Interdisciplinary Pain Rehabilitation Programs: Evidence and Clinical Real-World Results

Chronic pain conditions are influenced by and interact with physical, psychological, social, and contextual factors. These conditions are associated with psychological distress, poor health, sick leave, and high socio-economic costs. Therefore, modern clinical practice applies a biopsychosocial (BPS) framework. Interdisciplinary pain rehabilitation programs (IPRPs) for chronic pain distinguish themselves as well-coordinated complex interventions. This chapter describes the contents of such programs. We will briefly review the evidence for IPRPs and discuss problems when evaluating these complex interventions. Furthermore, we will report practice-based results from a large Swedish pain registry—the Swedish Quality Registry for Pain Rehabilitation (SQRP). The SQRP collects data from a relevant special clinical department in Sweden—i.e., real-life outcomes will be depicted. Characteristics of patients that benefit the most from IPRPs will be described and discussed. The indications for IPRPs will also be presented. Finally, we will discuss how to improve rehabilitation for chronic pain patients

Prolonged exposure for pain and comorbid PTSD: A single-case experimental study of a treatment supplement to multiprofessional pain rehabilitation

It is unclear how to address PTSD in the context of chronic pain management. Here we examine the potential benefits of an addition of prolonged exposure (PE) therapy for PTSD for adults attending multidisciplinary CBT for chronic pain. Four adults seeking treatment for chronic pain from a specialized pain rehabilitation service were offered PE for PTSD using a replicated, randomized, single-case experimental phase design, prior to commencing a 5-week multidisciplinary CBT program for chronic pain. Pre-, post-, follow-up, and daily measures allowed examination of PTSD and pain outcomes, potential mediators, and the trajectory of these outcomes and potential mediators during the subsequent pain-focused CBT program. Visual inspection of the daily data demonstrated changes in all outcome variables and potential mediators during the PE phase. Changes came at different times and at different rates for the four participants, highlighting the individual nature of putative change mechanisms. Consistent with expectation, PE produced reliable change in the severity of PTSD symptoms and trauma-related beliefs for all four participants, either by the end of the PE phase or the PE follow-up, with these gains maintained by the end of the 5-week pain-focused CBT program. However, few reductions in pain intensity or pain interference were seen either during the PE phase or after. Although "disorder specific"approaches have dominated the conceptualising, study, and treatment of conditions like PTSD and chronic pain, such approaches may not be optimal. It may be better instead to approach cases in an individual and process-focused fashion

A Validation and Generality Study of the Committed Action Questionnaire in a Swedish Sample with Chronic Pain

Purpose Psychological flexibility is the theoretical model that underpins Acceptance Commitment Therapy (ACT). There is a growing body of evidence indicating that ACT is an effective treatment for chronic pain but one component of the model, committed action, has not been sufficiently researched. The purpose of this study is to validate Swedish-language versions of the full length Committed Action Questionnaire (CAQ; CAQ-18) and the shortened CAQ (CAQ-8), to examine the generality of previous results related to committed action and to further demonstrate the relevance of this construct to the functioning of patients with chronic pain. Method The study includes preliminary analyses of the reliability and validity of the CAQ. Participants were 462 consecutive referrals to the Pain Rehabilitation Unit at Skåne University Hospital. Results The Swedish-language versions of the CAQ (CAQ- 18 and CAQ-8) demonstrated high levels of internal consistency and satisfactory relationships with various indices of patient functioning and theoretically related concepts. Confirmatory factor analyses showed that the Swedish versions of the CAQ yielded similar two-factor models as found in the original validation studies. Hierarchical regression analyses identified the measures as significant contributors to explained variance in patient functioning. Conclusion The development, translation and further validation of the CAQ is an important step forward in evaluating the utility of the psychological flexibility model to the treatment of chronic pain. The CAQ can both assist researchers interested in mediators of chronic pain treatment and further enable research on change processes within the psychological flexibility model

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.Funding Agencies|Swedish Research CouncilSwedish Research CouncilEuropean Commission [2018-02470]; County Council of ostergotland [LIO-608021]</p

Treatment outcomes in group-based CBT for chronic pain: An examination of PTSD symptoms

Background: The relevance of PTSD symptoms to outcomes of Cognitive Behavioral Therapy (CBT) for chronic pain is unclear. This study examines whether (a) traumatic exposure or the severity of PTSD symptoms at pre‐treatment predict outcomes (pain intensity/interference) (b) participation in this treatment is associated with reduced PTSD symptoms, and (c) any observed changes in PTSD symptoms are mediated by changes in psychological mechanisms that have been shown to be of importance to PTSD and chronic pain. Methods: Participants were 159 chronic pain patients who were consecutively admitted for a multidisciplinary, group‐based CBT program at the Pain Rehabilitation Unit at Skåne University Hospital. A self‐report measure of traumatic exposure and PTSD symptoms was administered before and after treatment, and at a 12‐month follow‐up, along with measures of depression, anxiety, pain intensity, pain interference, psychological inflexibility, life control, and kinesiophobia. Results: Traumatic exposure and PTSD symptom severity did not predict pain intensity or interference at 12‐month follow‐up. There were no overall significant changes in PTSD symptom severity at post‐treatment or follow‐up, but 24.6% of the participants showed potential clinically significant change at follow‐up. Psychological inflexibility mediated the changes that occurred in PTSD symptoms during treatment. Conclusions: Neither traumatic exposure nor baseline symptoms of PTSD predicted the treatment outcomes examined here. Despite improvements in both comorbid depression and anxiety, participation in this pain‐focused CBT program was not associated with improvements in comorbid PTSD. To the extent that changes in PTSD symptoms did occur, these were mediated by changes in psychological inflexibility during treatment. Significance: Pain‐focused CBT programs yield clinically meaningful improvements in pain and comorbid symptoms of depression and anxiety, but may have little effect on comorbid PTSD. This raises the issue of whether current pain‐focused CBT programs can be modified to improve outcomes for comorbid conditions, perhaps by better targeting of psychological flexibility, and/or whether separate treatment of PTSD may be associated with improved pain outcomes

Pain intensity and psychological distress show different associations with interference and lack of life control: A clinical registry-based cohort study of &gt;40,000 chronic pain patients from SQRP

BackgroundBoth chronic pain and depressive and/or anxiety symptoms are associated with negative impacts on daily living, including interference and lack of life control. However, little is known about how pain and psychological distress affect these impacts.AimThe first aim was to assess how pain intensity, psychological distress, and social support interact with interference and lack of life control. A second aim was to investigate whether the strength of these relationships is moderated by the presence or absence of depression and/or anxiety.Subjects and methodsPatient-Reported Outcome Measures (PROMs), which are available in the Swedish Quality Registry for Pain Rehabilitation (SQRP), were retrieved for patients with chronic pain (N = 40,184). A theoretical model with the constructs/latent variables pain intensity, psychological distress, interference, lack of life control, and social support was proposed and analyzed using Partial Least Squares Structural Equation Modelling (PLS-SEM). Indicators for these constructs were identified from the PROMs of the SQRP. Two models of the total cohort, which differed with respect to the causal relationship between pain intensity and psychological distress, were investigated. The moderating effects of anxiety and/or depression were also analyzed.ResultsRelatively low correlation and explanatory power (R-2 = 0.16) were found for the pain intensity-psychological distress relationship. Pain intensity had a stronger effect on interference than on lack of life control. The reverse was found for psychological distress - i.e., psychological distress seemed to have a higher negative influence on function than on interference. The underlying assumption of the causal relationship between pain intensity and psychological distress determined how strong pain intensity and psychological distress influenced interference and lack of life control. Social support showed very similar absolute significant correlations with interference and lack of life control. Interference and lack of life control showed relatively weak associations. The psychological distress level was a moderating factor for several of the paths investigated.Discussion and conclusionA clinical treatment consequence of the low correlation between pain intensity and psychological distress may be that clinically treating one may not reduce the effect of the other. The relative importance of pain intensity and psychological distress on interference and lack of life control depends on the underlying assumption concerning the pain intensity-psychological distress relationship. Interference and lack of life control showed relatively weak associations, underscoring the need to clinically assess them separately. Social support influenced both impact constructs investigated. The cohort display heterogeneity and thus presence of definite signs of anxiety and/or depression or not was a moderating factor for several of the associations (paths) investigated. The results are important both for the assessments and the design of treatments for patients with chronic pain