[Acute inpatient multimodal pain therapy and rehabilitation: Framework conditions, tasks and differentiated patient allocation]

[Pain management in the rehabilitative setting]

BACKGROUND

In rehabilitation medicine, differentiated concepts of interdisciplinary multimodal pain management have existed for years, or even decades.

OBJECTIVES

What does orthopedic pain management include? How do these treatment measures carried out in the curative and rehabilitative setting differ?

METHODS

In addition to the content of rehabilitative pain management, further established models such as IMST (interdisciplinary multimodal pain therapy) are discussed.

RESULTS

The duration and intensity of the rehabilitation treatment differ from the models offered in topical medicine or in the curative sector. The treatment is also based on different questions or goals. In addition to the actual treatment, the aspect of complaint validation and socio-medical assessment is also typical for the rehabilitation sector.

CONCLUSIONS

Orthopedic rehabilitation through pain management provisos is part of a tiered and diversified system of treatment methods and models; A leap in quality was again achieved in the past few years through the introduction of behavioral medicine-oriented rehabilitation (VMO).

[The judgment of the Federal Social Court on the involvement of psychological psychotherapists in interdisciplinary multimodal pain therapy : A critical comment]

In the context of their offer of interdisciplinary multimodal pain therapy (day-patient and inpatient), hospitals repeatedly have to contend with strict detailed checks of the procedure codes (OPS 8-918.xx; 8-91c) by health insurers and the medical service. The necessity of day-patient or inpatient treatment in the respective sector, documented therapy components, and the qualifications of the therapists are regularly reviewed. On 27 October 2020, the Federal Social Court ruled on the specific qualification of psychological psychotherapists (BSG, 27 October 2020, Ref.: B 1 KR 25/19 R). The ruling and its potential impact are explained and discussed in this overview.

[Evaluation of an early interdisciplinary multimodal assessment for patients with pain : Protocol of a randomized controlled study (PAIN2020)]

Health care provision for patients with pain and risk factors for chronicity is still insufficient and characterized in particular by over-, under- and misuse of existing approaches. The PAIN2020 project is funded by the German Federal Ministry of Health Care (Innovationsfonds 01NVF17049) and aims to improve health care delivery for this group of patients by implementing an early ambulatory diagnostic approach by a pain specialist, resulting in an improvement in pain and restored or maintained function. A randomized clinical trial in 31 facilities Germany-wide will identify eligible patients and guide them into early specialized pain diagnostics. The interventional arm provides an interdisciplinary multimodal assessment, delivered by pain medicine specialists, physiotherapists and clinical psychologists. The control arm contains a single assessment by a pain specialist. Patients and caregivers receive detailed recommendations for evidence-based interventions tailored to the needs of the individual patient. Two evaluation approaches will be merged. The first requires a net sample size of 3840 patients, assessed (admission) and followed-up (3 and 6 months) by clinical data (German Pain Questionnaire, additional scales) and analyzed by a multi-level approach. In a second evaluation arm the clinical data of the included patients will be supplemented by secondary data from a statutory health insurance (BARMER) and compared to a sample of policyholders not addressed by the study. Data analyses will be performed by an external evaluation institute. The project started in April 2018.

[Prevention of chronic pain in the German healthcare system : Current state and perspective]

The current healthcare provision in Germany is established, in particular, for the diagnostics and treatment of chronic pain conditions; however, the current aim is to initiate the diagnostic and therapeutic approaches oriented towards the biopsychosocial pain model in the early stages of pain, i.e. before the onset of chronification, for patients with pain and a risk of chronification in order to actively avoid chronification processes. In this context, multiple risk factors play an important role for the diagnostic and therapeutic approaches as well as for the interdisciplinary multimodal pain therapy developed for this purpose. The Global Year of the International Association for the Study of Pain (IASP) 2020 addressed the prevention of (chronic) pain, a welcome opportunity to provide a short review of the evidence for and clinical experiences with timely diagnostic and therapeutic options and to summarize the current framework conditions and scientific recommendations for Germany. At the end of this article the implications for future research are summarized, particularly for the treatment of patients with pain and risk of chronification.

[Is interdisciplinary multimodal pain therapy threatened? : Increasing controversy on the necessity for inpatient treatment]

Interdisciplinary multimodal pain therapy (IMST) is recognized as a scientifically founded form of therapy for inpatient treatment of chronic pain conditions. The indications are assessed by private practitioners and must be confirmed by physicians at the inpatient institution. The health insurance companies are obliged to remunerate this treatment but are allowed to test the conditions in individual cases. Recently, reports from members of the German Pain Society on a drastic increase in testing and rejection quotas have become more frequent. Therefore, this article discusses the legal foundations of the treatment of patients with chronic pain in the inpatient sector. Hard criteria for treatment in a certain sector could not be established. A decision in individual cases will depend on the complexity of the disease in the individual patient. A treatment in hospital is principally only necessary when the treatment corresponds to the generally recognized state of medical knowledge and treatment options in daycase units have not been successful. Important guidance can be found in the treatment guidelines of the medical specialist societies. The transfer to a more intensive treatment sector must be made dependent on the severity and complexity of the symptoms and the insufficient effectiveness of the treatment in the previous sector. Simple ICD-10 diagnoses are not suitable as decision-making criteria and therefore, also not as testing criteria for the indications for inpatient treatment. Decompensated and acutely exacerbated chronic pain conditions must as a rule be treated in hospital, also due to the mental component of the pain disease.

[Guideline for the planning of personalized, interdisciplinary multimodal pain treatment]

Interdisciplinary multimodal pain therapy (IMPT) should be delivered in a personalized, mechanism- and goal-oriented manner on the basis of an individual case conception. To the authors' knowledge, a practical instrument for planning IMPT does not exist. The model and guideline presented here for treatment should help practitioners to optimize the planning of IMPT and execute it efficiently. Based on the relevant interference mechanisms, goals for change and treatment are set and possible interventions are proposed. This involves explicitly including the patient's existing resources.

[Implementation of interdisciplinary multimodal pain therapy according to OPS 8‑918 : Recommendations of the ad hoc commission for interdisciplinary multimodal pain therapy of the German Pain Association]

With the implementation of the German diagnosis-related groups (DRG) reimbursement system in hospitals, interdisciplinary multimodal pain therapy was incorporated into the associated catalogue of procedures (OPS 8‑918). Yet, the presented criteria describing the procedure of interdisciplinary multimodal pain therapy are neither precise nor unambiguous. This has led to discrepancies in the interpretation regarding the handling of the procedure-making it difficult for medical services of health insurance companies to evaluate the accordance between the delivered therapy and the required criteria. Since the number of pain units has increased in recent years, the number of examinations by the medical service of health insurance companies has increased. This article, published by the ad hoc commission for interdisciplinary multimodal pain therapy of the German Pain Association, provides specific recommendations for correct implementation of interdisciplinary multimodal pain therapy in routine care. The aim is to achieve a maximum level of accordance between health care providers and the requirements of the medical examiners from health insurance companies. More extensive criteria regarding interdisciplinary multimodal pain treatment in an in-patient setting, especially for patients with chronic and complex pain, are obviously needed. Thus, the authors further discuss specific aspects towards further development of the OPS-code. However, the application of the OPS-code still leaves room regarding treatment intensity and process quality. Therefore, the delivery of pain management in sufficient quantity and quality still remains the responsibility of each health care provider.

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.