traumatic neck pain: a replicated single-case experimental study of exposure in vivo. J Pain. 2008;9(12):1123-34. DOI: 10.1016/j.jpain.2008.06.015
    10. Flink I, Nicholas M, Boersma K, et al. Reducing the threat value of chronic pain: A preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain. Beh Res Ther. 2009;47:721-728. DOI: 10.1016/j.brat.2009.05.003
    11. Buhrman M, Gordh T, Andersson G. Internet interventions for chronic pain including headache: a systematic review. Internet Interventions 2016;4:17-34. DOI: 10.1016/j.invent.2015.12.00
    12. Eccleston C, Blyth F, Dear B, et.al. Managing patients with chronic pain during the COVID-19 outbreak considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain. 2020;161:889-93. DOI: 10.1097/j.pain.0000000000001885
    13. Linton S, Boersma K, Jansson M, et al. A randomized controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-related activities. Eur J Pain 2008; 12:722–730p. DOI: 10.1016/j.ejpain.2007.11.001
    14. Dorresteijn T, Zijlstra G, Van Haastregt J, et al. Feasibility of a nurse-led in-home cognitive behavioural program to manage concerns about falls in frail older people: a process evaluation. Res Nurs Health. 2013;36(3):257-70. DOI: 10.1002/nur.21534
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