Multimodal pain therapy in chronic noncancer pain-gold standard or need for further clarification?

Treatment Expectations-You Get What You Expect-and Depression Plays a Role

Positive treatment expectations demonstrably shape treatment outcomes regarding pain and disability in patients with chronic low back pain. However, knowledge about positive and negative treatment expectations as putative predictors of interindividual variability in treatment outcomes is sparse, and the role of other psychological variables of interest, especially of depression as a known predictor of long-term disability, is lacking. We present results of the first prospective study considering expectations in concert with depression in a sample of 200 patients with chronic low back pain undergoing an inpatient interdisciplinary multimodal pain therapy. We analyzed the characteristics of pain and disability, treatment expectation, and depression assessed at the beginning (T0), at the end of (T1), and at 3-month follow-up (T2) of interdisciplinary multimodal pain therapy. Treatment expectations did emerge as a significant predictor of changes in pain intensity and disability, respectively, showing that positive expectations were associated with better treatment outcomes. Mediation analyses revealed a partially mediating effect of treatment expectations on the relation between depression and pain outcomes. PERSPECTIVE: These results expand knowledge regarding the role of treatment expectations in individual treatment outcome trajectories in chronic pain patients, paving the way for much-needed efforts toward optimizing patient expectations and personalized approaches in clinical settings.

Setting the stage for pain relief: how treatment setting impacts interdisciplinary multimodal pain treatment for patients with chronic back pain

ABSTRACT

While interdisciplinary multimodal pain treatment (IMPT) is an effective treatment option for chronic low back pain, it is usually accomplished as an inpatient treatment incurring substantial healthcare costs. Day hospital IMPT could be a resource-saving alternative approach, but whether treatment setting is associated with differences in treatment outcomes has not yet been studied. In a retrospective matched cohort study including data from N = 595 patients diagnosed with chronic back pain and undergoing IMPT at the back pain center in Essen, Germany, we investigated the association between treatment setting (ie, inpatient or day patient of an otherwise identical IMPT) and pain intensity, disability, and self-efficacy after treatment. Outcomes were assessed by questionnaires used in clinical routine, collected at pre-IMPT, post-IMPT, and at 3-, 6-, and 12-month follow-up. The results indicate that day patients showed greater improvements in pain-related disability at 3-month post-IMPT (d = 0.74) and in pain intensity at 6-month post-IMPT (d = 0.79), compared to a matched sample of inpatients. Moreover, day patients achieved higher scores in pain-related self-efficacy at discharge, 3- and 6-month post-IMPT (d = 0.62, 0.99, and 1.21, respectively) and reported fewer incapacity-for-work days than inpatients at 6-month post-IMPT (d = 0.45). These data suggest that day hospital IMPT can be as effective as inpatient treatment and might even be more effective for the less afflicted patients. Further research regarding treatment setting and indication could guide optimized and cost-efficient treatments that are more closely tailored to the individual patient's needs.

PRECISE trial (Pain RElief Combination Intervention StratEgies): protocol for the clinical trial of a pregabalin-melatonin combination for fibromyalgia

INTRODUCTION

Fibromyalgia is associated with chronic widespread pain and disturbed sleep. Multidisciplinary, multimodal management often includes pharmacotherapy; however, current drugs used to treat fibromyalgia provide meaningful benefit to only 30-60% of treated individuals. Combining two or more different drugs is common in clinical practice with the expectation of better efficacy, tolerability or both; however, further research is needed to identify which combinations actually provide added benefit. Thus, we are planning a clinical trial to evaluate melatonin (MLT)-pregabalin (PGB) combination in participants with fibromyalgia.

METHODS AND ANALYSIS

This will be a single-centre, double-blind, randomised, double-dummy, three-period, crossover trial comparing a MLT-PGB combination to each monotherapy in 54 adult participants satisfying the 2016 American College of Rheumatology criteria for fibromyalgia. Participants will receive maximally tolerated doses of MLT, PGB and MLT-PGB combination for 6 weeks. The primary outcome will be daily pain intensity (0-10); secondary outcomes will include the Fibromyalgia Impact Questionnaire, SF-36 survey, Medical Outcomes Study Sleep Scale, Beck Depression Inventory (BDI-II), adverse events and other measures. Analysis of the primary and secondary outcomes will involve a linear mixed model with sequence, period, treatment, the first-order carryover and baseline pain score as fixed effects and participant as a random effect to test whether there are any treatment differences among three treatments and to estimate the least square mean of the mean daily pain intensity for each treatment, adjusting for carryover as well as period effects (ie, stability of pain levels).

ETHICS AND DISSEMINATION

This trial has been registered with the International Standard Randomised Controlled Trial Number Registry, ISRCTN #18278231, has been granted ethical approval by the Queen's University Health Sciences Research Ethics Board (Queen's HSREB Protocol #6040998) and is currently under review for a Clinical Trial Application to Health Canada Natural and Non-prescription Health Products Directorate. All participants will provide written informed consent prior to trial participation. Following trial completion, results will be disseminated in one or more biomedical journal publications and presented at one or more scientific meetings.

TRIAL REGISTRATION NUMBER

This trial has been registered with the International Standard Randomised Controlled Trial Number Registry, ISRCTN18278231.

Vulnerability Factors, Adjustment, and Opioid Misuse in Chronic Noncancer Pain Individuals

Several person variables predate injury or pain onset that increase the probability of maladjustment to pain and opioid misuse. The aim of this study was to evaluate the role of 2 diathesis variables (impulsiveness and anxiety sensitivity [AS]) in the adjustment of individuals with chronic noncancer pain and opioid misuse. The sample comprised 187 individuals with chronic noncancer pain. The hypothetical model was tested using correlation and structural equation modeling analyses. The results show a significant association between impulsiveness and AS and all the maladjustment variables, and between impulsiveness and AS and opioid misuse and craving. However, although the correlation analysis showed a significant association between adjustment to pain and opioid misuse, the structural equation modeling analysis showed a nonsignificant association between them (as latent variables). The findings support the hypothesis that both impulsiveness and AS are vulnerability factors for maladaptive adjustment to chronic pain and opioid misuse. PERSPECTIVE: This article adds to the empirical literature by including AS and impulsiveness as antecedent variables in a model of dual vulnerability to chronic pain maladjustment and opioid misuse. The findings suggest the potential utility of assessing both factors in individuals in the first stages of chronic pain.

[Booster treatments in interdisciplinary multimodal pain therapy : Preparing structural and process parameters for the implementation of cross-sectoral booster treatments]

Interdisciplinary multimodal pain therapy (IMPT) is an established procedure in the treatment of chronic pain. In daily practice, many institutions regard so-called booster units as an integral part of IMPT. However, no consensual recommendations and evidence for booster concepts are available to date. This article uses the results of a discussion between clinical experts in the field of IMPT at the German Pain Congress in 2022 in order to show the status quo in care. It has been shown that currently applied booster offers vary greatly in terms of time intervals, intensities, therapy content and patient selection and that there is a need for structural and process parameters for the implementation of cross-sectoral booster treatments. In conclusion, the authors outline how the development of these parameters will be planned as an expert consensus with the participation of interested institutions and the inclusion of the patient perspective and offer opportunities for participation in this process.

Personality systems interactions theory: an integrative framework complementing the study of the motivational and volitional dynamics underlying adjustment to chronic pain

In the endeavor to advance our understanding of interindividual differences in dealing with chronic pain, numerous motivational theories have been invoked in the past decade. As they focus on relevant, yet different aspects of the dynamic, multilevel processes involved in human voluntary action control, research findings seem fragmented and inconsistent. Here we present Personality Systems Interactions theory as an integrative meta-framework elucidating how different motivational and volitional processes work in concert under varying contextual conditions. PSI theory explains experience and behavior by the relative activation of four cognitive systems that take over different psychological functions during goal pursuit. In this way, it may complement existing content-related explanations of clinical phenomena by introducing a functional, third-person perspective on flexible goal management, pain acceptance and goal maintenance despite pain. In line with emerging evidence on the central role of emotion regulation in chronic pain, PSI theory delineates how the self-regulation of positive and negative affect impacts whether behavior is determined by rigid stimulus-response associations (i.e., habits) or by more abstract motives and values which afford more behavioral flexibility. Along with testable hypotheses, multimodal interventions expected to address intuitive emotion regulation as a central process mediating successful adaptation to chronic pain are discussed.

PAIN2.0: study protocol for a multicentre randomised controlled trial to evaluate the efficacy of a 10-week outpatient interdisciplinary multimodal pain therapy to manage recurrent pain for patients with risk factors of developing chronic pain in Germany

BACKGROUND

Up to 27% of the German population suffers from recurrent or persistent pain (lasting more than three months). Therefore, prevention of chronic pain is one major object of pain management interventions. The aim of this nationwide, multicentre, randomised controlled trial is to evaluate the efficacy of a 10-week ambulatory (outpatient) interdisciplinary multimodal pain therapy (A-IMPT) for patients with recurrent pain and at risk of developing chronic pain. This project was initiated by the German Pain Society (Deutsche Schmerzgesellschaft e.V.) and the public health insurance provider BARMER. It is currently funded by the German Innovation Fund (01NVF20023). The study PAIN2.0 focuses on reducing pain intensity and pain-related disability and investigates whether this intervention can improve physical activity, psychological well-being, and health literacy.

METHODS

PAIN2.0 is designed as a multicentre 1:1 randomised controlled trial with two parallel groups (randomisation at the patient level, planned N = 1094, duration of study participation 12 months, implemented by 22 health care facilities nationwide). After 6 months, patients within the control group also receive the intervention. The primary outcomes are pain intensity and pain-related impairment, measured as Characteristic Pain Intensity (PI) and Disability Score (DS) (Von Korff), as well as patient-related satisfaction with the intervention. Secondary outcomes are the number of sick leave days, sickness allowance, treatment costs, psychological distress, health-related quality of life, and catastrophizing. The effects of the intervention will be analysed by a parallel-group comparison between the intervention and control groups. In addition, the long-term effects within the intervention group will be observed and a pre-post comparison of the control group before and after the intervention will be performed.

DISCUSSION

Recurrent or persistent pain is common in the German population and causes high costs for patients and society. The A-IMPT aims to improve pain and pain-related impairments in pain patients at risk of chronification, thereby reducing the risk of developing chronic pain with its high socioeconomic burden. This new therapy could easily be integrated into existing therapy programs if positively evaluated.

TRIAL REGISTRATION

The trial PAIN2.0 has been registered in the German Clinical Trials Register (DRKS) since 21/11/2022 with the ID DRKS00030773 .

Sickness Absence and Disability Pension Among Patients With Chronic Pain in Interdisciplinary Treatment or Unspecified Interventions

Interdisciplinary treatment is a widely implemented strategy for the rehabilitation of patients with chronic pain. A primary treatment objective is to decrease the load on the social insurance system; however, it is questionable whether interdisciplinary treatment reduces sickness absence and disability pension (SA/DP). This register-based observational study compared SA and DP between patients in interdisciplinary treatment and unspecified interventions. With data from 7,752 Swedish specialist health care patients in their prime working age, we analyzed total net SA/DP days over 3 years from the first visit to a pain rehabilitation center. A zero-one-inflated beta model, adjusted for theoretically substantiated confounders, was used to estimate the mean differences in total days and the proportions of patients with both zero and maximum days. Compared with unspecified interventions, interdisciplinary treatment resulted in a mean (95% confidence interval) absolute increase of 50 (37, 62) total days, a 13.0% (11.3%, 14.6%) decrease in patients with zero days, and a 1.5% (.2%, 2.8%) decrease in patients with the maximum days. These findings support that interdisciplinary treatment increases SA/DP compared to less intensive interventions but reduces the risk of maximum days, implying that it is advantageous for patients with the highest absence. This highlights the need for improved patient selection procedures and the adaptation of interdisciplinary treatment programs to more adequately target SA/DP reduction. PERSPECTIVES: This study provides an accessible overview of SA/DP among working-age patients with chronic pain in Swedish specialist health care. It also shows that interdisciplinary treatment does not decrease SA/DP more than alternative treatments in most patients but is advantageous for the patients with the longest absence.

Changes in Brain GABA and Glutamate and Improvements in Physical Functioning Following Intensive Pain Rehabilitation in Youth With Chronic Pain

Intensive interdisciplinary pain treatments (IIPT) have been developed to treat youth with unmanaged chronic pain and functional disability. Dysregulation of metabolites gamma-aminobutyric acid (GABA) and glutamate are thought to play a role in the chronification of pain due to imbalances in inhibition and excitation in adults. Using magnetic resonance spectroscopy (MRS), we investigated the effect of IIPT on GABA and Glx (glutamate + glutamine) in 2 pain-related brain regions: the left posterior insula (LPI) and the anterior cingulate cortex (ACC). Data were collected in 23 youth (mean age = 16.09 ± 1.40, 19 female) at entry and discharge from a hospital-based outpatient IIPT. GABA and Glx were measured using GABA-edited MEGA-PRESS and analyzed using Gannet. Physical measures including a 6-minute walk test were recorded, and patients completed the PLAYSelf Physical Literacy Questionnaire, PROMIS Pain Interference Questionnaire, and Functional Disability Inventory. LPI GABA (P < .05) significantly decreased, but not ACC GABA (P > .05), following IIPT. There were no significant Glx changes (P > .05). The decrease in LPI GABA was associated with increased distance in the 6-minute walk test (P < .001). IIPT may decrease GABAergic inhibitory tone within the LPI, thereby promoting plasticity and contributing to improvements in physical outcomes with IIPT. PERSPECTIVE: Regional GABA changes are associated with a reduction in pain interference and improvement in physical function in youth following intensive pain rehabilitation. GABA may serve as a possible biomarker for IIPT; and may also further aid in the development of IIPT, and other treatments for chronic pain in youth.

How Does Meditation-Based Lifestyle Modification Affect Pain Intensity, Pain Self-Efficacy, and Quality of Life in Chronic Pain Patients? An Experimental Single-Case Study

INTRODUCTION

Chronic pain is a growing worldwide health problem and complementary and integrative therapy options are becoming increasingly important. Multi-component yoga interventions represent such an integrative therapy approach with a promising body of evidence.

METHODS

The present study employed an experimental single-case multiple-baseline design. It investigated the effects of an 8-week yoga-based mind-body intervention, Meditation-Based Lifestyle Modification (MBLM), in the treatment of chronic pain. The main outcomes were pain intensity (BPI-sf), quality of life (WHO-5), and pain self-efficacy (PSEQ).

RESULTS

Twenty-two patients with chronic pain (back pain, fibromyalgia, or migraines) participated in the study and 17 women completed the intervention. MBLM proved to be an effective intervention for a large proportion of the participants. The largest effects were found for pain self-efficacy (TAU-U = 0.35), followed by average pain intensity (TAU-U = 0.21), quality of life (TAU-U = 0.23), and most severe pain (TAU-U = 0.14). However, the participants varied in their responses to the treatment.

CONCLUSION

The present results point to relevant clinical effects of MBLM for the multifactorial conditions of chronic pain. Future controlled clinical studies should investigate its usefulness and safety with larger samples. The ethical and philosophical aspects of yoga should be further explored to verify their therapeutic utility.

"INTEGRO INTEGRated Psychotherapeutic InterventiOn" on the Management of Chronic Pain in Patients with Fibromyalgia: The Role of the Therapeutic Relationship

Fibromyalgia (FM) is a chronic disease characterized by a heterogeneous set of physical and psychological conditions. The chronic experience of disability felt by patients and the impact on quality of life (QoL) of the disease may worsen the cognitive reappraisal ability and contribute to maintaining an altered pain modulation mechanism. This paper presents the study protocol of an INTEGRated psychotherapeutic interventiOn on the management of chronic pain in patients with fibromyalgia (INTEGRO). The aim of the study is to investigate the efficacy of an integrated psychotherapeutic intervention focused on pain management on QoL and pain perception, in a pilot sample of 45 FM patients with idiopathic chronic pain. The contribution of perceived therapeutic relationship (alliance) and physiological attunement, in both the patient and therapist, will be considered as possible mediators of intervention efficacy. Attachment dimensions, traumatic experiences, difficulties in emotion regulation, mindfulness attitude and psychophysiological profile will also be considered as covariates. The objectives are to evaluate longitudinally if patients will experience an increase in QoL perception (primary endpoint), pain-managing self-efficacy and emotion-regulation abilities as well as a reduction in pain intensity (secondary endpoints), considering the mediating role of perceived therapeutic alliance and physiological attunement in both the patient and therapist.

Disability Among Persons With Chronic Severe Back Pain: Results From a Nationally Representative Population-based Sample

We evaluated the association between the chronic severe back pain with disability and participation, in U.S. Adults using data from the US 2019 National Health Interview Survey. In our sample of 2,925 adults (weighted n: 20,468,134) who reported having chronic severe back pain, 60% reported mobility disability, 60% had work limitations, 34% were limited for social participation and 16% had self-care limitations. Older age (65+) was associated with mobility difficulties (OR 1.99, 95% CI 1.28,6.09) and work limitation (OR 2.21, 95% CI 1.61,3.05). Lower socioeconomic status was associated with increasing odds of disability across the 4 categories. Being obese was only associated with mobility difficulties (OR 1.95, 95% CI 1.41,2.71), while not working in the past week was associated with difficulties in mobility (OR 3.55, 95% CI 2.64,4.75), self-care (OR 3.34, 95% CI 2.20,5.08), and social participation (OR 3.20, 95% CI 2.13,4.80). Comorbidities were highly associated with limitations in all 4 categories. Those deeming their ability to manage their pain ineffective were twice as likely to have limitations in self-care, social and work participation but not mobility. Identifying factors associated with disability and limitation may help target appropriate management for persons with chronic pain at high risk for disability. PERSPECTIVE: We evaluated the association between the chronic severe back pain with disability and participation, in a representative sample of Americans. Identifying factors associated with a likelihood of disability may help target appropriate pain management for persons at high risk for disability due to chronic severe back pain.

Systematic description of an interdisciplinary multimodal pain treatment programme for patients with chronic musculoskeletal pain, using the TIDieR checklist

OBJECTIVE

To provide a thorough and systematic description of an interdisciplinary multimodal pain treatment programme (IMPT) for patients with chronic musculoskeletal pain (CMP), using the TIDieR checklist as a guide.

RESULTS

The main goal of the 'Centre for Integral Rehabilitation (CIR) Excellent' IMPT is to improve daily functioning, participation and quality of life of patients with CMP by helping them to adapt their behaviour so as to better manage their symptoms. A combination of physical and psychosocial treatment methods is employed, including Emotional Awareness and Expression Therapy (EAET), Pain Neuroscience Education (PNE), Acceptance and Commitment Therapy (ACT), graded activity, exposure in vivo, and experiential learning through physical training. The interdisciplinary treatment team comprises physiotherapists, psychologists and a physiatrist. The programme lasts 10 weeks (61 h in total) and consists of three phases: a start (Week 1), education (Weeks 2-3), and skills learning phase (Weeks 4-10). Patients come in twice a week and participate in 2-4 sessions (3-4 h) per treatment day. The programme consists of both individual (physical and mental coaching) and group sessions (education, movement and behaviour outdoors/indoors). Individualisation through personal goal-setting is an important characteristic of the treatment, as well as frequent interdisciplinary consultation between care providers.

Longitudinal resting-state electroencephalography in patients with chronic pain undergoing interdisciplinary multimodal pain therapy

ABSTRACT

Chronic pain is a major healthcare issue posing a large burden on individuals and society. Converging lines of evidence indicate that chronic pain is associated with substantial changes of brain structure and function. However, it remains unclear which neuronal measures relate to changes of clinical parameters over time and could thus monitor chronic pain and treatment responses. We therefore performed a longitudinal study in which we assessed clinical characteristics and resting-state electroencephalography data of 41 patients with chronic pain before and 6 months after interdisciplinary multimodal pain therapy. We specifically assessed electroencephalography measures that have previously been shown to differ between patients with chronic pain and healthy people. These included the dominant peak frequency; the amplitudes of neuronal oscillations at theta, alpha, beta, and gamma frequencies; as well as graph theory-based measures of brain network organization. The results show that pain intensity, pain-related disability, and depression were significantly improved after interdisciplinary multimodal pain therapy. Bayesian hypothesis testing indicated that these clinical changes were not related to changes of the dominant peak frequency or amplitudes of oscillations at any frequency band. Clinical changes were, however, associated with an increase in global network efficiency at theta frequencies. Thus, changes in chronic pain might be reflected by global network changes in the theta band. These longitudinal insights further the understanding of the brain mechanisms of chronic pain. Beyond, they might help to identify biomarkers for the monitoring of chronic pain.

Living with Chronic Pain During the COVID-19 Pandemic: A Qualitative Analysis

Purpose

COVID-19 pandemic containment measures have led to changes in various areas of life, including restrictions on health care. Patients with chronic pain may have faced an increased burden during pandemic and the resources of this vulnerable population are unknown. Therefore, a qualitative study was conducted to understand how people with chronic pain have experienced the course of the pandemic.

Patients and Methods

Twenty semi-structured telephone interviews were conducted six months after the initial lockdown in Germany. The participants were patients with chronic pain who exhibited varying changes in their pain during the first German lockdown, recruited from a German outpatient pain clinic at a Department of Anesthesiology and Intensive Care. The semi-structured interview guidelines were designed to explore how patients with chronic pain experienced their pain during the pandemic, how they coped, and how they experienced pain management during this time. The interview recordings were transcribed verbatim and coded using the qualitative content analysis method.

Results

Four themes emerged from the results: differential impact on pain experience, difficulty coping with pain, supportive pain management, and endurance.

Conclusion

During this uncertain time, it was particularly important to maintain pain treatment in order to establish a sense of safety and stability. This underscores the special role of maintaining therapeutic contact during a pandemic and the potentially special role of telemedicine.

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.

Associations of health-related quality of life with sociodemographic characteristics, health, pain, and lifestyle factors, and motivation for changing lifestyle in adults living with chronic pain: a cross-sectional exploratory study

OBJECTIVES

We investigated the associations between health-related quality of life (HRQoL) and health, pain and lifestyle factors, as well as motivation for lifestyle changes, in adults living with chronic pain referred to a Danish pain centre.

METHODS

A total of 144 outpatients completed a questionnaire on HRQoL (EQ-5D-5L), health, pain, lifestyle factors (Body Mass Index [BMI], physical activity, smoking, alcohol, physical fitness, eating, sleep and stress) and motivation for lifestyle changes. We used multiple linear regression analyses to assess associations between HRQoL and the independent variables.

RESULTS

The participants (age mean 50 years, 81% females) had ≥2 body pain sites (93%), BMI≥25 (64%), sedentary lifestyle (43%) and multiple (n≥2) elevated metabolic risk factors (58%). Most considered lifestyle important for HRQoL (72%) and expressed moderate to very high motivation for changing lifestyle (92%). Poorer HRQoL in the study population was significantly associated with higher pain intensity in the most painful body site (β=-0.316, p=0.001) and very poor sleep quality (β=-0.410, p=0.024). Serious-to-extreme problems in usual activities were associated with significantly poorer health (β=-0.328, p=0.030).

CONCLUSIONS

Adults living with chronic pain participating in this survey had significantly lower self-evaluated HRQoL than the general population. Lower HRQoL was significantly associated with greater pain intensity and poor sleep quality. Serious-to-extreme problems in usual activities, such as work, study, housework, family and leisure, were associated with poorer self-evaluated health. We observed high frequencies of overweight, obesity, sedentary lifestyle, pain in multiple body sites and multiple lifestyle-related risk factors in the study population. Most participants felt motivated for changing lifestyle. Further interventions addressing pain alleviation, sleep quality, prevention of problems in usual activities and promotion of healthy lifestyle, e.g. physical activity and healthy eating, are needed to estimate the effect of a lifestyle-oriented approach on health and quality of life in people living with chronic pain. The results of this study will inform the research project reg. SJ-703, the Danish the Research Ethics Committee for Region Zealand, Denmark.

Monitoring Pharmacological Treatment in Patients With Chronic Noncancer Pain

Chronic pain has been not recognized as a chronic illness, and its far-reaching impacts are often ignored. Chronic noncancer pain (CNCP) is a chronic disease and health care professionals need recommendations on how to monitor treatments, patients and long-term side effects of the different medications used to control CNCP. CNCP patients make up a vulnerable population due to the various associated pathologies and the challenging socio-economic conditions experienced by many of these patients. CNCP is more common among older adults, females, cancer survivors, indigenous peoples, veterans, and populations affected by social inequities and discrimination. These social determinants can lead to a complex interplay between chronic pain, mental illness, and substance use disorders. Given these realities, long-term pharmacological and side effect surveillance is more complex. Follow-up of patients with CNCP is a challenge for physicians, and thus it is important to provide recommendations on how to monitor treatments and long-term side effects of the different medications used to control CNCP.

[Results of a pilot study on the role of therapy expectation in interdisciplinary multimodal pain therapy for chronic back pain]

Hintergrund

Chronische Rückenschmerzen sind eine schwerwiegende und global sehr häufig auftretende Erkrankung mit enormen persönlichen sowie sozioökonomischen Auswirkungen. Die interdisziplinäre multimodale Schmerztherapie (IMST) ist eines der wenigen evidenzbasierten Behandlungsverfahren für chronische Schmerzen. Obwohl bekannt ist, dass Schmerzen sowie deren Chronifizierung und Behandlung von den persönlichen Erwartungen der Patienten beeinflusst werden, gibt es wenige etablierte Interventionen oder Richtlinien für eine aktive Modulation dieses Effekts.

Ziel der Arbeit

Wir möchten mit dieser Arbeit die Rolle der Erwartung als Prädiktor für Schmerzen sowie schmerzbezogene Beeinträchtigung in der klinischen Praxis verdeutlichen und präsentieren hierzu beispielhaft explorative Pilotdaten einer Beobachtungskohorte unserer Klinik.

Material und Methoden

Die Untersuchung zeigt erste Daten einer prospektiven longitudinalen Beobachtungsstudie bestehend aus bis zu 41 Patienten mit chronischen Rückenschmerzen, die im Setting einer IMST am Essener Rückenschmerz-Zentrum behandelt wurden. Es wurden Daten zum Zeitpunkt der Aufnahme (T0) und der Entlassung (T1) sowie drei Monate nach Therapieende (T2) erhoben. Primäre Endpunkte waren die Schmerzintensität und die Schmerzbeeinträchtigung. Zusätzlich erfassten wir die Therapieerwartung zum Zeitpunkt der Aufnahme als möglichen Prädiktor. Die Bedeutung der vor der Therapie erhobenen Therapieerwartung wurde mittels linearer Regression erfasst.

Ergebnisse

Die IMST führte zu einer signifikanten Besserung in Bezug auf die Schmerzintensität und -beeinträchtigung. Der Effekt auf die Schmerzintensität war über den Zeitraum von drei Monaten nach Therapieende anhaltend und die Beeinträchtigung sank in diesem Zeitraum weiter signifikant.

Diskussion

Erwartung war ein signifikanter Prädiktor für die Abnahme der Schmerzintensität und erklärte ca. 15 % der Varianz. In der klinischen Praxis sollten daher valide Methoden etabliert werden, negative Erwartungen zu reduzieren und positive Erwartungen zu fördern.

[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.

The value of interdisciplinary treatment for sickness absence in chronic pain: A nationwide register-based cohort study

BACKGROUND

Interdisciplinary treatment (IDT) is an internationally recommended intervention for chronic pain, despite inconclusive evidence of its effects on sickness absence.

METHODS

With data from 25,613 patients in Swedish specialist healthcare, we compared sickness absence, in the form of both sick leave and disability pensions, over a 5-year period between patients either allocated to an IDT programme or to other/no interventions (controls). To obtain population-average estimates, a Markov multistate model with theory-based inverse probability weights was used to compute both the proportion of patients on sickness absence and the total sickness absence duration.

RESULTS

IDT patients were more likely than controls to receive sickness absence benefits at any given time (baseline: 49% vs. 46%; 5-year follow-up: 36% vs. 35%), and thereby also had a higher total duration, with a mean (95% CI) of 67 (87, 48) more days than controls over the 5-year period. Intriguingly, sick leave was higher in IDT patients (563 [552, 573] vs. 478 [466, 490] days), whereas disability pension was higher in controls (152 [144, 160] vs. 169 [161, 178] days).

CONCLUSION

Although sickness absence decreased over the study period in both IDT patients and controls, we found no support for IDT decreasing sickness absence more than other/no interventions in chronic pain patients.

SIGNIFICANCE

In this large study of chronic pain patients in specialist healthcare, sickness absence is compared over a 5-year period between patients in an interdisciplinary treatment programme and other/no interventions. Sickness absence decreased over the study period in bothgroups; however, there was no support forthat it decreased more with interdisciplinary treatment than alternative interventions.

Predictive variables of prescription opioid misuse in patients with chronic noncancer pain. Development of a risk detection scale: A registered report protocol

BACKGROUND

Opioid therapy is utilized for a broad range of chronic pain conditions. Several studies have highlighted the adverse effects of opioid medication due to the misuse of these drugs. The gradual increase in the use of opioids has become a global phenomenon and is generating social concern. Several treatment guidelines have strongly recommended assessing the risks and benefits of pharmacological treatment with opioids. These guidelines also recommend the psychological assessment of patients with chronic noncancer pain in order to make informed decisions on the advisability of intervention with opioids. Some authors have emphasized the relevance of assessing the risk of opioid misuse in patients with noncancer chronic pain before initiating treatment.

METHODS AND ANALYSIS

Two studies will be conducted, each with a different primary objective. The primary objective of the first study (Study 1) will be to conduct a comprehensive investigation to identify the factors most closely associated with subsequent opioid misuse; and based on the results of Study 1, the primary objective of the second study (Study 2) will be to develop a brief, reliable, valid, and useful instrument that would enable health care providers to make decisions on opioid prescription and on the required level of monitoring and follow-up. These decisions would have positive consequences for patient wellbeing. Study 1 will include a logistic regression analysis to test the hypothetical model. Study 2 will have a longitudinal design and include three assessment sessions in order to develop a measure to assess the risk of prescribed opioid misuse and to analyse its reliability and validity. Participants will be individuals with chronic noncancer pain attending three Pain Units. These individuals will either be undergoing pharmacological treatment that includes opioid analgesics (Study 1, N = 400) or are going to commence such treatment (Study 2, N = 250).

European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1: Role of opioids in the management of chronic noncancer pain

BACKGROUND

Opioid use for chronic non-cancer pain (CNCP) is complex. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).

METHODS

The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.

RESULTS

The key clinical practice recommendations suggest: (a) first optimizing established non-pharmacological treatments and non-opioid analgesics and (b) considering opioid treatment if established non-pharmacological treatments or non-opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence- and clinical consensus-based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation.

CONCLUSIONS

Opioids remain a treatment option for some selected patients with CNCP under careful surveillance.

SIGNIFICANCE

In chronic pain, opioids are neither a universal cure nor a universally dangerous weapon. They should only be used for some selected chronic noncancer pain syndromes if established non-pharmacological and pharmacological treatment options have failed in supervised pain patients as part of a comprehensive, multi-modal, multi-disciplinary approach to treatment. In this context alone, opioid therapy can be a useful tool in achieving and maintaining an optimal level of pain control in some patients.

Dual Enkephalinase Inhibitors and Their Role in Chronic Pain Management

PURPOSE OF REVIEW

Dual enkephalinase inhibitors (DENKIs) are pain medications that indirectly activate opioid receptors and can be used as an alternative to traditional opioids. Understanding the physiology of enkephalins and their inhibitors and the pharmacology of these drugs will allow for proper clinical application for chronic pain patients in the future.

RECENT FINDINGS

DENKIs can be used as an alternative mode of analgesia for patients suffering from chronic pain by preventing the degradation of endogenous opioid ligands. By inhibiting the two major enkephalin-degrading enzymes (neprilysin and aminopeptidase N), DENKIs can provide analgesia with less adverse effects than nonendogenous opioids. The purpose of this paper is to review the current literature investigating DENKIs and explore their contribution to chronic pain management.

Exploring the Feasibility of Relapse Prevention Strategies in Interdisciplinary Multimodal Pain Therapy Programs: Qualitative Study

BACKGROUND

Although interdisciplinary multimodal pain treatment (IMPT) programs are widely regarded as treatment of choice for patients with chronic pain, there are signs that many patients are unable to maintain their treatment gains in the long term. To facilitate the maintenance of positive treatment outcomes over time, we developed two relapse prevention strategies.

OBJECTIVE

The main objective of this study was to explore the feasibility of these strategies within the context of IMPT programs.

METHODS

We performed a feasibility study using 3 workbook prototypes containing either one or both strategies. For a period of 6 months, the workbooks were made available in two IMPT facilities. Qualitative data were collected through a focus group and semistructured interviews. We performed a thematic analysis using a deductive approach with (1) applicability to the treatment program, (2) acceptability of the workbook content, and (3) form, as predefined themes.

RESULTS

The final dataset consisted of transcripts from a focus group with health care providers and 11 telephone interviews and 2 additional in-depth interviews with patients. In general, the intervention was perceived as useful, easy to use, and in line with the treatment program. The data also include suggestions to further improve the use of both strategies, including more specific implementation guidelines, revised goal-setting procedure, and development of a mobile health version. However, several factors, including a high dropout rate and small sample size, impact the external validity of our findings.

CONCLUSIONS

This study should be regarded as a first step in the process of transforming the prototype workbook into an effective intervention for clinical practice. Although these initial results indicate a favorable evaluation of both behavior regulation strategies within the workbook, this study encountered multiple barriers regarding implementation and data collection that limit the generalizability of these results. Future research efforts should specifically address the fidelity of HCPs and patients and should include clear procedures regarding recruitment and use of both relapse prevention strategies during treatment.

Systematic scoping review of interactions between analgesic drug therapy and mindfulness-based interventions for chronic pain in adults: current evidence and future directions

Supplemental Digital Content is Available in the Text.

None of the mindfulness-based clinical trials for chronic pain included in this review analyzed the interaction effects between mindfulness interventions and concomitant analgesic drug therapies.

Most patients with chronic pain do not find adequate pain relief with a single treatment, and accumulating evidence points to the added benefits of rational combinations of different treatments. Given that psychological therapies, such as mindfulness-based interventions (MBIs), are often delivered in conjunction with concomitant analgesic drug therapies (CADTs), this systematic scoping review examines the evidence for any interactions between MBIs and CADTs. The protocol for this review has been published and registered. MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and PsycINFO databases were searched until July 2019. We included randomized controlled trials that evaluated the efficacy of MBIs for the treatment of chronic pain. A total of 40 randomized controlled trials (2978 participants) were included. Thirty-nine of 40 (97.5%) included mindfulness-based clinical trials allowed the use of CADTs. However, only 6 of these 39 (15.4%) trials provided adequate details of what these CADTs were, and only 4 (10.3%) trials controlled for CADTs. Of great relevance to this review, none of the included trials analyzed the interactions between MBIs and the CADTs to determine whether they have an additive, synergistic, or antagonistic effect on chronic pain. Adverse events were inconsistently reported, and no judgment could be made about safety. Future trials assessing the interactions between MBIs and CADTs, with better harms reporting, are needed to better define the role of MBIs in the management of chronic pain.

Effect of Additional Pain Neuroscience Education in Interdisciplinary Multimodal Pain Therapy on Current Pain. A Non-Randomized, Controlled Intervention Study

Purpose

Interdisciplinary multimodal pain therapy (IMPT) programs for chronic back pain are effective and recommended. The patient-centered and biopsychosocial nature of IMPT is grounded in contemporary understanding that chronic pain states reflect heightened sensitization of the nervous system rather than an issue in the tissue. Teaching patients about pain is part of IMPT programs, though a clinical guideline is lacking. This study aims to answer the following question: Does the addition of an evidence-based pain neuroscience education (PNE) lecture for patients, into an IMPT program, produce superior results than the IMPT program itself?

Patients and Methods

A non-randomized, controlled intervention study was performed with 179 back pain patients indicated for IMPT. Intervention group (N=102) received a four-week IMPT program, which contained 4 one-hour sessions PNE. Control group (N=77) received the same IMPT without the additional PNE. Primary outcome was current pain after intervention. Pain knowledge, physical function, depression, anxiety, stress, quality of life and fear-avoidance were analyzed as secondary outcomes. Outcomes were defined as change of the parameter measured before and immediately after the four-week IMPT. For each outcome, linear regression models were used to estimate the raw and adjusted (sex, age and BMI) effect of additional PNE.

Results

Despite improvement in all outcomes for both groups during the treatment phase, the implemented PNE did not result in additional pain reduction (regression coefficient for PNE effect on pain level 0.34; 95% CI −6.23–6.97). Between-group differences could only be shown for pain-related knowledge in favor for the intervention group (0.78; 95% CI 0.35–1.20).

Conclusion

The additional PNE lecture did not lead to pain reduction beyond the usual IMPT. However, the PNE did increase pain-related knowledge and, therefore, might be helpful in coping with pain after the IMPT program.

Accessing care in multidisciplinary pain treatment facilities continues to be a challenge in Canada

BACKGROUND

Multidisciplinary pain treatment facilities (MPTFs) are considered the optimal settings for the management of chronic pain (CP). This study aimed (1) to determine the distribution of MPTFs across Canada, (2) to document time to access and types of services, and (3) to compare the results to those obtained in 2005-2006.

METHODS

This cross-sectional study used the same MPTF definition as in 2005-2006-that is, a clinic staffed with professionals from a minimum of three different disciplines (including at least one medical specialty) and whose services were integrated within the facility. A comprehensive search strategy was used to identify existing MPTFs across Canada. Administrative leads at each MPTF were invited to complete an online questionnaire regarding their facilities.

RESULTS

Questionnaires were completed by 104 MPTFs (response rate 79.4%). Few changes were observed in the distribution of MPTFs across Canada compared with 12 years ago. Most (91.3%) are concentrated in large urban cities. Prince Edward Island and the Territories still lack MPTFs. The number of pediatric-only MPTFs has nearly doubled but remains small (n=9). The median wait time for a first appointment in publicly funded MPTFs is about the same as 12 years ago (5.5 vs 6 months). Small but positive changes were also observed.

CONCLUSION

Accessibility to public MPTFs continues to be limited in Canada, resulting in lengthy wait times for a first appointment. Community-based MPTFs and virtual care initiatives to distribute pain services into regional and remote communities are needed to provide patients with CP with optimal care.

[Psychotherapy in the Context of Interdisciplinary Multimodal Pain Therapy: Update]

Interdisciplinary multimodal pain therapy (IMPT) is based on the biopsychosocial model of pain and describes an integrated treatment for patients with chronic pain. IMPT incorporates a close cooperation of different disciplines, including physicians, psychotherapists, physiotherapists, and others. IMPT mainly aims to restore and increase patients' physical, social and psychological functional capacity. The efficacy of IMPT has been evidenced by systematic reviews and meta-analyses. A number of studies further indicate IMPT's cost-efficiency. Psychotherapy is an essential component of IMPT. Its main goal within the framework of IMPT is to identify and modify dysfunctional patterns of pain coping, and to diagnose and potentially treat psychological comorbidities. Pain psychotherapy comprises mostly cognitive-behavioral interventions which address dysfunctional coping at the three levels of the pain experience (i.e., cognitive, emotional, and behavioral). Research into the efficacy of pain psychotherapy is rather sparse and studies have mostly focused on chronic back pain, yet existing results show promising evidence both for psychotherapy within IMPT and for psychotherapy as a monotherapy. This paper aims at providing an overview of (a) commonly employed cognitive-behavioral psychotherapeutic approaches and strategies in the treatment of chronic pain, and (b) the existing empirical evidence of pain psychotherapy both within the framework of IMPT and as a monotherapy. Future research should include a wider range of pain diagnoses and also investigate the potential benefit of individually-tailored treatments.

What Is the Effectiveness of Different Duration Interdisciplinary Treatment Programs in Patients with Chronic Pain? A Large-Scale Longitudinal Register Study

Chronic pain is a leading cause of disability globally. Interdisciplinary multimodal pain rehabilitation (IMPR) targets pain with a bio-psycho-social approach, often delivered as composite programs. However, evidence of optimal program duration for the rehabilitation to succeed remains scarce. This study evaluated the effectiveness of different duration IMPR-programs-using within- and between-effects analyses in a pragmatic multicenter register-based controlled design. Using the Swedish Quality Registry for Pain Rehabilitation, data from fifteen clinics specialized in chronic pain rehabilitation across Sweden were retrieved. Participants were patients with chronic musculoskeletal pain who had taken part in short (4-9 weeks; n = 924), moderate (10 weeks; n = 1379), or long (11-18 weeks; n = 395) IMPR programs. Longitudinal patient-reported outcome data were assessed at baseline, post-intervention, and at a 12-month follow-up. Primary outcomes were health-related quality of life, presented as perceived physical and mental health (SF-36). Secondary outcomes included the Hospital Anxiety and Depression Scale (HADS), pain intensity (NRS 0-10), the Multidimensional Pain Inventory (MPI), and perceived health (EQ-5D). Overall, all groups showed improvements. No clinically important effect emerged for different duration IMPR. In conclusion, while our results showed that patients following IMPR report improvement across a bio-psycho-social specter, a longer program duration was no more effective than a shorter one.

Pain therapy - Are there new options on the horizon?

This article reviews the role of analgesic drugs with a particular emphasis on opioids. Opioids are the oldest and most potent drugs for the treatment of severe pain, but they are burdened by detrimental side effects such as respiratory depression, addiction, sedation, nausea, and constipation. Their clinical application is undisputed in acute (e.g., perioperative) and cancer pain, but their long-term use in chronic pain has met increasing scrutiny and has contributed to the current opioid crisis. We discuss epidemiological data, pharmacological principles, clinical applications, and research strategies aiming at novel opioids with reduced side effects.

A Meta-Epidemiological Appraisal of the Effects of Interdisciplinary Multimodal Pain Therapy Dosing for Chronic Low Back Pain

Using a meta-analysis, meta-regression, and a meta-epidemiological approach, we conducted a systematic review to examine the influence of interdisciplinary multimodal pain therapy (IMPT) dosage on pain, disability, return to work, quality of life, depression, and anxiety in published randomised controlled trials (RCTs) in patients with non-specific chronic low back pain (CLBP). We considered all RCTs of IMPT from a Cochrane review and searched PubMed for additional RCTs through 30 September 2018. A subgroup random-effects meta-analysis by length, contact, and intensity of treatment was performed followed by a meta-regression analysis. Using random and fixed-effect models and a summary relative odds ratio (ROR), we compared the effect sizes (ES) from short-length, non-daily contact, and low-intensity RCTs with long-length, daily contact, and high-intensity RCTs. Heterogeneity was quantified with the I² metric. A total of 47 RCTs were selected. Subgroup meta-analysis showed that there were larger ES for pain and disability in RCTs with long-length, non-daily contact, and low intensity of treatment. Larger ES were also observed for quality of life in RCTs with short-length, non-daily contact, and low intensity treatment. However, these findings were not confirmed by the meta-regression analysis. Likewise, the summary RORs were not significant, indicating that the length, contact, and intensity of treatment did not have an overall effect on the investigated outcomes. For the outcomes investigated here, IMPT dosage is not generally associated with better ES, and an optimal dosage was not determined.

Risks of harm with cannabinoids, cannabis, and cannabis-based medicine for pain management relevant to patients receiving pain treatment: protocol for an overview of systematic reviews

Supplemental Digital Content is Available in the Text.

Introduction:

With the increasing availability of cannabis and cannabinoids and their potential utility for pain treatment, there is a growing need to evaluate the risk-benefit considerations of cannabinoids for the management of pain. As part of the IASP Cannabis and Cannabinoids Task Force, this protocol describes a planned overview of systematic reviews summarizing the risks of harm with cannabinoids that are relevant to patients receiving pain treatment.

Methods:

This overview will involve literature searches of several databases and a defined search strategy that will target systematic reviews or meta-analyses of cannabinoids where harms are the primary focus. Data extraction will include various features of the cannabinoid(s) and the harm(s) being studied as well as other methodological features of each included systematic review. Methodological quality of each included review will be assessed using AMSTAR-2 as well as compliance with the PRISMA harms checklist. Prospero registration pending.

Discussion:

The broad overview of reviews defined by this protocol is expected to synthesize available good quality evidence of harms that will help inform risk-benefit considerations about the use of cannabinoids for pain management.

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.

Who benefits from multimodal rehabilitation - an exploration of pain, psychological distress, and life impacts in over 35,000 chronic pain patients identified in the Swedish Quality Registry for Pain Rehabilitation

BACKGROUND

Chronic pain patients frequently suffer from psychological symptoms. There is no consensus concerning the prevalence of severe anxiety and depressive symptoms and the strength of the associations between pain intensity and psychological distress. Although an important aspect of the clinical picture is understanding how the pain condition impacts life, little is known about the relative importance of pain and psychological symptoms for individual's life impact. The aims of this study were to identify subgroups of pain patients; to analyze if pain, psychological distress, and life impact variables influence subgrouping; and to investigate how patients in the subgroups benefit from treatments.

METHODS

Background variables, pain aspects (intensity/severity and spreading), psychological distress (depressive and anxiety symptoms), and two life impact variables (pain interference and perceived life control) were obtained from the Swedish Quality Registry for Pain Rehabilitation for chronic pain patients and analyzed mainly using advanced multivariate methods.

RESULTS

Based on >35,000 patients, 35%-40% had severe anxiety or depressive symptoms. Severe psychological distress was associated with being born outside Europe (21%-24% vs 6%-8% in the category without psychological distress) and low education level (20.7%-20.8% vs 26%-27% in the category without psychological distress). Dose relationships existed between the two psychological distress variables and pain aspects, but the explained variances were generally low. Pain intensity/severity and the two psychological distress variables were significantly associated (R 2=0.40-0.48; P>0.001) with the two life impact variables (pain interference and life control). Two subgroups of patients were identified at baseline (subgroup 1: n=15,901-16,119; subgroup 2: n=20,690-20,981) and the subgroup with the worst situation regarding all variables participated less in an MMRP (51% vs 58%, P<0.001) but showed the largest improvements in outcomes.

CONCLUSION

The results emphasize the need to assess both pain and psychological distress and not take for granted that pain involves high psychological stress in the individual case. Not all patients benefit from MMRP. A better matching between common clinical pictures and the content of MMRPs may help improve results. We only partly found support for treatment resistance in patients with psychological distress burden.

Qualitative evaluation of an interdisciplinary chronic pain intervention: outcomes and barriers and facilitators to ongoing pain management

Background

Many leaders in the field of chronic pain treatment consider interdisciplinary pain management programs to be the most effective treatments available for chronic pain. As programs are instituted and expanded to address demands for nonpharmacological chronic pain interventions, we need to better understand how patients experience program impacts, as well as the challenges and supports patients encounter in trying to maintain and build on intervention gains.

Methods

We conducted a qualitative evaluation of an interdisciplinary chronic pain coaching program at the Atlanta Veterans Affairs. A purposive sample of Veterans were engaged in interviews (n=41) and focus groups (n=20) to elicit patient outcomes and barriers and facilitators to sustainment of improvements. Transcripts were analyzed using matrix and thematic analyses.

Results

Veterans reported various outcomes. Most frequently they described adopting new self-care or lifestyle practices for pain management and health. They also often described accepting pain, being better able to adjust and set boundaries, feeling more in control, participating in life, and changing their medication use. A small portion of the sample reported no improvement in their conditions. When outcomes were examined as a whole, individuals described impacts that could be placed along a spectrum from whole life change to no change. Facilitators to maintenance of improvements included having building blocks (eg, carrying forward practices learned), support (eg, access to resources), and energy (eg, motivation), and improving incrementally. Challenges were not having building blocks (eg, life disruptions), support (eg, unknown follow-up options), and energy (eg, competing demands) and having an unbalanced rate of improvement.

Conclusion

Most Veterans identified experiencing multiple areas of improvement, especially learning about and taking up new pain and general health management skills. Ensuring participants can build on and find support for these outcomes when applying what they have learned in their dynamic social and physical worlds remains a challenge for this program and other relatively short-term interdisciplinary chronic pain interventions.

Prognostic Factors for Physical Functioning After Multidisciplinary Rehabilitation in Patients With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

OBJECTIVES

This systematic review aimed to identify and evaluate prognostic factors for long-term (≥6 mo) physical functioning in patients with chronic musculoskeletal pain following multidisciplinary rehabilitation (MDR).

MATERIALS AND METHODS

Electronic searches conducted in MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science, and Cochrane CENTRAL revealed 25 original research reports, published 1983-2016, (n=9436). Potential prognostic factors relating to initial pain and physical and psychological functioning were synthesized qualitatively and quantitatively in random effects meta-analyses. The level of evidence (LoE) was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Pain-related factors (intensity and chronicity) were not associated with function/disability at long-term follow-up, odds ratio (OR)=0.84; 95% confidence interval (CI), 0.65-1.07 and OR=0.97; 95% CI, 0.93-1.00, respectively (moderate LoE). A better function at follow-up was predicted by Physical factors; higher levels of initial self-reported functioning, OR=1.07; 95% CI, 1.02-1.13 (low LoE), and Psychological factors; low initial levels of emotional distress, OR=0.77; 95% CI, 0.65-0.92, low levels of cognitive and behavioral risk factors, OR=0.85; 95% CI, 0.77-0.93 and high levels of protective cognitive and behavioral factors, OR=1.49; 95% CI, 1.17-1.90 (moderate LoE).

DISCUSSION

While pain intensity and long-term chronicity did not predict physical functioning in chronic pain patients after MDR, poor pretreatment physical and psychological functioning influenced the prognosis negatively. Thus, treatment should further target and optimize these modifiable factors and an increased focus on positive, psychological protective factors may perhaps provide an opening for yet untapped clinical gains.

Motor Responses to Noxious Stimuli Shape Pain Perception in Chronic Pain Patients

Pain serves vital protective functions, which crucially depend on appropriate motor responses to noxious stimuli. Such responses not only depend on but can themselves shape the perception of pain. In chronic pain, perception is often decoupled from noxious stimuli and motor responses are no longer protective, which suggests that the relationships between noxious stimuli, pain perception, and behavior might be changed. We here performed a simple experiment to quantitatively assess the relationships between noxious stimuli, perception and behavior in 22 chronic pain patients and 22 age-matched healthy human participants. Brief noxious and tactile stimuli were applied to the participants’ hands and participants performed speeded motor responses and provided perceptual ratings of the stimuli. Multi-level moderated mediation analyses assessed the relationships between stimulus intensity, perceptual ratings and reaction times for both stimulus types. The results revealed a significantly stronger involvement of motor responses in the translation of noxious stimuli into perception than in the translation of tactile stimuli into perception. This significant influence of motor responses on pain perception was found for both chronic pain patients and healthy participants. Thus, stimulus-perception-behavior relationships appear to be at least partially preserved in chronic pain patients and motor-related as well as behavioral interventions might harness these functional relationships to modulate pain perception.