Dosage of pain rehabilitation programmes for patients with chronic musculoskeletal pain:a non-inferiority randomised controlled trial

PURPOSE: To analyse the effects of interdisciplinary pain rehabilitation programmes with different dosages; care as usual versus short form. METHODS: A single blinded, two armed, randomised controlled trial, with non-inferiority design was performed. All patients with chronic musculoskeletal pain referred to an outpatient multidisciplinary pain rehabilitation programme were eligible for this study. Only dosage differed, content was similar. The difference on Pain Disability Index was the primary outcome measure. Four points difference on Pain Disability Index was applied as a non-inferiority margin. Treatment effects within groups were expressed in standardised mean difference and effect sizes were calculated between the groups. RESULTS: Because care as usual was frequently extended, the difference in dosage between groups was limited. The study was stopped prematurely because of an a-priori stopping rule. Interim analyses are presented. Both groups (care as usual n = 58, short form n = 54) improved significantly (mean Pain Disability Index change care as usual: -10.8; short form: -8.3). Mean difference between groups was 2.5 points (95% confidence interval was -2.2 to 7.3). Effect size between groups was 0.2. CONCLUSIONS: The 95% confidence interval for the difference in mean pain disability reduction exceeded the upper limit of the non-inferiority margin. The results of the primary analyses of this trial are, therefore, inconclusive. Ancillary analyses revealed that programme dosage was not associated with differences in the disability outcomes. Implications for rehabilitation Optimum dosage of interdisciplinary pain rehabilitation programs is unknown and scarcely studied. This study is the first to analyse dosage as primary aim. Although results are inconclusive, they also suggest that differences in dosage may not automatically lead to differences in effects. Further research is needed to analyse what dosage works for whom; to detect optimum effective and cost-effective dosage of pain rehabilitation programmes

Course of disability reduction during a pain rehabilitation program:a prospective clinical study

The aim of this study was to analyze the course of reduction of disability during a pain rehabilitation program (PRP) and factors influencing this course. A prospective cohort study was carried out. All patients with chronic musculoskeletal pain treated in a PRP between March 2010 and December 2010 were eligible for this study. All patients were treated at a University-based rehabilitation center and received an outpatient multidisciplinary PRP. Main outcome measures, Pain Disability Index (PDI), and average pain measured with a numeric rating scale were measured every 2 weeks during the PRP. To analyze the course of disability, a linear mixed-effect model was applied. One hundred and twenty-eight patients participated in the study, of whom 20% dropped out during the PRP. Initial PDI (beta=0.8), treatment week (beta=-0.2), treatment week squared (beta=0.03), average pain (beta=2.3), and interaction between initial PDI and treatment week (beta=-0.02) influenced the course of disability during PRP. Disability reduces during the PRP. Initial PDI, treatment week, average pain, and interaction between initial PDI and treatment week influence the course of disability reduction during the PRP. These results could aid in predicting the required duration of a PRP at the start. Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights reserved

Case complexity in patients with chronic nonspecific musculoskeletal pain:a Delphi and feasibility study

Assessment of case complexity in patients with chronic nonspecific musculoskeletal pain (CMP) is currently clinician based, not transparent, and with low reliability. The objective of this study was to explore case complexity and to initiate the development of a case complexity index (CCI). A three-round Delphi study among clinicians involved in multidisciplinary Pain Rehabilitation Programs was performed to identify important factors that are assumed to influence functioning in patients with CMP. The 10 most important factors were used to initiate the development of a CCI, with mean ratings of importance per factor as weights. The feasibility of the CCI was tested in a pilot study on 16 patients with CMP. In the first round, 166 factors were identified; in the second round, the 10 most important factors were selected; in the third round, relative weights of each factor were calculated, ranging from 1.75 (features of complaints) to 3.56 (psychiatric disorders) on a scale from 0 (no weight) to 4 (very heavy weight). The assessments for the factors were mainly based on clinical examination and reasoning. Clinicians could rate all patients using the CCI, which confirmed feasibility of the CCI. Ten, mainly psychosocial, factors were identified, which were assumed to be most important for the assessment of case complexity in a patient with CMP. With these factors, a CCI was created, for which feasibility was established. This CCI is transparent, easy to use, and might provide a basis for further development of a structured assessment of case complexity, which may have scientific and clinical relevance

Dosage of pain rehabilitation programs: a qualitative study from patient and professionals' perspectives

BACKGROUND: There is a large and unexplained practice variation in prescribed dosages of pain rehabilitation programs (PRP), and evidence regarding the optimum dosage is unknown. METHODS: To explore perspectives of patients and rehabilitation professionals regarding dosages of PRP an explorative qualitative research design was performed with thematic analysis. Patients and rehabilitation professionals were recruited from three rehabilitaton centers in the Netherlands. A purposive sample of patients who completed a PRP, with a range of personal and clinical characteristics was included. Rehabilitation professionals from all different disciplines, working within multidisciplinary PRP for a minimum of two years, for at least 0.5 fte were included. Individual semi-structured interviews were conducted with 12 patients undergoing PRP, and three focus groups were formed with a total of 17 rehabilitation professionals involved in PRP. RESULTS: All patients were satisfied with received dosage. Factors important in relation to dosage of PRP were categorized into patient related characteristics (case complexity from a biopsychosocial perspective) to treatment related characteristics (logistics and format of the program, interaction between patients and professionals), and external factors (support from others, costs, traveling distance and injury compensation). Professionals concluded that dosage was currently based on historical grounds and clinical expertise. CONCLUSION: Patients and professionals from different centers considered the same factors related to dosage of PRP, but these considerations (from patients and professionals) led to different dose choices between centers. PRP dosage appeared to be mainly based on historical grounds and clinical expertise. The insights of this study could assist in future research regarding optimum dosage of PRP and rehabilitation programs in general

Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain:A systematic review

We sought to systematically analyze the influence of dose of pain rehabilitation programs (PRPs) for patients with chronic low back pain (CLBP) on disability, work participation, and quality of life (QoL). Literature searches were performed in PubMed, Cochrane Library, Cinahl, and Embase up to October 2012, using MeSH terms, other relevant terms and free-text words. Randomized controlled trials in English, Dutch, and German, analyzing the effect of PRPs, were included. One of the analyzed interventions had to be a PRP. Outcomes should be reported regarding disability, work participation, or QoL. To analyze dose, the number of contact hours should be reported. Two reviewers independently selected titles, abstracts, and full-text articles on the basis of inclusion and exclusion criteria. Data were extracted and risk of bias was assessed. Effect sizes (ES) were calculated for each intervention, and influence of dose variables was analyzed by a mixed model analysis. Eighteen studies were identified, reporting a wide variety of dose variables and contents of PRPs. Analyses showed that evaluation moment, number of disciplines, type of intervention, duration of intervention in weeks, percentage of women, and age influenced the outcomes of PRPs. The independent effect of dose variables could not be distinguished from content because these variables were strongly associated. Because dose variables were never studied separately or reported independently, we were not able to disentangle the relationship between dose, content, and effects of PRPs on disability, work participation, and QoL. (C) 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved