Assessing multidisciplinary follow-up pattern efficiency and cost in follow-up care for patients in cervical spondylosis surgery: a non-randomized controlled study

Background

The use of multidisciplinary treatment programs in out-of-hospital healthcare is a new area of research. Little is known about the benefits of this method in the management of discharged patients undergoing cervical spondylosis surgery.

Objective

This study aimed to explore the effect of a contracted-based, multidisciplinary follow-up plan in patients after cervical spondylosis surgery.

Methods

This non-blinded non-randomized controlled study was conducted with 88 patients (44 in the intervention group, 44 in the control group). The clinical outcomes, including Neck Disability Index (NDI), pain score (VAS), Self-Efficacy for Managing Chronic Disease 6-item Scale (SECD-6), and 12-Item Short-Form Health Survey (SF-12) score were assessed at the time of discharge, 24-72 h, 1 month, and 3 months post-discharge. The complications, patient satisfaction, and economic indicators were assessed at the final follow-up (3 months).

Results

Patients who received contracted follow-up showed greater improvement in neck dysfunction at 24-72 h, 1 month, and 3 months after discharge compared to those who received routine follow-up (p < 0.001). At 1 month after discharge, the intervention group exhibited better self-efficacy (p = 0.001) and quality of life (p < 0.001) than the control group, and these improvements lasted for 3 months. The intervention group reported lower pain scores at 24-72 h and 1 month (p = 0.008; p = 0.026) compared to the control group. The incidence of complications was significantly lower in the intervention group (11.4%) compared to the control group (40.9%). The total satisfaction score was significant difference between the two groups (p < 0.001). Additionally, the intervention group had lower direct medical costs (p < 0.001), direct non-medical costs (p = 0.035), and total costs (p = 0.04) compared to the control group. However, there was no statistically significant difference in indirect costs between the two groups (p = 0.59).

Conclusion

A multidisciplinary contract follow-up plan has significant advantages regarding neck disability, self-efficacy, quality of life, postoperative complications, patient satisfaction, and direct costs compared with routine follow-up.

Multidisciplinary rehabilitation with a focus on physiotherapy in patients with Post Covid19 condition: an observational pilot study

There is a lack of interventions that treat the Post-Covid-19 Condition (PCC) itself. Accordingly, treatment guidelines recommend physiotherapy interventions to alleviate symptoms and enhance functioning. In cases where unimodal treatments prove ineffective, non-organ-specific multidisciplinary bio-psycho-social rehabilitation (MBR) programs are a suitable option. In a pilot observational study with assessments at the entry and end of treatment we aimed to evaluate the feasibility of a 3-week day clinic MBR program and explore its effects on physical functioning in PCC patients with fatigue and reduced physical capacity. Patient selection was based on an interdisciplinary assessment involving a physician, a psychologist and a physiotherapist. Feasibility was determined based on full participation (≥ 8 of 9 days) and maintenance of stable endurance in the 6-Minute Walk Test (6MWT). From 37 patients included in the study, 33 completed the MBR (mean age: 43 ± 12 years, 73% female). Four patients discontinued the MBR, with two of them having reported deterioration of PCC symptoms. The 6MWT showed a numerical improvement from 501 ± 97 m to 512 ± 87 m, although it did not reach statistical significance. These results support the feasibility of outpatient MBR with a focus on active physiotherapy interventions in PCC patients with fatigue. This study aligns with previous research supporting the effectiveness of physiotherapy and rehabilitation in PCC patients. However, further research is needed to address possible different treatment responses and varying treatment approaches in subgroups of PCC patients.

Effectiveness of multimodal exercises integrated with cognitive-behavioral therapy in working patients with chronic neck pain: protocol of a randomized controlled trial with 1-year follow-up

Background

The etiology of neck pain is multifactorial and includes personal and work-related factors such as age, sex, wrong postures, and repeated strains. Studies based on bio-psychosocial model also link chronic neck pain to psychological factors. Over time, the use of multidisciplinary interventions for chronic neck pain has grown in order to improve disability, pain, and adaptive cognitions and behaviors towards patients’ problems. The objective is to evaluate the effectiveness of an individual-based multidisciplinary rehabilitation program that integrates cognitive-behavioral therapy focused on kinesiophobia with specific exercises in the treatment of patients with chronic neck pain, employed in different working activities.

Methods

A randomized, parallel-group superiority-controlled trial will be conducted with 1-year follow-up. One hundred seventy patients engaged in several working activities (blue collar and white collar workers) will be randomly allocated to either the experimental (receiving a multidisciplinary rehabilitation program combining multimodal exercises with psychologist-lead cognitive-behavioral therapy sessions) or the control group (receiving general care physiotherapy). Both groups will follow individual-based programs once a week for 10 weeks. The main outcome measures will be the Neck Disability Index, the Tampa Scale for Kinesiophobia, the Pain Catastrophizing Scale, a pain numerical rating scale, the Short-Form Health Survey, and the Work Ability Index. Participants will be evaluated before, after training, and after 12 months.

Discussion

Findings may provide empirical evidence on the effectiveness of an individual-based multidisciplinary rehabilitation program on inducing clinically significant and long-term improvements in the disability, pain, psychological factors, and quality of life of workers with chronic neck pain and that these would be maintained in the long term. Hence, this trial might contribute towards refining guidelines for good clinical practice and might be used as a basis for health authorities’ recommendations.

Trial registration

ClinicalTrials.gov NCT04768790. Registered on 24 February 2021

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

Cervical fusion for treatment of degenerative conditions: development of appropriate use criteria

BACKGROUND CONTEXT

High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) are a means of determining appropriate recommendations when high quality evidence is lacking.

PURPOSE

Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine.

STUDY DESIGN/SETTING

Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations.

OUTCOME MEASURES

Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters.

METHODS

Inclusion criteria for scenarios included patients aged 18 to 80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed.

RESULTS

Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, p<.01). A multivariable ordinal regression adjusting for symptom type, diagnosis, and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance.

CONCLUSIONS

Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."

Is multidisciplinary rehabilitation for low back pain effective in patients above 65 years? An observational cohort study with 12-month follow-up

BACKGROUND

In contrast to the broad evidence for the effectiveness of multidisciplinary biopsychosocial rehabilitation (MBR) in chronic low back pain (CLBP) patients of working age, little is known about the benefit in patients aged ≥ 65 years.

AIM

To quantify the short-term and 12-month effects of a 3-week CLBP specific MBR program in patients ≥ 65 years of age; to compare the effects in patients ≥ 65 years of age to the effects in younger patients.

DESIGN

Observational prospective cohort study.

SETTING

Outpatient clinic at a tertiary physical medicine and rehabilitation centre.

POPULATION

Consecutive patients with CLBP who participated in a CLBP a specific MBR program.

METHODS

The 3-week MBR program included 44 hours of treatment. The primary outcomes pain and disability were measured by the North American Spine Society Questionnaire (NASS). Secondary outcome measures were the Short-Form 36 (SF-36) and the numerical rating scale for pain. Effects were quantified using effect sizes (ES).

RESULTS

From 203 included patients, 104 patients older than 65 years (mean: 70.7; SD: 4.0) were compared to 99 patients younger than 65 years (mean: 56.4; SD: 6.7). The older patients had more comorbidities (two or more comorbidities: 49.5% versus 23.5%; p < 0.001). Both groups showed significant improvements in pain and disability at discharge (both groups: p<0.001) and at the 12 months' follow-up (old: p < 0.001; young: 0.039) with slightly higher effects for the older patients compared to the younger patients (discharge: ES = 0.67 versus ES = 0.53; 12 months: ES = 0.42 versus ES = 0.29). Both groups also improved in the SF-36 Physical Component Summary with slightly lower effects for the older patients (discharge: ES =0.31, p<0.001 versus ES=0.43, p<0.001; 12 months: ES=0.27, p=0.025 versus ES=0.39, p=0.001). The group differences of the change scores were not significant in any of the outcome measures.

CONCLUSIONS

MBR shows similar improvements in pain and disability in patients aged ≥ 65 compared to younger patients for at least 12 months.

CLINICAL REHABILITATION IMPACT

The findings support the concept of MBR in the growing population of CLBP patients older than 65 years of age.

Prognostic factors for the improvement of pain and disability following multidisciplinary rehabilitation in patients with chronic neck pain

Background

Recent clinical studies have demonstrated the effectiveness of specific, multidisciplinary, bio-psychosocial, rehabilitation programmes for chronic neck pain. However, prognostic factors for the improvement of pain and disability are mostly unknown. Therefore, the aim of this study was to explore prognostic factors associated with improvements in chronic neck pain following participation in a three-week, multidisciplinary, bio-psychosocial, rehabilitation programme.

Methods

In this observational, prospective cohort study, a total of 112 patients were assessed at the beginning, end, and 6 months following the completion of a multidisciplinary, bio-psychosocial, rehabilitation programme. Inclusion for participation in the rehabilitation programme depended upon an interdisciplinary pain assessment. The primary outcome was neck pain and disability, which was measured using the Northern American Spine Society questionnaire for pain+disability and was quantified with effect sizes (ES). Multivariable linear regression analyses were used to explore potential prognostic factors associated with improvements in pain and disability scores at discharge and at the 6-month follow-up period.

Results

The mean age of the patients was 59.7 years (standard deviation = 10.8), and 70.5% were female. Patients showed improvement in pain+disability at discharge (ES = 0.56; p < 0.001), which was sustained at the 6-month follow-up (ES = 0.56; p < 0.001). Prognostic factors associated with improvement in pain+disability scores at discharge included poor pain+disability baseline scores (partial, adjusted correlation r = 0.414, p < 0.001), older age (r = 0.223, p = 0.024), a good baseline cervical active range-of-motion (ROM) (r = 0.210, p < 0.033), and improvements in the Short-form 36 mental health scale (r = 0.197; p = 0.047) and cervical ROMs (r = 0.195, p = 0.048) from baseline values. Prognostic factors associated with improvements in pain+disability at the 6-month follow-up were similar and included poor pain+disability baseline scores (partial, adjusted correlation r = 0.364, p < 0.001), improvements in the Short-form 36 mental health scale (r = 0.232; p = 0.002), cervical ROMs (r = 0.247, p = 0.011), and better cervical ROM baseline scores. However, older age was not a factor (r = 0.134, p = 0.172).

Conclusions

Future prognostic models for treatment outcomes in chronic neck pain patients should consider cervical ROM and mental health status. Knowledge of prognostic factors may help in the adoption of individualized treatment for patients who are less likely to respond to multidisciplinary rehabilitation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04194-9.

The effects of whole-body electromyostimulation (WB-EMS) in comparison to a multimodal treatment concept in patients with non-specific chronic back pain-A prospective clinical intervention study

Background

According to present guidelines, active exercise is one key component in the comprehensive treatment of nonspecific chronic back pain (NSCBP). Whole body electromyostimulation (WB-EMS) is a safe, and time-effective training method, that may be effective in NSCBP-patients.

Methods

In this prospective and controlled nonrandomized clinical study, two therapeutic approaches were compared. One group received 20 minutes WB-EMS per week. An active control group (ACG) received a multimodal therapy program. A third group included subjects without back pain. To all groups, the following measurement instruments were applied: Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), North American Spine Society Instrument (NASS); SF 36 survey and measurements for muscular function and postural stability. In the EMS-group: T0: baseline; T1: at 6 weeks; T2: at 12 weeks and T3: at 24 weeks. In the ACG: T0 baseline and T1 after 4 weeks.

Results

In the intervention group, 128 patients with low back pain were enrolled, 85 in the WB-EMS group and 43 in the ACG. 34 subjects were allocated to the passive control group. The average age was 58.6 years (18–86 years). In the EMS group, the NRS (1–10) improved statistically and clinically significantly by 2 points. The ODI was reduced by 19.7 points. The NASS and most of the SF 36 items improved significantly. In the multimodal treatment group, only the muscular function improved slightly.

Conclusion

Our data support the hypothesis that WB-EMS is at least as effective as a multimodal treatment, which is often referred to as being the golden standard. Therefore WB-EMS may be an effective and, with 20 min./week training time, very time-efficient alternative to established multimodal treatment models.

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.

Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP)

Examination of a patient with chronic low back pain (LBP) is aimed at eliminating its specific cause and assessing the social and psychological factors of chronic pain. The diagnosis of chronic nonspecific (musculoskeletal) LBP is based on the exclusion of a specific cause of pain, discogenic radiculopathy, and lumbar stenosis. It is advisable to identify possible pain sources: pathology of intervertebral disc pathology, facet joints, and sacroiliac joint and myofascial syndrome.

An integrated multidisciplinary approach (a high level of evidence), including therapeutic exercises, physical activity optimization, psychological treatments (cognitive behavioral therapy), an educational program (back pain school for patients), and manual therapy, is effective in treating chronic musculoskeletal LBP. For pain relief, one may use nonsteroidal anti-inflammatory drugs in minimally effective doses and in a short cycle, muscle relaxants, and a capsaicin patch, and, if there is depressive disorder, antidepressants (a medium level of evidence). Radiofrequency denervation or therapeutic blockages with anesthetics and glucocorticoids (damage to the facet joints, sacroiliac joint), back massage, and acupuncture (a low level of evidence) may be used in some patients.

Therapeutic exercises and an educational program (the prevention of excessive loads and prolonged static and uncomfortable postures and the use of correct methods for lifting weights, etc.) are recommended for preventive purposes. 

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.