312 Pain Management
theidiographicapproach and the generic nomotheticap-
proach that has characterized much of the pain treatment out-
come studies. At this point, whether treatment tailoring will
produce greater therapeutic effects than providing com-
pletely idiographic or generic treatments can only be viewed
as a reasonable hypothesis. The fact that signi“cant propor-
tions of chronic pain patients are not successfully treated by
generic approaches makes investigation of treatment match-
ing of particular relevance.
MULTIDISCIPLINARY PAIN REHABILITATION
PROGRAMS (MPRP)
In MPRPs, patients are usually treated in groups. Patients
work on at least four generic issues simultaneously: physical,
pharmacological, psychological, and vocational. Programs
usually emphasize gaining knowledge about pain and how the
body functions, physical conditioning, medication manage-
ment, and acquisition of coping and vocational skills. Indi-
vidual and group counseling address patient needs. The
emphasis is on what the patient accomplishes, not on what the
provider accomplishes. The providers envision themselves as
teachers, coaches, and sources of information and support.
MPR requires the collaborative efforts of many health
care providers, including, but not limited to, physicians,
nurses, psychologists, physical therapists, occupational ther-
apists, vocational counselors, and social workers. The health
care providers must act as a team, with extensive interactions
among the team members.
For many chronic pain patients, the factors that lead pa-
tients to report persistent pain remain obscure. Traditional di-
agnostic processes have failed to identify a remediable cause
of pain. These patients require treatment because of the dis-
ruption of their life that they ascribe to pain. Indeed, their
health care providers must feel comfortable abandoning the
search for a cure and, instead, accept palliation and rehabilita-
tion as a viable outcomes. The goal is to improve the patient•s
ability to function, not to cure the disease that has led to pain.
Hence, the diagnostic process must identify the areas of func-
tional impairment and disability, and treatment must address
all of the factors that contribute to disability. In contrast to tra-
ditional medical therapy, patients cannot be passive recipients
of the ministrations of providers. Patients must accept respon-
sibility and work to achieve the bene“ts of treatment.
The effects of an MPRP are greater than the sum of its
parts. Common features of all programs include physical
therapy, medication management, education about how the
body functions, psychological treatments (e.g., coping skills
learning, problem solving, communication skills training),
vocational assessment, and therapies aimed at improving
function and the likelihood of return to work. MPRPs usually
have a standard daily and weekly format that providers can
tailor to individual patient needs. The overall length of a pro-
gram depends in part on unique patient requirements. The
goals of MPRPs should be speci“c, de“nable, operationaliz-
able, and realistic in nature.
As they have evolved, MPRP have become performance
based, goal-directed, and outcome driven. Integration of out-
comes related to patients• pain and functional limitation due to
pain; how these behaviors in”uence patients• physical capac-
ity; how others respond to the patient; the in”uence of psy-
chosocial factors that contribute directly and indirectly to
patients• physical and emotional status, and the potential for re-
habilitation are essential. The treatment team must build an al-
liance with patients to instill acceptance of self-management.
Psychological strategies generally target alteration of
behavior rather than the patient•s personality (Turk, 1997).
Patients learn coping skills because this is frequently a de“-
ciency in either knowledge or implementation that has led to
the patients• many dif“culties. Issues that patients raise re-
ceive attention in either the group format or in individual
therapy, as needed. As depression is so often a component of
the chronic pain problem, it may warrant both psychological
as well as pharmacological interventions. Psychologists pro-
vide relaxation and consolidation sessions that allow the
patients to work on newly acquired skills and explore educa-
tional topics and new psychological skills.
Given constraints on health care resources, there is a
growing interest in accountability and evidence-based treat-
ment outcome data. All components of health care delivery
are under scrutiny to determine whether they are not only
clinically effective but also cost effective. The effectiveness
of pain treatment facilities and, in particular, multidiscipli-
nary pain rehabilitation treatment have been debated and sin-
gled out by some third-party payers for special criticism
(Federico, 1996). Often the debates have been acrimonious,
centering on anecdotal information and hearsay. Surprisingly,
the dialog largely ignores the growing body of outcomes
research published over the past quarter century. Referring
physicians and third-party payers tend to rely on salient
cases, usually failures, treating them as representative and
relying upon them as the basis for criticizing MPRPs. Con-
versely, MPRPs often respond based on their clinical experi-
ence and the recall of particular successes that are viewed as
representative of the outcomes from their facility, rather than
systematically collected empirical data. There are, however,
a growing number of studies, reviews, and meta-analyzes
that support the clinical success of MPRPs (Cutler et al.,
1994; Flor et al., 1992; Morley et al., 1999).