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Multidisciplinary pain treatment – Which patients do benefit?

  • Tarja Heiskanen EMAIL logo , Risto P. Roine and Eija Kalso
Published/Copyright: October 1, 2012
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 3 Issue 4

Abstract

Background

The prevalence of chronic non-malignant pain in developed countries is high, ranging from 14% to 50%. Patients with chronic pain are active users of health-care services and they report impaired health-related quality of life (HRQoL) when compared with the general population. Psychological distress has been identified as one of the risk factors for pain chronicity. Depression, anxiety and negative beliefs are associated with pain interference and perceived disability. Multidisciplinary pain management (MPM) aims to rehabilitating chronic pain patients by addressing both physical, psychological, social and occupational factors related to the pain problem. MPM programmes have been shown to be effective in reducing pain and improving function in patients with diverse chronic pain states. However, MPM programmes are often heterogeneous and predicting MPM treatment results in different patients groups may be difficult.

Methods

The present study examined changes in HRQoL after MPM in 439 patients treated at a multidisciplinary pain clinic using the 15D HRQoL questionnaire. The characteristics of the 100 patients with the greatest improvement and the 100 patients with the largest decrease in HRQoL were examined more closely (demographics, characteristics of pain, pain interference, psychiatric comorbidity, employment status, details of MPM) after answering a follow-up 15D questionnaire at three years after their MPM had ended.

Result

During MPM, HRQoL was significantly improved in 45.6% of the 439 patients, decreased in 30.7% of the patients and did not change in 23.7% of the patients. Patient-related factors that predicted a better HRQoL among the 100 patients with good MPM outcome compared with the 100 patients with poor MPM outcome were higher education and better employment status. Age, gender, marital status, duration of pain, number of pain sites, pain intensity or pain interference at baseline did not differ between the patient groups. Patient expectations regarding MPM were similar. A tendency towards more psychiatric comorbidity in the non-responder group was seen. The duration of MPM in the two patient groups was similar, as well as the number of medications started, the variety of specialists seen and psychiatric counselling with supportive therapy included. More non-responder than responder patients had died during the three-year follow-up period, some of the deaths were related to substance abuse.

Conclusions and Implications

HRQoL in chronic pain patients was significantly improved during MPM compared with the baseline. Pain duration of several years, multiple pain sites and neuropathic pain were not discerning factors between the responders and non-responders of the present study, implying that a positive change in HRQoL may be achieved by MPM even in these pain patients. In agreement with previous studies, factors predicting poor treatment outcome in the non-responder group of chronic pain patients were not treatment related. To further improve MPM outcome even in pain patients with risk factors for less benefit of treatment such as low education and poor general health, more individualized MPM approaches with emphasis on analysis and treatment of psychological symptoms and patient beliefs is essential.

Keywords: Chronic pain; Health-related quality of life; 15D questionnaire; Multidisciplinary pain treatment; Benefit from treatment

1 Introduction

The prevalence of chronic pain in developed countries ranges from 14% to 50% ([1,2,3]. Chronic pain is associated with poor self-reported health [2] and impaired health-related quality of life (HRQoL) when compared with the general population [4] and patients with other chronic diseases [5,6].

Psychosocial factors have been identified as risk factors for chronic pain [7,8,9]. Anxiety, depression, and negative beliefs are associated with pain interference and perceived disability [10] and they predict impaired HRQoL in chronic pain patients [8,11].

Multidisciplinary pain management (MPM) aims to rehabilitate chronic pain patients by addressing pain related physical, psychological, social, and occupational factors [12]. MPM should include a medical consultation and a psychological, social or vocational intervention, or a combination of these [13]. MPM is usually implemented as outpatient treatment [14]. Interventions most often included in the MPM programmes in addition to medical treatment are patient education, cognitive-behavioural sessions, physical exercises, relaxation, occupational therapy and socioeconomic counselling [12,14,15,16,17,18,19].

MPM has reduced pain and improved function in patients with low back pain [12], musculoskeletal pain [14,19] and diverse chronic pain states [20]. The efficacy of MPM is reflected in the improvement of HRQoL [14,20,21].

Prognostic factors for greater improvement after MPM have included high pain intensity, depression and fearavoidance beliefs [15,18,22]. Patients who are able to accept their chronic pain and change pain-related cognitions and coping responses [17,23,24] are likely to benefit most from MPM. Antisocial personality, panic disorder, opioid dependence disorder, and long duration of disability predict non-completion of MPM [25,26]. Educational level, gender or civil status are not related to MPM treatment outcome [15].

MPM programmes are effective but it is not known which MPM components are the most important. The objective of the present study was to examine patient and treatment related factors that might predict improvement in HRQoL as a measure of MPM outcome. The primary endpoint was the change of the 15D HRQoL score from baseline to 12 months after start of MPM. The secondary endpoint was to find any significant difference in patient demographics, quality of pain, psychiatric comorbidity, employment status or components of MPM that might explain the different outcome of MPM.

2 Material and methods

2.1 Subjects

Since September 2004, chronic pain patients treated at the Helsinki University Central Hospital Pain Clinic have been routinely asked to fill in a 15D [27] quality of life questionnaire at the beginning of the treatment period and 6 and 12 months later. Patients with active cancer were not included. Of the patients treated at the Pain Clinic between 14.9.2004 and 26.8.2007, 439 patients returned all three questionnaires (Table 1a). The 100 patients with the greatest improvement and the 100 patients with the poorest outcome in the 15D scores between baseline and 12 months composed the sample of this study. These patients were sent a letter informing about the study and, after signing an informed consent form, they were asked to fill in a fourth 15D questionnaire. A letter reminding of the study and the questionnaire were re-sent approximately three weeks later to all the patients who had not returned the questionnaire. The study was approved by the Ethics Committee of the Helsinki University Central Hospital.

Table 1a

Changes in HRQoL 15D scores in the total population (n = 439) and the study groups (n = 195).

Total population HRQoL baseline (mean ± SD) HRQoL 12 months (mean ± SD) HRQoL change (mean ± SD)
Improved n = 200 (45.6%) 0.711 ± 0.106 0.805 ± 0.102[*] 0.094 ± 0.056
No change n = 104 (23.7%) 0.720 ± 0.115 0.723 ± 0.117 0.003 ± 0.017
Deteriorated n = 135 (30.7%) 0.715 ± 0.107 0.624 ± 0.122[*] –0.091 ± 0.049
Study groups
 Responders n = 99 0.692 ± 0.097 0.824 ± 0.092[*] 0.132 ± 0.060
 Non-responders n = 96 0.704 ± 0.104 0.597 ± 0.113[*] –0.107 ± 0.045

  1. Responders: the 99 patients from whom clinical data was available of the original 100 patients with the greatest positive change in HRQoL at 12 months after start of MPM when compared with baseline. Non-responders: the 96 patients from whom clinical data was available of the original 100 patients with the greatest negative change in HRQoL at 12 months after start of MPM when compared with baseline

Table 1b

Changes in HRQoL 15 D scores in the study patients who returned the follow-up 15 D questionnaire at 43 months (mean) after start of MPM.

HRQoL baseline (mean ± SD) HRQoL 12 months (mean ± SD) HRQoL follow-up (mean ± SD)
Responders n = 79 0.699 ± 0.095 0.823 ± 0.091[*] 0.789 ± 0.108[**]
Non-responders n = 67 0.712 ± 0.100 0.601 ± 0.118[*] 0.650 ± 0.149[**]

2.2 Multidisciplinary management

The staff of the Helsinki University Central Hospital Pain Clinic consists of physicians, psychologists, a physiotherapist, a social worker and nurses. The medical specialties represented are anaesthesiology, neurology, rehabilitation medicine, psychiatry and dentistry. Pain management at the Helsinki University Central Hospital Pain Clinic was individually designed and consisted of diagnostic evaluation and at least two of the following: analgesic medication, local analgesia, spinal cord stimulation, physiotherapeutic counselling and exercise programmes, psychological evaluation, supportive psychological therapy, teaching of pain management strategies (e.g. relaxation training), and socioeconomic counselling.

2.3 Measures

HRQoL was measured with the 15D questionnaire that is a generic, 15-dimensional, standardised, self-administered HRQoL instrument that can be used both as a profile and a single index utility score measure [47]. The 15D questionnaire consists of 15 dimensions: mobility, vision, hearing, breathing, sleeping, eating, speech, excretion, usual activities, mental function, discomfort and symptoms, depression, distress, vitality and sexual activity. For each dimension, the respondent must choose one of the five levels that best describes his/her state of health at the moment (the best level = 1; the worst level = 5). The valuation system of the 15D is based on an application of the multi-attribute utility theory. A set of utility or preference weights, elicited from the general public through a 3-stage valuation procedure, is used in an additive aggregation formula to generate the utility score, i.e., the 15D score (single index number) over all the dimensions. The maximum score of the 15D is 1 (no problems on any dimension), and the minimum score is 0 (equal to being dead). In most of the important properties the 15D compares favourably with other similar instruments [27,28,29,30,31].

The patient charts and the Helsinki University Central Hospital Pain Clinic pain questionnaire that the patients fill in before their first visit were reviewed to collect information on demography (age, gender, marital status, educational level, occupation), pain (duration of disease, pain characteristics), psychiatric comorbidity (ongoing psychiatric treatment and/or psychiatric symptoms diagnosed by the Pain Clinic psychiatrist or psychologist) and employment status at the time of treatment. Pain interference was assessed by scoring the answers to the 19-item question “Does pain interfere with the following” (not at all = 0, moderately = 1, very much = 2) and calculating a total score (maximum score 38) (lying down, sitting, standing, walking, lifting items, getting dressed, cooking, washing dishes, cleaning, reading, watching TV, writing, climbing stairs, driving, falling asleep, sleeping, enjoying sex, social relationships, other). Patient expectations of MPM were recorded from answers to the open question “What do you expect from your treatment at the Pain Clinic?”). Details of pain treatment at the Pain Clinic were recorded (specialists seen, physical therapy, psychological therapy, number of medications started, duration of MPM). Death certificates, when appropriate, were obtained from Statistics Finland by permission.

2.4 Statistical methods

Patients with complete baseline HRQoL data and those with ≤3 missing responses on the 15 dimensions (≤3 missing responses can be predicted by regression models with the responses on the other dimensions, age and gender, as explanatory variables) were included in the analysis. Data were analysed using SPSS for Windows version 17.0 statistical software (SPSS, Inc., Chicago, IL, USA). The results are given as mean and standard deviation (±SD), or as percentages. For continuous variables, the significance of the differences between the groups was analysed using one-way analysis of variance followed by post hoc comparisons with independent samples t-test, and for categorical variables using Pearson’s chi-square test. The significance of the change in the 15D score or any of its dimensions over time was tested using paired samples t-test. P-values smaller than 0.05 were considered statistically significant.

3 Results

The mean HRQoL 15D score at baseline for the total chronic pain patient population (n = 439) was 0. 714 ± 0.108. The baseline 15D score for the 100 responders and the 100 non-responders were 0. 692 ± 0.097 and 0.704 ± 0.104, respectively (Table 1a).

3.1 Patient characteristics

No significant differences in age or marital status were seen between the two patient groups (Table 2). Compared with the non-responders, significantly more responders had high (>12 years) education (45% vs. 28%, respectively). A significant difference in the employment status was also seen, as more responders were working full-time or part-time and fewer received pension at baseline. Very few patients were applying for pension (2% of responders and 4% non-responders) or had a litigation process on-going (3% of responders and 4% of non-responders).

Table 2

Patient characteristics.

Responders (n = 99) Non-responders (n = 96)
Age (years), mean ± SD 52.5±14.6 56.4±15.6
Females 64% 52%
Married/cohabiting 64% 61%
Educational level
 Low (≥9 years) 22% 39%
 Intermediate (10–12years) 33% 33%
 High (>12 years) 45% 28%
 Employed at baseline 33% 15%[**]
 at 12 months 39% 14%[**]
 Sick leave at baseline 16% 20%
 Disability/old age pension at baseline 38% 60%[**]
Type of pain
 Nociceptive 16% 15%
 Neuropathic 57% 60%
 Mixed/unknown 23% 24%
Pain duration
 <1 year 8% 6%
 1–5 years 47% 46%
 ≤6 years 44% 48%
Pain intensity at baseline (0-100mm), 64 ± 25 62 ± 26
 mean ± SD

  1. Responders: the 99 patients from whom clinical data was available of the original 100 patients with the greatest positive change in HRQoL at 12 months after start of MPM when compared with baseline. Non-responders: the 96 patients from whom clinical data was available of the original 100 patients with the greatest negative change in HRQoL at 12 months after start of MPM when compared with baseline

In both groups, most participants had had pain for several years, with a small minority (8% and 6% in responders and non-responders, respectively) having had pain for less than twelve months. The primary site of pain varied, low back being the most common. The majority of patients in the responder and non-responder groups reported more than one site of pain (84% vs. 81%, respectively). According to evaluation of the primary pain type by the Pain Clinic physician, neuropathic pain was predominant in both responders and non-responders. More patients in the non-responder group had coexisting mood disorder symptoms (depression, anxiety or other) when compared with the responder group, but the difference did not reach statistical significance (51% vs. 38%, respectively).

The responders were more active than the non-responders in answering the open question of patient expectations of MPM at baseline (96% vs. 77%). Main expectations were similar in responders and non-responders: pain relief (47% in both groups), diagnosis (12% vs. 9%), advice for coping with pain (12% vs. 15%) and better pain medication (10% vs. 9%).

The intensity of pain that the patients considered acceptable at baseline was similar in responders and non-responders (20 vs. 18 mm, respectively, on VAS 0–100 mm).

Pain interference at baseline did not differ between responders (mean score 20, range 2–35) and non-responders (mean score 18, range 3–36).

One patient from the group of responders and nine patients from the group of non-responders died during follow-up. One patient from the non-responding group died during MPM, the other patients more than a year (median 13 months) after the end of MPM (Table 3). The patients who died were older than the study patients on the whole (mean 66.8 years vs. 54.5 years, respectively). Six patients died of diseases unrelated to the pain problem or psychiatric comorbidity (cardiac or circulatory disease or peritonitis). One patient (responder) died of pneumonia after excessive alcohol use and delirium. One non-responder died of pneumonia and suspected drug overdose. Two non-responder deaths were classified as suicides by drug overdose.

Table 3

Causes of death forthe 10 patients who died during or after multidisciplinary pain management (MPM) before the follow-up 15 D questionnaire at 43 months (mean) after start of MPM was sent.

Patient Resp/nonresp Pain diagnosis Time since end of MPM Age at death Cause of death
TB R Posttraumatic back and shoulder pain 10 mo 65 Pneumonia Alcoholic delirium on admission to hospital
MV NR Chronic postoperative abdominal pain MPM ongoing 44 Cerebral oedema Intoxication (amitriptyline, morphine)
VH NR CRPS 7 mo 48 Intoxication (codeine, quetiapine, alcohol)
KK NR Chronic abdominal pain 2 y 8 mo 81 Pneumonia Oxycodone overdose
TK NR Spinal stenosis 2 y 10 mo 87 Pneumonia
IL NR Osteoporotic back pain 1 y 7 mo 67 Cardiac insufficiency
PM NR Facial pain 1 y 5 mo 59 Coronary artery disease
EN NR Back pain and radiculopathy 4 y 3 mo 91 Coronary artery disease
HR NR Spondylarthritis 1 y 1 mo 66 Intestinal perforation and peritonitis
TS NR Polyneuropathy 1 y 1 mo 60 Pulmonary hypertension

  1. MPM, multidisciplinary pain management; R, responders whose health-related quality of life improved after multidisciplinary pain management; NR, non-responders whose health-related quality of life deteriorated after multidisciplinary pain management; y, year; mo, months; CRPS, complex regional pain syndrome

3.2 HRQoL

MPM resulted in a clinically significantly improved HRQoL (i.e. a 15D score improvement of ≥0.03) at 12 months when compared with baseline in 45.6% of the total chronic pain patient population treated at the Helsinki University Central Hospital Pain Clinic (Table 1a). A smaller group of patients (23.7%) reported no clinically significant change in HRQoL (i.e. the 15D score change was between–0.03 and 0.03) at 12 months, whereas in 30.7% of the patients HRQoL had deteriorated (the 15D score decrease was >0.03).

In the study samples of the 100 patients with the largest improvement in HRQoL and the 100 patients with the poorest outcome, response rates for the first three 15D questionnaires (baseline, 6 months and 12 months) were 99% and 96% (responders and non-responders, respectively). The follow-up questionnaire was returned by 79% and 67% of responders and non-responders, respectively. The mean follow-up time between baseline and the fourth 15D questionnaire was 43 months (range 25–70 months).

In the 99 responders, the mean increase in the 15D score from baseline to 12 months was 0.132, whereas the 96 non-responders scored on average 0.107 less at 12 months when compared with the baseline values (Table 1a). The responders had retained the positive effects of treatment on HRQoL at follow-up: the 15D scores were significantly higher than at baseline but significantly lower than at 12 months (Fig. 1a and b). In the non-responders the deterioration of HRQoL seen during treatment had diminished at follow-up but HRQoL scores still remained lower than at baseline (Table 1b).

Fig. 1 15D-profiles of health-related quality of life.(a)15D-profiles of the 99 chronic pain patients with the best multidisciplinary pain management results. (b)15D-profiles of the 96 chronic pain patients with the poorest multidisciplinary pain management results.
Fig. 1

15D-profiles of health-related quality of life.(a)15D-profiles of the 99 chronic pain patients with the best multidisciplinary pain management results. (b)15D-profiles of the 96 chronic pain patients with the poorest multidisciplinary pain management results.

Pain intensity at baseline was not significantly correlated with the total 15D score or the 15D dimension “discomfort and symptoms” at baseline.

3.3 Multidisciplinary pain management

The details of pain management did not differ between the patients responding well to treatment when compared with the patients whose quality of life deteriorated during treatment (Table 4). The duration of the MPM programme was not significantly longer in the non-responder group, nor was the number of medications started or the variety of specialists participating in MPM. Psychiatric or psychologist counselling and supportive therapy were included in the individually designed MPM programme equally often in both responders and non-responders.

Table 4

Details of multidisciplinary pain management: different pain management specialists seen, number of medications started, psychological methods used (relaxation, supportive therapy, pain management group), stimulation methods used (TENS, spinal cord stimulation) and duration of pain treatment at the Pain Clinic.

Responders (n = 99) Non-responders (n = 96)
Specialists participating in pain treatment
more than one physician 52% 70%
psychiatrist 10% 18%
psychologist 50% 50%
physiotherapist 39% 42%
social worker 4% 13%
Number of medications started 2.4 ± 1.8 3.0 ± 2.6
(mean ± SD)
Relaxation 4% 2%
Supportive therapy 11% 13%
Pain management group 12% 10%
TENS 19% 25%
Spinal cord stimulation 0% 3%
Duration of treatment (months) 6.0 ± 5.0 7.2 ± 5.5
(mean ± SD)

  1. TENS: transcutaneous nerve stimulation

4 Discussion

The results of our study show that the health-related quality of life of chronic pain patients can improve during MPM. As this was not a controlled study we cannot make conclusions regarding the exact role of MPM. Importantly, however, a subgroup of chronic pain patients does not seem to benefit from MPM. In the present study population, the factors explaining poor response to MPM were not treatment related, since no significant differences in pain management interventions between patients with good outcome compared with patients with poor outcome were seen. This is in agreement with a systematic review of 35 studies on MPM [14] that found no evidence to indicate that MPM components influence the success of the intervention in general.

Depression, anxiety and other psychiatric symptoms are prevalent in chronic pain patients [10,19,32,33]. Previous studies have shown that psychiatric comorbidity such as panic disorder or personality disorders predict non-completion of functional restoration in painful chronic musculoskeletal disorders [25,26] and return to work after MPM [16]. Non-completers of functional restoration were more likely to report severe or extreme depression than completers [26]. On the other hand, depression does not independently link to poor treatment outcome [25]. According to a Dutch study, more depression at baseline predicted a more favourable outcome after MPM in patients with chronic back pain [18]. In accordance with previous findings, psychiatric symptoms in our study patients were common in both responders and non-responders, but these symptoms did not explain the difference in treatment outcome. However, almost twice as many patients in the non-responder group had been seen by a psychiatrist compared with the responders.

The duration of pain in the study patients was less than a year in a small minority of both responders and non-responders. Symptom duration is an important factor determining the prognosis of pain management [34]. Disability management intervention in patients with musculoskeletal pain, concurrent depression and work absence of less than 6 months reduced both pain and depressive symptoms significantly more compared with pain patients with work absence of more than 6 months [35]. Regarding pain chronicity, the patients in the present study were far beyond the limit of 3–6 months often considered to define chronic pain [1,36]. The duration of pain was similar in the two study groups, but in the non-responding group there was a tendency towards more depression or anxiety, which might mean a higher symptom load with poor treatment response compared with the responders. Dysfunction of the hypothalamic-pituitary-adrenal stress axis has been suggested to be a moderator of psychosocial risk factors for the development of chronic widespread pain [37].

Previous studies have shown that patients with single-site pain may benefit from MPM more than patients with three or more pain sites [14,19]. Patients with a higher number of pain sites had greater activity interference at one year after cognitive-behavioural therapy for chronic temporomandibular disorder pain [38]. In the present study, as well as in other studies on chronic pain populations [6,16,22], low back was the most common pain site. However, single site pain syndromes, low back or other, were equally few in the group of responders (16%) and non-responders (19%). The number of pain sites thus was not an explaining factor for the MPM outcome difference between the two groups.

The primary pain mechanism in more than 50% of the patients in each group was classified as neuropathic, which in low back pain patients usually means radiculopathy. Simple low back pain without radicular symptoms is more responsive to various pain management methods whereas radiculopathy, similar to other neuropathic pain syndromes, may be more resistant to treatment [39]. However, neuropathic pain or pain intensity at baseline were not discerning factors between the responders and the non-responders of our study.

The only patient-related factors that differed between the two patient groups with opposite outcomes of MPM in the present study were education and employment status. Previously, in the study of Becker et al. [15], educational level did not predict MPM outcome. In a recent study, however, educational level was the best predictor of outcome at 6 months after an in-patient multidisciplinary pain treatment programme for 413 patients with chronic pain [40]. Low educational level has been shown to contribute to unemployment in chronic pain patients [41]. The low employment status in the non-responder group of our study patients (15% working at baseline) was very similar to that of the Danish chronic pain patients [15] and could probably at least in part be explained by the lower educational level of the non-responder group compared with the responders. The employment rate of the responders, about one-third, was not high either but close to the previously reported rates in successfully treated chronic pain patients [42].

The percentage of non-responders receiving disability or retirement pension was also high (60%). In the Danish study [15], applying for disability pension was a significant negative outcome predictor of MPM. In the present study, patients currently applying 2 for pension were few and equally divided between responders and non-responders.

More non-responders than responders had died after the end of MPM before the follow-up questionnaire was sent. Causes for six out of the ten deaths were due to older age and concomitant diseases unrelated to the pain problem. These non-responder patients were obviously in poorer general health than patients in the non-responding group, which also probably was reflected in the HRQoL scores. MPM, focused on management of pain and pain-related cognitions, did not have an effect on concomitant diseases and thus did not prevent worsening of HRQoL during the MPM period. However, the deaths of three non-responders and one responder (40% of all deaths) were caused by alcohol or drug intoxication. In chronic pain patients, substance abuse disorders are more prevalent than in the general population [43]. Excessive alcohol and analgesic use may also reflect the mood disorder symptoms that were more common in the non-responders than responders, although not significantly so.

Our study results are in agreement with previous findings where medical history, pain character and pain intensity do not have any predictive value of MPM outcome in patients with chronic pain [44,45]. Previous studies have shown that self-efficacy beliefs may contribute to pain-related disability [41] and changes in self-efficacy and patient beliefs mediate the effects of MPM and cognitive-behavioural therapy in chronic pain [23,38]. Psychological flexibility [46] has also been shown to be an important mediator of improving pain-related disability after rehabilitation. Therefore, analysing patient beliefs and other psychological factors such as flexibility may be more important in predicting MPM success than the pain-related medical background of the patient.

The study is limited by the fact that it was not controlled. However, randomising patients to waiting lists or providing them with limited treatment would not have been possible in a study where the follow-up is three years. All patients had already had several treatment efforts by primary care physicians during the course of their pain disease. Neuropathic pain patients were the largest group in both the responders and non-responders and many patients had both neuropathic and nociceptive pain. The relative small size of this cohort does not really allow subgrouping the patients further. Importantly, all patients had a long history of pain reducing the likelihood of spontaneous recovery. In future larger studies we will certainly assess the pain diagnoses in more detail.

5 Conclusions

The HRQoL of almost half of the chronic pain patients was significantly improved during MPM. However, one third of the patients did not benefit from the pain management or their HRQoL even deteriorated. Future research needs to identify factors that enable more individualized management of those chronic pain patients who do not respond to the commonly used approaches.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2012.08.005.

Tel.: +358 50 4272386; fax: +358 9 4717 5641

  1. Conflict of interest: The authors have no conflict of interest.

  2. Role of the funding source: The study was supported by a grant from the Helsinki University Central Hospital research funds (T102010066).

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Received: 2012-03-04
Revised: 2012-05-15
Accepted: 2012-05-16
Published Online: 2012-10-01
Published in Print: 2012-10-01

© 2012 Scandinavian Association for the Study of Pain

Articles in the same Issue

  1. Editorial comment
  2. What should we assess in outcome-studies to learn which patients benefit from treatments in multidisciplinary pain clinics?
  3. Clinical pain research
  4. Multidisciplinary pain treatment – Which patients do benefit?
  5. Editorial comment
  6. Sleeping with pain—A nightmare
  7. Clinical pain research
  8. Are sleep problems and non-specific health complaints risk factors for chronic pain? A prospective population-based study with 17 year follow-up
  9. Editorial comment
  10. The life long burden of suffering from postherpetic neuralgia is reduced by adult vaccination and by topical anti-hyperalgesic treatment with lidocaine and capsaicin
  11. Topical review
  12. Postherpetic neuralgia: New hopes in prevention with adult vaccination and in treatment with a concentrated capsaicin patch
  13. Editorial comment
  14. Can we measure the relative contributions of peripheral and central mechanisms of painful conditions, and how can it guide therapy?
  15. Human experimental study
  16. ‘Central sensitization’ in chronic neck/shoulder pain
  17. Editorial comment
  18. Appropriate interventional management of whiplash-associated pain disorders is effective
  19. Educational case report
  20. Treatment of post-traumatic pain, and autonomic and muscular dysfunction by ganglion impar block and medial branch block of the facet joints: A case report
https://doi.org/10.1016/j.sjpain.2012.05.073
Keywords for this article
Chronic pain; Health-related quality of life; 15D questionnaire; Multidisciplinary pain treatment; Benefit from treatment

Articles in the same Issue

  1. Editorial comment
  2. What should we assess in outcome-studies to learn which patients benefit from treatments in multidisciplinary pain clinics?
  3. Clinical pain research
  4. Multidisciplinary pain treatment – Which patients do benefit?
  5. Editorial comment
  6. Sleeping with pain—A nightmare
  7. Clinical pain research
  8. Are sleep problems and non-specific health complaints risk factors for chronic pain? A prospective population-based study with 17 year follow-up
  9. Editorial comment
  10. The life long burden of suffering from postherpetic neuralgia is reduced by adult vaccination and by topical anti-hyperalgesic treatment with lidocaine and capsaicin
  11. Topical review
  12. Postherpetic neuralgia: New hopes in prevention with adult vaccination and in treatment with a concentrated capsaicin patch
  13. Editorial comment
  14. Can we measure the relative contributions of peripheral and central mechanisms of painful conditions, and how can it guide therapy?
  15. Human experimental study
  16. ‘Central sensitization’ in chronic neck/shoulder pain
  17. Editorial comment
  18. Appropriate interventional management of whiplash-associated pain disorders is effective
  19. Educational case report
  20. Treatment of post-traumatic pain, and autonomic and muscular dysfunction by ganglion impar block and medial branch block of the facet joints: A case report
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