The organisation of biopsychosocial pain rehabilitation treatment; who should deliver?

Abstract

Twenty percent of the European population perceive chronic pain. The most frequent reported chronic pain complaint is chronic musculoskeletal pain (CMP) (e.g. low back pain). In line with an ageing population, the number of people with disability from CMP is rapidly increasing. CMP has a considerable impact on quality of life of patients, and due to its associated high socioeconomic costs, it has a high societal impact. It has been shown that low back pain, one of the CMP conditions, accounts for many years lived with disability (disability-adjusted life-years) even more than conditions such as, COPD, diabetes, and major depression [1–3]. For patients with CMP, interdisciplinary biopsychosocial rehabilitation programs (IBRPs) have been developed showing moderate but promising effects [1,2,4]. IBRPs are aimed to modify pain cognitions, stimulate active coping behaviour, self-management, and improve the level of functioning despite pain. Current IBRPs are often quite extensive and are often chosen as a last resort option [3]. Therefore, most patients enter an IBPRP after a long and often frustrating journey (over five years) through health care. The current organisation of care for patients with CMP, is fragmented and organised per ‘body part or system’ in so called ‘silos’. This results in a wide variety of monodisciplinary treatments, which are restricted in resources. Patients with CMP often do not receive the right care, at the right place, at the right time, resulting in overand under-treatment. The increasing number of patients with CMP and the mismatch of current care to their needs seem both important to re-consider the organisation of health care in general and more specific for chronic conditions such as CMP. In the subacute phase, when normal recovery is lagging, a shift in treatment focus from solely pain reduction towards improving functioning despite pain is needed to prevent secondary long-term disability, lower quality of life and unnecessary costs. The World Health Organization (WHO) developed a guideline for redesigning rehabilitation in health systems [5]. It indicates that rehabilitation services should be integrated within primary care, as well as between primary, secondary, and tertiary levels of health systems. Healthcare professionals should be trained not only to deliver a broader biopsychosocial intervention, but also to recognise and manage patients at risk becoming chronic pain patients. This shift in organisation of care is assumed to have a favourable impact on all four domains of the Quadruple Aim [6]: improving population health, reducing costs, enhancing patient experience of care, and improving the work life of healthcare professionals. This could be achieved by organising an integrated, transmural biopsychosocial rehabilitation care network. In this network, healthcare professionals from different backgrounds, working within primary, secondary and tertiary care offer diagnostic and therapeutic services from an integral vison aiming at self-management. These healthcare professionals are for example general practitioners, practice nurses in mental health, psychologists and physiotherapists and occupational therapists in primary care. In secondary and tertiary care, (rehabilitation) physicians and their teams will assist primary care by a focus on a select patient group with complex pain related disability. To organise the right care, at the right place, by the right person, for the right price, objective screening tools, treatment protocols, training and supervision/intervision modules should be organised and made available. Currently, several collaborating initiatives are initiated to implement this integrated care collaborations. However, it has been shown that currently no interventions are already available in which interdisciplinary care within primary care as well as between primary care and other healthcare settings is adequately organised [7]. Most existing interventions focus only on a part of the service delivery system. Diverse barriers seem to hinder the organisation of interdisciplinary rehabilitation care for patients with CMP. First, an adequate financial compensation system for multidisciplinary treatment is very important to facilitate collaboration in health care and when not available, such compensation system is desperately needed. In addition to a change in the way healthcare professionals face CMP, also the patient’s expectations regarding the treatment needs to change. Patients expect a more biomedically oriented treatment with a focus on explaining and resolving the pain rather than coping with pain. Therefore, a broad societal shift is strongly warranted.