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A multidisciplinary approach to the treatment of chronic pain: Lindsay Stephenson, DipPhty, DipMT, PGDipRehab Stephenson Murray Physiotherapists, Invercargill ABSTRACTPersistent pain is a problem facing a high proportion of our society and is best treated by a multidisciplinary team approach. This case report reviews the client's presenting history from a multidisciplinary perspective and the functional assessment of a client with chronic heel pain. The use of outcome measures is an integral part of the client's assessment and treatment. The client's problems are identified and a treatment plan is developed with the physiotherapy treatment, including an Activity-Based Programme, described. The successful treatment outcome can be attributed to a team approach with regular communication between providers to co-ordinate the programme. Regular monitoring of goals set, and evaluation of improvement using outcome measures were utilised throughout the client's rehabilitation. The use of outcome measures helped the client to gain confidence, manage pain and increase activity levels. Stephenson L (2008): A multidisciplinary approach to the treatment of chronic pain: a case report. New Zealand Journal of Physiotherapy 36(1): 15-21.
Key Words: Pain management, multidisciplinary, physiotherapy, outcome measures, cognitive behavioural interventions.
by ACC for assessment and recommendations for Pain, although essential for survival, is the second appropriate treatment. The three practitioners work most common reason for people seeking medical as part of a multidisciplinary company who have a care (Turk and Okifuji, 1998). The fragmented and special interest in pain management. The reason unimodal approach of conventional medicine often for the referral had been explained to J by her ACC delivers poor outcomes for the client (Turk and case manager, the process of the assessment was Okifuji, 1998). Turk and Okifuji (1998) concluded explained, and consent gained.
that multidisciplinary pain centres delivered care that not only improved overall functioning, but was also cost effective in treating patients with chronic pain. J is a 61 year old female who, prior to her injury, Further research on multidisciplinary treatment worked as an assistant in a café. She married at 23 for chronic pain has been mainly directed at low and after eight years left her marriage as a result of back and neck pain. Jensen et al (2005) concluded an ongoing abusive relationship. Her four children from their longitudinal study that multidisciplinary remained with her. J rebuilt their lives with minimal rehabilitation for women with chronic neck or back outside assistance and became involved in another pain had a substantial rehabilitation impact and relationship, which also ended after ten years due was "a cost effective method for improving health to physical abuse.
and increasing return to work." At the time of the interview she was again The New Zealand Accident Rehabilitation and in another abusive relationship and was in the Insurance Corporation (ACC) has multidisciplinary process of leaving after 8 years. J's children had pain management services for chronic pain (ACC left home but were supportive of her decisions. website) with the aim of delivering a service that will She maintained close contact with her children enable the claimant to regain independence and/or and is currently involved in the after school care a return to work. This approach utilises a team of for two of her grandchildren aged 12 and 10 years. professionals including doctors, physiotherapists, She has done this since her daughter-in-law died occupational therapists and psychologists with the approximately two years ago. common goal of working together with claimants Before her current injury J enjoyed participation to return them to maximum function. in a wide range of sports including golf, rock and This case report reviews the multidisciplinary roll, ballroom dancing and walking, as well as assessment, rehabilitation and outcomes of a lady gardening and completing renovation projects.
who developed chronic regional pain after an injury In February 2001 J was standing on a bar to her foot.
stool tending some over-hanging plants when she jumped down. J stated she immediately felt pain in her right foot and thought she had re-injured an J was concurrently referred to a physiotherapist Achilles tendon that she had previously ruptured. (LS), an occupational therapist and a psychologist She reported she had an immediate sharp pain NZ Journal of Physiotherapy – March 2008, Vol. 36 (1) in her heel that radiated into her calf muscle and Table 1. Aggravating Factors posterior right knee. The pain continued to persist causing her difficulty to fully weight-bear and mobilise. Some days later her general practitioner Walking is limited and that "doing the supermarket referred her to physiotherapy and gave her a medical shopping was difficult and very painful", certificate to be off work. Her physiotherapist gave She will drive and find a park outside a shop and felt she was unable to walk more than one block. She no a provisional diagnosis of an acute plantar fascia longer walked on rough ground.
injury. Despite extensive physiotherapy the problem She had some difficulty getting in and out of her car did not resolve. and had pain with driving, although could drive for Since this time she has had numerous orthopaedic referrals, a review by a Rheumatologist and an Initial She has difficulty putting on shoes and socks.
Medical Assessment. She has had x-rays and blood Standing was limited, and prolonged sitting also tests that were unremarkable. Medication, that she became painful, limiting sitting to about twenty minutes. (During her interview she often changed felt gave some pain relief, consists only of celecoxib position, especially moving her leg and foot.) (Celebrex), used regularly rather than as-needed. She longer no dances, but used to "dance all night".
Orthopaedic treatment consisted of cortisone Digging the garden is no longer possible.
infiltration into the plantar fascia and calcaneal She is no longer able to do al her housework to the level attachment. This gave her limited short duration or frequency that she used to, however, still manages relief. Her orthopaedic specialist advised she had her own housework. She stated she used to be a developed a chronic plantar fasciitis. She was perfectionist and always had a clean, tidy home.
Standing to prepare a meal aggravates her pain informed that nothing more could be done and she and she now uses a bar stool to decrease her weight would have to learn to live with, and manage her pain. J has remained off work as an ACC beneficiary since her injury. Table 2. Easing Factors Previous Relevant History J is unsure of the exact date, but had previously J reported that heat helps to ease her pain and that she regularly uses her spa pool at the end of the day. ruptured her right Achilles tendon which was Medication gives some relief but she does not want to surgically repaired. Although rehabilitation was be reliant on medication as it "is only a short term cure slow after this she had regained full function and and I would rather be able to do something about the had returned to all her sporting activities.
She had surgery for a bunion on her left foot in February 2004 and subsequently had problems is aware that nothing more medically or surgically with pain, keloid scarring and loss of function. can be done to help her and that "I have been told I This responded well to physiotherapy resulting in a will have to learn and live with it". She wants to be return to full weight bearing and a normal pattern able to socialise without getting sore, and be able of gait, although some pain persisted. to return to some form of work. J was prepared to look at options that might help her to manage PHYSICAL EXAMINATION her pain and improve her lifestyle.
J presented well dressed and was not overweight. She walked with a significant limp and had decreased weightbearing through her lateral foot. Functional Assessment J described her pain as an almost constant J walked on the outer border of her foot and had toothache throb in her heel and the lateral border an antalgic gait. She watched the ground directly of her foot with pain in her calf when walking. J in front of her and was unable to walk with eyes rated her pain at a resting level to be 4/10 and her maximum levels of pain to be 8-9/10 on a Numeric In standing she had a pronated talus, causing Rating Scale where10 is maximum pain.
increased tension on the medial calf muscles and J reported she had difficulty getting to sleep, medial plantar fascia; dorsiflexion was slightly then woke early, often not getting back to sleep. restricted and increased her pain. Pain prevented Pain in her foot and at times her calf disturbed her plantarflexion in standing and joint proprioception sleep. She did not get up to try and relieve her pain although would rise early if she could not sleep. She On palpation she reported mild pain along had pain on rising in the morning which became the medial forefoot and locally over the calcaneal progressively worse throughout the day, although attachment of the plantar fascia. J did, however, would ease with rest. have active trigger points in her upper medial Aggravating factors described by J are shown in soleus, flexor digitorum longus, and her lateral Table 1 and Easing factors in Table 2.
gastrocnemius had an extremely tight band along its length.
Belief about her Problem Functional Tests/Outcome Measures utilised Despite no recent improvement she was still in J's assessment are outlined in Table 3, and hopeful her injury would improve with time. She described in Appendix 1. NZ Journal of Physiotherapy – March 2008, Vol. 36 (1) Table 3. Outcome Measures Initial Assessment Mid ABP – 6 weeks •Timed Up and Go •(Noonan and Dean, •2000) •10 metre Walk •(Richards and Malouin, •1995): 1 minute 57 seconds. seconds. J's gait seconds. J's gait J's gait became more became slower on laboured and slow on laboured and slow the second 100m the second 100m and and she developed pain increased to 8/10 on completion.
increased to 8/10 on completion.
increased to 7/10 on completion.
•Dynamic Balance •Test (Hill, Bernahrdt, •McGann, Maltese, and •Berkovits, 1996) •Stepping on and off a J did not want to J achieved this with lead with her right right foot, but she still had difficulty difficulty pushing pushing up to get onto the step. She the step. She also had poor balance had poor balance •Lower Extremity 16/80 indicating not repeated.
33/80 indicating a 41% 40/80 indicating •Functional Score level of function.
11 minutes 51 seconds with only a slight limp at the end and a pain rating of 6/10. J was delighted with this result and had surprised herself with the ease that she had been able to achieve the walk.
Assessment Summary/Findings frustrated she was no longer able to be as fastidious J has both psychosocial and functional problems in her house and found it difficult to pace activities associated with her ongoing pain which needed to as previously she would have cleaned her whole house in one go.
From a psychosocial approach she is in a J's current social situation, recent surgery on traumatic and abusive relationship that she is her left foot and fear avoidance behaviours would leaving. She does not feel unsafe, although fears be perpetuating her problem.
she may still be likely to suffer from both physical Functionally J has developed a poor gait pattern, and verbal abuse. and along with poor joint biomechanics (Travell She has lost significant confidence, general fitness and Simon, 1983; Donatelli et al, 1988) this was and is no longer socialising. J is demonstrating stressing the medial arch and soft tissues of her activity related fear avoidance behaviours (Linton foot and medial calf resulting in active trigger points 1999, Robinson and Riley 1999), such as not (Travell and Simon, 1983).
walking further than is necessary. She no longer Several Yellow flags (Kendal et al, 2003) were dances and has stopped all sporting activities. J felt identified as part of J's Assessment.
NZ Journal of Physiotherapy – March 2008, Vol. 36 (1) and Simon, 1983). In this situation, the active 1. Attitudes and Beliefs about the pain – Fear triggers in J's medial gastrocnemius are referring pain to her medial instep. This trigger point may 2. Behaviours – Use of extended rest.
also cause nocturnal pain (Travell and Simon, - Reduced activity and withdrawal 1983), and to a lessor extent the trigger point in her from activities of daily life.
soleus. Trigger points from soleus refer primarily - Sleep quality reduced since onset to the heel with some pain in the medial calf and also restrict dorsiflexion (Travell and Simon, 1983). 3. Emotions – anxiety or heightened awareness of Finally the trigger point in flexor digitorum longus (Travell and Simon, 1983) has a referral pattern to the lateral border of the foot with some pain in the 4. Family – Extent of support in attempts to return lateral calf.
to normal activities, including work.
As a result of the excessive pronation of J's talus - History of abuse.
the rigid lever required for push off is unable to These needed to be addressed for her rehabilitation be achieved (Travell and Simon, 1983; Donatellei plan to be effective.
et al 1988), thus decreasing forefoot stability and J was living in a dysfunctional abusive relationship flexor stabilisation. Flexor digitorum longus in turn (Robinson and Riley, 1999; Turk and Okifuji, 2002) acts earlier and longer in an attempt to stabilise and it has been shown that there is an "increased the forefoot (Travell and Simon, 1983). It could risk for the negative emotion….to the effects of be hypothesised that this is the reason for active a patient's social interactions and interpersonal triggers in J's flexor digitorum longus.
relationships" (Robinson and Riley, 1999, p.81). "In Coupled with poor joint function, weak muscles addition, marital dissatisfaction and conflict have and poor fitness, J was adding to the pre-existing been linked to poor patient adaptation to chronic fear avoidance issues associated with her chronic pain" (Robinson and Riley, 1999, p.81).
J was stressed about her relationship and her pending separation as well as the fact she was PHYSIOTHERAPY INTERVENTION again going to be alone. As a result J could have On receipt of the report, J's ACC Case Manager an increase in her pain response and lowered referred her back to me to provide the recommended coping mechanisms and strategies (Melzak R, 1999; Boothby J, Stratford PW, Stroud MW et al, 1999). It was decided that local treatment would be This would have an additive factor to the emotional undertaken prior to the Activity Based Programme. factors that co-exist with her chronic pain.
The rationale for this was to ascertain whether we J was an over-achiever who always took a pride would gain a change in J's pain status and, also, to in her house and garden and this contributed to a allow time to address the fear avoidance issues and significant loss of her self esteem (Linton, 1999). In discuss ways of self help for pain management.
addition, she had the loss of her third relationship, Initially J was fitted with custom made orthotics the loss of a daughter in law, and the loss of her for her walking shoes that addressed her specific employment to contend with. She had lost social biomechanical needs with fore and rearfoot wedging. contact with a lot of her friends. Her main social A comfort insole with arch support was fitted into contact was her immediate family, where she also J's casual shoes. The orthotics made an immediate undertook a significant supporting role.
difference to the way J was able to weightbear and J had developed fear-avoidance behaviours walk, however, no change in pain was noticed.
(Butler and Mosely, 2003; Nicholas et al, 2001; Local trigger point release of massage and dry Vlaeyen and Linton 2000) that need to be addressed needling (Travell and Simon, 1983) were used to to enable her to achieve her goal of increased address the active trigger points. During treatment, socialisation and activity.
J's lateral foot pain was reproduced indicating To allow J to get to sleep more readily and refocus this to be a source of some of the pain she her thoughts away from pain the development experienced. Trigger point treatment was followed of relaxation techniques (Winterowd, 2003), including distraction and imagery would be helpful. Acupuncture was based on a Western approach, In addition, the occupational therapist could addressing the acupuncture channels along the educate J on strategies to improve sleep hygiene. trigger points with local needles to stimulate These strategies are well documented in Dr Glen the release of, beta endorphins, norepinephrine, Johnson's online book Traumatic Brain Injury serotonin, histamine and GABA (Lundeburg, Guide (2007).
1998; Baldry, 1993). The master point of muscle In addition, to the psychological factors that and tendon GB34 was also needled to promote could be relating to J's chronic pain she had some healing and increase Qi (Maciocai, 1989). Needles biomechanical issues that would be beneficially were inserted and Qi achieved and with further stimulation were left in for 20 minutes.
Trigger points are known to refer pain to sites Treatment was scheduled on a weekly basis. away from the location of the trigger point (Travell After 4 treatments J reported a decrease in her NZ Journal of Physiotherapy – March 2008, Vol. 36 (1) medial calf and lateral foot pain, with pain becoming At the six week point of her programme she localised to her heel. The intensity of pain had not was reassessed using the functional outcomes changed, however, her activity had increased and previously used and her goals were reviewed. As J she had a decreased fear of activity.
had not achieved the planned level of independent During this time a cognitive behavioural walking a 1.5km walk was also undertaken. approach (Sharp, 2001; Thompson, 2005) was However, J's results indicated a significant level of taken to encourage J to increase her level of activity. improvement of function as reported in Table 3.
Discussion around the issues of what chronic pain The next week at the gym, J reported that she is and the Gate-Control Theory (Melzak and Wall, had increased her walking and had achieved 50 1996) of pain was undertaken.
minutes. She kept to the grass and was more After 7 treatments it was decided, in consultation confident on uneven surfaces. Over the next 5 with J and the clinical psychologist, that the weeks J continued to walk for an hour most days, Activity Based Programme would commence. The attended the gym 2-3 times a week and had begun initial functional assessments were repeated to to socialise. She had also walked on hills and was gain baseline performance measures to enable very positive about her progress.
assessment of J's progress. Results can be seen On completion, J had again made progress with the functional assessments undertaken (Table 3). The following goals were set by J to be achieved She reported that when caught in rain she had been within the 12 week time frame able to run to avoid it, and although painful, it had not remained so. J had much less difficulty doing minutes at 6/52 and at 12/52 will be able to many activities including light household chores walk for 60 minutes. and had started to feel confident to tackle heavier activities. Pain scores were not discussed at this regained recovery to her "normal" level after stage as J was no longer focusing on the pain. A review of the goals that J had set indicated that she had achieved them all. In addition she had been out to the driving range with an iron to practice, as well as caddying for 5 holes while away with friends for a weekend. She planned to join a nine hole golf competition. Overall she was pleased The goals were to be achieved through a gym with the outcome and had regained a positive based programme and an independent walking and outlook on life. home exercise programme.
She attributed her progress to a number of things J was taken to a local gym and I set up a but particularly felt the use of orthotics has enabled programme, teaching all the exercises. Exercises her to walk in a much improved pattern with a were chosen that would minimise the need to fully decreased stretch on her muscles and tendons. weightbear, but would strengthen all muscle groups This gave her confidence to be able to walk further as well as increase J's joint proprioception to help without the fear that her limp and pain would with her ability to walk on uneven ground. Weight prevent her from getting home.
training was followed by a progressive low impact cardiovascular programme. Multidisciplinary Care J attended the gym 2-3 times a week and I Due to the number of underlying psychosocial monitored and progressed her programme on factors that were likely to be impacting on her a weekly basis. Time was spent discussing the pain levels and on her ability to cope with these, progress of her independent walking programme it is less likely physiotherapy alone would have and monitoring her home-based exercises, as well achieved such a good outcome (Dersch et al, 2002). as encouraging an increase in functional activity The treatment approach utilised by the clinical with task setting (Beattie, 2001; Vlaeyen and psychologist was that of a Cognitive Behavioural Linton, 2000) to help diminish the fear of walking. Therapy model and addressed J's grief and For example, she was asked to park her car some loss from leaving her relationship, symptoms of distance from the corner store and walk to and depression, fear avoidance and social isolation. The from the shop. Daily walking was undertaken on occupational therapist's intervention was aimed to a distance contingent basis starting with a block assist J with self management strategies for task walk and progressing from there.
simplification, pacing of activities, relaxation and J attended a further two times for local treatment, at sleep hygiene.
which time she had latent trigger points with localised With appropriate communication between heel pain. During treatment discussion centred on providers I was able to complement these strategies pacing and the increased activity she achieved in during her therapy sessions and gained a trust that her new home and garden. In conjunction with her enabled us to challenge J to undertake more activity concurrent psychological therapy her outlook had and overcome the isolation and low self esteem that become more positive and she demonstrated fewer had developed as a result of her chronic pain and fear avoidance behaviours.
relationship breakdown. NZ Journal of Physiotherapy – March 2008, Vol. 36 (1) Linton SJ (1999): Prevention with Special Reference to Chronic This case report has demonstrated the complexity Musculoskeletal Disorders In: Psychosocial Factors in Pain. New York, London: The Guilford Press. of disability attributable to chronic pain. Pain, fear Lundeburg T (1998): course notes: A practical approach to and sleep were addressed by the physiotherapist, neurophysiology based acupuncture, Christchurch New occupational therapist and clinical psychologist Maciocai G (1989): The Foundations of Chinese Medicine A respectively. The team approach was valuable comprehensive text for acupuncturists and herbalists. in managing the assessment, planning and goal Edinburgh, London, Melbourne, New York: Churchill setting for the complex situation. By utilising a Melzak R (1999) Pain and Stress: A New Perspective In: cohesive multidisciplinary approach a positive Psychosocial Factors in Pain New York, London The Guilford and rewarding clinical outcome was achieved for all concerned.
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completing this test which was therefore deemed Dersh J, Polatin PB and Gatchel RJ (2002): Chronic pain to be an appropriate measure to undertake.
and psychopathology: research findings and theoretical considerations. Psychosomatic Medicine 64:773-786 Jensen I B, Bergstrom G, Ljungquist et al (2005): A 3-year follow- 10 metre Walk (Richards and Malouin, 1995): up of a multidisciplinary rehabilitation programme for back This test measures maximum walking speed over and neck pain. Pain xx: 1-11 a set distance and the results are compared against Hill K, Bernhardt J and McGann et al (1996) A new test of dynamic standing balance for stroke patients: reliability, those of the same client.
validity and comparisons with healthy elderly Canadian Journal of Physiotherapy 48:257-262.
Kendall N et al. (2003): ACC New Zealand Acute Low Back Guidelines incorporating the Guide to Assessing Psychosocial This was set as a specific measurable distance to Yellow Flags in Pain in Acute Low Back Pain Wellington New assess J's walking speed and was able to be repeated Zealand, New Zealand Guidelines Group.
on a regular basis. This test gave J encouragement NZ Journal of Physiotherapy – March 2008, Vol. 36 (1) to see how she was improving as well as offering Lower Extremity Functional Scale: observation of her pattern of walking. This looks at twenty general activities related to function in the lower limb, and is completed by the Dynamic Balance Test (Hill, Bernahrdt et al client. Items are scaled on a five point scale 0 = extreme difficulty or unable to perform This test is used to assess the patient's ability to 4 = no difficulty step up and down of a 700mm step and assesses The maximum score is 80 and it has been joint proprioception and balance. The assessment assessed to have an error of +/- 5 scale points at is based on construct validity and in J's case it a 90% confidence interval (Binkley, 1999). In J's was chosen as she did not like walking on uneven case, we achieved a 24 point difference which was ground and found steps and stairs difficult. It was therefore clinically significant. It proved a useful tool a measurable and repeatable test that was able to for assessing J's initial level of function, on=going assess changes in function and also expose J to a progress, and completion outcome as well as being task she was not confident in undertaking.
helpful in setting functional goals.
NZ Journal of Physiotherapy – March 2008, Vol. 36 (1)

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