The efficacy of a multidisciplinary group program for patients with refractory chronic pain

[Management of chronic non-oncologic pain by multicomponent programs using non-pharmacologic therapies: A systematic review of the literature]

Chronic pain is a public health problem suffered by 20% of the world's population. Pharmacological approaches are insufficient, so a multi-therapeutic approach that also includes non-pharmacological therapies (psychological therapies, meditation, physical exercise, healthy habits, etc.) is proposed. The aim of this review was to review the existing scientific evidence on the effect of multicomponent programs with non-pharmacological therapies in people with chronic non-oncologic pain. To this end, a search for scientific articles was carried out in three databases (PubMed, Web of Science and PsycINFO) and 17 articles were selected, following the PRISMA recommendations. The patients who participated in these programs were mostly women, aged 18 to 80years, working or on sick leave due to pain, with secondary education or less and married. The most frequent pain was musculoskeletal, mainly low back pain. All the articles studied the effectiveness of two or more therapies, highlighting psychological therapies, physical exercise and education. Positive results were obtained in the reduction of different variables such as pain, pain catastrophizing, anxiety and depression, in addition to improving functionality and quality of life. It has also been shown that patients' prior expectations regarding the intervention influence its effectiveness. Although throughout the review there was great heterogeneity in the interventions, in the evaluation methods and in the results themselves, it can be concluded that multicomponent programs show positive results in the management of chronic pain, and should therefore be incorporated as a routine therapeutic treatment.

A Novel Exercise Facilitation Method in Combination with Cognitive Behavioral Therapy Using the Ikiiki Rehabilitation Notebook for Intractable Chronic Pain: Technical Report and 22 Cases

Recent clinical practice guidelines for chronic pain indicate, with a high evidence level, that the combination of exercise and cognitive behavioral therapy (CBT) is effective. The purpose of this study was to evaluate the effectiveness of an exercise facilitation method in combination with CBT using the "Ikiiki Rehabilitation Notebook" for patients with intractable chronic pain. "Ikiiki" means active in Japanese. A total of 22 cases with chronic low back (n = 13), lower extremity (n = 8), or neck (n = 1) pain were treated using this notebook. Two cases dropped out, leaving 22 cases. Each case was evaluated in terms of the numerical rating scale (NRS) of the pain, activities of daily living (ADL), pain catastrophizing scale (PCS), and quality of life (QOL) at pretreatment and post-treatment. The endpoint of the method was to achieve the long-term goals set by the patients. The mean treatment period was 11.2 months. The outcomes were as follows: improvement of presenteeism: nine cases; enhanced participation in hobbies: seven cases; improved school attendance: two cases; return to work: one case; improvement of self-care and/or self-efficacy: three cases. The NRS, ADL, PCS, and QOL were significantly improved after the treatment. This method is possibly valuable for educating patients about the cause and treatment of chronic pain and actively facilitating exercise and social participation. Further studies are needed to investigate the effectiveness of using this notebook for the patient with intractable chronic pain.

A Meta-Analysis of Group-Based Pain Management Programs: Overall Effect on Quality of Life and Other Chronic Pain Outcome Measures, with an Exploration into Moderator Variables that Influence the Efficacy of Such Interventions

OBJECTIVES

Group-based pain management programs (GPMPs) have been found to significantly improve quality of life and other pain outcome measures in patients with chronic musculoskeletal pain. The aims of this meta-analysis were to reevaluate the overall effect of GPMPs on various pain outcomes for individuals experiencing chronic musculoskeletal conditions and to explore moderator variables that potentially contribute to the overall efficacy of GPMPs.

METHODS

Using the R package called metaphor and RevMan, we estimated the overall effectiveness of GPMPs on various pain outcome measures. The differential effectiveness of GPMPs was examined by conducting a mixed-effects meta-analytic model using various study-level characteristics. Moderator analyses included three content moderator variables and seven format moderator variables. Receiver operating characteristic curves investigated optimal points in some of the moderator variable analysis results.

RESULTS

Significant overall main effects of GPMPs were found on all the explored outcome measures in this study (P < 0.05). In moderator analyses, it was found that the structure of GPMPs, rather than the content, significantly improved outcomes (P < 0.05). Receiver operating characteristic curve analyses identified the optimal number of GPMP sessions and number of participants per group.

DISCUSSION AND CLINICAL RELEVANCE

GPMPs have a statistically significant overall effect on all explored pain outcome measures. The investigation into content and structural moderators suggests that certain GPMP design factors have a greater effect on pain outcomes than do content factors. Therefore, GPMP structural designs appear to be important in reducing pain and improving quality of life for patients with chronic pain and warrant further investigation.

A Consideration of the Psychological Aspects to Managing Patients with Painful Diabetic Neuropathy: An Insight into Pain Management Services at a Tertiary Centre in the UK

Painful diabetic neuropathy (pDN) is characterised by both sensory and affective disturbances, suggesting a complex bidirectional relationship of neuropathic pain and mood disorders. Data on pDN indicate that neuropathic pain reduces quality of life, including mood and physical and social functioning. Depression and pain coping strategies such as catastrophising and social support predict pain severity. There is a significant and reciprocal relationship between depressed mood and increased pain. The key features of assessing people with neuropathic pain in relation to psychological aspects of their health are discussed in the context of management in a tertiary pain management centre (The Walton Centre, Liverpool, UK) including cognitive behavioural interventions amongst others to improve the quality of life in patients with pDN. We consider psychological issues as a factor influencing treatment and outcome in patients with pDN.

Unmet needs in the management of functional impairment in patients with chronic pain: a multinational survey

Background: A survey of European Pain Federation 2019 attendees was conducted to identify unmet needs in chronic pain patients. Materials & methods: Four questions were asked focusing on functional impairment in chronic pain, including who are at increased risk and ways to better identify and manage these patients. Results: In total 143 respondents indicated that key issues were lack of knowledge, lack of resources/time to assess and manage chronic pain and lack of sufficient tools to identify patients at risk for functional impairment. Education and training of primary care physicians, simplified guidelines and practical tools for assessment and use of multidisciplinary teams to treat chronic pain were recommended. Conclusion: There are many unmet needs in the management of functional impairment in chronic pain patients.

Psychological Treatment Strategy for Chronic Low Back Pain

Studies have indicated that chronic low back pain (LBP) should be approached according to its morphological basis and in consideration of biopsychosocial interventions. This study presents an updated review on available psychological assessments and interventions for patients with chronic LBP. Psychosocial factors, including fear-avoidance behavior, low mood/withdrawal, expectation of passive treatment, and negative pain beliefs, are known as risk factors for the development of chronic LBP. The Örebro Musculoskeletal Pain Questionnaire, STarT Back Screening Tool, and Brief Scale for Psychiatric Problems in Orthopaedic Patients have been used as screening tools to assess the development of chronicity or identify possible psychiatric problems. The Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, and Injustice Experience Questionnaire are also widely used to assess psychosocial factors in patients with chronic pain. With regard to interventions, the placebo effect can be enhanced by preferable patient-clinician relationship. Reassurance to patients with non-specific pain is advised by many guidelines. Cognitive behavioral therapy focuses on restructuring the negative cognition of the patient into realistic appraisal. Mindfulness may help improve pain acceptance. Self-management strategies with appropriate goal setting and pacing theory have proved to improve long-term pain-related outcomes in patients with chronic pain.

Development and implementation of an inpatient multidisciplinary pain management program for patients with intractable chronic musculoskeletal pain in Japan: preliminary report

Introduction

Multidisciplinary pain management is a useful method to treat chronic musculoskeletal pain. Few facilities in Japan administer a multidisciplinary pain management program, especially an inpatient program. Therefore, we implemented a multidisciplinary pain management program in our hospital based on biopsychosocial factors guided by the recommendations of the International Association for the Study of Pain. The purpose of this study is to describe our inpatient pain management program for Japanese patients, which uses the biopsychosocial method of pain self-management.

Materials and methods

Fourteen patients with intractable chronic musculoskeletal pain, who were implemented a multidisciplinary pain management program in our hospital, were studied using the evaluation of the pain and associated factors and physical function.

Results

Significant improvement in outcomes were seen in the brief pain inventory, the pain catastrophizing scale (rumination, magnification, and helplessness), the pain disability assessment scale, the hospital anxiety and depression scale (anxiety and depression), the pain self-efficacy questionnaire, the EuroQol five dimensions questionnaire, and muscle endurance and physical fitness. We found no statistically significant differences in static flexibility or walking ability.

Conclusion

We developed an inpatient chronic pain management program for Japanese patients. Our results suggest that our program improves chronic musculoskeletal pain coping mechanisms, and that the program can improve patients' quality of life and some physical function. This inpatient pain management program is being expanded to better help intractable chronic musculoskeletal pain patients.

Improved health-related quality of life, participation, and autonomy in patients with treatment-resistant chronic pain after an intensive social cognitive intervention with the participation of support partners

Despite the availability of various specific treatments, most patients with chronic pain (CP) consider their pain problem as undertreated. Recently, multiple sclerosis (MS) patients who were given an intensive 3-day social cognitive treatment with the participation of support partners experienced lasting improvements in health-related quality of life (HRQoL) and self-efficacy. In this study, a similar intervention was given to treatment-resistant CP patients with stressors, relational problems with support partner, and distress, anxiety or depression. Before and 1, 3, and 6 months after the intervention, patients completed the Euro-Qol 5 Dimensions 5 Levels (EQ-5D-5L) and Impact on Participation and Autonomy (IPA) questionnaires (primary outcomes), and the Survey Of Pain Attitudes (SOPA), the Four-Dimensional Symptom Questionnaire (4DSQ) (distress, depression, anxiety, and somatization), and Visual Analog Scale for pain intensity, whereas the support partners completed the Caregiver Strain Index (CSI) questionnaire. Differences between baseline and post-treatment were tested via paired t-tests (significance level 0.05). Of the 39 patients who were included, 34 (87.2%) completed the 3-day treatment. At 1, 3, and 6 months, improvements were seen in EQ-5D-5L-Index (+40.6%; +22.4%; +31.7%), Health Today (+61.8%; +36.3%; +46.8%), Control attitude (+45.8%; not significant [NS]; +55.0%) and decreases in IPA-Problems (−14.8%; NS; −20.4%), Harm attitude (−18.9%; −15.0%; −17.7%), Distress (−17.7%; −31.8%; −37.1%), and Depression (−37.4%; −31.4%; −35.7%) scores. The CSI score had decreased by −29.0%, −21.4%, and −25.9%, respectively. In conclusion, after an intensive 3-day social cognitive intervention, treatment-resistant CP patients experienced substantial and lasting improvements in HRQoL and in problematic limitations to participation and autonomy, in association with improvements in pain attitudes, depression, and distress. To assess whether this innovative approach may be an effective treatment for this subgroup of CP patients, future randomized controlled studies are needed.

Management of chronic pain through pain management programmes

INTRODUCTION

Chronic pain carries significant impact and is difficult to treat with limited success. Pain management programmes (PMPs) use cognitive behavioural therapy (CBT)-based multidisciplinary rehabilitative approaches to drive functional improvement.

SOURCES OF DATA

A search was conducted using Medline and the Cochrane Library to identify published literature about PMPs or CBT to treat chronic pain.

AREAS OF AGREEMENT

PMPs have significant benefit on functioning for some patients but relatively little impact on the pain. Not all patients, nor pain types, benefit. Around a third of patients show improvement, with considerable variability.

AREAS OF CONTROVERSY

There is much heterogeneity between approaches and outcomes measured, and the extent and duration of benefit is inconsistently reported. The investment required of patients, staff and commissioners is significant. Existing data provides limited information to judge whether PMPs represent good value for each of those stakeholders.

GROWING POINTS

The British Pain Society provide guidelines for PMPs, due for revision in 2018 which may provide opportunities for greater clarity and demonstrating value. Other approaches are emerging and being evaluated.

AREAS TIMELY FOR DEVELOPING RESEARCH

Participation may have more subjective impact than objective outcomes and merits qualitative research. With a (significant) minority of patients showing improvement, research into patient and treatment selection is essential alongside longterm outcomes and sustaining benefits.

Calidad de vida, emociones negativas, autoeficacia y calidad del sueño en pacientes con dolor crónico: efectos de un programa de intervención psicológica

El dolor crónico es un problema de salud que afecta a entre el 10 y el 30% de la población. El objetivo del presente estudio consiste en evaluar la eficacia de un programa de intervención grupal en dolor crónico. Se realizó un estudio cuasi experimental. La muestra estuvo compuesta por 105 participantes de la Unidad de Dolor del Hospital General Universitario de Alicante. Se administró una batería de cuestionarios pre y post a la aplicación del programa. En el estudio se midió el nivel de dolor, la calidad de vida, ansiedad, depresión, atributos del sueño y autoeficacia. Se obtuvieron mejoras significativas en los niveles de ansiedad, depresión calidad de vida física, autoeficacia en todas sus dimensiones (control de síntomas, funcionamiento físico y control del dolor) y aspectos de los atributos del sueño, como cantidad y alteraciones del sueño. El programa protocolizado y realizado por profesionales entrenados es efectivo para disminuir la percepción del dolor, aumentar la calidad de vida en su componente físico, mejorar la autoeficacia y los atributos del sueño en pacientes con dolor crónico.

Analysis of follow-up data from an outpatient pain management program for refractory chronic pain

BACKGROUND

Numerous reports indicate that multifaceted pain management programs based on cognitive-behavioral principles are associated with clinically meaningful long-term improvements in chronic pain. However, this has not yet been investigated in Japan. This study investigated the effects of a multifaceted pain management program in Japanese patients with chronic pain, both immediately after the program and 6 months thereafter.

METHODS

A total of 96 patients, 37 male and 59 female (mean age 63.8 years) experiencing treatment difficulties and suffering from intractable pain for more than 6 months were enrolled in the study. The programs were conducted with groups of 5-7 patients who met weekly for 9 weeks. Weekly sessions of approximately 2 h in duration incorporating a combination of lectures and exercise were conducted. Several measures related to pain and physical function were assessed at the start of the program, the end of the program, and 6 months after completion of the program. The resulting data were analyzed via Wilcoxon signed-rank test, and 'r' estimated by effect size was also assessed.

RESULTS

Of the 96 initial participants, 11 dropped out during the program and 85 completed it. Thereafter, we evaluated 62 subjects at 6 months after the program, while 23 could not be evaluated at that time-point. Pain intensity upon moving, catastrophizing scores, and pain disability scores showed good improvements at the 6-month follow-up, with large efficacy (r > 0.5). Moving capacity and 6-min walking distance also showed good improvements with large efficacy, both at the end of the program and at the 6-month follow-up (r > 0.5).

CONCLUSIONS

A multifaceted pain-management program based on cognitive-behavioral principles was effective in Japanese patients with chronic pain, resulting in improved long-term clinical outcomes.

The Effect of Guidance regarding Home Exercise and ADL on Adolescent Females Suffering from Adverse Effects after HPV Vaccination in Japanese Multidisciplinary Pain Centers

Background. Two prophylactic papillomavirus (HPV) vaccines have been available for primary prevention of cervical cancer. Although serious adverse effects (AE) were rare, more than 230 women have been suffering from severe AEs such as persistent pain and headache in Japan. Our research group started to treat adolescent females suffering from the AEs. Objective. To survey the characteristics of and the effects of cognitive behavioral therapy on adolescent female suffering from the AEs in Japanese multidisciplinary pain centers. Methods. One hundred and forty-five patients suffering from the AEs were reviewed retrospectively and 105 patients of them were provided guidance on home exercise and activities of daily living based partially on a cognitive-behavioral approach. The intensity of pain was rated by the patients using a numerical rating scale (NRS). Furthermore, the Hospital Anxiety and Depression Scale (HADS) and the Pain Catastrophizing Scale (PCS) were used. Results. Eighty out of the 105 patients who received the guidance were followed up, 10 displayed a marked improvement, and 43 showed some improvement. Conclusions. Guidance on home exercise and activities of daily living based on a cognitive-behavioral approach alleviated the AEs that women suffered from after HPV vaccination in Japan.

Telephone Consultation Partially Based on a Cognitive-Behavioral Approach Decreases Pain and Improves Quality of Life in Patients With Chronic Pain

Background:

Chronic pain tends to be difficult to manage because of its complex natural history and poor response to therapy. Recently, it has been reported that telecare management by nurses improved outcomes of patients with chronic pain.

Objectives:

The aim of this study was to investigate the effect of a telephone consultation approach partially based on a cognitive-behavioral approach on pain and quality of life (QOL) in patients with chronic pain in Japan.

Patients and Methods:

Telephonic consultation was provided by nurse care managers for the management of pain. They informed the patients how to correct or eliminate excessive fear of pain, improper thinking for treating pain, as well as how to control activity levels by appropriate pacing. We received 463 consultations about chronic pain; however, 153 patients allowed us to recall for follow-up assessment. Finally, we could evaluate the pain intensity for 121 patients and the EuroQOL 5 dimension (EQ-5D) for 37 patients at the initial call and on their condition at 3 to 6 months after that. Wilcoxon signed-rank test and Cohens’d were used for both analyses. We also asked them to rate, by feeling, marked signs of improvement, some improvement, no improvement, or deterioration in pain and QOL, depending on their condition 3 to 6 months after the initial call (n = 121).

Results:

The pain intensities were significantly decreased from 7.6 ± 2.0 at baseline to 5.7 ± 2.9 on follow-ups assessed by a numerical rating scale (range; 0 - 10, P < 0.001, effect size (ES); 0.76). The EuroQOL 5 dimension scores were also significantly improved after telephone intervention; 0.5 ± 0.2 to 0.6 ± 0.2 (range; 0 - 1, P < 0.001, ES; 0.65). Moreover, as a result of the consultation, approximately half of the participants felt an improvement in the intensity of pain and QOL.

Conclusions:

Telephone consultation partially based on a cognitive-behavioral approach significantly reduced the intensity of pain and improved the QOL in patients with chronic pain in Japan.

Burdensome problems of chronic musculoskeletal pain and future prospects

According to a recent survey, about 15 % of the Japanese population suffers from moderate-severe chronic musculoskeletal pain persisting for at least 6 months. Social factors and related psychological factors (including depression) thus appear to greatly affect chronic musculoskeletal pain. This suggests the need for measures that take these factors into account. Treatment for musculoskeletal pain at present is generally based on a biomedical model that has been used for many years in this field, and modern medical imaging technologies have been a high priority to support this model and treatment strategy. Under the concept of the biomedical model, nonsteroidal antiinflammatory drugs, channel blockers and opioid analgesics are generally used as pharmacotherapy to alleviate chronic pain. However, these drugs are commonly associated with problems such as adverse effects, drug dependency and drug abuse, and they must be used with care. Surgery may also be effective in treating certain diseases, but studies have shown that many patients suffer residual chronic pain even after such treatment. Besides, exercise therapy has been found to be effective in treating many different types of chronic pain. Lately, various countries have been launching interdisciplinary pain centers that use a multidisciplinary approach to treat chronic musculoskeletal pain. Treatment in these centers is provided by a team of specialists in anesthesiology, psychiatry and orthopedics as well as the relevant paramedical professionals. The therapeutic strategy is based on a cognitive-behavioral approach, and patients are taught about methods for restoring physical function and coping with pain, mostly with drugs and exercise therapy, so that any pain present does not impair function and the patient can reintegrate into society.