Long-term effects of interprofessional biopsychosocial rehabilitation for adults with chronic non-specific low back pain: a multicentre, quasi-experimental study

Disparities in access but not outcomes: Medicaid versus non-Medicaid patients in multidisciplinary chronic pain rehabilitation

Purpose: There are known disparities in chronic pain severity, treatment, and opioid-related risks amongst individuals from lower socioeconomic status, including Medicaid beneficiaries, but little is known about whether Medicaid beneficiaries benefit in a similar way from multidisciplinary chronic pain rehabilitation. This study investigated differences in clinical outcomes between Medicaid and non-Medicaid beneficiaries who completed a 3-week multidisciplinary chronic pain rehabilitation program.Methods: Participants (N = 131) completed a broad range of clinical measures pre- and post-treatment including pain severity, pain interference, depression, anxiety, objective physical functioning, and opioid misuse risk. Patients with Medicaid were compared with non-Medicaid patients in terms of baseline characteristics and rate of change, utilizing two-factor repeated measures analyses of variance.Results: There were baseline characteristic differences, with Medicaid beneficiaries being more likely to be African American, have higher rates of pain, worse physical functioning, and lower rates of opioid use. Despite baseline differences, both groups demonstrated significantly improved outcomes across all measures (p<.001) and no significant difference in rate of improvement.Conclusions: Results suggest that pain rehabilitation is as effective for Medicaid recipients as non-Medicaid recipients. Patients with Medicaid are particularly vulnerable to disparities in treatment, so efforts to expand access to multidisciplinary pain treatments are warranted.

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.

Effect of multidimensional physiotherapy on non-specific chronic low back pain: a randomized controlled trial

BACKGROUND

Many people with non-specific chronic low back pain (NSCLBP) do not recover with current conventional management. Systematic reviews show multidimensional treatment improves pain better than usual active interventions. It is unclear whether multidimensional physiotherapy improves pain better than usual physiotherapy. This study determines the effectiveness of this treatment to reduce pain and disability and improve quality of life, pain cognitions, and electroencephalographic pattern in individuals with NSCLBP.

METHODS

70 eligible participants aged 18 to 50 years with NSCLBP were randomized into either the experimental group (multidimensional physiotherapy) or the active control group (usual physiotherapy). Pain intensity was measured as the primary outcome. Disability, quality of life, pain Catastrophizing, kinesiophobia, fear Avoidance Beliefs, active lumbar range of motion, and brain function were measured as secondary outcomes. The outcomes were measured at pre-treatment, post-treatment, 10, and 22 weeks. Data were analyzed using intention-to-treat approaches.

RESULTS

There were 17 men and 18 women in the experimental group (mean [SD] age, 34.57 [6.98] years) and 18 men and 17 women in the active control group (mean [SD] age, 35.94 [7.51] years). Multidimensional physiotherapy was not more effective than usual physiotherapy at reducing pain intensity at the end of treatment. At the 10 weeks and 22 weeks follow-up, there were statistically significant differences between multidimensional physiotherapy and usual physiotherapy (mean difference at 10 weeks, -1.54; 95% CI, -2.59 to -0.49 and mean difference at 22 weeks, -2.20; 95% CI, - 3.25 to - 1.15). The standardized mean difference and their 95% confidence intervals (Cohen's d) revealed a large effect of pain at 22 weeks: (Cohen's d, -0.89; 95% CI (-1.38 to-0.39)). There were no statistically significant differences in secondary outcomes.

CONCLUSIONS

In this randomized controlled trial, multidimensional physiotherapy resulted in statistically and clinically significant improvements in pain compared to usual physiotherapy in individuals with NSCLBP at 10 and 22 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04270422; IRCT IRCT20140810018754N11.

[Is the relationship between depressive symptoms and work-related factors mediated by pain self-efficacy in non-specific chronic low back pain?]

BACKGROUND

The transition from acute to non-specific chronic low back pain (CLBP) is especially associated with psychological factors. However, working mechanisms of psychological factors have been little examined in non-specific CLBP, especially the mediator effect of pain self-efficacy.

OBJECTIVE

Does pain self-efficacy mediate the long-term prediction of work-related factors by depressive symptoms?

METHODS

Within the framework of an exploratory secondary analysis, simple mediation analyses were conducted to longitudinally predict prognosis of gainful employment, as well as subjective physical and mental work ability by depressive symptoms mediated by pain self-efficacy in 382 inpatients with non-specific CLBP.

RESULTS

The findings suggest that depressive symptoms prior to rehabilitation predicted levels of all three work-related factors 24 months after rehabilitation, and pain self-efficacy 12 months after rehabilitation mediated this relationship.

CONCLUSION

To improve the success of work-related rehabilitation in the long-term, pain self-efficacy in particular, but also depressive symptoms should be targeted by treatments of non-specific CLBP.

[Debora: Long-Term Effectiveness of an Inpatient Combined Pain Competence and Depression Prevention Training for Non-Specific Chronic Low Back Pain and Depressive Symptoms]

OBJECTIVE

To investigate the effects of an intervention for pain competence and depression prevention for multidisciplinary inpatient rehabilitation of non-specific chronic low back pain on psychological and work-related outcomes over a 2-year period.

METHODS

This prospective randomized controlled multicenter trial evaluated the effects of pain competence training with and without depression prevention on depressive symptoms (General Depression Scale; ADS; primary outcome), anxiety (Hospital Anxiety and Depression Scale), pain self-efficacy (Pain Self-Efficacy Questionnaire) and subjective prognosis of gainful employment (SPE; secondary outcomes) in n=422 patients aged 32-64 years from four rehabilitation clinics. Per protocol analyses were conducted. In the three-factorial design with a repeated-measures factor, patients were stratified by treatment condition; the control group (CG) received only pain management training but the intervention group (IG) was additionally treated with depression prevention training (Debora). Based on the ADS, patients were assigned to without or low depressive symptoms (ADS<23; n=208) and medium or high depressive symptoms (ADS≥23; n=214). The fivefold repeated-measures factor included the following sample points: admission, immediately after and 6, 12, and 24 months after rehabilitation. Per protocol results of univariate 2×2×5 analyses of variance were validated by n=1225 multiple imputed data.

RESULTS

No significant effects of treatment condition over the 2-year period were yielded in the primary outcome "depressive symptoms", but only patients with the combined training Debora benefited in pain self-efficacy in the long term. Intention-to-treat analyses suggest incremental effects of Debora on pain self-efficacy and anxiety at 24-month follow-up. In the long term, patients with high levels of depressive symptoms improved exclusively in depressive symptoms or they benefited more than patients with low depression in anxiety. However, favorable effects receded in general from post rehabilitation to 24-month follow-up.

DISCUSSION

 The results support that a disorder-specific depression prevention training is needed for the long-term improvement in pain self-efficacy, which is considered a crucial psychological protective factor in pain chronification. Findings on depressive symptoms support the effectiveness of multidisciplinary inpatient rehabilitation in high depression, but also the great importance of early treatment of depressive symptoms.

CONCLUSION

 Overall, the results strengthen the need to implement psychotherapeutic treatment elements and, in particular, cognitive-behavioral methods and, moreover, a systematic allocation of patients to needs-based treatments in order to improve long-term effects.

Long-term effects of rehabilitation and prevention of further chronification of pain among patients with non-specific low back pain

BACKGROUND

Psychological factors influence the development and persistence of chronic low back pain (CLBP) and may impair the psychosocial rehabilitation success.

OBJECTIVE

To examine the effects of a combined pain competence and depression prevention training compared to the pain competence training alone and as well as the patients' stages of pain on the long-term psychosocial rehabilitation success.

METHODS

In this controlled multicentre study with cluster-block randomization, patients with CLBP in different stages of pain (I-III) received either pain competence training (control group, CG; n= 255) or combined pain competence and depression prevention training (intervention group, IG; n= 271; per protocol). Depressive symptoms (primary outcome), anxiety, somatization, health status, and average pain intensity (secondary outcomes) were assessed up to 12 months of follow-up. Standardised questionnaires were used to record the outcomes, which were filled out by the patients themselves. Analyses after multiple imputation (N= 1225) were conducted to validate multi- and univariate analyses of variance.

RESULTS

Patients in stage of pain I and II showed significant improvements in depressive symptoms, anxiety, mental health, and average pain intensity at the 12-month follow-up, irrespective from treatment condition.

CONCLUSIONS

Multidisciplinary rehabilitation seems to be appropriate for patients with CLBP in stage of pain I and II. However, patients in stage of pain III need more psychological treatments to manage their mental comorbidities.

Interprofessional collaboration and patient-reported outcomes in inpatient care: a systematic review

BACKGROUND

Interprofessional collaboration (IPC) is seen as the "gold standard" of comprehensive care, but credible evidence concerning the effects on patient-reported outcomes (PRO) is lacking. The aim of this systematic review is to study the effect of IPC on PRO in inpatient care.

METHODS

We systematically searched six electronic databases (PubMed, Web of Science/Social Science Citation Index, CENTRAL (Cochrane Library), Current Contents (LIVIVO), CINAHL, and Embase) for studies published between 1997 and 2021. Additional studies were identified through citation tracking, manually searching the Internet and Google Scholar, and consultation of experts. Risk of bias (RoB) was assessed using the RoB 2 tool for randomized controlled trials (RCTs) and ROBINS-I for non-randomized studies (NRS). The included controlled before-and-after study (CBA) was assessed using both the ROBINS-I and the Effective Practice and Organization of Care (EPOC) quality criteria. Results were synthesized through narrative description, grouping, and thematic analysis of extracted data.

RESULTS

The search yielded 10,213 records, from which 22 studies (16 RCTs, five NRS, and one CBA) fulfilled the inclusion criteria. In all but five studies, RoB was assessed as being high (RoB 2) resp. critical or serious (ROBINS-I). Within these 22 studies, nine inductively derived outcomes were assessed: (i) quality of life, (ii) coping, (iii) functional ability and health status, (iv) psychiatric morbidity, (v) pain, (vi) managing one's own health care, (vii) treatment success, (viii) satisfaction, and (ix) therapeutic relationship. While some studies do not report effect estimates, and some of the reported effects appear to be imprecisely estimated, the overall results indicate that IPC may affect PRO positively across all outcomes.

CONCLUSIONS

Due to high clinical heterogeneity and high RoB, the question whether IPC affects PRO cannot be answered conclusively. Methodically rigorous studies are needed in order to answer the question of effectiveness of IPC.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017073900.

Health care providers' understanding of self-management support for people with chronic low back pain in Ethiopia: an interpretive description

BACKGROUND

Healthcare providers play a key role in supporting people with chronic low back pain to self-manage their condition. The study aimed at exploring how health care providers understand and conceptualize self-management and how they provide self-management support for people with chronic low back pain in Ethiopia.

METHODS

Health care providers who have supported people with low back pain, including medical doctors and physiotherapists, were approached and recruited from three hospitals in Ethiopia. This study employed an interpretive descriptive approach using semi-structured interviews.

FINDINGS

Twenty-four participants (7 women; 17 men) with a median age of 28 (range 24 to 42) years and a median of 9.5 years (range 1 to 11 years) of helping people with chronic low back pain were interviewed. Seven major themes related to health care providers' understanding of self-management support for people with chronic low back pain in Ethiopia emerged. The findings show that self-management was a new concept to many and health care providers' had a fragmented understanding of self-management. They used or suggested several self-management support strategies to help people with CLBP self-manage their condition without necessarily focusing on enhancing their self-efficacy skills. The participants also discussed several challenges to facilitate self-management support for people with chronic low back pain. Despite the lack of training on the concept, the providers discussed the potential of providing self-management support for people with the condition.

CONCLUSIONS

Self-management was a new concept to health care providers. The providers lack the competencies to provide self-management support for people with chronic low back pain. There is a need to enhance the health care providers' self-management support competencies through training.

Longitudinal outcome evaluations of Interdisciplinary Multimodal Pain Treatment programmes for patients with chronic primary musculoskeletal pain: A systematic review and meta-analysis

Background and objectives

Although Interdisciplinary Multimodal Pain Treatment (IMPT) programmes share a biopsychosocial approach to increase the wellbeing of patients with chronic pain, substantial variation in content and duration have been reported. In addition, it is unclear to what extent any favourable health outcomes are maintained over time. Therefore, our first aim was to identify and analyse the change over time of patient‐related outcome measures in cohorts of patients who participated in IMPT programmes. Our second aim was to acquire insight into the heterogeneity of IMPT programmes.

Databases and data treatment

The study protocol was registered in Prospero under CRD42018076093. We searched Medline, Embase, PsycInfo and Cinahl from inception to May 2020. All study selection, data extraction and risk of bias assessments were independently performed by two researchers. Study cohorts were eligible if they included adult patients with chronic primary musculoskeletal pain for at least 3 months. We assessed the change over time, by calculating pre‐post, post‐follow‐up and pre‐follow‐up contrasts for seven different patient‐reported outcome domains. To explore the variability between the IMPT programmes, we summarized the patient characteristics and treatment programmes using the intervention description and replication checklist.

Results

The majority of the 72 included patient cohorts significantly improved during treatment. Importantly, this improvement was generally maintained at follow‐up. In line with our expectations and with previous studies, we observed substantial methodological and statistical heterogeneity.

Conclusions

This study shows that participation in an IMPT programme is associated with considerable improvements in wellbeing that are generally maintained at follow‐up. The current study also found substantial heterogeneity in dose and treatment content, which suggests different viewpoints on how to optimally design an IMPT programme.

Significance

The current study provides insight into the different existing approaches regarding the dose and content of IMPT programs. This analysis contributes to an increased understanding of the various approaches by which a biopsychosocial perspective on chronic pain can be translated to treatment programs. Furthermore, despite theoretical and empirical assertions regarding the difficulty to maintain newly learned health behaviors over time, the longitudinal analysis of health outcomes did not find a relapse pattern for patients who participated in IMPT programs

Volitional Action Control and Depression in Chronic Pain: Does Action versus State Orientation Moderate the Relations of Pain-Related Cognitions to Depression?

In this study, we examined the conditional indirect and direct relations of pain-related cognitions to depression. Subjective helplessness was included as presumably mediating the relations of catastrophizing and thought suppression to depression due to motivational deficits. In addition, moderating effects of dispositional action versus state orientation were analyzed, whereby state orientation indicates volitional deficits in coping with distress. The study was based on self-report data from 536 patients with chronic non-specific low back pain at the beginning of inpatient rehabilitation. Moderated mediation analyses were performed. The indirect catastrophizing- and thought suppression-depression relations were (partially) mediated by subjective helplessness; and moderated by failure-related action versus state orientation. Moreover, action versus state orientation moderated the direct relation of thought suppression to depression. Results suggest that catastrophizing, thought suppression, and subjective helplessness do not lead to depression unless associated with self-regulatory inability (i.e., state orientation). In contrast, action-oriented patients more effectively self-regulate pain-related emotions, disengage from rumination, and distract from pain and thus better avoid the debilitating effects of negative pain-related cognitions on depression. Future research and treatment may more strongly focus on the role of motivational and volitional deficits underlying learned helplessness and depression in chronic pain.

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.

Effects of behavioural exercise therapy on the effectiveness of multidisciplinary rehabilitation for chronic non-specific low back pain: a randomised controlled trial

Background

The long-term effects of behavioural medical rehabilitation (BMR), as a type of multidisciplinary rehabilitation, in the treatment of chronic non-specific low back pain (CLBP) have been shown. However, the specific effects of behavioural exercise therapy (BET) compared to standard exercise therapy (SET) within BMR are not well understood. The aim of the study was to assess the effectiveness of BMR + BET compared to BMR + SET in individuals with CLBP in a two-armed, pre-registered, multicentre, parallel, randomised controlled trial (RCT).

Methods

A total of 351 adults with CLBP in two rehabilitation centres were online randomised based on an ‘urn randomisation’ algorithm to either BMR + SET (n = 175) or BMR + BET (n = 176). Participants in both study groups were non-blinded and received BMR, consisting of an multidisciplinary admission, a psychosocial assessment, multidisciplinary case management, psychological treatment, health education and social counselling. The intervention group (BMR + BET) received a manualised, biopsychosocial BET within BMR. The aim of BET was to develop self-management strategies in coping with CLBP. The control group (BMR + SET) received biomedical SET within BMR with the aim to improve mainly physical fitness. Therapists in both study groups were not blinded. The BMR lasted on average 27 days, and both exercise programmes had a mean duration of 26 h. The primary outcome was functional ability at 12 months. Secondary outcomes were e.g. pain, avoidance-endurance, pain management and physical activity. The analysis was by intention-to-treat, blinded to the study group, and used a linear mixed model.

Results

There were no between-group differences observed in function at the end of the BMR (mean difference, 0.08; 95% CI − 2.82 to 2.99; p = 0.955), at 6 months (mean difference, − 1.80; 95% CI; − 5.57 to 1.97; p = 0.349) and at 12 months (mean difference, − 1.33; 95% CI − 5.57 to 2.92; p = 0.540). Both study groups improved in the primary outcome and most secondary outcomes at 12 months with small to medium effect sizes.

Conclusion

BMR + BET was not more effective in improving function and other secondary outcomes in individuals with CLBP compared to BMR + SET.

Trial registration

Current controlled trials NCT01666639, 16/08/2012.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04353-y.

Endurance and avoidance response patterns in pain patients: Application of action control theory in pain research

BACKGROUND

Identifying pain-related response patterns and understanding functional mechanisms of symptom formation and recovery are important for improving treatment.

OBJECTIVES

We aimed to replicate pain-related avoidance-endurance response patterns associated with the Fear-Avoidance Model, and its extension, the Avoidance-Endurance Model, and examined their differences in secondary measures of stress, action control (i.e., dispositional action vs. state orientation), coping, and health.

METHODS

Latent profile analysis (LPA) was conducted on self-report data from 536 patients with chronic non-specific low back pain at the beginning of an inpatient rehabilitation program. Measures of stress (i.e., pain, life stress) and action control were analyzed as covariates regarding their influence on the formation of different pain response profiles. Measures of coping and health were examined as dependent variables.

RESULTS

Partially in line with our assumptions, we found three pain response profiles of distress-avoidance, eustress-endurance, and low-endurance responses that are depending on the level of perceived stress and action control. Distress-avoidance responders emerged as the most burdened, dysfunctional patient group concerning measures of stress, action control, maladaptive coping, and health. Eustress-endurance responders showed one of the highest levels of action versus state orientation, as well as the highest levels of adaptive coping and physical activity. Low-endurance responders reported lower levels of stress as well as equal levels of action versus state orientation, maladaptive coping, and health compared to eustress-endurance responders; however, equally low levels of adaptive coping and physical activity compared to distress-avoidance responders.

CONCLUSIONS

Apart from the partially supported assumptions of the Fear-Avoidance and Avoidance-Endurance Model, perceived stress and dispositional action versus state orientation may play a crucial role in the formation of pain-related avoidance-endurance response patterns that vary in degree of adaptiveness. Results suggest tailoring interventions based on behavioral and functional analysis of pain responses in order to more effectively improve patients quality of life.

Physical activity and health promotion for nursing staff in elderly care: a study protocol for a randomised controlled trial

INTRODUCTION

Nursing staff is burdened by high workload and stress. Furthermore, heavy lifting, as well as transferring nursing home residents, cause lumbar tissue damage and back pain. Exercise intervention studies to reduce work-related problems are rare and the evidence for efficacy of studies among nurses is limited. Studies including targeted analysis of requirements are necessary to generate effective recommendations and tailored interventions for health promotion programmes. The purpose of this multicentred intervention study is to identify work-related problems, to implement health promotion programmes and to evaluate their effectiveness.

METHODS AND ANALYSIS

A randomised controlled trial will be conducted, including a total of 48 nursing home facilities in eight regions of Germany with an estimated sample size of 700 nurses. Standardised ergonomics and posture training (10 weeks, once a week for 20-30 min) and subsequently, back-fitness training (12 weeks, once a week for 45-60 min) will be administered. Following the implementation of standardised health promotion programmes, further demand-oriented interventions can be implemented. The perceived exposure to work-related demands, work-related pain in different parts of the body, health-related quality of life, perceived stress, work-related patterns of behaviour and experience, presentism behaviour, work environment as well as general needs and barriers to health promotion, will be assessed at baseline (pre-test), at 10 weeks (post-test, after ergonomics training), at 22 weeks (post-test, after back-fitness training) and at 34 weeks of the programme (follow-up).

ETHICS AND DISSEMINATION

The study was reviewed and approved by the local ethics committee of the University of Hamburg (AZ: 2018_168). The results of the study will be published in open-access and international journals. Furthermore, the results will be presented in the participating nursing homes and at national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS.de (DRKS00015241).

Pain rehabilitation's dual power: Treatment for chronic pain and prevention of opioid-related risks

The purpose of this article is to provide a data-driven exploration of an interdisciplinary pain rehabilitation program (PRP) as a viable option for addressing the dual crises of chronic pain and opioid use. Psychologists are crucial providers in the PRP, in both intervention and leadership roles. There is well-established literature supporting pain rehabilitation as an effective treatment for chronic pain and functioning, but there are few studies examining the effects of pain rehabilitation on opioid misuse risk. We evaluated data from 60 patients with diverse chronic pain conditions who completed an interdisciplinary PRP to evaluate changes in pain, functioning (self-report and objective physical measure), psychological symptoms, and health-related quality of life. To evaluate the effect of pain rehabilitation on opioid-related risks, we examined opioid use and opioid misuse behaviors (measured by the Current Opioid Misuse Measure; COMM) pre- and posttreatment. Results demonstrated statistically significant improvements in all outcomes, with medium effect sizes for pain severity and large effect sizes for functioning, psychological symptoms, and emotional quality of life. Fifty-eight percent of patients were on opioid medications at entry compared with 15% at discharge. Among patients who entered on opioids, mean COMM scores were significantly reduced from above the cutoff for misuse risk (M = 13.57) to below the cutoff (M = 5.86). Overall, this study provided strong support for pain rehabilitation as an effective treatment for chronic pain and related suffering, while also providing a prevention-based opportunity for reducing opioid-related risk. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

'It's very complicated': Perspectives and beliefs of newly graduated physiotherapists about the biopsychosocial model for treating people experiencing non-specific low back pain in Brazil

Non-specific low back pain is a common complaint frequently presented by patients and this complex clinical condition has challenged the biomedical model. The Biopsychosocial (BPS) model is recognized as an option for better guidance and patient management. However, physiotherapy training is based on the biomedical perspective, added to which, in clinical practice the applicability of the BPS model is a challenge for many professionals. In this article, we explore the feelings, beliefs, and attitudes of newly trained physiotherapists about using the BPS model to treat people with non-specific low back pain. It also aims to understand to what extent these physiotherapists are willing and prepared to use this model. Method: A qualitative phenomenological research was carried out in the Brazilian federal capital. A set of criteria was used to select 10 physiotherapists. The data were collected through semi-structured interviews and analyzed using five steps: familiarization, identification, indexation, mapping, and interpretation. Results: We identified one theme and three categories. The theme 'a practitioner physiotherapist can consider BPS aspects, but it is not necessary in his/her role to approach them' explains a shared belief about the use of BPS. The theme is better understood when looking at the three categories that explore and exemplify key elements of the theme: (i) understanding the BPS model and its relation to non-specific low back pain; (ii) the role of practitioner physiotherapists regarding the BPS model; and (iii) barriers: from undergraduate training to clinical settings.

Comorbid chronic pain and opioid use disorder: literature review and potential treatment innovations

Chronic pain (CP) and opioid use disorder (OUD) remain challenging complex public health concerns. This is an updated review on the relationship between CP and OUD and the use of stepped care models for assessment and management of this vulnerable population. A literature search was conducted from 2008 to the present in PubMed, Embase, and PsycInfo using the terms pain or chronic pain and opioid-related disorders, opiate, methadone, buprenorphine, naltrexone, opioid abuse, opioid misuse, opioid dependen*, heroin addict, heroin abuse, heroin misuse, heroin dependen*, or analgesic opioids, and stepped care, integrated services, multidisciplinary treatment, or reinforcement-based treatment. Evidenced-based data exists on the feasibility, implementation, and efficacy of stepped care models in primary care settings for the management of CP and opioid use. Although these studies did not enroll participants with OUD, they included a sub-set of patients at risk for the development of OUD. There remains a dearth of treatment options for those with comorbid CP and OUD. Future research is needed to explore the aetiology and impact of CP and OUD, and greater emphasis is needed to improve access to comprehensive pain and substance use programmes for high-risk individuals.

Self-management education for rehabilitation inpatients: A cluster-randomized controlled trial

OBJECTIVE

To evaluate generic self-management modules (SelMa) as an adjunct to disease-specific educational programs during inpatient medical rehabilitation.

METHODS

A bi-center cluster-randomized controlled trial with 698 patients with coronary artery disease, metabolic syndrome, or inflammatory bowel disease was conducted. We compared two versions of SelMa, a group with 3 h or a lecture with 1 h, respectively, in addition to disease-related patient education, to usual care (only disease-related education). SelMa aims at providing skills that may help implementing health behavior. The primary outcomes were goal setting and behavior planning at discharge and goal attainment and health behavior at 6- and 12-months follow-up. Secondary outcomes included motivation, knowledge and self-management competences.

RESULTS

At discharge, SelMa group, but not SelMa lecture, proved superior to usual care regarding goal setting (p = 0.007, d = 0.26), but not behavior planning (p = 0.37, d = 0.09). Significant effects were also observed on several secondary outcomes. At later follow-up, however, no effects on primary outcomes emerged. Participants' satisfaction was higher in the group than the lecture format.

CONCLUSIONS

These short modules did not succeed in improving self-management skills in the long-term.

PRACTICE IMPLICATIONS

A self-management group may foster self-management skills in short term. Interventions should be developed to increase sustainability of effects.

Characterizing the demographics of chronic pain patients in the state of Maine using the Maine all payer claims database

BACKGROUND

Chronic pain is currently a significant health problem in the United States. A comprehensive strategy is needed to increase prevention of chronic pain and to improve care for chronic pain patients. However, development of a successful strategy relies, in part, on a better understanding of the demographics and socioeconomics of patients living with chronic pain conditions. The current study was designed to understand the burden of chronic pain in the state of Maine by identifying the prevalence of chronic pain and its relationship with selected demographic and socioeconomic factors in Maine.

METHODS

The Maine All Payer Claims Database (MEAPCD) (2006-2011) was used in the secondary data analysis to assess the demographic characteristics (such as age, sex, insurance type, and county of residence) of chronic pain patients in Maine. Chronic pain patients were identified based on the presence of pre-identified chronic pain-associated ICD-9 code(s) and opioid prescription information. Potential associations between the prevalence of chronic pain and a number of socioeconomic factors were determined by comparisons to Maine Census data.

RESULTS

More women in the state were identified as having chronic pain across all counties and all age groups (> 10 years old). Surprisingly, the majority of chronic pain patients were identified based on the diagnostic code criteria and not the opioid prescription criteria. A greater utilization of public health insurance was seen within the chronic pain patients. At the county level, although neither education level nor income were associated with the prevalence of chronic pain, these factors significantly correlated with the usage of public health insurance.

CONCLUSIONS

Further detailed characterization of the chronic pain patient population in the state of Maine, using multiple data sources, can help design population-targeted strategies to prevent and manage chronic pain.

Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma

BACKGROUND

Over 100 million Americans are living with chronic pain, and pain is the most common reason that patients seek medical attention. Despite the prevalence of pain, the practice of pain management and the scientific discipline of pain research are relatively new fields compared to the rest of medicine - contributing to a twenty-first century dilemma for health care providers asked to relieve suffering in the "Fifth Vital Sign" era.

METHODS

This manuscript provides a narrative review of the basic mechanisms of chronic pain and history of chronic pain management in the United States - including the various regulatory, health system and provider factors that contributed to the decline of multidisciplinary pain treatment in favor of the predominant opioid treatment strategy seen today. Multiple non-opioid pain treatment strategies are then outlined. The manuscript concludes with three key questions to help guide future research at the intersection of pain and addiction.

CONCLUSIONS

The assessment and treatment of chronic pain will continue to be one of the most common functions of a health care provider. To move beyond an over reliance on opioid medications, the addiction and pain research communities must unite with chronic pain patients to increase the evidence base supporting non-opioid analgesic strategies.

Gesundheitskompetenz durch Patientenschulungen – ein Überblick

Chronisch Kranke benötigen Kompetenzen, die sie dazu befähigen, möglichst selbstbestimmt mit ihrer Erkrankung umzugehen (Selbstmanagement). Solche Kompetenzen können durch Patientenschulungen vermittelt werden (Empowerment). Kontrollierte Studien konnten Effekte innovativer, interaktiver Schulungsprogramme auf Gesundheitskompetenz und Selbstmanagement-Outcomes nachweisen. Außerdem zeigte sich, dass Verbesserungen der Gesundheitskompetenz Verbesserungen der Lebensqualität mit sich bringen.