CHAPTER 24: Chronic Pain, Disability, and Interdisciplinary Rehabilitation

INTERDISCIPLINARY CHRONIC PAIN REHABILITATION

Patients with chronic pain suffer dramatic reductions in physical, psychological, and social well-being with health-related quality of life rated lower than those with almost all other medical conditions.¹ Evidence-based practice guidelines emphasize interdisciplinary rehabilitation, integrated treatment, and patient selection criteria.² Interdisciplinary pain rehabilitation programs provide the full range of treatments for the most difficult pain syndromes within a framework of collaborative ongoing communication among team members, the patient, and other interested parties.³ Unfortunately, there is considerable variability in the type of practitioners and scope of practice of “multidisciplinary” pain clinics.⁴ A recent survey in North Carolina found that only 7% met the criteria of having a medical physician, registered nurse, physical therapist, and mental health specialist.⁵

There is substantial evidence that interdisciplinary pain rehabilitation programs improve patient functioning in a number of areas for patients with a number of chronic pain syndromes, even the severely disabled.^6-9 In a seminal review, a meta-analysis of 65 studies evaluated the efficacy of treatments in patients who attended multidisciplinary pain clinics.¹⁰ Although there were limitations, the study concluded that multidisciplinary pain clinics are efficacious. Combination treatments were superior to unimodal treatments or no treatment; treatment effects were maintained over a period of up to 7 years; and improvements were found, not only on subjective but also objective measures of effectiveness, on such variables as return to work and decreased health care utilization. More recent analyses of interdisciplinary programs that use comprehensive assessments, severity-adapted or stepped-care treatments, and rehabilitation goals demonstrate significant reductions in pain along with functional and quality of life improvements.^11,12

The goal of treating patients with chronic pain is to end disability and return people to work or other productive activities. Multidisciplinary interventions do show efficacy in returning patients to work.¹³ In a long-term follow-up study, only half of the patients remained unemployed after treatment in an inpatient pain management program.¹⁴ In a 30-month follow-up study of patients with chronic pain receiving multidisciplinary treatment, employment status was predicted by the patient's desire to return to work, the perception of a job's dangerousness, and the patient's education level.¹⁵ Patients not intending to return to work were more likely to complain of their job's excessive physical demands and reported more job dissatisfaction and feelings of disability. Individualized subjective quality of life (ISQoL) is defined as the appraisal of quality of life based on personal values, desired goal attainment, and life priorities.¹⁶ Poorer ISQoL was not predicted by work status but by higher levels of distress, pain intensity, and perceived disability.

THE PAIN TREATMENT PROGRAM AT THE JOHNS HOPKINS HOSPITAL

The Pain Treatment Program (PTP) at The Johns Hopkins Hospital is a patient-centered, systematic, organized, and rational approach for restoring the benefits of health and alleviating the consequences of sickness for patients with ...