The concept of multimodal treatment in chronic pain management goes back to some of the early established pain clinics in the United States, where healthcare professionals (HCPs) from various specialties would collaborate in a nonhierarchical manner to provide comprehensive care. The formalization of the multidisciplinary pain clinic started with Dr John J. Bonica, who wrote, “…the understanding and treatment of pain would be best achieved through cooperation among different disciplines.” The contributions of Melzack and Wall and the gate-control theory of pain further shifted the pain paradigm, increasing the emphasis on cultural and psychological components of pain and the need for a multidisciplinary approach.
Multimodal pain management, as practiced today, incorporates clinical therapies such as pharmacotherapeutics and interventional techniques; behavioral management therapies such as mental health optimization, stress reduction, and structured techniques; body therapies such as physical therapy, functional rehabilitation, and sleep regulation; nutrition counseling about weight control, consumption of an anti-inflammatory and antiallergenic diet, and maintenance of a diverse microbiome; and complementary therapies such as acupuncture, aromatherapy, and use of virtual reality. Plenty of emphasis is placed on the pharmacologic treatments for pain management, but equally important is a clear understanding of the functional utilization of the various nonpharmacologic therapeutic options for pain management.
Over the years, interventional therapies have advanced from injection techniques to treat musculoskeletal and joint pains to injection and implant techniques that can target both deep and superficial neuralgias. Although many interventional therapies require formal training and certification, some are easily taught and performed in a clinic setting. Below is a list of various interventional therapies and their clinical indications.
Clinical Pearl: For in-office procedures such as plasma-rich protein injections or onabotulinumtoxinA injections for chronic migraine, consider reaching out to your local product representatives for formalized training opportunities. If you are unable to provide certain injection therapies within your practice, get to know which practices within your area can provide these treatments for your patients and establish professional relationships to support your referral base and provide your patients with better treatment options.
Behavioral and Mental Health Therapies
Experts in chronic pain management have long recognized the important relationship between physical pain and psychological health. Psychological factors can play an important role in an individual’s experience and response to pain, which can affect treatment adherence, pain chronicity, and disability status. In addition, patients with chronic pain are at increased risk for psychological distress, maladaptive coping, and physical inactivity. The US Department of Health and Human Services “Pain Management Best Practices Inter-agency Task Force Report” calls for increased access to behavioral health approaches as part of comprehensive multidisciplinary pain management. Below is a list of various evidence-based behavioral therapies for chronic pain management.
Clinical Pearl: Often, formalized therapies such as CBT or ACT may be difficult to find in a local community. Even if they are available, the cost (if not covered by insurance) may be prohibitive. Having knowledge of and access to the plethora of online services can help HCPs connect their patients with needed services and therapies. Below is a list of online resources.
Body and restorative therapies play a significant role in chronic pain management, such that (following a comprehensive assessment) positive clinical outcomes are more likely if restorative therapy is part of a multidisciplinary treatment plan. These therapies emphasize improvement in functional outcomes, help maintain functionality, and—in cases of significant dysfunction and when paired with behavioral management techniques—help to modify fear avoidance. Body/restorative therapies can be administered by physical therapists, occupational therapists, and others in various settings. Examples of such therapies include:
Clinical Pearl: Similar to behavioral therapies, patients and HCPs may face several challenges in full engagement with body/restorative therapies. These include fear of injury, financial burden, and access. As with behavioral therapies, there are a plethora of available guided videos demonstrating body/restorative therapies that patients can access from their own home and go through at their own pace. A few of those examples are noted below. With body/restorative therapies, it is important to stay mindful of a patient’s level of fear avoidance because it may affect their willingness to engage. If your patient exhibits fear avoidance of a physical approach to pain management, it is helpful to incorporate a behavioral management aspect and explore ways to address their fear, possibly through graded exposure to activities.
Somewhat of a “catchall” title of therapy, complementary/integrative therapies consist of various interventions that can be combined with the mind‒body interventions mentioned above. Techniques such as acupuncture and massage, osteopathic and chiropractic manipulation, and meditative movement therapies are effective complements to other forms of therapies. Examples of some common, and not so common, complementary and integrative therapies for pain management include:
Clinical Pearl: Reports have shown that patients seek out, engage in, and spend out-of-pocket money to participate in complementary and alternative medicine (CAM) treatments regularly. Reports also have shown that when recommended by a trusted HCP, CAM therapies are even more embraced. The role of the HCP is to help educate and guide their patients to resources that are evidence based and cost appropriate. Below are a few resources to have in your practice to help educate patients on pain and direct them to support groups.
Patient support groups:
Multimodal pain management for acute and chronic pain is the gold standard of modern pain management. When embracing the biopsychosocial model for pain management, HCPs must be empowered to make reasonable recommendations to patients and assist with accessing these rational and achievable nonpharmacologic solutions.
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