Is There a Need for Including Spiritual Care in Interdisciplinary Rehabilitation of Chronic Pain Patients? Investigating an Innovative Strategy

Biopsychosocial rehabilitation in the working population with chronic low back pain: a concept analysis

OBJECTIVE

To identify the essential attributes of biopsychosocial rehabilitation for chronic low back pain in the working population.

DESIGN

A concept analysis was conducted according to the 8-step method of Walker and Avant. This framework provides a clear concept and theoretical and operational definitions.

METHODS

Five databases were searched, followed by a systematic screening. Subsequently, attributes, illustrative cases, antecedents, consequences and empirical referents were formulated.

RESULTS

Of the 3793 studies identified, 42 unique references were included. Eleven attributes were identified: therapeutic exercise, psychological support, education, personalization, self-management, participation, follow-up, practice standard, goal-setting, social support, and dietary advice. Subsequently, illustrative cases were described. Antecedents, such as motivation, preparedness and a multidisciplinary team, were found, together with consequences such as decreased pain, less sick-leave and increased function and work status. Finally, examples of empirical referents were given.

CONCLUSION

This study identified the attributes that are necessary to develop biopsychosocial rehabilitation intervention programmes for chronic low back pain. The defined concept of biopsychosocial rehabilitation for chronic low back pain may serve as a solid base to further develop and apply interventions. Future research should focus on the objectification of biopsychosocial rehabilitation and conceptualization regarding how personalization is done.

Lessons learned from the chronic pain clinic: a qualitative study of the perspectives of healthcare providers

Aim: The chronic pain clinic (CPC) was established to address chronic non-cancer pain and opioid-related harm. Materials & methods: Employing community participatory research design First Nation Metis representatives, clinicians and a researcher collectively agreed to document lessons learned from healthcare providers' perspective, 1 year post-clinic-implementation. 17 individual interviews were conducted. Results: Thematic analysis revealed that a multidisciplinary team offered client-centered care, education, counseling and multimodal treatment options. Medication reviews and case management ensured patient safety. Communication and education of community providers enhanced pain management capacity ensuring safe opioid prescribing. Evidence-based best practices were implemented through system-level monitoring. Access to Indigenous healing strategies provided culturally responsive spiritual care upon request. Conclusion: The multidisciplinary and multimodal CPC care model effectively manages chronic non-cancer pain.

Healthcare Professionals' Perceptions of and Attitudes towards a Standardized Content Description of Interdisciplinary Rehabilitation Programs for Patients with Chronic Pain-A Qualitative Study

Interdisciplinary pain rehabilitation (IPR) is a recommended treatment for people with chronic pain. An inadequate description of the content of IPR programs makes it difficult to draw conclusions regarding their effects. The purpose of this study was to describe the perceptions and attitudes of healthcare professionals toward a content description of IPR programs for patients with chronic pain. Individual interviews with healthcare professionals (n = 11) working in IPR teams in Sweden were conducted between February and May 2019. Analysis of the interviews resulted in a theme: interdisciplinary pain rehabilitation is a complex intervention, with three categories: limitations in the description of IPR programs; lack of knowledge about IPR and chronic pain; and facilitating and hindering factors for using the content description of IPR programs. Conclusion: Healthcare professionals perceived that IPR programs could be described through a general content description. A general content description could enhance the quality of IPR programs through a better understanding of their content and a comparison of different IPR programs. Healthcare professionals also expressed the importance of a content description being a guide rather than a steering document.

Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization

Background

While there is recognition by the greater medical community and physical therapists to address the biopsychosocial needs of people with chronic, persistent pain, there are challenges in implementation and delivery including wide variability in interventions, lack of clear rationale, and absence of clinical models that are feasible and acceptable on a large scale. Important components for psychologically informed physical therapy (PiPT) for pain care include behavioral approaches (e.g., Acceptance and Commitment Therapy), mindfulness, pain neuroscience education, motivational interviewing (MI), and interoceptive skills-building. The Empower Veterans Program (EVP) Mindful Movement framework blends these components and emphasizes a mindfulness and self-compassion approach with MI and body-based experiential learning. This program was offered in-person at the Atlanta and Maryland VA Health Care Centers with published positive Patient Reported Outcomes (PRO) pre-COVID 19 crisis and shifted to entirely remote delivery in March 2020.

Objective

This paper offers an evidence-based and theory driven framework to operationalize a remotely delivered group-based psychologically informed mindful movement physical therapy intervention as part of an interdisciplinary pain care program.

Methods

Since 2021 PRO and demographics are collected using a survey administered through Qualtrics over a 12-month period at baseline, immediately post TelePain EVP, at 6 months, and at 12 months, with findings forthcoming.

Discussion/Results

Tele-pain EVP offers 6-9 groups a week with 7-9 veterans from Atlanta based team and 3-4 groups a week with 5-9 veterans from Maryland based team. Adaptations for remote delivery optimized mindfulness and active learning strategies including interoceptive skills-building and use of MI to support self-efficacy to trust, restore a sense of safety in the body, and explore adaptations for safe movement.

Conclusion

TelePain-EVP Mindful Movement provides a framework for other programs to translate for their populations and systems to further develop best practices in PiPT for pain care and integration into interdisciplinary care.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Comprehensive pain management as a frontline treatment to address the opioid crisis

BACKGROUND

The opioid crisis continues to devastate individuals and communities in the United States and abroad. While there have been several measures to address the over-prescription of opioid analgesics, the number of overdose deaths related to prescription opioids has not changed appreciably in the last 10 years. Comprehensive (or multidisciplinary) pain recovery programs consist of providers from multiple backgrounds that treat pain on an individual level through a combination of approaches including physical therapy, emotional and spiritual support, cognitive behavioral therapy, and non-opioid pharmacotherapies. Because there is a dynamic interplay between a given chronic pain patient and multiple providers, comprehensive pain programs are not as "standardized" as other medical treatments because they are meant to meet the individual needs of each patient and their specific pain diagnoses Methods: Review of the literature.

RESULTS

There is evidence that comprehensive pain treatment can reduce pain severity and improve functioning; comprehensive pain treatment can be used to treat those with post-surgical pain, thus preventing the onset of non-medical opioid use and opioid use disorder, and in persons with chronic pain who are on long-term opioid therapy, as a method to reduce or eliminate opioid medication use. Comprehensive pain recovery programs were abundant for a period from the 1960s through the 1980s, but for a variety of reasons, they became financially unsustainable as the national reimbursement environment evolved.

CONCLUSIONS

In the context of the protracted and deadly opioid crisis, revitalizing and expanding comprehensive pain treatment should be considered as a frontline approach to treat chronic pain.

Spiritual Care und chronischer Schmerz: Die Sicht von Fachpersonen. Eine qualitative Untersuchung

Chronischer Schmerz ist ein komplexes Phänomen, das alle Lebensdimensionen betrifft: die psychische, soziale und spirituelle nicht weniger als die physische. Diesem Umstand muss in der Behandlung dieser Patientengruppe Rechnung getragen werden. Wir untersuchten, an welche Voraussetzungen dafür im Deutschschweizer Raum bereits angeknüpft werden kann. An fünf Studienzentren wurden insgesamt 34 Fachpersonen in interprofessionell gemischten Fokusgruppen dazu interviewt, welche spirituellen Anliegen und Bedürfnisse von Patient/-innen mit chronischen Schmerzen sie wahrnehmen und wie diese im Behandlungsprozess berücksichtigt werden können. Eine thematische Analyse zeigte drei Kernthemen: die Relevanz spiritueller Aspekte in der multimodalen Schmerztherapie, handlungsleitende Überzeugungen und die Kompetenz zu Spiritual Care. Die Befragten waren der spirituellen Thematik gegenüber generell aufgeschlossen. Aus ihrer Sicht stellt die Integration spiritueller Anliegen und Bedürfnisse im Behandlungsprozess einen Mehrwert für die Behandlungsqualität in dieser Patientengruppe dar. Dies konsequent umzusetzen, stellt sie jedoch vor teilweise ungelöste Herausforderungen. Hier braucht es Befähigung und institutionelle Unterstützung, um Spiritual Care den entsprechenden Raum zu geben.

Spirituality Needs in Chronic Pain Patients: A Cross-Sectional Study in a General Hospital in Malaysia

Evidence-based practices that rely upon pain relieving medications and interventional strategies for symptom alleviation in chronic pain survivors have shown modest benefits. The recent emphasis of spiritual care as a new dimension of treatment strategy incorporated within the biopsychosocial model has inspired new hopes to mediate mental and physical health for illness coping. This study aimed to explore the factors associated with spirituality needs among chronic pain patients in a general hospital in Malaysia. An analytical cross-sectional study was conducted among 117 chronic pain patients in a general hospital in Malaysia. Clinical features and assessments were evaluated by an experienced pain physician and retrieved from patient medical records. An interviewer-administered questionnaire that consisted of items on socio-demographics, the validated 19-items spiritual needs questionnaire and the visual analog scale was utilized. Multivariate linear regression analysis was conducted to identify the factors associated with spiritual needs in chronic pain patients. Patients had higher actively giving score as compared to other spirituality need domains. Central neuropathic pain (β = 1.691, p = 0.040) predicted existential. Renal problems (β = 5.061, p = 0.019) highly predicted religiosity; followed by head pain (β = 3.774, p = 0.036), central neuropathic pain (β = 2.730, p = 0.022), heart problems (β = 1.935, p = 0.041), income (β = 0.001, p = 0.003), living arrangement (β = - 3.045, p = 0.022), face (β = - 3.223, p = 0.005) and abdominal (β = - 4.745, p = 0.0001) pains. Predictors of inner peace include renal problems (β = 3.752, p = 0.021), shoulder pain (β = 1.436, p = 0.038) and pain duration (β = - 0.012, p = 0.027). Predictors of actively giving were renal problems (β = 3.803, p = 0.001), central neuropathic pain (β = 1.448, p = 0.017), heart problems (β = 1.004, p = 0.042), income (β = 0.001, p = 0.0001), age (β = - 0.046, p = 0.004) and abdominal pain (β = - 2.617, p = 0.0001). Chronic pain patients had higher actively giving score compared to other spirituality needs. Their spirituality needs were significantly influenced by pain type, duration and site, co-existing medical conditions and socio-demographics.

Effectiveness of Serious Gaming During the Multidisciplinary Rehabilitation of Patients With Complex Chronic Pain or Fatigue: Natural Quasi-Experiment

BACKGROUND

Current evidence for the effectiveness of specialist multidisciplinary programs for burdensome chronic pain and functional somatic syndromes drives the effort to improve approaches, strategies, and delivery modes. It remains unknown to what extent and in what respect serious gaming during the regular outpatient rehabilitation can contribute to health outcomes.

OBJECTIVE

The objectives of our study were to determine the effect of additional serious gaming on (1) physical and emotional functioning in general; (2) particular outcome domains; and (3) patient global impressions of change, general health, and functioning and to determine (4) the dependency of serious gaming effects on adherence.

METHODS

We conducted a naturalistic quasi-experiment using embedded qualitative methods. The intervention group patients received an additional guided (mindfulness-based) serious gaming intervention during weeks 9-12 of a 16-week rehabilitation program at 2 sites of a Dutch rehabilitation clinic. Simultaneously, 119 control group patients followed the same program without serious gaming at 2 similar sites of the same clinic. Data consisted of 10 semistructured patient interviews and routinely collected patient self-reported outcomes. First, multivariate linear mixed modeling was used to simultaneously estimate a group effect on the outcome change between weeks 8 and 16 in 4 primary outcomes: current pain intensity, fatigue, pain catastrophizing, and psychological distress. Second, similar univariate linear mixed models were used to estimate effects on particular (unstandardized) outcomes. Third, secondary outcomes (ie, global impression of change, general health, functioning, and treatment satisfaction) were compared between the groups using independent t tests. Finally, subgroups were established according to the levels of adherence using log data. Influences of observed confounding factors were considered throughout analyses.

RESULTS

Of 329 eligible patients, 156 intervention group and 119 control group patients (N=275) with mostly chronic back pain and concomitant psychosocial problems participated in this study. Of all, 119 patients played ≥75% of the game. First, the standardized means across the 4 primary outcomes showed a significantly more favorable degree of change during the second part of the treatment for the intervention group than for the control group (beta=-0.119, SE=0.046, P=.009). Second, the intervention group showed a greater outcome change in depressive mood (b=-2.748, SE=1.072, P=.011) but not in "insufficiency" or concentration problems. Third, no significant group effects on secondary outcomes were found. Fourth, adherence was generally high and invariant.

CONCLUSIONS

The findings of this study suggest a very small favorable average effect on relevant health outcomes of additional serious gaming during multidisciplinary rehabilitation. The indication that serious gaming could be a relatively time-efficient component warrants further research into if, when, how, and for which patients serious gaming could be cost-effective in treatment and why.

TRIAL REGISTRATION

Netherlands Trial Registry NTR6020; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6020 (Archived by WebCite at http://www.webcitation.org/71IIoTXkj).

Serious gaming during multidisciplinary rehabilitation for patients with complex chronic pain or fatigue complaints: study protocol for a controlled trial and process evaluation

INTRODUCTION

Many individuals suffer from chronic pain or functional somatic syndromes and face boundaries for diminishing functional limitations by means of biopsychosocial interventions. Serious gaming could complement multidisciplinary interventions through enjoyment and independent accessibility. A study protocol is presented for studying whether, how, for which patients and under what circumstances, serious gaming improves patient health outcomes during regular multidisciplinary rehabilitation.

METHODS AND ANALYSIS

A mixed-methods design is described that prioritises a two-armed naturalistic quasi-experiment. An experimental group is composed of patients who follow serious gaming during an outpatient multidisciplinary programme at two sites of a Dutch rehabilitation centre. Control group patients follow the same programme without serious gaming in two similar sites. Multivariate mixed-modelling analysis is planned for assessing how much variance in 250 patient records of routinely monitored pain intensity, pain coping and cognition, fatigue and psychopathology outcomes is attributable to serious gaming. Embedded qualitative methods include unobtrusive collection and analyses of stakeholder focus group interviews, participant feedback and semistructured patient interviews. Process analyses are carried out by a systematic approach of mixing qualitative and quantitative methods at various stages of the research.

ETHICS AND DISSEMINATION

The Ethics Committee of the Tilburg School of Social and Behavioural Sciences approved the research after reviewing the protocol for the protection of patients' interests in conformity to the letter and rationale of the applicable laws and research practice (EC 2016.25t). Findings will be presented in research articles and international scientific conferences.

TRIAL REGISTRATION NUMBER

A prospective research protocol for the naturalistic quasi-experimental outcome evaluation was entered in the Dutch trial register (registration number: NTR6020; Pre-results).

Feasibility of Applied Gaming During Interdisciplinary Rehabilitation for Patients With Complex Chronic Pain and Fatigue Complaints: A Mixed-Methods Study

Background

Applied gaming holds potential as a convenient and engaging means for the delivery of behavioral interventions. For developing and evaluating feasible computer-based interventions, policy makers and designers rely on limited knowledge about what causes variation in usage.

Objective

In this study, we looked closely at why and by whom an applied game (LAKA) is demanded and whether it is feasible (with respect to acceptability, demand, practicality, implementation, and efficacy) and devised a complementary intervention during an interdisciplinary rehabilitation program (IRP) for patients with complex chronic pain and fatigue complaints.

Methods

A mixed-methods design was used. Quantitative process analyses and assessments of feasibility were carried out with patients of a Dutch rehabilitation center who received access to LAKA without professional support during a 16-week interdisciplinary outpatient program. The quantitative data included records of routinely collected baseline variables (t0), additional surveys to measure technology acceptance before (t1) and after 8 weeks of access to LAKA (t2), and automatic log files of usage behavior (frequency, length, and progress). Subsequently, semistructured interviews were held with purposively selected patients. Interview codes triangulated and illustrated explanations of usage and supplemented quantitative findings on other feasibility domains.

Results

Of the 410 eligible patients who started an IRP during the study period, 116 patients participated in additional data collections (108 with problematic fatigue and 47 with moderate or severe pain). Qualitative data verified that hedonic motivation was the most important factor for behavioral intentions to use LAKA (P<.001). Moreover, quotes illustrated a positive association between usage intentions (t1) and baseline level (t0) coping by active engagement (Spearman ρ=0.25; P=.008) and why patients who often respond by seeking social support were represented in a group of 71 patients who accessed the game (P=.034). The median behavioral intention to use LAKA was moderately positive and declined over time. Twenty patients played the game from start to finish. Behavioral change content was recognized and seen as potentially helpful by interview respondents who exposed themselves to the content of LAKA.

Conclusions

Variation in the demand for applied gaming is generally explained by perceived enjoyment and effort and by individual differences in coping resources. An applied game can be offered as a feasible complementary intervention for more patients with complex chronic pain or fatigue complaints by embedding and delivering in alignment with patient experiences. Feasibility, effectiveness, and cost-effectiveness can be evaluated in a full-scale evaluation. New observations elicit areas of further research on the usage of computer-based interventions.