Multidimensional approach to chronic pain management

A multidimensional approach to chronic pain management simultaneously addresses all sociopsychobiomedical factors affecting the patient’s pain, and helps patients achieve their goals sooner compared to approaches that address only some contributors to the patient’s pain. For example, if pain affects a patient’s sleep, and poor sleep exacerbates the patient’s pain, managing both pain intensity and sleep simultaneously may lead to substantial and lasting gains. Using medication to reduce pain intensity may be insufficient, because unresolved sleep issues will continue to affect the patient’s pain. Conversely, addressing sleep may be fraught if pain remains untreated.

A multidimensional approach should be based around active management strategies that the patient can use to achieve self-management. These include:

increasing social connections
addressing thoughts and emotions
increasing physical activity
improving nutrition
improving sleep.

Specific interventions can be added, as required, to create a chronic pain management plan tailored to the individual. See Chronic pain management strategies for a list of first-line and second-line management strategies, as well as strategies of uncertain benefit.

A multidimensional approach may be delivered by a single provider (eg the patient’s GP), or by a multidisciplinary team (eg GP, psychologist and physiotherapist).

Table 1. Chronic pain management strategies
First-line management strategies
Strategy	Rationale for strategy
social or environmental interventions (eg work retraining, volunteering, school reintegration, community support groups, time in nature, reduced screen time)	People feel safe when socially connected, and under threat when socially isolated. This has the potential to influence nervous system sensitisation and pain intensity.
psychological techniques (eg patient education, targeted reassurance, relaxation techniques, cognitive behavioural therapy)	Psychological techniques can reduce nervous system arousal, sensitisation and pain intensity, and also facilitate behavioural change. Other outcomes include improved quality of life, mood and treatment adherence.
physical activity (eg walking groups, unstructured play, exercise, pool-based activities, stretching)	Physical activity improves brain and nervous system function in addition to improving metabolic, musculoskeletal and cardiovascular health. Practices such as yoga and Tai Chi can combine physical and psychological techniques. Activity scheduling (spreading physically hard jobs throughout the day with breaks in between to reduce sustained physical loading) and pacing (gradually increasing activity) reduces the likelihood of unhelpful cycles of overexertion followed by inactivity.
improve sleep	Sleep improvement reduces nervous system sensitisation and pain. Useful techniques include reduced screen time and caffeine intake, and a consistent wake-up time.
improve nutrition	Healthy dietary habits are beneficial for overall health and wellbeing, and may reduce nervous system sensitisation and pain intensity, and improve function. Encourage a healthy diet with increased vegetable intake, reduced processed foods and limited alcohol intake. For dietary advice in adults, see the Eat For Health website. For dietary advice in children, see the Healthy Kids website. In all patients, encourage smoking cessation.
Second-line management strategies [NB1]
Strategy	Rationale for strategy
analgesics	Analgesics are helpful in some patients, particularly over a defined period of time while a patient achieves supported self-management. However, overemphasising medical treatments for chronic pain can distract both the patient and clinician from a supported self-management approach that has greater potential to improve function. Any illicit substances and unhelpful medications should be stopped (see Reviewing analgesia efficacy for chronic noncancer pain and Deprescribing analgesics for chronic noncancer pain).
invasive procedures	Invasive procedures (eg surgery, nerve blocks) can be considered in some patients if there is a clear indication—specialist advice should be sought if there is uncertainty about the appropriateness of an invasive procedure.
Management strategies with uncertain benefit and potential harm [NB1] [NB2] NB3]
Strategy	Rationale for strategy
acupuncture	Acupuncture has its origins in traditional Chinese medicine and is based on the concept of meridians and energy lines. There is little evidence for the effectiveness of acupuncture for chronic pain management and it is difficult to assess the efficacy because an adequate placebo has not been identified [NB4].
dry needling	Dry needling is sometimes called Western acupuncture as it utilises the same needles, but places them into soft tissues that are perceived to be tight or painful. Most trials are of low quality, and a number of systematic reviews conclude that dry needling has a small beneficial effect for chronic pain. Dry needling should only be undertaken by a clinician who is AHPRA registered.
graded motor imagery (including mirror box therapy)	Graded motor imagery is a complex series of cognitive exercises that aim to retrain the brain and central nervous system. It may be a treatment component for some chronic pain conditions (eg complex regional pain syndrome, phantom limb pain, chronic poststroke pain). Graded motor imagery can be useful to engage young people and adults in their rehabilitation because it is available via an app (‘Recognise’).
hot and cold superficial therapy	Hot and cold superficial therapies can temporarily reduce pain by changing blood flow and nerve conduction, providing sensory distraction, or inducing psychological relaxation. Hot or cold packs can cause acute damage to skin (eg burns) or chronic skin damage (eg erythema ab igne) if used repeatedly for chronic pain. Hot and cold superficial therapies are contraindicated in any area of skin that is insensate or has reduced thermal sensation awareness.
massage	Massage is passive movement of soft tissues. This may bring short-term reduction in pain intensity, but there is a lack of evidence of mid- to long-term benefit for chronic pain.
passive mobilisation	Passive mobilisation involves repetitive movement of joints to reduce pain or improve range of motion. It is often provided by a physiotherapist. The effect of passive mobilisation is short term and benefit may decline over time. For chronic neck or low back pain, there is moderate evidence to support a slight improvement in pain intensity and function, but there is no evidence to support the use of passive mobilisation for longer than 3 months. Passive spinal joint mobilisation is associated with a lower risk of harm compared to spinal manipulation.
spinal manipulation	Spinal manipulation involves high velocity thrust techniques applied to vertebral segments. There are significant risks associated with spinal manipulation (eg fracture of the ribs, radicular pain, vertebral artery dissection), particularly at cervical level. Spinal manipulation is contraindicated in children, people with connective tissue disorders, people at risk of fractures, and elderly. The effectiveness of spinal manipulation for chronic pain appears to be similar to that of mobilisation, which has a lower risk of harm. For chronic neck or low back pain, there is moderate evidence to support a slight improvement in pain intensity and function, but there is no evidence to support the use of spinal manipulation for longer than 3 months.
trigger point therapy	Trigger points and taut bands are theorised to be areas of overactive skeletal muscle, but the pathology has never been objectively demonstrated and there are no reliable diagnostic criteria. Trigger point therapy involves injection of local anaesthetic or saline, or dry needling to relieve pain. There is a risk of infection with trigger point therapy and there is no evidence of effectiveness for chronic pain. Trigger point therapy should only be undertaken by a clinician who is AHPRA registered.
transcutaneous electrical nerve stimulation (TENS)	Transcutaneous electrical nerve stimulation (TENS) uses superficial electrodes to deliver low-voltage current to the skin. TENS may be ineffective in opioid-tolerant patients because its analgesic effects are mediated via the endogenous analgesia system. The evidence of effectiveness and harm for chronic pain is weak, but TENS may interfere with cardiac implanted electronic devices [NB5]. There is no evidence that one TENS device is superior to another.
Note: AHPRA=Australian Health Practitioner Regulation Agency NB1: These strategies should be used in conjunction with first-line management strategies. NB2: All strategies in this section have uncertain benefit; however, the degree of harm varies. Some strategies are unlikely to cause harm beyond financial stress (eg graded motor imagery), while others are associated with significant harm (eg spinal manipulation). NB3: Passive techniques with uncertain benefit but potential harm should be reserved for short-term use (ie less than 12 weeks) to support the patient while they are achieving self-management. Long-term use of passive techniques can lead to dependence on therapists at the expense of self-management. NB4: For the role of acupuncture in musculoskeletal conditions, see the Rheumatology guidelines. NB5: TENS can sometimes be used safely in people with cardiac implanted electronic devices (eg pacemakers, cardioverter defibrillators) depending on the type of device, positioning of leads and other factors. Advice from a specialist with expertise in this area is recommended before TENS is used in the presence of these devices.