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Results of a Multidisciplinary Pain Management Program: A 6- and 12-Month Follow-up Study
The aim of this study was to evaluate an 8-week multidisciplinary pain management program offered to patients suffering from chronic pain. The study initially included 88 participants, and 61 of the sample completed a follow-up program conducted at 6 and 12 months after the initial programs. The pain mangement program was based on a cognitive behavioral approach with active patient participation in learning new coping skills. The intervention consisted of supervised dialog, physical activity, and education. The main goals were change of focus from pain and disability to resources and functional coping strategies. It was hypothesized that the positive changes gained at posttest registration after an 8-week program on coping, health-related quality of life, and pain intensity would be maintained during follow-up sessions. The results indicated that these hypotheses were mainly supported and further pain reduction, decreased emotion-focused coping, better social functioning, and overall physical and mental health gains were observed. The participants who did not complete the follow-up program did not differ from the patients who completed the program on background variables investigated. The study also supported the claim that professional nurses are competent to lead such programs and to evaluate treatment results. Clinical and research implications are discussed.
Given the importance of psychosocial factors in the management of chronic pain and the increasing number of persons with this diagnosis, the development and implementation of effective multidisciplinary pain management programs is warranted. Such interventions could help chronic-pain sufferers improve coping and health-related quality of life (HRQOL). According to Dunajcik (1999), treatment of chronic pain requires a rehabilitative focus with active patient participation and a multidisciplinary team knowledgeable in treating chronic conditions. Chronic pain is “pain that has lasted 6 months or longer, is ongoing, is due to non-life-threatening causes, has not responded to currently available treatment methods, and may continue for the remainder of the patient’s life” (Dunajcik, p. 471).
Chronic pain is a demoralizing situation that creates stress that compromises all domains of life: emotional, cognitive, and behavioral disturbances are well documented (Turk, 1996). Consequently, people with chronic pain are challenged continuously to cope with multiple problems, and chronic pain often necessitates adoption of new and various coping skills. Despite advances in pain-management therapies, chronic pain continues to be a major health problem in Norway, as well as in many other countries.
The consequences of chronic pain in terms of poor coping and reduced HRQOL have been addressed by cognitive behavioral approaches (CBT, Turk, & Okifuji, 1999). Such approaches are based on a biopsychosocial model, which considers chronic pain not simply as a neurophysiological state, but as a multidimensional phenomenon with both physical and psychosocial aspects. Multidisciplinary pain management programs adopting this approach generally are considered to be effective in treating chronic pain (Morley, Eccleston, & Williams, 1999; Turk & Okifuji, 1999). These programs involve a variety of interventions and share common features (Turk & Okifuji). Among these features is providing the patient with techniques to gain a sense of control over the effects of pain as well as modifying the affective, behavioral, cognitive, and sensory components of the experience of pain. Group approaches are common and have many advantages, such as exposure to others with similar problems; a better understanding of pain and the role that own behavior, thoughts and feelings can play; and learning more effective coping skills (Keefe, Beaupré, & Gil, 1996).
Several studies in medicine (Basler, Jäkle, & Kröner-Herwig, 1997; Becker, Sjøgren, Bech, Olsen, & Eriksen, 2000; Morley et al., 1999) as well as in nursing (Lewis, Frain, & Donnelly, 1993; Raak, Wikblad, Raak, Carlsson, & Wahren, 2002; Vines, Cox, Nicoll, & Garrett, 1996) generally have demonstrated positive treatment effects in comprehensive pain management programs. Loss of treatment effect, however, is often reported in follow-up studies (Linton, Hellsing, & Larsson, 1997; Maruta, Swanson, & McHardy, 1990). The effectiveness of these programs may depend on several factors, such as the supervisors, intervention components, and patient characteristics (Dijkstra, Vlaeyen, Rijnen, & Nielson, 2001). Methodological limitations include designing suitable controls, great variety of instruments (Morley et al., 1999), and uncertainty in evaluating which elements of the program are most successful or minimally necessary (Grant & Haverkamp, 1995).
Unfortunately, in addition to relapse problems, other difficulties, such as program “drop-outs,” are common (Basler et al., 1997; Becker, Højsted, Sjøgren, & Eriksen, 1998; Maruta et al., 1990). Thus, giving follow-up sessions is suggested. Although the length of follow-up time is debated, Rudy and Kubinski (1996) suggest a minimum of 1 year after treatment. Practical limitations in administering follow-up programs, however, seem to have hindered their development and implementation (Linton et al., 1997).
The aim of this study was to evaluate an 8-week multidisciplinary pain management program based on CBT, offered to patients suffering from chronic pain with 6- and 12-month follow-ups. The researchers hypothesized that (1) 6- and 12-month follow-ups after a multidisciplinary pain management program would improve coping and HRQOL and decrease pain intensity, (2) program dropouts would have the most severe health problems, and (3) the follow-up sessions could prevent relapse.
A consecutive sample of 88 outpatients recruited from their private practitioners was included in this quasiexperimental design. Although this was not a random sample, it was considered representative of the different counties in Norway, because Norwegian society is rather homogeneous. The subjects met the following inclusion criteria: (1) 18–67 years of age, (2) chronic nonmalignant pain lasting for more than 6 months, (3) medical investigation and/or treatment completed prior to referral, (4) motivation to participate in an active rehabilitation program, and (5) no ongoing litigation related to the cause of their pain. Before the study began, 5 patients dropped out; after 8 weeks, 13 more dropped out; 10 dropped out at 6 months; and 4 dropped out at the 1 year follow-up. Patient demographics and medical data of those who completed the program and those who dropped out are presented in Table 1.
Before inclusion in the study, all patients underwent a medical evaluation. They also were fully informed about the program, including expectations and obligations, during a clinical interview. In addition, they were provided with written instructions. Confidentiality was guaranteed and a written consent form was obtained at inclusion. The study was approved by the regional ethical committee and the data inspectorate and was carried out in accordance with the Helsinki Declaration.
The Rehabilitation Program
This 8-week multidisciplinary pain management program (one weekly session), including one follow-up session after 6 and 12 months, consisted of three parts—supervised dialogue, physiotherapy, and education. Each session lasted for 3 hours. The main goals were changing focus from pain and disability to resources and functional coping strategies and discovering the connection between factors that increase or decrease pain. Table 2 details the main goal, basic assumptions, and topics covered in the program.
The multidisciplinary team consisted of a physician, a physiotherapist, a psychologist, an ergotherapist, and two nurses. As core members of the team, the nurses took an active part in the clinical interviews and worked as supervisors conducting the groups. The groups were conducted according to a structured protocol. Self-help educational materials included in the program were structured on the pedagogical framework of Brattberg (1996, 2001). Dr. Brattberg has 25 years of professional experience as a clinical rehabilitation practitioner to patients suffering from chronic pain that medical interventions have failed to alleviate. Her framework is based on homework, described as tools, to be used before group discussions that focus on the participants’ own experiences. Accordingly, the major emphasis is to gain knowledge to improve understanding and behavior. At the 6-month follow-up, the education piece related to nutrition and pain. During the final session at the 12-month follow-up, all aspects of the program were reviewed, and suggestions for continuing work were discussed.
Immediately before the start of treatment, at posttreatment, and after 6 and 12 months, respectively, the patients completed the questionnaires listed below:
Short Form Health Survey (SF-36): The survey was used to measure HRQOL, and norm-based comparisons are available (Loge & Kaasa, 1998). This instrument has been validated and tested for reliability in several international and Norwegian studies (Loge, Kaasa, Hjermstad, & Kvien, 1998). The SF-36 has proven to be useful in estimating changes in HRQOL due to specific clinical treatments and monitoring outcomes in clinical practice (Ware & Gandek, 1994). Eight measurement scales are included: physical functioning (PF), role physical (RP), referring to limitations in daily activities, bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), referring to limitations in daily activities, and mental health (MH). An additional item reports health transition over the past year and provides useful information about actual changes in health status during the year prior to adminstration of the SF-36. (Ware, Snow, & Kosinski, 2000). Two global scores, physical health (PCS) and mental health (MCS), can be calculated (Ware & Kosinski, 2001). The higher the score, the better the HRQOL. In this study, internal consistency (Cronbach’s alpha) of SF-36 suggests that this instrument possessed satisfactory reliability estimates (PF = 0. 90, RP = 0. 70, BP = 0. 70, GH = 0. 79, VT = 0. 78, SF = 0. 75, RE = 0. 89, MH = 0. 81).
The Visual Analogue Scale (VAS): The VAS provides a simple measure of pain intensity and often has been used in research. This scale consists of a 100-mm horizontal line with the two end points labeled “no pain” and “worst pain ever. ” The patient places a mark on the line at the point which corresponds to his or her level of pain intensity. Particular advantages of the VAS are its sensitivity, simplicity, reproducibility, and universality (Huskisson, 1983).
The Ways of Coping Checklist (WCCL): The WCCL is a measure of coping derived from Lazarus and Folkman’s (1984) transactional model of stress and coping, and a 42-item revised version of the WCCL was administered in the present study (Vitaliano, Russo, Carr, Maiuro, & Becker, 1985). This instrument consists of one scale called problem-focused coping (PFC), three scales for emotion-focused coping (EFC)—labelled wishful thinking (WT), self-blame (SB) and avoidance (A)—and one scale labelled social support (SS). The WCCL measures coping in terms of what the person uses to respond to the demands of a stressful encounter. The person scores items on a 4-point scale (i. e., 0 = not used, to 3 = used very much) to indicate the degree to which it was used to deal with the situation. High scores indicate more use of a coping strategy. In this study, internal consistency (Cronbach’s alpha) of the WCCL suggests that this instrument possessed satisfactory reliability (PFC = 0. 83, EFC = 0. 83, SS = 0. 85).
Body diagrams (BD): These diagrams facilitate the documentation of the location and distribution of pain, ranging from 1 (local and regional) to 3 (involving the whole body). The advantage of BD is that they are easy to use and they provide illustrations of the intensity and location of pain. The disadvantage is that BD measure only a very limited part of the pain experience, and exaggerations have been reported (Jensen & Karoly, 2001).
Assessment of quality of life now and at 5 years: Cantril’s ladder is used to assess patients’ perceptions of quality of life now and in a 5-year period to gain knowledge about future expectations. The scale depicts two items as a ladder and permits the individual to identify the best and the worst possible quality of life situations (Cantril, 1965).
Assessment of analgesic use: Analgesic use was scored on a 5-point Likert scale. The participants were asked to score their use of analgesics during the last month, with 1 indicating not at all and 5 indicating several times daily.
Assessment of reasons for dropping out: The participants were asked to write down their reasons for leaving the program.
Chi-square tests and analyses of variance were used to compare the characteristics at referral of the participants who completed the program and those who did not. Descriptive statistics (mean, standard deviation) were used to identify items where changes had taken place during the course of treatment. The scores on coping, pain intensity, and HRQOL were taken at three points in time during the study and were analyzed using the repeated measure module and a within-subject design. The option “difference contrast” was used. For each variable, the difference score on posttest (after 8 weeks) was compared to the mean of the pretest (baseline); the scores on the 6-month and the 12-month follow-up were compared to the mean scores of the previous points in time.
Among those who dropped out, five participants reported social problems as a reason for leaving the program, five reported general dissatisfaction, and four felt too physically or mentally impaired. No significant medical or sociodemographic differences were found in the distribution of the initial values between those who completed the program and those who did not (Table 1). Table 3 lists mean values and standard deviations at four points in time and reveals that improvements from the posttest were largely maintained. The repeated measure design (Table 4) mainly supported the positive changes after posttest (Dysvik, Vinsnes, & Eikeland, 2004). Although the significant changes were quite small, they clearly indicate a positive direction. Of the factors that represented coping, further improvements were observed in emotion-focused coping, wishing, and avoidance. Social support and self-blame items remained unchanged, and problem-focused coping reverted toward baseline results. Pain intensity was reduced at the 12-month follow-up. A similar pattern was discovered in the bodily pain dimension of HRQOL, supporting validation of this dimension. Several dimensions of HRQOL were further improved, such as overall physical and mental health, social function, physical function, and general health. Individual scores for factors such as vitality, role physical, and role emotional, no significant changes took place during the course of the program. In contrast with coping results and pain intensity, several improvements in HRQOL leveled off after 6 months.
The follow-up sessions incorporated into the cognitive-behavioral rehabilitation program for patients with chronic pain appeared to help maintain or further improve beneficial outcomes in most of the sets of variables under investigation. One indication of success was pain reduction. In our follow-up study, further pain reduction was observed as compared with the posttest (Dysvik, Vinsnes, & Eikeland, 2004). This result indicates that physical reconditioning and acquisition of various cognitive and behavioral coping skills modify the sensory components of the pain experience. This finding also was supported by decreased focus on emotion-focused coping, which often is referred to as a passive and less adaptive way of coping (Lazarus & Folkman, 1984). Within this dimension, coping strategies often considered maladaptive, such as wishful thinking (Vitaliano et al., 1985) and avoidance (Maes, Leventhal, & de Ridder, 1996), were significantly reduced, thus supporting improvements in mental health. The use of problem-focused coping (i.e., active problem solving), however, seems to have decreased toward a pretest level, which may indicate that this focus should be further highlighted during the follow-up program. Another possible explanation could be that less use of problem-solving coping may be an important step toward adaptation. Emotion-focused efforts may be the best choice, because it is the balance between problem-solving and emotional efforts, which makes coping efficacious or not in stressful situations (Lazarus, 1999).
As measured by the SF-36, HRQOL is considered to be an important outcome measure because it indicates the burden of chronic pain. A recent study by Dysvik, Lindstrøm, Eikeland, and Natvig (2004) indicated lower levels on all HRQOL domains, relative to the normal population and other patient groups. This result illustrates that many pain conditions adversely and severely affect quality of life (Okifuji & Turk, 2001). The follow-up results showed, however, that overall physical and mental health gains from the basic program were further improved, indicating that a better adaptation to the pain problem might have taken place. The individual scores reflecting better health, better social functioning, and fewer restrictions in daily life supported these findings. The follow-up findings were also supported by more optimistic general health beliefs compared to 1 year prior, which may indicate that a more positive attitude toward the future and the pain problem had been taken. This conjecture is in accordance with the principle of expectations of success.
The main goal during the follow-up sessions was to address all aspects of the total pain problem and further strengthen coping and HRQOL. Although the changes on coping HRQOL and pain intensity during the study period took place at different times on different variables, these findings support the claim that the major goals of the treatment program have been maintained. According to Dworkin, Nagasako, Hetzel, and Farrar (2001), treatment that both relieves pain and improves HRQOL has a greater value than treatment that only reduces pain.
It was expected that the participants who were able to attend the follow-up program and maintain treatment gains would manage pain more effectively. On the other hand, those who dropped out might be more prone to relapse. During the 6-month follow-up, a 13% dropout rate was registered, with an additional 6% dropping at 12 months. When the dropout rate was related to referrals, we found a dropout rate of 30%. High dropout rates have been reported in other follow-up studies. When comparing such results across studies, it is prudent to avoid generalizations because there are broad differences in referral patterns, inclusion criteria, treatment offered, arrangement of follow-up sessions, and reporting (Turk, 2002). This study’s dropout rate of 30% after the 6-month follow-up, relative to referrals, is consistent with the results reported by Basler et al. (1997). According to Basler et al., 11% of the patients left the program in the period between the posttest and the 6-month follow-up period. During the same interval, Becker et al. (1998) reported a 41% dropout rate, of which 30% were lost after 6 months. In another study, Maruta et al. (1990) showed a different way of reporting and had a longer follow-up period of 3 years. In total, a 49% dropout rate was registered after referral, of which 39% of dropouts were registered at posttest; furthermore, 17% of those who agreed to a 3-year follow-up declined to participate. Although different intervals and lengths of elapsed time before follow-up were reported in these studies, Rudy and Kubinski (1996) suggest a follow up be done a minimum of 1 year after treatment and recommend another follow-up be required after 6 months.
Maruta et al. (1990) called for a means to differentiate partial success from failure at the time of initial evaluation. No significant differences were found during screening between those who completed the full program and the dropouts in the present study: this may indicate that potential dropouts may be difficult to identify initially. Among those who dropped out, five participants reported social problems were the reason for leaving the program, while five reported dissatisfaction with the program, and four felt too physically or mentally impaired to continue. Given these results, it seems clear that more focus on social problems in the screening test, as well as individual consultation from the supervisors, may be important strategies to reduce the dropout rate. The participants also could benefit from more focus on relapse prevention in the education portion. A small number of dropouts must be expected because some individuals’ pain histories may include decline in health status over time, while others may be inappropriate for group approaches.
The underlying principle guiding maintenance of treatment gains is the notion that when helping individuals change their behaviors, one needs to plan to prevent relapses. By including 6- and 12-month follow-up sessions, the present study aimed to provide a more solid basis for the maintenance of positive treatment effects (Dysvik, Lindstrøm, Eikeland, & Natvig, 2004). Toward this goal, the major aim for the group therapists in this follow-up study was expanding and strengthening the patients’ coping repertoire, relaxation skills, self-help abilities, HRQOL, and if possible, by further reducing their pain. In addition, follow-up results indicate that these relapse-preventing strategies seem to succeed by keeping the focus on adaptive and positive behavior.
The studies reviewed indicated that chronic pain patients differ in their long-term response to CBT interventions and that improvement after interventions tends to disappear within 1 year. For example, Linton et al. (1997) found that 50% of treatment gains were lost during an 18-month follow-up period. They concluded that this result does not mean that the rehabilitation was ineffective, but rather that many patients lose a significant portion of the gains made during treatment (Linton et al., 1997). In another study, nearly two-thirds of the patients who completed the program either failed initially or could not maintain the improvements at the end of 3-year follow-up (Maruta et al., 1990). Vines et al. (1996), reported significant improvements in activity and role function during a 3- to 11-month follow-up period. Becker et al. (2000) did not report loss of treatment effect at 6-month follow-up, either. Furthermore, treatment success was reported by Basler et al. (1997), whose the experimental subjects reported less pain, better control, and fewer psychological problems at the 6-month follow-up. Based on methodological considerations, however, caution must be used when interpreting relapses. Response bias may be present because those who are most positive about the treatment they received may be more likely to comply with follow-up requests (Turk & Rudy, 1991).
Some limitations of this study should be acknowledged. First, generalization is limited because the sample consisted of patients referred to a specific rehabilitation program. Second, a proper control group was not established in spite of attempts to establish wait-list controls. This limitation may reduce internal validity and limit the conclusions. Moreover, one of the major problems with similar approaches has been the difficulty in generating suitable research designs so that a clear cause-effect link can be established. According to Gamsa (1994), it may be necessary to accept methodological limits in such studies defined by multiple interacting variables that cannot be isolated and controlled. In line with this consideration, Davis (2000) emphasized that there might be too much dependence on the preferred design “gold standard” of randomized controlled design.
Clinical and Research Implications
A multidisciplinary team approach maximizes the opportunity for addressing the multiple factors that contribute to pain. Group therapists encounter a number of problems when leading groups of chronic pain patients. The experiences reported here show that a successful group approach requires attention to a number of important practical and therapeutic issues, such as the characteristics of the patients, the composition of the groups, the program ingredients, and supervisors.
Several implications for nursing practice should be emphasized. Because of the unique biopsychosocial perspective, nurses play a vital role in chronic pain care. The rehabilitation nurse is responsible for assisting the chronic pain patient to select the most appropriate program. Nurses can give up-to-date information about different programs, goals, and degrees of efficacy. This study includes a long-term approach with outcome measurements. It is important to note that some gains occurred at 6 months, while others were not observed until 12 months. This is valuable information for the practitioner. Nurses work with a variety of patients who experience chronic pain. If nurses can provide better interventions to help patients manage their pain, patients should experience a better HRQOL. Because of monetary concerns, programs that have demonstrated positive results are more likely to be adapted to institutions. Larsen (1995) points out that as one looks at cost-benefit results of rehabilitation, one also needs to look at long-term benefits.
Challenges for further research include evaluating treatment outcome because the pain experience is a multidimensional phenomenon, and different domains of life are involved. More follow-up, randomized studies should be carried out on the long-term effects of such a rehabilitation program, to improve our understanding of pain management. Special awareness of the different patterns in the changing process, focusing on coping, HRQOL, and pain intensity, should be considered to match the program to patients’ readiness to adapt at several points in time. Considering modifications to the existing program also is recommended to improve the results and accommodate the needs of program dropouts.
Favorable changes in HRQOL, coping, and pain intensity can be maintained or improved during the follow-up period. These results are in accordance with the ultimate goal of CBT interventions, which is to help chronic pain patients cope more effectively with the long-term demands of chronic pain and to improve HRQOL. To reach this goal, there is a clear need for research to test the efficacy of follow-up interventions designed to prevent dropping out and relapses. Thus, further research not only may lead to major advances in our understanding of chronic pain, but also it may contribute to more effective treatment.
The authors believe rehabilitation based on a multidisciplinary program, systematic attention to the multiple problems of the patients and comprehensive behavioral structuring, follow-up sessions, and careful evaluation are essential. According to Vines et al. (1996), this study supports the assertion that professional nurses involved in rehabilitation can lead such pain management programs as well as evaluate treatment interventions. Further focus on follow-ups, drop-outs, and relapses may be just as important for the multidisciplinary team as successful completion of a basic program.
This study was supported by grants from Rogaland Central Hospital, Division of Rehabilitation and Stavanger University College. The authors would like to thank Torbjørn Aarsland, manager at Hjertelaget Research Foundation, for setting up the database.
About the Authors
Elin Dysvik, MS RN, is an Assistant Professor, Faculty of Social Sciences, Department of Health Studies, University of Stavanger, Stavanger, Norway.
Gerd Karin Natvig, PhD RN, is an Associate Professor of the Department of Public Health and Primary Health Care at the University of Bergen, in Bergen, Norway.
Ole-Johan Eikeland is the Director of Eikeland Research and Teaching in Bergen, Norway.
Gunilla Brattberg, MD, is a Professor at the Division of Rehabilitation Engineering Research, Department of Design Sciences at Lund University in Sweden.
Address correspondence about this article to Elin Dysvik, MS RN, Stavanger University College, Faculty of Social Sciences, Department of Health Studies, University of Stavanger, N-4036 Stavanger, Norway, or via e-mail to elin.dysvik@uis. no.
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