Copyright 2017 - Clinical Commissioning Groups Association

The Evolution of Multidisciplinary Services for Chronic Pain - Dr Susan Childs, Dr Bianca Kuehler & Dr Lorraine Maher-Edwards

1. The Doctor’s role 

(Dr Bianca Kuehler):

The founding-father of pain management, John Bonica devoted his career to the study of pain, establishing it as a multidisciplinary field. He believed in a team approach to the field of pain management, incorporating various specialties to treat acute and chronic pain. The first pain clinics were developed in the 1950s. The International Association for the Study of Pain (IASP) definition of pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” is derived from a 1964 definition by Harold Merskey. This definition alone should be enough to address the management of chronic and even acute pain from a multi-disciplinary approach, taking into consideration the underlying medical condition and the complexity of each patient’s emotional condition, cultural background, previous treatments and genetic components. 

 

Unfortunately, even in today’s multidisciplinary treatments the biological/medical model delivered by doctors often comes first, and then only when all the medical interventions and treatments are not successful is a referral made to the psychologists and physiotherapists. This linear model, with the patient being handed on down the line, starting with the doctor and ending with the physiotherapist, does not always benefit the patient maximally. To remedy this I think we need two adjustments. First, the patient needs to meet with all the treatment team (doctor, physiotherapist, psychologist) at the very beginning of the treatment.  Second, we need continual involvement of the doctor throughout the treatment. I have experienced in the past that the lack of interaction with doctors at the later stages of treatment can keep the patient from moving forward, for example if there are treatment side effects and problems with medications. Thus, I believe that as pain doctors we should see ourselves as one part of the multidisciplinary team, and we in fact need a circular treatment model, with each one of us playing a role, but constantly interlinking and feeding back with the rest of the team. This also applies for other team members, as patients benefit from the feedback and input from the doctors. 

 

But I want to go a step further: to provide the best treatment we also need to address the social, and even spiritual, parts of the model more effectively. We are excellent at psychology and physiotherapy but forget to see the patient in their cultural and social complexity. A recent Cochrane database systemic review looked at multidisciplinary biopsychosocial rehabilitation (MBR) for patients suffering from chronic low back pain, as this condition creates a substantial burden on healthcare throughout the world.  The outcome was clearly favouring MBR with patients having less pain, and most importantly, less disability over usual care or physical treatments alone. We have therefore developed specialist clinics and pain management programmes which are population-driven and culturally sensitive.

 

2. Evolving Psychological Models for Chronic Pain 

(Dr Lorraine Maher-Edwards): 

For more than 30 years cognitive behavioural therapies have been the dominant non-medical treatment for chronic pain. This cognitive behavioural approach is evolving and traditional CBT (Cognitive Behavioural Therapy) has been joined by so called third wave acceptance and mindfulness approaches in particular Acceptance and Commitment Therapy (ACT). 

 

The CBT model of pain is a bio-psychosocial one. Chronic Pain leads to lower activity levels and deconditioning and psychological components such as catastrophizing (predicting the worst), anxiety (contributing to muscle tension), and low mood contribute to unhelpful behavioural responses, such as social withdrawal and loss of meaningful activity. From a psychological perspective, the CBT model assumes that irrational, unhelpful thoughts are central to maintaining the vicious cycle and so the approach aims to change thinking and emotions to bring about behavioural change. CBT-based programmes have been tried and tested and have formed the cornerstone of pain management programmes (PMPs) for many years. These programmes are typically delivered in a multidisciplinary setting and are facilitated by a combination of psychologists and physiotherapists, with input from medical staff.  Sessions include cognitive restructuring (challenging unhelpful thoughts), pacing, education, behavioural activation ( increasing positively -reinforcing activities), goal setting, stretching/exercise, relaxation, sleep management and relapse prevention. PMP lengths and formats vary from residential intensive programmes of over a hundred therapy hours to shorter outpatient programmes of as little as 15 hours. 

 

The inherent ‘common senseness’  of the CBT model coupled with the ease with which it fits with current dominant problem-solving, biomedical narratives around health have likely contributed to its popularity. Undoubtedly the evidence that CBT is a useful approach to chronic pain is robust; the most recent Cochrane review (2012) included data from 35 randomized controlled trials looking at over 4,500 participants and concluded this to be the case; however, the model has its limitations.  Generally effects on pain, function and mood are small and often wane within the follow up period and the mechanism of change hasn’t been well supported by the research as hoped for. Therefore an expansion of the model to include newer 3rd wave approaches has been a welcome addition to the cognitive behavioural tradition. 

 

ACT is growing in popularity and, whilst evidence is in earlier stages, many randomized controlled trials now support efficacy for a range of mental health problems. More recently, ACT has been expanded into the domain of physical health (including diabetes, smoking, cancer, epilepsy, headache, and multiple sclerosis) and this has been led by growing evidence for ACT in chronic pain. 

 

The ACT approach moves away from emphasis on controlling, or getting rid of painful sensations and thoughts/feelings that accompany them. The natural human tendency to avoid the difficult  is seen as central to psychological suffering. People with chronic pain will often invest much effort in what are ultimately ineffective strategies aimed to avoid or control pain; such as avoiding painful activities, ruminating on causes, seeking treatment after treatment and fixating on finding a solution. These strategies usually don’t prove fit for purpose (they don’t get rid of or provide a sense of being in control of pain) and as importantly, come at significant costs both for the patient and the NHS. Important life areas are sacrificed, intimate relationships suffer, self-care and health get pushed aside and overall life is on hold, often awaiting the problem to be ‘sorted out’. In short, life gets smaller and smaller and yet pain persists. In effect, the problem-solving mind, which serves us well in the outside world, runs aground when applied indiscriminately to our internal experience. In effect, persistent attempts to control what is uncontrollable brings us to conclude that control is not the answer but the problem.  ACT aims to supports people to let go of ineffective control strategies and gain space from (relate more flexibly to) difficult thoughts and feelings; change in the content of thoughts is not required. This work is in the service of freeing patients of internal barriers to allow for movement towards what matters in their lives. Therapy is highly experiential in nature with emphasis on metaphor and in-the-moment exercises and less on didactic teaching or education. 

 

ACT for chronic pain has shown early promise with an emerging body of evidence showing improvements in pain, function and mood still present at follow-up. Whilst it’s wise to be cautious as evidence is less robust than for CBT, the model shows promise and is shedding important light on how people improve with PMPs. Interestingly research is showing that increasing acceptance of pain (willingness to experience pain and continue with important life activities) is a central process in bringing about improvements in function, psychological distress and reported pain levels. Importantly this has been shown to be the case in both ACT and CBT- based Pain Management Programmes. 

 

Therapy for chronic pain is changing and evolving with efforts well-served focusing on better understanding how and why people improve with these treatments. We like to suggest to our patients that therapy will focus on helping them to live well and move forward in their lives; as for the pain that may have to come along for the ride!

 

3. Specialist Clinics Offered at the Chelsea & Westminster Hospital 

(Dr Susan Childs): 

Every Trust has a unique and differing inward population into their services. When I came into post 10 years ago there were no pain management therapies rehabilitation programmes running so the first focus had to be upon establishing a programme that met the needs of the largest part of the population that came through our clinics.

 

This meant that we needed to provide a pain management programme for patients with moderate levels of pain with related mood issues (contrary to general belief, pain patients are often not depressed in a way that is consistent with the general understanding of the word). They have been worn down by constant painful sensations and seen a downward sliding ability to function and live their lives. They have avoided many life activities due to their pain and end up having their entire life focus around the pain. There is little room left for anything else. Over the years (and as staff levels have grown – albeit slowly) we have been able to provide for other parts of our population. We now offer a wide range of programmes and therapy input for those patients mentioned above, to patients who have chronic pain but still manage to live their lives to some degree of success (but often overdo and end up in a repetitive cycle of boom and bust) to patients who are afraid to make even basic movements associated with everyday life who need encouragement to live without fear of increasing pain.

 

Having seen this range of services evolve we were then freed up to look at the outlying groups that appear in the population of Chelsea & Westminster (or from anywhere in the country as we are a tertiary centre). There were 3 distinct groups of patients who we observed did not do well in any of our pain management settings / therapies and these were Arabic speaking women, patients who were survivors of torture and patients diagnosed with Fibromyalgia. We decided to write some specific services for these patients as their population numbers were big enough to warrant such and I piloted some specific services. Our Arabic women’s only and Survivors of Torture groups were / are the first in the UK. 

 

In terms of the Arabic speaking women, I noticed that they would often attend the first session in mixed groups then drop out of the service. Often this would mean that they would be discharged from the service (in line with hospital policy). I invited 8 of these patients to a focus group held at the hospital and they told us that they found it difficult,  due to cultural and religious reasons, to exercise in front of male group members and that they found being in a mixed sex group difficult. They also reported that they found the timings difficult due to childcare commitments. Many of the women told us that older, first generation women from other countries often had low levels of literacy in their own language. I wrote a short intervention pain management programme that offered a short time frame, with physiological messages around the importance of movement for health and how to use stretches and warm ups to “wake up” your muscles. It also contained  sessions aimed at helping them to understand that chronic pain is different from damage (or acute) related pain, alongside targeted psychological sessions around their identified issues that came out of their first session (so varied with each group). Sessions could also offer diaphragmatic breathing as way of managing in the moment pain, relaxation strategies to reduce generalised muscle stiffness, stress management, sleep issues and managing activity rates. We used an all-female team and a female interpreter. This group was unable to complete outcome questionnaires due to their literacy levels so we held a second focus group. The patients reported feeling that the targeted group had really helped them understand their pain and that it didn’t mean that they were in any kind of danger. They also said it had given them confidence to move again without fear and that many had resumed exercise groups and increased their daily activity. Dropout rates improved massively (and went from a 20% retention rate to about 95%) and have continued to show these outcomes. We would like to offer a longer group in this manner but will need to develop such as interpreting changes the amount of time available for sessions / messages.

 

Where Fibromyalgic patients were concerned Dr Kuehler and I noticed that these patients often would be long term patients within our department and attend for many treatments but often would shy away from treatments involving psychologist input. I think this is because, like many other patients, they worry that their suffering could be explained away by a mental health issue. However, as with any long term pain condition, these patients can greatly benefit from access to psychological techniques that help them to have more choice over habitual reactions, thinking patterns, emotional response and behaviours that come along as a response to pain. In order to improve the uptake rate of psychologically informed services such as pain management we decided to offer a joint specialist clinic with both medical and psychological models on-board. Their first pain clinic appointment has both Dr Kuehler and myself in assessment so that the patient can be introduced to the concept of pain management without invoking the idea that they are not believed or that it could be explained away and access medications and investigations that they may need. This has allowed such patients to access pain management services from a place of understanding and having met a psychologist. This has increased pain management services uptake by these patients and hopefully decreased their attendance at GP surgeries and A&E (but sadly this is not something we can track).

 

We then built upon this model to provide our one stop multidisciplinary assessment clinic for patients who have survived torture. Dr Kuehler and I had been discussing how to manage these patients for a few years. We had noticed that this small but significant group struggled with the most basic elements of attending a pain clinic. Waiting in a busy clinic area seemed to be the first hurdle for these patients. At that time it was routine for televisions in waiting areas to show continuous news. I realised that this could be affecting the patients mental health state prior to even being assessed as it may have been vicariously re-traumatising them. I then contacted CW+ charity and they funded having the TV stream changed from news to calming images. We also changed the clinic so that it was in a quiet time for the clinic also to reduce noise and other stimulus. We added a nurse to see the patients first and to get a full medications list as well as introduce them to the concept that they would also be seen by a pain speciality doctor and a clinical psychologist. This works very well and the patients are most often more at ease with the concept and the idea of talking when they arrive in our medical / psychological clinic. From there we can easily discuss their pain medications and possible treatments alongside the concept of meeting with a psychologist. I could then arrange to meet the patient again alongside a physiotherapist if we deem it useful. This clinic moves away from the traditional cognitive behavioural therapies root of looking at the inter connections between thoughts, feelings, bodily sensations (such as pain) and behaviours and gently brings these patients towards work that embodies the ACT perspective. This can focus on any of the core principles of ACT but mainly seems to revolve around helping the patients to think about what they value in life and begin thinking with them how it might be possible to move towards these (and this is often where the specialist physiotherapist can help). It is here also that we try to introduce aspects of compassionate focussed therapy to help patients get in contact with a concept of learning some self-soothing techniques. Sadly, a high number of these patients present while in a phase of severe mental ill health and here is where we become stuck. Last year we won £10,000 to help develop this service. We desperately need a small amount of time of a psychiatrist to help these patients but have been unable to find one. This lack of psychiatric support then results in them returning to their GP’s and them often waiting long periods of time to access services. If we had access to a psychiatrist this would make this useful, first of its kind service a true one stop shop.

 

None of these specialist clinics have been provided on a new budget either, we looked at the way these patients were currently accessing services and changed them to suit need. We would love to spread this message (and would be happy to share ideas and how we went about these clinics) with NHS Trusts as they target population need and offer voices to those whom often go unheard in large hospital populations.

Content provided by Dr Susan Childs: Consultant Clinical Psychologist, Lead Therapist for Pain Management Services.

Dr Bianca Kuehler: Speciality Doctor in Pain, Lead Doctor for Specialist Pain Services. 

Dr Lorraine Maher-Edwards, Deputy Lead Pain Management Services.

The Chelsea & Westminster Hospital.

f t g m