Philosophy and Evidence Base

  1. Purpose

The NSW Health Minister assigned a taskforce in 2011 for the management of persistent pain with the aim of easing the burden and improving the quality of life of people suffering from persistent pain whilst helping them re-enter the workforce (Health.nsw.gov.au, 2012). This is the purpose behind Northern Pain Centre’s Pain Management Program.

 

  1. Background

It has been established that Pain Management Programs based on cognitive behavioural therapy and active self-management principles are part of the gold standard in treatment of people suffering from persistent pain and the myriad physical, psychological and social issues associated with it (Williams et al., 2012; Longmore & Worrell, 2007).

Evidence shows that intensive Pain Management Programs of 90+ hours over three or more weeks reduce health care utilisation, enable appropriate use of healthcare resources and reduce presentation of pain-related issues to hospitals and emergency departments.  In addition, subsequent referrals to specialist services and increasing medication usage in participants with moderate-severe chronic pain and depression are also decreased (Williams et al., 1996; Turk & Okifuji, 1998; Stack et al., 2013).

Evidence suggests that a multidisciplinary pain program can positively affect participants with persistent pain whom are re-entering the workforce, by reducing time to return to work and helping participants remain employed (Karjalainen et al., 2001, 2003; Guzmán et al., 2001).  Pain programs that promote effectively dealing with vocational issues may also increase the ability of participants to re-engage in the workforce, allowing for an increase in self-esteem, physical health and reduction in financial concerns (Waddell & Burton, 2006).

The NSW Health Minister taskforce established in 2011 highlighted that programs that allow people to self-manage their pain, provide an effective alternative to reliance on opioids for chronic pain; whilst minimising pain-related chronic disability and depression.  These programs can provide return to work support for injured workers whose pain is persistent.

Chronic pain after work-related injury is a common barrier to return to work.  Patients frequently experience low mood, sleep disturbance, social isolation and financial disadvantage as a result of both chronic pain and associated disability.  Managing a sustainable return to work plan under these circumstances is a challenging and complex task, and is most effectively co-ordinated by applying an intensive multidisciplinary approach.

In March of 2019, Pain Australia published the “Cost of Pain in Australia”, which highlighted the benefits gained by increasing access to multidisciplinary care for chronic pain management.  The findings of this report were that multidisciplinary care “improved work attendance, reducing absenteeism by seven days per person per year compared to standard care. Overall, multidisciplinary pain management can save $9,582 per person per year.”

 

  1. Mission Statement

We at Northern Pain Centre believe in the invaluable role of a pain education program in the management of persistent pain.  Our program will teach patients the skills and strategies for addressing the multiple factors that influence their pain experience.  The basis of this evidence-based program is to encourage an active self-management approach to restore a sense of purpose and quality of life to participants (Morley et al., 1999; Guzmán et al., 2001; European Guidelines, 2004; Koes et al., 2006; Hoffman et al., 2007; Williams et al., 2012).

We believe that the integration of procedural interventions, pharmacotherapy and specialised allied health involvement allows participants to achieve a restoration of physical function, improved mood and sleep and overall optimism about the future.  High-quality evidence suggests the effectiveness of similar pain management programs worldwide (Morley et al., 1999; Guzmán et al., 2001; European Guidelines, 2004; Koes et al., 2006; Hoffman et al., 2007; Williams et al., 2012) and there is evidence to suggest early enrolment can reduce future disability (Linton, 2000, 2005; Pincus et al., 2001).

Our program will not exclude participants with ongoing surgical and/or procedural needs and/or moderate opioid intake, as evidence suggests delaying access to pain education and CBT-based active self-management can be detrimental to improving healthcare outcomes (Health.nsw.gov.au, 2012).  Participants will not cease or limit the use of implanted neuromodulation devices, as evidence suggests the pain relief provided by these should be utilised to restore functional goals and manage pain severity (Kapural et al., 2016).

Our Empower team acknowledges that one of the greatest challenges of living with chronic pain is the difficulty in returning to work.  We will devise a sustainable return to work plan with the participant, insurer, rehabilitation provider, return-to-work coordinator and employer, and ensure mutually agreed upon goals for the future are achieved within the program.  We will work with participants to return to meaningful employment, which provides a sense of purpose, self-confidence and financial security.

Attending and participating in a group learning environment confers the specific benefits of reducing the perception of isolation in the persistent pain experience, and enhancing social interaction with like-minded individuals.  These group interactions can assist with building confidence and ongoing peer support beyond the duration of the program itself.

Northern Pain Centre is committed to delivering a high-quality multidisciplinary pain program that is tailored to individual participant goals and needs over a wide range of timeframes and intensity levels as recommended by the Chronic Pain Management Programs (PMPs) – A consensus view (ACI, 2013).

 

  1. Core Values
  • To align with the current recommendations for Pain Management Programs by the Chronic Pain Program Working Group (ACI, 2013)
  • To provide a Pain Management Program that aligns with our current evidence-based multidisciplinary treatment pathway for patients with persistent pain.
  • To deliver high quality outpatient care to our patients.
  • To harness the collective experience of our highly qualified, trained and experienced Pain Specialists to achieve a restoration of function, improved quality of life and sense of purpose in participants.
  • To optimise return to meaningful employment for participants.
  • To measure and evaluate outcomes, monitor patient feedback, engage stakeholders for the ongoing improvement of our program and service delivery

 

  1. The Enrolment Procedure
  • “New” Participants will be referred from GP or a secondary Specialist (e.g. orthopaedic surgeon, neurosurgeon, rheumatologist).
  • Assessment for inclusion will be completed by the Pain Specialist at Northern Pain Centre. This will allow treatable pathology to be excluded, a discussion of treatment options and an introduction of the concepts of persistent pain and pain management.
  • All participants will be assessed by a member of the multidisciplinary team prior to admission to the program to ensure realistic goals for the program, an understanding of the purpose of the program and ensure the participant has the right motivation in attending the program (Britishpainsociety.org, 2013).
  • Participants will be given an outline of their role and responsibility in attending and engaging in the program.

 

  1. Participants

We consider patients with the following features eligible for and likely to benefit from Empower Pain Management Program, in accordance with the ACI criteria identified in 2013:

  • Patient reports a significant impact of pain on their sleep, mood, physical function, relationships, ability to work and participate in daily activities
  • Medication Usage >50mg Morphine equivalence
  • Issues with following areas:
    • Avoidance of activity
    • Interpersonal conflict at work and/or home
    • Poor pain coping strategies

 

The following list describes our exclusion criteria:

  • Patients where a definitive treatment is more appropriate to ensure appropriate pain reduction.
  • Participants unable to communicate in the language the program is conducted in.
  • Participants with uncontrolled psychosis/mood disorder or limiting cognitive impairment.

 

All participants will be given an overview:

  • Where the program will be located
  • Access by public transport and parking
  • The time and date of the program
  • The purpose of the program
  • What the program will cover
  • Who will be presenting the content
  • The learning outcomes from the program
  • The responsibilities of the team

 

  1. Goals of program

The use of an individualised CBT-based active self-management program:

  • To improve participants understanding of persistent pain
  • To promote changes to behaviour and thinking despite pain
  • To improve physical function and promote activities of daily living
  • To improve goal-setting, problem-solving and coping skills
  • To implement strategies where possible for return to work and addressing obstacles
  • To encourage the use of strategies including mindfulness and relaxation for managing persistent pain and enhancing “psychological flexibility”
  • To encourage stretching, hydrotherapy and exercise for ongoing persistent pain management
  • To reduce pain severity and the suffering associated with this
  • To address comorbidity and complications to participation and adjust the program where necessary

 

  1. Program Structure
  • 3-week intensive pain program, 5 days per week, 6.5 hours per day
  • Include classroom-based education sessions focusing on neuroscience education, graded activation guided by participant return to work goals, cognitive therapy methods and methods to encourage acceptance, mindfulness and psychological flexibility.
  • Include graded exposure to activity using hydrotherapy, physical exercises, strengthening exercises and stretching.

 

  1. Group format
  • Group size to be from 6-12 participants
  • Content will be tailored to meet the individual needs of the enrolled participants.

 

  1. Delivery

Sessions will be run by experienced members of Northern Pain Centre’s multidisciplinary team. These sessions will be interactive to encourage learning opportunities and normalising the experience of pain within the group and use workbook activities to promote self-identification and management.

  • Medical Pain Specialist run individual medication review and classroom-based education sessions (on neuroscience education; the role of surgery, intervention, radiology and medications)
  • Clinical Psychologist run classroom-based education sessions (on cognitive behavioural therapy; neuroscience education; active coping strategies; the mind-body connection; reducing catastrophic thinking; improving self-efficacy; communication skills; return to work strategies)
  • Vocational Counsellor run classroom-based education session (on navigating return to work)
  • Physiotherapist physical activity-based education run sessions (on movement; fear-avoidance; pacing; goal setting; balance, strength and endurance; core muscles; flare management; and occupational health).
  • Physiotherapist run graded exposure-based land-based exercise sessions, hydrotherapy sessions and tai chi sessions.
  • Pain management trained yoga-instructor graded exposure-based yoga sessions.
  • Registered nurse run classroom-based education sessions (on goal setting, planning and managing day-to-day activities; wellbeing and pain; nutrition and pain; sleep and pain; finding resources, support and meaningful activity).

 

  1. Facilities
  • Disability friendly venue, where ramps and lifts are available
  • Access to public transport and adequate parking
  • A class-room with adequate sound, lighting, air-conditioning, seating and space
  • An exercise area with sufficient floor space, exercise equipment and seating
  • A hydrotherapy pool with adequate heating, ramps, rails, water-wheelchair access
  • Accessible toilets and showers
  • Refreshment facilities
  • When applicable, suitable and affordable accommodation within short distance of venue

 

  1. Outcomes

Northern Pain Centre will collect outcome measurements at baseline, end of program and 6 months post program, to ensure expectations of providers are met and the program delivers effective results for participants.  Northern Pain Centre will use the same data set established as best practice by ePPOC for outcome measurement with persistent pain.  These metrics include:

  • Demographic information (including age, gender, postcode, work status, BMI, comorbidities, indigenous status, country of birth, communication needs, Australian Defence Force participation or Veteran’s Affairs status)
  • Medication use (oMEDD, major drug groups and whether patient is taking opioids on more than 2 days per week)
  • Healthcare utilisation in last 3 months
  • Treatment pathways (types of treatments received)
  • Brief Pain Inventory
  • Depression, Anixety, Stress Scale
  • Pain Catastrophising Scale
  • Pain Self-Efficacy Questionnaire
  • CARRA Body Chart

 

References

ACI. (2013). Pain Management Programs – Which Patient for Which Program? A guide for NSW Tier 3 and Tier 2 public health facilities providing pain programs. [online] Available at: https://www.apsoc.org.au/PDF/Publications/20131216_ACI13-015-pain-programs.pdf [Accessed 27 Feb. 2019].

Britishpainsociety.org. (2013). Guidelines for Pain Management Programmes for adults An evidence-based review prepared on behalf of the British Pain Society. [online] Available at: https://www.britishpainsociety.org/static/uploads/resources/files/pmp2013_main_FINAL_v6.pdf

European Guidelines for the management of non-specific low back pain (2004).  Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3454542/pdf/586_2006_Article_1072.pdf

Health.nsw.gov.au (2012).  NSW Pain Management Report. [online] Available at: https://www.health.nsw.gov.au/PainManagement/Publications/government-response-taskforce-report.pdf

Hoffman B.M., Papas R.K., Chatko D.K., Kerns R.D. (2007). Meta-analysis of psychological interventions for chronic low back painHealth Psychology 26, 1–9.

Kapural, L., Yu, C., Doust, M., Gliner, B., Vallejo, R., Sitzman, B., Amirdelfan, K., Morgan, D., Yearwood, T., Bundschu, R., Yang, T., Benyamin, R. and Burgher, A. (2016). Comparison of 10-kHz High-Frequency and Traditional Low-Frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg PainNeurosurgery, 79(5), pp.667-677.

Karjalainen K., Malmivaara A., van Tulder M., Roine R., Jauhiainen M., Hurri H., Koes B. (2001). Multidisciplinary biopsychosocial rehabilitation for subacute low back pain in working-age adults: a systematic review within the framework of the Cochrane Collaboration Back Review GroupSpine 26, 262–269.

Karjalainen K., Malmivaara A., van Tulder M., Roine R., Jauhiainen M., Hurri H. (2003). Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults.[update of Cochrane Database Systematic Reviews 2000;(3):CD002194; PMID: 10908529]. Cochrane Database of Systematic Reviews:CD002194.

Koes, B.W., van Tulder, M.W., Thomas, S. (2006). Diagnosis_and_treatment_of_low_back_painBritish Medical Journal. 332, 1430–1434.

Linton S.J. (2000). A review of psychological risk factors in back and neck painSpine 25, 1148–1156.

Longmore R.J., Worrell M. (2007). Do we need to challenge thoughts in cognitive behavior therapy? Clinical Psychology Review 27, 173–187.

Morley S., Eccleston C., Williams A. (1999). Systematic review and meta-analysis of randomised controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 80, 1–13.

Pincus T., Burton A.K., Vogel S., Field A.P. (2001). A systematic review of psychological factors as predictors of disability in prospective cohorts of low back painSpine 27, 109–120.

Stack C., Pang D., Barker E., Kothari S., Woolfenden A. (2013). Opiate reduction following Pain Management Programme. British Journal of Pain 7(2), Supplement 1, 67

Turk D.C., Okifuji A. (1998). Treatment of chronic pain patients: clinical outcomes, cost-e ectiveness, and cost- bene ts of multidisciplinary pain centersCritical Reviews in Physical and Rehabilitation Medicine, 10:181–208

Waddell G., Burton A.K. (2006). Is Work Good for Your Health and Well Being? London: TSO.

Williams A.C.de C., Richardson P.H., Nicholas M.K., Pither C., Harding V.R., Ridout K.L., Ralphs J.A., Richardson I.H., Justins D.M., Chamberlain J.H. (1996). Inpatient vs outpatient pain management: results of a randomised controlled trial.Pain 66, 13–22.

Williams A.C.de C., Eccleston C., Morley S. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD007407. doi: 10.1002/14651858.CD007407.pub3.

 

Additional supporting literature

Pain Australia: Cost of Pain in Australia final report (2019)

Pain Australia: Budget Submission (2018-2019)

Pain Australia: Annual Report (2018)

NSW Permanent Impairment Guidelines 4th Edition (2015)

GIO Workcover NSW: Return to Work Programs

NSW: Clinical Framework for the Delivery of Health Services

Recovery at Work: GAP Strategic Roundtable Report (2016)

Report: Work Injury Compendium

Report: Patient Outcomes in Pain Management

Report: Compensable injuries and health outcomes

NSW Government (2012) Literature Review: Models of Care for Pain Management.

Self-Management: A Comprehensive Approach to Management of Chronic Conditions.  Patricia A. Grady, RN, PhD and Lisa Lucio Gough, PhD. Read here

The Role of Exercise and Types of Exercise in the Rehabilitation of Chronic Pain: Specific or Nonspecific Benefits. Amy Burleson SullivanJudith SchemanDeborah Venesy & Sara Davin. Read here

The effectiveness of Tai Chi for chronic musculoskeletal pain conditions: A systematic review and meta‐analysis. Amanda Hall, Chris Maher, Jane Latimer & Manuela Ferreira.  Read here

Patterns of sickness absence a decade after pain-related multidisciplinary rehabilitation. Author links open overlay panelHilleviBuschLennartBodinGunnarBergströmIrene B.Jensen. Read here

Managing pain effectively The Lancet. Read here