A systematic review of the outcomes reported in multimodal pain therapy for chronic pain

Associations of long-term clinical recovery and improved quality of life across ICD-11 chronic pain categories in a real-world registry study

BACKGROUND

There is little knowledge of what factors are needed for successful chronic pain management. We aim to identify psychosocial and treatment predictors of clinical recovery and improved quality of life (QOL) at 12-month follow-up across three chronic pain groups, based on the International Classification of Diseases-11: neuropathic pain, secondary non-neuropathic pain, and primary pain. Furthermore, we investigate baseline differences across diagnostic groups.

METHODS

The sample included baseline and 12-month follow-up data from 1056 chronic pain patients from the Oslo University Hospital's Pain Registry. Logistic regression models investigated longitudinal associations between psychosocial and treatment characteristics, and the outcome measures clinical recovery and improved QOL. Characteristics were compared across the diagnostic groups.

RESULTS

Increased odds of clinical recovery and improved QOL were seen in patients receiving invasive treatment (OR = 8.04, 95% CI = 3.50-19.40; OR = 5.47, 95% CI = 2.42-12.86), while decreased odds of clinical recovery were seen for secondary non-neuropathic pain patients with pain-related disability (0.05, 95% CI = 0.01-0.29). In comparing baseline characteristics, neuropathic pain patients had lower QOL, and more severe insomnia compared to the other groups.

CONCLUSION

Invasive treatment modalities were strongly associated with clinical recovery and improved QOL. Although this could be due to patient selection, it does warrant further examination as an intervention alternative for chronic pain. Intervention efficacy, risk factors and predictors of clinical recovery across diagnostic groups should be further investigated through longitudinal RCTs.

SIGNIFICANCE

This observational study indicates a potential advantage in sustained recovery for pre-selected individuals with chronic pain who undergo invasive treatments. The relationship between sustained recovery and psychosocial factors differs across neuropathic, secondary non-neuropathic, and primary pain patients. This suggests that employing ICD-11 for classifying patients into mechanistically distinct pain groups could inform the evaluation and management of chronic pain. Furthermore, factors previously identified as negative indicators for long-term outcomes in chronic pain cohorts were not clinically significant in this study.

Multimodal Approaches in the Treatment of Chronic Peripheral Neuropathy-Evidence from Germany

Patients with chronic peripheral neuropathy suffer greatly and their quality of life is often restricted. Drug therapy can be accompanied by undesirable side effects and intolerances, or the hoped-for effect does not materialize. Therefore, in addition to drug therapy, attempts are also made to treat the physical symptoms with complementary procedures. In the case of severe forms, the search for a suitable form of therapy is difficult. Complex treatments can be an innovative way to treat peripheral neuropathy. At the same time, several different therapy methods are carried out at high frequency by a specialized treatment team. This study aimed to provide an overview of possible complementary forms of therapy. The focus was on a comparison of two interdisciplinary complex therapies that are used in severe cases in an acute inpatient care setting in Germany. The six dimensions (energy, sleep, pain, physicality, emotional response and social isolation) of the Nottingham Health Profile (NHP) were used to assess quality of life. Both complex treatments (naturopathic complex therapy/multimodal pain therapy) showed a significant reduction in impairment in all dimensions of the NHP. In addition, a multivariate analysis was carried out to take into account several influencing variables at the same time. At the time of admission to the hospital, the degree of chronicity was recorded for each patient. This allowed statements to be made about the effect of the respective therapy depending on the chronification stage of the patient. It has been shown that patients with acutely exacerbated pain with the highest degree of chronicity also benefit from both complex treatments. The naturopathic complex treatment gives the treatment team more options. Aspects such as nutrition, methods from phytotherapy and traditional Chinese medicine can be integrated into inpatient care. Thus, a patient-centered, holistic therapy can take place. However, an interdisciplinary holistic therapy requires more time for both the practitioner and the patient. This should be taken into account in the health systems in the context of the diagnosis related groups.

Endorsing a Biopsychosocial Perspective of Pain in Individuals With Chronic Pain: Development and Validation of a Scale

OBJECTIVES

Patients' beliefs about pain play an important role in their readiness to engage with chronic pain self-management. The central aim of this study was to validate a self-report instrument to assess a specific set of pain beliefs, patients' endorsement of a biopsychosocial model of chronic pain Patients' Endorsement of a Biopsychosocial Model of Chronic Pain Scale (PEB).

METHODS

Interdisciplinary experts in the field of pain were involved in creating an instrument, the PEB Scale, to operationalize patients' endorsement of a biopsychosocial pain model. A sample of 199 patients with chronic pain was recruited to evaluate the factorial structure (principal axis factoring), the internal consistency (Cronbach alpha), the convergent and discriminant validity (correlational analyses), incremental validity (multiple, hierarchical regression analyses), and construct validity (differential population analysis) of the instrument.

RESULTS

The factor analysis resulted in a unidimensional, 11-item instrument that explained 51.2% of the total variance. Cronbach alpha (=0.92) indicated high internal consistency of the created set of pain-related beliefs. Regression analyses demonstrated that PEB is a strong predictor of patients' engagement with pain self-management ( P < 0.001) after controlling for demographic variables, anxiety, depression, and other pain-related beliefs.

DISCUSSION

Our results show that the PEB Scale is a highly reliable self-report instrument that has the potential to predict patients' readiness to adopt pain self-management. Future research should focus on revalidating the scale to operationalize PEB. Moreover, the PEB Scale should be implemented in longitudinal study designs to investigate its ability to predict the transition from acute to chronic pain and patients' long-term pain management.

[Do pain therapy patients benefit from their fellow patients? : A retrospective observational study on the influence of the stage of pain management and therapy experience of fellow patients on the individual therapy success in an inpatient interdisciplinary multimodal pain therapy (IMPT)]

BACKGROUND

Interdisciplinary multimodal pain therapy (IMPT) is mostly run in a group setting to encourage the exchange of experiences between patients and thus facilitate the change of pain-related attitudes and behavior. As is known from psychotherapy research, the fellow patients in a therapy group have a relevant influence on the success of the therapy for the individual patient.

OBJECTIVE

We examined the extent to which therapy success in an IMST group is influenced by individual co-patient characteristics, such as cognitive behavioral pain management, the difference to their own pain management and the proportion of co-patients who repeat therapy.

METHOD

In a retrospectively planned investigation of the psychometric tests of all patients in an inpatient IMST between January 2013 and February 2020, the influence of fellow patient characteristics on clinically relevant changes with respect to various parameters of the severity of chronic pain disorders was analyzed using binary logistic regression analyses.

RESULTS

We examined 636 treatment cases of which 540 were first-time stays. On each day of treatment, 5 fellow patients were present, 15% of whom had repeated the therapy. We were able to show that the proportion of fellow patients who repeat the therapy (p < 0.001; odds ratio, OR = 1.032) and the cognitive behavioral pain management of the fellow patients (p < 0.001; OR = 2.885) significantly increase the probability of achieving success in at least one of the parameters examined. An influence of a specific parameter on the success of therapy could not be proven.

CONCLUSION

Despite methodological limitations our results suggest that in patient groups of an IMST, patients with therapy experience and those with advanced cognitive behavioral methods for pain management should be combined with novices and patients who are still at the beginning of coping with the chronic pain disorder.

[Chronic eye pain]

Numerous conditions in the field of ophthalmology are associated with pain in or around the eye. Chronic pain associated with the eye is a common finding in the daily routine of ophthalmologists and can be associated with primary ocular or extraocular diseases as well as with other conditions. Appropriate diagnostic assessment and management of people with chronic pain requires an understanding of the condition based on the biopsychosocial model in which the interactions of biological/somatic, psychological and social factors are determining pain and suffering. Beyond the ophthalmological findings,  close interdisciplinary cooperation and assessment are required. Therefore, if eye pain is insufficiently responsive to treatment or if symptoms of chronic pain are evident, pain medicine expertise should be involved. The management of chronic ocular pain is based on interdisciplinary multimodal approaches, in addition to the ophthalmologist-specific approaches. These focus on self-efficacy, patient competence and acceptance of pain as central goals of treatment rather than pain relief. Patient information, education and the development of a suitable concept by the interdisciplinary team are essential therapeutic aspects in this context.

The use of PROMIS measures in clinical studies in patients with inflammatory arthritis: a systematic review

PURPOSE

Although the use of Patient-Reported Outcomes Measurement Information System (PROMIS) measures is widely advocated, little is known on their use in patients with inflammatory arthritis. We systematically describe the use and outcomes of PROMIS measures in clinical studies involving people with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA).

METHODS

A systematic review was conducted according to the PRISMA guidelines. Through a systematic search of nine electronic databases, clinical studies including patients with RA or axSpA and reporting the use of PROMIS measure were selected. Study characteristics, details of PROMIS measures and their outcomes, if available, were extracted.

RESULTS

In total, 29 studies described in 40 articles met the inclusion criteria, of which 25 studies included RA patients, three studies included axSpA patients and one study included both RA and axSpA patients. The use of two general PROMIS measures (PROMIS Global Health, PROMIS-29) and 13 different domain-specific PROMIS measures was reported, of which the PROMIS Pain Interference (n = 17), Physical Function (n = 14), Fatigue (n = 13), and Depression (n = 12) measures were most frequently used. Twenty-one studies reported their results in terms of T-scores. Most T-scores were worse than the general population mean, indicating impairments of health status. Eight studies did not report actual data but rather measurement properties of the PROMIS measures.

CONCLUSION

There was considerable variety regarding the different PROMIS measures used, with the PROMIS Pain interference, Physical function, Fatigue, and Depression measures being the most frequently used. In order to facilitate the comparisons across studies, more standardization of the selection of PROMIS measures is needed.

[Expected areas of impact of the disciplines medicine, psychology and physiotherapy in pain treatment : A survey among members of the professions]

BACKGROUND

Interdisciplinary multimodal pain treatment (IMPT) is an essential element in the treatment of people with chronic pain. Although IMST is defined in terms of content, it is evident that its practical design is very heterogeneous. This refers not only to the composition of the contents of the treatment but also to the concrete distribution of tasks among the professions involved. This article deals with the attribution of the effect of the activities of the three professional groups involved in IMPT: medicine, psychology and physiotherapy. The aim of this work is to examine how the professions of medicine, psychology and physiotherapy assess the effectiveness of their work and the effectiveness of the other two disciplines in the care of chronic pain patients.

MATERIAL AND METHODS

A newly designed questionnaire with 19 items was used. Each item describes a possible effect that treatment by the professions of medicine, psychology and physiotherapy can have. Based on factor analysis, items were combined for which the three effect attributions had the same items. The restriction to factor analysis areas was intended to avoid redundancies in the presentation and interpretation of results. The evaluation was carried out by means of a variance analysis for the impact areas with the factors "profession" and "attribution of impact".

RESULTS

A total of 233 participants from the 3 disciplines (medicine, n = 78; psychology, n = 76; physiotherapy, n = 79) answered the questionnaire. The three areas of effect "pain reduction", "strength and movement" and "functional pain coping" could be identified by factor analysis. The impact areas attributed to the different professions are largely reflected in the participants' answers. The variance analysis revealed significant main effects for the two factors "profession" and "attribution of impact" and for their interactions.

CONCLUSION

Professionals in medicine, psychology and physiotherapy have clear expectations of their own and the other professions mentioned here with respect to their effectiveness in certain areas of change. Overall, the three professions agree in their assessment of the contribution of medicine, psychology and physiotherapy to the areas of pain reduction, gain in strength and movement and functional pain coping.

Exploring the Potential of Transcranial Direct Current Stimulation for Relieving Central Post-Stroke Pain: A Randomized Controlled Pilot Study

The potential of transcranial direct current stimulation (tDCS) as a non-invasive brain stimulation technique for treating pain has been studied. However, its effectiveness in patients with central post-stroke pain (CPSP) and the impact of lesion location remain unclear. This study investigated tDCS's pain reduction effects in patients with CPSP. Twenty-two patients with CPSP were randomized into the tDCS or sham groups. The tDCS group received stimulation of the primary motor cortex (M1) for 20 min, five times weekly, for two weeks, and underwent evaluations at baseline, immediately after the intervention, and one week after the intervention. The tDCS group had no significant improvement compared to the sham group in pain, depression, and quality of life. Nevertheless, significant changes were identified within the tDCS group, and the pain trends appeared to be influenced by the lesion location. These findings provide important insights into the use of tDCS in patients with CPSP, which could inform further research and development of pain treatment options.

The effect domains, measures, and methods reported in pediatric-specialized multidisciplinary outpatient rehabilitation programs: An integrated review

OBJECTIVES

Specialized pain rehabilitation is recognized as the treatment of choice for youth with pain-related disability. Appropriate outcomes for program evaluation are critical. This study aimed to summarize the effect domains and methods used to evaluate pediatric-specialized outpatient pain rehabilition programs, map them to the PedIMMPACT statement, and highlight future directions.

METHODS

An integrated review framework, incorporating stakeholders, was used. Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO, and Google Scholar were searched for studies published in 1999-2021 featuring the treatment effects of specialized outpatient pain rehabilitation on youth with pain-related disability and their parents. Selected studies were critically appraised using the Quality Assessment Tool for Studies of Diverse Design, organized by study characteristics, and analyzed using constant comparison.

RESULTS

From the 1951 potentially relevant titles, 37 studies were selected. Twenty-five effects targeted youth and 24 focused on parents, with a maximum of 15 youth and 11 parent effect domains (median = 5 domains per study). Although most studies measured a combination of effect domains and were inclusive of some recommended in the PedIMMPACT statement, no effect was measured consistently across studies. Youth physical functioning and parent emotional functioning were measured most often. Eighty-five instruments were used to assess youth outcomes and 59 for parents, with self-report questionnaires dominating.

DISCUSSION

A lack of standardization exists associated with the domains and methods used to evaluate the effects of pediatric-specialized outpatient pain rehabilitation programs, hindering comparisons. Future program evaluations should be founded on their theory, aim, and anticipated outcomes.

Reported Outcomes in Interdisciplinary Pain Treatment: An Overview of Systematic Reviews and Meta-Analyses of Randomised Controlled Trials

Background

There is considerable diversity of outcome selections and methodologies for handling the multiple outcomes across all systematic reviews (SRs) of Interdisciplinary Pain Treatment (IPT) due to the complexity. This diversity presents difficulties for healthcare decision makers. Better recommendations about how to select outcomes in SRs (with or without meta-analysis) are needed to explicitly demonstrate the effectiveness of IPT.

Objective

This overview systematically collates the reported outcomes and measurements of IPT across published SRs and identifies the methodological characteristics. Additionally, we provide some suggestions on framing the selection of outcomes and on conducting SRs of IPT.

Methods

Three electronic databases (PubMed, Cochrane Library, and Epistemonikos) and the PROSPERO registry for ongoing SR were supplemented with hand-searching ending on 30 September 2021.

Results

We included 18 SRs with data on 49007 people from 356 primary randomised controlled trials (RCTs); eight were followed by meta-analysis and ten used narrative syntheses of data. For all the SRs, pain was the most common reported outcome (72%), followed by disability/functional status (61%) and working status (61%). Psychological well-being and quality of life were also reported in half of the included SR (50%). The core outcome domains according to VAPAIN, IMMPACT, and PROMIS were seldom met. The methodological quality varied from critically low to moderate according to AMSTAR2. The AMSTAR2 rating was negatively correlated to the number of outcome domains in PROMIS, and VAPAIN was positively correlated with IMMPACT and PROMIS, indicating the intercorrelations between the reported outcomes.

Conclusion

This systematic overview showed wide-ranging disparity in reported outcomes and applied outcome domains in SRs evaluating IPT interventions for chronic pain conditions. The intercorrelations between the reported outcomes should be appropriately handled in future research. Some approaches are discussed as well.

Prognostic Factors for Quality of Life After Interdisciplinary Pain Rehabilitation in Patients with Chronic Pain-A Systematic Review

BACKGROUND

Health-related quality of life (hrQoL) is a core outcome in evaluating interdisciplinary pain rehabilitation (IPR). This systematic review aimed to identify prognostic factors for hrQoL at least six months after IPR in chronic pain patients.

METHODS

A systematic search was conducted in MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science and Cochrane CENTRAL until September 2020. Included were prognostic studies on the outcome hrQoL in adults aged 18 to 67 years with chronic pain (excluding malignancies, systemic-, inflammatory or degenerative joint diseases) who had undergone IPR. Studies were assessed with The Quality in Prognostic Studies-tool. Potential prognostic factors at baseline for the domains pain, psychological and physical functioning were qualitatively synthesized for hrQoL. Grading of Recommendations Assessment, Development and Evaluation was used to evaluate the level of evidence.

RESULTS

Fourteen studies on 6,668 participants (mean age 37.4-52.8 y), with musculoskeletal pain/fibromyalgia and a pain duration ranging between 13.1 and 177.4 months were considered eligible. With a very low certainty of evidence, pain intensity, emotional distress, and physical functioning at baseline were inconsistent for prediction of hrQoL and pain duration was not predictive. With low certainty of evidence, fewer pain sites, lower levels of negative cognitive behavioral factors, and higher levels of positive cognitive behavioral factors predicted a better outcome.

CONCLUSIONS

The overall certainty of evidence was low to very low, making it difficult to reach definitive conclusions at present. Future studies with a predefined core set of predictors investigating hrQoL in patients with chronic pain after IPR are needed.

Multimodal Chronic Pain Therapy for Adults via Smartphone: Randomized Controlled Clinical Trial

BACKGROUND

Combination therapies delivered remotely via the internet or mobile devices are increasingly being used to improve and promote the self-management of chronic conditions. However, little is known regarding the long-term effects of these interventions.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of a multimodal intervention program that measures associated variables such as catastrophizing, pain acceptance, and quality of life using a mobile device in people with chronic pain in an outpatient setting.

METHODS

A randomized controlled clinical trial was performed using parallel treatment groups. A total of 209 patients with chronic musculoskeletal pain were randomly assigned to one of the two study arms. The intervention group received a standard web-based psychosocial therapy-type program of activities through a smartphone for 6 weeks. The control group only had access to the Find out more section of the app, which contained audiovisual material for pain management based on a self-help approach. The primary outcome was catastrophizing measured using the Pain Catastrophizing Scale (PCS). Secondary outcomes were pain acceptance measured using the Chronic Pain Acceptance Questionnaire and health-related quality of life measured using the EuroQol Visual Analogue Scale. Assessments were conducted at baseline (T1), after treatment (T2), and at the 3-month follow-up (T3). The variations between the different phases were assessed using the percentage change rescaled with log base 2. The Cohen d was calculated based on the results of the linear mixed model. The investigators of the study who evaluated the results were not involved in patient recruitment and were blinded to the group assignment.

RESULTS

Positive effects were found in the intervention group (T2-T1) in catastrophizing between the baseline and posttreatment phases (P<.001) and in helplessness (-0.72 vs 0.1; P=.002), rumination (-1.59 vs -0.53; P<.001), acceptance (0.38 vs 0.05; P=.001), and quality of life (0.43 vs -0.01; P=.002), although no significant changes were found for magnification (0.2 vs 0.77; P=.14) and satisfaction with health (0.25 vs -0.27; P=.13). Three months after treatment, significant differences were observed in the intervention group for the outcome variable of catastrophizing (PCS; -0.59 vs 0.2; P=.006) and the PCS subscales of helplessness (-0.65 vs 0.01; P=.07), rumination (1.23 vs -0.59; P=.04), and magnification (0.1 vs 0.86; P=.02).

CONCLUSIONS

The results of our study suggest that app-based mobile multidimensional treatments for adults with chronic pain improve catastrophizing, quality of life, and psychological flexibility immediately after treatment and that the effects are maintained for the primary outcome of catastrophizing for at least 3 months following treatment. Moreover, they promote self-management and can be used to complement face-to-face pain treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04509154; https://clinicaltrials.gov/ct2/show/NCT04509154.

Long term outcomes of chronic pain patients attending a publicly funded community-based interdisciplinary pain program in the Greater Toronto area: results of a practice-based audit

Background

Chronic pain management multi/interdisciplinary programs attempt to address all elements of the biopsychosocial model. The primary objective of this retrospective study (based on practice-based audit) was to determine the effectiveness of a patient-centered, comprehensive and intense interdisciplinary pain management program in a publicly funded community-based pain clinic in the Greater Toronto Area.

Method

This retrospective longitudinal study was conducted on 218 carefully selected sequential chronic pain patients, with 158 completing a 3–4-month interdisciplinary program between January 2016 and December 2018. Data collected upon exit, at 6 months and 12 months post-discharge included demographic information, pain characteristics, emotional/functional status obtained by validated instruments and global impression of change (GIC). Additionally, social health outcomes (return to work or school) were retrieved through retrospective chart review. Means of pre-and post-program variables were compared to assess changes of each patient’s “journey”.

Results

Physical and mental/ emotional health outcomes at exit, 6 months and 12 months post-discharge, showed initial and sustained, statistically and clinically significant improvement from pre-treatment levels, with GIC (much/very much improved) reported as 77%, 58% and 76%, respectively. Additionally, a substantial positive change in social health outcomes was noted particularly in patients on disability (29%), part time workers gaining full time employment (55%), and students (71%) who improved their level of schooling.

Conclusion

The study showed that careful patient selection in a community-based publicly funded interdisciplinary pain management program can produce significant improvement in pain, physical, mental/emotional health and social function, with sustained long-term outcomes.

The Critical Role of Nutrition Care to Improve Pain Management: A Global Call to Action for Physical Therapist Practice

Physical therapists have unique education in the comprehensive biopsychosocial assessment and treatment of chronic pain and its mechanisms. Recently, physical therapists have raised awareness regarding the impact of nutrition on promoting health and managing noncommunicable diseases. Robust evidence supports the implementation of nutrition in physical therapist education and practice. Of particular interest for the physical therapist are investigations that use dietary interventions for the treatment of chronic pain. Yet physical therapists have received little guidance regarding their role in nutrition care for pain management and may pass on opportunities to counsel their patients on the connection between nutrition and pain. Therefore, a clinical paradigm shift and unified voice within the profession is called on to encourage physical therapists to develop tailored multimodal lifestyle interventions that include nutrition care for the management of chronic pain. This Perspective describes evidence supporting the implementation of nutrition care in physical therapist practice, supports the role of nutritional pain management for physical therapists, and encourages the use of nutrition care for primary, secondary, tertiary, prevention, health promotion, and wellness related to chronic pain. To achieve these aims, this Perspective offers suggestions for how physical therapists can (1) enhance clinical decision making; (2) expand professional, jurisdictional, and personal scope of practice; (3) evolve entry-level education; and (4) stimulate new investigations in nutrition care and pain science research. In doing so, physical therapists can assert their role throughout the pain management continuum, champion innovative research initiatives, and enhance public health by reducing the impact of chronic pain.

IMPACT

The nutrition care process for pain management is defined as the basic duty to provide adequate and appropriate nutrition education and counseling to people living with pain. Including the nutrition care process as part of a multimodal approach to pain management provides an opportunity for physical therapists to assert their role throughout the pain management continuum. This includes championing innovative research initiatives and enhancing public health by reducing the impact of chronic pain for over 50 million Americans.

The use of PROMIS measures in clinical research in stroke patients, a systematic literature review

Objective

To systematically describe the use and outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) measures in clinical studies in populations with stroke.

Data Sources

A systematic search on the use of PROMIS measures in clinical stroke studies in 9 electronic databases.

Study Selection

Studies had to be original, reporting on outcome data using PROMIS measures in populations with stroke (ischemic and/or hemorrhagic), from January 1st, 2007. Initially, 174 unique studies met the inclusion criteria. In 2 steps, titles, abstracts and full-text articles were screened for eligibility (2 authors independently).

Data Extraction

From the selected articles, study characteristics, type of PROMIS measures, and its outcomes were extracted by 2 authors independently. The authors discussed their views to achieve consensus. A third author was consulted if necessary.

Data Synthesis

In total, 27 studies (24,366 patients) were included, predominantly from the United States (22); most study populations were hospital-based (20); the number of patients ranged from 30-3283. In general, patients had no or mild symptoms (median modified Rankin scale 1). Two different generic PROMIS measures were reported (PROMIS Global Health, PROMIS 29) and 9 PROMIS measures focusing on specific domains (sleep, pain, physical functioning, self-efficacy, satisfaction with social roles, depression, anxiety, cognition, fatigue). These match the International Classification of Functioning, Disability, and Health (ICF) domains mentioned in the Core Set for Stroke. The measures were administered 1-55 months after stroke. Outcome data are provided. Pooling of data was not achieved because of a large variety in study characteristics (inclusion criteria, follow-up moments, data processing).

Conclusions

The PROMIS measures in this review could be relevant from a patient's perspective, covering ICF core set domains for patients with stroke. The large variety in study characteristics hampers comparisons across populations. Many different outcome measures are used to report results of stroke rehabilitation studies.

Multidisciplinary rehabilitation treatments for patients with fibromyalgia: a systematic review

INTRODUCTION

Fibromyalgia (FM) is a pathology that causes physical, psychological, and social problems. For this reason, it requires treatment that involves all of these elements. The main of study is to examine multidisciplinary rehabilitation treatment (MRT) in fibromyalgia and to identify healthcare approaches developing effective MRT tools for the treatment of FM.

EVIDENCE ACQUISITION

In this systematic review, we searched the following databases: CINAHL, PubMed, Scopus, Cuidatge, Cuiden, ENFISPO, IBEC and IME.

EVIDENCE SYNTHESIS

Of 356 articles found we selected 13 to analyze and summarize. We created 4 different categories: 1) multidisciplinary rehabilitation treatment focusing on health education and cognitive behavioral therapy (CBT); 2) multidisciplinary rehabilitation treatment that includes dietetics; 3) multidisciplinary rehabilitation treatment adapted to the patients' characteristics; 4) multidisciplinary rehabilitation treatment based on physical exercise.

CONCLUSIONS

This review identifies the most effective treatments that may be usefully applied in many different rehabilitation contexts. These include all treatments that incorporated an education (ED) program to patients and an exercise program complete with aerobic exercise (AE), stretching (SE), relaxation (RE), strengthening (TE), endurance (EN), and which includes the entire body and biofeedback. Furthermore, many approaches also include cognitive behavioral therapy (CBT) for self-management such as occupational therapy, moderation, acceptance, commitment, motivation to change and forgiveness.

The descending pain modulation system predicts short term efficacy of multimodal pain therapy - an observational prospective cohort study

OBJECTIVES

Treating chronic pain patients with multimodal pain therapy (MMPT) alters perception, awareness, and processing of pain at multiple therapeutic levels. Several clinical observations suggest that the effects of therapy may go beyond the possible sum of each level of therapy and may be due to a central descending inhibitory effect measurable by conditioned pain modulation (CPM). Thus, we investigated whether CPM is able to identify a group of patients that benefit particularly from MMPT.

METHODS

This was an observational prospective cohort study. Patients were hospitalized on a special pain medicine ward with specially trained staff for 10 days. The patients were questioned and had investigations before and shortly after MMPT and were followed-up on 3 months post discharge. Before and after treatment, subjects were investigated via CPM and quantitative sensory testing (QST) as well as completing questionnaires. The study was registered in the German Clinical Trials Register (DRKS00006850).

RESULTS

During the study period of 24 months, 224 chronic pain patients were recruited. 51 percent of patients completed the study period. There was an improvement in overall groups regarding all domains assessed, lasting beyond the end of the intervention. Patients with a sufficient CPM effect, defined as a reduction in pain during the conditioning stimulus, at baseline did show a more pronounced reduction in mean pain ratings than those without. This was not the case 3 months after therapy. Furthermore, sufficient CPM was identified as a predictor for pain reduction using a linear regression model.

CONCLUSION

In conclusion, this study shows that while a heterogeneous group of patients with chronic pain disorders does sustainably benefit from MMPT in general, patients with a sufficient CPM effect do show a more pronounced decrease in pain ratings directly after therapy in comparison to those without.

Multimodal Interventions Including Rehabilitation Exercise for Older Adults With Chronic Musculoskeletal Pain: A Systematic Review and Meta-analyses of Randomized Controlled Trials

BACKGROUND AND PURPOSE

Musculoskeletal disorders (MSKDs) are the most common causes of disabilities for older adults. The aim of this systematic review and meta-analysis is to assess the effectiveness of multimodal interventions including exercise rehabilitation for older adults with chronic MSKDs.

METHODS

A literature search was conducted up to February 2019 in 5 bibliographical databases to identify randomized controlled trials (RCTs) that compared multimodal interventions including exercise rehabilitation with usual medical care or no intervention. Randomized controlled trials were assessed with the Cochrane risk-of-bias tool. Meta-analyses were performed and pooled mean differences (MDs) or standardized mean differences (SMDs) were calculated.

RESULTS

Sixteen RCTs (n = 2322 participants) were included. One RCT was considered at low risk of bias, 8 had some concerns of bias, and 7 had a high risk of bias. Participants suffered from hip or knee osteoarthritis (OA) (n = 12 RCTs), low back pain (LBP) (n = 2 RCTs) and generalized chronic pain (GCP) (n = 2 RCTs). Multimodal interventions were significantly more effective than usual care to decrease pain (visual analog scale, out of 10 points) in the short term, MD: -0.71 (95% confidence interval [CI] -1.08 to -0.34, n = 900), and in the long term: MD: -0.52 (95% CI -0.98 to -0.05, n = 575), but these differences are not considered clinically important. In terms of disabilities, multimodal interventions were also significantly more effective than usual care. The SMDs were -0.47 (95% CI -0.61 to -0.34, n = 903) and -0.29 (95% CI -0.46 to -0.13, n = 568) for OA trials in the short and long terms, respectively, and -0.47 (95% CI -0.81 to -0.12, n = 211) for LBP and GCP trials in the short term. The magnitude of these effects may be considered as small to moderate.

CONCLUSION

Multimodal intervention including exercise rehabilitation combined with usual medical care is an efficacious therapeutic option to reduce disabilities in older adults with chronic MSKDs. A significant but not clinically important effect was observed for pain. The most beneficial component of the multimodal interventions in terms of education, exercises, or medication remains to be determined.

A Randomized controlled trial of the Sources of Meaning Card Method: A new meaning-oriented approach predicts depression, anxiety, pain acceptance, and crisis of meaning in chronic pain patients

OBJECTIVE

Although considered the first-line psychological treatment of chronic pain, cognitive behavioural therapy has recently been criticized as being too limited, insufficient, and sometimes ineffective in the treatment of chronic pain patients. Moreover, important existential perspectives are sparsely or not at all integrated into CBT. We therefore propose to complement chronic pain treatment with a meaning-based intervention, the Sources of Meaning Card Method (SoMeCaM). This study tested its efficacy.

DESIGN

A randomized controlled trial was conducted with 42 chronic pain patients, comparing an intervention group (standard care and participation in the SoMeCaM, a meaning-oriented approach) with a control group (standard care). We evaluated both groups at baseline, 1 (t1) and 2 months (t2) after the intervention. The primary outcome assessed was pain acceptance, while depression, anxiety, pain intensity, pain medication, satisfaction with life, meaningfulness, and crisis of meaning were examined as secondary outcomes.

RESULTS

Comparisons within and between groups showed significant treatment effects at t1. Higher increases in pain acceptance and decreases in anxiety, depression and crisis of meaning were observed in the intervention group. Improvements in pain acceptance and anxiety persisted until t2, when pain intensity was also lower. Effect sizes at t2 were medium to large.

CONCLUSION

Our preliminary work demonstrates the importance of the existential perspective in chronic pain therapy.

Longitudinal outcome evaluations of Interdisciplinary Multimodal Pain Treatment programmes for patients with chronic primary musculoskeletal pain: A systematic review and meta-analysis

Background and objectives

Although Interdisciplinary Multimodal Pain Treatment (IMPT) programmes share a biopsychosocial approach to increase the wellbeing of patients with chronic pain, substantial variation in content and duration have been reported. In addition, it is unclear to what extent any favourable health outcomes are maintained over time. Therefore, our first aim was to identify and analyse the change over time of patient‐related outcome measures in cohorts of patients who participated in IMPT programmes. Our second aim was to acquire insight into the heterogeneity of IMPT programmes.

Databases and data treatment

The study protocol was registered in Prospero under CRD42018076093. We searched Medline, Embase, PsycInfo and Cinahl from inception to May 2020. All study selection, data extraction and risk of bias assessments were independently performed by two researchers. Study cohorts were eligible if they included adult patients with chronic primary musculoskeletal pain for at least 3 months. We assessed the change over time, by calculating pre‐post, post‐follow‐up and pre‐follow‐up contrasts for seven different patient‐reported outcome domains. To explore the variability between the IMPT programmes, we summarized the patient characteristics and treatment programmes using the intervention description and replication checklist.

Results

The majority of the 72 included patient cohorts significantly improved during treatment. Importantly, this improvement was generally maintained at follow‐up. In line with our expectations and with previous studies, we observed substantial methodological and statistical heterogeneity.

Conclusions

This study shows that participation in an IMPT programme is associated with considerable improvements in wellbeing that are generally maintained at follow‐up. The current study also found substantial heterogeneity in dose and treatment content, which suggests different viewpoints on how to optimally design an IMPT programme.

Significance

The current study provides insight into the different existing approaches regarding the dose and content of IMPT programs. This analysis contributes to an increased understanding of the various approaches by which a biopsychosocial perspective on chronic pain can be translated to treatment programs. Furthermore, despite theoretical and empirical assertions regarding the difficulty to maintain newly learned health behaviors over time, the longitudinal analysis of health outcomes did not find a relapse pattern for patients who participated in IMPT programs

Multimodal Interventions to Improve the Management of Chronic Non-Malignant Pain in Primary Care Using Participatory Research

BACKGROUND

The use of diverse therapies combined with a multidisciplinary approach and prevention initiatives for patients with chronic non-malignant pain (CNMP) can improve health and have a positive impact on psychotropic drug use and the self-management of pain.

PURPOSE

This purpose of this study has been two-fold: to conduct a literature review with a view to selecting best evidence recommendations for CNMP and to prioritize self-care recommendations using a participatory methodology for the analysis and selection of interventions.

METHODS

A qualitative, descriptive, and documentary method based on participatory action research was used.

FINDINGS

Based on the study results, a multimodal psychosocial intervention program has been designed for CNMP that includes psychoeducational therapy, pharmacological therapy, physical exercise, and health assets.

DISCUSSION

The findings are consistent with previous studies underlining the need to invest in resources for the management of CNMP, including strategies for good differential diagnoses and pharmacological treatments combined with non-pharmacological treatments to confer greater well-being for people living with pain who want to participate in their own recovery.

Cognitive Change and Relaxation as Key Mechanisms of Treatment Outcome in Chronic Pain: Evidence From Routine Care

Despite effective treatment approaches within the cognitive behavioral framework general treatment effects for chronic pain are rather small to very small. Translation from efficacy trials to naturalistic settings is questionable. There is an urgent need to improve the effectiveness of well-established treatments, such as cognitive-behavior therapy (CBT) and the investigation of mechanisms of change is a promising opportunity. We performed secondary data analysis from routine data of 1,440 chronic pain patients. Patients received CBT in a multidisciplinary setting in two inpatient clinics. Effect sizes and reliable change indices were computed for pain-related disability and depression. The associations between changes in the use of different pain coping skills (cognitive restructuring, activity despite pain, relaxation techniques and mental distraction) and changes in clinical outcomes were analyzed in structural equation models. Pre-post effect sizes range from g = 0.47 (disability) to g = 0.89 (depression). Changes in the use of cognitive restructuring, relaxation and to a lesser degree mental distraction were associated with changes in disability and depression. Effects from randomized trials can be translated to naturalistic settings. The results complement experimental research on mechanisms of change in the treatment of chronic pain and indicate an important role of cognitive change and relaxation as mechanisms of change. Our findings cautiously suggest that clinicians should optimize these processes in chronic pain patients to reduce their physical and emotional disability.

Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty

ABSTRACT

The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.

The evolution of social health research topics: A data-driven analysis

The realm of social health has not yet been properly established in terms of fixed definitions, concepts, and research areas. This study attempts to define social health using macro and micro perspectives and explores trends in social health research by mapping their topics and fields. We used Latent Dirichlet allocation (LDA) topic modeling, which allows the extraction of key terms and topics derived from a large volume of literature. We traced the evolution of research topics from past (the literature that "present" articles cited), present (existing journal articles on social health), to future (the literature which cited the articles) studies based on connections between citations. The datasets were collected by the query terms "social health" in the Scopus database, including title, abstract, and keywords of journal articles. We collected a total of 443 articles from recent social health literature, 6588 articles from past literature that the recent articles on social health cited, and 2680 articles from future literature in which recent social health articles were cited. We defined social health as positive interaction that increases individual engagement in social life at the micro level, and the high degree of social integration that deals with collective problems in society at the macro level. The results of LDA showed that social health research has developed into seven fields: Health Care Delivery; Vulnerable Groups; Measurement; Health Inequality; Social Network and Empowerment; Clinical/Physical Health; and Mental/Behavioral Health. Based on citation relationships, topics grounded in an individual/micro perspective have grown increasingly specialized and productive, while topics grounded in a social/macro perspective have stagnated or was underexplored. Our findings imply that social health studies should follow a more interdisciplinary approach to integrate current health models of individual-centered treatments with social science concerns on building collective capacity for social well-being.

Reported Outcomes in Published Systematic Reviews of Interdisciplinary Pain Treatment: Protocol for a Systematic Overview

BACKGROUND

Interdisciplinary pain treatment (IPT) is a complex intervention; its outcomes are very diverse, as are the methodologies for handling those outcomes. This diversity may hamper evidence-based decision making. Presently, there is no gold standard recommendation of how to select reported outcomes in published systematic reviews and meta-analyses to explicitly demonstrate the effectiveness of IPT.

OBJECTIVE

In this systematic overview, we aim to evaluate the reported outcome domains and measurements across published systematic reviews and meta-analyses and to identify any methods, considerations, and discussion regarding the handling of the chosen outcome domains and measurements.

METHODS

This article describes the protocol for a systematic overview of the outcomes reported in published systematic reviews and meta-analyses of randomized control trials for the effectiveness of IPT versus any control. To this end, we searched the PubMed, Cochrane Library, and Epistemonikos databases from inception to December 2019. Two independent investigators screened the titles, the abstracts of the identified records, and the full texts of the potentially eligible systematic reviews and meta-analyses, performed data extraction according to predefined forms, and rated the quality of the included systematic reviews and meta-analyses. The quality of the included systematic reviews and meta-analyses will be rated with AMSTAR (A MeaSurement Tool to Assess systematic Reviews) 2. Data will be analyzed descriptively and stratified by AMSTAR 2.

RESULTS

We introduced the rationale and design of a systematic overview to summarize and map the chosen IPT outcome domains and the methods of handling these outcomes reported in published systematic reviews and meta-analyses. As of December 2019, we collected 5229 systematic reviews, of which 147 (2.81%) were examined in-depth for eligibility. Topline results are anticipated by September 2020.

CONCLUSIONS

The results of this study will be published as soon as they are available. Our results will fill a gap in the related literature and will be used to inform the development of a set of recommendations that can be applied in systematic reviews and hopefully serve as a gold standard.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/17795.

Less Pain, Better Sleep? The Effect of a Multidisciplinary Back Pain App on Sleep Quality in Individuals Suffering from Back Pain - a Secondary Analysis of App User Data

Purpose

Mobile health solutions are finding their way into health systems. The Kaia app has been shown to be able to reduce back pain in two studies. Since pain often comes along with disturbed sleep and both symptoms are strongly related we investigated whether the Kaia app training is associated with improved sleep quality.

Methods

User data of individuals with back pain were collected in two app versions (cohort 1: N = 180; cohort 2: N = 159). We analyzed the ratings of sleep quality and pain intensity on a 11-point numeric ratings scale (NRS; 0–10) both at the beginning of usage (baseline: BL) and on the individual last day of usage (follow-up: LU) within a 3-month training program.

Results

In both cohorts, we found a significant reduction in pain intensity from BL to LU (cohort 1: M_BL = 4.80; SD = 1.59 to M_LU = 3.75; SD = 1.76, Δ_pain = –1.04; SD = 2.12; t(158) = 6.207; p<.001/cohort 2: M_BL = 4.20; SD = 1.98 to M_LU = 3.65; SD = 1.78; Δ_pain = –0.50; SD = 2.04; t(147) = 3.001; p = 0.003) and a significant improvement of sleep quality (cohort 1: M_BL = 5.76; SD = 2.12 to M_LU = 6.56; SD = 1.72; Δ_sleep = t(158) = 4.310; p < 0.001/cohort 2: M_BL = 6.08; SD = 2.08 to M_LU = 6.76; SD = 1.55; Δ_sleep = 0.67; SD = 2.13; sleep: t(147) = 3.825; p < 0.001). Interestingly, improvement of sleep quality was not fully mediated by pain reduction.

Conclusion

Our analysis underlines the relationship between pain and sleep in the clinical context. Improvement of sleep quality came along with pain reduction and vice versa. Further study should explain the exact mechanisms of action which are associated with the improvement of both symptom parameters.

Core patient-reported outcome domains for routine clinical care in chronic pain management: patients' and healthcare professionals' perspective

PURPOSE

To identify a core patient-reported outcome (PRO) domain set to be used in routine clinical care in settings offering specialized and supra-specialized multidisciplinary care to individuals with chronic pain (CP).

METHODS

Two online cross-sectional surveys were administered: one with healthcare professionals (HCPs) and one with individuals with CP. Both surveys included domains of health-related quality of life (HRQoL) from the Patient-Reported Outcomes Measurement Information System (PROMIS) framework. The patients' survey also included the Patient Generated Index (PGI). Areas affected by CP identified in the PGI were mapped to The International Classification of Functioning, Disability and Health (ICF).

RESULTS

According to HCPs, the five most relevant HRQoL domains to be assessed in routine clinical care were pain interference, pain intensity, physical function, anxiety and depression. The five areas that were the most valued by individuals with CP were recreation and leisure; global mental function; work and employment; household tasks and walking and moving. In total, these represented 74% of all nominated areas. When triangulating both frameworks (ICF/PROMIS) and perspectives (HCPs/patients), 10 core PRO domains were identified: pain interference, pain intensity, physical function, sleep disturbance, anxiety, depression, ability to participate in social roles and activities, fatigue, sleep-related impairments and self-efficacy.

CONCLUSIONS

This study identified 10 core PRO domains covering the physical, psychological and social consequences of CP on an individual's life from the perspective of individuals with CP and HCPs. The results can help identify appropriate PRO measures to assess the outcomes of multidisciplinary interventions.

How do we assess musicians' musculoskeletal symptoms?: a review of outcomes and tools used

Recent reviews of musicians' musculoskeletal symptoms (MSS) have reported heterogeneity in the outcomes reported and data collection tools used, making it difficult to compare and synthesise findings. The purpose of this present review was to improve the consistency of future research, by documenting the outcomes reported in recent studies of musicians' MSS and the data collection tools used. All English language, peer-reviewed studies, published 2007-2016 that reported musicians' self-reported MSS outcomes were identified. Details of the types of outcomes reported and the tools used were extracted, and synthesised descriptively. A range of MSS outcomes were reported, including MSS with a temporal relationship to activities performed, and the consequences of symptoms. Only 24% of studies used standardised questionnaires, with the Nordic Musculoskeletal Questionnaire (NMQ) being the most commonly used. To improve the homogeneity of outcomes and data collection tools when investigating musicians' MSS, we recommend using the NMQ, where appropriate. Recall periods of 12-months and 7-d are the most appropriate for prevalence, and 7-d recall periods for ratings. Importantly, outcomes and the tools used to collect data should be reported in sufficient detail to ensure that the study can be replicated, critiqued, and accurately interpreted.

The effectiveness of interdisciplinary intensive outpatient programs in a population with diverse chronic pain conditions: a systematic review and meta-analysis

Aim: To explore the overall effectiveness of interdisciplinary intensive outpatient treatment programs in adults with chronic pain. The secondary aim was to examine the effect of the intervention on individual outcome measures including pain intensity, pain catastrophizing, depressive symptoms, quality of life and describe its effect on medication use. Methods: The preferred reporting items for systematic review and meta-analysis protocols reporting guidelines were followed in this systematic review and meta-analysis. Results: A total of 13 peer-reviewed studies were included in analysis: one randomized controlled trial and 12 observational studies. Conclusion: Although interdisciplinary intensive outpatient programs for chronic pain have only been examined in a limited number of studies, trends suggest that participation in these programs may improve physical, emotional, social and mental health as measured by quality of life measures, while decreasing pain intensity, pain catastrophizing and depressive symptoms in a population with diverse diagnoses.

Developing a core outcome domain set to assessing effectiveness of interdisciplinary multimodal pain therapy: the VAPAIN consensus statement on core outcome domains

Interdisciplinary multimodal pain therapy (IMPT) is a biopsychosocial treatment approach for patients with chronic pain that comprises at least psychological and physiotherapeutic interventions. Core outcome sets (COSs) are currently developed in different medical fields to standardize and improve the selection of outcome domains, and measurement instruments in clinical trials, to make trial results meaningful, to pool trial results, and to allow indirect comparison between interventions. The objective of this study was to develop a COS of patient-relevant outcome domains for chronic pain in IMPT clinical trials. An international, multiprofessional panel (patient representatives [n = 5], physicians specialized in pain medicine [n = 5], physiotherapists [n = 5], clinical psychologists [n = 5], and methodological researchers [n = 5]) was recruited for a 3-stage consensus study, which consisted of a mixed-method approach comprising an exploratory systematic review, a preparing online survey to identify important outcome domains, a face-to-face consensus meeting to agree on COS domains, and a second online survey (Delphi) establishing agreement on definitions for the domains included. The panel agreed on the following 8 domains to be included into the COS for IMPT: pain intensity, pain frequency, physical activity, emotional wellbeing, satisfaction with social roles and activities, productivity (paid and unpaid, at home and at work, inclusive presentism and absenteeism), health-related quality of life, and patient's perception of treatment goal achievement. The complexity of chronic pain in a biopsychosocial context is reflected in the current recommendation and includes physical, mental, and social outcomes. In a subsequent step, measurement instruments will be identified via systematic reviews.

Pain Measurement in Rheumatic and Musculoskeletal Diseases: Where To Go from Here? Report from a Special Interest Group at OMERACT 2018

Objective.

Establishing a research agenda on standardizing pain measurement in clinical trials in rheumatic and musculoskeletal diseases (RMD).

Methods.

Discussion during a meeting at the Outcome Measures in Rheumatology (OMERACT) 2018, prepared by a systematic review of existing core outcome sets and a patient online survey.

Results.

Several key questions were debated: Is pain a symptom or a disease? Are pain core (sub)domains consistent across RMD? How to account for pain mechanistic descriptors (e.g., central sensitization) in pain measurement?

Conclusion.

Characterizing and assessing the spectrum of pain experience across RMD in a standardized fashion is the objective of the OMERACT Pain Working Group.

'Put the illness in a box': a longitudinal interpretative phenomenological analysis of changes in a sufferer's pictorial representations of pain following participation in a pain management programme

Combining participant drawings with interviews can stimulate deep reflection and allow the inexpressible to be expressed. This case study uses visual methods to illustrate the 9-month self-management journey of a female chronic pain sufferer. The participant drew a picture of her pain at each of three interviews, and the drawings were used to discuss the changing impact pain was having on her life. Drawings and transcripts were jointly analysed longitudinally using interpretative phenomenological analysis, revealing how, as control is regained, a sufferer's relationship with their chronic pain can visibly change and how the drawings, when reviewed retrospectively, enable insight and ownership of progress.

A novel inpatient complex pain team: protocol for a mixed-methods evaluation of a single-centre pilot study

INTRODUCTION

Complex pain is a debilitating condition that is responsible for low quality of life and significant economic impacts. Although best practice in the treatment of complex pain employs a multidisciplinary team, many patients do not have access to this care, leading to poor outcomes.

METHODS AND ANALYSIS

This study evaluates a novel inpatient complex pain team at a large London teaching hospital. A multidisciplinary pain team comprising specialist doctors, nurses, psychologists and physiotherapists was instituted for inpatients with complex pain who will undergo an intense and bespoke evidence-based programme which will then be integrated into the community. A mixed-methods evaluation will take place and patients will be recruited over the course of 1 year. A qualitative arm will interview 15 staff and 15 patients on recruitment and again 6 months later looking to compare and contrast the new pain team with past experiences of pain management. A quantitative arm will assess clinical outcomes using validated scoring tools. An economic evaluation will seek to evaluate the relative cost of the service by comparing healthcare costs before and after the intervention.

ETHICS AND DISSEMINATION

The study was categorised as a service evaluation, so formal ethical approval was not considered necessary. Participant recruitment began in January 2016 and the 1-year follow-up will end in November 2017. The results of this study will be published in 2018.

[Patient perspectives in outcome research : Development of a focus group concept for collating patient perspectives on determination of effectiveness of multimodal pain therapy - A pilot study]

BACKGROUND

To assess the efficacy of multimodal pain therapy for chronic pain patients it is necessary to use suitable outcome domains as well as reliable and valid measurement instruments. Using pain intensity as an example, however, it is shown that there are critical issues with respect to suitability for chronic pain patients and the quality (e.g. content validity, feasibility and interpretability) of commonly used measurement instruments.

METHOD

A focus group concept was designed to discuss the construct of pain intensity and common measurement instruments with chronic pain patients who underwent multimodal pain therapy. The focus group concept was tested in two pilot groups (N = 10) where eight issues previously established in guidelines were discussed.

RESULTS

The results of the pilot studies affirmed that the construct of pain intensity as well as the measurement instruments must be critically considered when applied to chronic pain patients and the effectiveness of multimodal pain therapy. The concept of patient focus groups proved to be a suitable method for patient participation. Integrating patients should be considered not only in discussions of existing pain scales but also in developing new measurement instruments.

Validation of a core patient-reported-outcome measure set for operationalizing success in multimodal pain therapy: useful for depicting long-term success?

Background

The study aims to validate a previously developed and published combined success criterion for patients after multimodal pain therapy (Donath et al., BMC Health Serv Res 15:272, 2015). The criterion classifies treated patients as successful in the long term on the basis of pain severity, disability through pain, depressiveness, and health-related quality of life.

Methods

Routine longitudinal data of 135 pain patients treated with multimodal pain therapy in 2014–2015 at the Interdisciplinary Pain Center of the University Clinic Erlangen were available at baseline, therapy start, therapy end, and 12 months after treatment. Patients were, on average, 51.0 (SD 11.1) years old and to 63.7% female, two thirds were employed (66.7%). We conducted an analysis of concurrent validity (with: pain severity, disability through pain, depressiveness, mental and physical quality of life), criterion validity (with disability days, self-rated success), convergent validity (with stress, anxiety, well-being), and discriminant validity (with chronicity of pain, comorbidity), objectivity, and reliability. Statistically, descriptive and inference statistics, graphical methods and MANOVAs were used.

Results

Patients classified as successful had significantly better values on the 5 variables demonstrating concurrent validity (all p < .001), significantly fewer Disability days (M = 15.31 (SD = 23.15) vs. M = 26.75 (SD = 29.15)); t (133) = 2.308; p = .024, less Anxiety (Pillai-Spur: F (3, 131) = 2.972, p = .034), less Stress (Pillai-Spur: F (3, 131) = 9.907, p < .001), and better Well-being (Pillai-Spur: F (3, 131) = 9.594, p < .001) 12 months after treatment than patients classified as not successful. The Spearman correlation between success classification and Chronicity stage was .094 (p = .280).

Conclusion

We demonstrated the validity of the combined success criterion with long-term data in addition to confirming the reliability and objectivity of the criterion. Future research might consider identifying predictors of success in multi-modal pain therapy.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2911-6) contains supplementary material, which is available to authorized users.

[Clinical studies on multimodal pain therapy : Standardized measurement of therapy outcomes with a core outcome set]

Decision making in evidence-based medicine is based on general data on therapy outcomes as well as the effectiveness and safety in specific patient populations. Typically, findings concerning therapy outcomes from different studies are aggregated for a final conclusion. In this context a comparison of results is hampered by studies in which therapy outcomes are heterogeneously measured. Such methodological challenges exist for almost all areas of medical treatment, as well as for multimodal pain therapy (MMPT). Through establishing core outcome sets (COS) the required standardization of measurement of therapy outcomes in clinical research can be achieved. A COS is an evidence-based and consented minimum set consisting of outcome domains (i.e. partial aspects of the medical condition to be investigated, which have to be measured in order to give the best possible demonstration of therapy outcome of an intervention) accomplished by valid, reliable and sensitive measurement instruments which should be applied in each clinical trial. No such COS has so far been found for MMPT. The aim of this article is to give an overview about currently recommended methodological approaches to develop a COS accompanied by a brief introduction about existing COS initiatives focusing on chronic pain. The existing COS recommendations are discussed and conclusions are drawn on whether existing recommendations could also be applied for MMPT. Finally, the impact of healthcare research in Germany on a standardized assessment of therapy outcome in MMPT is outlined.