Multimodale Schmerztherapie bei chronischen und chronifizierenden Rückenschmerzen: Kriterien für den Behandlungserfolg

Pain chronification and the important role of non-disease-specific symptoms in patients with systemic sclerosis

Background

Pain is a frequent, yet inadequately explored challenge in patients with systemic sclerosis (SSc). This study aimed to conduct an extensive pain assessment, examining pain chronification and its association with disease manifestations.

Methods

Consecutive SSc patients attending their annual assessment were included. SSc-specific features were addressed as defined by the European Scleroderma Trials and Research (EUSTAR) guidelines. Pain analysis included intensity, localization, treatment, chronification grade according to the Mainz Pain Staging System (MPSS), general well-being using the Marburg questionnaire on habitual health findings (MFHW) and symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS).

Results

One hundred forty-seven SSc patients completed a pain questionnaire, and 118/147 patients reporting pain were included in the analysis. Median pain intensity was 4/10 on a numeric rating scale (NRS). The most frequent major pain localizations were hand and lower back. Low back pain as the main pain manifestation was significantly more frequent in patients with very early SSc (p = 0.01); those patients also showed worse HADS and MFHW scores. Regarding pain chronification, 34.8% were in stage I according to the MPSS, 45.2% in stage II and 20.0% in stage III. There was no significant correlation between chronification grade and disease severity, but advanced chronification was significantly more frequent in patients with low back pain (p = 0.024). It was also significantly associated with pathological HADS scores (p < 0.0001) and linked with decreased well-being and higher use of analgesics.

Conclusions

Our study implies that also non-disease-specific symptoms such as low back pain need to be considered in SSc patients, especially in early disease. Since low back pain seems to be associated with higher grades of pain chronification and psychological problems, our study underlines the importance of preventing pain chronification in order to enhance the quality of life.

Access to Pain Management Programs: A Multifactorial Analysis of the Pathways of Care for Chronic Pain Patients in the University Clinic Erlangen

BACKGROUND

Different treatment options are offered for patients suffering from chronic pain, which differ in intensity and costs: 1) monodisciplinary treatment, mostly in outpatient care and 2) interdisciplinary treatment with the option of participating in pain management programs as outpatients or inpatients. The present work investigates how patients at the University Clinic Erlangen receiving monodisciplinary treatment differ from those receiving interdisciplinary treatment (research question I) as well as how patients participating in a pain management program differ from those who do not (research question II). The aim is to generate insights into whether the differences between the patient groups under various treatment modalities reflect the officially defined criteria for the indication of chronic pain management programs.

METHODS

Routine data of 1,833 patients treated from January 2008 to March 2013 at the University Clinic Erlangen were analyzed. After univariate preanalyses and checks for multicollinearity, the remaining variables were used for the final multivariate model (multiple binary logistic regression) for research question I and II.

RESULTS

Research question I: Patients getting interdisciplinary treatment were more often employed, had higher affective experience of pain, more often regarded their pain as treatable, had more often participated in at least one pain-associated rehabilitation treatment in the past, were younger and rarely had application for retirement in consideration. Research question II: Patients who participated in a pain management program were more often female, more often employed, described their pain as mainly located at the upper part of the body, had more concomitant symptoms, were more often diagnosed with musculoskeletal pain and rarely had a retirement request pending.

CONCLUSIONS

It could be shown that patients in the analyzed pathways of care mainly differed in demographic variables, and regarding pain management programs, also in the type of pain. Differences between patients in different treatment paths reflecting the officially defined indication criteria for chronic pain management programs were detectable only to a minor extent. Clearer and operational practical guidance should help support the clinical decision to assign patients to different treatment options and close the gap between theory and practice.

[Interdisciplinary pain assessment in the hospital setting : Merely a door-opener to multimodal pain therapy?]

BACKGROUND

Chronic pain is characterized by a complex interaction of somatic, mental and social factors. Assessing these factors in patients with chronic pain is vital during the diagnostic work-up and when making a structured treatment plan. Interdisciplinary pain assessment (ISA) is the most promising method to deal with these challenges. This article presents our experience in performing pain assessments in the hospital setting and also illustrates the characteristic features of chronic pain patients undergoing such assessments.

METHODS

This study reviews and evaluates patient data from 2704 ISAs performed at the Interdisciplinary Pain Centre of the Zentralklinik Bad Berka, Germany, between 2008 and 2015.

RESULTS

The majority of our ISA patients are severely handicapped and show distinct signs of chronic disease. A large proportion of patients is either unable to work or receiving benefits (invalidity pension or retirement pension). In addition, patients reported long disease durations and high emotional distress. Treatment recommendations were based on the patients' individual clinical presentations and examination results. More than half of the patients required multimodal pain management, while adjustments or therapeutic withdrawal of pain medications, in particular of opioids, were indicated in many patients.

DISCUSSION

Our study shows that ISA enables fast, high-quality diagnostic assessments of chronic pain while taking the biopsychosocial model of pain in particular into account. In addition, ISA is not biased with regard to outcome results and recommends the further treatment that appears best for the individual patient. ISA leads not only to inpatient treatment, but also to treatment in other therapeutic settings and, as such, is not merely a door-opener to multimodal pain therapy.

[Mild whole body hyperthermia in combination with inpatient multimodal oriented pain therapy: evaluation in patients with chronic unspecific lumbar back pain]

PURPOSE

A randomized controlled clinical trial was implemented to evaluate the effectiveness of combined mild hyperthermia therapy (body core temperature 38.4 °C) and multimodal inpatient rehabilitation for patients suffering from chronic low back pain when compared to multimodal pain therapy alone.

PATIENTS AND METHODS

A total of 88 patients were randomly assigned to the combined or single therapeutic schemes according to a block randomization scheme. According to the trial inclusion criteria all patients suffered from chronic low back pain and showed morphological degeneration. All patients underwent a 12-day inpatient multimodal pain therapy, which was complemented with a 6-session schedule of mild hyperthermia therapy for the intervention group (1 h at 38.6 °C). On admission and 3 months after treatment the study patients were asked to complete an interview assessment with the Oswestry low back pain disability questionnaire (Oswestry disability index). The change in the Oswestry disability index total score (%) 3 months after versus before therapy was defined as the primary clinical endpoint of the investigation. The patients in the control group and in the intervention group had a median age of 50 years. In the intervention group 70 % of the patients were female and 55 % reported having half to full time employment compared to 55 % and 43 % in the control group, respectively.

RESULTS

On admission the control patients reported a median Oswestry disability index of 64 % and on recall the same of 64 %. The intervention group showed median Oswestry disability index estimates of 60 % and 66 %, respectively. The changes in the overall Oswestry disability index after 3 months differed significantly with an estimated 6 % for the intervention group versus 0 % for the control group (Wilcoxon p = 0.050).

CONCLUSION

When combined with a multimodal inpatient lower back pain functional therapy in patients showing morphological degeneration, the mild hyperthermia therapy demonstrated statistically significant, although not clinically relevant benefits in comparison to the multimodal treatment alone. However, regarding the moderate overall patient-related benefits as measured in terms of the Oswestry disability index, the benefit of the underlying multimodal therapy concept implementation must be critically discussed irrespective of its combination with mild hyperthermia therapy.

[Desire for early retirement and therapy of chronic back pain: relevance of social medical variables for outpatient psychotherapeutic treatment]

BACKGROUND

This study investigated the influence of patients' desire for early retirement on the success of an outpatient cognitive behavioural treatment (CBT) in patients with chronic back pain. Previous studies have shown that the desire for early retirement and social compensation had a negative influence on therapy outcome, e.g. pain intensity and pain disability. This study was conducted to reassess whether these results can be replicated in an outpatient CBT setting.

METHOD

Questionnaires assessing pain-related variables were issued to a total of 116 patients at the beginning, at the end of treatment and 6 months after termination of therapy.

RESULTS

Overall, the treatment showed significant positive results in the variables assessed. In contrast to other studies, patients with a desire for early retirement also showed improvement during treatment. The success of treatment proved to be stable after termination of therapy.

CONCLUSION

CBT in an outpatient setting seems to be an effective treatment for patients with chronic back pain and even patients with a desire for early retirement benefit from treatment.

[Interdisciplinarity and chronic pain therapy--implementation of a new Interdisciplinary Center at the University Hospital Dresden on the basis of an integrated health care contract]

Due to the bio-psycho-social complexity and presence of various health departments, chronic pain requires interdisciplinary cooperation which enables the accurate evaluation of the clinical findings and is a prerequisite for an individual and resource-oriented therapeutic concept focusing on both physical and mental activation. This concept forms the basis of medical care at the University Pain Center, which was founded in April 2004 at the Carl Gustav Carus University Hospital in Dresden. Since then, day care and inpatient services have been provided in addition to well-established outpatient care. The motive behind the foundation of the Pain Center was to sensitize health insurers to the complex problems of chronic pain and existing regional structural deficits. Following a draft version of a coherent multimodal, interdisciplinary healthcare concept along with full cost accounting after 1 1/2 years, an integrative healthcare contract got signed by two health insurances (AOK-Sachsen and VdAK) in June 2004. After two years of existence, the first experiences, results and especially the Pain Center's treatment spectrum ought to be demonstrated.