Original Article
A Transdisciplinary Team
From the New York University
Langone Medical Center, Rusk
Institute of Rehabilitation Medicine,
New York, New York.
Address correspondence to John R.
Corcoran, New York University
Langone Medical Center, Ambulatory
Care Center, 240 East 38th Street, 15th
Floor Rusk Rehabilitation, New York,
NY 10016. E-mail: John.Corcoran@
nyumc.org
Received September 28, 2012;
Revised January 18, 2013;
Accepted January 24, 2013.
1524-9042/$36.00
! 2014 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2013.01.004
Approach to Pain
Management in Inpatient
Health Care Settings
Robert M. Gordon, PsyD,
---
John R. Corcoran, PT, DPT, MS, Cert.MDT,
Patricia Bartley-Daniele, MSN, FNP-BC, CCRN, CNRN, CPAN,
CAPA, Dennis Sklenar, LCSW,
Phyllis Roach Sutton, APRN, ACHPN,
and Frances Cartwright, PhD, RN-BC, AOCN
- ABSTRACT:
This paper will discuss the transition from multidisciplinary to inter-
disciplinary and transdisciplinary team approaches to pain manage-
ment at New York University Langone Medical Center – Rusk Institute
of Rehabilitation Medicine. A transdisciplinary team approach to pain
management emphasizes mutual learning, training, and education,
and the flexible exchange of discipline-specific roles. Clinicians are
enabled to implement a unified, holistic, and integrated treatment
plan with all members of the team responsible for the same patient-
centered goals. The model promotes and empowers patient and
family/support system goals within a cultural context. Topics of
exploration include the descriptions of three team approaches to
patient care, including their practical, philosophical, and historical
basis, strengths and challenges, research support, and cultural diver-
sity. Case vignettes will highlight the strengths and limitations of the
transdisciplinary team approach to pain management throughout
a broad and diverse continuum of care, including acute medical,
palliative, and perioperative care and acute inpatient rehabilitation
services.
! 2014 by the American Society for Pain Management Nursing
HISTORICAL PERSPECTIVES ON PAIN MANAGEMENT
The clinical expression of pain is a highly complex and multi-determined
phenomenon. It involves the interaction and integration of biochemical, social,
psychological, social, and cultural factors (Bial & Cope, 2011, p. 10). Acute pain
symptoms are usually not experienced longer than 6 months and remit when the
underlying cause of pain has been addressed (Duckworth, Iezzi, & Sewell, 2009).
In contrast, chronic pain is a persistent condition that does not decrease over
time or respond to specific interventions (Merskey & Bogduk, 1994). Theories
of pain have ranged from an imbalance of vital forces, as a form of punishment
Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 426-435
 A Transdisciplinary Team Approach to Pain Management
or a path to spiritual rewards, a psychological reaction,
and a complex biological event (Bial & Cope, 2011).
Contemporary pain management perspectives have in-
corporated the possibility of concurrent experiences
of acute and/or chronic pain.
The evolution of pain management reflects histori-
cal, social, cultural, ethical, and religious influences;
medical and pharmacological innovations; and differing
conceptions of the treatment team. During the 19th cen-
tury, treatment goals ranged from symptomatic relief, to
severe pain palliation, to chronic pain management.
Ethical decision-making challenges consisted of the utili-
zation of opiate-pain relief benefits versus the risks of
addiction and that were influenced by delicate social, re-
ligious, and cultural norms (Meldrum, 2003). The impact
of combat-related injuries during the past century was
a catalyst for advances in acute and chronic pain manage-
ment strategies, the understanding of phantom limb con-
ditions, and the need for pain management clinics
(Meldrum, 2003). In addition, pharmacological advances
and other treatments in acute, chronic, and neuropathic
pain associated with physical, psychological, emotional,
social, cultural, spiritual and financial influences de-
manded multidisciplinary approaches (Dworkin et al.,
2007; White & Keheir, 2010). Effective pain management
evolved from individualistic approaches to institutional
commitments that were supported by communication,
education, and staff, patient, and family involvement
(Weissman, Dahl, & Beasley, 1993).
As a result of these advances, there were also
changes in the treatment of complex medical condi-
tions including the management of cancer pain. In
1986, the World Health Organization (WHO) devel-
oped the analgesic ladder to guide the international
treatment of cancer pain, which has served as a guide
to multimodal therapies for pain syndromes
(Eisenberg, Marinageli, Birkham, Paladin, & Varassi,
2005; Vargas-Schaffer, 2010). In addition, organiza-
tional commitments to effective pain management
have promoted the development of standards, quality
improvement strategies, accountability, education,
and patient satisfaction initiatives (Joint Commission,
2001; Centers for Medicare and Medicare Services
[CMS], 2002; CARF Medical Rehabilitation Standards
Manual [July 2011–June 2012], 2011).
Since 1970, The American Pain Society and the
International Association for the Study of Pain (IASP)
have been committed to research, education, treat-
ment, and advocacy that transcend geographical and
cultural borders (American Pain Society, 2011). More
than 60 scientific disciplines are members of the
IASP (Bial & Cope, 2011). This multidisciplinary
emphasis has continued during the past two decades
with the establishment of a formal subspecialty
427
board certification from the American Board of Anes-
thesiology in 1991, then by subspecialty certification
from both the American Board of Psychiatry and
Neurology (ABPN) and the American Board of Physical
Medicine and Rehabilitation (ABPMR) in 2000 (Bial &
Cope, 2011; Fishman, Gallagher, Carr, & Sullivan,
2004), and later by the American Society for Pain Man-
agement Nursing (ASPMN), and the American Nurses
Credentialing Center (ANCC, 2008).
Pain management has long been viewed as a basic
human right and in 1999 the Joint Commission formal-
ized pain standards to ensure that all patients have
a right to an appropriate level of assessment and man-
agement of their pain, describing pain as the ‘‘fifth vital
sign’’ (Bial & Cope, 2011; Lanser & Gesell, 2001). The
complexity of acute and chronic pain experiences has
demanded innovative team and clinical interventions.
TEAM APPROACHES TO PAIN
MANAGEMENT
Three team approaches have emerged in the field of
rehabilitation: multidisciplinary, interdisciplinary, and
transdisciplinary (Butt & Caplan, 2010). Each model
has distinct advantages, challenges, and implications
for assessment, roles, and goal-setting. The interdisci-
plinary and transdisciplinary approaches used in the
specialty of rehabilitation can be applied to the specialty
of pain management, as pain management is an impor-
tant component of the broader field of rehabilitation.
The goals of rehabilitation include the revitalization of
the patient’s power to live a meaningful life (Jennings,
1993), to maximize independence, and to facilitate rein-
tegration into the community. Pain management empha-
sizes alleviating, managing, and living with pain and
promoting comfort. While the goals of pain manage-
ment are more specific, the common threads of pain
management and rehabilitation medicine are to help pa-
tients overcome or manage overwhelming conditions to
function at their best in their day-to-day environments.
Multidisciplinary health care team members have
clearly defined roles and conduct independent evalua-
tions leading to discipline-specific treatment goals
(Butt & Caplan, 2010). A multidisciplinary approach
consists of various disciplines working with a patient,
but the staff members function independently of one
another. For example, a nurse, social worker, physical
therapist, occupational therapist, speech-language pa-
thologist, psychologist, and a physician may all be
working with a patient, but share minimal information
with each other. This approach can lead to different or
contradictory expectations and goals from various
members of the treatment team that can be confusing
for patients and their families (Linder, 1983).
428 Gordon et al.
The interdisciplinary team model is based on an
overlap and sharing of roles and skills across treatment
team members (Butt & Caplan, 2010). In an interdisci-
plinary team, there are also several disciplines working
with a patient, but the team shares the same goal.
There is a higher degree of collaboration fostering
discipline-specific goals. For example, the shared
team goal could be for the patient to return to work
on a part-time basis in 6 weeks. The challenges of
this model include the need for open, flexible, collabo-
rative and respectful communication among the vari-
ous disciplines in resolving conflicts, priorities,
negotiating roles, and developing common goals
(Butt & Caplan, 2010). Cifu and Stewart (1999) re-
viewed various stroke rehabilitation programs and con-
cluded that interdisciplinary team approaches were
more effective than multidisciplinary team models in
terms of shorter length of stay, an increase in patient’s
quality of life and functional outcome, and cost
effectiveness.
A further evolution of the interdisciplinary model
is the transdisciplinary approach reflected in a signifi-
cant overlap of responsibilities and functions among
the various disciplines (Butt & Caplan, 2010). This
team approach was introduced in this country in the
1970s in special educational settings for children
with physical disabilities (Rosen, Pit-ten Cate, Bic-
chieri, Gordon, et al., 1998). Salient components of
this model include integrated assessment and treat-
ment goals that can be implemented by each member
of the team (Butt & Caplan, 2010; Rosen et al., 1998).
This model is consistent with the Institute of Medi-
cine’s (IOM, 2011) blueprint for relieving pain in Amer-
ica. The transdisciplinary model addresses the IOM
recommendation which ‘‘.should be implemented
by the end of 2012—including developing a compre-
hensive strategy, developing strategies to reduce bar-
riers in care, supporting collaboration between pain
specialists and primary care clinicians..’’ (p. 4).
While there are similarities between interdisci-
plinary and transdisciplinary approaches in terms of
frequent communication between team members,
there are differences in the areas of role, assessment,
and underlying values. The members of a transdisciplin-
ary team have more fluid role boundaries in that each
team member takes responsibility for the patient as
a whole and the specific intervention is not the sole
responsibility of a particular discipline (Cammack &
Eisenberg, 1995; Cartmill, Soklaridis & Cassidy, 2011;
Haig & LeBreck, 2000). For example, visual/spatial,
receptive and expressive language, and stress manage-
ment/mindfulness interventions can be carried out by
different therapists. In addition, assessment is more
collaborative rather than discipline-specific (e.g.,
a speech-language pathologist and a neuropsychologist
can conduct an assessment together) (Rosen et al., 1998).
TRANSDISCIPLINARY TEAM
APPROACH DEFINITION
A transdisciplinary team approach to pain manage-
ment emphasizes mutual learning, training and educa-
tion, and the flexible exchange of discipline-specific
roles. Clinicians are enabled to implement a unified,
holistic, and integrated treatment plan with all mem-
bers of the team responsible for the same patient-
centered goals. The model promotes and empowers
patient and family/support systems within a cultural
context. It fosters mutual respect and trust among
team members and a strong appreciation of each disci-
pline’s knowledge, skills, and expertise. The approach
facilitates consistent communication, interaction, and
cooperation among team members.
In a transdisciplinary approach, the team not only
shares the same goal, but also shares the same treatment
plan regardless of discipline. In doing so, it maximizes
the team approach that is critical in pain management.
The various disciplines (e.g., nurse, physician, psychol-
ogist, nurse practitioner, social worker, speech-language
pathologist, occupational therapist, physical therapist,
pharmacist, integrative health practitioner, etc.) imple-
ment and coordinate the patient- centered plan.
Transdisciplinary care poses a number of challenges
including the potential for conflicts about role overlap
and ownership of information. Team members may expe-
rience a sense of competition or lack of boundaries
among each other. Therefore, time and openness to ongo-
ing dialogue that recognizes and respects these concerns
is required for ease of sharing and for trust to develop.
Transdisciplinary care may be best understood
through clinical examples. A critical component to
this model is the patient’s goals—what the patient
would like to accomplish with the team. It is important
for there to be consistency between the patient’s and
staff’s goals. For example, if the patient’s goal is to re-
sume walking pain-free without an assistive device to
feel independent, while the team’s goal is for the pa-
tient to ambulate with a walker to reduce the level of
pain and the risk of falling, a discussion between staff
and patient would need to occur that takes safety
into consideration while also addressing the patient’s
wishes. It is important to explore these different per-
spectives in a collaborative, respectful, and realistic
manner with all disciplines reinforcing the same plan.
Rosen et al. (1998) investigated the differences in
team functioning between multidisciplinary and trans-
disciplinary models when treating young children with
physical and cognitive disabilities. Staff members
 A Transdisciplinary Team Approach to Pain Management
favored the transdisciplinary model for treatment plan-
ning and development. This approach provided more
integrative information about the child and facilitated
more staff participation and qualitative improvements
during team meetings. For example, these researchers
found that there were more holistic statements about
the child, information was presented in a conversa-
tional style rather than reading or referencing re-
ports/notes verbatim, and patient-centered
transdisciplinary goals were significantly promoted.
There has been a parallel shift toward transdisci-
plinary research in health care settings. This innovative
approach emphasizes integrative and collaborative
communication to blend disciplines and perspectives.
It involves professionals from various disciplines work-
ing together on a common project and utilizes a new
common conceptual perspective that transcends the
traditional frameworks of each separate discipline
(Dankwa-Mullan et al., 2010). For example, scientists,
clinicians, educators, and public health professionals
work together on a complex problem that cannot be
resolved by any one discipline or constituency (e.g.,
obesity, pain management, smoking cessation)
(Abrams, 2006; Dankwa-Mullan et al., 2010). ‘‘A cul-
tural transformation is necessary to better prevent,
assess, treat, and understand pain of all types’’ (IOM,
2011, p. 1). Transdisciplinary research has supported
collaborative strategies to enhance the development
of knowledge and evidence based practice. Relation-
ships among patients, families, communities, and
health care teams have demanded diverse perspectives
that contribute to science, innovation, and quality
health care (Abrams, 2006). A trandisciplinary pain
management model implemented in an academic med-
ical center can successfully address these gaps
(Table 1).
CULTURAL DIVERSITY AND HEALTH
DISPARITIES
Transdisciplinary approaches have incorporated
patient-centered care into research, practice, and health
care policy. The Institute of Medicine (2001) describes
patient-centered care as being responsive and respectful
of the individual’s needs, preferences, culture, beliefs,
and values. These factors guide treatment decisions
and influence communication and goal setting. Treat-
ment is not limited to providing culturally and linguisti-
cally appropriate services (CLAS), but culturally
sensitive communication that reflects understanding, re-
spect, and appreciation of cultural diversity (U.S.
Department of Health and Human Services, 2007).
Health care professionals must determine that the
patient is literate and, most importantly, has the
429
cognitive and language ability to understand and fol-
low a recommended treatment plan. Therefore, an im-
portant application of a transdisciplinary model is
intensive, ongoing interaction among team members
from different disciplines enabling an exchange of in-
formation, knowledge, and skills in an effort to work
in unison (King et al., 2009). Social and cultural deter-
minants must be seen in the context of the individual
and the community that include the patient’s support
system. Diversity includes all aspects of culture, as
well as socioeconomic status, religion, disability or
ableness, age, gender, race, and sexual orientation,
which all interact in a dynamic manner (Falender &
Shafranske, 2004). The consideration of cognitive abil-
ities, language, education, health literacy, as well as
environmental and financial factors, provides an op-
portunity to view the patient in a broader context
and leads to a decrease in health disparities. Patient in-
formation obtained by the health care team members
must be shared across the various disciplines that are
involved in the patient’s care. Sharing information facil-
itates team member’s access to the patient’s life situa-
tion, which leads to a more comprehensive plan of
care. Exchange of these perspectives should be placed
in the context of each profession, while having respect
and appreciation for the unique contribution of each
discipline. This is in an effort to facilitate problem-
solving and formulate holistic patient-centered treat-
ment goals.
Cultural beliefs, social, psychological, and spiri-
tual needs, and values influence patient and family/
support system’s concepts of health and illness and
the meaning of visible and hidden disability (e.g., trau-
matic brain injury (TBI), multiple sclerosis), illness,
and loss (Brown & Landrum-Brown, 1995; Gordon &
Zaccario, 2010). For example, an individual with
a TBI may be physically independent, but have distress-
ing cognitive deficits that are not visible to others. Lim-
ited knowledge and understanding of these factors can
also affect an understanding of how the patient assigns
meaning to and experiences pain. If health care profes-
sionals do not explore cultural, environmental, and
economic factors related to each patient, managing
their illness and pain may result in unnecessary read-
missions and poor health outcomes. For example,
a patient cannot be expected to adhere to a pain med-
ication regimen if the health care team is unaware that
the patient does not have the means to pay for that
medication or there are certain cultural taboos to tak-
ing traditional pain medication.
Identifying and sharing information about cultural
nuances (e.g., avoiding eye contact as a sign of respect
for authority, leaving all decision-making to a particular
family member, or not reporting pain because it is

TABLE 1.
A Comparison of Multidisciplinary, interdisciplinary, and Transdisciplinary Team Approaches
Domain Multidisciplinary
Role Each staff member works independently
with the patient (Haig & LeBreck, 2000)
Clinicians work in discipline-specific work
areas with minimal overlap of modalities
(Cammack & Eisenberg, 1995)
Vertical team communication (Cammack &
Eisenberg, 1995)
Assessment Each professional conducts their own
discipline-specific assessment (Rosen
et al., 1998)
Goal-Setting Discipline-specific goals (Rosen et al., 1998)
Strengths Roles of each staff member are clearly
defined (Rosen et al., 1998)
Limitations/Challenges Different and/or contradictory expectations
and goals from various team members
can occur (Linder, 1983)
Interdisciplinary
Well-defined roles; frequent communication
between disciplines (Haig & LeBreck,
2000)
Each team member has equal value and
leadership is shared (Cammack &
Eisenberg, 1995)
Lateral team communication (Cammack &
Eisenberg, 1995)
Each professional conducts their own
discipline-specific assessment (Rosen
et al., 1998)
Development of communal goals (Butt &
Caplan, 2010)
Members may suggest goals and modalities
represented by another discipline
(Cammack & Eisenberg, 1995)
Roles of each staff member are clearly
defined (Haig & LeBreck, 2000)
Need for the team to communicate openly,
flexibly, and collaboratively to negotiate
priorities, role conflicts, and treatment
decisions (Butt & Caplan, 2010)
430
Transdisciplinary
Work across disciplinary boundaries
occurs (Cartmill, Soklaridis, & Cassidy,
2011)
Each team member takes responsibility
for the patient as a whole (Haig &
LeBreck, 2000)
A specific modality is not the sole
property of any particular discipline
(Cammack & Eisenberg, 1995)
Assessments are conducted in
a collaborative format (Rosen et al.,
1998)
Team-generated goals that are more
Gordon et al.
integrative in nature (Rosen et al.,
1998)
Patient-centered collaborative priorities
are integrated (Butt & Caplan, 2010)
Greater team participation and mutual
learning (Kilgo et al., 2003; Rosen et al.,
1998)
Prevents fragmentation across
disciplinary lines (Kilgo et al., 2003)
Provides easier flow of communication
and a high level of flexibility for
treatment interventions (Cammack &
Eisenberg, 1995)
Additional time needed for team
coordination, which may increase the
cost of delivery (Haig & LeBreck,
2000).
Specialized skills and expertise may not
get fully utilized (Haig & LeBreck, 2000)
Conflicts can occur regarding how to
share responsibilities (Rosen et al.,
1998)
Limited professional education
preparation/exposure to this approach
(Nandiwada & Dang-Vu, 2010)
 A Transdisciplinary Team Approach to Pain Management
a sign of weakness), across the continuum of care can
contribute to a successful transdisciplinary approach
to pain management. The integration of the patient’s
family, community, and other resources provides the
foundation for culturally sensitive transdisciplinary
care.
CLINICAL APPLICATION OF
A TRANSDISCIPLINARY APPROACH
ACROSS THE CONTINUUM OF CARE
The following section will describe the clinical applica-
tion of a transdisciplinary team model of pain manage-
ment across a continuum of inpatient care, including
palliative care, acute medical, perioperative care, and
acute inpatient rehabilitation services. Aspects of
a transdisciplinary approach include: patient/family
team meetings with multiple providers to determine
goals of care and establish a goal-directed plan. The
plan of care is established based on prognosis, risk/
benefit and burden/benefit ratios of interventions,
patient’s level of understanding and acceptance, relief
of symptoms with acceptable side effects, and goals of
care as set by the patient and family. Transdisciplinary
meetings to set common goals facilitate patient goal
achievement.
Flexibility, openness, and ongoing communica-
tion are vital in establishing and revising the goals to
match frequently changing circumstances in pain man-
agement. This model emphasizes each health team
member’s collective responsibility for continuous and
consistent communication (Kilgo et al., 2003). In con-
trast, when each discipline knows about and focuses
only on their specific area, conversations are limited
and information is lost, preventing the full disclosure
that facilitates planning and desired outcomes. Clinical
vignettes are provided to emphasize that effective pain
management is enhanced by transdisciplinary commu-
nication and shared responsibility with patients, fami-
lies, and health care providers. Conflicts can arise
between different perspectives of the patient, family/
support system, or team members on treatment
options involving pain management, functional status,
goal-setting, and plan of care.
CASE EXAMPLE #1: PALLIATIVE CARE
SERVICE
A 70-year old male from a traditional conservative
Jewish family with deep religious beliefs had a diagno-
sis of advanced lung cancer. He was admitted to a palli-
ative care service for IV hydration with the intention of
administering the next cycle of chemotherapy. Upon
admission, the patient’s functional status was poor
431
with limited ambulation and difficulty with basic trans-
fers. Yet, the patient and family were adamant that all
aggressive treatment interventions be maximally ex-
plored and implemented. As a reflection of their reli-
gious convictions and values, the patient and family
firmly believed that whatever interventions could pro-
long life or lead to recovery is worth pursuing, even if
the quality of that life is somewhat compromised.
However, knowledge of and sharing the literature on
prognosticators in advanced cancer regarding perfor-
mance status, serum albumin values, and stage of dis-
ease were key to the discussion of plan and goals of
care. Education of all disciplines in this area enhanced
successful transdisciplinary work. The palliative care
team focused on respecting patient’s goals and reli-
gious beliefs and working hand in hand with the
primary team in the provision of all interventions
deemed to have a benefit that outweighed the risk/bur-
den, including the patient’s pain and discomfort level.
At the same time, the palliative care team worked to-
gether with the primary team to educate the patient/
family regarding prognosis and correlation of func-
tional status to outcome and tolerance of chemother-
apy, as well as the importance of adequate pain
management to achievement of goals, especially im-
proving performance status.
Working in a transdisciplinary approach allowed
all team members to maximize improvement of func-
tion within the patient’s tolerance and provided a uni-
fied message regarding disease and potential risk/
benefit of treatments that facilitated informed decision
making. The family was able to understand and agree
with the reasoning for not using the most aggressive
treatment when the team worked together to educate
them. The key to this approach was that optimal and
feasible treatment options were clearly defined and
each discipline understood how these options would
meet the patient’s needs and desires. Additionally,
the transdisciplinary team included the patient, family,
and rabbi in the discussion. Therefore, the patient and
family were able to make informed choices that were
reflective of their religious and cultural beliefs. In-
creased quality of time and, occasionally, quantity of
time is often obtained with careful decisions about in-
terventions. With all team members sharing knowl-
edge of the patient’s goals, as well as information
about the disease and prognosis, each responded to is-
sues with the same message while providing their own
expertise to achieve the goal. Through a transdisciplin-
ary approach, the patient and family were able to make
informed decisions that included their religious beliefs
and could feel more supported and perhaps less
conflicted with decision making. Religious resources
to patients and families can aid in decision making
432 Gordon et al.
and, when educated to disease status and prognosis
with the patient’s permission, can add to transdisci-
plinary efforts and show respect for patients’ religious
beliefs and values. Before using the transdisciplinary
model in this paper, it was not uncommon for varied
members of the health care team to share inconsistent
options and goals.
This case highlights some challenges in a hospital
setting. A conflict can occur when the treatment team
believes that a patient should choose a less aggressive
focus on curing, but the patient, because of cultural or
religious reasons, is unable to make that decision.
Patients’ and families’ cultures, values, and beliefs in-
fluence the use of pain modalities and treatment
choices. With a transdisciplinary approach, these po-
tentially emotionally charged situations rise to a higher
level of awareness because everyone shares informa-
tion and message regarding planning and attainment
of goals of care.
CASE EXAMPLE #2: AN ACUTE
MEDICAL SERVICE
This case example of the transdisciplinary model in-
volves a 35-year-old female from Asian descent who
experienced a significant level of pain due to advanced
ovarian cancer with metastases to multiple organs.
Although, it was clear to the entire treatment team
that the patient was suffering, she was reluctant to
take the recommended pain medication. Her elderly
parents, who were non-English speaking and had min-
imal ways of communicating with the treatment team
due to the language barrier, frequently visited the pa-
tient. In time, it was revealed to the social worker
that the patient believed taking medication would dis-
appoint her parents who always valued stoicism in the
face of adversity. Therefore, a qualified medical inter-
preter was obtained through the hospital to hold a fam-
ily meeting with the patient and her parents in their
preferred language. The nurse and social worker lead-
ing this discussion became aware that her parents felt
frustrated, helpless, and guilty watching the suffering
of their adult child, however simultaneously held
firmly to the belief that tolerating pain without com-
plaint was a value that their child should live by. The
ability to address these issues in the context of the fam-
ily’s culture and in their own language enabled them to
understand that pain management is an integral part of
the treatment plan.
The health care team explained to the patient and
family that pain relief would be integral to their suc-
cessful participation in the plan of care. The team ex-
plored other strategies with the patient and family
that could complement pharmacologic strategies. For
example, the team learned that guided imagery and
meditation were valued methods of pain control for
the patient and family. Team members were thus in-
structed in these pain control strategies. The essential
part of the transdisciplinary team is that each discipline
employed the same pain management interventions
(e.g., meditation, guided imagery, and adherence/rein-
forcement of medication schedule). The family was
also brought into the team to help guide the patient
in her meditation. Combining pain medication with in-
tegrative pain management strategies proved effective.
The family was also more open to pain medication
when other methods of pain management were em-
ployed. The team initiated effective pain control mea-
sures and found a consistent and culturally sensitive
way to communicate with the family while balancing
the patient’s ability to function and participate in the
therapies.
Teaching pain management strategies that were
consistent with the family’s culture decreased the level
of family resistance and facilitated the quality of time
during visits. The inclusion of the patient’s beliefs
and meaningful rituals into the pain management inter-
ventions increased the family’s comfort level. Most im-
portantly, these comprehensive and culturally sensitive
plans of action lead to a greater level of patient/family
trust of the medical providers (Hobbs, 2005).
Including the patient and family/support systems
in the formulation of shared goals of care and establish-
ing strategies to achieve these goals in the context of
cultural, environmental, economic, and social factors
in today’s health care system may be viewed as ambi-
tious. However, not including them will likely lead to
an ineffective plan with miscommunication between
the patient, the health care team, the family and within
the team itself. The following two case examples high-
light aspects of the trandisciplinary approach, includ-
ing the challenges and benefits of developing
integrated goals and realistic expectations when chas-
ing pathogenic pain with opioids.
CASE EXAMPLE #3: PERIOPERATIVE
PATIENT CARE
A 55-year-old woman with a history of chronic lower
back pain and diabetic neuropathy was scheduled to
have a partial mastectomy with an axillary sentinel
node biopsy. Preoperative medications included trans-
dermal fentanyl 50 mcg. Her pain level was 4 on a 0–
10 pain rating scale where 0 ¼ none, 10 ¼ worst. Her
symptoms included fatigue, drowsiness, and neuro-
pathic radiating and tingling pain. Multiple members
of the transdisciplinary team were consulted. The
perioperative nurse practitioner recommended that
 A Transdisciplinary Team Approach to Pain Management
neuropathic pain is best treated with anti-epileptic or
antidepressant medications (NCCN, Version 2, 2011,
Page PAIN-G, 1–2). She consulted with the patient’s
internist, and the combined use of gabapentin with
transdermal fentanyl was prescribed to provide cross-
over tolerance. These two medications promoted her
ability to benefit from physical therapy and increase
her functional abilities. The social worker called the
patient’s local pharmacy to make sure that the transder-
mal fentanyl patch was available. The nurse met with
the patient to provide bowel prophylaxis. The surgeon,
primary care physician, anesthesiologist, perioperative
nurses, nurse practitioner, physical therapist, patient,
and family developed a plan of care to maintain comfort
and continue acute and chronic perioperative pain
management. Initially, the patient, family, and some
team members expected the goal of care to be a pain-
free postoperative recovery. The perioperative team
expressed concern regarding this expectation. The
team continually spoke with the patient and family to
support more realistic expectations that perioperative
pain is normal but could be managed with multiple
strategies. As the patient went through the continuum
of care, all members of the treatment team shared a com-
mon message and goals of care using the same language
and the same pain score of 1–3 on a scale of 0–10.
Familiar and comforting pain management strate-
gies that had been utilized in the OR and PACU, includ-
ing placing pillows under her knees and using warm
blankets on her back, were incorporated into the pa-
tient’s plan of care. Her resultant pain scores ranged
from 1–3 out of 10 on a numerical pain scale. The pa-
tient was taught to use specific pain management strat-
egies at home, which were all reinforced by each
treatment team member. The unit social worker was
consulted and discharge transportation arrangements
and homecare services were confirmed with the pa-
tient and family. The patient’s discharge summary
was forwarded to the patient’s primary care provider.
The medication reconciliation process remained accu-
rate, and changes were incorporated into the medical
record and patient discharge documents. The postop-
erative nurse telephoned the patient on the first
postoperative day and confirmed effective pain man-
agement and arrangements for surgical and primary
care provider follow-up. The patient indicated comfort
(pain score 1–3 on a scale of 0–10) and satisfaction
with a ‘‘coordinated’’ plan of care.
This case emphasized each transdisciplinary
health team member’s collective responsibility for
continuous and consistent communication (Kilgo
et al., 2003). Team members shared roles and responsi-
bilities that assisted patient and family/support systems
through the multiple perioperative care transitions.
433
CASE EXAMPLE #4: AN ACUTE
INPATIENT REHABILITATION SERVICE
Posttraumatic brain injury pain can be clinically chal-
lenging in an acute inpatient rehabilitation service due
to its impact on attention, sleep patterns, pain manage-
ment, and compliance (Walker, 2004). A 16-year-old
male was admitted to an inpatient rehabilitation service
with a moderate TBI as a result of a motor vehicle acci-
dent. He had a premorbid history of attention deficit/
hyperactivity disorder. A magnetic resonance imaging
(MRI) scan of the brain revealed bilateral frontal hemato-
mas. During his inpatient hospitalization, he experi-
enced posttraumatic headaches and pain, displayed
poor judgment, lack of awareness of his deficits and
the impact of his behavior on others, and problems
with multi-tasking and evaluating the effectiveness of
problem-solving strategies. His frequent headache pain
exacerbated his attention difficulties, including the abil-
ity to focus on tasks, retain multi-step directions, block
out extraneous stimuli, and persevere during physical
and occupational therapy. The treatment team, includ-
ing but not limited to physiatry, physical therapy,
occupational therapy, speech-language pathology, reha-
bilitation psychology, and neurology to monitor his
headaches, established a number of transdisciplinary
goals that emphasized his ability to increase his level
of attention, which was felt to be the foundational prob-
lem for his cognitive and behavioral deficits. Each staff
member implemented the same strategies with the com-
mon goal of having the patient become maximally fo-
cused on the task at hand. The patient was taught to
(1) use a meta-cognitive phrase before initiating an activ-
ity such as ‘ Stop, look, and listen’’ or ‘ What am I sup-
posed to be doing right now?’’, (2) take a deep breath
and count from 1–10, (3) use guided imagery, (4) iden-
tify and challenge extreme negative thoughts such as
‘ My pain will never go away’’, and (5) frequently rate
his level of pain from 1–10 using visual analogues. His
parents were instructed to carry out these same strate-
gies in the evening and during weekend home visits
and were educated on the neurobehavioral aspects of
TBI. Having every team member reinforce the same
goals increased understanding and confidence.
His headache pain gradually declined during his
hospitalization. His lack of awareness and impulsivity
were the major issues at the time of discharge. A num-
ber of members of the treatment team met with his
teachers, therapists, and school psychologist before
his discharge from the hospital to provide education
on TBI and strategies to deal with his cognitive deficits.
His discharge plan included physiatry, physical ther-
apy, occupational therapy, speech-language pathology,
cognitive remediation, a referral to a neurologist to
434 Gordon et al.
monitor his headache pain, as well as a recommenda-
tion for a neuropsychological reevaluation in 6 months
to monitor his progress and educational needs. This
transdisciplinary approach led to more integrated
goal-setting and consistent communication shared by
each discipline, which in turn helped to monitor and
facilitate this patient’s progress.
CLINICAL IMPLICATIONS OF
A TRANSDISCIPLINARY APPROACH TO
PAIN MANAGEMENT
The benefits of a transdisciplinary approach to patient
care are well-documented in the literature related to re-
habilitation settings, early intervention programs, and
community-based clinics. When making the transition
from an interdisciplinary to a transdisciplinary team ap-
proach to pain management, health care professionals
need to consider the strengths and limitations of the
transdisciplinary approach, as well as the practical ap-
plications, which are highly dependent on the needs of
the clinical service.
The unique features of a transdisciplinary team in-
clude: (1) integrated goal-setting that can be shared by
each discipline (i.e., the same goal can be carried out
by more than one discipline), (2) co-treatment when
clinically indicated, (3) assessment that is performed
together by a number of disciplines, (4) an emphasis
of mutual learning and the flexible exchange of
discipline-specific interventions, and (5) the impor-
tance of consistent communication provided to pa-
tients and their families/support systems. Sensitivity
to cultural and diversity issues are part of any well-
functioning transdisciplinary team. While integrated
goal-setting can be applied to each of the four treat-
ment settings discussed in this paper (i.e., acute medi-
cal, palliative, perioperative care, and inpatient
rehabilitation services), co-treatment is more easily in-
corporated in a rehabilitation or palliative care service,
while assessment carried out at the same time by sev-
eral disciplines is more practical on acute medical, pal-
liative and perioperative care services.
Professional transdisciplinary team educational
preparation has been limited. As a result, clinicians
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