Multidisciplinary, Behavioral, and Rehabilitative Care
Biopsychosocial framing
Pain is not only nociception; distress, beliefs, sleep, and context modulate it. Screen for yellow flags early-fear-avoidance, catastrophizing, depression, anxiety, and work dissatisfaction-because they predict chronification better than imaging does. Validate the patient's pain while reframing it as treatable; never imply the pain is "all in the head."
Team structure
Multidisciplinary care means several disciplines working in parallel; interdisciplinary care means an integrated team with shared goals and communication. The strongest evidence supports interdisciplinary functional restoration for chronic low back pain, combining physical conditioning, psychological intervention, and vocational rehabilitation.
Psychological treatments
Cognitive behavioral therapy targets maladaptive thoughts and behaviors. Acceptance and commitment therapy builds psychological flexibility around values. Mindfulness-based stress reduction, relaxation training, and pain neuroscience education-explaining central sensitization in plain language-are useful adjuncts. Graded activity and graded exposure reverse deconditioning and fear-avoidance without provoking flares; pacing prevents boom-and-bust cycles.
Rehabilitation
The goal is function, not pain elimination. Measure outcomes with validated instruments (Oswald Disability Index, Neck Disability Index, PROMIS), set functional goals, and address ergonomics and vocational needs.
Worked example
A patient with two years of low back pain, unremarkable imaging, high catastrophizing, and fear of movement asks for another MRI and a higher opioid dose. The best next step is referral to an interdisciplinary pain program with CBT and graded exercise-not further imaging or dose escalation.
Rule of thumb: ask both "where does it hurt?" and "what does the patient do and believe?"-the second question predicts outcome.