Multimodal management – with regard to the multi-faceted nature of pain

Severe chronic pain is multifactorial in nature and therefore requires multimodal management that includes physical and psychological treatment and patient support together with the use of pharmacological therapy based on underlying mechanisms.1-4

Nociceptive and neuropathic components both contribute to pain. With increasing severity of chronic low back pain, the presence of a neuropathic component is more frequent (up to 77% for severe chronic low back pain). Since neuropathic pain correlates with more intense pain, more severe co-morbidity and poorer quality of life, accurate diagnosis is a milestone in choosing appropriate therapy.5

The patient-physician relationship and optimal use of analgesic therapies is central to a management plan that should include providing the patient with educational support and guidance on coping with pain. Management plans should include encouraging and supporting patients to be physically active and to take part in sports as well as relaxation activities.

Other elements of a multimodal management approach comprise:

  • Physical therapies such as physiotherapy and sports
  • Psychological therapy such as relaxation, hypnosis, and cognitive-behavioural interventions
  • Pain education for patients and their relatives
  • Peripheral stimulation such as TENS and acupuncture
  • Interventional therapy such as spinal cord stimulation

Pharmacological therapy plays a key role in the management of chronic pain. The combination of multimodal pain therapy should be based on an analysis of the underlying mechanisms of the disease.3

The choice of treatment depends on the pain characteristics and the state of pain chronification in the individual patient. The more severe the pain, the greater the impact on the patient’s life, and the need for comprehensive multimodal therapy.

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


1 Argoff CE et al. Multimodal analgesia for chronic pain: rationale and future directions. Pain Med. 2009; 10(S2):S53-66.
2 Dickman A et al. Chronic pain. Oxford Pain Management Library; 2008.
3 Gatchel RJ et al. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006; 7:779-93.
4 Dworkin RH et al. Advances in Neuropathic Pain. Arch Neurol. 2003; 60:1524-34.
5 Freynhagen R et al. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006; 22(10):1911-20.