Effectiveness of multidisciplinary rehabilitation treatment for patients with chronic pain in a primary health care unit

1 Introduction

Chronic non-cancer pain appears as a significant phenomenon and a public health problem in Scandinavia and other countries [1, 2, 3]. Breivik et al. investigated chronic pain in Europe and found that pain with moderate to severe intensity occurs in 19% of adult Europeans with a prevalence of 18% chronic pain among the general Swedish population [4]. A significant proportion of those affected have difficulty living with their pain which is affecting “their social and working lives” [4]. The prevalence of pain in the patients treated in primary care practice is about 30%. A little less than half of these patients received a prescription for analgesic drugs. The pain diagnoses at a primary care level showed a predominance of musculoskeletal pain [5].

Most research on treatment with multidisciplinary pain rehabilitation (MDR) has taken place in specialized expert level units, usually at rehabilitation centers where the level of knowledge and therapeutically options to treat pain conditions are considered to be high. There are few studies about MDR outcome in primary health care, especially in those units situated in rural areas and with a different population than that encountered in the university hospitals. For example, the distance from Arvika, a town of about 17,000 inhabitants situated in Värmland in the middle of Sweden, to the closest university clinic in Örebro is 150 km. To travel there several times a week or a month to access a rehabilitation program simply is not possible for many chronic pain patients. This is in spite of the well-known fact that chronic pain is a condition which is not limited to urban settings [6,7]. There are differences between urban and local programs when considering the main outcomes such as pain, pain intensity, physical or social activity and also important psychometric values such as depression and anxiety [8].

There is evidence that MDR of chronic pain, which today is mostly available in special pain units, affects the quality of life and sick-leave in a positive and sustainable manner [3,8]. However, there is not enough evidence to determine which patients should be treated in highly specialized units and which may be treated in primary care MDR-programs. In recent years, multidisciplinary rehabilitation (MDR) became an alternative treatment option for chronic pain [3,9, 10, 11]. It is considered that MDR improves the potential for patients to return to work [12], and reduces sick leave [13,14]. These benefits were mostly observed after multimodal rehabilitation treatment in patients with chronic back pain [15]. Evidence-based treatment with multimodal rehabilitation for patients with complex pain syndromes is still poorly studied.

The aim of the study was to determine if patients with chronic pain problems could benefit from multidisciplinary pain rehabilitation in primary health care units.

2 Methods

The MDR program at the local primary health care unit was developed according to the Swedish recommendations for rehabilitation of non-cancer pain patients [3]. The present study was conducted as a prospective controlled pragmatic trial [16]. This study was performed in accordance with the Declaration of Helsinki and the CONSORT Statement [17,18] and approved by the Regional Ethical Board.

2.2 Interventions

The aim of treatment was not to reduce pain but to focus on patients’ quality of life, reduce their drug consumption and maintain or restore their capacity to work. The team was working multidisciplinarily and consisted of 2 cognitive-behavioral educated psychologists, one general practitioner with a special interest in pain rehabilitation, one medical secretary, an ergonomic therapist and 2 physiotherapists with special education in body-awareness and cognitive-behavioral therapy. It may be noted that no member of the team had special experience in pain treatment more than on the primary health care level. In Sweden, there is an ambition that all these professions should be available in all primary health care units throughout the country. The 6-week treatment took place in group sessions with 6–8 members each. The first patient group was started in November 2008. Up to August 2011 a total of 8 groups underwent treatment. In this way, all patients could receive MDR-treatment as outpatients while living at home, avoiding long travel. There was the possibility to have close contact with the responsible general practitioner as well as the local office of the Swedish Insurance Agency and the place of work. This model provided a unique link between patient’s rehabilitation on the one hand and every-day-life on the other hand.

Table 1

Inclusion and exclusion criteria.

Inclusion criteria: Age between 16 and 65 years Chronic non-cancer pain (>3 months) Diagnosis of pain in the neck-shoulder region, low back pain or generalized pain conditions High motivation to life changes and return to work after completing rehabilitation

Exclusion criteria: Psychiatric disease moreover moderate depression and anxiety Drug abuse Use of opioids >40 mg oral morphine equivalents/day Ongoing medical treatment for pain condition

Fig. 1

Flow diagram.

If the interdisciplinary team assessed the patient as qualified for MDR, he/she was included in the next program. The rehabilitation treatment was scheduled over 6 weeks which included 3 days of treatment with 5 h each day, interrupted by two free days a week (Table 2).

At the third week, a mid-program interview was held by one of the psychologists. During treatment, the participant was given the opportunity to have individual contacts with all team members. At the end of the MDR, the patient met all team members individually again for treatment follow-ups. The aim of these meetings was to encourage the patient to go back to work and to use the new skills in every-day-life. At this point, the referring GP, the local Swedish Insurance Agency and the employer were invited to attend to inform them about the treatment results. Before, at the end of program and one year after MDR program the patients filled in the questionnaires. The follow-up was done one year after the patient finished treatment.

3 Statistics

GraphPad PRISM version 4.0 (GraphPad Software, San Diego, CA) was used for handling and analyzing the data. Data are presented as either means ± SD or as median with ranges, 25% and 75% percentiles. The level of significance was set at a p value <0.05. This study was a descriptive observational study, thus no randomization or blinding was done. Non-parametric statistical methods were performed as follow: the chi-square test and the Mann-Whitney U test were used to test for differences in patient characteristics at admission and after 12 months. The independent-samples t-test was used to test for differences in the changes in pain intensity and the physical sub-scores of SF-36 scores at admission and at 12 months after.

4 Results

A total of 169 patients were referred to the local pain rehabilitation group at the health care pain unit Arvika. Eighty-six were excluded because at assessment that they did not fulfill the inclusion criteria (Table 1). Thus, the remaining 59 patients were admitted to the rehabilitation program and completed the routine questionnaires. All the 59 patients who started the MDR program finished it successfully, no one discontinued or withdrew before the end. After completing MDR the SQRP-questionnaires was answered by 59, at one-year follow-up by 51 patients. Patients’ characteristics are shown in Table 3. Most participants were female (86%, n = 44) and the mean age was 48 ± 7.8 years for both women and men. The major complaint category was generalized pain such as fibromyalgia (53%). Others were pain from neck and shoulder such as whiplash-trauma (28%) or low back pain (12%).

Fig. 2

Results: A box-and-whisker plot indicating the smallest observation, lower quartile, median, upper quartile, and largest observation for (a) pain intensity, (b) pain severity, (c) anxiety score, (d) depression score, (e) social score, (f) physical activity score, (g) health care utilization, and (i) sick leave.

The study results are presented in Fig. 2. Sick leave decreased from 75.6 ± 32% before MDR to 61.5 ± 36% at one-year follow-up (p<0.05). Mean health-care utilization decreased from 27.4 ± 7 contacts during the 12 months before treatment to 20.1 ± 14 contacts during the 12 months after treatment (p = 0.02). Consumption of opioids decreased without reaching statistically significance from 1828 mg morphine equivalents per patient during 12 months before to 1382 mg 12 months after treatment (p >0.05). Regarding the primary outcomes, there were significant differences concerning social activity (p = 0.03), but not physical activity (p = 0.08). Patients improved in the psychometrical outcomes depression and anxiety with mean values in HAD for depression 8.15 before and 6.28 one year after treatment (p<0.05). For anxiety, MDR-participants had a mean value for HAD of 8.71 before and 7.0 12 months after treatment (p > 0.05). The mean level of pain intensity reported before MDR was reported as 6.71 on NRS-scale and sank to 6.27 one year after treatment finished. This decrease was not statistically significant (p > 0.05). The mean pain severity decreased from 4.38 to 3.97 and this change was not of statistical significance.

5 Discussion

In the present study, the effectiveness of multidisciplinary rehabilitation for patients with chronic non-cancer pain in a local primary health care setting was analyzed. The baseline characteristics of the population observed at the Pain Unit Arvika differed from the observed population of the Swedish Quality Register for Pain. The latter represents only participants from larger pain rehabilitation units. The Arvika-population consisted of a higher percentage of women, many patients with generalized pain conditions such as fibromyalgia, lower education levels, patients with a longer duration of complaints and a longer duration of sick-leave. In several studies, these items were described as negative predictors for successful rehabilitation [39, 40, 41]. A possible explanation might be that the socioeconomic population structure of rural inhabitants on average is often regarded as lower educated and with lower socio-economic status. In these rural areas, there might exist a different sociocultural view on pain and chronic pain conditions with women still take higher responsibility for children, family and housework leading to a higher burden and fewer possibilities to focus on disease prevention or rehabilitation.

Many studies on MDR focus on outcomes such as pain intensity, pain severity, depression and anxiety [42]. There is less known the role played by MDR concerning sick leave from work, in spite of the fact that avoiding sick leave is considered a primary goal of most rehabilitation concepts. Some studies used data from institutions such as social insurance systems, to examine levels of sick leave [19], but in the present study we used Swedestar, a computerize way to collect information from the patients’ journals. The tight correlation between pain intensity and pain severity on one hand and psychometric values such as anxiety and depression on the other hand is a well-known fact and discussed in many trials [43]. In spite of this, little is known on the impact of rehabilitation at primary care level to anxiety and depression. Depression and anxiety are common among patients with chronic pain [25] and have been found to increase the risk for reduced activity levels or social functioning. Improvement in psychological factors is described as essential for increased physical activity. In the present study, anxiety and depression declined at follow-up with significant reduction for depression (p<0.05). Furthermore, the effects of MDR in primary care on both physical and social activity are widely unknown. The MDR in the present primary care setting showed improvement in all three primary outcomes sick-leave, health care utilization and opioid prescription with a significant reduction in health-care utilization. It is well-known that patients with chronic pain complaints are characterized by specific healthcare consumption patterns with often a high frequency of contacts with primary health-care units as well as emergency units [44,45] but without improvement in symptoms. In that way, they are often described as a group of high users of the medical system putting special press on providers, although, there is hardly any focus on health-care utilization in rehabilitation research. This is possibly due to the fact that links between rehabilitation centers on the one hand and primary health care units on the other hand are minimal in many settings. Rehabilitation programs located in primary health care must therefore have a natural focus on the effectiveness regarding which extended health care is needed after completion of rehabilitation. Although the MDR itself did not in any way focus on medication more than optimizing it at assessment, there was a numerical decrease of opioid consumption at one-year follow up. All these findings mean a reduction of health care costs after treatment [46,47]. These benefits of MDR might be explained by a change in patients’ behavior, pain self-management or the way of dealing with more complex pain conditions. Possibly participants of MDR at the primary care level may feel more safe or secure due to the multidisciplinary treatment setting the patient in focus. Although in previous studies a decrease of pain intensity and pain severity was described [43,48] no statistically significant change was found in the present study, but the items for both social and physical activity increased. These findings may support the assumption as above stating that MDR in primary care may lead to better self-esteem in chronic pain patients who often are trapped in a vicious circle of pain, physical and social inactivity, sick leave, depression and a self-fulfilling prophecy of even more pain. In future, there is a strong need for more research analysing these outcomes on larger study populations, e.g. in multicentre studies.

This study suggests that MDR in primary care settings may lead to better coping in chronic pain condition with the result of lower depression scores and higher activity, leading to lower sick leave. This study demonstrated that there is a place for MDR in primary health care units with the advantage of local intervention in rural areas allowing the patients to achieve rehabilitation in their home environment.

6 Study limitations

A weakness of the analysis is the low study number with only 51 patients. This low number and the high proportion of women (86%) may be a source of bias. There is a need for evidence based studies concerning local rehabilitation programs in order to find out which patients may benefit from MDR at the primary care [41]. Naturally, there will be fewer participants in local settings compared to larger units at e.g. university hospitals or more urban rehabilitation clinics.

Another weakness is the lack of a control group. Here the patients have acted as their own controls, before and one year after participation in the pain rehab program. This is not optimal, a separate control group receiving no treatment would have been more appropriate. This is however difficult to arrange.

Therefore, the design using the patients as their own controls, before and after treatment, and comparing the results with data from a national quality register for pain rehabilitation is considered sufficient.

7 Conclusion

This trial describes a patient population that did not have access to larger units for MDR treatment. Further research is needed to identify practical criteria by which patients may best receive MDR at primary care units and which patients should be referred to a specialized pain unit. We furthermore are in need for larger and better conducted studies assessing MDR in primary care. As a suggestion for the future, local MDR therapy may become available for patients with access to a pain-or rehabilitation specialist. In that way, the specialist could use his/her special knowledge for recommendations of rehabilitation levels locally or in more specialized units. As well, all MDR units should have close contact with the larger specialized rehabilitation units for tight cooperation.

HIGHLIGHTS

• Multidisciplinary rehabilitation for chronic pain in primary health care was analyzed

• Depression and social activity improved significantly one year after treatment.

• Sick leave and utilization of health care decreased significantly.

• Patients with chronic pain benefit from rehabilitation in primary health care.