Interdisciplinary Pain Management

“Chronic pain is a complex biopsychosocial phenomenon that may interfere with many aspects of a person’s life—ability to work, personal relationships, and both physical and mental health”.

The National Pain Strategy

“Pain for me, arrives as a complete package, and that demands a team approach.”

Patrick Wall, PhD

Introduction

Interdisciplinary pain rehabilitation incorporates a team-based approach based on a biopsychosocial model of care. This chapter will review the history of multi- and interdisciplinary care, functional restoration, and the various treatment disciplines involved that contribute to the success of chronic pain rehabilitation programs. The chapter will review the author’s interdisciplinary program in the Pacific Northwest as an example and means for a deeper discussion of program philosophy, workflow, and processes. This section also highlights additional federal, academic, and private programs across the United States, including recent outcomes studies. This overview of interdisciplinary care will help represent where a strong interdisciplinary pain rehabilitation model can be integrated into a traditional comprehensive pain center at a healthcare system level or as an independent freestanding entity. Most importantly, an explanation of specific therapeutic disciplines and treatment focus provided by physical therapy (PT) and occupational therapy (OT), pain psychology, relaxation training (RT), medical management, and pain education will be reviewed along with the unique synergies a team-based approach provides helping patients struggling to manage chronic pain decrease their pain and suffering, better understand their condition, and improve psychosocial function and quality of life.

History of Pain Rehabilitation

Pain rehabilitation and treatment of injured workers go back to the Egyptians under Ramses II in 1500 BD. The modern development of more formal rehabilitation models of care evolved after both World Wars, with the birth and advancements in the fields of rehabilitation medicine and OT. The advancement of various medical specialties and health psychology helped advance further growth in the mid-twentieth century. Dr. John Bonica championed a “multi-disciplinary” approach and formalized a consultation-based program in the early 1960s at the University of Washington. Patients were assessed by a multi-disciplinary group of providers, discussed in a multi-disciplinary manner where patient specific treatment plans and recommendations were made. Over time, the consultation-based multi-disciplinary clinic has evolved into providing more structured inpatient programs in collaboration with anesthesia, physical medicine and rehabilitation, and health psychology. Wilbert Fordyce, a psychologist and early leader in the field of behavioral medicine, joined Bonica and applied operant conditioning and behavioral interventions in what was initially an inpatient eight week program. Fordyce had a primary interest in operant conditioning principles that shape both pain-related and healthy behaviors, noting several learned processes that maintained “pain behaviors,” those behaviors that can be positively and negatively reinforced. The approach was a sharp contrast to the more contemporary practiced biomedical model, which emphasizes physiologic pathology shifting to a more comprehensive and patient-centered “biopsychosocial” approach. The biopsychosocial model, championed by George Engel, has been used to treat medical conditions, including cardiovascular and gastrointestinal disorders and infectious diseases.

In 1983 John Loeser and Bill Fordyce at the University of Washington formalized a more “structured program,” three weeks in duration, that become a model of “interdisciplinary” treatment around the word. In Texas, Mayer and Gatchel in the 1970s and 1980s incorporated “functional restoration” into the interdisciplinary model to better address deconditioning and prolonged disability associated with low back pain with injured workers. The interdisciplinary functional restoration approach focused on physical reconditioning and cognitive behavioral “crisis intervention” for helping patients manage related psychosocial problems. The functional restoration model grew from a sports medicine approach to work related injuries focusing on endurance training and strengthening. Along with cognitive behavioral support and didactic teaching about the nature of pain, pain management principles, and disability avoidance, functional restoration programs are also highly interdisciplinary, with a focus on the progressive increase in levels of task-oriented rehabilitation and work simulation, with ongoing objective and functional assessments.

These interdisciplinary functional restoration programs have been shown to improve pain and function and improve spine surgical outcomes when integrated as a “prehabilitation” intervention prior to surgery. Over time, “interdisciplinary treatment” and “functional restoration” have become terms synonymous with structured rehabilitation-based programs. Okifuji et al. described three common elements of interdisciplinary treatment, including medication management, graded physical exercises, and cognitive and behavioral techniques for pain and stress management.

With a strong emphasis on interdisciplinary care, pain program treatment facilities grew in the 1980s and the 1990s worldwide, including in the United States. Accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) and other organizations led to the growth of these programs in the United States, many of which focused on rehabilitating injured workers and returning them to work. Unfortunately, despite evidence of interdisciplinary treatment efficacy, a significant decline in CARF accredited programs began in the early 2000s. However, in the federal health system, the availability of these programs grew significantly in 2009 because of the Veterans Health Administration (VHA) Directive in response to the growing opioid epidemic and an increase in the prevalence of chronic pain. The directive outlined a new standard of multimodal pain care at all levels of clinical care by formally establishing a more seamless population-based, patient-centered, stepped care model of pain management. The model includes “Step One: Primary Care,” “Step Two: Secondary Consultation,” and “Step 3: Tertiary Interdisciplinary Care” with Step 3 helping to better the needs of more complex patients requiring advanced pain medicine diagnostics and pain rehabilitation.

In 2011, the Agency for Healthcare Research and Quality (AHRQ) published a technical brief on multi-disciplinary pain programs, which included reviews of interdisciplinary programs describing programs that provide medical therapy, behavioral therapy, physical reconditioning, and education. The AHRQ report reviewed the literature on the positive efficacy of interdisciplinary care and described the growth of programs in Europe while declining the number of programs in the United States. Efforts to curb the growing drug overdose epidemic and increased reported prevalence of chronic pain and high-impact chronic pain have led to greater support for comprehensive pain care, including interdisciplinary care. In the near future, the development of value-based care models and payer systems in the United States healthcare system may offer an opportunity for greater integration of a continuum of team-based approaches to improve comprehensive pain care. An interdisciplinary care model is the foundation of this care system.

Legislative and Federal Initiatives Highlighting the Need for Interdisciplinary, Team-Based Care

Initiatives and legislative acts supporting multi- and interdisciplinary care include the National Pain Strategy, the Centers for Disease Control and Prevention (CDC) Chronic Opioid Management Guideline, the National Academies of Medicine report, Health and Human Services (HHS) Pain Management Interagency Task Force report, and National Governor’s Association report.

The 2010 Patient Protection and Affordable Care Act (ACA) required the Secretary of HHS to coordinate through the Institute of Medicine (IOM) a strategy to increase awareness and recognition of pain as a significant public health problem. The IOM report included several recommendations for improvements in pain spanning data collection, education, research, and delivery of care, leading to a congressionally mandated federal effort into a comprehensive population health-level strategy, the National Pain Strategy (NPS). The NPS, released in 2017, and endorsed “a population-based, biopsychosocial approach to pain care that is grounded in scientific evidence, integrated, multimodal, and interdisciplinary while, at the patient level, is tailored to individual needs.” The NPS lays the foundation for greater integration of team-based interdisciplinary care and better delivery strategies and integrates this type of care into current treatment models, payers, and healthcare systems. The report included definitions that will help guide this overview of interdisciplinary care. The ACA, which increased access to medical coverage for the uninsured, has also helped to support the growth of interdisciplinary and comprehensive care within state Medicaid systems, including novel team-based programs that may help to more widespread use of programs within Medicare and commercial payor programs.

The National Academy of Sciences and the HHS Interagency Task Force report emphasized a multi-disciplinary approach based on a biopsychosocial model and included an endorsement of multi-disciplinary care as a critical part of biopsychosocial-based care. Besides behavioral health approaches, interventional procedures, medications, and complementary and integrative health, the range of restorative therapies (physical and OT, therapeutic exercise, and movement modalities) are critical components of interdisciplinary, multimodal pain care. ^,

As shown in Figure 4.1 , response to the drug overdose epidemic highlighted the need for states to examine current evidence, coverage, and access for non-opioid therapies and explore innovative, coordinated, interdisciplinary care delivery models “that function as best practice models for patients experiencing complex high-impact chronic pain.” In 2020 the National Governor’s Association report addressed strategies to expanding access to non-opioid pain management in the context of the COVID-19 pandemic. The report also highlighted progress in several states through waivers, health home programs, and performance improvement projects to promote evidence-based non-opioid therapies, including interdisciplinary rehabilitation, and improve how chronic pain is addressed in primary care.

Figure 4.1, Biopsychosocial factors impacting pain.

Models of Care

A few important definitions are reviewed to describe the models of care. The terms “multi-disciplinary” and “interdisciplinary” as models of care are commonly used interchangeably, although they represent treatment models across a continuum of care in modern clinical practice. Heterogeneity in the terminology used to describe pain management programs in the literature may lead to some confusion. “Multi-disciplinary” implies multiple disciplines being used for a clinical purpose but not necessarily delivered in one setting. “Interdisciplinary” implies the use of multiple disciplines, such as occupational and PT, behavioral medicine, RT, vocational services, and nursing education in one setting or facility.

Boon et al. described a conceptual framework of models of care in order of increasing comprehensiveness and philosophical complexities, starting with a more biomedically based model parallel to a collaborative, coordinated care. This is followed by a multi-disciplinary, then interdisciplinary biopsychosocial model, and finally, a fully integrative one, which could include acute medical care, such as an emergency room, where different team members have defined roles (i.e. phlebotomy, nursing, radiology technician, and emergency medicine provider). A “collaborative” or “coordinated” model may include practitioners acting independently and sharing medical records facilitated by a case manager. Across the models, there is an increasing need for communication, less individual autonomy, increased goals, and shared philosophy. “Multi-disciplinary” in pain management may commonly include a patient being managed by a pain medicine specialist who is directing care, a physical therapist providing care at an outside facility, and a vocational counselor working with the patient individually. At an even higher level of integration, “interdisciplinary” care, a basic tenet of functional restoration, includes multiple disciplines providing care at one facility. This is often led by a pain management specialist or behavioral health specialist, with multiple allied health disciplines (physical and OT, behavioral health [pain psychology, counseling, social work], nursing education) working together, agreeing upon treatment goals, and ongoing active communication, including formal team conferences or meetings. Integrated pain management programs are centered in and integrated into primary care with some embedded or easy access to multi-disciplinary providers and services. This arrangement has been described primarily in the federal healthcare system, including the Veterans Administration and the Department of Defense. This continuum starts with a more biomedical, pathology-focused approach, progressing to more multi-disciplinary, then interdisciplinary and integrative models more heavily dependent on a biopsychosocial team-centered approach. The continuum and progression in philosophy can similarly be appropriate for how a person with pain is treated, starting with acute pain, chronic pain, and finally high-impact chronic pain, but all models equally consider individual patient risks, values, engagement, education, and knowledge ( Figure 4.2 ). The following important definitions better define the population and scope of treatment:

Figure 4.2, Models of care, philosophy, and biomedical to biopsychosocial continuum.

High-impact chronic pain: Pain associated with substantial restrictions on participation in work, social, and self-care activities for six months or more

Integrated care: The systematic coordination of medical, psychological, and social aspects of healthcare includes primary care, mental health, and, when needed, specialist services.

Interdisciplinary care: Care is provided by a team of health professionals from diverse fields who coordinate their skills and resources to meet patient goals.

Multimodal pain treatment: Addresses the full range of an individual patient’s biopsychosocial challenges by providing a range of multiple and different types of non-pharmacologic (active therapy, behavioral health, interventional procedures) and pharmacologic therapies as needed.

Continuum of Care: Pain Rehabilitation

A continuum of pain rehabilitation approaches for chronic pain can include various models, including back schools, primary care integrative programs, and interdisciplinary functional restoration. A consistent emphasis on education and self-management was seen at varying levels with these approaches. A brief description of these models helps put into context the most comprehensive pain rehabilitation continuum, interdisciplinary care.

Back Schools

Back schools have been defined as interventions that include group education, training, and exercise, often delivered by a physical therapist or other healthcare provider organized in an occupational setting or part of a multi-disciplinary treatment program. Programs include brief education by a single provider within a management-based group. Back schools encourage self-management, advice to stay active, and reduce potential concerns about low back pain.

Low back pain education programs were championed by Lidstrom, Zachrisson, and Forsell in the late 1960s as the “Swedish Back School” model. Swedish back school classes focus specifically on biomechanics, ergonomics, exercise, and skill acquisition. ^, Studies have demonstrated efficacy in treating low back pain. The content of back schools has varied over time, and endorsement of these programs in treatment guidelines has waned. Recent reviews found limitations, including insufficient studies and low quality evidence, although more effective than placebo on work status, and may be more effective as an added treatment versus provided alone. Other reviews have demonstrated conflicting evidence that schools are better than waiting lists or no intervention for reducing disability or improving return to work.

Integrative Primary Care

Collaborative care models for chronic pain, conceptually based on treating chronic illnesses such as diabetes and depression, based on primary care have demonstrated efficacy. ^, Focus areas for collaborative care for chronic pain include patient identification and population management, a defined care team with access to specialty pain and behavioral health with standard workflows and system supports, coordinated and collaborative care management, and evidence-informed care (that is trauma-informed, addressing pain amplifiers like sleep problems, appropriate use of integrative health such as massage and acupuncture, and movement and body awareness strategies). Finally, patient-supported self-management is provided by a team member where goals are identified, and barriers to making progress toward goals are addressed ( Table 4.1 ).

TABLE4.1

Primary Care Collaborative Care for Chronic Pain Focus Areas (Bree Collaborative)

Patient Identification and Population Management	Identifying patients with persistent pain with life activity impacts Preventing the transition from acute to chronic pain with life activity impacts Through screening with a brief, validated instrument for psychosocial barriers To recovery (e.g. STarT Back Tool for low back pain) Tracking patients in a registry and participating in performance improvement Based on the aggregation of data for collaborative care performance Use of a dashboard for patient progress Patient-reported outcome measures at the initial visit and follow up
Care Team	Defined roles for care team members, care team Communication expectations Access to specialty pain or behavioral health consultation, if needed Patient point of contact for the care team Standard workflow with planned interactions System supports (e.g. technology, training) Identifying, supporting, and enhancing what patients are already doing to manage chronic pain with life activity impacts
Care Management	Coordination of the collaborative care process, including facilitation of care team access Identifying diverse resources and interventions that patients can use in managing chronic pain with life activity impacts, depending on motivations and preferences Facilitation of referrals, if needed Management of medication Proactive outreach
Evidence-Informed Care	Trauma-informed care Developing and improving pain management skills (e.g. relaxation) Conventional medical treatment options (e.g. nonsteroidal anti-inflammatory drugs as first line treatment rather than opioids, topical, heat, and ice) Addressing pain amplifiers (e.g. sleep problems) Integrative health practices (e.g. massage, acupuncture) Movement and body awareness strategies
Supported Self-Management	Helping patients identify goals for resuming life activities and addressing barriers to making progress toward goals

Collaborative care for chronic pain: report and recommendations. Bree Collab. 2018.

Primary care-based integrative pain management programs are often based on medical home models. Various primary care models exist but often include coupling a decision-support component such as an algorithm-guided treatment (such as analgesic optimization) or stepped care with proactive treatment monitoring, stratifying patients based on the extent of their medication management, psychosocial, and/or comorbid medical illness factors. Programs are commonly led by case managers who communicate with patients via phone or other automated symptom monitoring (apps, internet). Education was delivered in multiple weekly group sessions. In some cases, primary care-based integrated programs also include physicians, pharmacists, dieticians, and physical therapists who provide group or individual care. A recent review of primary care models found clinically relevant improvements in pain intensity and function, with variable improvement in other core outcomes such as mood, sleep, and medication use. Additional trials are ongoing with the integration of interdisciplinary pain care within primary care, including models that include comprehensive evaluations, cognitive behavior therapy (CBT)-based pain coping skills training, and adaptive movement training provided over a 12-week period in group sessions (led by a trained nurse and behavioral specialist), and primary care consultation.

Interdisciplinary Pain Rehabilitation and Functional Restoration

Interdisciplinary models are based on a biopsychosocial approach to pain and pain-related loss of function (i.e. disability). The biopsychosocial approach emphasizes pain and disability as complex and dynamic interactions among physiologic, psychological, and social factors that may perpetuate each other, leading to complex pain and prolonged disability. Importantly, in contrast to a biomedical model, chronic pain is understood as a disease, making the traditional biomedical model often inadequate at addressing the complexities of pain unique to each patient. The evidence for interdisciplinary pain rehabilitation programs as effective interventions for reducing pain and pain-related disability is well established in the literature. ^, ^,

Important in this complex biopsychosocial relationship underscoring pain and affective distress is evidence supporting neurophysiologic changes, including neurophysiologic activation, and more recent evidence of chronic pain perpetuating central sensitization. Central sensitization has been defined as “a process of abnormal and intense enhancement of pain caused by increased neuronal responses to stimuli in the central nervous system.” ^, Central sensitization is associated with psychosocial and cognitive behavioral factors. Central sensitization plays an important role across many chronic pain conditions and contributes to the transition process from acute to chronic pain, amplification of pain in many chronic pain conditions, and in the development of chronic post-operative pain ( Figure 4.3 ).

Figure 4.3, Chronic pain conditions and central sensitization. 37

In addition to sensitization, neurophysiologic changes may be closely linked to psychological and behavioral factors. The classic cognitive activation theory of stress links neurophysiologic activation and an individual’s innate stress alarm, where there is a discrepancy between what is expected and experienced by the individual with chronic pain. The resulting sustained state of anxiety and sustained neurophysiologic activation may be reduced by improved coping behaviors or decreasing feelings of hopelessness. Many of these related psychological factors are targets for fear avoidance training for persistent pain. Sensitization to pain processing also contributes to elevated pain perception and affective distress. Decreasing “sensitization” of the nervous system serves as a useful broad or shared target for pharmacologic, behavioral, and active non-pharmacologic interventions (exercise, movement-based therapies) for pain management. It remains an important and growing area of clinical focus and patient-directed education within interdisciplinary and multi-disciplinary treatments.

Interdisciplinary Care and Functional Restoration

Over 30 years ago, Kinney et al. described the basic elements (i.e. nine core attributes”) of interdisciplinary functional restoration programs. With advancements in understanding persistent pain, pain pharmacology, health psychology, and integration of mind body techniques, these nine core attributes remain, but with updated modifications. These nine core attributes will help describe the continuum of interdisciplinary care ( Table 4.2 ).

TABLE 4.2

Core Attributes of a Functional Restoration Program: Swedish Pain Services/Swedish Health System)

1
Pain medicine assessment and management: Review of past treatment, diagnostic workup, comprehensive musculoskeletal, neuromuscular examination, assessment of neuropathic, nociceptive, and nociplastic pain; discussion with the patient regarding treatment plan; rationale for treatment program specific to patient needs; and ongoing visits reviewing progress.
2
Pain Psychology Evaluation and Treatment; psychosocial functioning: semi-structured pain psychology assessment, completion of psychosocial packet questionnaires.
3
PT directed reconditioning, strengthening, stabilization, and wellness, and pain education, many times including a model based on PNE.
4
OT directed work and home physical functioning assessment, pacing and ergonomic training, integration of relaxation techniques and mindfulness, Tai Chi, and Qi Gong training.
5
Behavioral health, including pain psychology and RT CBT, mindfulness, acceptance and commitment therapy (ACT) approaches, biofeedback-assisted RT, and nervous system education.
6
Pharmacologic interventions targeting analgesia, mood, and sleep, including detoxification or opioid tapering when appropriate, medication trials, and medication optimization, are usually led by a pain medicine specialist, physiatrist, and psychiatrist.
7
Interdisciplinary, medically-directed team approach with formal weekly team conference meetings, including structured report generation from all disciplines.
8
Work and avocational reintegration guided by nurse educators, pain medicine specialists, OT, PT, and behavioral health teams include a return to work plan, work release, and flare up management.
9
Ongoing outcomes assessments.

Interdisciplinary functional restoration can be best described as involving four phases:

1
Comprehensive interdisciplinary assessment: Multiple specialists (pain medicine, pain psychologist, and/or vocational counselor) evaluate the patient, help clarify the underlying pain and psychological diagnoses, and consider candidacy for interdisciplinary care.
2
Pre-programing: Pre-programing as needed to complete workup, complete related assessments, and/or stabilize psychiatric or medical issues and program orientation.
3
Formal interdisciplinary management.
4
Post-program: Follow up care, outcome assessments, and maintenance classes.

The intensity of treatment, disciplines involved, and how the four phases are delivered can vary widely across programs. An overview of four interdisciplinary programs in the United States is included in Table 4.3 , highlighting program setting, specific disciplines used, treatment duration, integration of integrative therapies, billing structure, outcome measures used, payer mixes, and unique features of individual programs. The table helps represent an example of the variability of program structure, components, and payer mixes across successful programs in the United States. The five programs highlight a shared philosophy of biopsychosocial patient-centered care focusing on education and learning new skills ( Table 4.3 ).

TABLE 4.3

Interdisciplinary Pain Rehabilitation Programs in the United States

Name of Program, System of Care	Mayo Clinic Pain Rehabilitation Center	Pacific Rehabilitation Centers	Savas Health Unitized Transdisciplinary Care™	Stanford University School of Medicine Pain Management Clinic	Swedish Health System, Swedish Pain Services
Location (city, state)	Rochester, MN	Bellevue, Everett, Puyallup, WA	Inland Empire, CA	Redwood City, CA	Seattle, WA
Setting (academic, hospital system, private)	Academic	PrivateEstablishedCARF Accredited	Private	Academic	Health System
Inpatient/outpatient	Outpatient	Outpatient	Outpatient	Outpatient/Inpatient	Outpatient
Program (s): h/day, days/week, duration	15 day program, weekdays 8 am-4 pm	Six (6) h/day, five (5) days/week, 20 days	The complex pain programs use the Unitized Transdisciplinary Care™ model.One year program consists of:Four cycles: 12 week treatment focusing on specific goalsPeriods: each cycle consists of three four week periodsUnits: A Unit is a focused 2.5 h transdisciplinary treatment session combining group and individual treatments. The frequency of Units depends on the participant’s conditions, goals, and progress and is adjusted throughout the program.	Various programs including: Outpatient: Pain psychology services/therapy, with or without biofeedback (weekly for four to eight sessions); Free CBT Pain Coping Skills Group (2 h, once a week for eight weeks); CBT + Movement Group (pain psychology + PT [Tai Chi] [3 h, once a week for eight weeks]);Back in Action (pain psychology, MD + physical therapy): 4 h twice a week for six weeks; All About Sleep and Pain Group (pain psychology + sleep psychology): 2.5 h once a week for six weeks;Pain and Purpose (ACT based group): 2 h once a week for six weeks); Empowered Relief (2 h, one time PNE intervention); Inpatient:Stanford Comprehensive Interdisciplinary Pain Program (SCIPP): inpatient stay varies based on patient needs.	Two programs: 1. Structured Functional Restoration Program (SFRP): 5 h/day, three days per week for four weeks; two days 1:1, one day group sessions.Round-robin 1 h PT, OT, relaxation training, pain psychology, and nursing education lecture.Weekly pain medicine visitsWeekly team conference meetings 2. Weekly Functional Restoration Program (1:1): 4 h per day, six to eight weeks, 1 h round-robin of PT, OT, pain psychology, and relaxation training, with additional 1 h pain education lecture.Group pain psychology class weekly by virtual visit.
Disciplines (PT, OT, Pain Psych, Relaxation training, Vocational counseling)If groups, #/group, or cohort	Psychiatry, psychology, NP, OT, RN (case managers), PT, Vocational counseling, biofeedback trainingGroup based practice with a rolling admission model.Approximately 25–27 patients were actively receiving care at any point in time.	Medicine (PM&R) & Nursing Psychology (Licensed) & Relaxation Vocational Counseling Physical Therapy Occupational Therapy 10–12 Patients/group/clinic	The transdisciplinary concept establishes the participant’s needs and combines the services that each treatment team member can perform based on their training, experience, and certifications. The transdisciplinary team consists of: Medical: Medicine MD (Anesthesia, PM&R), Physician Assistant, Nurse Practitioner, Care Manager (RN), and Care Coordinator (LVN);Behavioral Health: Pain Psychology (Licensed), LMFT, LCSW; Physical Reconditioning: Chiropractic, Massage, Physical Therapy, Mindful Movement Classes (combines elements of Yoga, Tai Chi, Feldenkrais);Alternative Therapies: Acupuncture, Chinese Medicine, Naturopathic Medicine, Dietitian)---Eight to 12 Participants/ Unit	Medicine MD (Anesthesia, Neurology, Dentist), Physician Assistant, Nurses, and Nurse Practitioner Pain Psychology (Licensed) and Pain Psychology Fellows (two to three Fellows/year), Pain Physicians and Fellows, Complex Case Care Managers, Physical Therapy Acupuncture, eight to 12 patients/group	Medical: Pain Medicine Specialist (PM&R/Anesthesia)Behavioral Health: Relaxation Training (certified) Pain Psychology (PhD) Nurse Educator (RN, PhD) Physical Therapy (DPT): (traditional PT training, pelvic PT, and Pain Neuroscience Education [PNE]) Occupational Therapy (OT): (traditional OT training & Tai Chi) Structured Functional Restoration Program: cohorts of four patients, per group, two to three groups per month.Weekly Functional Restoration Program (six to eight weeks). Six to eight patients/cohort
Behavioral Health Interventions	CBT, mindfulness, ACT (disproportionately CBT-based)	Individual and Group CBT	CBT, Mindfulness, Motivational Interviewing, Meditation	CBT, Mindfulness, ACT, Biofeedback, Hypnosis, Motivational Interviewing	CBT, Mindfulness, ACT, Motivational Interviewing, Relaxation Training, Biofeedback
Integrative therapies: yoga, Tai Chi, acupuncture	Yoga, Tai Chi	Yoga, Tai Chi	Tai Chi, yoga, acupuncture	Tai Chi, yoga, acupuncture	Tai Chi, Qigong
Virtual Services (yes/no)	Yes	Yes - Full CARF Accredited IPR Program Track via Secure Telehealth (patients’ homes)	Yes	Yes	Yes
Billing: fee for service, day rate, case rate	Fee for Service	Daily Rate	Case Rate	Fee for service, Empowered Relief, Pain Science Lecture Series, CBT follow up group, and eight week CBT Pain coping skills offered free of charge	Fee for service
Payers: workers compensation, commercial, Medicare, Medicaid	Commercial, Medicare, WC	Workers’ Compensation (Labor and Industries & Self-Insured Employers)	Medicaid	Commercial, Medicare, Worker’s Compensation	Commercial, Medicare, Medicaid, self-insured.No WA State workers compensation coverage, patients referred to local SIMP accredited programs.
Outcome Measures: PHQ-9, GAD-7, PCS, ODI, 6 min walk test, PEG	Self-report - WHYMPI (pain severity and pain interference scales only), SF-36, PHQ-9, PCS, PSEQ, PCL-5 Performance based measures (administered by physical therapy) - Simmonds Physical Performance Test Battery. Battery includes: 5 min walk, 50 foot walk, timed up-and-go, repeated sit to stand, repeated trunk flexion, loaded reach Occupational Therapy - Canadian Occupational Performance Measure (COMP)	PHQ-9, GAD-7, PCS, ODI, TKS, WHODAS-2, Mid-Range Lift, Chair to Stand Test (CST)	PROMISNPRSPEGODQPDIPHQ-9GAD-7PCSPGICDAST-10AUDIT	CHOIR (including PROMIS) PCSCES-DPCLCPAQ-8PASS-40PSEQTSK	BESS Balance TestCPAQ-8COPMGAD-7ODIPEGPHQ-9PCSPSFSTSKFive times sit to stand test6 min walk test
Level of Medical Management: opioid detoxification, medication trials,	Opioid detoxification was concurrent with programming.Additional tapering of benzodiazepines, muscle relaxants, hypnotics when appropriate	Medication trials (non-opioids), opioid tapering and elimination, coordination with inpatient detoxification, and substance abuse treatment programs. Individual/group patient education	Medication trials (non-opioids), opioid tapering, Medication Assisted Treatment integrated into the program (MAT-Units)	Medication trials (non-opioids), opioid tapering and optimization EMPOWER, inpatient comprehensive interdisciplinary pain program (SCIPP), transcranial magnetic stimulation study, Pain Science Lecture Series, Individual/group patient education	Medication trials (non-opioids), opioid tapering, and optimization.Board certified addiction specialist integrated into clinical practice and available for consultation, coordination of care for medication management (buprenorphine), and tapering
Aftercare, maintenance services, classes	Monthly, in-person aftercare program (one day group)	Follow Up Community Reintegration (4 h/day, two days/week, three weeks) In Clinic and Virtual Tracks	Follow up available at pain clinics under the FFS model with incorporated community services	Maintenance services, free monthly CBT/ACT follow up classes	Maintenance group classes for PT, OT, relaxation training, pain psychology
Unique features:		Only full service interdisciplinary telehealth CARF program in the region	– Scalable transdisciplinary solution based on a proprietary software platform– Use of proprietary assessment system to allow for easy communication among disciplines and goal tracking (Patient Global Health Score™)– Use of artificial intelligence driven predictive modeling for optimal treatment planning and execution– Regular Systematic Case Review by the treatment team for all participants	Pain Psychology and MD Fellowship programs, only med-behavioral inpatient pain experience in the western United States (SCIPP), Bi-weekly interdisciplinary case conference	Pain rehabilitation programs integrated within physical space and cost center of comprehensive pain center hub for the large health system.Behavioral health co-treatment with integrated behavioral health services in the system’s primary care clinics helps stabilize patients prior to and provide additional behavioral health support after completing structured programs.
Program Content Contributors	Wesley Gilliam, PhD	Michael D. Harris, PhD	Tobias Moeller-Bertram, MD	Kristen Slater, PhDHeather Poupore-King, PhD	Becca Taylor, RN, PhD Wilson Chang, MD

AUDIT, Alcohol Use Disorders Identification Test;

BESS, Balance Error Scoring System;

CES-D, Center for Epidemiological Studies Depression;

COPM, Canadian Occupational Performance Measure;

CPAQ-8, Chronic Pain Acceptance Questionnaire-8;

CHOIR, Collaborative Health Outcomes Information Registry;

DAST-10, Drug Abuse Screening Test-10;

GAD-7, Generalized Anxiety Disorder-7;

NPRS, Numeric Pain Rating Scale;

ODI, Oswestry Disability Index;

ODQ, Oswestry Low Back Pain Disability Questionnaire;

PASS-40, Pain Anxiety Symptoms Scale-40;

PCL-5, PTSK Checklist for DSM 5;

PCS, Pain Catastrophizing Scale;

PEG, Pain, Enjoyment in Life and General Activity [PEG] Scale;

PDI, Pain Disability Index;

PHQ-9, Patient Health Questionnaire-9;

PGIC, Patient Global Impression of Change;

PROMIS, Patient-Reported Outcomes Measurement Information System;

PSEQ, Pain Self-Efficacy Questionnaire;

PSFS, Patient Specific Functional Scale;

SF-36, Short Form Survey- 36 Item;

TSK, Tampa Scale of Kinesiophobia;

WHODAS-2, WHO Disability Assessment Schedule 2.0;

The author will describe below more specifics related to his teams’ interdisciplinary program presently provided at the Swedish Health System in Seattle, Washington. This will serve as an example and represent the four phases of interdisciplinary care in more detail. Many of these same principles and treatment philosophies can be applied to the programs in Table 4.3 and interdisciplinary programs in the United States and across the world.

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