Multimodal treatment strategies

Chronic pain requires multimodal management

The aim of multimodal therapy is to help restore patients to an improved level of function and promote patient responsibility for managing disease.

Interdisciplinary pain therapy is an option particular in patients whose chronic pain has become a disease in its own right.

Typical features of chronic pain patients are:

  • Multiple locations of pain
  • Long pain history
  • Psychosocial problems
  • Many ineffective attempts at treatment

Important elements in multimodal pain therapy are:

  • Active physiotherapy and sports training (e.g. stretching)
  • Education of the patient on the main points of the analgesic and non-medical procedures and their value
  • Peripheral stimulation and interventional therapy (e.g. TENS, acupuncture etc.)
  • Psychological therapy

Active physiotherapy and sports training

Non-pharmacological pain therapy

Various methods are used to treat pain: massage, cryotherapy (treament with cold) or thermotherapy (treatment with heat) are particularly used for the treatment of musculoskeletal pain.

The benefits of sports therapy and movement therapy include helping patients overcome any loss of fitness and mobility and improving physical performance.

Exercise and movement can help patients develop positive attitudes and coping strategies.

There are opportunities for social contact and feelings of success.

Physiotherapy and movement therapy
  • Increase in strength
  • Increase in endurance
  • Increase in self confidence
  • Feeling of success
  • Social contacts
  • Positive social experiences
Adams ML, Arminio GJ. Non-pharmacologic pain management intervention. Clin Podiatr Med Surg. 2008;25:409-29.


Psychological therapies

Psychological care of pain patients is indicated especially in chronic pain

Psychological therapy
The fact that the administration of placebos reduces pain shows that the psychic constitution has a great effect on pain perception.
Psychological care of pain patients is indicated especially in chronic pain and includes for example relaxation training, hypnosis, behavioural therapy and psychotherapy.

One particular psychological treatment approach that has been found to be highly effective in helping patients to reduce pain, disability and distress is Cognitive Behavioral Therapy (CBT), which involves modifying negative thoughts related to pain and on increasing a person’s activity level and productive functioning.

CBT for pain management is tailored to the individual needs of the patient but may include:
  • Relaxation Training
  • Cognitive Restructuring
  • Stress and Anger Management
  • Sleep Hygiene
  • Activity Pacing

Other therapeutic approaches are e.g. hypnosis and biofeedback


Peripheral stimulation and interventional therapy


Transcutaneous electrical nerve stimulation (TENS)
TENS is a stimulation procedure to activate endogenous pain inhibition systems at the spinal and supra-spinal level. Electrodes are applied to the skin in the region of the pain, in the direct vicinity, or also over trigger or acupuncture points, and set at a special frequency, usually depending on the nature of the pain.
Acupuncture is a method of treatment originating from Chinese medicine, which has been very successful in the treatment of pain. Fine needles are inserted into the cutaneous areas with an accumulation of sensory cells (acupuncture points). Pain-inhibiting substances, e.g. endorphins, are thus presumably released, which inhibit the transmission of the pain impulse. In addition, an electrical current can be applied to the needles.
Neurosurgical procedures
The basic principal of neurosurgical procedures is the interruption of the transmission pathways which transmit the pain stimuli from the damaged tissue. In chordotomy the spinothalamic tract is interrupted in the spinal cord. A less radical method is radicotomy, where surgery is not performed directly in the spinal cord, but the nerve root is severed at its exit from the spinal column. Peripheral nerves may also be blocked, either reversibly with local anaesthetics as transmission blockade or irreversibly as neurolysis using neurolytics (alcohol, phenol, etc.), electrocoagulation or irradiation. As these techniques cause permanent nerve damage, they are “last resort” treatments for the relief of very severe intractable pain.


Education of the patient and relatives

Learning about chronic pain and its management

Patients and relatives can benefit from understanding more about their pain and its management1.

Pain education for patients and relatives includes:

  • Explanation of the biopsychosocial pain model
  • Basic information on physiology, anatomy
  • Explanation that inactivity leads to more pain, and activity to a reduction of the pain
  • Understanding pharmacological principles
  • Patients can be familiarised with non invasive procedures such as acupressure and transcutaneous electrical nerve stimulation
Argoff CE, Albrecht P, Irving G, et al. Multimodal analgesia for chronic pain: rationale and future directions. Pain Med. 2009;10 Suppl. 2:S53-66.


Optimal pharmacological treatment

Non-opioids and co-analgesics should be continued whenever possible and sensible.

Pharmacological substance classes used in pain therapy include:
  • Non-opioid Analgesics (e.g. NSAIDs, Paracetamol)
  • Opioid Analgesics (e.g. Tramadol, Codeine, Morphine, Oxycodone)
  • Antidepressants (e.g. Amitriptyline) Anticonvulsants (e.g. Gabapentin, Pregabalin)

The WHO guidelines for chronic pain therapy were originally developed for chronic cancer pain. However, they are widely used as guidelines for chronic non-cancer pain treatment as well. According to the WHO ladder, treatment decisions are mainly based on pain intensity.1

Chronic pain is often multifactorial in nature and rational pain management should be based on underlying mechanisms.2

There are also several other guidelines for the treatment of specific chronic pain indications.

Varrassi G., Müller-Schwefe GHH et al. Pharmacological treatment of chronic pain – the need for CHANGE. Curr Med Res Opin 2010; 26 (5): 1231-1245


Quick check

Which of the following should be involved in interdisciplinary multimodal pain management? Select the correct response.
The use of two or more drugs of different classes to manage pain.
Use of analgesic agents in conjunction with physical therapies, psychological patient support, pain education and peripheral stimulation
Drug treatment combined with patient support
Stepwise combination of different analgesic agents
Which of the following elements don’t belong to Cognitive Behavioral Therapy (CBT):
Activity Pacing
Relaxation Training
Cognitive Restructuring


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