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Open Access Full Text Article ORIGINAL RESEARCH

Development and implementation of an inpatient

multidisciplinary pain management program for
patients with intractable chronic musculoskeletal
pain in Japan: preliminary report
This article was published in the following Dove Press journal:
Journal of Pain Research

Naoto Takahashi 1,2 Introduction: Multidisciplinary pain management is a useful method to treat chronic musculo-
Satoshi Kasahara 1,2 skeletal pain. Few facilities in Japan administer a multidisciplinary pain management program,
Shoji Yabuki 1,2 especially an inpatient program. Therefore, we implemented a multidisciplinary pain manage-
ment program in our hospital based on biopsychosocial factors guided by the recommendations
1
Department of Pain Medicine,
Fukushima Medical University of the International Association for the Study of Pain. The purpose of this study is to describe
School of Medicine, Fukushima, 2Pain our inpatient pain management program for Japanese patients, which uses the biopsychosocial
Management Center, Hoshi General
method of pain self-management.
Hospital, Koriyama, Japan
Materials and methods: Fourteen patients with intractable chronic musculoskeletal pain, who
were implemented a multidisciplinary pain management program in our hospital, were studied
using the evaluation of the pain and associated factors and physical function.
Results: Significant improvement in outcomes were seen in the brief pain inventory, the pain cata-
strophizing scale (rumination, magnification, and helplessness), the pain disability assessment
scale, the hospital anxiety and depression scale (anxiety and depression), the pain self-efficacy
questionnaire, the EuroQol five dimensions questionnaire, and muscle endurance and physical
fitness. We found no statistically significant differences in static flexibility or walking ability.
Conclusion: We developed an inpatient chronic pain management program for Japanese
patients. Our results suggest that our program improves chronic musculoskeletal pain coping
mechanisms, and that the program can improve patients’ quality of life and some physical
function. This inpatient pain management program is being expanded to better help intractable
chronic musculoskeletal pain patients.
Keywords: chronic musculoskeletal pain, multidisciplinary pain management, biopsychosocial
model, inpatient pain management program

Introduction
It is sometimes difficult to treat chronic musculoskeletal pain because the related
symptoms vary and the pathophysiology is complex. The International Association
for the Study of Pain (IASP) defines pain as “An unpleasant sensory and emotional
experience associated with actual or potential tissue damage, or described in terms
Correspondence: Naoto Takahashi
Department of Pain Medicine, Fukushima of such ­damage”.1 Chronic pain states develop during tissue recovery following
Medical University School of Medicine, 1 various injuries and may persist for long periods after tissue recovery. Because of
Hikarigaoka, Fukushima City, Fukushima
9601295, Japan its various manifestations, chronic pain may be difficult to treat successfully. Patient
Tel +81 24 547 1964 management using a multidisciplinary pain approach is a useful treatment method for
Fax +81 24 547 1966
Email [email protected] chronic musculoskeletal pain, as has been demonstrated in the USA since 1960. A

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biopsychosocial model2,3 of well-being is a very important each 30–60 minutes, total 20 times. The objectives of the
concept in multidisciplinary pain management. This is a program were for the patients to return to a functional daily
general model or approach stating that biological, psycho- life habit and to receive education in coping methods for
logical, and social factors play a significant role in human intractable chronic musculoskeletal pain and guidance for a
functioning in disease or illness. Multidisciplinary pain continuous ­exercise program. Finally, participation in some
treatment requires special facilities; however, few facilities in lectures and psychotherapy programs includes not only
Japan are able to provide a multidisciplinary pain approach, patients but also family members or significant others.8
especially an inpatient multidisciplinary pain management
program, because of the medical administration needs and Role of each of the 7 specialists
the Japanese insurance system. We implemented an inpatient 1. Orthopedic surgeons:
multidisciplinary pain management program in our hospital (a) To evaluate physical, neurological, and imaging find-
based on biopsychosocial models guided by the recommenda- ings, including radiographs/radiography, computed
tions.3–8 The purpose of this study is to describe our inpatient tomography, and magnetic resonance imaging, and to
pain management program for Japanese patients, which uses diagnose the presence of any specific musculoskeletal
the biopsychosocial method of pain self-management, and disorders.
to show the preliminary results. (b) To treat with conservative therapy, including injectable
therapy, pharmacotherapy, and cognitive behavioral
Materials and methods therapy, if needed.
Multidisciplinary pain management (c) To provide fundamental knowledge associated with
program chronic musculoskeletal pain to both patients and their
The pain management center discussed in this study was family members or significant others.
implemented in the Hoshi General Hospital, technically (d) To confirm patients’ changes in symptoms and levels
supported by the Department of Pain Medicine, Fukushima of progress in the program, during morning and/or
Medical University School of Medicine, in April 2015 with evening patient rounds.
a team of orthopedic surgeons, psychiatrists, nurses, physical 2. Psychiatrists:
therapists, clinical psychologists, pharmacists, and nutrition- (a) To diagnose patients’ psychological disorders asso-
ists. Our 3-week inpatient multidisciplinary pain manage- ciated with chronic musculoskeletal pain, including
ment program is indicated for patients who have difficulty psychiatric disorders, pervasive developmental disor-
working or attending school because of intractable chronic der, attention deficit hyperactivity disorder (ADHD),
musculoskeletal pain, and/or those who are confined to home or personality disorder.
but wish to return to work or school. The program consists (b) To treat with conservative therapy, including pharma-
of the following: 1) exercise therapy: physical fitness and cotherapy and cognitive behavioral therapy, if needed.
individual training by physical therapists, which consisted of 3. Nurses:
aerobic exercise (walking and/or underwater exercise), and (a) To observe inpatients’ behaviors and support patients
strengthening and stretching of trunk muscle, leg muscle, during hospitalization.
and hip joint muscle, among other things. For strengthening, (b) To confer with patients regarding their anxiety and
a sit-up exercise was used for the trunk flexor muscles and an problems associated with chronic musculoskeletal
extension exercise for the trunk extensor muscles, 6–7 hours a pain, and to act as liaison between specialists.
week, total 20 hours; 2) psychotherapy and cognitive behav- 4. Physical therapists:
ioral therapy: assertiveness (60–120 minutes, total 3 times), (a) To evaluate the changes of physical function.
relaxation training (60–120 minutes, total 2 times), and role (b) To educate patients about exercise and stretching.
playing to increase healthy behaviors and decrease pain behav- (c) To guide during strength training, with a focus on the
ior (60–120 minutes, total 2 times), led by psychologists; and trunk muscles and/or leg muscles to improve blood
3) patient education by each specialist, which consisted of the flow and muscle tone in the lumbar region.
lectures by orthopedic surgeon on pain mechanism, exercise (d) To help patients perform aerobic exercise, including
and pacing by physical therapist, assertiveness and relaxation walking and underwater exercise.
training by psychologist, side effects of drugs by pharmacist, (e) To guide during voluntary training, including stretch-
and daily life habit associated with nutrition by nutritionists; ing, walking, and other exercises.

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Dovepress Inpatient multidisciplinary pain management program in Japan

(f) To educate about the importance of pacing during activ- (PSEQ)14 to assess the psychosocial factors; and 3) the Euro-
ity and working within each patient’s limits of activity. Qol five dimensions (EQ-5D) questionnaire15 to evaluate the
5. Clinical psychologists: quality of life (QOL). Physical function was also evaluated
(a) To analyze patients’ self-expression type: aggressive, as follows: patients’ degree of flexibility, muscle endurance
defensive, or assertive. evaluated using a 2-step test for walking ability, and 6 minutes
(b) To guide self-expression to increase healthy behaviors of walking to assess physical fitness.
using role playing for both patients and their family
members. Statistical analysis
(c) To explain the gate control theory associated with The paired t-test was used for statistical analyses. A p-value
pain.8,9 of <0.05 was considered statistically significant. Statistical
(d) To educate about abdominal breathing and progressive analyses were performed using StatView 5.0 statistical soft-
muscle relaxation. ware (SAS Institute, Cary, NC, USA).
(e) To educate about the importance of pacing during activ-
ity and working within each patient’s limits of activity. Ethics approval and consent to
6. Pharmacists: participate
(a) To explain the half-life of medications to prevent This study was approved by the ethics committees of the
overdose, and to provide guidance about excess intake participating institutions of Fukushima Medical University
and its effects on internal medicine. (Reference number: 2429) and Hoshi General Hospital (Ref-
(b) To discuss the correct way to take the analgesic drugs erence number: 27-3). All participants gave written informed
orally based on the medical doctor’s instructions. consent for this study.
(c) To educate patients about the different analgesic drugs
and the side effects of opioids. Results
(d) To educate patients about endogenous opioids, and Patients’ clinical characteristics, chief complaints, structural
that oral analgesic drugs may not always be necessary. disorders, and psychiatric diagnoses are shown in Table 1.
7. Nutritionists: Fourteen patients, who received our 3-week inpatient multi-
(a) To analyze the average number of consumed calories disciplinary pain management program from April 2015 to
based on photographs of what patients ate, including March 2017, were included. Comparing results before and
both staple foods and between-meal snacks for 3 days after the program, the following significant improvement in
before hospitalization. outcomes were seen for 1) BPI; 2) rumination, magnifica-
(b) To provide a nutrition plan after calculating calories tion, helplessness and total on the PCS; 3) PDAS; 4) anxiety
spent during exercise, which is discussed during the and depression score on the HADS; 5) PSEQ; 6) EQ-5D;
treating program in collaboration with the physical 7) 30-second sit to stand test; and 8) 6-minute walking test
therapists. (Figures 1 and 2, Tables 2 and 3). We found no statistically
(c) To educate about lifestyle and nutritional support for significant differences in the following scales: 1) static flex-
both patients and their family members. ibility test and 2) two-step test (Figure 2 and Table 3).

Patients A representative case report

We evaluated 14 patients with intractable chronic musculo- Case 1: A 41-year-old man presented with a complaint of
skeletal pain undergoing our inpatient multidisciplinary pain severe low back pain for 2 years. He had a history of depres-
management program. sion, but no underlying diseases such as diabetes mellitus,
renal failure, hypertension, or thyroid disease. He was diag-
Evaluations of pain and associated factors nosed with lumbar disc herniation by a previous orthopedic
We evaluated inpatients with chronic musculoskeletal pain surgeon at a private clinic and was treated with conservative
using 1) a brief pain inventory (BPI)10 to assess pain ­severity; therapy, including medication and physical therapy. However,
2) a) an evaluation of the degree of rumination, magnification, he did not improve, and because he complained of general
and helplessness on a pain catastrophizing scale (PCS),11 b) malaise later, a referral to a psychiatrist was recommended.
pain disability assessment scale (PDAS),12 c) anxiety and He underwent treatment for depression, but his chief com-
depression assessment using the hospital anxiety and depres- plaint of low back pain did not improve. He provided written
sion scale (HADS),13 and d) a pain self-efficacy q­ uestionnaire informed consent to have the case details published.

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Table 1 Characteristics of 14 cases

Case Chief complaint Structural disorder Psychiatric diagnosis
1. 41-year-old man Low back pain None found Pervasive developmental disorder, attention deficit
hyperactivity disorder, somatoform disorders
2. 53-year-old woman Posterior cervical pain, bilateral None found Dependency personality disorder, somatoform
omalgia, low back pain disorders
3. 69-year-old woman Posterior cervical pain, bilateral Spondylosis Compulsive personality disorder, somatoform
omalgia, low back pain disorders
4. 55-year-old woman Posterior cervical pain, bilateral Ossification of posterior Narcissism personality disorder
upper extremity numbness longitudinal ligament
(after surgery)
5. 20-year-old man Low back pain None found Pervasive developmental disorder, attention deficit
hyperactivity disorder, somatoform disorders
6. 56-year-old woman Posterior cervical pain, bilateral Spondylosis, knee Attention deficit hyperactivity disorder, dependency
omalgia, low back pain, bilateral osteoarthritis personality disorder, somatoform disorders
gonalgia
7. 31-year-old woman Posterior cervical pain, bilateral None found None diagnosed
omalgia, low back pain
8. 47-year-old woman Low back pain None found Attention deficit hyperactivity disorder, histrionic
personality disorder, somatoform disorders
9. 56-year-old woman Low back pain, left leg pain None found None diagnosed
10. 51-year-old man Low back pain None found Pervasive developmental disorder, attention deficit
hyperactivity disorder, somatoform disorders
11. 55-year-old man Posterior cervical pain, bilateral None found Pervasive developmental disorder, autism spectrum
omalgia, back pain, bilateral arm pain, disorder, attention deficit hyperactivity disorder,
low back pain, bilateral leg pain somatoform disorders
12. 58-year-old woman Posterior cervical pain, bilateral Right hip osteoarthritis, Pervasive developmental disorder, attention deficit
omalgia, low back pain, right coxalgia, 4th lumbar degenerative hyperactivity disorder, somatoform disorders
bilateral gonalgia, bilateral leg pain spondylolisthesis
13. 75-year-old woman Low back pain, bilateral leg pain Spondylosis None diagnosed
14. 73-year-old woman Low back pain, bilateral leg pain Spondylosis, scoliosis None diagnosed

*
35

30 *

25
*
*
20
Points

*
15
Before
10 *
* * After
*
5
*
0
I n) n) ) l) y) n)
BP tio tio ess ta AS iet io EQ -5
D
na ca sn (to PD nx es
s PS EQ
m
i ifi es S (a pr
(ru ag
n pl PC S e
el AD (d
S (m (h H S
PC S S AD
PC PC H

Figure 1 Changes of pain and associated factors.

Notes: *p<0.05.
Abbreviations: BPI, brief pain inventory; EQ-5D, EuroQol five dimensions questionnaire; HADS, hospital anxiety and depression scale; PCS, pain catastrophizing scale;
PDAS, pain disability assessment scale; PSEQ, pain self-efficacy questionnaire.

Orthopedic surgeons of our team assessed the patient’s found no abnormal findings, no neurological deficits, and
physical, neurological, and imaging findings (lumbar radio- no abnormal structural disorders. He was diagnosed with
graphs/radiography and magnetic resonance imaging), and nonspecific low back pain. The psychiatric diagnoses were

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Dovepress Inpatient multidisciplinary pain management program in Japan

600
550 *
500
450
400
350
300 Before
250 After
200
150
100
50 *
0
Static flexibility 30-second 2-step test 6-minute walking
test sit to stand test (cm) test
(cm) (times) (m)
Figure 2 Changes in physical functions.
Note: *p<0.05.

Table 2 Changes of pain and associated factors

Before program After program p-value
(Average ± standard error) (Average ± standard error)
BPI 23.4 ±2.9 19.4 ±2.3 0.001
PCS (rumination) 15.3 ±1.0 12.6 ±1.1 0.01
PCS (magnification) 6.7 ±1.0 4.5 ±0.8 0.003
PCS (helplessness) 11.8 ±1.4 7.7 ±0.9 0.007
PCS (total) 33.8 ±3.1 24.8 ±2.6 0.003
PDAS 29.1 ±3.2 17.9 ±3.1 0.02
HADS (anxiety) 8.8 ±1.2 5.8 ±1.0 0.004
HADS (depression) 9.6 ±1.4 6.7 ±1.3 0.03
PSEQ 19.5 ±2.9 34.1 ±3.1 0.0002
EQ-5D 0.525 ±0.05 0.643 ±0.04 0.04
Abbreviations: BPI, brief pain inventory; EQ-5D, EuroQol five dimensions questionnaire; HADS, hospital anxiety and depression scale; PCS, pain catastrophizing scale;
PDAS, pain disability assessment scale; PSEQ, pain self-efficacy questionnaire.

Table 3 Changes of physical functions

Before program After program p-value
(Average ± standard error) (Average ± standard error)
Static flexibility test (flexibility) 24.7 ±2.9 cm 31.8 ±2.8 cm 0.15
30-second sit to stand test (muscle endurance) 14.2 ±2.4 times 18.2 ±2.9 times 0.02
2-step test (walking ability) 203.2 ±15.0 cm 224.5 ±12.3 cm 0.15
6 minutes walking test (physical fitness) 411.7 ±40.7 m 475.1 ±42.5 m 0.03

pervasive developmental disorder and ADHD (Table 1). increase tolerance in the seated position. The rehabilitation
We recommended that he enroll in the inpatient multidis- plan included stretching to raise his level of flexibility and
ciplinary pain management program at our hospital. He muscular endurance, and maintain a healthy posture. His
suffered severe pain, decreased QOL, mental anguish, and ADHD was treated using selective noradrenalin reuptake
physical dysfunction. Psychiatric evaluations clarified that inhibitors. Significant improvement was seen in pain severity,
the stress was related to his work as a public servant and his psychosocial factors, and QOL after 3 weeks of participation
relationship with his mother. The goals of therapy were to in the inpatient multidisciplinary pain management program
make him well enough to return to work and improve his rela- compared with that before starting the program (Table 4). All
tionship with his mother. Since he had difficulty remaining the physical functions including flexibility, muscle endur-
seated for extended periods, the goal of rehabilitation was to ance, walking ability, and physical fitness improved after the

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program as a result of the supervised exercise therapy by the A biopsychosocial model of well-being
physical therapists (Table 5). After discharge, he visited the A biopsychosocial model2,3 of well-being is a very important
pain management center as an outpatient once a week, the concept in determining the underlying mechanisms in chronic
psychiatry clinic every 2 weeks, and the rehabilitation center musculoskeletal pain. This is a general model or approach
or pool for underwater exercise once a week. He continued incorporating the biological factors that constitute the physi-
exercise every day. He also received counseling with regard to cal structural disorders diagnosed by medical personnel, and
interpersonal relationships with a goal of returning to work. the psychological and social factors that constitute stress,
Finally, he returned to work as a public servant 7 months including a lack of control, depression, anxiety with regard to
after completing the program. health and/or life issues, age, environment, and the patient’s
social situation. This model stresses the importance of using
Discussion a psychological and social approach to treat pain that does
Our study of implementing a Japanese-style inpatient not improve with pharmacotherapy and/or surgery. The IASP
multidisciplinary pain management program was based on recommends an interdisciplinary or multidisciplinary pain
biopsychosocial models guided by the IASP recommenda- management approach for treating chronic musculoskeletal
tions. We showed that pain severity, pain-associated factors pain. Interdisciplinary or multidisciplinary pain management
such as psychosocial factors, QOL, muscle endurance, and approaches have been implemented in some institutes in
physical fitness in inpatients with intractable chronic mus- Japan, but there remains no nationwide interdisciplinary or
culoskeletal pain were statistically significantly improved multidisciplinary pain management approach.
after the program.
Characteristics of our inpatient
Table 4 Changes of the various scores after treatment in a multidisciplinary pain management
representative patient program
Before treatment 3W treatment The multidisciplinary pain management program in our
Degree of pain hospital is an inpatient program. The characteristics of this
BPI 24 21 program are that a team consisting of orthopedic surgeons,
Psychosocial factors
PCS (rumination) 20 8
psychiatrists, nurses, physical therapists, clinical psycholo-
PCS (magnification) 16 10 gists, pharmacists, and nutritionists treats patients with
PCS (helplessness) 9 3 chronic musculoskeletal pain based on the patient’s lifestyle
PDAS 29 7
and therapeutic targets, including sleep and nutrition, using
HADS (anxiety) 15 9
HADS (depression) 19 6 cognitive behavioral therapy and exercise therapy. The goals
PSEQ 10 40 of our program are as follows: 1) to decrease pain catastroph-
QOL score izing for chronic musculoskeletal pain, 2) to decrease pain
EQ-5D 0.384 0.724
behavior, and 3) to increase healthy behavior.
Abbreviations: BPI, brief pain inventory; EQ-5D, EuroQol five dimensions
questionnaire; HADS, hospital anxiety and depression scale; PCS, pain catastrophizing
scale; PDAS, pain disability assessment scale; PSEQ, pain self-efficacy questionnaire;
3W, 3 weeks.
Exercise therapy
Exercise and stretching with pacing, including maintain-
Table 5 Changes of physical function after treatment in a ing correct alignment and posture, training for trunk core
representative patient muscle strength, and aerobic exercise such as walking, are
Before 3W important in treating chronic musculoskeletal pain. Exercise
treatment treatment
and stretching with pacing improves flexibility, muscle endur-
Flexibility
Static flexibility test (cm) 22 36.5
ance, walking ability, and physical fitness, and also activates
Muscle endurance dopaminergic neurotransmission and/or serotonin and nor-
30-second sit to stand test (times) 10 15 epinephrine in descending spinal pain inhibition.16–20 The
Walking ability supervised exercise therapy, which includes aerobic exercise
2-step test (cm) 246 295
Physical fitness
such as walking and underwater exercise, and stretching with
6-minute walking test (m) 375 397 pacing, has an important role in our inpatient pain manage-
Abbreviation: 3W, 3 weeks. ment program.

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Dovepress Inpatient multidisciplinary pain management program in Japan

Pathomechanisms of chronic Multidisciplinary pain management programs for

musculoskeletal pain chronic musculoskeletal pain
Psychological factors related to chronic Scascighini et al opined that compared with other non-
musculoskeletal pain disciplinary treatments, moderate evidence of higher effec-
Previous studies have suggested that 1) pain-related fear and tiveness for multidisciplinary interventions was shown.38
avoidance appear to be essential features of the development Other countries have also implemented multidisciplinary
of a chronic pain state in patients with musculoskeletal pain management programs.39–55 For instance, the University
pain,21–29 and 2) fear-avoidance beliefs and catastrophizing of Washington Center for Pain Relief in Seattle, WA, USA,
have been implicated in chronic pain and may interact with which was one of the first establishments for interdisci-
the experience of pain.30,31 These studies suggest that it is plinary and/or multidisciplinary pain management in the
very important to decrease fear-avoidance beliefs and pain world, has outpatient programs that include treatment for
catastrophizing to improve the QOL of patients with chronic acute and chronic pain using intervention therapy.45 Their
musculoskeletal pain. The importance of psychological multispecialty clinical team consists of internists, psychia-
factors such as depression, anxiety, and catastrophizing in trists, anesthesiologists, physical therapists, pharmacists,
the development of pain severity and physical functioning and nurses. The center’s treatment outcomes are very good
has also been reported.32–34 We confirmed decreased pain and patient satisfaction is high. Similar programs in Japan
behavior and increased healthy behavior in patients with include a multidisciplinary approach at Aichi Medical Uni-
chronic musculoskeletal pain after completing our pro- versity46 that involves a 9-week outpatient program based on
gram. Vachon-Presseau et al suggested that corticolimbic cognitive behavioral therapy and exercise for patients with
anatomical characteristics predetermine the risk for chronic refractory chronic pain, and a multidisciplinary outpatient
pain, and a high prevalence of depression and negative affect program at Okayama University for patients with intractable
are associated with risk for chronic pain.35 Also, Jiang Y chronic pain.47 These teams consist of orthopedic surgeons,
et al reported that 1) patients with chronic pain had exag- psychiatrists, anesthesiologists, nurses, physical therapists,
gerated and abnormal amygdala connectivity with central trainer, and nutritionists at the Aichi Medical University, and
executive network, which was most exaggerated in patients orthopedic surgeons, anesthesiologists, psychiatrists, neuro-
with the greatest pain catastrophizing, and 2) the normally surgeons, dental anesthesiologists, nurses, physical therapists,
basolateral-predominant amygdala connectivity to the default occupational therapists, clinical psychologists, and social
mode network was blunted in patients with chronic pain.36 workers at the Okayama University. Another program at
Patients’ fear-avoidance beliefs and catastrophizing may Whittington Hospital, London, UK, ran 1 afternoon per week
involve exaggerated and abnormal amygdala connectivity for 7 weeks and was conducted by a multidisciplinary team
with the central executive network. Following our inpatient aiming to increase patients’ skills for coping with chronic
pain management program, our patients showed decreased pain and its social, emotional, and physical consequences.48
fear-avoidance beliefs and catastrophizing, and improved The efficacy of an inpatient multidisciplinary pain man-
pain levels and aggressive self-expression. The results of the agement program has been reported in several studies.49–55 Our
current study support these findings. pain management program is an inpatient multidisciplinary
program with a team consisting of orthopedic surgeons, psy-
Social factors related to chronic musculoskeletal pain chiatrists, nurses, physical therapists, clinical psychologists,
Eisenberger et al suggested that the anterior cingulate cortex pharmacists, and nutritionists. We compared the outcomes
was more active during social exclusion than during social of our inpatient multidisciplinary pain management program
inclusion in a physical pain study, and that the right ventral with those of other facilities. Table 6 shows the multidisci-
prefrontal cortex was active during social exclusion and cor- plinary pain management programs in other facilities.49–54 The
related negatively with self-reported distress in a neuroimag- program at the Rehabilitation Medicine Clinic49 in coopera-
ing study.37 The authors suggested that these findings might tion with the University of Washington Center for Pain Relief
be very important during social inclusion; that the family or includes a multidisciplinary rehabilitation team consisting
a significant other is necessary when treating patients with of rehabilitation medicine physicians, pain psychologists,
chronic musculoskeletal pain. Our inpatient pain manage- and physical and occupational therapists. Patients stay near
ment program includes family or significant others, since we the hospital for 4 weeks – 1 week longer than our inpatient
believe that another person’s support is essential. program. Their treatment program is similar to ours, based on

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Table 6 Inpatient multidisciplinary pain management programs in other countries

Facility Staff Hospitalization Treatment method Outcomes
Washington Center Rehabilitation medicine 4 weeks Multidisciplinary rehabilitation program, Improvements in reported
for Pain Relief (Seattle, physicians, pain which includes physical exercise and pain, pain worry, fear-
WA, USA) psychologists, physical reconditioning, and psychological avoidance beliefs, depression,
and occupational strategies for managing pain and the and physical function,
therapists, vocational associated emotional and behavioral 74% of patients returned to
counselors changes work or underwent retraining
Center for Clinical Physicians, nurses, 3–4 weeks Multidisciplinary inpatient orthopedic Significantly improved
Psychology and therapists, clinical rehabilitation program, which includes psychological and pain-related
Rehabilitation, psychologist physical exercise training, cognitive outcome measures, especially
University of Bremen behavioral therapy, progressive muscle anxiety level
(Bremen, Germany) relaxation, and psychological counseling
Institute for Rheumatologists, 4 weeks Interdisciplinary approach including Significantly improved pain
Physiotherapy, Bern clinical psychologists, drug therapy, physiotherapy (aerobic scores, mental health, and
University Hospital physiotherapists, endurance training, qigong/tai chi coping outcomes
(Bern, Switzerland) occupational therapists, exercises), and individual psychotherapy
nurses, a movement that includes cognitive behavioral therapy,
analyst, and a humor relaxation therapy, humor therapy, and
therapist education in coping skills
University of Physicians, nurses, 2 weeks Multidisciplinary pain management Significant improvements in
Duisburg-Essen (Essen, mind–body therapists program, which includes classical pain intensity, pain disability,
Germany) naturopathy (hydrotherapy, pain perception, quality of life,
thermotherapy, manual therapy, massage, depression, and perceived
physiotherapy, exercise, nutritional stress
therapy, and fasting), stress reduction,
nutritional counseling, and self-help skills
Chronic Pain Anesthesiologists, 4 weeks An inpatient cognitive behavioral pain Significant improvements for all
Management and clinical psychologists, program with physical and psychological measures of psychological and
Neuromodulation physical therapists, assessment, exercise therapy and physical function.
Centre at St. Thomas’s occupational therapists, stretching, and relaxation technique A majority of patients were
Hospital (London, UK) and nurses training satisfied with the treatment
Auckland City Hospital Registered 4 weeks Cognitive behavioral pain program, which Significant improvements at
(Auckland, New psychiatrists, medical includes education about physiology posttreatment for measures
Zealand) and nursing staff, and psychology in pain; behavioral of psychological distress,
psychologists, pain management; promoting adaptive pain behavior, health-related
physiotherapists, cognitions via cognitive restructuring, disability, and pain intensity
occupational therapists, visualization, and imagery techniques; following physical exertion
and vocational exercise; individual, group, family, and
rehabilitation officers vocational counseling; medication; and
staff verbal reinforcement of patients’
activity

multidisciplinary rehabilitation that includes pain education. University Hospital in Switzerland51 involves interdisciplin-
The Washington program showed improvements in pain, pain ary inpatient therapy with a team of rheumatologists, clini-
worry, fear-avoidance beliefs, depression, and physical func- cal psychologists, physiotherapists, occupational therapists,
tion. The program at the Center for Clinical Psychology and nurses, a movement analyst, and a humor therapist. Patients
Rehabilitation at the University of Bremen in Germany50 is a are hospitalized for 4 weeks. Because their method involves
multidisciplinary inpatient orthopedic rehabilitation program interdisciplinary pain management, results may differ from
with a team of physicians, nurses, therapists, and clinical psy- our multidisciplinary program; however, the improvements in
chologist. Patients are hospitalized for 3–4 weeks. The Center pain, mental health, and coping outcomes are similar to our
also uses a multidisciplinary rehabilitation approach that results. The program at the University of Duisburg-Essen in
includes pain education, and their outcome in psychological Germany52 is a multidisciplinary pain management program
and pain-related outcome measures is similar to that of our consisting of a team of physicians, nurses, and mind–body
program. The program at the Institute for Physiotherapy, Bern therapists. Patients are hospitalized for 2 weeks; treatment

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Dovepress Inpatient multidisciplinary pain management program in Japan

methods are similar to our multidisciplinary approach and in both groups compared with untreated controls; however,
include physiotherapy, exercise, stress reduction, and nutri- inconsistent methodologies made direct comparisons of
tional education. However, the program differs from ours the 2 groups of patients impossible.54 The authors reported
because it also includes naturopathy. The improvements in that at 1 year, inpatients showed a greater likelihood than
pain intensity, pain perception depression, perceived stress, outpatients of maintaining treatment gains,55 suggesting that
and QOL are similar to our results. The Chronic Pain Man- inpatient programs were more useful for some patients with
agement and Neuromodulation Centre at St. Thomas’s Hos- intractable chronic pain. Future studies comparing inpatient
pital in London53 has a multidisciplinary pain management with outpatient pain management programs in detail would
program consisting of a team of anesthesiologists, clinical be useful.
psychologists, physical and occupational therapists, and
nurses. Patients are hospitalized for 4 weeks, and the program Limitations
involves a cognitive behavioral pain program with physical Controversial points in our inpatient
therapy, similar to our program, but differs in that they do not multidisciplinary pain management program
include nutritional education. The outcomes in all measures Along with the advantages of our inpatient multidisciplinary
of psychological and physical function are similar to our pain management program, there are also weak and/or con-
program’s results. The program at the Auckland City Hospital troversial points. First, although this program is open to all,
in Auckland, New Zealand,54 is a behavioral pain program we must consider each patient’s rehabilitation, carefully.
involving a team of registered psychiatrists, medical and Second, because it may be difficult to sufficiently change the
nursing staff, psychologists, physiotherapists, occupational patients’ cognition and behavior in a short period, it may be
therapists, and vocational rehabilitation officers, and the pro- necessary to continue patient follow-up by each specialist
gram includes education about the physiology and psychology after discharge. Finally, a high number of medical personnel
of pain; behavioral pain management; promotion of adaptive are involved in this inpatient program, and incomes may not
cognitions via cognitive restructuring, visualization, and be adequately reflected because of the insufficient Japanese
imagery techniques; exercise; individual group, family, and insurance system for chronic pain. We must correct these
vocational counseling; medication; and verbal staff reinforce- controversial points to generalize our inpatient program.
ment of patients’ activity. As in our program, the Auckland
City Hospital’s program involves educating both patients and Limitation in this study
family, and includes cognitive behavioral therapy and medica- The present study has certain important limitations. First,
tions. The outcomes in measures of psychological distress, there was no control group in this study. We compared the
pain behavior, health-related disability, and pain intensity treatment outcomes of our inpatient multidisciplinary pain
following physical exertion are similar to that of our results. management program with previous programs in other
Overall, the outcomes of our inpatient multidisciplinary pain countries; however, future studies, including a control group
management program are consistent with similar inpatient are required. Second, our study population was small; larger
multidisciplinary pain management programs in other coun- populations are needed in future studies. Third, the follow-up
tries49–54 with regard to improved pain intensity, psychosocial period was relatively short, and future studies are needed to
factors such as fear-avoidance, physical function, and QOL. evaluate long-term follow-up.
Hospitalization duration was 2–4 weeks in all the studies
we used for comparison;49–54 therefore, our 3-week duration Conclusion
appears to be appropriate. We developed an inpatient multidisciplinary pain manage-
ment program and reported the results of our first 14 cases.
Inpatient vs. outpatient pain management Our inpatient multidisciplinary pain management program
programs is being expanded to better help intractable chronic muscu-
There are few randomized comparisons of inpatient vs. loskeletal pain patients.
outpatient pain management programs. Scascighini et al
found that the evidence that comprehensive inpatient pro- Acknowledgments
grams were more beneficial than outpatient programs was The authors are very grateful to each participant in the
­moderate.38 Peters et al performed a randomized trial compar- study and the clinical staff who supported this research:
ing ­inpatient and outpatient treatment and found improvement Kou ­Matsudaira, Kozue Takatsuki, Hidemi Ohsuka, Saori

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Takahashi et al Dovepress

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