Multimodal Pain Therapy in Chronic

Noncancer PainGold Standard or Need

for Further Clarification?
Ulrike Kaiser; Rolf-Detlef Treede; Rainer Sabatowski

Pain. 2017;158(10):1853-1859.

Abstract and Introduction

Introduction

Chronic pain (CP) is a frequently encountered phenomenon with considerable psychosocial

and socioeconomic consequences. Within the scope of a telephone survey, data from 15
European countries and Israel demonstrated a prevalence of CP of moderate to severe
intensity in 19% of the participants.[6] In every fifth patient the pain lasted for more than 20
years.[6] CP affecting approximately 30% of the US population has been recognized to have
significant implications for the nation's health and economy.[9,22] The most common types of
CP include low back pain, osteoarthritis, headache, and neuropathic pain.[6,22,32] Lower back
and neck pain was the leading cause of disability not only in high-income but also in low-
and middle-income countries.[25,36] Migraine and tension-type headache affected more than
10% of the world's population.[25] Treatment for patients suffering from CP was often
evaluated as being inadequate and waiting times for installment of adequate treatment were
on the order of many months or years, even in wealthy countries. The surveys did not provide
information as to whether and to what extent, more complex treatment strategies, such as
multicomponent programs were offered.[6,32]

There is growing evidence that patients with a CP-disorder require a treatment structure that consists
of a broad range of components as provided in interdisciplinary multimodal pain therapy (IMPT) (Fig.
1). This can be achieved by inpatient, day-clinic, and outpatient settings (eg, primary care-based
interdisciplinary approach) and usually requires cooperation of several disciplines and
professions.[10,61] Although the basic components of IMPT have been defined by IASP, there are major
gaps in knowledge that hinder its global implementation.[34] Because of lack of resources, national
policies, and attitudes among health care professionals, facilities for pain management including
IMPT-programs are grossly inadequate or nonexisting in many developing countries.[14,65]

Figure 1.

Treatment structure of an interdisciplinary multimodal pain therapy approach.

The aim of this topical review is to highlight the conceptual backgrounds and problems because of
incongruent definitions of IMPT. A standardization of such programs (eg, therapeutic
procedures/aims) is needed for research purposes to perform comparative clinical trials and meta-
analyses. The outcome of such a program of research will define the role of IMPT in the treatment of
patients suffering from CP.
The Beginnings of Multimodal Programs

Chronic pain was interpreted as a predominantly biomedical problem until well into the 20th
century.[5] According to this view, the origin of CP is to be found in clearly specifiable
etiologic factors (eg, injury) or is considered a pathophysiological part of another disease and
is thus interpreted as a symptom of the same. According to this concept, North American and
European pain clinics, which were established in the second half of the 20th century, mainly
provided unimodal treatment approaches (eg, nerve blocks, pharmacotherapy), focusing on
the treatment of the underlying disease or the "pain symptom".[5] However, these concepts
proved to be ineffective with an increasing number of patients suffering from CP. [16,46,52,59]
This experience resulted in a number of fundamental conceptual considerations that
ultimately led to a new understanding of the phenomenon of "chronic pain."

Starting after World War II John J. Bonica established the first multidisciplinary pain facility
consisting of an anesthesiologist, neurosurgeon, orthopedist, psychiatrist, and radiation
therapist at the Tacoma General Hospital, Tacoma, Washington.[5,59] In his opinion, a team
approach was much more efficient and effective than traditional medical practice.[5]
Furthermore, he regarded CP as a disease entity that could be autonomous of its etiological
origins and did not have to be only a symptom of an underlying disease.[43]

Later on, a number of basic conceptual considerations were developed and discussed. In the
late 1960's and early 1970's Fordyce and Sternbach demonstrated pathological changes and
pain-illness being independent variables requiring careful evaluation of both of them.[7] They
emphasized a behavioral approach because of the hypothesis of psychological factors
contributing to CP apart of being "psychopathological".[1820,66] In 1977 the concept of
"biopsychosocial model" was published by G.L. Engel.[12] He described that the subjective
perception of the patient being sick, often does not correspond with the presence of objective,
physical findings. This dilemma was later strikingly verified by examples of "radiological
findings in nonspecific low back pain" and "incidental meniscal findings" on knee magnetic
resonance imaging.[13,29,70] In both groups of patients a firm relationship between imaging
findings and pain was missing. Engel suggested an integrated view of the patient based on
somatic as well as psychosocial aspects of chronic diseases, always to be seen and ultimately
diagnosed and treated in the biopsychosocial context of the patient.[12]
Previous Efforts Towards Standardization

A first major report on the development and experience of multidisciplinary pain clinics and
pain centers was given in Bethesda, Maryland, at a conference of the National Institutes of
Health in 1980.[44] Important basic requirements of multidisciplinary treatment were
emphasized such as a holistic approach, an interdisciplinary assessment, a cooperative,
nonadversarial cooperation of the treatment group with the patient, and the patient's own
active role in achieving an improvement.[44] Addison summarized, that the "importance of the
integrated, multidisciplinary approach cannot be overemphasized".[1] Mayer and Gatchel
proposed the concept of "functional restoration" in the treatment of patients suffering from
chronic back pain. A key tenet was that physical as well as mental performance should be
restored by an integrated approach provided by a multiprofessional team consisting of
physicians, psychologists/psychiatrists, nurses, physical, and occupational therapists.[22,46]
Here, the primary goal was no longer the sole reduction of pain, but the improvement of the
individual's perceived impairment, disability, and functional limitations.[16] Passive
interventions were largely eliminated and replaced by "activating" procedures (eg, graded
increases in activity level and exercise) that gave the patient an active role in managing
his/her own condition. Despite the wide therapeutic offer, sports medicine treatment
approaches predominated in these programs; traditional psychotherapeutic treatments were
primarily aimed at dealing with obstacles to improvement and crisis intervention. Principal
ideas of this interdisciplinary concept were integrated into the ICF-Classification
(International Classification of Functioning, Disability and Health) by the World Health
Organization. Physiological function, activity, and participation in daily living were key parts
of this model in addition to pain.[35]

In 2008, Sullivan suggested to broaden the conceptualization of pain focusing more on

behavioral components. He argued that pain behaviors are not just a consequence of a
sensory problem but should be regarded as an integral and independent component as well.
Key components of the "biopsychomotor pain concept" were communicative, protective, and
social response pain behaviors.[67] Once again, these considerations acknowledge that CP is a
"complex multidimensional construct".[63]

Even though all of the pain concepts (eg, biopsychosocial, biopsychomotor) and treatment
approaches (eg, functional restoration, behavioral programs) are slightly different, the
common denominator is, that CP has to be regarded as an illness requiring a multicomponent
treatment approach.

Soon, these conceptual and structural considerations were taken up internationally primarily
in North America, Western Europe, and Australia. In several countries IMPT is accepted as
the optimal approach in the management of CP and finds increasing acceptance and
dissemination.[41,53,61] A growing number of facilities providing pain management programs,
which are based on the ideas as aforementioned, can be recognized worldwide.[61]

A systematic investigation referring to IMPT in noncancer patients defined this type of

therapy consisting of 4 components (medical, behavioral therapy, physical reconditioning,
and education) and follows therefore closely the definition of functional restoration
published earlier by Mayer and Gatchel.[37] A large body of studies reported on approaches
with all 4 components, delivered by a multidisciplinary team of physicians, nurses,
psychologists or other behavioral therapists, and a physical or occupational therapist. The
need for a fully integrated team approach across all disciplines was emphasized. If one
component was left out or provided outside the program the effectiveness of the program was
diminished.[56] Furthermore, the advantages of integrated treatment by simultaneously
addressing multiple influences on CP were highlighted. A task force of the German IASP
chapter defined structure and process parameters for pain clinics and especially in IMPT
since 2009 and has contributed to a formalization of this approach.[3,4,8,58] These
recommendations go even beyond previous reports in demanding regular team meetings as a
basis for an integrated diagnostic and therapeutic process. Effectiveness and cost
effectiveness of this application of IMPT has been demonstrated.[41]

A well founded diagnosis that provides the indication for multicomponent programs is an
important prerequisite for implementation of IMPT as a standard. To address the complex
character of CP adequately, a definition of chronic pain with somatic and psychological
factors (F45.41) has been introduced into the German version of ICD-10 in 2009[49,55] and
biopsychosocial factors will be considered in the new ICD-11-classification as well.[68]
Furthermore, the indication should be confirmed by an interdisciplinary assessment
performed by a pain physician, psychotherapist/psychologist, and physiotherapist in an
integrated diagnostic collaboration.[8,57]
Structural features adopted by the German task force are consistent with the IASP-criteria for
multidisciplinary pain centers.[34] Both have therefore contributed independently to the
creation of conditions for the integrative approach of IMPT. However, in contrast to
Germany, an internationally consented definition of "IMPT" is still lacking.

The Need for Standardized Definitions for Research Purposes

There is still a failure to distinguish between interdisciplinarity vs multidisciplinarity, with

these terms often used interchangeably.[10,23] Table 1 summarizes several descriptions of
multicomponent therapy programs and reveals overlaps in definitions as well as distinctions.
Similar concepts[4,22] have been labeled differently (multimodal vs interdisciplinary), whereas
the description of other concepts is imprecise and important components not being defined
(eg, therapy aims, structural requirements). An overlap among the roles of the professions can
be found. Furthermore, sometimes obligatory professions have been defined while in other
instances no statement is provided on this issue. Referring to the concept of the
biopsychosocial model, a minimum of 3 involved professions representing all dimensions is
widely considered to be mandatory.[3,4,23] The need for regular team meetings and structured
interprofessional communication is felt to be mandatory as well,[3,4,23] as this has been proven
to be an important prerequisite for therapy success.[56] The quite different understandings of
IMPT and the pitfalls of an unprecise definition became obvious in 2 systematic reviews,[42,72]
where the authors stated that the heterogeneity of the included approaches hampered
systematic analysis. Kamper et al. highlighted problems related to the absence of a consistent
definition of multidisciplinary.[42] Although a consistent definition is highly desirable,
differences inherent in national health care systems and the stratification of treatment
approaches in terms of treatment goals and (different) patient populations have to be
considered as well. Conceptual work seems to be necessary to obtain interpretable results of
specific therapy effects of IMPT in CP.

Effectiveness of Interdisciplinary Multimodal ProgramsMeasurability and Problems

In recent decades, clinical and health services research has provided numerous, substantial
international contributions to our understanding of IMPT-programs. Particularly in relation to
back pain, numerous studies have provided a basis for a large number of systematic reviews
eg,[30,42,50,69,72] This is also true for systematic reviews of nonspecifically defined pain
subpopulations.[17,60] Furthermore, numerous studies have examined the effectiveness of
IMPT for headache,[24,71] fibromyalgia,[31,51] and for other patient populations (eg, children,
elderly, patients with a wide variety of pain diagnoses).[33,45,54,62]

At present, it seems fair to conclude that views on the definition, content, and design of IMPT
are in some cases widely diverging. This state of affairs hinders the assessment of the
effectiveness of IMPT within the scope of evidence-based medicine. Almost all previous
reviews, in accordance with their definition of "multimodal," have included studies that did
not consistently meet the criteria of "functional restoration."[46] Often, no distinction is made
between passive physiotherapy and therapy designed to activate the patient. To date, the
heterogeneity of approaches has not been well recognized or controlled for, though there is
growing recognition that such heterogeneity may contribute to varying results.[72] Large
differences can arise if, for example, only workplace-related measures are applied in
physiotherapy, because these do not specifically address the cognitive components of the
disease (eg, pain catastrophizing, or low self-efficacy). Content-related aspects of treatment
components are also neglected. Programs such as those by Smeets,[64] addressing problem
solving and operant behavioral-graded activity training, differ in the content design of
psychotherapy significantly from approaches like those of Alaranta,[2] or Monticone[47] that
primarily address maladaptive cognitive response strategies, such as catastrophizing, fear of
movement, or coping. The duration of interventions varies considerably in these studies, as
well as the intensity of the measures (from intensive psychotherapeutic or physiotherapeutic
approaches, to rather educational measures of both disciplines). Waterschoot et al. could not
answer the question regarding the significance of intensity of multimodal programs since this
requires uniformity in the implementation of the therapy content.[72] Here, all of the included
studies were heterogeneous in their choice of approaches and their implementation. [38]
Kamper et al. state explicitly the fact that no consensus is present as to how
"multidisciplinary" is construed.[42]

A clear definition is the starting point for a differentiated debate on the required and possible
contents, their composition and dose, the relevant patient groups, and adequate measuring
parameters, if any definitive understanding of the therapeutic success of IMPT is to be
obtained. The current situation allows one to draw no clear inference about what works for
whom and how all of the essential components altogether. Only a clarification of concepts,
objectives, and indication criteria would enable one to rigorously review the effectiveness of
IMPTs. The results of rigorous studies that use uniform definitions and reliable measurement
parameters would provide meta-analyses and systematic reviews with a solid foundation for
aggregations of findings and in-depth investigations.

Research Agenda

Standardization of structural and process parameters based on an internationally consistent

conceptualization of CP are important prerequisites of any research agenda on the
contribution of IMPT/multimodal programs to pain medicine. Currently, weak to moderate
effects of different multimodal programs have been demonstrated in RCTs.[42,73] However,
the next step needs to include studies that assess which treatment components (eg,
physiotherapy, behavioural therapy, educational programs) work for which type of patient
(eg, headache, low back pain) on which outcomes.[73] In the end, standardized documentation
of outcome quality (eg, consented core outcome set, validated outcome instruments) will
determine the role of multimodal programs in pain management.[11,39,40,48] Considering those
fundamental aspects, a range of research questions need to be addressed:

1. Comparison of multicomponent to unimodal approaches (what is the minimum

number of modalities?)
2. Comparison of different multicomponent approaches (eg, "mixture" of different
treatment modalities)
3. Proof-of-concept clinical trials to identify novel treatment concepts
4. Subgroup analyses (eg, identification of patient characteristics predicting
responsiveness) to adjust key components of IMPT
5. Cost-benefit ratio of IMPT compared with waiting groups or other treatment settings
6. Identification of key barriers for IMPT implementation
7. Observational studies to obtain long-term outcome results

In general RCTs on different aspects of IMPT are still needed and have to be balanced with real-world
registries and observational studies which are providing more information concerning the
generalizability of the results of RCTs.[26]

Conclusions

There are several challenges currently faced by IMPT/multimodal programs. The issue in
question is a common understanding of the concept "multimodal" that underlies any further
consideration of effect relationships. This consensus is still missing in international debates.
In addition, the design of the content implementation is still unsolved. A large number of
studies have already investigated various therapeutic interventions. For example, there are
several published trials on combination therapy with different medications or procedures
which claim to be "multimodal" but do not refer to concepts such as the biopsychosocial
model.[15,21,27,28] Even trials with a reference to functional restoration or multidisciplinary
approaches refer to "in-house" definitions and are, therefore, often difficult to generalize. The
solution could be a consistent, internationally accepted broad conceptualization, regarding the
biopsychosocial nature of CP. We suggest that the dimensions outlined in Figure 1 are
essential components of IMPT, each further specified by particular treatment, application,
duration, and profession. And we strongly suggest that investigators start working on the
research agenda outlined above.

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Pain. 2017;158(10):1853-1859. 2017 International Association for the Study of Pain