Interdisciplinary Pain Program Research Articles

Regional comparison of specialized outpatient and (partial) inpatient pain medicine care in Germany

Chronic pain requires graduated and staged levels of care. The aim of this study is to provide aregional overview regarding the accessibility of specialized outpatient and (partial) inpatient pain medicine care from the patient's perspective in Germany. For 1000 model patients randomly generated from German postal code location combinations, the travelling time by car (individual transport, IT)and available public transport connections (PTC) to the nearest specialized outpatient and inpatient pain medicine clinics and units were assessed using aroute planner. Outpatient facilities (in apractice setting) were mostly realistically accessible depending on the proportion of pain treatment and the networking structure. University pain outpatient clinics were at a critically reachable distance with IT for 70% of the patients (80% with PTC) and had unrealistic accessibility for 49% of the patients with IT (68% with PTC). Interdisciplinary multimodal pain programs in day clinics were at a critically reachable distance for 68% of patients with IT (83% with PTC) and in 49% (75% PTC) at an unrealistic travelling time distance considering the more intense treatment requiring frequent travel. Full inpatient interdisciplinary multimodal treatment was more realistically reachable (IT 39% critical, 14% unrealistic, PTC 61% critical, 48% unrealistic). The results show relevant nationwide differences in the accessibility of facilities for specialized pain treatment depending on the place of residence. Considering the treatment of achronic condition with long-term therapeutic goals and the need for graduated care (outpatient and inpatient treatment), the results reveal apartly critical situation from the patient's perspective.

Interdisciplinary pain program participants with high catastrophizing scores improve function utilizing enriched therapeutic encounters and integrative health techniques: a retrospective study.

Pain catastrophizing describes helplessness, rumination, and magnification of a pain experience. High pain catastrophizing is an independent risk factor for disability, pain severity, inadequate treatment response, chronicity, and opioid misuse. Interdisciplinary pain programs (IPPs) are beneficial and cost-effective for individuals with chronic pain, but their functional impact on individuals with high pain catastrophizing is not well established. The emerging field of placebo studies suggests that patient-provider relationships, positive treatment expectations, and sociobiologically informed care trigger physiological responses that may enhance therapeutic interventions. In this retrospective observational cohort study, we compared admission and discharge data for 428 adults with high-impact chronic pain (mean 8.5 years) who completed the Spaulding-Medford Functional Restoration Program (FRP). The interdisciplinary FRP team of physiatrists, behavioral health clinicians, physical therapists, and occupational therapists specializes in evidenced-based conventional rehabilitation, integrative health, and pain psychoeducation via enriched therapeutic encounters, fostering collaboration, validation, trust, self-efficacy, and positive expectations. Clinical outcome measures included the Canadian Occupational Performance Measure (COPM) assessing functional performance (COPM-PS) and satisfaction with function (COPM-SS), the Pain Numeric Rating Scale (NRS), the Pain Catastrophizing Scale (PCS), and the Patient Health Questionnaire-9 (PHQ-9). FRP participants with clinically elevated catastrophizing at baseline (PCS ≥30, mean PCS 39) achieved statistically significant improvements in function (mean delta -2.09, CHI2 = 15.56, p < 0.001), satisfaction with function (COPM-SS mean delta -2.50, CHI2 = 7.42, p = 0.007), pain (NRS mean delta 2.7), mood (PHQ-9 mean delta 1.87, p = 0.002), and catastrophizing (PCS mean delta 4.16, p < 0.001). Subgroup analysis revealed racial disparities in pain scores, and exploratory analysis showed a trend toward reducing opiate consumption. Despite the known association of adverse outcomes with high catastrophizing, FRP participation was associated with increased productive engagement, reduced pain, reduced maladaptive thought processes, and improved mood. Although causation and efficacy cannot be established from a retrospective design, this is the first study to identify functional improvement in patients with high-impact chronic pain and clinically relevant high pain catastrophizing who participate in an IPP combining conventional and complementary rehabilitation with psychoeducation. These enriched therapeutic encounters may enhance the treatment process by promoting trust, empathy, collaboration, and beneficial reframing of patients' experiences, expectations, and goals.

Longitudinal qualitative perspectives of adolescents in an intensive interdisciplinary pain program

ObjectivesChronic pain in children and adolescents is often associated with functional, physical, and psychosocial challenges. Intensive interdisciplinary pain treatment (IIPT) programs are effective at helping these youth regain functioning, but little is known about their perspectives prior to and during IIPT participation. This study sought to better understand how children and adolescents experience the process from evaluation to completion of the IIPT program.MethodsIndividual interviews (n = 7) were conducted at three time-points; (1) prior to initial evaluation in a pain clinic, (2) after pain clinic evaluation while considering IIPT, and (3) after completion of an IIPT program.ResultsParticipants ranged in age from 13–17 years. Across these time points, participants demonstrated changes in thoughts and perspectives. While Time 1 was associated with ambivalence, skepticism, and some hope, Time 2 was characterized by processing information about the program and resolution of some of their ambivalence. At Time 3, participants described their experience as “challenging” and “intense” and reported recognition that they had benefited from the program. Participants also wished to pass along lessons learned to future potential patients.DiscussionThis study provides information to help clinicians better approach adolescents with chronic pain who may be considering IIPT.

Patient expectations and understanding of diagnosis entering an interdisciplinary chronic pelvic pain program: A cross-sectional study

Background: Chronic pelvic pain is a complex condition. Few studies have focused on patient expectations of diagnosis and treatment in female chronic pelvic pain populations. Not knowing this information can lead to disparity and frustration between provider care and patient expectations resulting in poor patient outcomes. The aim of this study was to explore patient expectations and understanding of diagnosis prior to engaging in an interdisciplinary pelvic pain program. Methods: This is a cross sectional study of women enrolled in a tertiary Chronic Pain Center pelvic pain program in May 2019. Data were extracted from intake questionnaires to classify demographic variables and analyzed using descriptive statistics. Expectations and diagnoses were clustered in themes. Student’s t-test was used to compare biomedical focus and biopsychosocial focus groups to the Pain Disability Index (PDI) and the EQ-5D results, and to compare self-reported diagnoses with treatment expectations between groups. Results: When asked about perceived diagnosis, 74% reported a gynecologic cause for their pain, 25.7% reported musculoskeletal causes, and 21.9% reported other health conditions. For treatment expectations: 46.6% believed they required rehabilitation, 30.8% responded “I don’t know”, and 21.2% reported perceived need for medication. There was no difference in PDI or EQ-5D scores between patients who identified perceived treatment options and those who reported “I don’t know”. Conclusions: Most patients identified a perceived cause for their pain, but there was uncertainty and ambiguity about treatment options. Understanding and addressing the perception and expectations of individuals is imperative to patient-centered care and can lead to improved outcomes.

Blinded Pain Cocktails: A Reliable and Safe Opioid Weaning Method.

Weaning opioids in patients with noncancerous chronic pain often poses a challenge when psychosocial factors complicate the patient's chronic pain syndrome and opioid use. A blinded pain cocktail protocol used to wean opioid therapy has been described since the 1970s. At the Stanford Comprehensive Interdisciplinary Pain Program, a blinded pain cocktail remains a reliably effective medication-behavioral intervention. This review (1) outlines psychosocial factors that may complicate opioid weaning, (2) describes clinical goals and how to use blinded pain cocktails in opioid tapering, and (3) summarizes the mechanism of dose-extending placebos and ethical justification of its use in clinical practice.

The Impact of Dorsal Root Ganglion Stimulation on Pain Levels and Functionality in Patients With Chronic Postsurgical Knee Pain

BackgroundChronic postsurgical pain is a considerable source of disabling neuropathic pain. Rates of knee replacement surgeries are increasing, and many patients report chronic postsurgical pain in their wake. When conventional therapies prove ineffective, neuromodulation options such as dorsal root ganglion stimulation (DRGS) may be used. However, little is known about the effect of DRGS on improvements in quantitative functional outcome parameters. Materials and MethodsIn a prospective observational study at two pain centers, patients with chronic postsurgical knee pain underwent implantation with a DRGS system after an interdisciplinary multimodal pain program. Ratings of pain, mood, quality of life, and function were captured at baseline and through 12 months of treatment. Quantitative measures (range of motion, walking distance, and pain medication usage) were also recorded. ResultsVisual analog scale ratings of pain decreased from 8.6 to 3.0 (p < 0.0001; N = 11), and other pain measures agreed. Quality of life on the 36-Item Short Form Health Survey questionnaire improved from 69.3 to 87.6 (p < 0.0001), whereas the improvement in depression ratings was nonsignificant. International Knee Documentation Committee questionnaire ratings of function improved from 27.7 to 51.7 (p < 0.0001), which aligned with other functional measures. On average, knee range of motion improved by 24.5°, and walking distance dramatically increased from 125 meters to 1481. Cessation of opioids, antidepressants, and/or anticonvulsants was achieved by 73% of participants. ConclusionsBoth subjective-based questionnaire and quantitative examination-based variables were in broad agreement on the value of DRGS in improving functionality and chronic postsurgical pain in the knee. Although this finding is limited by the small sample size, this intervention may have utility in the many cases in which pain becomes problematic after orthopedic knee surgery.

Attaining expert consensus on diagnostic expectations of primary chronic pain diagnoses for patients referred to interdisciplinary pediatric chronic pain programs: A delphi study with pediatric chronic pain physicians and advanced practice nurses.

Pediatric primary chronic pain disorders come with diagnostic uncertainty, which may obscure diagnostic expectations for referring providers and the decision to accept or re-direct patients into interdisciplinary pediatric chronic pain programs based on diagnostic completeness. We aimed to attain expert consensus on diagnostic expectations for patients who are referred to interdisciplinary pediatric chronic pain programs with six common primary chronic pain diagnoses. We conducted a modified Delphi study with pediatric chronic pain physicians, nurse practitioners and clinical nurse specialists to determine degree of importance on significant clinical indicators and diagnostic items relevant to each of the six primary chronic pain diagnoses. Items were identified through point of care databases and complimentary literature and were rated by participants on a 5-point Likert scale. Our consensus threshold was set at 70%. Amongst 22 experts across 14 interdisciplinary programs in round one and 16 experts across 12 interdisciplinary programs in round two, consensus was reached on 84% of diagnostic items, where the highest degree of agreement was with Complex Regional Pain Syndrome (CRPS), Type 1 (100%) and the lowest with chronic pelvic pain (67%). This study demonstrated a general agreement amongst pediatric chronic pain experts regarding diagnostic expectations of patients referred to interdisciplinary chronic pain programs with primary chronic pain diagnoses. Study findings may help to clarify referral expectations and the decision to accept or re-direct patients into such programs based on diagnostic completeness while reducing the occurrence of unnecessary diagnostic tests and subsequent delays in accessing specialized care.

Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial

ObjectiveTo evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions. DesignTwo-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up. SettingDepartment of Veterans Affairs medical facility. Participants103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions. InterventionsExperimental arm—a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm—usual care in a large Department of Veterans Affairs medical facility. Main Outcome MeasuresOswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect. ResultsVeterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms). ConclusionThese findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.

Long term outcomes of chronic pain patients attending a publicly funded community-based interdisciplinary pain program in the Greater Toronto area: results of a practice-based audit

BackgroundChronic pain management multi/interdisciplinary programs attempt to address all elements of the biopsychosocial model. The primary objective of this retrospective study (based on practice-based audit) was to determine the effectiveness of a patient-centered, comprehensive and intense interdisciplinary pain management program in a publicly funded community-based pain clinic in the Greater Toronto Area.MethodThis retrospective longitudinal study was conducted on 218 carefully selected sequential chronic pain patients, with 158 completing a 3–4-month interdisciplinary program between January 2016 and December 2018. Data collected upon exit, at 6 months and 12 months post-discharge included demographic information, pain characteristics, emotional/functional status obtained by validated instruments and global impression of change (GIC). Additionally, social health outcomes (return to work or school) were retrieved through retrospective chart review. Means of pre-and post-program variables were compared to assess changes of each patient’s “journey”.ResultsPhysical and mental/ emotional health outcomes at exit, 6 months and 12 months post-discharge, showed initial and sustained, statistically and clinically significant improvement from pre-treatment levels, with GIC (much/very much improved) reported as 77%, 58% and 76%, respectively. Additionally, a substantial positive change in social health outcomes was noted particularly in patients on disability (29%), part time workers gaining full time employment (55%), and students (71%) who improved their level of schooling.ConclusionThe study showed that careful patient selection in a community-based publicly funded interdisciplinary pain management program can produce significant improvement in pain, physical, mental/emotional health and social function, with sustained long-term outcomes.

Using quantitative sensory testing to predict attrition in an interdisciplinary pain management program: a pilot study.

Aim: To determine the extent to which quantitative sensory testing (QST) predicted attrition in an interdisciplinary pain program (IPP). Patients & methods: Participants (n=53) enrolled in an IPP completed pretreatment assessments of QST and the PROMIS-29 quality of life survey. Results & conclusion: Compared with completers, non-completers (24.5%) reported significantly higher pain intensity (7.1, 95% CI [5.8, 8.4] versus 5.4, 95% CI [4.8, 6.1]) and cold hyperalgesia (14.6°C, 95% CI [8.8, 20.4] versus 7.5°C, 95% CI [4.8, 6.1]), with both variables also predicting attrition. This finding highlights a potentially novel and clinically significant use of QST. Higher overall pain intensity and the presence of remote cold hyperalgesia may identify patients at risk for dropping out of an IPP.

Improved pain acceptance and interference following outpatient interdisciplinary pediatric chronic pain treatment

Objectives Intensive interdisciplinary chronic pain treatment programs have demonstrated that pain acceptance predicts positive treatment outcomes, but limited research has focused on less-intensive programs. This study aimed to examine associations between changes in pain acceptance and pain interference among youth participating in an outpatient interdisciplinary chronic pain treatment program. Design Youth presenting to an evaluation within an interdisciplinary outpatient pediatric chronic pain program completed questionnaires at initial program evaluation (T1) and three months later (T2). Main Outcome Measures Youth (N = 94, Mage = 14.59 years, 74% female) completed the Chronic Pain Acceptance Questionnaire, Adolescent Version (CPAQ-A) and PROMIS Pediatric Pain Interference scale. Results Pain acceptance increased significantly from T1 to T2 (p=.001), driven primarily by activity engagement (p=.001). Pain interference decreased from T1 to T2 (p<.001). Improvements in acceptance were strongly associated with reductions in interference (p<.001). An exploratory cross-lagged structural equation model revealed a number of direct and indirect effects between pain acceptance and pain interference at T1 and T2. Conclusion Pain acceptance and interference improved after three months in an outpatient chronic pain treatment program. Improvements in acceptance were strongly related to reductions in interference. Future research should examine these relationships over longer periods, in larger samples.

Maintaining Access to an Interdisciplinary Pain Program During COVID-19

Research Objectives1. To compare patient attendance in an interdisciplinary pain program (IPP) before and during the COVID-19 pandemic. 2. To describe programmatic changes in response to patient needs during the pandemic.DesignCohort comparison of IPP attendance rates before versus during the pandemic.SettingOutpatient IPP (consisting of physical therapy [PT], cognitive behavioral therapy [CBT], and medication management [MM]) within an academic medical center.ParticipantsAdults diagnosed with chronic pain (N=259) who attended ≥ 1 IPP session between March 2017 and February 2020.InterventionsBefore COVID-19, PT, CBT, and MM delivered in-person. During COVID-19, PT and MM delivered remotely and in person; CBT delivered via telehealth to individuals and groups to allow social distance and respond to facial affect.Main Outcome MeasuresObjective 1. Patient attendance = attending ≥ 6 days of PT or CBT (individual and/or group).ResultsObjective 1. Before COVID-19, IPP attendance (from 3/20/2017 to 3/4/2020) was 76%. Since COVID-19 and through 2/2021, attendance was 65%. Objective 2: During COVID-19, PT included both telehealth and masked, in-person sessions. CBT was delivered through telehealth. IPP psychologist's role grew to promote evidence-based nonpharmacologic intervention for COVID-19 and reduce vaccination hesitation.ConclusionsOverall, IPP clinicians and staff maintained safe access to interdisciplinary care for adults with chronic pain. Despite the global pandemic 65% of the patients completed the IPP. The 11% reduction in attendance may reflect increased biopsychosocial burdens experienced by patients with chronic pain during COVID-19. As chronic pain affects more Americans than diabetes, heart disease, and cancer combined, future studies are needed to identify the barriers to attendance among patients before and after COVID-19. Determining how to best reduce the risk of attrition will assist patients in benefiting fully from IPP treatment.Author(s) DisclosuresNone related to this project.

The Resurrection of Interdisciplinary Pain Rehabilitation: Outcomes Across a Veterans Affairs Collaborative

Despite empirical support for interdisciplinary pain rehabilitation programs improving functioning and quality of life, access to this treatment approach has decreased dramatically over the last 20 years within the United States but has grown significantly in the Department of Veterans Affairs (VA). Between 2009 and 2019, VA pain rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation Facilities increased 10-fold in the VA, expanding from two to 20. The aim of this collaborative observational evaluation was to examine patient outcomes across a subset of six programs at five sites. Outcomes were assessed using agreed-upon measures of patient-reported pain intensity, pain interference across various domains, pain catastrophizing, and sleep. A total of 931 patients enrolled in the selected VA interdisciplinary pain programs, with 84.1% of participants completing the full course of treatment. Overall, all programs showed significant improvements from pretreatment to posttreatment in nearly all patient-reported outcomes. The effect sizes ranged from medium to large. Notably, the results demonstrate that positive outcomes were typical despite differences in structure and resources across programs. The adverse impacts of opioid use have highlighted the importance of chronic pain treatment approaches that emphasize team-based care focused on functional improvements. This study represents the first and largest analysis of outcomes across chronic pain rehabilitation programs and demonstrates the need for increased access to similar comprehensive approaches to pain management across the health care system. Further, it suggests that a variety of structures may be effective, encouraging flexibility in adopting this interdisciplinary approach.

The development and efficacy of an interdisciplinary chronic pelvic pain program.

Chronic pelvic pain (CPP) is a significant issue, and approximately 14% of women experience CPP once in their life-time. 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. 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, psychoeducation, 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. 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. 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, highlight the unique needs of women with CPP, and implicate multiple factors for programming and treatment.

Feasibility of a Randomized Controlled Trial of Paediatric Interdisciplinary Pain Management Using Home-Based Telehealth.

PurposeChronic pain is common in adolescents. Evidence-based guidelines recommend interdisciplinary treatment, but access is limited by geography. The development of hybrid programs utilizing both face-to-face and videoconference treatment may help overcome this. We developed a 7-week hybrid pediatric interdisciplinary pain program (Hybrid-PIPP) and wished to compare it to individual face-to-face sessions (Standard Care). Our objective was to test the feasibility of a protocol that used a matched pair un-blinded randomized controlled design to investigate the efficacy and cost-effectiveness of the Hybrid-PIPP compared to Standard Care.Patients and MethodsParent–adolescent dyads were recruited from tertiary pediatric clinics and matched by disability before randomization to minimize allocation bias. The adolescents (aged 11–17) had experienced primary pain for >3 months. Hybrid-PIPP involved 11 hrs of group therapy and 4 individual videoconference sessions. Standard care was provided by the same clinical team, using the same treatment model and similar intensity as the Hybrid-PIPP. The intention was to recruit participants for 3 Hybrid-PIPP groups with a comparison stream. Recruitment was ceased after 2 groups due to the high participant disability requiring more intensive intervention.ResultsEighteen dyads were screened and 13 randomized (7 Hybrid-PIPP, 6 Standard Care, 2 unsuitable, 3 unallocated when the study was stopped). The study met a priori feasibility criteria for staff availability; recruitment rate; treatment completion; and data collection. Global satisfaction ratings were similar in both streams (SC median 7, range 5–9 and Hybrid-PIPP median 8.5, range 5–10). Challenges were identified in both streams. A future modified Hybrid-PIPP was considered acceptable if the intensity is increased to manage the high level of disability. Standard care was considered inefficient. No adverse events were reported.ConclusionThe study determined that the protocol met a priori feasibility criteria, but to be practicable in a real world, health environment requires significant modifications.RegistrationANZTR(ACTRN2614000489695).

Validation of PROMIS CATs and PROMIS Global Health in an Interdisciplinary Pain Program for Patients With Chronic Low Back Pain.

Retrospective cohort study. To (1) confirm validity of Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and pain interference computer-adaptive tests (CATs) and (2) assess the validity of PROMIS Global Health (GH) and five additional PROMIS CATs: social role satisfaction, fatigue, anxiety, depression, and sleep disturbance in a population of patients with chronic low back pain (cLBP) who completed a 3-month Interdisciplinary Pain Program (IPP). Recent recommendations for assessing outcomes in patients with cLBP have included PROMIS scales; however, there is a need for further evaluation, and PROMIS GH has not been studied in this population. The study cohort included patients with cLBP who completed the entirety of a 3-month IPP between August 2016 and December 2018. Patient-reported outcome measures (PROMs) were analyzed before the start of the IPP and at graduation. Convergent and discriminant validity were evaluated using Pearson correlation coefficients. Known groups' validity assessed the change in PROMIS scores stratified by improvement on the Modified LBP Disability Questionnaire. Responsiveness was evaluated with standardized response means based on global impression of change. IPP was completed by 217 patients (67.7% women, age 53.8 ± 12.8). Convergent validity was supported (P < 0.01 for all pairwise PROMs comparisons). All PROMs improved significantly by graduation, with the largest improvement for PROMIS pain interference, physical function, social role satisfaction, and Modified LBP Disability Questionnaire. Known groups' validity demonstrated the greatest change on PROMIS physical function, social role satisfaction, pain interference, and depression. Responsiveness was supported for all PROMs in 170 (78.3%) patients who indicated at least minimal improvement (standardized response means 0.43-1.06). Our study provides support of PROMIS CATs, highlights the importance of including other meaningful outcome measures, such as social role satisfaction, and provides the first validation of PROMIS GH, in patients with cLBP. PROMs collection can be streamlined through the use of PROMIS CATs which offer advantages over legacy measures. 3.

Factors Related to Agreement Between Child and Caregiver Report of Child Functioning With Chronic Pain: PROMIS Pediatric and Parent Proxy Report.

Valid and efficient assessment of patient-reported outcomes remains a priority to guide pain treatment and research. PROMIS pediatric self-report and parent proxy measures offer feasible and rigorous evaluation of functioning in children with chronic conditions, including pain. A key challenge is determining the usefulness of multisource information from children and caregivers for understanding pain and function. Our primary aim examined child-caregiver agreement across child functioning domains. Our secondary aim examined child and caregiver factors associated with the child-caregiver agreement. A sample of 806 children with chronic pain (Mage=14.50 y; 72% female individuals) and a caregiver (Mage=45.82 y; 85% mothers) completed PROMIS pediatric self-report and parent proxy measures of anxiety, depression, fatigue, pain interference, and mobility before intake in an interdisciplinary outpatient pediatric chronic pain program. The agreement was poor to good depending on the evaluation method (effect size, intraclass correlation, and clinical significance interpretation). Caregivers generally reported worse child symptoms across domains compared with child self-report. The greatest discrepancy was observed for child anxiety, pain interference, and peer relations, with the greatest agreement for child mobility. The greater caregiver-child discrepancy was found for younger children, girls, with a higher child or caregiver pain catastrophizing, and poorer caregiver physical or mental health. Findings are discussed within the interpersonal context of pain and indicate the relevance of both child and caregiver perspectives to personalize chronic pain assessment and treatment. Findings can be used by clinicians and researchers to guide whether and how to integrate multi-informant reports about child chronic pain functioning.

Improving Distress and Behaviors for Parents of Adolescents With Chronic Pain Enrolled in an Intensive Interdisciplinary Pain Program.

Intensive interdisciplinary treatment is emerging as an effective treatment of chronic pain in youth. These programs often include a parental component with the belief that targeting parental distress and responses to a child's pain will improve outcomes. However, few studies have evaluated the impact of a parental intervention in the interdisciplinary treatment of pediatric chronic pain. The present study consists of a nonrandomized pre-post design to evaluate change in psychological and behavioral functioning of parents who participated in intensive parent programming that utilized cognitive-behavioral therapy and acceptance and commitment therapy, delivered within the context of an interdisciplinary intensive 3-week pain treatment program for youth with chronic pain. Two hundred twelve parents and their children participated in the study, with 116 participants completing 3-month follow-up measures. Parents completed measures of depressive symptoms, pain catastrophizing, protective responses, and psychological flexibility at admission, discharge, and 3 months after the program. Child functional disability was assessed at the same time points. We examined change in parent factors over time, while controlling for change in child distress. Parents reported significant improvements in all areas of functioning from admission to discharge and improvements were maintained at 3-month follow-up. This study provides evidence suggesting parent interventions can be effective in reducing parent distress and behaviors known to be associated with child outcomes.

271. A biopsychosocial approach in the management of chronic low back pain: 2-year outcomes

BACKGROUND CONTEXT Back pain is a pervasive public health problem with two-thirds of the population experiencing it at some point in their lives and associated with significant costs for both treatment and associated loss of productivity. When pain is persistent, traditional single service approaches to treating back pain may be insufficient, as they do not address the psychosocial factors which frequently impact an individual's pain experience. PURPOSE This study aims to present effect of multidisciplinary program using patient reported outcomes measures in this approach to chronic low back pain (CLBP) management. STUDY DESIGN/SETTING The Cleveland Clinic operates an interdisciplinary pain program to care for patients with CLBP, called Back on TREK (BoT). PATIENT SAMPLE First 168 patients to graduate in BoT over a 2-year period (2016-2018). OUTCOME MEASURES Patient-reported outcomes were systematically collected at the point of care through a patient-entered data collection platform which integrates data into the electronic medical record and is immediately available to care providers. Questionnaires include the STarT Back Screening Tool, Oswestry Disasbility Index (ODI), The Patient Health Questionnaire-9 (PHQ-9) depression screen, and several Patient-Reported Outcome Measurement Information System (PROMIS) v1.0 scales, anxiety, satisfaction with social roles, fatigue, pain intensity, physical function and sleep disturbance. Reduction in ODI of 10 or more points is considered to indicate clinically meaningful improvement. PROMIS is a set of self-report measures that assess an individual physical, mental and social health. A change of 5 or more points in PROMIS scores is considered to reflect a meaningful difference. METHODS This retrospective study reviewed all graduated participants with CLBP enrolled in the BoT. RESULTS Analysis was performed on the outcomes of 168 patients completing the BoT program. At the time of graduation, these patients had significant improvement in pain-related disability as measured by MDQ compared to baseline assessments. Clinically significant changes across multiple functional quality of life metrics were also observed, including fatigue, physical function, pain interference and social role satisfaction. In addition, nearly half of the participants demonstrated clinically significant changes in depression and anxiety. CONCLUSIONS The Back on TREK program demonstrates promising 2-year outcomes and supports the basis for creating a standardized way of providing treatment for patients with chronic back pain based in a biopsychosocial treatment paradigm. The process behind the development of this program further emphasizes the value of multispecialty inputs in program development to ensure thorough assessment, intervention and evaluation protocols. The program has since expanded from a pilot status and holds future goals of reaching more individuals with chronic low back pain. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Impact of Symptom Reporting Agreement on Interdisciplinary Pain Program Participation.

To investigate whether physician-patient agreement of potential patient problem areas impacts subsequent patient enrollment in an interdisciplinary pain management program. Retrospective chart review of 544 patients who underwent evaluation of their chronic pain. Physicians and their patients endorsed perceived patient problems during the evaluation. The potential problems included 7 clinical domains: pain, sleep, mood, physical functioning, ability to cope with pain, ability to manage pain flare-ups, and pain medication effectiveness. Results indicated statistically significant levels of agreement among the physicians and their patients (free-marginal kappa range, 0.19 to 0.94, P's<0.001). The highest agreement occurred for pain and the lowest for pain medication effectiveness. Patients who enrolled in a recommended program did not differ from those who did not enroll based on either levels of agreement or average number of physician-patient agreements for the 7 clinical domains (P's>0.05). Patients recommended for higher-intensity programs were perceived by their evaluating physician to have a significantly greater number of problematic clinical domains than those recommended for less intense pain programs. The level of physician-patient agreement regarding the patients' current difficulties did not appear to influence patients' decisions to participate in interdisciplinary pain management. Extraneous, nonclinical factors may have had a greater impact on participation in interdisciplinary pain management than physician-patient agreement. Future research should focus on identifying these factors and their impact. Also, studying the impact of physician-patient agreement beyond enrollment status (eg, on successful program completion) may be helpful in potentially enhancing patient outcomes.