Long-Term Outcomes of a Multimodal Day-Clinic Treatment for Chronic Pain under the Conditions of Routine Care

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.

Outpatient interdisciplinary multimodal pain treatment programme for patients with chronic musculoskeletal pain: a longitudinal cohort study

PURPOSE

To describe the outcomes of an interdisciplinary multimodal pain treatment (IMPT) for chronic musculoskeletal pain (CMP) patients up until 12 months post-treatment.

MATERIALS AND METHODS

Data were gathered during routine clinical practice during a 3-year period (2019-2021) at six Dutch rehabilitation centres. Assessments included patient-reported outcome measures for multiple domains including disability, pain and fatigue. Longitudinal data were analysed using repeated-measures models and by quantifying responder rates.

RESULTS

Included were 2309 patients with a mean age of 43.7 (SD 12.9) years, of which 73% female. All outcomes showed significant improvements at each timepoint. At discharge, large effect sizes were found for disability, average and worst pain, fatigue and health-related quality of life. Improvements were largely sustained at 12-months. Relatively large proportions of patients had clinically relevant improvements after treatment (pain-related disability: 60%; average pain: 52%; worst pain: 37.4%; work capacity: 50%; concentration: 50%; fatigue: 46%). Patients who received a treatment extension showed further improvements for all outcome measures, except average pain.

CONCLUSIONS

At group level, all outcomes significantly improved with mainly large effect sizes. The results were mostly sustained. The proportion of patients showing clinically relevant improvements tends to be larger than previously reported for mixed CMP patients.

Machine learning clinical decision support for interdisciplinary multimodal chronic musculoskeletal pain treatment

Introduction

Chronic musculoskeletal pain is a prevalent condition impacting around 20% of people globally; resulting in patients living with pain, fatigue, restricted social and employment capacity, and reduced quality of life. Interdisciplinary multimodal pain treatment programs have been shown to provide positive outcomes by supporting patients modify their behavior and improve pain management through focusing attention on specific patient valued goals rather than fighting pain.

Methods

Given the complex nature of chronic pain there is no single clinical measure to assess outcomes from multimodal pain programs. Using Centre for Integral Rehabilitation data from 2019-2021 (n = 2,364), we developed a multidimensional machine learning framework of 13 outcome measures across 5 clinically relevant domains including activity/disability, pain, fatigue, coping and quality of life. Machine learning models for each endpoint were separately trained using the most important 30 of 55 demographic and baseline variables based on minimum redundancy maximum relevance feature selection. Five-fold cross validation identified best performing algorithms which were rerun on deidentified source data to verify prognostic accuracy.

Results

Individual algorithm performance ranged from 0.49 to 0.65 AUC reflecting characteristic outcome variation across patients, and unbalanced training data with high positive proportions of up to 86% for some measures. As expected, no single outcome provided a reliable indicator, however the complete set of algorithms established a stratified prognostic patient profile. Patient level validation achieved consistent prognostic assessment of outcomes for 75.3% of the study group (n = 1,953). Clinician review of a sample of predicted negative patients (n = 81) independently confirmed algorithm accuracy and suggests the prognostic profile is potentially valuable for patient selection and goal setting.

Discussion

These results indicate that although no single algorithm was individually conclusive, the complete stratified profile consistently identified patient outcomes. Our predictive profile provides promising positive contribution for clinicians and patients to assist with personalized assessment and goal setting, program engagement and improved patient outcomes.

[Development of two outpatient interdisciplinary group modules in the treatment of patients with pain and risk of chronification]

BACKGROUND AND OBJECTIVE

An early treatment of patients who suffer from pain and show risk factors for chronification is meaningful as these patients can benefit from an early interdisciplinary multimodal pain treatment (IMST). In view of the insufficient treatment, two outpatient treatment modules for the secondary prevention of pain chronification are developed within the framework of PAIN2020: the educative and accompanying IMST (E‑IMST and B‑IMST).

MATERIAL AND METHODS

The developmental process of both IMSTs is presented. In this context two target groups of patients were defined for which 1 session (E‑IMST) or 10 intervention appointments (B‑IMST) were planned, depending on the chronification, impairment and complexity of the disorder. The conception was carried out in five steps: development of the objectives, development of the main contents, workshop on the content and conceptional design (contents, mediation, exercises), preparation of a time schedule and processing of the results (manual, presentations, worksheets, handbook). The B‑IMST was initially developed from which the contents for the E‑IMST were subsequently extracted. Additionally, a concept for testing the feasibility and a working model for a pilot study were developed.

RESULTS

The objectives for both forms of IMST are improvement of the understanding of pain and contributing factors, the increase of the experience of control and self-efficacy and the increase in self-responsibility with respect to strategies to reduce pain. Differences between the two treatment modules arise from the needs and framework conditions. Medical, physiotherapeutic and psychotherapeutic contents and schedules were organized for both IMST modules. The B‑IMST consists of five modules each with two sessions as group interventions (biopsychosocial model, activation planning, regulation of needs, sleep and medication, routine transfer). The 3‑h E‑IMST group intervention mainly intends to mediate knowledge on pain and the biopsychosocial pain model. Theoretical and practical interventions, empirical knowledge and experience-oriented methods are employed.

CONCLUSION

There are now two interdisciplinary structured manuals for the secondary preventive treatment of patients with recurrent pain and a risk profile for chronification. These approaches must now prove themselves with respect to feasibility and effectiveness.

Improvement in pain interference and function by an allied health pain management program: Results of a randomized trial

BACKGROUND

Chronic pain is a significant health problem worldwide and requires a biopsychosocial treatment approach. Access to traditional pain medicine specialist services is limited and innovative treatment models are required to support patients in tertiary care. The study evaluated the clinical effectiveness and safety of the Treatment Access Pathway (TAP), an allied health expanded scope model of care which included innovative group assessment and collaboration with patients to create individualized treatment plans.

METHODS

One hundred and eighty-one patients referred to a tertiary level chronic pain service were randomly allocated to either the TAP or the waitlist study groups. Primary (pain interference) and secondary outcome measures were collected at recruitment and again at 6 months. Per-protocol analyses were utilized due to high participant attrition (46% across groups).

RESULTS

The TAP group reported greater reductions in pain interference at 6 months than waitlist group (0.9, 95% CI: 0.2-1.6), with more than half of the TAP group (52%) reporting clinically significant improvement. In addition, statistically significant differences between the TAP and waitlist groups were observed for objective measurements of walking endurance (5.4 m, 95% CI: 1.7-9.1); and global impressions of change (1.4 unit decrease, 95% CI: 1-1.9). Nil adverse events were recorded.

CONCLUSIONS

The study suggests that an expanded scope allied health model of care prioritizing patient choice and group-based interventions provides modest benefits for tertiary-referral chronic pain patients. TAP warrants further investigation as a potentially viable alternative for tertiary healthcare where traditional pain services are unavailable or have long waiting lists.

SIGNIFICANCE

The study tests effectiveness and safety of an expanded scope allied health-led chronic pain program. Despite a high attrition rate, the study showed reduced pain interference and increased physical function in those who completed the protocol. The results are promising and support introduction of this model as an adjunct to existing traditional chronic pain models of care, with a particular focus on improving participant retention in the program. Additionally, the model of care can be used as a standalone chronic pain model of care where no other pain management resources are available. The study was registered on ANZCTR (Trial ID: ACTRN12617001284358).

[Effectiveness of an individualized multimodal treatment of chronic pain patients : A retrospective real-life analysis with 3-year follow-up]

BACKGROUND

Chronic pain is a worldwide problem of healthcare along with social and economic factors. The Center for Pain Medicine (CPM) Nottwil offers individualized, interdisciplinary, multimodal pain rehabilitation based on the biopsychosocial approach. The aim of this study was to obtain a real-life analysis of chronic pain patients who were treated at the CPM Nottwil, to understand how they were treated and to analyze the long-term effects of the treatment.

METHODS

In a retrospective cohort study data of all patients who underwent a first medical examination at the CPM Nottwil in 2011 were included in the study. The effectiveness of the treatment was analyzed in a 3-year follow-up measurement. The main outcome was the general well-being of the patient.

RESULTS

In 2011, 628 chronic pain patients underwent a first medical examination at the CPM Nottwil. They showed low values in the dimension of general well-being and a high impairment due to severely limiting pain intensity. Although the power analysis suggested a sample size of 170 patients for the follow-up measurement, only 46 participants (responders) were included in the final analysis. Baseline characteristics between responders and non-responders of the follow-up-group showed statistically significant differences for health-related quality of life (SF-12) and the anxiety and depression scale (HADS), but not for other sample characteristics. Improvement from pretreatment to follow-up emerged in the dimension of well-being, physical well-being and pain intensity. At follow-up 30% reported being pain-free.

CONCLUSION

Individualized, interdisciplinary, multimodal and mostly outpatient pain programs are an effective treatment for patients suffering from chronic pain in the long term. For the first time this effect has been proven in a clinically representative cohort. Limitations of this study are low response rates in the follow-up group and differences in baseline characteristics (anxiety, depression and quality of life) between responders and non-responders.

Outcomes of Interdisciplinary Pain Rehabilitation Across Subgroups of the Multidimensional Pain Inventory - A Study From the Swedish Quality Registry for Pain Rehabilitation

INTRODUCTION

The Multidimensional Pain Inventory (MPI) is frequently used in the assessment of chronic pain. Three subgroups have been derived from MPI: adaptive coper (AC), dysfunctional (DYS), and interpersonally distressed (ID). The primary aim of this study was to examine whether outcome of Interdisciplinary Multimodal Pain Rehabilitation Programs (IMMRPs) differed across the MPI subgroups.

METHODS

Patients with chronic pain (N = 34,513), included in the Swedish Quality Registry for Pain Rehabilitation, were classified into MPI subgroups and a subset that participated in IMMRPs (N = 13,419) was used to examine overall treatment outcomes using a previously established Multivariate Improvement Score (MIS) and 2 retrospective patient-evaluated benefits from treatment.

RESULTS

The subgroups differed on sociodemographic characteristics, pain duration, and spatial spreading of pain. DYS and ID had the best overall outcomes to MIS. AC had the best outcomes according to the 2 retrospective items. Transition into other subgroups following IMMRP was common and most prominent in DYS and least prominent in AC.

CONCLUSION

The validity of the MPI subgroups was partially confirmed. DYS and ID had the most severe clinical presentations at baseline and showed most improvement following IMMRP, but overall severity in DYS and ID at post-treatment was still higher than in the AC group. Future studies should examine how processes captured by MPI interact with neurobiological, medical, sociodemographic, and adaptation/coping factors and how these interactions impact severity of chronic pain and treatment outcome.

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.

Development and Psychometric Testing of the Japanese Version of the Fremantle Neck Awareness Questionnaire: A Cross-Sectional Study

Purpose

Contemporary theories of pain suggest that how the body is perceived is central to the emergence of pain. The Fremantle Back Awareness Questionnaire (FreBAQ) was developed to assess body-perception specific to the back in people with chronic low back pain. However, there is no comprehensive measure to quantify self-perception of the painful area in Japanese people with neck pain. This study aimed to develop a Japanese version of a self-perception questionnaire specific to the neck and evaluate the validity and reliability of the scale using Rasch analysis.

Materials and Methods

The Fremantle Neck Awareness Questionnaire (FreNAQ-J) was developed by modifying the FreBAQ-J. One hundred people with chronic neck pain and fifty-six matched healthy controls completed the questionnaire. Rasch analysis was used to evaluate targeting, category order, unidimensionality, person fit, internal consistency, differential item functioning, and differential test functioning in the neck pain population. Validity was investigated by examining the relationship between the FreNAQ-J and clinical status.

Results

People with chronic neck pain endorsed FreNAQ-J items with greater frequency than healthy controls. FreNAQ-J did not reject the null hypothesis of fitting the Rasch model, had acceptable internal consistency and good test–retest reliability. Summed FreNAQ-J scores were significantly correlated with pain intensity, disability, pain-related catastrophizing and fear of movement.

Conclusion

The individual items of the FreNAQ-J can be validly summed to provide a score of self-perception. The FreNAQ-J is the first scale developed for comprehensively evaluating disturbed body perception in Japanese patients with chronic neck pain.

Influences of Sex, Education, and Country of Birth on Clinical Presentations and Overall Outcomes of Interdisciplinary Pain Rehabilitation in Chronic Pain Patients: A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

This study investigates the effects of sex, education, and country of birth on clinical presentations and outcomes of interdisciplinary multimodal pain rehabilitation programs (IMMRPs). A multivariate improvement score (MIS) and two retrospective estimations of changes in pain and ability to handle life situations were used as the three overall outcomes of IMMRPs. The study population consisted of chronic pain patients within specialist care in the Swedish Quality Registry for Pain Rehabilitation (SQRP) between 2008 and 2016 at baseline (n = 39,916), and for the subset participating in IMMRPs (n = 14,666). A cluster analysis based on sex, education, and country of origin revealed significant differences in the following aspects: best baseline clinical situation was for European women with university educations and the worst baseline clinical situation was for all patients born outside Europe of both sexes and different educations (i.e., moderate-large effect sizes). In addition, European women with university educations also had the most favorable overall outcomes in response to IMMRPs (small effect sizes). These results raise important questions concerning fairness and equality and need to be considered when optimizing assessments and content and delivery of IMMRPs for patients with chronic pain.

Early Changes in Pain Acceptance Predict Pain Outcomes in Interdisciplinary Treatment for Chronic Pain

Studies have shown that pain acceptance is associated with a better pain outcome. The current study explored whether changes in pain acceptance in the very early treatment phase of an interdisciplinary cognitive-behavioral therapy (CBT)-based treatment program for chronic pain predict pain outcomes. A total of 69 patients with chronic, non-malignant pain (at least 6 months) were treated in a day-clinic for four-weeks. Pain acceptance was measured with the Chronic Pain Acceptance Questionnaire (CPAQ), pain outcomes included pain intensity (Numeric Rating Scale, NRS) as well as affective and sensory pain perception (Pain Perception Scale, SES-A and SES-S). Regression analyses controlling for the pre-treatment values of the pain outcomes, age, and gender were performed. Early changes in pain acceptance predicted pain intensity at post-treatment measured with the NRS (B = −0.04 (SE = 0.02); T = −2.28; p = 0.026), affective pain perception at post-treatment assessed with the SES-A (B = −0.26 (SE = 0.10); T = −2.79; p = 0.007), and sensory pain perception at post-treatment measured with the SES-S (B = −0.19 (SE = 0.08); T = −2.44; p = 0.017). Yet, a binary logistic regression analysis revealed that early changes in pain acceptance did not predict clinically relevant pre-post changes in pain intensity (at least 2 points on the NRS). Early changes in pain acceptance were associated with pain outcomes, however, the impact was beneath the threshold defined as clinically relevant.

Criteria for inclusion in programs of functional restoration for chronic low back pain: Pragmatic Study

BACKGROUND

Individuals with chronic low back pain (cLBP) may benefit from multimodal functional restoration programs (FRPs).

OBJECTIVE

The aim of this study was to analyze characteristics of individuals with cLBP who were referred or not to an FRP. Because cLBP is a bio-psycho-social disorder, medical and social parameters were analysed.

METHODS

This was an observational cross-sectional study performed in 2017 in 6 tertiary centres in France. Consecutive individuals with cLBP visiting a rheumatologist or physical medicine and rehabilitation physician were included. Individuals referred or not to an FRP were compared by demographic characteristics, duration of sick leave over the past year, self-reported physical activity>1h/week, pain (numeric rating scale 0-10), anxiety/depression (Hospital Anxiety and Depression Scale), disability (Oswestry Disability Index) and kinesiophobia (Tampa Kinesiophobia Scale). Univariate and multivariate logistic regression analyses were performed, estimating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

We included 147 individuals with cLBP. The mean (SD) age was 49 (12) years and 88 (60%) were women; 58 (38%) were referred to an FRP. On multivariate analysis, referral to an FRP was associated with reduced pain level (OR: 0.95, 95% CI: 0.91-0.99, for each 1-point increase in pain score), self-reported lack of physical activity (OR: 0.84, 95% CI: 0.72-0.98) and longer sick leave (OR: 1.03, 95% CI: 1.01-1.05, for 30 more days of sick leave).

CONCLUSION

In this multicentric observational study, referral to an FRP was linked to pain, self-reported physical activity and sick leave but not medical characteristics assessed. These findings confirm the bio-psycho-social approach of FRPs for cLBP.

The effectiveness of interdisciplinary intensive outpatient programs in a population with diverse chronic pain conditions: a systematic review and meta-analysis

Aim: To explore the overall effectiveness of interdisciplinary intensive outpatient treatment programs in adults with chronic pain. The secondary aim was to examine the effect of the intervention on individual outcome measures including pain intensity, pain catastrophizing, depressive symptoms, quality of life and describe its effect on medication use. Methods: The preferred reporting items for systematic review and meta-analysis protocols reporting guidelines were followed in this systematic review and meta-analysis. Results: A total of 13 peer-reviewed studies were included in analysis: one randomized controlled trial and 12 observational studies. Conclusion: Although interdisciplinary intensive outpatient programs for chronic pain have only been examined in a limited number of studies, trends suggest that participation in these programs may improve physical, emotional, social and mental health as measured by quality of life measures, while decreasing pain intensity, pain catastrophizing and depressive symptoms in a population with diverse diagnoses.

Moderate and Stable Pain Reductions as a Result of Interdisciplinary Pain Rehabilitation-A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Few studies have investigated the real-life outcomes of interdisciplinary multimodal pain rehabilitation programs (IMMRP) for chronic pain. This study has four aims: investigate effect sizes (ES); analyse correlation patterns of outcome changes; define a multivariate outcome measure; and investigate whether the clinical self-reported presentation pre-IMMRP predicts the multivariate outcome. To this end, this study analysed chronic pain patients in specialist care included in the Swedish Quality Registry for Pain Rehabilitation for 22 outcomes (pain, psychological distress, participation, and health) on three occasions: pre-IMMRP, post-IMMRP, and 12-month follow-up. Moderate stable ES were demonstrated for pain intensity, interference in daily life, vitality, and health; most other outcomes showed small ES. Using a Multivariate Improvement Score (MIS), we identified three clusters. Cluster 1 had marked positive MIS and was associated with the overall worst situation pre-IMMRP. However, the pre-IMMRP situation could only predict 8% of the variation in MIS. Specialist care IMPRPs showed moderate ES for pain, interference, vitality, and health. Outcomes were best for patients with the worst clinical presentation pre-IMMRP. It was not possible to predict who would clinically benefit most from IMMRP.

The importance of emotional distress, cognitive behavioural factors and pain for life impact at baseline and for outcomes after rehabilitation – a SQRP study of more than 20,000 chronic pain patients

Background and aims

Although literature concerning chronic pain patients indicates that cognitive behavioural variables, specifically acceptance and fear of movement/(re)injury, are related to life impact, the relative roles of these factors in relation to pain characteristics (e.g. intensity and spreading) and emotional distress are unclear. Moreover, how these variables affect rehabilitation outcomes in different subgroups is insufficiently understood. This study has two aims: (1) to investigate how pain, cognitive behavioural, and emotional distress variables intercorrelate and whether these variables can regress aspects of life impact and (2) to analyse whether these variables can be used to identify clinically meaningful subgroups at baseline and which subgroups benefit most from multimodal rehabilitation programs (MMRP) immediately after and at 12-month follow-up.

Methods

Pain aspects, background variables, psychological distress, cognitive behavioural variables, and two life impact variables were obtained from the Swedish Quality Registry for Pain Rehabilitation (SQRP) for chronic pain patients. These data were analysed mainly using advanced multivariate methods.

Results

The study includes 22,406 chronic pain patients. Many variables, including acceptance variables, showed important contributions to the variation in clinical presentations and in life impacts. Based on the statistically important variables considering the clinical presentation, three clusters/subgroups of patients were identified at baseline; from the worst clinical situation to the relatively good situation. These clusters showed significant differences in outcomes after participating in MMRP; the subgroup with the worst situation at baseline showed the most significant improvements.

Conclusions

Pain intensity/severity, emotional distress, acceptance, and life impacts were important for the clinical presentation and were used to identify three clusters with marked differences at baseline (i.e. before MMRP). Life impacts showed complex relationships with acceptance, pain intensity/severity, and emotional distress. The most significant improvements after MMRP were seen in the subgroup with the lowest level of functioning before treatment, indicating that patients with complex problems should be offered MMRP.

Implications

This study emphasizes the need to adopt a biopsychosocial perspective when assessing patients with chronic pain. Patients with chronic pain referred to specialist clinics are not homogenous in their clinical presentation. Instead we identified three distinct subgroups of patients. The outcomes of MMRP appears to be related to the clinical presentation. Thus, patients with the most severe clinical presentation show the most prominent improvements. However, even though this group of patients improve they still after MMRP show a complex situation and there is thus a need for optimizing the content of MMRP for these patients. The subgroup of patients with a relatively good situation with respect to pain, psychological distress, coping and life impact only showed minor improvements after MMRP. Hence, there is a need to develop other complex interventions for them.