DOI: 10.1111/jabr.

12083

C O M M E N TA RY

Improving stress reduction and wellness in

interdisciplinary chronic pain management:
Is transdisciplinary care a better option?

Donald D. McGeary1, | Cindy A. McGeary1 | Paul Nabity1 |

Robert Villarreal1 | Trisha Kivisalu1 | Robert J. Gatchel2

1
Department of Psychiatry, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA
2
Department of Psychology, The University of Texas at Arlington, Arlington, TX, USA

Correspondence
Donald D. McGeary, Department of Psychiatry, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA.
Email: McGeary@uthscsa.edu

1 | INTRODUC TION

Chronic musculoskeletal pain is a growing problem in the United States, and there is significant recognition of the
need for effective treatment options (IOM, 2011). Studies of existing pain management strategies clearly show that
simplistic models of pain management (especially those emphasizing the use of opioid medications to manage chronic
pain) are poorly supported, and the vast majority of chronic pain researchers and clinicians agree that a complex
combination of disciplines is required to meet the challenge and complexity of chronic pain (Reuben et al., 2015). This
recognition has given rise to the study and implementation of chronic pain management services that incorporate
several medical disciplines, often referred to as “multidisciplinary” or “interdisciplinary” chronic pain management
programs. The present Commentary was developed to explore the scope and limitations of these interdisciplinary
pain management programs and offer recommendations based on theory and burgeoning research on how short-
comings of interdisciplinary pain management can be overcome using a new model of care: transdisciplinary Pain
Management.

1.1 | The difference between multidisciplinary and interdisciplinary care

Collaborative teams of pain management professionals range in scope from a simple combination of psychologi-
cal and physical rehabilitation practitioners (Gatchel et al., 2009) to a broad team including physical medicine,
rehabilitation, psychology, biofeedback, nursing, and case management (Stanos & Houle, 2006). Although the
scope of treatment teams varies across multidimensional clinical programs, there has been almost universal
agreement about the need to meaningfully integrate these components into a cohesive program of interven-
tion and research. Examinations of treatment team integration generally classify pain management programs as
either multidisciplinary or interdisciplinary. Although these two terms are often used interchangeably to describe

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206 | McGEARY et al.

a team-­based intervention, multi-­and interdisciplinary treatments differ significantly based on how practitioners
are integrated into the team. Differences in treatment team integration range across multiple domains including:
the extent and nature of communication among the providers; the unification of providers around common goals;
orientation of the providers to theories of rehabilitation; autonomy of treatment among providers; perceived
or practiced hierarchy of the disciplines; and the sharing of knowledge and perspective across providers (see
Table 1).
As shown in Table 1, both multidisciplinary and interdisciplinary models emphasize a team scope including mul-
tiple disciplines in treatment. In multidisciplinary treatment, however, these disciplines generally function inde-
pendently of one another, often with varying treatment goals, theories of rehabilitation, and interactions with the
patient (Jessup, 2007). Multidisciplinary treatment teams tend to be hierarchical, usually led by a physician (Koerner,
2010), and the constituent providers on the multidisciplinary team work in relative isolation from the other team
members with communication between them often limited treatment outcomes only. As a result, multidisciplinary
providers tend to address pain from varying theoretical perspectives, often with varying outcomes. Broad reviews
of multidisciplinary treatment have shown poor cost effectiveness, likely due to variability in treatment approaches
and communication between providers, and lack of appreciation for the value of interdisciplinary skills (Kane & Perry,
2016; Ke et al., 2013).
Interdisciplinary treatment models evolved as a solution to the weaknesses and poor cost-­effectiveness of mul-
tidisciplinary approaches. Contrary with the relative separation of professions on multidisciplinary teams, interdisci-
plinary treatment teams are highly integrated through shared treatment goals, a common understanding or theory
of clinical change, and a collaborative implementation of treatment often involving the sharing of knowledge and
technique (Gatchel, McGeary, McGeary, & Lippe, 2014). An “interdisciplinary approach” begins with collaborative as-
sessment in which metrics and observations are suggested, conducted, and shared among team members throughout
the treatment process in order to frequently update case conceptualizations and monitor outcomes. These common
assessments are rooted in a shared theory of rehabilitation and can be used to guide treatment across the participat-
ing treatment providers. Studies comparing multidisciplinary and interdisciplinary care clearly show better outcomes
for interdisciplinary programs (Koerner, 2010), and interdisciplinary treatment is now recognized as the pinnacle of
chronic pain management. Indeed, hundreds of papers have been published describing the beneficial socioeconomic
outcomes of interdisciplinary chronic pain management (Poulain et al., 2010), the incremental benefit of ICPM after
low back surgery (Caby, Vanvelcenaher, Letombe, & Pelayo, 2010), and the superiority of ICPM to less complex in-
tervention strategies (Roche-­Leboucher et al., 2011). Furthermore, interdisciplinary pain management has even been
shown to be effective in uniquely complex populations like the military (Gatchel et al., 2009; McGeary, McGeary,
Moreno, & Gatchel, 2016; Pujol et al., 2015).

TABLE 1 Dimensions of multidisciplinary and interdisciplinary treatment teams

Dimension Multidisciplinary Interdisciplinary

Scope Multiple disciplines Multiple disciplines

Constituency Multiple providers Multiple providers
Communication Frequent with patient Frequent with patient
Infrequent with other disciplines Frequent with other disciplines
Goals Vary across providers Shared between providers
Theory Vary across providers Shared between providers
Autonomy Independent Dependent and Collaborative
Hierarchy Clear leadership by physician All providers equal
Knowledge Specific to each discipline Shared across disciplines
Assessment Specific to each discipline Shared across disciplines
McGEARY et al. | 207

Interdisciplinary pain management has received significant attention in the extant research, with hundreds of
published studies supporting its use (Gatchel et al., 2014). Unfortunately, there is growing evidence that these
programs, despite their outcomes, are not the ideal solution for pain management in the United States that many
thought they were. The increased interaction and complexity of interdisciplinary treatment (which drastically im-
proved treatment efficacy beyond that offered by multidisciplinary care) has made these programs difficult to im-
plement in the managed healthcare environment, severely limiting the range of pain sufferers who can benefit from
this gold-­standard care. Indeed, there is an alarming dearth of interdisciplinary chronic pain management programs
(ICPM) in the United States, and some reports show an abatement of ICPM since 1999 (Jeffrey et al., 2011). Ruan,
Urman, and Kaye (2016) poignantly observe that the decrease in ICPM in the United States has resulted in an
alarming ratio of one ICPM clinic for every 670,000 Americans with chronic pain. With increasing recognition that
chronic pain is best managed using an interdisciplinary approach, it is now quite clear that more must be done to
foster the proliferation of effective interdisciplinary models of pain management in the United States. Improved
dissemination and implementation of ICPM begins with a sober evaluation of why the uptake of these programs has
been limited in the United States, and how the factors that contribute to poor uptake can be overcome through an
alternative approach.

1.2 | Strengths and limitations of interdisciplinary chronic pain management

1.2.1 | Strength: a clear blueprint for gold-­standard care

Implementation of novel care models can be difficult without clear guidelines describing the ideal components,
content, and integrated composition of care. It is possible that medical organizations fail to implement better pain
management because they simply lack the blueprint needed to so. Many of the numerous research studies describ-
ing successful ICPM outcomes included a manualized approach with clear descriptions of the ICPM team members,
clinical interventions, assessments, and timing. Thus, there is plentiful evidence in the extant research guiding the
format and outcomes assessment formulae for these programs. The core components of ICPM are generally well-­
defined, including the implementation of wellness and stress management interventions aimed specifically at over-
coming self-­limiting factors and poor pain coping (e.g., pain catastrophizing, low pain acceptance, fear avoidance),
and physical rehabilitation focused on improving functional and aerobic capacity. Ideally, these two components are
intertwined to the extent that a patient who improves in physical therapy will lead an improvement in wellness and
capacity for coping with pain (e.g., increased lifting capacity leads to improved self-­efficacy). Conversely, improved
stress management and wellness may lead to physical benefit through decreased self-­limiting and improvements in
pain coping and mood.
The powerful overlap between physical rehabilitation and wellness concepts (like stress and mood management)
has been formally noted as far back as the 1950s (Hill & Patton, 1956), and contemporary guidance on assembling
ICPM emphasizes the need for specific chronic pain competencies for disciplines being integrated into treatment.
The State of Texas published a 2007 report on accreditation of interdisciplinary pain management programs that
encouraged the adoption of specific theoretical models of ICPM (especially those rooted in a “functional restoration”
theory) as a way to “improve the quality and timeliness of interdisciplinary pain rehabilitation programs.” This State
report singled out specific ICPM models that are particularly well-­defined, the most notable of which is “Functional
Restoration Pain Management. Functional Restoration (FR) programs actively integrate physical rehabilitation, well-
ness, and medical management, using a unified theoretical perspective emphasizing function and de-­emphasizing
palliative approaches. This straightforward, integrative formula has made FR an effective and easy to implement pain
management model (cf. Mayer, McGeary, & Gatchel, 2004). The use of a FR blueprint for ICPM is the first step in
successful implementation of effective pain management.
Integrating different professions in ICPM requires the unification of disparate providers under a single goal
and theoretical framework of pain rehabilitation (Stanos, 2012). As noted above, the FR model is a good example
208 | McGEARY et al.

of an ICPM program with a defined theoretical framework and an outcomes emphasis on functional goals, de-
creased disability, and increased functional capacity as the primary mechanisms of successful rehabilitation
across multiple domains (Gatchel et al., 2014). The purpose of the unified goal and theory is to ensure that all of
the providers are working toward the same clinical ends so that their efforts are likely to promote one another
rather than serving as a potential barrier. For example, in a less unified, multidisciplinary program, a Clinical
Psychologist may give advice about relaxation, a Physician may recommend bedrest, and a Physical Therapist
(PT) may recommend increased exercise. Although all of these recommendations are well-­intended for pain
management, the outcomes of each provider’s intervention can complicate the goals of the other providers.
Unification of the disciplines across a common philosophy of pain management should result in multidimensional
treatments that catalyze rather than stymie one another. A FR pain program encourages all provider to work
toward increased functioning such that one provider may recommend increased exercise, and this recommen-
dation is supported by other providers who also encourage activity and teache the patient how to overcome
self-­limiting of activity. Each treatment provider amplifies the work of the others making the interdisciplinary
program more effective.

1.2.2 | Weakness: the need for multiple providers in ICPM

Although the active ingredients in effective ICPM are well-­known, it is possible that implementation is limited by
the sheer availability of the different disciplines needed to enact an interdisciplinary program. It can be difficult
to gather the expertise needed to effectively implement an interdisciplinary chronic pain management program,
which requires specific expertise in chronic pain management across several disciplines including: physical Therapy,
Occupational Therapy, Psychology, Nursing, and Medicine. None of these professions have a specific credential to
establish competency in chronic pain management, so identifying ideal personnel for ICPM can be difficult. As noted
above, well-­defined theoretical models of ICPM (e.g., FR) offer clear targets for pain management competency, but
naïve professionals must be trained to a competency standard in ICPM in order to maximize effectiveness and en-
sure successful integration. Gathering professionals from multiple pain management disciplines (regardless of their
chronic pain competencies) all in one place to implement an ICPM program can be prohibitive. For example, the
authors of this manuscript previously explored the medical resources available for interdisciplinary pain manage-
ment throughout the Department of Defense, and found that only six military treatment facilities worldwide had the
needed personnel to implement ICPM (without hiring additional personnel). Once multiple providers are identified,
however, they face an equally difficult obstacle in finding adequate space to run an integrated practice. Co-­location
of services is vital to ICPM, and attempts to carve ICPM sub-­components out of a shared location (i.e., referring
an ICPM patient to offsite Physical Therapy instead of co-­locating PT services with other ICPM components) can
worsen outcomes (Robbins et al., 2003). Participating providers should share clinical space as often as possible,
likely contributing to ICPM effectiveness through increased opportunities for communication and observation of
multidisciplinary work.
In cases where sufficient multidisciplinary staffing is available for an effective ICPM program, a treatment team
may still produce ineffective care if they fail to appropriately integrate their treatments across disciplines. This could
be due to a deficiency of time, funding, dedicated space, leadership, or unified vision for pain management strategy.
When integration is not achieved, different professionals will default to functioning in multidisciplinary “silos” result-
ing in less effective care (basically reverting back to a multidisciplinary model; Stanos, 2012). Many interdisciplinary
teams require regular meetings to ensure alignment of treatment goals and to discuss treatment issues that have
implications for other disciplines. For example, a provider offering Wellness and Stress Management services may
find out about a significant life stressor that affects patient mood and motivation in physical rehabilitation. In the
best cases, the Wellness Provider will be able to give advice to Physical Rehabilitation Specialists about incorporating
practiced stress and mood management strategies to help the patient maximize effort and enhance rehabilitation
outcomes. Unfortunately, this level of integration requires a common time for different providers to meet and share
McGEARY et al. | 209

information and skills, which can be limited based on the amount of time available for discussion and the number of
patients who are active in treatment. As more patients enter an ICPM program, more time will be needed to ensure
the best interdisciplinary care resulting in a potential “bottleneck” for productivity. The scope of the treatment team
can also contribute to an integration bottleneck. As more providers become involved in care, the scope of the discus-
sion on each patient will grow, as will the complexity of goal and treatment integration. There is very little guidance
about the ideal scope of an ICPM team, although some research has shown compelling evidence for programs of
smaller scope (cf. Gatchel et al., 2009). Regardless, it is quite clear that communication and care integration is a key
ingredient in ICPM effectiveness and any alternatives to interdisciplinary care need to strongly consider treatment
integration.

1.2.3 | Weakness: the need for interdisciplinary training

Even when there is a clearly defined theory of pain management available to all providers, it can be difficult to
integrate theory across disciplines unless all providers are adequately trained in the model (which is not likely com-
mon). In most cases, ICPM providers will need to be trained in an integrated model of care, but targets for training
are not easy to define in interdisciplinary programs. There is increasing attention on key chronic pain management
competencies, and the Interprofessional Chronic Pain Management Competency Program was established in 2011 to
identify important interdisciplinary competencies for effective chronic pain management (Fishman et al., 2013). The
resulting interprofessional consensus process established 21 different pain assessment and management competen-
cies across four domains:

1. Multidimensionality of Pain: chronic pain is complex with diversity in terminology, sociocultural inputs,
and impacts on society.
2. Pain Assessment: chronic pain should be measured using valid and reliable tools including patient, provider,
and system factors and assessment should be communicated reliably and validly between providers and the
patient.
3. Pain Management: chronic pain requires collaborative treatment (including the patient as a member of the
treatment team) with multiple care options available as part of the treatment plan.
4. Clinical Context: some special populations may require different care and the diversity of treatment providers
in interdisciplinary teams should be well-understood by each provider.

As interdisciplinary providers interact in ICPM, it is expected that they will develop a shared understanding and
appreciation of all 21 chronic pain management competencies. In order to facilitate this shared understanding, some
pain management programs (especially those implemented under a carefully controlled research protocol) may adopt
a manualized approach to care (Gatchel et al., 2014). These manualized interventions are designed to clearly estab-
lish the functional components of each dimension of ICPM, and are often used for training others. Unfortunately, it
remains unclear how often manuals are shared across disciplines, nor is there any good guidance on the extent to
which different specialties need to be trained on a manualized approach to establish interdisciplinary competence.
Training providers in chronic pain management within their own professional domain can take time, but training them
to competently collaborate with one another adds an entirely different layer of complexity that can further lengthen
the training process. Many disciplines may acknowledge the benefit of working closely with other disciplines, but
may stifle interdisciplinary care through an unwillingness to share their knowledge with others and to take on new
skills and knowledge from other disciplines. Interestingly, a study of the implementation of a structured protocol of
managing multiple symptoms in adult Intensive Care Unit patients found that lack of knowledge and respect across
different disciplines in the ICU hindered the implementation of the structured protocol (Carrothers et al., 2013). As
a result, ICPM implementation may be stunted due to extended time needed to adequately train and integrate the
treatment team.
210 | McGEARY et al.

1.2.4 | Weakness: the cost of ICPM/strength: the cost effectiveness of ICPM

In the age of managed health care, treatment cost is a very relevant factor in the implementation and dissemination
of effective treatment. Multicomponent pain management programs can be expensive regardless of the extent of
their integration. Time and resources for multiple clinical disciplines can generate costs around $10,000 per patient
depending on the brevity and frequency of treatment encounters. Despite this cost, ICPM has been shown to be
very cost-­effective. A meta-­analysis conducted by Okifuji in 2002 reveals that the average cost of an interdiscipli-
nary pain program, or comprehensive pain program as the author calls it, is approximately $8,100 per patient, with an
average treatment improvement of 67%. This is compared to conventional treatment at $26,000 per patient, with
24% improvement and surgical treatment at an average cost of $15,000 per patient and 43% improvement. Indeed,
numerous studies have shown that interdisciplinary pain management is likely to save costs in the long run through
changes in direct costs associated with pain treatment (e.g., decreased pain medication utilization resulting is cost
savings of over $2,000 per year; Cunningham et al., 2009) and indirect costs associated with work absenteeism and
entry into the disability compensation system (Gatchel & Okifuji, 2006; Gatchel et al., 2014). Surprisingly, third party
payers are relatively unlikely to compensate for interdisciplinary pain management, often due to the seemingly high
initial cost of ICPM driven by the scope of providers comprising the ICPM team (Clark, 2009)
There is some evidence suggesting that a smaller scope of interdisciplinary care may help drive down costs with-
out sacrificing patient satisfaction or treatment efficacy. If effective, an ICPM program with smaller scope could in-
crease the likelihood that managed care would reimburse through lower program costs. For example, Gatchel et al.
(2003) had earlier demonstrated the treatment-­ and cost-­effectiveness of a “smaller scope” FR program adminis-
tered to low back pain patients. Of course, this is only worth pursuing if program helpfulness can be maintained in
a smaller scope. In fact, one study of interdisciplinary cost effectiveness found that interdisciplinary treatments are
still seen as “helpful” by patients when the scope of care is decreased with lower costs, and small-­scale, low-­cost
interventions may actually be seen as more helpful than costlier options (Chapman, Jamison, Sanders, Lyman, &
Lynch, 2000).

1.3 | Another path to effective integrated treatment: transdisciplinary pain management

Based on the present review of Interdisciplinary Chronic Pain Management, the next evolution of pain care must
capitalize on the strengths of ICPM (e.g., a clear blueprint for care, obvious targets for training, multiple disciplines of
care, cost effective intervention), while also overcoming weaknesses that prohibit implementation of the model (e.g.,
the need for multiple providers, time and cost of integrating providers). As noted above, discussions and studies of
pain management integration have largely been limited to multidisciplinary and interdisciplinary models. Although
interdisciplinary treatment has improved treatment effectiveness, a multitude of factors contribute to significant dif-
ficulty in translating interdisciplinary programs into medical care. This is particularly true in rural areas, where there
is limited access to the multiple specialties with chronic pain experience that are needed to implement the best care.
Alternative care models can improve upon interdisciplinary care by decreasing the complexity of care, increasing the
portability of interdisciplinary treatment, and maintaining the key ingredients that make interdisciplinary programs
successful (e.g., multiple disciplines, unified goals, common theoretical framework).
One way to augment the ICPM model is to use technology to integrate care across several different sites. Doing
so would overcome the need to co-­locate services, overcoming the significant obstacle of locating mutldisciplinary
professionals in one place to implement ICPM. Previous reviews of distance technologies for pain management show
that the research is still growing and has not yet proven efficacious for pain management (McGeary, McGeary, &
Gatchel, 2012). However, there have been several more recent attempts to extend interdisciplinary pain management
into poorly equipped or resourced environments through telemedicine/telehealth platforms (often under a consulta-
tion model of training; Katzman et al., 2014) that have shown some benefit. Although these telemedicine programs
have been successful in expanding provider knowledge and confidence in chronic pain management, clinical gains
McGEARY et al. | 211

are small (though statistically significant in some cases; Carmody et al., 2013). Telehealth consultation may add to the
knowledge of the provider, but the geographical distance and lack of constant availability between the consultant(s)
and the provider may interfere with the critical interdisciplinary integration needed for effective ICPM.
In the past several years, some researchers have started to explore the concept of “transdisciplinary” team in-
tegration as a means of vesting the expertise of multiple disciplines into one provider. Transdisciplinary pain man-
agement models take identified key competencies across different disciplines and train these competencies into
individual providers. These approaches have started to gain some attention as an alternative to interdisciplinary
treatment, and the research on this new approach is still evolving. At present, there is burgeoning evidence indicat-
ing that transdisciplinary treatment might be as effective as ICPM and, because only a single provider is involved,
transdisciplinary providers are not encumbered by the sprawling infrastructure and need for frequent communication
to foster adequate service integration. With these obstacles of ICPM overcome, transdisciplinary models are likely
to be cheaper and easier to implement than ICPM, especially in areas where co-­locating multiple pain management
professionals would be nearly impossible (e.g., rural areas).
Although variably defined, most agree that transdisciplinary care differs from interdisciplinary treatment through
an integration of different disciplines that expands beyond traditional professional boundaries (Choi & Pak, 2006).
Whereas interdisciplinary pain management models involve the careful integration of disparate specialties, a trans-
disciplinary model involves disparate professions sharing knowledge and skills with one another and expanding the
scope of each provider. As a result, multiple disciplines can be seamlessly integrated because the knowledge and
skills of different disciplines are trained into a single individual. For example, a PT could learn stress management and
wellness skills that help their patients overcome self-­limiting behavior due to mood disruption and self-­doubt, leading
to an amplification in motivation and rehabilitation outcomes. Alternatively, other providers who already have skills
in wellness and stress management interventions could learn basic exercise recommendations for effective chronic
pain management that allow them to capitalize on the improved pain coping skills of their patients. As an example of
this, Broderick et al. (2014) demonstrated that Nurse Practitioners were able to successfully administer pain coping
skills training to osteopathic patients with chronic pain. Thus, in implementing such an approach, the complexity of
the interdisciplinary team becomes vested in each member of the team, all of whom establish sufficient competencies
in multiple disciplines to better approximate interdisciplinary treatment in their individual care. This transdisciplinary
approach solves a number of the logistical problems associated with interdisciplinary pain management by decreasing
the number of specialty providers needed to provide multidisciplinary treatment, increasing integration of treatment
goals (which are all driven by the patient and a single provider), and decreasing the cost of care through billing for one
care provider instead of a treatment team (see Table 2).

TABLE 2 Dimensions of multidisciplinary, interdisciplinary, and transdisciplinary treatment

Dimension Multidisciplinary Interdisciplinary Transdisciplinary

Scope Multiple disciplines Multiple disciplines Multiple disciplines

Constituency Multiple providers Multiple providers Single provider
Communication Frequent with patient Frequent with patient Frequent with patient
Infrequent with other disciplines Frequent with other disciplines
Goals Vary across providers Shared between providers Determined by single
provider
Theory Vary across providers Shared between providers Determined by single
provider
Autonomy Independent Dependent and Collaborative Independent
Hierarchy Clear leadership by physician All providers equal Not applicable
Knowledge Specific to each discipline Shared across disciplines Shared from other disciplines
Assessment Specific to each discipline Shared across disciplines Shared from other disciplines
212 | McGEARY et al.

In order to accomplish transdisciplinary care, training must be grounded in a clear rehabilitation theory and ex-
pected competencies across disciplines need to be clearly defined. Once a specific training model has been estab-
lished, however, the participating providers must be willing and able to adopt new clinical skills. There are good
reasons to believe that the outcomes of cross-­trained pain management would be effective. First, the scientific
and clinical communities have noticed the significant overlap of psychosocial and physical rehabilitation constructs
for decades, with PTs and Psychologists receiving strong encouragement to appreciate how each other’s fields can
impact treatment and treatment outcomes (Hill & Patton, 1956; Stewart, 1977). Second, both PTs and wellness pro-
viders (including Nursing and Psychologists) appear to place greater value on the skills and work of other disciplines
than their medical pain management counterparts. For example, a study of interdisciplinary work among Physician
Assistants (PAs) found that PAs expressed relatively little interest in the work of PTs and Psychologists, while PTs
and Psychologists showed a significant appreciation of one another (Hertweck et al., 2012). Third, there is increas-
ing evidence that wellness, stress management, pain coping and physical rehabilitation skills can all be effectively
trained to a defined level of competency into one provider. Bryant et al. (2014) attempted to formally train 11 PTs
on a 10-­session chronic pain coping skills program for individuals with lower extremity pain. Using workshops and
ongoing supervision by a Psychologist, the PTs were able to implement the pain management program with over 96%
fidelity, and with satisfactory performance ratings, and the outcomes of combined Physical Therapy and the pain
management program outpaced those of either intervention on its own up to 1 year later (Bennell et al., 2016). The
investigators achieved good clinical outcomes with this simple transdisciplinary approach, though it is quite likely that
outcomes would improve further with training in a manualized approach developed specifically for interdisciplinary
pain management (like FR).
The investigators of the transdisciplinary treatment study described above note that the excellent outcomes
of their study came with a significant investment of training time (150 hr) and ongoing performance review and
supervision (over 1,000 hr); a limitation of this transdisciplinary approach. However, it is also important to note
that once the competencies are established, they can be implemented at will throughout each PT’s future practice,
with significantly better treatment outcomes and lower costs than providing physical therapy and psychosocial pain
management separately. Furthermore, this is one of the first studies attempting to train transdisciplinary skills, and
further studies are needed to explore the extent to which training is needed to preserve good outcomes. Different
provider training vectors (i.e., teaching rehabilitation providers wellness skills and teaching wellness providers reha-
bilitation skills) could be studied to determine the most cost-­effectiveness permutation of transdisciplinary training,
and extended studies of adverse events could illuminate the safest implementation strategy for transdisciplinary pain
management. Once the best training model is established, individual providers would need to be trained once (with
possible refresher training in the future), resulting in significantly lower treatment costs for patients and third-­party
payers (due to the drastically decreased scope of treatment).
To further bolster implementation, future studies of transdisciplinary pain management must examine both the ef-
fectiveness and the cost of this new model of care. Determining costs for transdisciplinary pain management will re-
quire scrutiny by health economists and discourse with third-­party payers. State license and credentialing boards will
need to be consulted about regulating the expanding scope of care by their licensed providers. Interventions com-
pleted by transdisciplinary providers should be coded under an ICD-­10 code describing the complexity of the condi-
tion and the requirement for intervention tapping multiple dimensions. For example, ICD-­10 code F54 (Psychological
and behavioral factors associated with disorders or diseases classified elsewhere) could be paired with a chronic pain
code (e.g., G89.21-­89.3: Chronic pain not elsewhere classified) or a code for a patient’s specific pain complaint to
describe a need for complex treatment. CPT codes used for transdisciplinary billing could include codes for physical
rehabilitation (e.g., 97110 for strengthening and range of motion), health and behavior change (e.g., 9083X or 96150
for education and coping skills training), and medical management codes (e.g., 992XX for medical management based
on complexity).
Despite strong preliminary evidence, there is some concern that reducing the scope of interdisciplinary pain
management using a transdisciplinary format (in which a single provider is trained in multiple competency domains)
McGEARY et al. | 213

could worsen treatment in some cases by limiting the flexibility of ICPM to address individual patient needs. Multiple
clinical and research stakeholders (including the National Institutes of Health) have strongly encouraged tailored
approaches to medical care that are designed to ostensibly maximize effectiveness (Stamer, Zhang, & Stueber, 2010).
Although a tailored approach makes sense in the treatment of some medical conditions, chronic pain is already
complex, and there is little evidence to suggest that a tailored approach outperforms a generally structured ICPM
with proven efficacy. On the contrary, studies of psychological and physical pain management models have generally
found no difference between individually tailored interventions and standard/structured approaches in terms of
treatment participation/adherence (Kerns et al., 2014) and outcomes (Roche et al., 2007). Thus, transdisciplinary pain
management actually benefits from limiting the scope of competencies in training to those that have been shown to
work in studies of structured ICPM programs. This could also mean decreased training time needed for transdisci-
plinary models based on simpler ICPM approaches.
A transdisciplinary approach blends the sharing and practice of assessments, conceptualizations, and treat-
ment skills across disciplines in a way that could potentially boost creative thinking in team members. Educational
researchers have shown that effective teachers have creative ways of thinking that transcend specific disciplines
(Henriksen, 2016). Because part of clinical practice involves learning about patients, conceptualizing their prob-
lems, and providing education to patients, a transdisciplinary approach offers potential advantages over an inter-
disciplinary approach to enhance the way team members think about pain management and problem solve patient
issues. There are several potential barriers to transdisciplinary care that must be addressed before transdisci-
plinary care can be solidified as a feasible integrated pain management option. First, cross-­disciplinary training
must be guided by clear targets for establishing a sufficient level of competency in multiple disciplines preferably
rooted in an established model of ICPM. As noted above, Functional Restoration has received the greatest atten-
tion as one such model in which competencies for the constituent specialties are very well defined and, in some
cases, manualized. Thus, early explorations of transdisciplinary pain management would benefit from the adoption
of a manualized FR rubric to serve as a guidepost for the necessary competencies required maximally effective
care (Mayer et al., 2004). Not all providers will be amenable to transdisciplinary work, but those who endorse
physical rehabilitation and wellness/stress management skills appear to have a long history of shared appreciation
for the overlap of their professional domains. Recent published research has already shown that PTs can be trained
to an effective level of competency in psychosocial interventions for pain, suggesting that a transdisciplinary pain
management program blending PT and wellness skills (like FR) could be feasibly implemented. Future research
on transdisciplinary care should examine the added effect of training PTs on an ICPM pain management model
(existing studies have merely tested training on a unidimensional psychotherapeutic intervention for pain) and
whether or not other professions can be trained to an effective level of competency in physical rehabilitation
methods (Bennell et al., 2016; Bryant et al., 2014). Third party reimbursement for transdisciplinary pain manage-
ment is largely unexplored, so future research on transdisciplinary models should study reimbursement models
and credentialing issues that could serve as obstacles to transdisciplinary implementation. In light of the growing
gap between pain sufferers and effective non-­pharmacological ICPM, the evaluation of alternative models is one
of the highest priorities in pain management. With a decreased need for a costly multidisciplinary team, a smaller
scope, and the promise of effectiveness comparable to ICPM, transdisciplinary pain management is likely to be
the next best solution.

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