E Dysvik

et al.

International Journal of Nursing Practice 2004; 10: 224–234

✠ RESEARCH PAPER ✠

The effectiveness of a multidisciplinary pain

management programme managing chronic pain
Elin Dysvik RN MSc
Assistant Professor, School of Health and Social Work Education, Stavanger University College, Stavanger, Norway

Anne Guttormsen Vinsnes RN MPH PhD

Associate Professor, Faculty of Nursing, Sør-Trøndelag University College, Trondheim, Norway, and Associate Professor, Institute of Health Education,
Stavanger University College, Stavanger, Norway

Ole-Johan Eikeland MSc

Director, Eikeland Research and Teaching, Bergen, Norway

Accepted for publication June 2004

Dysvik E, Guttormsen Vinsnes A, Eikeland O.-J. International Journal of Nursing Practice 2004; 10: 224–234
The effectiveness of a multidisciplinary pain management programme managing chronic pain

The aim of this study was to develop and evaluate the effects of a multidisciplinary pain management programme on cop-
ing, health-related quality of life and pain intensity. Seventy-six outpatients suffering from chronic pain completed this
eight-week programme with the primary aims to increase coping, as measured by the Ways of Coping Checklist, and
health-related quality of life, as measured by the Short Form-36 Health Survey. Therapeutic dialogues and education, com-
bined with physical activity, were given in order to increase understanding of and attention to non-medical factors that
might affect pain perception. The programme was active, time-limited and structured on the basis of multidisciplinary pain
management programmes based on a cognitive–behavioural approach. The findings suggest that this programme has the
potential to improve coping skills and health-related quality of life. Additionally, pain intensity, as measured by the Visual
Analogue Scale, was reduced. Age and disability were revealed as the prominent predictors of change after treatment. The
differences in this sample indicated that the drop-outs tended to be older and reported more health problems, although
these findings were non-significant. Clinical and research implications are discussed.
Key words: chronic pain, coping, health-related quality of life, multidisciplinary pain management programme.

INTRODUCTION It is not clear whether this is related to an increasing prev-

Multidisciplinary and cross-cultural research has identi-
fied chronic pain as a major health problem.1–4 Despite
advances in understanding of nociception, as well as sur-
gical and pharmacological advances, satisfactory elimina-
tion of pain remains a challenge for health professionals.5
Correspondence: Elin Dysvik, Assistant Professor, Institute of Health
Education, Stavanger University College, Stavanger 4068, Norway.
Email: elin.dysvik@hs.his.no
alence of pain, a decreasing tolerance of pain or the fact that
the concept of pain has been enlarged, allowing existential
problems to be included.1 In order to treat chronic pain
successfully, a multidisciplinary approach comprising psy-
chosocial and behavioural factors that might influence the
responses to chronic pain seems necessary.6 Another factor
to consider is that people develop their individual belief
models of pain, including understanding and response.7
The formulation of the Gate Control Theory (GCT) of
pain by Melzack and Wall, and the continued work by
Multidisciplinary pain management
these authors, reflects a change away from viewing pain
solely as a nociceptive phenomenon towards taking into
account the many, diverse factors in pain perception.8–9
According to the GCT, the sensory–discriminative
component reflects location, severity and quality of the
stimulus that leads to pain. The affective–motivational
component refers to feelings of unpleasantness, distress
and threat. The third component, described as cognitive–
evaluative, refers to the patients’ attitudes and beliefs
about pain. The GCT was further extended so that social
factors are also taken into account, which underlies the
current understanding of the biopsychosocial model of
pain.6 This understanding suggests that rehabilitation pro-
grammes should have a holistic perspective where not
only physiological factors, but also psychological and
social factors, are considered. From the growing accep-
tance of this perspective on chronic pain, multidisci-
plinary treatment programmes have been developed.
Hence, pain might influence both coping strategies and
health-related quality of life (HRQL) domains. Efforts to
assess these variables and to determine whether they are
amenable to change after intervention were considered
crucial in the current multidisciplinary pain management
programme.
Coping is considered to be an important component in
multidisciplinary treatment programmes. Models of stress
and coping have been recognized as useful in explaining
coping strategies to predict adjustment to chronic pain.10–11
According to Lazarus and Folkman,12 coping is defined as
constantly changing cognitive and behavioural efforts to
manage specific external or internal demands that are
appraised as exceeding the resources of the person.
Applying this definition to the participants suffering from
chronic pain, one could say that coping constitutes all strat-
egies that are used to minimize threats to the person’s
integrity and emotional state and to maximize body
function.
Health-related quality of life is a multidimensional the-
oretical construct reflecting an individual’s global physical
and mental well-being.13 As an outcome measure, the
impact of chronic pain and its treatment on emotional,
physical and social functioning are addressed.Within med-
ical and caring sciences, improving the overall quality of
life is an important outcome of interventions, particularly
for persons suffering from chronic conditions, such as
pain.14 In this study, HRQL is measured to provide a sub-
jective, patient-led baseline where effects of this interven-
tion programme can be evaluated.
225
Multidisciplinary pain management programmes
employ various cognitive and behavioural approaches
(CBT) commonly used in psychology, physical therapy
and occupational therapy.15 Major aims are to improve
physical function, coping skills and quality of life in
patients suffering from chronic pain. The three dimen-
sions derived from GCT can be used to select potentially
powerful treatments for pain. The sensory–discriminative
dimension implies that muscle tension magnifies the expe-
rience of pain, so relaxation training and physical activity
might be useful. The affective–motivational dimension
indicates that negative and positive feelings can, respec-
tively, increase or decrease one’s perception of pain. Pro-
cedures based on distraction might address this dimension
beneficially. Finally, identifying and changing thoughts and
beliefs that underpin maladaptive behaviour and adversely
affect mood relate to the cognitive–evaluative dimension.
The classification of psychological treatment for pain in
this manner might permit greater conceptual clarity in
pain research and development of treatment programmes,
as each dimension of pain is addressed.16
The effectiveness of multidisciplinary pain manage-
ment programmes has been documented in reviews.17–18
However, the effectiveness might depend on several fac-
tors, such as the supervisors’ competence, intervention
components and patient characteristics.19 Methodological
limitations, such as recruitment problems, drop-outs and
relapse, are commonly reported.20 Other difficulties refer
to designing suitable controls18 and the uncertainty of
knowing which elements of the programme are most or
least successful.2
Based on CBT and previous research, a major aim of
this study was to develop a multidisciplinary pain man-
agement programme given in line with available resources
in this region. Furthermore, as cost-effectiveness is a
major aim in health care, the results were to be evaluated
by considering which persons could benefit from this
programme. Results, as well as feasibility, were to be
considered before implementation. On the basis of
these considerations, we hypothesized that: (i) a
multidisciplinary pain management programme would
be effective in improving coping and HRQL, and
decreasing pain intensity; and (ii) the drop-outs would
differ systematically due to age, employment, pain
duration, pain intensity, coping and HRQL and, thus,
were less suitable for participation. Lastly, we also
wanted to evaluate patient satisfaction with this
programme.
226 E Dysvik et al.

METHODS The average age of the participants was 47 years (range

Participants
Initially, a pilot study (n = 7) was conducted to validate
the feasibility of the multidisciplinary pain management
programme and the appropriateness of the chosen
questionnaires. Based on these evaluations, a consecutive
sample of 88 outpatients was included in this quasi-exper-
imental design. The participants were recruited through
their general practitioners and their home county was
considered representative of Norway for this purpose.
They met the following inclusion criteria: (i) aged from
18–67 years; (ii) chronic, non-malignant pain lasting for
> 6 months; (iii) medical investigation and/or treatment
completed prior to referral; (iv) motivation to participate
in an active rehabilitation programme; (v) no ongoing lit-
igation due to their pain problem; and (vi) attendance of
≥ 5 group sessions. All together, 76 participants fulfilled
the programme criteria.
Prior to inclusion, all patients had undergone a medi-
cal evaluation. All patients were fully informed about the
programme, including expectations and obligations, dur-
ing a clinical interview with one of the therapists. In
addition, written instructions were handed out. It was
emphasized that participation was voluntary and that the
participants could leave the programme at any time.
Confidentiality was guaranteed and a written consent
form was obtained at inclusion. The study was approved
by the Regional Ethical Committee and The Data Inspec-
torate and was conducted in accordance with the
Helsinki Declaration.21
27–66 years). There were 73 females and 15 males. The
sample included 21 widows, widowers or single people.
Information on educational status showed that 31% had
completed compulsory school education, 39% had com-
pleted upper secondary school and 30% had some college
or university education. Also, 20% were currently
employed either full or part-time while 24% of the sam-
ple was on sick leave. Furthermore, 24% were engaged in
retraining programmes and 32% were receiving disability
compensation due to their pain problem. The mean sever-
ity of pain using the Visual Analogue Scale (VAS) was
67 mm. The average time period since diagnosis related to
their pain problem was 10 years (range 1–46 years). The
participants suffered from a variety of pain complaints,
such as musculoskeletal pain (57%), headaches (16%),
abdominal/pelvic pain (13%), whiplash injury (7%), and
7% of the sample represented different conditions related
to neuropathic pain.
Treatment procedure
The intervention programme was active, time-limited and
structured on the basis of multidisciplinary pain manage-
ment programmes based on CBT.2,16,22 Table 1 lists the
topics covered in the course. The three important com-
ponents in the comprehensive programme were therapeu-
tic dialogue, physical activity and education. Self-help
educational material described as tools was developed
according to the theoretical framework of Brattberg23 and
the pain dimensions in the GCT. In total, 10 groups con-

Table 1 Topics covered in the course

Session Topics Homework

1 Establishment of the group Develop own goals

Goals
2 Physical activity and pain
3 Pain as a complex phenomenon
4 Muscle tension, relaxation and pain
5 Coping and pain
6 Self-esteem, social network and pain
7 Thoughts, feelings and behaviour
8 Communication
Self-help
Develop own plan for activity
Awareness of factors increasing/decreasing pain
Awareness of muscle relaxation and tension
Practice in relaxation techniques
Awareness of coping strategies and alternative ways of coping
Awareness of self-esteem, social network and alternative ways of behaving
Awareness of the relationship between thoughts, feelings and behaviour
Awareness of important factors in communication
How to continue working
Summing-up
Multidisciplinary pain management
sisting of 8–12 participants were offered this programme.
Each group, together with two supervisors, met for 3 h
per week for eight weeks. The supervisors involved were
a psychologist, a physiotherapist, a physician, two nurses
and an occupational therapist. The groups were conducted
according to a structured protocol.
The main goal was for patients to gain knowledge
and skills to improve coping and quality of life. The
basic assumptions were patients’ active participation and
collaboration with the supervisors, and that pain is con-
sidered to be an integral part of life, consisting of cog-
nitive, emotional and social elements. Thus, being
familiar with this overall philosophy, methods and goals
was considered crucial for improvement among the
participants.
The main question directed to the participants was:
‘What do you need to do differently to decrease pain and
improve coping skills and HRQL?’ Another main question
was directed towards the supervisors: ‘How can we help
the participants to interpret their pain and present the
tools in such a way that more effective coping strategies
can be integrated in daily life?’ The main emphasis for the
supervisors was to actively structure the group and pro-
vide an atmosphere of comfort and acceptance. Each ses-
sion began by giving a brief summary of the last group
meeting, followed by sharing positive experiences from
last week. A review of the group members’ practice at
home served as a basis for the therapeutic dialogue. Phys-
ical activity was the second part of the session and was
extended gradually. The third part of each session in-
cluded education with corresponding homework for the
next week.
MEASURES
Data were routinely collected before and after the treat-
ment period. The following instruments were used in the
data collections.
Assessment of the drop-outs’ suitability
for the course
The supervisors were asked to evaluate whether the drop-
outs were considered suitable for the course according to
a three-point Likert scale (1 = suitable, 2 = partly suit-
able, 3 = not suitable).
Assessment of pain intensity
To assess pain intensity, The VAS was used.24 This scale is a
100-mm horizontal line. The left end is defined as ‘no
227
pain’ and the right as ‘severe pain’ (100 mm). The patients
were asked to mark the line at a point corresponding to
the severity of their pain experience. Particular advan-
tages of the VAS are its sensitivity, simplicity, reproduc-
ibility and universality.24
Assessment of coping
To assess coping, the 42-item version of the Ways of
Coping Checklist (WCCL)25 was administered, which
derives from Lazarus and Folkman’s transactional model
of stress and coping.12 This instrument measures coping
in terms of what a person thinks in response to the
demands of a stressful encounter. The checklist consists
of one scale of problem-focused coping, three scales of
emotion-focused coping, being wishful thinking, self-
blame and avoidance, and one scale of social support.
The guidelines require that the participants focus on a
stressful situation in the previous week and respond to
each item on a four-point scale (0 = not used to
3 = used very much) regarding the degree to which a
coping strategy was used to deal with the situation.
High scores indicate more use of the relevant coping
strategy.
Assessment of health-related
quality of life
The Short Form Health Survey (SF-36)13 is a frequently
used measure of HRQL. Norm-based comparisons are
available.26 The instrument has been validated and tested
for reliability in several international studies.27 The SF-
36 is considered useful in measuring changes in clinical
treatments.28 Eight scales are included, measuring physi-
cal functioning, physical role (referring to limitations in
daily activities), bodily pain, general health, vitality,
social functioning, emotional role (referring to limita-
tions in daily activities) and mental health. An addi-
tional item reports health transition over the past year.
Two global scores, physical health and mental health,
can be calculated.29 The higher the score, the better the
HRQL.
Assessment of quality of life
within five years
Assessment of quality of life within five years was mea-
sured by Cantril’s ladder to gain knowledge about
future expectations.30 The scale is depicted as a ladder
and permits the individual to identify the best and the
228 E Dysvik et al.

worst possible life situation that is reflective of quality RESULTS

of life.
Assessment of patient satisfaction
Patient satisfaction was measured on a three-point Likert
scale (1 = little extent to 3 = great extent) and was related
to the therapeutic dialogue, physical activity, education,
homework, own contributions and the total course.
Statistical analyses
Simple frequency distributions were used to describe the
data computed by SPSS (SPSS, Chicago, USA). Paired t-
tests were used to identify items where significant changes
had taken place and corresponding d-values (effect size)
were computed.31,32 Multifactor ANOVA (MANOVA) was
used to reveal variables predicting significant change.
Results of the t-tests, comparing pretest and post-test
scores on coping, pain intensity and HRQL, are presented
in Table 2. As this table indicates, significant improve-
ments were related to problem-focused and emotion-
focused coping, as well as the avoidance subscale in
WCCL. There was also significant reduction in pain inten-
sity measured by VAS. As regards SF-36 data, global men-
tal health was improved as well as the subscale scores
labelled mental health, vitality, social functioning, physical
functioning and health transition. When comparing pre-
test scores between participants (n = 75) and drop-outs
(n = 13), the drop-outs seemed to be slightly older than
the compliance group (51.5 years vs 45.7 years), reported
higher pain intensity (76.2 mm vs 66 mm), a higher per-
centage of disability (53.9% vs 37.3%) and they also

Table 2 Paired t-tests comparing pretest and post-test scores of coping (WCCL), pain intensity (VAS) and health-related quality of life
(SF-36)

Outcome measure Pretest Post-test P d-value

Mean SD Mean SD

Coping
Problem-focused† 1.1 0.4 1.2 0.5 0.01 0.22
Emotion-focused† 1.1 0.5 1.0 0.5 0.02 -0.20
Wishing 1.4 0.7 1.3 0.7 NS –
Self-blame 0.7 0.7 0.8 0.7 NS –
Avoidance 1.0 0.5 0.9 0.5 0.01 -0.20
Social support 1.2 0.6 1.3 0.7 NS –
Pain intensity
VAS 66.0 18.8 61.6 20.8 0.03 -0.22
Health-related quality of life
Physical health† 26.5 7.8 27.8 8.7 NS –
Mental health† 43.9 11.4 46.5 11.4 0.00 0.23
Mental health 64.7 18.3 69.7 17.5 0.00 0.28
Vitality 33.7 20.8 39.2 20.8 0.02 0.26
Bodily pain 24.6 13.9 29.8 17.2 0.00 0.35
General health 40.8 24.3 43.4 24.0 NS –
Social function 52.0 22.5 60.8 22.0 0.00 0.40
Physical function 50.3 24.4 55.0 23.1 0.00 0.20
Physical role 7.0 19.0 9.0 23.1 NS –
Emotional role 50.7 44.6 54.2 44.8 NS –
Health transition 50.4 27.2 55.7 29.0 0.05 0.19

†
Sum score/global score; n = 75; degrees of freedom = 74 for all tests; SD, standard deviation; d-value, effect size; * P > 0.05; NS, not
significant; WCCL, Ways of Coping Checklist; VAS, Visual Analogue Scale; SF-36, Short Form Health Survey.
Multidisciplinary pain management 229

expected their quality of life (as measured by Cantril’s
nine-steps ladder30) to be lower within five years (5.5 vs
6.2), despite the fact that the different t-values were not
significant. The corresponding effect size was, however,
0.56, 0.55 (medium) and 0.35, 0.37 (small). According
to Polit, this should be taken seriously when dealing with
small groups.31,32
A multifactor ANOVA was used to examine differences
in the effectiveness of intervention with respect to the
patients’ gender, age, participation, levels of disability and
future expectations of quality of life. The multifactor
ANOVA summary table (Table 3) indicates that gender had
no treatment effect on post-test scores on HRQL, coping
and pain intensity. However, there was a significant treat-
ment interaction on mental health from age (F (1,
68) = 4.72, P < 0.03). Significant treatment interactions
from disability on physical health (F (1, 68) = 4.07,
P < 0.05) and problem-focused coping (F (1, 65) = 9.81,
P < 0.00) were also found.
Patient evaluation of the pain management programme
(Table 4) revealed that 61% of the group was satisfied to a
large extent. The therapeutic dialogue seemed to be the
most successful component of the programme. The home-
work, however, seemed to be the least appreciated com-
ponent. Only 37% of the participants evaluated their own
contribution to be successful to a great extent.
Evaluation from the supervisors showed that only one
of the drop-outs was considered well-suited to participa-
tion. The rest were considered less suitable as they had
severe physical and psychosocial problems.

Table 3 Multifactor ANOVA summary table for analysis of post-test scores on health-related quality of life global scores (physical and mental
health; SF-36), coping sum scores (WCCL) and pain intensity (VAS)

Post-test Physical health Mental health Problem-focused Emotion-focused Pain intensity

coping coping

F P F P F P F P F P

Pretest 71.32 0.00 47.24 0.00 13.30 0.00 58.66 0.00 45.45 0.00
Gender 3.51 0.07 1.29 0.26 2.08 0.16 0.44 0.51 0.86 0.36
Age 0.03 0.88 4.72 0.03 0.42 0.84 0.03 0.87 0.29 0.59
Participation 1.61 0.21 3.57 0.06 1.52 0.22 3.04 0.09 0.00 0.99
Disability 4.07 0.05 0.04 0.85 9.81 0.00 1.30 0.26 0.01 0.93
Expectations 0.63 0.43 0.31 0.58 3.36 0.07 0.02 0.88 2.31 0.13

n = 75; * P > 0.05; WCCL, Ways of Coping Checklist; VAS, Visual Analogue Scale; SF-36, Short Form Health Survey.

Table 4 Participant satisfaction with the pain management programme (n = 76)

Degree of satisfaction Great extent Moderate extent Little extent

N % N % N %

Therapeutic dialogue 49 64 22 29 5 7
Physical activity 40 53 29 38 7 9
Education 42 55 31 41 3 4
Homework† 32 43 36 48 7 9
Own contribution 28 37 43 57 5 6
Total course 46 61 26 34 4 5

†
n = 75.
230
DISCUSSION
The major aim of this study was to develop and evaluate
the effects of a multidisciplinary pain management pro-
gramme aimed at providing patients suffering from
chronic pain with information and skills to improve HRQL
and coping. The findings are in line with our hypotheses.
Outcome measures indicate that this programme has the
potential to improve coping skills and HRQL and to
reduce pain intensity. More specifically, problem-focused
coping, which focuses on active participation in the pro-
gramme and the use of problem solving methods, was
improved. However, emotion-focused coping, including
the avoidance subscale, was reduced. This reflects less use
of passive coping strategies, which have been associated
with dysfunction in several studies.12 Less use of emotion-
focused coping is also consistent with improvement in the
global mental component of HRQL. However, the global
physical component of HRQL remained unchanged. Upon
closer investigation of the subscales within this dimension,
improvements in physical functioning and role perfor-
mance were revealed.This result might indicate that global
scores, as well as subscale scores, should be considered in
order to reveal exact changes related to intervention.
Pain intensity was also reduced. However, the clinical
importance of this result will depend on the characteris-
tics of the condition being treated.33 Considering the
6.7%/17.4% pain reduction after the eight-week
courses, the corresponding effect sizes and the length of
time spent reporting chronic pain, this result clearly indi-
cates a positive direction. According to Dworkin et al.,
treatment that both relieves pain and improves HRQL has
a greater value than pain reduction alone.33
Lastly, participants experienced better health at the
time of investigation than in the previous year, which
might be an important motivational factor in active par-
ticipation leading to success. These changes might repre-
sent participants’ increased understanding of the multiple
aspects of pain, including what they believe is the cause
and what they think will help.
Group approaches offered to chronic pain patients are
common and give several benefits, such as mutual sup-
port, feedback and active participation.34 Numerous
variables have also been identified in prior research as
potentially important predictors of successful participa-
tion. When controlling for covariates by multifactor
ANOVA in this study, few variables predicting significant
change were found. Among these variables, gender did
not appear to be a significant predictor of outcome, which
E Dysvik et al.
also has been demonstrated by others.35 This finding sug-
gests that the programme is tailored to meet the needs of
both men and women. However, age did predict improve-
ment in mental health, which might relate to maturity,
willingness to acknowledge and change the negative emo-
tional components of pain and acceptance.
In this study, the effect of treatment on physical health
and problem-focused coping seemed to increase by the
level of disability. The disability pension has been a com-
mon reason for treatment resistance.20 Contrary to our
expectations, disability and receiving a disability pension
might represent financial security and acceptance, so that
the participants’ energy was more directed towards active
participation and problem-solving. The effect of treatment
on mental health also seems to increase by the level of dis-
ability. It could be argued that those with the most severe
conditions are likely to benefit from the early stage of the
programme as this result relates to less distress and limi-
tations in social role activities.
The participants were encouraged to attend all sessions
in order to ensure the continuity of the programme and
maintenance of group stability. Thus, patients who took
part in fewer than five sessions were excluded from this
study. However, participation was not a significant predic-
tor of change. The minimum attendance limit might
indicate that satisfactory progression and adherence was
established by reports from each group meeting and oblig-
atory homework.
Drop-outs
It is commonly known that patients with chronic pain
differ in terms of their ability to benefit from group
approaches and high drop-out rates are reported.20 Thus,
it is important to maintain the participants’ adherence to
the programme. As cost-effectiveness is a major aim in
health care, the drop-out group was investigated on sev-
eral variables to further investigate who might benefit
from this programme.
Contrary to our expectations, few obvious differences
were observed between the drop-outs and those who ful-
filled the course when considering significance and d-
values. This might be explained by the inclusion criteria,
which made the two groups quite homogeneous, and rea-
sons for drop-out are reported in more complex patterns
than can easily be captured by the instruments. The dif-
ferences in this sample indicate that the drop-outs tended
to be older and reported more health problems, although
these findings were not significant. These findings might
Multidisciplinary pain management
indicate that less motivation and hope for future health
improvements are present in this group. This tendency
also was supported by the participants’ supervisors, who
reported that only one person within the drop-out group
was considered well-suited for participation. The remain-
ing persons were considered less suitable or not suitable
for participation because of severe physical, emotional and
social difficulties.
According to Keefe et al., patients who are extremely
angry, have an extreme fear of social situations or who are
severely depressed might be poor candidates for group
approaches.34 As these problems were not revealed in the
screening test, this might suggest that changes had taken
place after initiation or that the inclusion criteria should
be considered more closely.
Patient evaluation
The participants in this study considered the therapeutic
dialogue to be the most successful component of the pro-
gramme. Several factors might have combined to explain
the participants’ satisfaction with the therapeutic dia-
logue. Their exposure to other group members with sim-
ilar problems might have created a feeling of community
and a better understanding of the different problems
caused by pain. Furthermore, problem-focused methods
were used to identify specific obstacles to practice and to
assist the participants in finding solutions to their prob-
lems. This approach to the pain problem is characterized
as particularly effective in a group setting.34 The partici-
pants also were exposed to a variety of tools describing
different coping skills.23 A positive focus was heavily
emphasized in the beginning of every session. Lastly,
group dynamics were used to strengthen coping, facilitate
learning and encourage a more positive attitude toward
the painful situation and the participants’ own resources.
Many chronic pain patients are physically inactive so
increased physical activity is considered to be particularly
beneficial for this group. Thus, physical activity is a
component often incorporated in multidisciplinary pain
management programmes for overcoming such physical
deconditioning. Our exercise programme was conducted
by the physiotherapist and put great emphasis on stability,
mobility and active exercise training. However, evaluation
of the physical activity session revealed that only 53% of
the participants were satisfied to a large extent, even
though the starting point was at a level that ensured that
everyone could succeed. The reasons might be that phys-
ical activity emphasizes different physical health problems,
231
making exercises difficult and leading to immobility and
increased pain following any movement. Other explana-
tions could be that the participants’ negative attitude
might reflect earlier, unsuccessful physical treatment pro-
grammes. Hence, important information should be fur-
ther emphasized, such as telling the patients that they will
not harm themselves by continuing the exercises and that,
in fact, immobility might be far more harmful for them.36
Thus, the participants should be further encouraged by
explaining the positive results of physical activity.
The majority of the participants claimed to be satisfied
with the education session. Only three participants expre-
ssed minimal benefit from this part, which might mean that
their intellectual capacity and motivation were decreased
or that the ‘noise’ from the pain made it difficult to con-
centrate. Several factors might explain the success of the
education session. A basic assumption underlying the edu-
cation was that improved knowledge and skills might pro-
mote a better adjustment to chronic pain. According to
Turk et al., the main issue was to help the patients recon-
ceptualize their pain problem and their own ability to con-
trol pain.22 Thus, visual aids and handouts describing tools
were used to supplement the education programme.23
Additionally, conceptualizing pain in terms of Melzack and
Wall’s model8 helped the patients to see their pain as a
complex phenomenon and to reveal areas for self-help.
Also, it was assumed that this model would help them focus
on the importance of learning new pain coping skills. The
importance of regular home practice in the development
of effective coping skills was also emphasized, with con-
siderable emphasis on the interaction between thoughts,
feelings and behaviour and their relationship to pain.
However, the majority of the participants were only
moderately satisfied with the corresponding homework,
which might reflect that this part of the programme was
too time-consuming or that feelings of resistance were
provoked. As their homework was also the basis for the
therapeutic dialogue, this part should be evaluated in
more depth in order to further improve the programme.
It was hypothesized that active participation in the
change process would be more likely to contribute to suc-
cessful personal competence. The participants’ own eval-
uations, however, showed that the majority was only
moderately satisfied with their own contribution. This
result could be explained by the fact that the participants’
self-esteem, as well as physical and mental capacity, were
decreased. The evaluation results also might point to the
potential for establishing more trust and encouraging the
232
patients to take greater responsibility in their own reha-
bilitation. However, when evaluating such results, the
supervisors also need to be sensitive to the fact that active
participation might be a new experience for the partici-
pants and that they might be quite sceptical.2
Clinical and research implications
It is well known that group therapists encounter a number
of problems when leading groups consisting of chronic
pain patients. This also was demonstrated while carrying
out these courses, as a variety of levels of functioning and
situations appeared more dramatic in some groups than
others. Although this made it difficult for the group to
establish a common ground for communication and
required a great deal of intervention from the supervisors,
it was an excellent opportunity for patients to learn to be
helpful to others by providing support and role modelling.
Additionally, this group approach provided an opportu-
nity for the supervisors to examine the participants’ inter-
personal communication skills and relationships with
others with different views. Three of the most common
and important problems reported by the supervisors were
dealing with distorted thinking, resistance to change and
high levels of emotional stress.
In summary, our experiences show that a successful
group approach to chronic pain patients requires atten-
tion to a number of important practical and therapeu-
tic issues. Pain perception is a complex phenomenon.
Hence, biological, psychological and social factors
combine and interact in different ways and might con-
tribute to the response to treatment. Our opinion is
that a team approach will maximize the opportunity
for addressing these multiple factors in pain mainte-
nance and disability. In this respect, this programme
provides a framework in which to promote change in
the pain experience by changing pain behaviour and
modifying pain-related thought processes. As the multi-
disciplinary team members represented different pro-
fessions, they also represented different approaches to
the problems. Thus, establishing a common theoretical
basis among the supervisors was considered crucial
for success. Furthermore, in developing such a pro-
gramme, existing treatment alternatives, the availabil-
ity of qualified members for the multidisciplinary
team, facilities and finances are important. According
to our experience, a pilot study is highly recom-
mended and should be considered before implementa-
tion of such programmes.
E Dysvik et al.
Some limitations of this study should be acknowledged.
First, generalization is limited as the sample consisted of
patients referred to a specific rehabilitation programme.
Second, a proper control group was not established, in
spite of attempts to establish waiting list controls. This
might reduce internal validity and limit the conclusions.
However, some of the competing threats had been care-
fully evaluated and compensated for by taking into
account the strengths and limitations. Among these are the
introduction of a pilot study, a structured protocol, con-
secutive referrals and systematic supervision by the
project leader. Despite methodological limitations, it is
important to bear in mind that the major goal of the study
was to establish and evaluate a multidisciplinary pain man-
agement programme in this region, and this goal was
achieved. Lastly, as with other cognitive procedures, it is
not clear which are the critical ingredients of the pro-
gramme and which of them are the most important. More
studies are needed within this field.
CONCLUSION
This study replicates the positive results of others using
similar interventions.17,18 Considering the complexity of
the pain problem treated and the pain management pro-
gramme used, this programme might provide encourag-
ing results such as improved HRQL and coping, and
decreased pain intensity. Age and disability are revealed to
be the prominent predictors of change after treatment.
Few obvious differences were observed between the drop-
outs and those who fulfilled the course. However, relapse
is often reported among this group of patients.20 Ways of
maintaining HRQL and coping would be to encourage the
patients to practice daily and to offer follow-up sessions.
Thus, further research is needed to evaluate the long-term
effect of this pain management programme, which has not
yet been firmly established within CBT approaches.37 Fur-
ther studies should investigate the effect of such rehabili-
tation programmes in a randomized sample, allowing a
more consistent generalization. Although this course is
now successfully implemented in the rehabilitation unit,
further efforts are required to modify the existing pro-
gramme to accommodate the needs of the drop-out
group. We also believe that this approach can be further
developed and differentiated to match the individual
patient’s needs. Considering the fact that a large percent-
age of the population suffers from chronic pain, it is of
vital importance to develop rehabilitation programmes
that are effective, readily available and cost-efficient.
Multidisciplinary pain management
ACKNOWLEDGEMENTS
This study was supported by grants from Rogaland
Central Hospital, Division of Rehabilitation, and Sta-
vanger University College, Norway. We would like to
thank Torbjørn Aarsland, Manager of Hjertelaget
Research Foundation, for setting up the database.
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