Disparities in access but not outcomes: Medicaid versus non-Medicaid patients in multidisciplinary chronic pain rehabilitation

Purpose: There are known disparities in chronic pain severity, treatment, and opioid-related risks amongst individuals from lower socioeconomic status, including Medicaid beneficiaries, but little is known about whether Medicaid beneficiaries benefit in a similar way from multidisciplinary chronic pain rehabilitation. This study investigated differences in clinical outcomes between Medicaid and non-Medicaid beneficiaries who completed a 3-week multidisciplinary chronic pain rehabilitation program.Methods: Participants (N = 131) completed a broad range of clinical measures pre- and post-treatment including pain severity, pain interference, depression, anxiety, objective physical functioning, and opioid misuse risk. Patients with Medicaid were compared with non-Medicaid patients in terms of baseline characteristics and rate of change, utilizing two-factor repeated measures analyses of variance.Results: There were baseline characteristic differences, with Medicaid beneficiaries being more likely to be African American, have higher rates of pain, worse physical functioning, and lower rates of opioid use. Despite baseline differences, both groups demonstrated significantly improved outcomes across all measures (p<.001) and no significant difference in rate of improvement.Conclusions: Results suggest that pain rehabilitation is as effective for Medicaid recipients as non-Medicaid recipients. Patients with Medicaid are particularly vulnerable to disparities in treatment, so efforts to expand access to multidisciplinary pain treatments are warranted.

Do baseline patient reported outcome measures predict changes in self-reported function, following a chronic pain rehabilitation programme?

Background

Interdisciplinary pain management programmes, based on cognitive-behavioural principles, aim to improve physical and psychological functioning and enhance self-management in people living with chronic pain. Currently there is insufficient evidence about whether psychological, biological or social factors are predictive of positive outcomes following pain rehabilitation. This study aims to evaluate predictors of change in Brief Pain Inventory - pain interference score (BPI) in a clinical data set to determine whether age, sex and baseline outcome measures are predictive of improvement in pain interference following pain rehabilitation.

Methods

A retrospective, pragmatic observational analysis of routinely collected clinical data in two pain rehabilitation programmes, Balanced Life Programme (BLP) and Get Back Active (GBA) was conducted. Standard regression and hierarchical regression analyses were used to identify predictors of change to assess temporal changes in BPI. Responder analysis was also conducted.

Results

Standard regression analyses of 208 (BLP) and 310 (GBA) patients showed that higher baseline BPI and better physical performance measures predicted better improvement in BPI across both programmes. Hierarchical regression showed that age and sex accounted for 2.7% (BLP) and 0.002% (GBA) of the variance in change in BPI. After controlling for age and sex, the other measures explained an additional 23% (BLP) and 19% (GBA) of the variance, p = < .001 where BPI and physical performance measures were consistently statistically significant predictors, p < .05. Responder analysis also showed that pain interference and physical performance were significantly associated with improvement (p = < .0005).

Conclusions

The combination of high self-reported pain interference and better physical performance measures may be a useful indicator of who would benefit from interdisciplinary rehabilitation. Further validation of the results is required.

"It has changed my picture of myself": how did females living with chronic pain perceive the impact of the standard pain rehabilitation, including the occupational therapy lifestyle intervention REVEAL(OT)?

PURPOSE

This study investigated patient perceptions of multidisciplinary chronic pain rehabilitation, including the occupational therapy lifestyle management program REVEAL(OT), on everyday life with chronic pain.

METHODS

Individual interviews were conducted using video conferencing after completing multidisciplinary chronic pain rehabilitation. The interviews followed a semi-structured interview guide and investigated patient experiences with occupational therapy-supported health behavior transformation. The interviews were transcribed verbatim and analyzed iteratively using an inductive semantic data-driven approach inspired by Braun & Clarke's methodology.

RESULTS

Five females, 34 to 58 years old, revealed three common themes: To discover oneself anew; Increased energy and calmness; and Look into the future. The themes reflected transformations towards a healthier lifestyle through enhanced self-control, developing meaningful and secure everyday activities, and gaining reaffirmed dignity. The study also identified the participants' need for professional assistance to cope with the pain after discharge.

CONCLUSIONS

Chronic pain rehabilitation that included an occupational therapy intervention supported health behavior transformation and chronic pain self-management in females, where meaningful daily occupations and physical activity played an important role. Individually tailored support, also available after chronic pain rehabilitation, would benefit the transformation process towards improved pain coping in females.Implications for rehabilitationPersonal gains for health and well-being may develop over a shorter or longer time after chronic pain rehabilitation.Targeting daily occupations and physical activity during chronic pain rehabilitation appears meaningful for females living with chronic pain.Progression from an individual to group approach can be relevant in planning chronic pain rehabilitation, but the individual capacities shall be considered.Male perspectives on chronic pain rehabilitation that includes focus on daily occupations and lifestyle need further investigation.

transcranial Direct Current Stimulation (tDCS) for the treatment and investigation of Phantom Limb Pain (PLP)

Phantom limb pain (PLP) is a complex medical condition that is often difficult to treat, and thus can become detrimental to patients' quality of life. No standardized clinical treatments exist and there is no conclusive understanding of the underlying mechanisms causing it. Noninvasive brain stimulation (NIBS) has been used to find correlations between changes in brain activity and various brain conditions, including neurological disease, mental illnesses, and brain disorders. Studies have also shown that NIBS can be effective in alleviating pain. Here, we examined the literature on a particular type of NIBS, known as transcranial direct current stimulation (tDCS), and its application to the treatment of PLP. We first discuss the current hypotheses on the working mechanism of tDCS and then we examine published evidence of its efficacy to treat PLP. We conclude this article by discussing how tDCS alone, and in combination with brain imaging techniques such as electroencephalography (EEG) and magnetic resonance imagining, could be applied to further investigate the mechanisms underlying PLP.

Insomnia symptoms and chronic pain: Outcomes of an interdisciplinary pain rehabilitation program

OBJECTIVES

Insomnia is a highly prevalent problem among patients with chronic pain. Interdisciplinary pain rehabilitation programs (IPRPs) are a leading treatment option for chronic pain; however, research is limited and existing findings are mixed on the impact of insomnia symptoms on IPRP outcomes and the extent to which insomnia symptoms improve as a result of IPRP treatment.

METHODS

In this study, insomnia and pain-related outcomes following a 10-week IPRP were examined from a relatively large sample (N = 393) of adult patients with varying chronic pain conditions who completed the Insomnia Severity Index (ISI) at program admission and discharge. Both group- and individual-level changes in insomnia severity were examined to evaluate statistically and clinically significant changes in insomnia symptoms, along with the impact of insomnia symptoms on measures of pain, emotional distress, and functioning. Participants were categorized as having no clinically significant insomnia symptoms (NCSI), mild, moderate, or severe insomnia based on ISI scores.

RESULTS

Higher levels of insomnia severity were associated with worse pain, functioning, and emotional distress. Most patients reporting mild, moderate, or severe insomnia symptoms at program admission moved to a lower insomnia symptom category at the time of discharge (62%); however, only 33% of these patients reported a meaningful score reduction (i.e., ISI change ≥8 points). In addition, insomnia symptoms had a negative impact on treatment gains related to pain interference and physical health-related quality of life.

DISCUSSION

These findings suggest that usual IPRP care confers overall treatment benefit for individuals with chronic pain and insomnia. However, insomnia symptoms may negatively impact pain treatment outcomes and usual care appears insufficient to address elevated insomnia symptoms for many patients. Additional insomnia-specific treatment may be warranted for patients with comorbid chronic pain.

Patients with Clinically Elevated Depressive Symptoms Report Improvements in Mood, Pain, and Functioning following Participation in Interdisciplinary Pain Rehabilitation

OBJECTIVE

Chronic pain and depression frequently co-occur and exacerbate one another; therefore, it is important to treat both conditions to improve patient outcomes. The current study evaluates an interdisciplinary pain rehabilitation program (IPRP) with respect to the following questions: 1) How do clinically elevated depressive symptoms impact pain-related treatment outcomes? and 2) To what extent does IPRP participation yield reliable and clinically significant change in depressed mood?

METHODS

Participants in this study included 425 adults who engaged in a 10-week IPRP and completed self-report measures of pain, mood, and functioning at intake and discharge. Participants were categorized into 4 groups based on self-reported depressive symptoms (PROMIS Depression): within normal limits (WNL; n = 121), Mild (n = 115), Moderate (n = 153), and Severe (n = 36).

RESULTS

Participants reported significant improvement in pain, pain-related life interference, health-related quality of life, pain catastrophizing, and depressed mood regardless of initial symptom level. In addition, 43.4% of patients with Mild, Moderate, or Severe depressed mood reported reliable and clinically significant improvement in depressive symptoms and 30.3% were in remission at the end of treatment.

CONCLUSIONS

These findings support the assertion that IPRPs represent an effective treatment for patients with comorbid chronic pain and depression and that participation is associated with improvement in both conditions.

Lose Pain, Lose Weight, and Lose Both: A Cohort Study of Patients with Chronic Pain and Obesity Using a National Quality Registry

Background

It is known that chronic pain makes it difficult to lose weight, but it is unknown whether obese patients (body mass index ≥30 kg/m²) who experience significant pain relief after interdisciplinary multimodal pain rehabilitation (IMMPR) lose weight.

Objective

This study investigated whether obese patients with chronic pain lost weight after completing IMMPR in specialist pain units. The association of pain relief and weight change over time was also examined.

Methods

Data from obese patients included in the Swedish Quality Registry for Pain Rehabilitation for specialized pain units were used (N=224), including baseline and 12-month follow-up after IMMPR from 2016 to 2018. Patients reported body weight and height, pain aspects (eg, pain intensity), physical activity behaviours, psychological distress, and health-related quality of life (HRQoL). A reduction of at least 5% of initial weight indicates clinically significant weight loss. Patients were classified into three groups based on the pain relief levels after IMMPR: pain relief of clinical significance (30% or more reduction of pain intensity); pain relief without clinical significance (less than 30% reduction of pain intensity); and no pain relief. Linear mixed regression models were used to examine the weight changes among the groups with different pain relief levels.

Results

A significant reduction of pain intensity was found after IMMPR (p < 0.01, effect size Cohen’s d = 0.34). A similar proportion of patients in the three groups with different pain relief levels had clinically significant weight loss (20.2%~24.3%, p = 0.47). Significant improvements were reported regarding physical activity behaviour, psychological distress, and HRQoL, but weight change was not associated with changes of pain intensity.

Conclusion

About one-fifth of obese patients achieved significant weight reduction after IMMPR. Obese patients need a tailored pain rehabilitation program incorporating a targeted approach for weight management.

Improvements in Sleep Correlate With Improvements in Clinical Outcomes Among Adolescents Undergoing Intensive Interdisciplinary Pain Treatment

OBJECTIVES

Intensive interdisciplinary pain treatment (IIPT) programs have been shown to restore function, improve coping, and reduce pain in adolescents with chronic pain. Yet, little is known about patients' sleep during IIPT and whether or not improvements in pain treatment outcomes are associated with changes in sleep pre-to-post IIPT treatment. The objectives of the current study were to describe sleep among adolescents entering IIPT and examine associations between sleep parameters and IIPT treatment effects.

MATERIALS AND METHODS

Self-reported sleep measures and clinical outcomes (eg, functional disability, coping, average pain), were collected from 44 adolescents (mean age=14.57, 68.2% female) at admission and discharge from an inpatient IIPT program. Wrist-worn actigraphy data and sleep diaries from participants' first week and last week in the program were analyzed to characterize sleep parameters.

RESULTS

Participants self-reported poor sleep/wake patterns, high levels of insomnia symptoms, and subclinical problems with daytime sleepiness upon admission into IIPT, although actigraphic indices of sleep from the first week of IIPT admission were only just under clinical guidelines for healthy adolescent sleep. Better self-reported sleep quality assessed via aggregated sleep diaries from the first week was associated with improvement in average pain and disability over the course of the program. Furthermore, improvements in insomnia symptoms and daytime sleepiness throughout the program were positively correlated with concurrent improvements in functional disability and coping.

DISCUSSION

Taken together, results suggest that sleep may be associated with IIPT treatment effects and pave the way for future research to continue examining these relationships.

Sleep among Youth with Severely Disabling Chronic Pain: Before, during, and after Inpatient Intensive Interdisciplinary Pain Treatment

Poor sleep is commonly reported in pediatric chronic pain. There are signals that intensive interdisciplinary pain treatments (IIPT) may inadvertently improve objective sleep, but this claim cannot be substantiated without baseline sleep data prior to IIPT. This study followed the objective sleep/wake patterns (e.g., duration, quality, timing, consistency) of pediatric patients with severely functionally disabling chronic pain before, during, and after inpatient IIPT (the Functional Independence Restoration Program-"FIRST Program"), alongside a similarly-disabled chronic pain Comparison Group. The final sample included N = 10 FIRST Patients and N = 9 Comparison Group patients. At baseline, the whole sample showed healthy sleep duration (~9 h), average sleep efficiency <90%, late sleep onset and offset (mean = 11:56 p.m.-8:50 a.m.), and highly inconsistent sleep schedules night to night. During IIPT, FIRST Patients maintained healthy sleep durations, moved sleep schedules 2 h earlier, and decreased timing and duration variability by >60 min while the Comparison Group maintained similar sleep to baseline. At follow up (1-2 months later), FIRST Patients' sleep schedules shifted later but were still less variable than at baseline. Results point to the malleability of sleep/wake patterns within treatment contexts with strict environmental control but suggest that these gains may be difficult for youth with chronic pain to maintain in the home environment.

Involvement of relatives in chronic non-malignant pain rehabilitation at multidisciplinary pain centres: part one - the patient perspective

OBJECTIVES

Chronic non-malignant pain (CNP) is a significant healthcare problem with considerable consequences for patients, relatives and society. CNP is a lifelong condition that calls for acceptance and self-management. Existing research indicates that the involvement of relatives improves patients' and relatives' management of CNP, but the area is, at present, scarcely described. Research is required to obtain knowledge about the patients' experiences, needs and preferences concerning the involvement of their relatives within the frame of CNP rehabilitation, which is the aim of this study.

METHODS

The study applied a qualitative phenomenological-hermeneutic design conducting individual interviews with 10 patients with CNP from three selected Multidisciplinary Pain Centres (MPC). The analysis was guided by Paul Ricoeur's philosophy of interpretation of the text.

RESULTS

The findings illuminated the patients' perspectives on the involvement of relatives within three key themes, each having two or three sub-themes. The analysis revealed that patients in CNP rehabilitation had various interpretations of the substance of involving relatives, reflecting their sparse experiences. It seemed arbitrary, who during the rehabilitation actually experienced the involvement of their relatives, leaving the impression of an area short of structure. This shortage was troublesome, due to a heartrending impact of CNP. Patients' reduced functional level, combined with their surroundings difficulties in grasping the magnitude of CNP led to a loss of relationships and a risk of social isolation. Patients' close relationships became essential but were under pressure as well. Patients living with a spouse/cohabitant experienced that the relationship was affected by a disrupted balance and pain-related emotional outbursts. The patients experienced a profound need for being understood, but the text also revealed a need for mutual understanding to acknowledge the relatives' strain as well. Particular patients with children living at home experienced to be under great strain, complicated by a deep concern for long-term consequences for their children growing up influenced by parental CNP. Experienced involvement of relatives, even to a minor extend was perceived as beneficial for the patients, who experienced increased understanding and support from the relatives. However, due to the lack of a structured service, the patients' access to the involvement of relatives became dependent on their ability to define their need and pick it out. Thus the patients also expressed a general preference for mandatory and structured involvement, yet tailored to the specific patient.

CONCLUSIONS

The study showed an overwhelming need for the involvement of relatives among patients with CNP, indicating that increased attention and investigation of relevant interventions are required. Despite differences between the MPC, our primary impression was that the involvement of relatives reached a minimal level of what was expected, which might entail desertion of patients scarce of resources. Individualised adjusted involvement of relatives is assumed to improve patient's management of CNP in everyday life. A family systems nursing (FSN) approach is a relevant proposal for intervention, useful in other illness areas. Still, research needs to shed light on the appropriateness of FSN when involving relatives in the rehabilitation of CNP.

Breaking the vicious circle: Experiences of people in chronic pain on the pain rehabilitation journey

Aim

To explore the lived experience of individuals' in chronic pain of participating in a pain rehabilitation programme in Iceland.

Design

Phenomenological research.

Method

The Vancouver School of Doing Phenomenology. Eleven participants were interviewed.

Results

The overarching theme was as follows: "the journey of breaking the vicious circle of chronic pain." Before the programme, the participants felt they were in survival mode, trying to survive each day; they were stuck in a vicious circle of chronic pain, simultaneously trying to ease and conceal the pain. Reaching out for professional help was a turning point. While attending the programme, participants began deconstructing their old ways of dealing with chronic pain. After completing the programme, they were still reconstructing their daily lives. In conclusion, pain rehabilitation programmes can be the first step towards breaking the vicious circle of chronic pain.

A Meta-Epidemiological Appraisal of the Effects of Interdisciplinary Multimodal Pain Therapy Dosing for Chronic Low Back Pain

Using a meta-analysis, meta-regression, and a meta-epidemiological approach, we conducted a systematic review to examine the influence of interdisciplinary multimodal pain therapy (IMPT) dosage on pain, disability, return to work, quality of life, depression, and anxiety in published randomised controlled trials (RCTs) in patients with non-specific chronic low back pain (CLBP). We considered all RCTs of IMPT from a Cochrane review and searched PubMed for additional RCTs through 30 September 2018. A subgroup random-effects meta-analysis by length, contact, and intensity of treatment was performed followed by a meta-regression analysis. Using random and fixed-effect models and a summary relative odds ratio (ROR), we compared the effect sizes (ES) from short-length, non-daily contact, and low-intensity RCTs with long-length, daily contact, and high-intensity RCTs. Heterogeneity was quantified with the I² metric. A total of 47 RCTs were selected. Subgroup meta-analysis showed that there were larger ES for pain and disability in RCTs with long-length, non-daily contact, and low intensity of treatment. Larger ES were also observed for quality of life in RCTs with short-length, non-daily contact, and low intensity treatment. However, these findings were not confirmed by the meta-regression analysis. Likewise, the summary RORs were not significant, indicating that the length, contact, and intensity of treatment did not have an overall effect on the investigated outcomes. For the outcomes investigated here, IMPT dosage is not generally associated with better ES, and an optimal dosage was not determined.

Multidisciplinary Pain Management for Pediatric Patients with Acute and Chronic Pain: A Foundational Treatment Approach When Prescribing Opioids

Opioid therapy is the cornerstone of treatment for acute procedural and postoperative pain and is regularly prescribed for severe and debilitating chronic pain conditions. Although beneficial for many patients, opioid therapy may have side effects, limited efficacy, and potential negative outcomes. Multidisciplinary pain management treatments incorporating pharmacological and integrative non-pharmacological therapies have been shown to be effective in acute and chronic pain management for pediatric populations. A multidisciplinary approach can also benefit psychological functioning and quality of life, and may have the potential to reduce reliance on opioids. The aims of this paper are to: (1) provide a brief overview of a multidisciplinary pain management approach for pediatric patients with acute and chronic pain, (2) highlight the mechanisms of action and evidence base of commonly utilized integrative non-pharmacological therapies in pediatric multidisciplinary pain management, and (3) explore the opioid sparing effects of multidisciplinary treatment for pediatric pain.

Benzodiazepine use in patients with chronic pain in an interdisciplinary pain rehabilitation program

Objectives

In the context of widespread opioid use, increased emphasis has been placed on the potentially deleterious effects of concurrent benzodiazepine (BZD) and opioid use. Although use of opioids in chronic pain has been a major focus, BZD use is equally concerning. Thus, the primary aim of this study was to determine the associations between BZD and opioid use in adults with chronic pain upon admission to an outpatient interdisciplinary pain rehabilitation (IPR) program.

Methods

The study cohort involved 847 consecutive patients admitted to a 3-week outpatient IPR program from January 2013 through December 2014. Study variables included baseline demographic and clinical characteristics, Center for Epidemiologic Studies-Depression Scale, Pain Catastrophizing Scale, and the pain severity subscale of the Multidimensional Pain Inventory.

Results

Upon admission, 248 (29%) patients were taking BZDs. Patients using BZDs were significantly more likely to use opioids and to be female. Additionally, patients using BZDs had significantly greater depression, pain catastrophizing, and pain severity scores. In univariable logistic regression analysis, opioid use, female sex, and greater scores of depression, pain catastrophizing, and pain severity were significantly associated with BZD use. In multivariable logistic regression analysis adjusted for age, sex, pain duration, opioid use, depression, pain catastrophizing, and pain severity, only female sex and greater depression scores were significantly associated with BZD use.

Discussion

Among patients participating in an outpatient IPR program, female sex and greater depression scores were associated with BZD use. Results identify a high prevalence of BZD use in patients with chronic pain and reinforce the need to weigh the risks versus benefits when prescribing in this patient population.

Preliminary Evaluation of the Values Tracker: A Two-Item Measure of Engagement in Valued Activities in Those With Chronic Pain

Engagement in valued activities is an important outcome, particularly in treatments that aim to enhance quality of life in those with chronic conditions. The present study describes the initial evaluation of the Values Tracker (VT), a two-item measure of values engagement, in 302 treatment-seeking adults with chronic pain. Hierarchical regression analyses were conducted to examine the utility of the VT in the statistical prediction of pain-related functioning, after controlling for demographic variables, pain intensity, and pain-related distress. Across analyses, pain intensity accounted for significant variance (range ΔR2 = .06-.09) with pain-related distress adding additional unique variance (range ΔR2 = .07-.19). The VT accounted for additional unique variance (range ΔR2 = .02-.17) for all variables with the exception of physical disability. These findings provide initial support for the utility of the VT in those with chronic pain. Given the VT's brevity, it may be particularly useful for tracking changes in engagement in values across sessions.

Connecting parents of children with chronic pain through art therapy

OBJECTIVES

To help address the unique needs of parents of children with chronic pain, a four module, parent-only, group art therapy curriculum was designed and implemented within an interdisciplinary pain rehabilitation treatment program. We evaluated perceived satisfaction and helpfulness of the group intervention.

METHODS

Fifty-three parents of children experiencing chronic pain enrolled in a day hospital interdisciplinary pain rehabilitation program participated. The voluntary parent art therapy group was offered one time per week for one hour. Participants completed a measure of satisfaction, helpfulness, and perceived social support at the end of each group session.

RESULTS

Parents enjoyed participating in the group, agreed that they would try art therapy again, and found it to be a helpful, supportive, and validating experience.

CONCLUSIONS

Initial results are promising that group art therapy is an appropriate and helpful means of supporting parents of children with chronic pain during interdisciplinary pain rehabilitation.

Moving from tube to oral feeding in medically fragile nonverbal toddlers

The current article describes a 14-week outpatient protocol for transitioning from gastrostomy tube to oral feeding in toddlers with medical complications. The team ensured that eating skills were mastered before treating patients for 8 weeks with continuous gastrojejunal drip tube feedings and low-dose tricyclic antidepressant and/or gabapentin. We prescribed 6 weeks of megestrol for hunger provocation while withdrawing tube feedings. A chart review after treatment demonstrated 9 subjects were eating exclusively orally and 1 was eating 50% orally.