[Evaluation of an early interdisciplinary multimodal assessment for patients with pain : Protocol of a randomized controlled study (PAIN2020)]

Evaluating an early Interdisciplinary Multimodal Assessment for Patients at Risk of Developing Chronic Pain: Results of a Multicentre RCT in Germany

INTRODUCTION

Patients at risk of developing chronic pain are often significantly impaired in their daily, social and work activities. An early interdisciplinary multimodal assessment (IMA) includes a systematically integrated view of medical, psychosocial and functional factors to direct patients to need-based treatment services. This multicentre, randomised, controlled trial examined the effects of an IMA on preventing chronic pain and improving care for adult patients.

METHODS

The intervention group (IG) received an IMA in accordance with standardised guidelines. The control group (CG) was offered a unimodal medical pain assessment (MPA). Data from the Characteristic Pain Intensity (PI) and Disability Score (DS), as primary outcomes, were collected at assessment and 3 and 6 months later together with secondary outcomes (e.g. depression, anxiety, stress, catastrophizing, health-related quality of life).

RESULTS

A total of 620 (68.4%) valid questionnaires were available at the 6-month follow-up. The mean reduction (numerical rating scale, 0-10) in terms of improvement within both groups (IG/CG) was 1.6/1.7 points for PI and 1.9/1.8 points for DS. Most secondary outcomes improved as well. However, the differences between the two groups did not reach statistical significance, although there was a tendency for the IG to have a greater effect on some psychological outcomes. Regarding the recommended treatment approaches, the focus in the IG was more on physical activity and psychological and psychosomatic interventions, whereas in the CG there was also a preference for adjusting the medication.

CONCLUSIONS

Both early MPA and IMA seem to have a positive effect on outcomes such as pain intensity, functional limitations and psychological factors for patients at risk of developing chronic pain. We critically reflect on the results of the primary research question by discussing the limitations in detail and conclude that further research should ensure that the control conditions reflect standard care and that the follow-up period is long enough.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID: DRKS00015443).

Evaluation of a Four Week Interdisciplinary Multimodal Pain Therapy on Chronic Pain Patients-A Comprehensive Approach

Chronic pain syndrome poses a significant challenge to healthcare systems worldwide, affecting millions of individuals and resulting in reduced quality of life and substantial socio-economic costs. This prospective, non-interventional, single-center study evaluated the effectiveness of a four-week interdisciplinary multimodal pain therapy (IMPT) program incorporating neuromuscular training with the HUBER® 360 evolution device. The study included 66 patients diagnosed with chronic pain disorder, divided into an intervention group (n = 49) that completed weekly supervised HUBER® 360 sessions and a control group (n = 17). Measurements were taken at four time points: day of admission (t1), during therapy (t2), at discharge (t3), and three months post-discharge (t4). The study assessed changes in psychological factors, pain intensity, postural control, and quality of life. The results show that this four-week therapy led to significant improvements in psychological factors such as depression, anxiety, and stress, and significantly reduced the subjects' pain. The intervention group showed more pronounced improvements compared to the control group. These findings highlight the potential benefits of IMPT in managing chronic pain and improving both physical and psychological health outcomes. This study contributes to the ongoing development of chronic pain management strategies, emphasizing the importance of a multidisciplinary, patient-centered approach. Future research should explore the scalability of IMPT, stratify results based on demographic factors, and evaluate the long-term efficacy of adjunctive tools like the HUBER® 360 device.

[Interprofessional and interdisciplinary collaboration in the implementation of health services research in pain medicine]

Health services research looks at a form of care under contextual conditions. Often, and especially in the treatment of recurrent or chronic pain, these forms of care are complex interventions. Ensuring internal validity for subsequent interpretability of the results achieved as an essential requirement for studies in health services research therefore presents researchers with the challenge that they have to develop complex study protocols and implement and monitor them in clinical care. By its very nature, interdisciplinary multimodal pain therapy (IMST) involves multimodal interventions in an interdisciplinary care setting. In the reality of care, contextual factors for the effectiveness and feasibility of IMST are of great importance. On the one hand, health services research provides appropriate recommendations for the planning, implementation and evaluation of studies on complex interventions under contextual conditions, which can be of great importance for further research into the effectiveness of IMST. On the other hand, experience from interdisciplinary pain research can also help to successfully plan and conduct studies on complex interventions. This article introduces the understanding of interdisciplinarity (and interprofessionalism) in pain medicine and research, outlines possible key points for study planning and implementation using the example of two health services research studies and concludes by discussing gaps in research on interdisciplinary collaboration in pain medicine and research.

[How does an intervention work?-German Version. : Development of an effect model for a complex intervention to prevent recurring or persistent pain using the example of PAIN 2.0]

In addition to the usual evaluation approach (usually a clinical randomized trial in the sense of the question: does an intervention work), complex interventions require further systematic investigations to prove their effectiveness. The role of the context in which the intervention is delivered is essential here, as is consideration of the question of why an intervention works (or does not work). Detailed recommendations exist for the planning and implementation of effectiveness studies on complex interventions, to which interdisciplinary multimodal pain therapy undoubtedly belongs. In an effectiveness model, concrete, verifiable assumptions are formulated as to how an intervention produces changes that are reflected in the endpoint. This article provides a brief introduction to methodological approaches to effectiveness research on complex interventions and uses the PAIN 2.0 project (01NVF20023) to describe in concrete terms what an effectiveness model for interdisciplinary multimodal pain therapy for the prevention of chronic pain in an outpatient setting might look like.

How does an intervention work?-English Version : Development of an effect model for a complex intervention to prevent recurring or persistent pain using the example of PAIN 2.0

In addition to the usual evaluation approach (usually a clinical randomized trial in the sense of the question: does an intervention work), complex interventions require further systematic investigations to prove their effectiveness. The role of the context in which the intervention is delivered is essential here, as is consideration of the question of why an intervention works (or does not work). Detailed recommendations exist for the planning and implementation of effectiveness studies on complex interventions, to which interdisciplinary multimodal pain therapy undoubtedly belongs. In an effectiveness model, concrete, verifiable assumptions are formulated as to how an intervention produces changes that are reflected in the endpoint. This article provides a brief introduction to methodological approaches to effectiveness research on complex interventions and uses the PAIN 2.0 project (01NVF20023) to describe in concrete terms what an effectiveness model for interdisciplinary multimodal pain therapy for the prevention of chronic pain in an outpatient setting might look like.

[Validity of the Chronic Pain Grade Scale in nonspecific chronic low back pain]

BACKGROUND

Higher pain grades are associated with high psychological burden and increase the risk for the persistence of chronic low back pain (CLBP).

OBJECTIVES

Previous results on the criterion validity of the Chronic Pain Grade Scale (CPGS) have been extended to the context of inpatient multidisciplinary orthopedic rehabilitation (MOR) and have been supplemented with additional psychosocial and work-related measures.

METHODS

In this multicenter study, psychological, work- and pain-related outcomes were examined among 1010 individuals with nonspecific CLBP (ICD-10: M51/53/54) prior to the beginning of an inpatient MOR stratified by pain grade (I-IV). Additionally, frequency distributions of scores regarding pain-specific self-efficacy, depression, and subjective prognosis of gainful employment by pain grade in patients were investigated.

RESULTS

The CPGS differed between all pain grades in the psychological, work- and pain-related outcomes in the expected direction. In post hoc pairwise comparisons, grade IV was significantly different from the lower grades. Patients with higher pain grades showed unfavorable levels in psychosocial parameters and more frequently scores in the clinical range than expected.

CONCLUSIONS

These results confirm the criterion validity of the CPGS. The psychosocial risk pattern observed in higher pain grades supports the importance of conducting early pain-related and psychological diagnostic assessments and implementing systematic allocation to needs-based interdisciplinary multimodal treatments.

Avoidance and Endurance Responses to Pain Before and with Advanced Chronification: Preliminary Results from a Questionnaire Survey in Adult Patients with Non-Cancer Pain Conditions

Purpose

The Avoidance-Endurance Model postulates fear-avoidance responses and endurance responses as important psychological mechanisms in the development and maintenance of chronic pain. The present study aims to investigate potential differences in avoidance and endurance responses to pain before and with advanced chronification.

Patients and Methods

Two samples of adults with non-cancer pain at two different stages of chronicity were compared: One with pain and risk factors for chronicity (n=26, part of the PAIN2020 project) and one with chronic pain (n=33 from a pain day care clinic). The German Pain Questionnaire, the Graded Chronic Pain Scale (GCPS) and medical reports were used to measure duration and severity of pain. Responses to pain were assessed with the Avoidance-Endurance Questionnaire (AEQ) and psychological strain with the Depression, Anxiety and Stress Scales (DASS).

Results

Both groups were primarily affected by musculoskeletal pain. Although not yet chronified, the risk group reported comparable GCPS levels of pain intensity and disability. Depression and stress ratings were also similar, except for anxiety, which was significantly elevated in the chronic pain sample (p<.001). The AEQ scales did not differ between groups, neither on any of the fear-avoidance- nor endurance-related dimensions. A post-hoc regression analysis revealed a significant prediction of fear-avoidance by pain-related disability (p<.001). The regression model for endurance responses was not significant.

Conclusion

Patients with risk factors of chronification experience substantial pain-related burden. Responses to pain in the realm of the Avoidance-Endurance model do not appear to vary as a function of chronification. While fear-avoidance and pain-related disability correlate positively, endurance could not be associated to any of our variables.

[Feasibility of the interdisciplinary multimodal assessment-The team perspective]

BACKGROUND

Secondary preventive outpatient diagnostic services for patients with pain and risk factors for chronification have not yet been sufficiently established. In the PAIN2020 project (Innovation Fund, 01NVF17049) an outpatient interdisciplinary multimodal assessment (IMA) was introduced for the first time early in the course of the disease.

OBJECTIVE

For the implementation of the IMA procedures for team cooperation and decision criteria were developed, which were implemented by a team of medical, physiotherapeutic and psychological therapists. These procedures and decision criteria are to be discussed against the background of clinical experience and examined with respect to their feasibility (qualitative).

METHODS

In PAIN2020 a workshop on IMA was held in September 2021 to jointly reflect on the findings and experiences gained in the process so far through monitoring and structuring documentation in the implementation with staff or teams of PAIN2020 centers on the feasibility of implementing a structured interdisciplinary multimodal assessment. In three work phases, occupational group-specific and cross-occupational group topics were addressed.

RESULTS

In the decision-making processes of the occupational groups, in addition to profession-specific focal points within the framework of the assessment of findings (somatic, functional or psychosocial core criteria), overarching core criteria within the professions as well as complementary patient-related aspects are evident, which are included in the integrative team process. With respect to team collaboration, the implementation of the team meeting and the final discussion can be used to identify structural and process parameters that promote or inhibit implementation, which are also accompanied by interactional factors.

DISCUSSION

For the implementation of the IMA, there were (1) adaptations of the IMA, which is currently implemented as A‑IMA in the selective agreement with BARMER and (2) new dimensions or task fields and ideas for evidence-based concepts for the content design of integrative diagnostics as well as for the feedback of the results to the patients, which should be discussed in the future.

[Interdisciplinary multimodal assessment : Interprofessional interaction in team meetings and final talks]

BACKGROUND

In PAIN2020 (Innovation Fund, 01NVF17049), an outpatient interdisciplinary multimodal assessment (IMA) was introduced early in the course of the disease. The central quality feature is the close interdisciplinary collaboration of pain medicine, physiotherapy and psychology, which requires a complex organizational and coordination process, especially in team meetings and final discussions.

OBJECTIVES

The (different) views of the professional groups involved are brought together in the team process as a common consensus. The process of shaping the interaction of the professional groups among each other in the team meeting and final discussion as well as with the patients is examined (qualitatively) and discussed.

METHODS

In PAIN2020, a workshop on IMA was held to jointly reflect on the insights and experiences gained in the process so far through monitoring with staff or teams of the PAIN2020 centers. In one of three work phases, interprofessionally composed groups gathered statements from participants on the design of the interaction in team meeting and final discussion in three rotating rounds within the framework of a World Café.

RESULTS

It was possible to identify conducive and obstructive factors for the design of interdisciplinary collaboration in team meetings and final discussions, which were brought together in a superordinate framework model.

DISCUSSION

The provision of the new care service as an interdisciplinary task in a team goes beyond existing structural and process parameters in the definition of framework conditions in interdisciplinary multimodal pain therapy and should therefore also take personal competencies and professional competencies into account. Therefore, new dimensions arise for the implementation of the IMA, which should be discussed in the future.

PAIN2.0: study protocol for a multicentre randomised controlled trial to evaluate the efficacy of a 10-week outpatient interdisciplinary multimodal pain therapy to manage recurrent pain for patients with risk factors of developing chronic pain in Germany

BACKGROUND

Up to 27% of the German population suffers from recurrent or persistent pain (lasting more than three months). Therefore, prevention of chronic pain is one major object of pain management interventions. The aim of this nationwide, multicentre, randomised controlled trial is to evaluate the efficacy of a 10-week ambulatory (outpatient) interdisciplinary multimodal pain therapy (A-IMPT) for patients with recurrent pain and at risk of developing chronic pain. This project was initiated by the German Pain Society (Deutsche Schmerzgesellschaft e.V.) and the public health insurance provider BARMER. It is currently funded by the German Innovation Fund (01NVF20023). The study PAIN2.0 focuses on reducing pain intensity and pain-related disability and investigates whether this intervention can improve physical activity, psychological well-being, and health literacy.

METHODS

PAIN2.0 is designed as a multicentre 1:1 randomised controlled trial with two parallel groups (randomisation at the patient level, planned N = 1094, duration of study participation 12 months, implemented by 22 health care facilities nationwide). After 6 months, patients within the control group also receive the intervention. The primary outcomes are pain intensity and pain-related impairment, measured as Characteristic Pain Intensity (PI) and Disability Score (DS) (Von Korff), as well as patient-related satisfaction with the intervention. Secondary outcomes are the number of sick leave days, sickness allowance, treatment costs, psychological distress, health-related quality of life, and catastrophizing. The effects of the intervention will be analysed by a parallel-group comparison between the intervention and control groups. In addition, the long-term effects within the intervention group will be observed and a pre-post comparison of the control group before and after the intervention will be performed.

DISCUSSION

Recurrent or persistent pain is common in the German population and causes high costs for patients and society. The A-IMPT aims to improve pain and pain-related impairments in pain patients at risk of chronification, thereby reducing the risk of developing chronic pain with its high socioeconomic burden. This new therapy could easily be integrated into existing therapy programs if positively evaluated.

TRIAL REGISTRATION

The trial PAIN2.0 has been registered in the German Clinical Trials Register (DRKS) since 21/11/2022 with the ID DRKS00030773 .

[Development of two outpatient interdisciplinary group modules in the treatment of patients with pain and risk of chronification]

BACKGROUND AND OBJECTIVE

An early treatment of patients who suffer from pain and show risk factors for chronification is meaningful as these patients can benefit from an early interdisciplinary multimodal pain treatment (IMST). In view of the insufficient treatment, two outpatient treatment modules for the secondary prevention of pain chronification are developed within the framework of PAIN2020: the educative and accompanying IMST (E‑IMST and B‑IMST).

MATERIAL AND METHODS

The developmental process of both IMSTs is presented. In this context two target groups of patients were defined for which 1 session (E‑IMST) or 10 intervention appointments (B‑IMST) were planned, depending on the chronification, impairment and complexity of the disorder. The conception was carried out in five steps: development of the objectives, development of the main contents, workshop on the content and conceptional design (contents, mediation, exercises), preparation of a time schedule and processing of the results (manual, presentations, worksheets, handbook). The B‑IMST was initially developed from which the contents for the E‑IMST were subsequently extracted. Additionally, a concept for testing the feasibility and a working model for a pilot study were developed.

RESULTS

The objectives for both forms of IMST are improvement of the understanding of pain and contributing factors, the increase of the experience of control and self-efficacy and the increase in self-responsibility with respect to strategies to reduce pain. Differences between the two treatment modules arise from the needs and framework conditions. Medical, physiotherapeutic and psychotherapeutic contents and schedules were organized for both IMST modules. The B‑IMST consists of five modules each with two sessions as group interventions (biopsychosocial model, activation planning, regulation of needs, sleep and medication, routine transfer). The 3‑h E‑IMST group intervention mainly intends to mediate knowledge on pain and the biopsychosocial pain model. Theoretical and practical interventions, empirical knowledge and experience-oriented methods are employed.

CONCLUSION

There are now two interdisciplinary structured manuals for the secondary preventive treatment of patients with recurrent pain and a risk profile for chronification. These approaches must now prove themselves with respect to feasibility and effectiveness.

[Low back pain from an orthopedic and pain medical point of view]

Low back pain is not a diagnosis but a symptom of various causes. The differentiation between specific and non-specific low back pain is diagnostically difficult and only of limited help with regard to the further therapeutic procedure. A large proportion of the causes of low back pain are functional disorders that can be detected on the basis of clinical findings and not (or only insufficiently) by imaging procedures. Early recognition and timely adequate therapy are crucial for the prognosis of chronic low back pain. Low back pain at risk of chronicity or chronic low back pain requires early assessment and the initiation of an interdisciplinary multimodal pain therapy program (IMPT).

[Presentation of an innovative interdisciplinary and cross-sector therapeutic concept for pain patients as part of a regional selective contract]

Hintergrund

Eine gestufte Versorgung in der Behandlung chronisch schmerzkranker Patient*innen ist in Deutschland nur in Ansätzen vorhanden. Vor dem Hintergrund der aktuellen Pandemiebedingungen hat sich eine Unter- und Fehlversorgung weiter verschärft.

Ziel

Entwicklung und Aufbau eines sektorenübergreifenden Behandlungskonzepts für schmerzkranke Patient*innen im Rahmen eines Selektivvertrags.

Methoden

Eingebettet in bereits vorhandene Versorgungsstrukturen wurden nach vorbezeichneten Kriterien sieben Versorgungspfade (Clinical Pathways, CP) definiert, in die eingeschriebene Patient*innen nach einem interdisziplinären Assessment geleitet werden.

Aufbau

Im CP I verbleiben die Patient*innen in der Regelversorgung. Im CP II wird zusätzlich eine einmalige interprofessionelle Edukation von 3 h zur Prophylaxe weiterer Chronifizierung angeboten. Im CP III gehen die Patient*innen für sechs Monate in eine fachärztlich spezialisierte ambulante Schmerzbehandlung. Das CP IV ist eine teilstationäre multimodale Therapie, bei der viele Präsenztage durch telemedizinische Inhalte mit Unterstützung einer Reha-App ersetzt werden. CP V und VI sind vollstationäre multimodale Behandlungen über acht und 15 Tage. In CP VII kann bei ambulantem psychotherapeutischen Behandlungsbedarf für Patient*innen nach vollstationärer Behandlung zur Überbrückung des Wartezeitraums über sechs Monate eine niederfrequente Psychotherapie erfolgen.

Qualitätssicherung und Evaluation

Die wissenschaftliche Begleitung erfolgt mittels ausgewählter Fragebögen und psychometrischer Testverfahren jeweils drei, sechs und zwölf Monate nach erfolgtem Assessment, um die Inhalte des Vertrags zu evaluieren.

[Prevention of chronic pain in the German healthcare system : Current state and perspective]

The current healthcare provision in Germany is established, in particular, for the diagnostics and treatment of chronic pain conditions; however, the current aim is to initiate the diagnostic and therapeutic approaches oriented towards the biopsychosocial pain model in the early stages of pain, i.e. before the onset of chronification, for patients with pain and a risk of chronification in order to actively avoid chronification processes. In this context, multiple risk factors play an important role for the diagnostic and therapeutic approaches as well as for the interdisciplinary multimodal pain therapy developed for this purpose. The Global Year of the International Association for the Study of Pain (IASP) 2020 addressed the prevention of (chronic) pain, a welcome opportunity to provide a short review of the evidence for and clinical experiences with timely diagnostic and therapeutic options and to summarize the current framework conditions and scientific recommendations for Germany. At the end of this article the implications for future research are summarized, particularly for the treatment of patients with pain and risk of chronification.