Multimodal Rehabilitation Programs (MMRP) for patients with longstanding complex pain conditions – The need for quality control with follow-up studies of patient outcomes
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Dag Lemming
In this issue of the Scandinavian Journal of Pain, Andrea Hållstam and coworkers report on a one-year follow-up of a multimodal rehabilitation programme carried out at a “conventional pain clinic” at the Karolinska Institutet in Sweden [1].
1 Treatment options for relieving the burden of chronic pain for patients and society
The burden of chronic pain on society and the health care system is immense [2] and resources for treatment and rehabilitation are not evenly distributed in the world. The topic of the article by Hållstam et al. [1] is of special interest since it reflects the actual situation at many hospitals and clinical departments dealing with chronic pain in Scandinavia. The “conventional pain clinic”, which is the term used by the authors, is usually driven from an anaesthesiology perspective.The treatment options often comprise unimodal treatments such as pharmacological interventions, injection therapies or blocks, radiofrequency neurolysis, and other types of radiofrequency interventions. Sometimes psychological assessments and treatments are given but not always coordinated in the way multimodal/multidisciplinary rehabilitation programmes (MMRP) require.
2 Multimodal or multidisciplinary rehabilitation programmes, evolution and evidence base
The concept of MMRP is not new, has its roots in the late World War era, and is generally based upon a biopsychosocial model of pain [3]. The general idea of MMRP is closely linked to the need for multiprofessional assessments and coordinated actions when dealing with chronic pain. Since the beginning of the millennium, a growing evidence-base has successfully evolved in this area. However, until now the evidence is mostly limited to chronic musculoskeletal pain along the spine and generalized pain [3,4].
More research with long term follow-up is needed to build evidence for other pain conditions (e.g. neuropathic pain, visceral pain).
3 Pharmacological treatment should be a minor part of MMRP
The escalating problem with the long-term use of opioids and opioid-dependence in chronic non-cancer pain is worrying, to say the least [5]. Other treatment options than the systemic pharmacological route need to be further explored and MMRP is promising in this respect. Usually a stable pharmacological treatment regime is desired when patients are included in MMR and if possible, new major pharmacological interventions should be avoided during rehabilitation. However, this is not always the case and besides adding further stress for the patient with discontinuation – and side-effects, assessing effects of MMRP becomes more difficult in this situation.
4 MMRP do not aim to remove pain from the pain condition
From a rehabilitation perspective MMR deals with the fact that in most cases of chronic pain it is not possible to “cure” the pain as such, the primary goal is to mitigate consequences and increase function and activity. With a MMRP approach, the biopsychosocial model of pain can be applied [6], and the three major domains of intervention can be addressed, i.e., biological, psychological, and social. MMRP at the specialist level is needed to assess and rehabilitate patients with complex psychological comorbidity; the intervention is usually only available in the large urban areas (in Sweden). A specialist in pain medicine or rehabilitation medicine usually initiates MMRP at this level after careful pain analysis.
5 Cornerstones of multimodal rehabilitation of pain patients
The corner-stones of evidence-based MMR today consists of physical fitness training [7], cognitive behavioural therapy (CBT) [8] including acceptance commitment therapy (ACT) [9], pain education 10,11], and early actions aimed for return to work [12]. MMRP is now also being offered in primary care settings in some parts of Sweden, with follow-up through the Swedish Quality Registry for Pain Rehabilitation (SQRP) [13]. MMRP in primary health care is typically offered to chronic pain patients with less complicated clinical presentation.
6 Prerequisites for selection of chronic pain patients to MMRP
MMRP requires some degree of acceptance and willingness –from the patient – to actively engage in and work with all the aspects of behaviour change and thoughts. Thus, MMRP is not the right treatment for all and a passive approach to pain treatment from the patients’ perspective is very hard to accommodate within MMRP today. The MMRP intervention as such can vary greatly, even within the same country. Usually the main corner-stones apply, but the intensity and add-ons of different adjuvant interventions differ and are not always based on evidence. Another significant problem relates to difficulties with dropouts and missing data at long-term follow-ups, this represents a major limitation when it comes to assessing effects of MMRP.
7 Predictors for outcome from MMRP for chronic pain patients: challenging research
All these factors taken together, although MMRP is a well-established complex intervention, more work needs to be done finding predictors for positive outcome and how to ensure a reliable follow-up process. A national or international consensus regarding the intensity and content of MMRP would be beneficial in the long run, the situation today makes it difficult to compare interventions between different centres, even within the same country. The selection process, criteria for inclusion, intensity of the different components and the length of the intervention as such are all variables likely to affect the outcome greatly and should be described in detail. The consolidation of rehabilitation results (at the end of specialist treatment) with primary care units, is another factor very likely to affect the outcome of MMR in the long run. Techniques and strategies for maintaining positive results, together with differences in the social security system in different countries should be addressed when designing future studies.
8 Well done efforts to document long-term effects of MMRP
The findings by Hållstam and coworkers [1] indicate that successful results can be reached in several areas of activity and quality of life even when MMR is not performed at a rehabilitation clinic. Their study also highlights several of the common difficulties related to assessing effects of multimodal rehabilitation: (1) Selection and symptom severity of chronic pain patients. (2) Intensity of and the actual content of the intervention as such (the “black box”). (3) Using a national quality registry, like the SQRP, or not. (4) Low follow-up response rates.
Another important and well done follow-up study of multi disciplinary pain management was recently reported in the Scandinavian Journal of Pain from Eija Kalso’s research group in Helsinki focusing on which patients are more likely to benefit from a MMRP [14]. They found that those who are better educated and have a stable social and working life when a complex pain condition develops benefit most from their multidisciplinary pain management programme. Their findings and conclusions were supported in an editorial comment by a similar multidisciplinary pain management programme inTrondheim, Norway, a pain centre with strong input from clinical psychologists, experts at CBT for chronic pain patients [15].
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2015.08.008.
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Conflict of interest: No conflict of interest is reported.
References
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© 2015 Scandinavian Association for the Study of Pain
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- Editorial comment
- Plasma pro-inflammatory markers in chronic neuropathic pain: Why elevated levels may be relevant for diagnosis and treatment of patients suffering chronic pain
- Original experimental
- Plasma pro-inflammatory markers in chronic neuropathic pain: A multivariate, comparative, cross-sectional pilot study
- Editorial comment
- Genetic variability of pain – A patient focused end-point
- Observational study
- COMT and OPRM1 genotype associations with daily knee pain variability and activity induced pain
- Editorial comment
- Complex Regional Pain Syndrome (CRPS) after viper-bite in a pregnant young woman: Pathophysiology and treatment options
- Clinical pain research
- Complex regional pain syndrome following viper-bite
- Editorial comment
- An investigation into enlarging and reducing the size of mirror reflections of the hand on experimentally induced cold-pressor pain in healthy volunteers
- Original experimental
- An investigation into enlarging and reducing the size of mirror reflections of the hand on experimentally-induced cold-pressor pain in healthy human participants
- Editorial comment
- Multimodal Rehabilitation Programs (MMRP) for patients with longstanding complex pain conditions – The need for quality control with follow-up studies of patient outcomes
- Observational study
- Patients with chronic pain: One-year follow-up of a multimodal rehabilitation programme at a pain clinic
- Editorial comment
- Advancing methods for characterizing structure and functions of small nerve fibres in neuropathic conditions
- Clinical pain research
- Structural and functional characterization of nerve fibres in polyneuropathy and healthy subjects
- Editorial comment
- Stimulation-induced expression of immediate early gene proteins in the dorsal horn is increased in neuropathy
- Original experimental
- Stimulation-induced expression of immediate early gene proteins in the dorsal horn is increased in neuropathy
- Editorial comment
- Targeting glial dysfunction to treat post-surgical neuropathic pain
- Topical review
- Glial dysfunction and persistent neuropathic postsurgical pain
- Editorial comment
- Mechanisms of cognitive impairment in chronic pain patients can now be studied preclinically by inducing cognitive deficits with an experimental animal model of chronic neuropathic pain
- Original experimental
- Impaired recognition memory and cognitive flexibility in the ratL5–L6 spinal nerve ligation model of neuropathic pain
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- Original experimental
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- Editorial comment
- The obesity epidemic makes life difficult for patients with herniated lumbar discs – and for back-surgeons: Increased risk of complications
- Observational study
- Obesity has an impact on outcome in lumbar disc surgery
- Editorial comment
- Finnish version of the fear-avoidance-beliefs questionnaire (FABQ) and the importance of validated questionnaires on FAB in clinical praxis and in research on low-back pain
- Clinical pain research
- Translation and validation of the Finnish version of the Fear-Avoidance Beliefs Questionnaire (FABQ)
- Editorial comment
- Pain, sleep and catastrophizing: The conceptualization matters Comment on Wilt JA et al. “A multilevel path model analysis of the relations between sleep, pain, and pain catastrophizing in chronic pain rehabilitation patients”
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