Differences in pain, function and coping in Multidimensional Pain Inventory subgroups of chronic back pain: a one-group pretest-posttest study

A Scoping Review of Chronic Low Back Pain Classification Schemes Based on Patient-Reported Outcomes

BACKGROUND

In 2014, the National Institutes of Health Pain Consortium Research Task Force recommended that patients with chronic low back pain (CLBP) be stratified by its impact on their lives. They proposed the Impact Stratification Score (ISS) to help guide therapy and facilitate study comparability. The ISS has been evaluated as a continuous measure, but not for use as a stratification or classification scheme.

OBJECTIVES

Identify the characteristics of successful schemes to inform the use of the ISS for stratification or classification.

STUDY DESIGN

Scoping review of the peer-reviewed literature.

METHODS

Search of PubMed, CINAHL, and APA PsycInfo to identify patient self-report-based classification schemes applicable to CLBP. Data were captured on the methods used for each scheme's development, the domains covered, their scoring criteria and what the classification has successfully measured. The study was reviewed and approved by the RAND Human Subjects Protection Committee (2019-0651-AM02).

RESULTS

The search identified 87 published articles about the development and testing of 5 classification schemes: 1) The Subgroups for Targeted Treatment (STarT) Back Screening Tool, 2) Multiaxial Assessment of Pain, 3) Graded Chronic Pain Scale, 4) Back Pain Classification Scale, and 5) Chronic Pain Risk Score. All have been shown to be predictive of future outcomes and the STarT Back has been found useful in identifying effective classification-specific treatment. Each scheme had a different classification scoring structure, was developed using different methods, and 3 included domains not found in the ISS.

LIMITATIONS

Expanding the search to other databases may have identified more classification schemes. Our minimum number of publications inclusion criterion eliminated dozens of cluster analyses, some of which may have eventually been replicated.

CONCLUSIONS

The methods used to develop these successful classification schemes, especially those that use straightforward scoring schemes, should be considered for use in the development of a scheme based on the ISS.

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.

Differences in psychological factors, disability and fatigue according to the grade of chronification in non-specific low back pain patients: A cross-sectional study

BACKGROUND

Differences in pain processing, muscle structure and function have been reported in patients with low back pain (LBP) with different grades of pain chronicity.

OBJECTIVE

The present study aims to examine differences in psychological factors, disability and subjective fatigue between subgroups of LBP based on their chronification grade.

METHODS

Twenty-one healthy controls (HC) and 54 LBP patients (categorized based on the grades of chronicity into recurrent LBP (RLBP), non-continuous chronic LBP (CLBP), or continuous (CLBP)) filled out a set of self-reporting questionnaires.

RESULTS

The Hospital Anxiety and Depression Scale (HADS) and Multidimensional Pain Inventory (MPI) scores indicated that anxiety, pain severity, pain interference and affective distress were lower in HC and RLBP compared to non-continuous CLBP. Anxiety scores were higher in non-continuous CLBP compared to RLBP, continuous CLBP and HC. The Pain Catastrophizing Scale for Helplessness (PSCH) was higher in non-continuous CLBP compared to HC. The Survey of Pain Attitudes (SOPA) showed no differences in adaptive and maladaptive behaviors across the groups. The Pain Disability Index (PDI) measured a higher disability in both CLBP groups compared to HC. Moreover, the Rolland Morris Disability Questionnaire (RMDQ) showed higher levels of disability in continuous CLBP compared to non-continuous CLBP, RLBP and HC. The Checklist Individual Strength (CIS) revealed that patients with non-continuous CLBP were affected to a higher extent by severe fatigue compared to continuous CLBP, RLBP and HC (subjective fatigue, concentration and physical activity). For all tests, a significance level of 0.05 was used.

CONCLUSIONS

RLBP patients are more disabled than HC, but have a tendency towards a general positive psychological state of mind. Non-continuous CLBP patients would most likely present a negative psychological mindset, become more disabled and have prolonged fatigue complaints. Finally, the continuous CLBP patients are characterized by more negative attitudes and believes on pain, enhanced disability and interference of pain in their daily lives.

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.

Why are patients dissatisfied following a total knee replacement? A systematic review

BACKGROUND

Although total knee replacement (TKR) is an effective intervention for end-stage arthritis of the knee, a significant number of patients remain dissatisfied following this procedure. Our aim was to identify and assess the factors affecting patient satisfaction following a TKR.

MATERIALS AND METHODS

In accordance with the PRISMA guidelines, two reviewers searched the online databases for literature describing factors affecting patient satisfaction following a TKR. The research question and eligibility criteria were established a priori. Any clinical outcome study that described factors relating to overall satisfaction after primary TKR was included. Quality assessment for the included studies was performed by two accredited orthopaedic surgeons experienced in clinical research.

RESULTS

The systematic review identified 181 relevant articles in total. A history of mental health problems was the most frequently reported factor affecting patient satisfaction (13 reportings). When the results of the quality assessment were taken into consideration, a negative history of mental health problems, use of a mobile-bearing insert, patellar resurfacing, severe pre-operative radiological degenerative change, negative history of low back pain, no/less post-operative pain, good post-operative physical function and pre-operative expectations being met were considered to be important factors leading to better patient satisfaction following a TKR.

CONCLUSION

Surgeons performing a TKR should take these factors into consideration prior to deciding whether a patient is suitable for a TKR. Secondarily, a detailed explanation of these factors should form part of the process of informed consent to achieve better patient satisfaction following TKR. There is a great need for a unified approach to assessing satisfaction following a TKR and also the time at which satisfaction is assessed.

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.

Psychological and behavioral differences between low back pain populations: a comparative analysis of chiropractic, primary and secondary care patients

Background

Psychological, behavioral and social factors have long been considered important in the development of persistent pain. Little is known about how chiropractic low back pain (LBP) patients compare to other LBP patients in terms of psychological/behavioral characteristics.

Methods

In this cross-sectional study, the aim was to investigate patients with LBP as regards to psychosocial/behavioral characteristics by describing a chiropractic primary care population and comparing this sample to three other populations using the MPI-S instrument. Thus, four different samples were compared. A: Four hundred eighty subjects from chiropractic primary care clinics. B: One hundred twenty-eight subjects from a gainfully employed population (sick listed with high risk of developing chronicity). C: Two hundred seventy-three subjects from a secondary care rehabilitation clinic. D: Two hundred thirty-five subjects from secondary care clinics. The Swedish version of the Multidimensional Pain Inventory (MPI-S) was used to collect data. Subjects were classified using a cluster analytic strategy into three pre-defined subgroups (named adaptive copers, dysfunctional and interpersonally distressed).

Results

The data show statistically significant overall differences across samples for the subgroups based on psychological and behavioral characteristics. The cluster classifications placed (in terms of the proportions of the adaptive copers and dysfunctional subgroups) sample A between B and the two secondary care samples C and D.

Conclusions

The chiropractic primary care sample was more affected by pain and worse off with regards to psychological and behavioral characteristics compared to the other primary care sample. Based on our findings from the MPI-S instrument the 4 samples may be considered statistically and clinically different.

Trial registration

Sample A comes from an ongoing trial registered at clinical trials.gov; NCT01539863, February 22, 2012.

'Two pains together': patient perspectives on psychological aspects of chronic pain while living with HIV

OBJECTIVE

Chronic pain is common in HIV-infected individuals. Understanding HIV-infected patients' chronic pain experience not just from a biological, but also from a psychological perspective, is a critical first step toward improving care for this population. Our objective was to explore HIV-infected patients' perspectives on psychological aspects of chronic pain using in-depth qualitative interviews.

METHODS

Investigators engaged in an iterative process of independent and group coding until theme saturation was reached.

RESULTS

Of the 25 patients with chronic pain interviewed, 20 were male, 15 were younger than age 50, and 15 were African-American. Key themes that emerged included the close relationship between mood and pain; mood and pain in the context of living with HIV; use of alcohol/drugs to self-medicate for pain; and the challenge of receiving prescription pain medications while dealing with substance use disorders.

CONCLUSIONS

The results suggest that psychological approaches to chronic pain treatment may be well received by HIV-infected patients.

Development and validation of the ankle fracture outcome of rehabilitation measure (A-FORM)

STUDY DESIGN

Delphi panel and cohort study.

OBJECTIVE

To develop and refine a condition-specific, patient-reported outcome measure, the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), and to examine its psychometric properties, including factor structure, reliability, and validity, by assessing item fit with the Rasch model.

BACKGROUND

To our knowledge, there is no patient-reported outcome measure specific to ankle fracture with a robust content foundation.

METHODS

A 2-stage research design was implemented. First, a Delphi panel that included patients and health professionals developed the items and refined the item wording. Second, a cohort study (n = 45) with 2 assessment points was conducted to permit preliminary maximum-likelihood exploratory factor analysis and Rasch analysis.

RESULTS

The Delphi panel reached consensus on 53 potential items that were carried forward to the cohort phase. From the 2 time points, 81 questionnaires were completed and analyzed; 38 potential items were eliminated on account of greater than 10% missing data, factor loadings, and uniqueness. The 15 unidimensional items retained in the scale demonstrated appropriate person and item reliability after (and before) removal of 1 item (anxious about footwear) that had a higher-than-ideal outfit statistic (1.75). The "anxious about footwear" item was retained in the instrument, but only the 14 items with acceptable infit and outfit statistics (range, 0.5-1.5) were included in the summary score.

CONCLUSION

This investigation developed and refined the A-FORM (Version 1.0). The A-FORM items demonstrated favorable psychometric properties and are suitable for conversion to a single summary score. Further studies utilizing the A-FORM instrument are warranted. J Orthop Sports Phys Ther 2014;44(7):488-499. Epub 22 May 2014. doi:10.2519/jospt.2014.4980.

The clinical utility of the Multidimensional Pain Inventory (MPI) in characterizing chronic disabling occupational musculoskeletal disorders

PURPOSE

The Multidimensional Pain Inventory (MPI) was designed to help capture unique characteristics of chronic pain patients. The present study examined the proportion of subgroups classified by the MPI in a chronic disabling occupational musculoskeletal disorder (CDOMD) patient cohort, and described characteristics of MPI profile groups in terms of other psychosocial variables.

METHODS

A cohort of 1,270 CDOMD patients undergoing an interdisciplinary functional restoration program was studied. Before the start of the program, all patients received a standard psychosocial assessment battery. A MPI computer program scored and identified pre-defined MPI subgroups: Adaptive Coper (AC); Interpersonally Distressed (ID); and Dysfunctional (DYS).

RESULTS

The distribution of MPI profiles for CDOMD patients was similar with those of highly disabled patients, with the largest proportion of patients having the DYS profile (44 %), followed by AC (33 %) and ID (23 %). The DYS profile group showed the highest level of pain severity, and psychosocial distress; the ID group had a moderate level; and the AC profile group had the lowest level. Higher rates of psychiatric disorders were also found in the DYS and ID groups. The DYS profile group was less likely to complete the treatment program.

CONCLUSION

The present study further demonstrated the clinical utility of the MPI classification in a large cohort of CDOMD patients, indicating that the MPI profiles successfully distinguish among patients who may require extra psychosocial attention to achieve successful treatment gains and program completion.

Primary total knee replacement in patients with mental disability improves their mental health and knee function: a prospective study

We assessed the effect of mental disability on the outcome of total knee replacement (TKR) and investigated whether mental health improves post-operatively. Outcome data were prospectively recorded over a three-year period for 962 patients undergoing primary TKR for osteoarthritis. Pre-operative and one year Short-Form (SF)-12 scores and Oxford knee scores (OKS) were obtained. The mental component of the SF-12 was stratified into four groups according to level of mental disability (none ≥ 50, mild 40 to 49, moderate 30 to 39, severe < 30). Patients with any degree of mental disability had a significantly greater subjective physical disability according to the SF-12 (p = 0.06) and OKS (p < 0.001). The improvement in the disease-specific score (OKS) was not affected by a patient's mental health (p = 0.33). In contrast, patients with mental disability had less of an improvement in their global physical health (SF-12) (p < 0.001). However, patients with any degree of mental disability had a significant improvement in their mental health post-operatively (p < 0.001). Despite a similar improvement in their disease-specific scores and improvement in their mental health, patients with mental disability were significantly more likely to be dissatisfied with their TKR at one year (p = 0.001). Patients with poor mental health do benefit from improvements in their mental health and knee function after TKR, but also have a higher rate of dissatisfaction.

Socioeconomic status affects the Oxford knee score and short-form 12 score following total knee replacement

We assessed the effect of social deprivation upon the Oxford knee score (OKS), the Short-Form 12 (SF-12) and patient satisfaction after total knee replacement (TKR). An analysis of 966 patients undergoing primary TKR for symptomatic osteoarthritis (OA) was performed. Social deprivation was assessed using the Scottish Index of Multiple Deprivation. Those patients that were most deprived underwent surgery at an earlier age (p = 0.018), were more likely to be female (p = 0.046), to endure more comorbidities (p = 0.04) and to suffer worse pain and function according to the OKS (p < 0.001). In addition, deprivation was also associated with poor mental health (p = 0.002), which was assessed using the mental component (MCS) of the SF-12 score. Multivariable analysis was used to identify independent predictors of outcome at one year. Pre-operative OKS, SF-12 MCS, back pain, and four or more comorbidities were independent predictors of improvement in the OKS (all p < 0.001). Pre-operative OKS and improvement in the OKS were independent predictors of dissatisfaction (p = 0.003 and p < 0.001, respectively). Although improvement in the OKS and dissatisfaction after TKR were not significantly associated with social deprivation per se, factors more prevalent within the most deprived groups significantly diminished their improvement in OKS and increased their rate of dissatisfaction following TKR.

Life impact of ankle fractures: qualitative analysis of patient and clinician experiences

BACKGROUND

Ankle fractures are one of the more commonly occurring forms of trauma managed by orthopaedic teams worldwide. The impacts of these injuries are not restricted to pain and disability caused at the time of the incident, but may also result in long term physical, psychological, and social consequences. There are currently no ankle fracture specific patient-reported outcome measures with a robust content foundation. This investigation aimed to develop a thematic conceptual framework of life impacts following ankle fracture from the experiences of people who have suffered ankle fractures as well as the health professionals who treat them.

METHODS

A qualitative investigation was undertaken using in-depth semi-structured interviews with people (n=12) who had previously sustained an ankle fracture (patients) and health professionals (n=6) that treat people with ankle fractures. Interviews were audio-recorded and transcribed. Each phrase was individually coded and grouped in categories and aligned under emerging themes by two independent researchers.

RESULTS

Saturation occurred after 10 in-depth patient interviews. Time since injury for patients ranged from 6 weeks to more than 2 years. Experience of health professionals ranged from 1 year to 16 years working with people with ankle fractures. Health professionals included an Orthopaedic surgeon (1), physiotherapists (3), a podiatrist (1) and an occupational therapist (1). The emerging framework derived from patient data included eight themes (Physical, Psychological, Daily Living, Social, Occupational and Domestic, Financial, Aesthetic and Medication Taking). Health professional responses did not reveal any additional themes, but tended to focus on physical and occupational themes.

CONCLUSIONS

The nature of life impact following ankle fractures can extend beyond short term pain and discomfort into many areas of life. The findings from this research have provided an empirically derived framework from which a condition-specific patient-reported outcome measure can be developed.

Reliability of the Multidimensional Pain Inventory and stability of the MPI classification system in chronic back pain

Background

This cross validation study examined the reliability of the Multidimensional Pain Inventory (MPI) and the stability of the Multidimensional Pain Inventory Classification System of the empirically derived subgroup classification obtained by cluster analysis in chronic musculoskeletal pain. Reliability of the German Multidimensional Pain Inventory was only examined once in the past in a small sample. Previous international studies mainly involving fibromyalgia patients showed that retest resulted in 33–38% of patients being assigned to a different Multidimensional Pain Inventory subgroup classification.

Methods

Participants were 204 persons with chronic musculoskeletal pain (82% chronic non-specific back pain). Subgroup classification was conducted by cluster analysis at 4 weeks before entry (=test) and at entry into the pain management program (=retest) using Multidimensional Pain Inventory scale scores. No therapeutic interventions in this period were conducted. Reliability was quantified by intraclass correlation coefficients (ICC) and stability by kappa coefficients (κ).

Results

Reliability of the Multidimensional Pain Inventory scales was least with ICC = 0.57 for the scale life control and further ranged from ICC = 0.72 (negative mood) to 0.87 (solicitous responses) in the other scales. At retest, 82% of the patients in the Multidimensional Pain Inventory cluster interpersonally distressed (κ = 0.69), 80% of the adaptive copers (κ = 0.58), and 75% of the dysfunctional patients (κ = 0.70) did not change classification. In total, 22% of the patients changed Multidimensional Pain Inventory cluster group, mainly into the adaptive copers subgroup.

Conclusion

Test-retest reliability of the German Multidimensional Pain Inventory was moderate to good and comparable to other language versions. Multidimensional Pain Inventory subgroup classification is substantially stable in chronic back pain patients when compared to other diagnostic groups and other examiner-based subgroup Classification Systems. The MPI Classification System can be recommended for reliable and stable specification of subgroups in observational and interventional studies in patients with chronic musculoskeletal pain.

The Relationship between Beliefs about Pain and Functioning with Rheumatologic Conditions

Pain beliefs influence understanding of pain mechanisms and outcomes. This study in rheumatologic conditions sought to determine a relationship between beliefs about pain and functioning. Participants in Arthritis New Zealand's (ANZ) exercise and education programmes were used. Demographic data and validated instruments used included the Arthritis Impact Measurement Scale 2nd version-Short Form (AIMS2-SF) to measure functioning, and two scales of organic and psychological beliefs in Pain Beliefs Questionnaires (PBQ) to measure pain beliefs. 236 Members of ANZ were surveyed anonymously with AIMS2-SF and PBQ, with a 61% response rate; 144 responses were entered into the database. This study used α of 0.05 and a 1-β of 0.8 to detect for significant effect size estimated to be r = 0.25. Analysis revealed a significant relationship between organic beliefs scale of PBQ and functioning of AIMS2-SF, with an r value of 0.32 and P value of 0.00008. No relationship was found between psychological beliefs scale of PBQ and AIMS2-SF. Organic pain beliefs are associated with poorer functioning. Psychological pain beliefs are not. Beliefs might have been modified by ANZ programmes. Clinicians should address organic pain beliefs early in consultation. Causal links between organic pain beliefs and functioning should be clarified.