The role of the nurse in interdisciplinary chronic pain management

Early pain management interventions were guided by the belief that pain has various origins. These reasons were mainly somatogenic or psychogenic: for example in the brain, the heart, the nerves, but also included certain spiritual or religious beliefs. Pain itself was often related to punishment, suffering, sins or bad behavior associated with the gods. In Christianity, for example, pain always held two opposing meanings. On the one hand it was viewed as a result of sin or a form of punishment; on the other it was viewed as a test of faith. The variation in these explanations throughout history resulted in special pain interventions such as trephination and exorcism (1-2). Consequently, the various models of pain have been based on (i.e. reflect) various religious, philosophical, cultural and scientific aspects.

Dualistic vision
The traditional biomedical model of pain was modernized by Descartes in the 17th century and was very influential until the mid 1950’s. The model views the mind and body as two separate entities and pain as a sensory experience. In the biomedical model, the physical pathology (injury or disease) leads to a stimulation of nociceptors, which causes the experience of pain. Within this model, the effect of psychological, social and behavioral factors are not considered in the diagnosis and treatment of pain. Scientific knowledge supports the use of drug and surgery treatments in this model (3). Both approaches are used today in chronic pain management, nevertheless, the dualistic model of pain was already enhanced. About 60% of patients with nonmalignant chronic pain use opioids, with 20% of them on a long-term basis (4), and surgical interventions for chronic low back pain also significantly increased over the last 10 years (5). The subsequent dualistic perspectives, the psychodynamic models of pain, view chronic pain as an expression of emotional conflict. For example Freud’s model (6) focused on the process of conversion, through which expressing emotional pain is seen as an unresolved conflict converted into somatic symptoms. The additional model of Engel (7) introduced the concepts of psychogenic pain and a pain-prone personality. A pain-prone personality might have people sick from hysteria, depression, hypochondriasis or paranoid schizophrenia. Within this model, chronic pain, described as psychogenic or psychological, does not necessarily need any physical pathology and is a psychological event in its own right. Engel´s model completed Blumer and Heilbroon (8), in that means chronic pain represents kind of major depressive disorder, masked depression, depressed affect, alexithymia, or family history of depression and chronic pain. Over the years, studies have shown that the prevalence of psychiatric conditions in chronic pain patients has increased in comparison with the general population (9). It is debatable whether psychiatric morbidity leads people with a proneness to pain to use this pain as an unconsciousdefence mechanism. Nonetheless, the psychodynamic models played a major role in bringing attention to the importance of psychological factors in pain enjoyment. This deep focus on psychological factors was a basis for the later development of biopsychosocial approaches.

First integration
Melzack and Wall were probably the first to integrate both physiological and psychological mechanisms of pain. Their gate theory of pain provided a framework for understanding the relationship between a peripheral noxious stimulus and the experience of pain (10). The theory suggested that the transmission of pain messages can be modulated by somatic mechanisms as well as by non-specific modulation mechanisms (such as personal characteristics, mood, social impacts, learning, etc.) that can in turn increase or decrease the intensity of pain. In 1968, Melzack and Casey described the three basic dimensions of pain: “sensory-discriminative”, “affective-motivational” and “cognitive-evaluative” (11). It was an important finding that pain can also be treated by influencing one’s affective-motivational and cognitive factors. The subsequent years were devoted to further attempts to understand the psychological and sociocultural factors involved in pain. For example, Price´s model (12) suggests the central network of brain structures and pathways, comprising of both serial and parallel connections, as the mechanism through which the emotional aspect of pain is affected and expressed (13). In the late 1980s, Melzack’s neuromatrix theory (14) was the first to attempt to explain the strange but very common phenomenon of phantom pain. Melzack’s proposed explanation was that pain is actually generated by neural activity in a network made up of several different brain structures, and that this network can generate pain even when there is no sensory stimulus to trigger it. The neuromatrix theory shifted away from the Cartesian concept of pain as a sensation produced by injury or tissue pathology, and moved towards a view of pain as a multidimensional experience produced by multidimensional factors.

Biopsychosocial approach
Compared to the biomedical model, the target of the biopsychosocial approaches to view pain as an illness and not as disease. Illness is understand as a special type of behavior (15) and pain behavior is a process, which influence biological, psychological and social agents. Psychological and social factors may play a primary role in the maintenance and exacerbation of pain. The biopsychosocial approach in pain management means that the experience of pain is influenced by the relationships between biological, psychological and social factors. Psychological factors may include pain cognition, emotions and pain behavior. Social factors may entail, among others, the social and cultural relationships, which influence a person’s experience and response to pain. The pain can interfere with central processes and influence one’s attentional focus, lower and reorganise mental and cognitive processes as well as behavior to the perceived threat, and alter social communication processes in pain sufferers (16). In comparison with the biomedical or psychodynamic approaches, the biopsychosocial approach demonstrates a multidimensional view of pain (17). Important influence on development of biopsychosocial approaches and the concept of multimodal pain management had in the late 1960s and early 1970s Fordyce´s operant model (18), Glasgow model, biobehavioral model, fear avoidance models and integrated diathesis–stress model (13). The Glasgow model understood chronic low back pain as an illness, and although pain behavior was based on pathology, it was seen to be affected by cognitive, emotional and social agents (19-20). Biological, psychological and social factors and environments interact and support a person’s pain behavior and disability. The model recognizes the concept of fear avoidance as an important agent in the biopsychosocial model of low back pain, and is a part of the fear-avoidance models (13). The biobehavioral model aimed to expand Fordyce´s operant model (17;21). The term “bio” entails biological factors and “behavioral” comprises of a wide range of psychological, social and cultural factors. The fear-avoidance models have a basis in observations of anxiety in the pathology of pain, in the theory of operant conditioning and in illness behavior. The fear-avoidance model of Vlaeyen and Linton (22), supported by the work of Lethem et al. (23), Philips (24) and Waddell et al. (25), is based on the idea that the experience of pain increases one’s need to escape and avoid this pain. The model predicts two different behavioral reactions to pain: confrontation and avoidance. Even though chronic pain itself cannot be avoided, activities believed by the patient to increase the pain’s intensity or cause a potential injury can be avoided. Therefore, a decrease in activity and functional capacity can be observed. The model helps explain why chronic pain develops in a minor group of patients with acute back pain (26). The integrated diathesis–stress model combines the operant, Glasgow, biobehavioral and fear-avoidance models (13). The model takes into consideration the importance of somatic, psychological and sociocultural factors in the aetiology, exacerbation and maintenance of chronic pain. Somatic pathology is understood as necessary together with predispositional vulnerability (diathesis). Predisposed individuals have a reduced threshold for nociceptive activation and increased reply with fear to all bodily sensations. That is why that people probably more reply to pain with anxious signs and develop cognitive and behavioral patterns. Hereafter that supports the readiness. Learning processes relate to the maintenance, to anxious anticipation, pain-specific distress and disability. People without this predisposition understand their pain as a non-hazardous sensation, which is why they do not respond to it with maladaptive cognitive or behavioral reactions and can mostly overcome it. The human pain system appears to be an interconnected entity, involving biological, psychological, social, cultural and other aspects and relationships among them, which are neither simple nor direct.

The role of nurses in interdisciplinary care
Due to the complexity of chronic pain, no single discipline has the sole right to its assessment and management. Firstly, it is important to clearly distinguish between the multidisciplinary and interdisciplinary management of pain, as these terms can be interpreted differently (3) and are often used interchangeably. Multidisciplinary care means the involvement of health care providers, such as pain doctors, nurses, psychologists, psychiatrists, physiotherapists, occupational therapists, social workers and others, who do not work in the same building or hospital and their treatment goals may thus vary. Interdisciplinary care, on the other hand, is the coordination of all types of pain management within a single programme. It includes the communication amongst all the pain management care providers, who have one common programme and usually work in one department or center on achieving the same goal. Interdisciplinary pain treatment gives the patients an opportunity for pain relief and to improve their functioning (27). Interdisciplinary pain centers should focus on the biopsychosocial model of pain and primarily treat the person as a whole. The diagnostic and treatment possibilities should be comprehensive and include somatic medicine treatment (meaning medical exams and medication), psychosocial treatment (biopsychosocial assessment and cognitive-behavioral therapy), physical and occupational treatment, and others. All members of the pain team are of equal importance. The entire team meets to evaluate the patient’s current problems, the course of the programme and the treatment. The pain team also, naturally, consists of the patient and their close people. This is why the team meets with each new patient following their initial complex assessment and counselling in order to evaluate the expected effect of the treatment and the patient’s motivation for participation in the programme. The team then meets with each patient once a week to evaluate the treatment, and communicates with their doctors who recommended them for the program. Each team member has their own specific role. The nurse plays an important role in the interdisciplinary management of pain, concentrating on components of a healthy life style, (3;27-28). The nurse must be well familiar with the overall treatment plan, the methods and modalities being used, and the goals of each of the care providers working with the patient. For example that a physiotherapist may focus on strength, flexibility of the body and the establishment of a self-management program; a psychologist focuses on increasing interpersonal skills, effective communication with others and through this improves the person’s emotional status; a pain doctor optimizes the benefits of medication, etc. The nurse also assists physicians, provides follow-up sessions for all procedures (injections, nerve blocks, etc.), but may interact as the patient’s case manager, communicating with the treatment team, attending the interdisciplinary treatment team meetings, can help review the patient’s progress, helps, evaluates and monitors the treatment outcomes, educates the patients, delivers non-pharmacological therapy such as education, biofeedback and relaxation strategies (based on their training in cognitive-behavioral therapy), and may be involved in research. Nurses usually develop a unique trust and relationship with the patients, which can be helpful in achieving satisfaction with care and established goals. All goals must be clear, realistic and measurable. The evaluation of the treatment’s effectiveness must be based on a clearly specified method of assessment and the nurse plays an important role in this.

The basic goal of dividing pain specific models within a historical perspective was to find an effective pain management. We now have a much broader model of pain based on the biopsychosocial models. These models replaced the old biomedical model and traditional approaches to pain assessment and management, and established the interdisciplinary approach provided by pain management teams. It is worth noting that there is a lack of available resources for interdisciplinary care and it is not always possible to use. Nevertheless, chronic pain poses a great challenge not only to pain doctors, but also to psychologists, physiotherapists, nurses and the other involved professions. The role of nurses in interdisciplinary pain teams is crucial and irreplaceable. Pre-graduate and postgraduate training for nurses in pain management should focus on a biopsychosocial approach, on an interdisciplinary spirit and should allow for the possibility to receive training in cognitive-behavioral therapy.

Supported by the Ministry of Health, Czech Republic – conceptual development of research organization, Motol University Hospital, Prague, Czech Republic 00064203.

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