Interventional pain medicine: retreat from the biopsychosocial model of pain

Abstract

The field of pain medicine has shifted from multidisciplinary rehabilitation to procedure-focused interventional pain medicine (IPM). Considerable controversy exists regarding the efficacy of IPM and its more narrow focus on nociception as an exclusive target of pain treatment. This topical review aims to examine pain research and treatment outcome studies that support a biopsychosocial model of pain, and to critique the clinical practice of IPM given its departure from the premises of a biopsychosocial model. A modern definition of pain and findings from clinical and basic science studies indicate that pain-related psychological factors are integral to pain perception. The clinical viability of IPM is challenged based upon its biomedical view of peripheral nociception as a primary source of pain and the potential of this viewpoint to foster maladaptive pain attributions and discourage the use of pain coping strategies among chronic pain patients. IPM should adopt a biopsychosocial perspective on pain and operate within a framework of multidisciplinary pain rehabilitation to improve its effectiveness. KEYWORDS

Recent data from radiofrequency denervation trials further emphasise that treating nociception is not the same as treating pain

“…In this approach, various diagnostic practices are used to identify a peripheral ‘nociceptive driver’, with the presumption that denervation of the peripheral structure will eradicate or significantly reduce pain and improve function 3. The growth in the use of radiofrequency denervation is surprising given that, until recently, the evidence base was equivocal2 and based on conflicting results from a limited number of small trials.…”

“…Despite decades of research illustrating the equivocal link between nociception and pain,3 as well as the disparity between reported pain and disability,3 many in the back pain community continue to see the management of nociception as the primary focus in the management of LBP. The results of six moderately sized and well conducted clinical trials that demonstrate no efficacy4–6 and no real-world effectiveness2 for denervation procedures are a stark illustration of how flawed this approach is.…”

Biopsychosocial model of disease: 40 years on. Which way is the pendulum swinging?

“…For instance, there has been criticism of interventional pain medicine for its departure from the premises of a biopsychosocial model back to a narrow focus on nociception as a sole target of pain treatment without any due regard and consideration of pain-related psychological factors 5. In other quarters, the pendulum has swung in the opposite direction away from the biological domain to focus on psychosocial domains with behavioural treatments being the sole intervention 6.…”

A brief primary care intervention to reduce fear of movement in chronic low back pain patients

“…Instead, for more than a decade, the treatment option for CNP is often a single modality pain intervention. Unfortunately, no evidence-based support has been found for the reversion to a single modality medical conceptualization and treatment of chronic pain [3]. As a result, primary care providers are left with limited options for their patients with CNP.…”