OBJECTIVES: Although inpatient multidisciplinary pain management programs (PMPs) are effective for chronic pain, not all patients benefit equally and there is limited evidence regarding predictors of outcome. This meta-analysis aimed to identify patient or program characteristics associated with outcomes from inpatient PMPs, and to examine the time course of effects following discharge.
MATERIALS AND METHODS: Medline, EBSCO, and Scopus were searched to identify articles reporting outcomes from inpatient multidisciplinary PMPs. Information was extracted on study design, participant and program characteristics, and outcomes. Effect sizes were computed for pain, physical function, depression, anxiety, and mental health outcomes. Study-level predictors of outcome were investigated with moderator analyses and meta-regression. A risk of bias assessment and sensitivity analyses were conducted and the GRADE criteria for prognostic studies were applied to assess confidence in findings.
RESULTS: In all, 85 studies (111 cohorts; 15,255 participants) were included. Three quarters of studies demonstrated low risk of bias. Larger effect sizes (for at least 1 outcome measure) occurred in studies where participants had more severe pain (greater intensity/longer duration), participants with alcohol or drug problems were not excluded, samples comprised mixed pain conditions, and programs included a cognitive component and/or a passive therapy component. Effect sizes for pain and physical function were maintained at follow-up, but effect sizes for depression and anxiety declined over time.
DISCUSSION: Inpatient multidisciplinary PMPs may be well suited to patients with severe or long-lasting pain. Programs should adopt broad patient inclusion criteria, and outcomes were similar for programs based on cognitive-behavioral versus mindfulness/acceptance-based therapies.
|Rehab Clinician (OT/PT)|
As chronic pain is becoming more prevalent this article forms a good basis/starting point for further research. Understanding the different facets of pain is necessary to provide therapeutic outcomes and treatment modalities for the patient.
This is a useful article to practice for pain management.
As a clinician, I found quite surprising, while useful, that the most consistent predictors of good outcome were higher baseline pain intensity and longer pain duration. Beyond a potential floor effect, it is plausible that these cases are the most open to the requirements of pain acceptance and self-management. It is also useful that effect sizes were maintained at follow-up for pain intensity and physical function, but reduced over time for depression and anxiety. While most treatments target pain and function, further attention should be devoted to distress. Finally, it is also crucial to me either that passive therapy components improved pain but this improvement did not translate into gains in physical function or mood, or the need to consider the compatibility of passive therapy with the underpinnings of the psychological treatment.
The authors note that while multidisciplinary pain programs are "the gold standard," effect sizes are small and tend to be transient. Their review suggests these programs should broaden inclusion criteria (e.g., do not exclude people with substance abuse problems) and that those with more severe pain may benefit the most. Once again, no therapeutic modality appeared to be superior.
Excellent piece of work contributes greatly to the literature and points to the direction of further research.
The abstract gives little away, however there is one statement in the article that I think is noteworthy: "Practices such as excluding those with substance or alcohol problems, or those with ongoing litigation or compensation, or establishing separate programs for different pain conditions are all unnecessary."
Robust article that focused on inpatient based pain group programs.