Effect of subgroup-specific multimodal therapy on chronic spinal back pain and function-a prospective inpatient multicentre clinical trial in Germany

Personalized assessment and management of non-specific low back pain

BACKGROUND AND OBJECTIVE

Low back pain (LBP), and in particular non-specific low back pain (NSLBP), which accounts for approximately 90% of LBP, is the leading cause of years lived with disability worldwide. In clinical trials, LBP is often poorly categorized into 'specific' versus 'non-specific' and 'acute' versus 'chronic' pain. However, a better understanding of the underlying pain mechanisms might improve study results and reduce the number of NSLBP patients.

DATABASES AND DATA TREATMENT

Narrative review.

RESULTS

NSLBP is a multi-dimensional, biopsychosocial condition that requires all contributing dimensions to be assessed and prioritized. Thereby, the assessment of the contribution of nociceptive, neuropathic and nociplastic pain mechanisms forms the basis for personalized management. In addition, psychosocial (e.g. anxiety, catastrophizing) and contextual factors (e.g. work situation) as well as comorbidities need to be assessed and individually weighted. Personalized treatment of NSLBP further requires individually choosing treatment modalities, for example, exercising, patient education, cognitive-behavioural advice, pharmacotherapy, as well as tailoring treatment within these modalities, for example, the delivery of tailored psychological interventions or exercise programs. As the main pain mechanism and psychosocial factors may vary over time, re-assessment is necessary and treatment success should ideally be assessed quantitatively and qualitatively.

CONCLUSIONS

The identification of the main contributing pain mechanism and the integration of the patients' view on their condition, including beliefs, preferences, concerns and expectations, are key in the personalized clinical management of NSLBP. In research, particular importance should be placed on accurate characterization of patients and on including outcomes relevant to the individual patient.

SIGNIFICANCE STATEMENT

Here, a comprehensive review of the challenges associated with the diagnostic label 'non-specific low back pain' is given. It outlines what is lacking in current treatment guidelines and it is summarized what is currently known with respect to individual phenotyping. It becomes clear that more research on clinically meaningful subgroups is needed to best tailor treatment approaches.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Back pain treatment: a new perspective

This article aims to provide new perspectives for the treatment of low back pain (LBP). A narrative literature review highlights the treatment strategies currently anchored in the guidelines as well as the extensive attempts to identify subgroups within the non-specific low back pain (NSLBP) classification. A variety of multimodal approaches exist for both diagnostic assessments and therapy approaches. Nonetheless, there are often gaps in the classification systems as well as in published treatment concepts with regard to the implementation of musculoskeletal functional disorders. Indeed, a growing body of evidence shows that more holistic and flexible approaches are needed to individually diagnose and target the complexity of LBP. As an example, both a diagnostic and a (independently developed) therapeutic LBP concept will be presented and discussed. Ultimately, guidelines and subgroup classification systems can only reflect the complexity of LBP, if they capture its entire multidimensional and biopsychosocial character in both the diagnostic and therapeutic processes. Furthermore, the expansion of the pain definition to include the nociplastic pain mechanism, as an important driver of LBP, has the potential to provide important impulses for further necessary research. In conclusion, the implementation of a functional musculoskeletal approach along with the emerging nociceptive pain concept in individually targeted holistic approaches seems to be the successful way to deal with the complexity of LBP.

[A functional approach to disorders of the loco-motor system-a way to a better understanding?]

BACKGROUND

Disorders of the loco-motor system are frequent and expensive. The current method of diagnosing and treating these disorders does not appear to be successful.

DIAGNOSTICS

A functional approach based on the model of the functional system incorporates all aspects relevant to disorders of the loco-motor system. Most disturbances the system can compensate. If compensating mechanisms are not sufficient, the system decompensates, and symptoms develop. It is important to search not only for structural changes but also for somatic dysfunction, psychosocial factors, and changes in neuromodulation. On this basis, treatment strategies can be developed. If there are complex disturbances on different levels, a multimodal interdisciplinary treatment is indicated. The model of the functional system highlights the important role of manual medicine in the diagnostics, treatment, prevention, and rehabilitation of disorders of the loco-motor system.

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

What Influences Outcomes From Inpatient Multidisciplinary Pain Management Programs?: A Systematic Review and Meta-analysis

OBJECTIVES

Although inpatient multidisciplinary pain management programs (PMPs) are effective for chronic pain, not all patients benefit equally and there is limited evidence regarding predictors of outcome. This meta-analysis aimed to identify patient or program characteristics associated with outcomes from inpatient PMPs, and to examine the time course of effects following discharge.

MATERIALS AND METHODS

Medline, EBSCO, and Scopus were searched to identify articles reporting outcomes from inpatient multidisciplinary PMPs. Information was extracted on study design, participant and program characteristics, and outcomes. Effect sizes were computed for pain, physical function, depression, anxiety, and mental health outcomes. Study-level predictors of outcome were investigated with moderator analyses and meta-regression. A risk of bias assessment and sensitivity analyses were conducted and the GRADE criteria for prognostic studies were applied to assess confidence in findings.

RESULTS

In all, 85 studies (111 cohorts; 15,255 participants) were included. Three quarters of studies demonstrated low risk of bias. Larger effect sizes (for at least 1 outcome measure) occurred in studies where participants had more severe pain (greater intensity/longer duration), participants with alcohol or drug problems were not excluded, samples comprised mixed pain conditions, and programs included a cognitive component and/or a passive therapy component. Effect sizes for pain and physical function were maintained at follow-up, but effect sizes for depression and anxiety declined over time.

DISCUSSION

Inpatient multidisciplinary PMPs may be well suited to patients with severe or long-lasting pain. Programs should adopt broad patient inclusion criteria, and outcomes were similar for programs based on cognitive-behavioral versus mindfulness/acceptance-based therapies.

Multidisciplinary pain management program for patients with chronic musculoskeletal pain in Japan: a cohort study

Introduction

Multidisciplinary pain management is a useful method for treating chronic musculoskeletal pain. Currently, few facilities in Japan offer multidisciplinary pain treatment, especially in the inpatient setting. We implemented a multidisciplinary pain management program based on International Association for the Study of Pain recommendations. This study described our initial efforts in implementing the program, and reported 3- and 6-month follow-up results.

Materials and methods

Our pain management team included orthopedic surgeons, psychiatrists, nurses, physical therapists, clinical psychologists, pharmacists, and nutritionists. The 3-week inpatient pain management program comprised exercise therapy, psychotherapy, and patient education. We evaluated patients using the Brief Pain Inventory (BPI), Pain Catastrophizing Scale (PCS), Pain Disability-Assessment Scale (PDAS), Hospital Anxiety and Depression Scale (HADS), Pain Self-Efficacy Questionnaire (PSEQ), EuroQol Five Dimensions (EQ-5D), and physical examinations (flexibility, muscle endurance, walking ability, and physical fitness). Statistical analyses were performed using paired t-tests and Wilcoxon matched-pairs signed-rank sum tests with Bonferroni correction after the Friedman test.

Results

Data for 23 patients were analyzed before and immediately after the program. Statistically significant improvements were seen in BPI, PCS, PDAS, HADS, PSEQ, EQ-5D, flexibility, muscle endurance, walking ability, and physical fitness. Eight patients were also assessed 3 and 6 months after the program. PCS (rumination and helplessness) scores and flexibility showed significant improvement at 3 and 6 months. Significant improvement was seen in PDAS and HADS (anxiety) scores and muscle endurance at 6 months, and in PSEQ scores immediately and at 3 and 6 months.

Conclusion

Our inpatient pain management program can improve patients' physical function and ability to cope with chronic musculoskeletal pain, which supports improved quality of life. Our program is currently being expanded to better assist patients with chronic musculoskeletal pain.