Chronic pain program management outcomes: Long-term follow-up for Veterans and civilians

LAY SUMMARY Interdisciplinary pain rehabilitation programs are effective in treating chronic pain. Not many studies have explored how Veterans differ from civilians in responding to treatment. In this study, several measures were administered at different time points to examine and compare the long-term treatment outcomes of Veteran and civilian men and women. Results from 67 participants showed an overall long-term improvement in levels of pain-related disability, anxiety, and depression, as well as many other pain-related variables. While no differences in treatment outcomes between Veterans and civilians were found, men and women showed some differences. Women reported higher depressive symptoms overall and more pain-related disability than men at follow-up from the program. This study demonstrates the long-term effectiveness of interdisciplinary pain management programs regardless of Veteran status. It highlights some differences between genders. Previous studies have not compared the long-term outcomes of Veterans and civilians from an interdisciplinary program.

Pattern of Cumulative Treatment Hours on Pain Impact and PROMIS Outcomes

ABSTRACT Introduction Participation in interdisciplinary treatments is associated with improvement in pain intensity, physical function, and additional pain-related outcome domains. However, the effect of cumulative treatment hours on outcomes remains unknown among military patients. The present analysis examined the relationship between cumulative interdisciplinary treatment hours and pain management outcomes at a single interdisciplinary pain management center (IPMC). Materials and Methods This is a retrospective observational study of data previously collected as standard of care at the Madigan Army Medical Center, approved by the Institutional Review Board. We included patients who received treatment at the IPMC and completed at least two self-report assessment batteries: one at baseline and at least one between 90 and 180 days after baseline (n = 882). The primary outcome was pain impact. Secondary outcomes included fatigue, depression, anxiety, and sleep-related impairment. Results Generalized additive models indicated that cumulative treatment hours were significantly associated with improvement in pain impact, fatigue, and depression. Patients who had higher baseline pain impact, who had mild or no depressive symptoms, and who were >40 years of age had greater improvements in pain impact following treatment, relative to those with lower pain impact, moderate-to-severe depressive symptoms, and were 40 years of age or younger, respectively. Additional research is needed to elucidate the effect of different therapies and additional patient factors in understanding the “therapeutic dose” of interdisciplinary pain management. Conclusions A higher number of cumulative treatment hours was associated with improvement of pain impact, fatigue, and depression among military personnel receiving interdisciplinary pain treatment. At least 30 hours of sustained interdisciplinary treatment appears to be the threshold for improvement in pain impact and related outcomes.

Measuring ‘self’: preliminary validation of a short form of the Self Experiences Questionnaire in people with chronic pain

Background: People with chronic pain often struggle with their sense of self and this can adversely impact their functioning and well-being. Acceptance and Commitment Therapy particularly includes a process related to this struggle with self. A measure for this process, the Self Experiences Questionnaire (SEQ), was previously developed in people with chronic pain. Purpose: The aim of the current study was to validate a shorter version of the SEQ in people with chronic pain to reduce respondent burden and facilitate further research. Methods: Data from 477 participants attending an interdisciplinary pain management programme were included. Participants completed measures of treatment processes (self-as-context, pain acceptance, cognitive fusion and committed action) and outcomes (pain, pain interference, work and social adjustment and depression) at baseline and post-treatment. Confirmatory factor analysis was used for item reduction. Correlations between scores from the shorter SEQ and other process and outcome variables were calculated to examine validity. Change scores of the shorter SEQ and their correlations with changes in outcome variables were examined for responsiveness. Results: An eight-item SEQ (SEQ-8) scale including two factors, namely Self-as-Distinction and Self-as-Observer, emerged, demonstrating good reliability (Cronbach’s α = .87–.90) and validity (|r| = .14–.52). Scores from SEQ-8 significantly improved after the treatment (d = .15–21), and these improvements correlated with improvements in most outcomes. Conclusions: The SEQ-8 appears to be a reliable and valid measure of self. This shorter format may facilitate intensive longitudinal investigation into sense of self and functioning and well-being.

The development and efficacy of an interdisciplinary chronic pelvic pain program

Introduction: Chronic pelvic pain (CPP) is a significant issue, and approximately 14% of women experience CPP once in their lifetime. While interdisciplinary pain management is considered the gold standard of treatment, few programs offer this type of treatment in Canada. The aims of this paper were to: 1) describe the development of an interdisciplinary CPP program; and 2) demonstrate changes in patient-related outcomes after attending an interdisciplinary CPP program. Methods: Referrals were received from community urologists and obstetricians/gynecologists, and pain physicians at the Michael G. DeGroote Pain Clinic. Patients attended an orientation session, completed an interdisciplinary assessment, and if appropriate attended an eight-day interdisciplinary CPP program. Each day consisted of group-based pelvic floor physiotherapy, psycho-education, goal-setting, cognitive behavioral therapy, and mindfulness. Psychometric questionnaires were completed pre- and post-program by patients, and paired sample t-tests were used to evaluate the changes in patient-related outcomes after attending the program. Results: Thirty-seven female patients completed the program, and results demonstrate that the CPP program was associated with significant improvements in impact of pelvic pain on quality of life, readiness for change, and pain-related self-efficacy, as well as decreases in pain catastrophizing and fear of pain/re-injury. Conclusions: CPP is a complex condition that requires interdisciplinary management and care. The results of this study demonstrate the short-term benefits of an interdisciplinary CPP program and highlight the unique needs of women with CPP and implicate multiple factors for programming and treatment.

Evaluation of a Functional Restoration Program at Fort Bliss Interdisciplinary Pain Management Clinic

Introduction In partnership with the Veterans Health Administration, in 2010, the Department of Defense/Veterans Health Administration Pain Management Task Force Final Report recommended a comprehensive pain management plan. Consequently, each Army medical center established an Interdisciplinary Pain Management Clinic (IPMC) for pain treatment, and each IPMC implements a multidisciplinary outpatient functional restoration program (FRP) as an alternative to or in addition to pharmacological therapy. This article reports our first-year FRP results at William Beaumont Army Medical Center IPMC. Materials and Methods The FRP is designed to improve the participants’ functionality and quality of life, both personally and professionally. Service members with chronic pain were evaluated for psychological and physical clearance before enrollment in an intense and structured FRP for 8 hours a day over 3 weeks. The program focused on physical and occupational exercises, yoga, acupuncture, and educational classes regarding pain medications, nutrition, and coping skills. The resulting data were analyzed using paired two-tailed t-tests with a predetermined significance level of 0.05 to examine the participants’ mean changes upon completion of the FRP. Results The pre-post comparison indicated significant improvement after completion of the FRP. The fear-avoidance of physical activities and the fear of movement scores were reduced significantly (P < 0.05); the Canadian occupational performance and satisfaction, physical strength and endurance were improved significantly (P < 0.0001) in sit-to-stand, plank balance, lifting and carrying, and 10-minute 7-to-1 Pyramid tests; however, fear-avoidance of work was not significantly reduced (P = 0.2319). Conclusions Because of the lack of randomization and the small number of subjects (N = 32, 7 cohorts), unknown sources of bias may have influenced the results. Despite these limitations, the results from this report support the program’s effectiveness and are consistent with the outcomes from FRP programs in other military facilities and in civilian studies.

Structural MRI Analysis of Chronic Pain Patients Following Interdisciplinary Treatment Shows Changes in Brain Volume and Opiate-Dependent Reorganization of the Amygdala and Hippocampus

Objective The present study examined pre- to post-treatment changes in volumes for brain structures known to be associated with pain processing (thalamus, caudate, putamen, pallidum, hippocampus, amygdala, and accumbens) following an interdisciplinary pain management program. Design Twenty-one patients participating in a four-week interdisciplinary pain management program completed the study. The program consisted of individual and group therapies with the following disciplines: physical therapy, occupational therapy, pain psychology, biofeedback/relaxation training, nursing lectures, and medical management. All patients underwent functional magnetic resonance imaging of the brain before the start and at completion of the program. They also completed standard outcome measures assessing pain, symptoms of central sensitization, disability, mood, coping, pain acceptance, and impressions of change. Results Our results showed a significant increase in total brain volume, as well as increased volumes in the thalamus, hippocampus, and amygdala. As expected, we also found significant improvements in our standard outcome measures. The majority of patients rated themselves as much or very much improved. The increase in volume in the hippocampus was significantly associated with patient perceptions of change. However, the correlations were in the unexpected direction, such that greater increases in hippocampal volume were associated with perceptions of less improvement. Further exploratory analyses comparing patients by their opioid use status (use vs no use) showed differential program effects on volume increases in the hippocampus and amygdala. Conclusions These findings show that a four-week interdisciplinary pain management program resulted in changes in the brain, which adds objective findings further demonstrating program efficacy.