Evidence-Based Rehabilitation Approaches to Acute and Chronic Pain Management

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A rehabilitation approach utilizes a combination of person-centered, non-pharmacologic, and pharmacologic strategies for pain management. A number of different healthcare practitioners participate and can provide rehabilitation to the patient, including physicians who specialize in physical medicine and rehabilitation, pain medicine, sports medicine, and clinicians in physical therapy, occupational therapy, and integrative health. Rehabilitation for a person with pain is used to provide treatment during the acute, sub-acute, or chronic phases and aims to reduce functional improvement and pain reduction. Rehabilitation is best approached using a multi-disciplinary team approach. While both pharmacologic and non-pharmacologic strategies are used in rehabilitation, the focus of this chapter will be on the use of non-pharmacologic strategies.

Rehabilitation Approach

A rehabilitation approach is a multi-faceted, multimodal approach to pain management with the goal of client independence in self-management. The approach is based on a biopsychosocial model for pain prevention, assessment, and intervention to address the multidimensional aspects of pain and provide a personalized approach to pain management (see Figure 59.1A ). The goal of the self-management program is to enhance the ability of a person to self-manage their pain through the use of physical activity, pacing, and non-drug therapies. Successful self-management requires the client to develop a mastery of transferable skills and strategies into a comprehensive self-management plan. The plan may include many aspects of pain management, such as education, movement, physical activity, and adjunctive non-pharmacologic strategies.

Figure 59.1, A, Biopsychosocial factors to consider in pain management. B, Biopsychosocial Model: Adapted from Chimenti RL, et al. (2018). 1

Multiple guidelines have been published to assist healthcare providers in developing person-centered self-management plans for the treatment of pain for a variety of painful conditions. These guidelines routinely include exercise recommendations with strong evidence. A recent review of guidelines for non-specific low back pain reviewing 15 different guidelines for care suggests a consistent agreement in the approaches with few discrepancies in practice guidelines. ^, ^, Bed rest is avoided for all stages of injury, and education, psychosocial interventions, and exercise are particularly recommended for chronic pain.

The release of the Institute of Medicine (IOM) Report in 2011, Relieving Pain in America, recommended the use of a comprehensive, interdisciplinary approach as the most effective way to treat pain. In addition, the Department of Health and Human Services National Pain Strategy in 2016 emphasized self-management approaches for the management of chronic pain as well as prevention strategies for acute and chronic pain. The National Pain Strategy also recommended the use of self-management programs.

The National Pain Strategy (United States) recommends that “people experiencing pain would have timely access to patient-centered care that meets their biopsychosocial needs and takes into account individual preferences, risks, and social contexts.” The use of a biopsychosocial approach by the clinician entails a comprehensive assessment of individuals with chronic pain to develop an integrated, patient-centered plan of care using evidence based practices. While most individuals are managed through primary care providers, referral to an interdisciplinary team should be used when needed. Therefore treatment is often multi-disciplinary and aims to alleviate pain and improve the client’s physical function and psychological health.

Ideally, rehabilitation team approaches involve multiple practitioners and can be multi-disciplinary or interdisciplinary. The approach used will likely depend on the current status of the individual with pain, geographic location, access to care, and client resources. Multi-disciplinary treatment, defined as a multimodal treatment provided by practitioners from different disciplines, is the most common and generally involves each profession working separately with discipline-specific therapeutic goals. On the other hand, interdisciplinary treatment, defined as multimodal treatment provided by a multi-disciplinary team collaborating in assessment and intervention using a shared biopsychosocial model and shared goals, is often used when unimodal treatment is insufficient.

An interdisciplinary team will vary in size and depend on the needs of the individual. Interdisciplinary team members begin with an individual or a person with pain. Physicians, physical therapists, psychologists, or psychiatrists make up the remainder of the team. Additional team members may comprise professionals from occupational therapy, pharmacy, dietetics, and complementary and integrative health fields. A key aspect of an interdisciplinary team is regular communication and meetings between team members and between the patient and team. A physician provides comprehensive examination and assessment of pain and clinical presentation, coordinates care for the individual, and provides both pharmacologic and non-pharmacologic strategies for pain relief. Physical therapy pain management focuses on improving function and movement through education, exercise, and electrophysical agents. Occupational therapists assist individuals’ participation in daily activities through the adaptation of activities, self-management, education, and exercise. Psychologists provide skills for individuals with pain to cope with emotions, feelings, and behavior related to pain, using various approaches to assist in self-management related to pain beliefs. ^, Pharmacists provide services through education and management of medications, including dosage, monitoring adverse responses to medication, costs, and decision making, to both individuals with pain and with prescribing providers. ^, Other professionals who may be part of the rehabilitation team may include care in diet, chiropractic, acupuncture, massage therapy, music therapy, recreational therapy, and vocational therapy, to name a few. Each interdisciplinary team will be unique to the individual and focus on the inclusion of professions and strategies to best meet the needs of the individual ( Table 59.1 ).

TABLE 59.1

Roles of Professionals in Rehabilitation Approach to Pain Management

Profession	Role
Physician	A medical provider or physician provides comprehensive examination and assessment of pain and clinical presentation with a specialty in musculoskeletal conditions. A physician may utilize pharmacologic and non-pharmacologic strategies for pain relief for acute to chronic pain. A medical provider assists in coordinating care through the interdisciplinary team, and a pain management specialist may provide interventional pain management procedures.
Nursing	Nursing pain management includes both pharmacologic and non-pharmacologic strategies. Nursing pharmacologic strategies include monitoring analgesic therapy, medication reconciliation, medication education, and safety. Non-pharmacologic strategies in nursing include client education regarding pain and pain management, relaxation, distraction, and assisting in the referral process for the interdisciplinary team.
Physical Therapy	Physical therapy pain management focuses on improving function and movement through education, exercise, electrical stimulation, heat and cold modalities, motor imagery, sensory re-education, and virtual reality. ^,
Occupational Therapy	Occupational therapists assist individuals with pain to participate in daily activities through adaptation of activities, self-management, education, and exercise. The occupational therapist will also include interventions for relaxation, stress management, pacing, problem solving, and communication skills training.
Psychology	Psychologists help individuals and caregivers cope with emotions, feelings, and behavior related to pain, most often chronic pain. They have a wide variety of approaches to assist in self-management related to pain beliefs (self-efficacy, catastrophizing, coping fear and avoidance, life control acceptance and psychological flexibility, sleep, negative affect, cognition, quality of life, relaxation, biofeedback, cognitive behavior approaches to pain self-management). ^,
Pharmacy	Pharmacists have an integral role in the pain self-management process. They provide services through and between the stages of pain–acute, subacute, and chronic. They provide education to individuals with pain regarding medication information, use, dosage, monitoring, and possible adverse responses to medication, costs, and decision making to both individuals with pain and with prescribing providers (ref- us pharmacist resource). As part of the interdisciplinary pain management team, pharmacists collaborate for medication reconciliation, the timing of medication if needed for interventions, and possible adverse responses to medication.
Dietitian	Dietitians play an important part of the interdisciplinary team for the individual with pain. Nutrition plays a large part in how the body responds to increased inflammation and pain. A dietitian assesses an individual’s diet and nutritional status, caloric intake, hydration, and medical and nutritional needs. They provide education for food planning that may include anti-inflammatory foods, whole foods, and nutrients to assist in the self-management of pain. Studies looking at the influence of diet on inflammatory markers show that consumption of foods high in fiber, healthful oils, fruits, vegetables, and those low in sugars, starchy carbohydrates, and unhealthful fats can reduce inflammation and disease. The dietitian includes the biopsychosocial aspects of diet and nutrition in a person-centered approach.
Other	Other professionals of the interdisciplinary team may include caregivers in chiropractic, acupuncture, massage therapy, music therapy, recreational therapy, and vocational therapy, to name a few. Each interdisciplinary team will be unique to the individual and focus on the inclusion of professions and strategies to meet the needs of the individual best.

Approach to Treatment

In a rehabilitation approach to pain, a hierarchy of care is used to treat pain. Acute pain treatment is designed to determine and treat the underlying cause, maintain or improve function, and reduce pain. Chronic pain treatment is designed to promote self-management and improve function and quality of life. Adequate treatment of pain and risk factors during an acute episode of pain is essential to decrease the potential for transition to chronic pain.

Based on pain presentation, patient preference, clinical experience, and clinical evidence, various approaches can be used in rehabilitation. The primary interventions in rehabilitation are education and exercise. Secondary interventions can include the use of electrophysical agents, manual therapy, ^, and pharmacology.

Pain Management Considerations

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