Multidisciplinary Pain Management Program Research Articles

Patient perspectives on the unwanted effects of multidisciplinary pain management programmes: A qualitative study.

This study aimed to understand the impact of pain management programmes, focusing on the unwanted effects and their influence on patients' long-term use of self-management strategies. Qualitative study. Specialist musculoskeletal hospital in North London, England. Patients with chronic musculoskeletal pain that have completed a pain management programme. Multidisciplinary pain management programmes. Data were collected regarding patients' experiences and unwanted effects from the pain management programme using semi-structured interviews. Data were analysed using thematic analysis. Fourteen participant interviews were included in the analysis (median age 54 years, 12 females). Four themes were generated from the data: Benefits and burdens, Pain management programme and real life, Social support and Healthcare interventions. Unwanted effects included heightened anxiety related to negative interactions with peers, being in a new environment, worries about ability to cope with the programme, social anxiety from being in a group, the strain on families due to participants being away from home and a sense of abandonment at end of the programme. Burdens associated with implementing pain management strategies were identified, including the emotional burden of imposing their self-management on close family and competing demands with time and energy spent on self-management at the expense of work or home commitments. Pain management programmes have an important role in helping patients to learn how to self-manage chronic pain. Their unwanted effects and the treatment burdens associated with long-term self-management may be an important consideration in improving the longevity of their beneficial effects.

Chronic Pain: An Update of Clinical Practices and Advances in Chronic Pain Management.

Chronic pain affects a significant amount of the population and represents a heavy personal and socioeconomic burden. Chronic pain mechanisms can be categorized as nociceptive, neuropathic, or nociplastic. Although mechanism-based pain treatment is optimal, different types of pain mechanisms may overlap in patients. Recently, the biopsychosocial model with the multidisciplinary pain management program is widely accepted as one of the most effective methods to assess and manage chronic pain. The treatment of chronic pain consists of a personalized, stepwise, and multimodal approach that includes pharmacotherapy, psychotherapy, integrative treatments, and interventional procedures. Somatic and peripheral nerve blocks for the treatment of chronic pain are often deferred. With the increasing use of ultrasound in pain medicine, newly defined interfascial plane blocks, which may be performed alone or as an adjuvant to multimodal management, have gained popularity. Adequate pain management can improve physical functioning, mental health and quality of life indicators, and reduce pain chronification. The aim of this current article is to perform a comprehensive and updated review of existing treatment options, particularly interfascial plane blocks in chronic pain syndromes.

The use of wearable technology in a comprehensive chronic pain management programme

Technology is increasingly used to promote physical activity and reduce sedentary behaviour in the general population, but the possibility of using it to support physical activity in chronic pain patients is still sparse. Physical activity is crucial for improving quality of life of chronic pain patients. However, long-term physical activity goals widely depend on pain perception, actual or anticipated pain exacerbation, and lack of confidence when doing physical activity. We aimed to determine whether wearable technology can improve management of chronic pain. Full protocol of this 8-week clinical trial is available in the Clinical Trials Registry (NCT 03837080). In short, chronic pain patients enrolled in the 4-week multidisciplinary chronic pain management programme wore fitness wristbands during the 4-week programme (0-4 weeks) and during the follow-up (4-8 weeks). Fitness wristbands measured physical activity and sleep patterns. Additionally, anthropometric measurements and psychological condition of patients (by using Pain Catastrophizing Scale and Depression, Anxiety and Stress Scale – 21 Items questionnaires) was measured. The number of steps and average time of activity per day increased, as well as deep sleep time per day but without reaching statistical significance. Significant improvements in waist circumference and waist-to-hip ratio and waist-to-height ratio with longer deep sleep time were found. No significant correlation was found between physical activity, sleep quality and psychological characteristics or catastrophizing. By wearing fitness wristbands, patients feel actively involved in their chronic pain management. In a clinical/research setting, wristbands provide better, continuous oversight of patient’s progress end enables tailoring of individualized strategies. However, the use of wristbands requires some level of IT knowledge, and sudden malfunctions of the wristband and/or the software can be expected. Additionally, some individual characteristics (i.e., demographics, psychosocial factors, lack of motivation) can also be obstacles to their use.

The use of wearable technology in a comprehensive chronic pain management programme

Technology is increasingly used to promote physical activity and reduce sedentary behaviour in the general population, but the possibility of using it to support physical activity in chronic pain patients is still sparse. Physical activity is crucial for improving quality of life of chronic pain patients. However, long-term physical activity goals widely depend on pain perception, actual or anticipated pain exacerbation, and lack of confidence when doing physical activity. We aimed to determine whether wearable technology can improve management of chronic pain. Full protocol of this 8-week clinical trial is available in the Clinical Trials Registry (NCT 03837080). In short, chronic pain patients enrolled in the 4-week multidisciplinary chronic pain management programme wore fitness wristbands during the 4-week programme (0-4 weeks) and during the follow-up (4-8 weeks). Fitness wristbands measured physical activity and sleep patterns. Additionally, anthropometric measurements and psychological condition of patients (by using Pain Catastrophizing Scale and Depression, Anxiety and Stress Scale – 21 Items questionnaires) was measured. The number of steps and average time of activity per day increased, as well as deep sleep time per day but without reaching statistical significance. Significant improvements in waist circumference and waist-to-hip ratio and waist-to-height ratio with longer deep sleep time were found. No significant correlation was found between physical activity, sleep quality and psychological characteristics or catastrophizing. By wearing fitness wristbands, patients feel actively involved in their chronic pain management. In a clinical/research setting, wristbands provide better, continuous oversight of patient’s progress end enables tailoring of individualized strategies. However, the use of wristbands requires some level of IT knowledge, and sudden malfunctions of the wristband and/or the software can be expected. Additionally, some individual characteristics (i.e., demographics, psychosocial factors, lack of motivation) can also be obstacles to their use.

Alternatives to opioids for managing chronic pain: a patient education programme in the US

As the US is experiencing an opioid epidemic, patients with non-malignant chronic pain must understand the risks of opioids and identify safe and effective treatment alternatives. Multidisciplinary pain management programmes have been shown to be effective in reducing non-malignant chronic pain. A pilot project was conducted in a primary care clinic in the US with the aim of educating patients on the neurophysiology of pain, biopsychosocial responses to pain, risks and benefits of opioids and non-opioid alternatives, and pain management techniques. The programme was shown to be associated with use of reduced amounts of opioids, reduced catastrophising and reduced pain among the 13 participants. After the programme, participants reported having a better understanding of pain and pain management and being willing to work with primary care clinicians to decrease their use of opioids. Programmes that teach patients how to manage chronic pain and reduce opioid use are crucial to addressing the opioid epidemic in the US.

The therapeutic effect of the multidisciplinary inpatient pain management program for chronic musculoskeletal pain classified by ICD–11J

The therapeutic effect of the multidisciplinary inpatient pain management program for chronic musculoskeletal pain classified by ICD–11J

Cancer pain management program: Patients' experiences–A qualitative study

Cancer patients frequently experience unrelieved pain as a significant symptom. However, several studieshave found that cancer-related pain is frequently undertreated. This study aimed to understand the pain experiences of cancer patients who were newly engaged in a multidisciplinary pain management program (PMP) at King Hussein Cancer Centre and still receiving cancer treatments and cancer pain management. A qualitative study design and semi-structured interviews were used to obtain data from 21 cancer patients who were purposefully selected. All patients had advanced cancer, including skeleton metastases. All female participants had breast cancer, and all male participants had prostate cancer. It was found that the patient-healthcare professional relationship and satisfaction with services emerged as two themes in healthcare professionals' pain management. The results from this study can offer a new understanding of the knowledge related to satisfaction of patients with cancer in terms of the quality of pain management. Additional qualitative studies are required to replicate the findings in populations from different backgrounds, ethnicities, and cultures experiencing cancer pain.

A Multidisciplinary Transitional Pain Management Program Is Associated With Reduced Opioid Dependence After Primary Total Joint Arthroplasty

Overprescription of opioids after total joint arthroplasty (TJA) increases risks of opioid dependence, overdose, and death. The authors hypothesized that a multidisciplinary, perioperative pain management program (the Transitional Pain Service or TPS) for TJA would lead to fewer patients becoming opioid dependent. A TPS was implemented at a Veterans Affairs Medical Center focused on nonopioid pain management, cessation support, and prospective data tracking. A historical control, interventional study design was used to assess opioid use at 90 days post-discharge. Secondary analysis of the implementation group included post-operative outcome scores, time to opioid cessation, and median opioid tablets consumed at 90 days. Fewer patients in the TPS group demonstrated persistent opioid use at 90 days post-discharge (0.7% vs 9.9%; P= .004). Independent predictors of total opioid tablet prescriptions included TPS (β=-19.41; 95% confidence interval [CI]-35.37 to-3.47), number of tablets prescribed at discharge (β= 1.08; 95% CI 0.86-1.31), and TKA surgery (β= 16.84; 95% CI 4.58-29.10). Under the TPS, median tablets consumed was 20.5 for THA and 36.5 for TKA; median time to cessation was shorter in THA (7 days; 95% CI 2-10) when compared to TKA (13 days; 95% CI 11-16). In opioid-naïve veterans undergoing TJA, the TPS was associated with a 93% reduction in opioid dependence and a 60% reduction in opioid tablet prescriptions at 90 days post-discharge. Under the TPS, median 90-day opioid consumption was 20.5 and 36.5 tablets for THA and TKA, respectively. Widespread adoption of similar programs may greatly reduce opioid use and dependence in orthopedic patients nationally. III.

The Effect of Adjunct Telephone Support on Adherence and Outcomes of the Reboot Online Pain Management Program: Randomized Controlled Trial.

BackgroundInternet-based treatment programs present a solution for providing access to pain management for those unable to access clinic-based multidisciplinary pain programs. Attrition from internet interventions is a common issue. Clinician-supported guidance can be an important feature in web-based interventions; however, the optimal level of therapist guidance and expertise required to improve adherence remains unclear.ObjectiveThe aim of this study is to evaluate whether augmenting the existing Reboot Online program with telephone support by a clinician improves program adherence and effectiveness compared with the web-based program alone.MethodsA 2-armed, CONSORT (Consolidated Standards of Reporting Trials)–compliant, registered randomized controlled trial with one-to-one group allocation was conducted. It compared a web-based multidisciplinary pain management program, Reboot Online, combined with telephone support (n=44) with Reboot Online alone (n=45) as the control group. Participants were recruited through web-based social media and the This Way Up service provider network. The primary outcome for this study was adherence to the Reboot Online program. Adherence was quantified through three metrics: completion of the program, the number of participants who enrolled into the program, and the number of participants who commenced the program. Data on adherence were collected automatically through the This Way Up platform. Secondary measures of clinical effectiveness were also collected.ResultsReboot Online combined with telephone support had a positive effect on enrollment and commencement of the program compared with Reboot Online without telephone support. Significantly more participants from the Reboot Online plus telephone support group enrolled (41/44, 93%) into the course than those from the control group (35/45, 78%; χ21=4.2; P=.04). Furthermore, more participants from the intervention group commenced the course than those from the control group (40/44, 91% vs 27/45, 60%, respectively; χ21=11.4; P=.001). Of the participants enrolled in the intervention group, 43% (19/44) completed the course, and of those in the control group, 31% (14/45) completed the course. When considering the subgroup of those who commenced the program, there was no significant difference between the proportions of people who completed all 8 lessons in the intervention (19/40, 48%) and control groups (14/27, 52%; χ21=1.3; P=.24). The treatment efficacy on clinical outcome measures did not differ between the intervention and control groups.ConclusionsTelephone support improves participants’ registration, program commencement, and engagement in the early phase of the internet intervention; however, it did not seem to have an impact on overall course completion or efficacy.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12619001076167; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619001076167

“Living more and struggling less”: a qualitative descriptive study of patient experiences of physiotherapy informed by Acceptance and Commitment Therapy within a multidisciplinary pain management programme

ObjectivesPhysiotherapists increasingly deliver treatment informed by cognitive-behavioural therapy, including Acceptance and Commitment Therapy (ACT), for persistent pain. This study explored patients’ experiences of ACT-informed physiotherapy to better understand therapeutic processes and outcomes. DesignA qualitative descriptive study was conducted. Focus groups explored participants’ experience of ACT-informed physiotherapy in the context of a pain management programme. Responses were audio recorded, transcribed verbatim, and analysed using a hybrid inductive-deductive reflexive thematic analysis. SettingA single tertiary care pain management service. ParticipantsThe sample consisted of fifteen patients from two treatment groups who completed an intensive multidisciplinary ACT-based pain management programme. Participants were included irrespective of their treatment response. ResultsOne overarching theme (living more and struggling less) and four interconnected themes were generated from the data: 1) awareness and openness help to approach physical activities flexibly; 2) from battling against to working with the body compassionately; 3) from narrow focus to curiosity, freedom, and expansion; and 4) social connection is a catalyst for openness and engagement. ConclusionsParticipants experienced ACT-informed physiotherapy as helping them to live more and struggle less with pain; this occurred in the context of a psychologically flexible relationship with the physiotherapist and was catalysed by social connection. These findings should be seen as preliminary given the small number and relatively brief duration of focus groups conducted. Further research is needed to explore how principles within ACT-informed physiotherapy may support patients and clinicians to respond effectively to the challenges that persistent pain can bring.

Impaired Health-Related Quality of Life in Brazilian Children with Chronic Abdominal Pain: A Cross-Sectional Study.

We compared the health-related quality of life (HRQOL) of children and adolescents with functional abdominal pain disorders (FAPDs) and organic abdominal pain disorders (ORGDs). This was a single-center, cross-sectional, observational study. The PedsQL 4.0 generic cores scales parent proxy-report was administered to parents/caregivers of 130 and 56 pediatric patients with FAPDs and ORGDs respectively on their first visit. The self-reported pain intensity in the patients was assessed using a visual analog scale (VAS) and facial affective scale (FAS). Irritable bowel syndrome was the most prevalent FAPDs, and the most prevalent ORGDs were reflux esophagitis (41.1%) and gastritis associated with Helicobacter pylori (21.4%). There was no difference in HRQOL among patients diagnosed with ORGDs and FAPDs (p>0.05). Patients with ORGDs and FAPDs had lower HRQOL Scale scores than healthy Brazilian and American children's references, with a high proportion of children at risk for impaired HRQOL (p<0.0001). There was no difference in the VAS and the FAS scores between the ORGDs and the FAPDs. FAPDs had a higher prevalence of girls' and couples' disagreement (p<0.02), although poor school performance (p<0.0007) and bullying (p<0.01) were higher in patients with ORGD. This study revealed that there was a difference in impaired HRQOL between patients with ORGDs and FAPDs. Thus, considering the high prevalence of chronic abdominal pain in children, a well-founded treatment plan is necessary for a multidisciplinary cognitive-behavioral Pain management program.

What factors predict outcome from an inpatient multidisciplinary chronic pain service? A prospective cohort study.

Objective To identify baseline factors associated with outcomes from an inpatient multidisciplinary pain management program (PMP) located in a bicultural area of Aotearoa New Zealand. Methods A prospective cohort study was undertaken involving 164 people with chronic pain who attended the PMP. Demographic, clinical, and psychosocial measures were obtained at baseline, whereas clinical and psychosocial outcome measures were also obtained at program discharge and 3-month follow up (N = 100). Multivariate analyses were used to determine baseline demographic variables that were associated with outcomes at discharge and follow up. Results Being male and working full-time were associated with poorer outcomes in select measures at discharge. At the 3-month follow up, Māori ethnicity, working full-time, being retired or unemployed, or having chronic widespread pain were associated with poorer outcomes for some measures, whereas those with rheumatoid arthritis had greater self-efficacy. Conclusions Sex, ethnicity, employment status, and patient condition impact clinical outcomes from the program and in the time from discharge to follow up. Program content and/or delivery should be altered to promote more equitable outcomes for all patients in the long term.

Does group-based cognitive therapy improve functional ability, pain, catastrophic thoughts and quality of life in patients with persistent low back pain and psychological risk factors? A randomised controlled trial in a secondary care setting

Objective To investigate the effects of a group-based cognitive behavioural intervention for patients with persistent low back pain (LBP) and psychological risk factors referred to secondary care. Design A randomised controlled trial. Setting Silkeborg Regional Hospital, Denmark. Subjects A total of 136 participants with chronic LBP and psychological risk factors. Interventions Participants were randomised to the standard care group, including examination by a rheumatologist and/or a physiotherapist, or the intervention group, including standard care plus a multidisciplinary group-based pain management programme. Main measures Patient-reported outcomes were collected at baseline and after 6 and 12 months. The primary outcome was disability (Roland Morris Disability Questionnaire). Secondary outcomes included low back pain intensity, pain catastrophising, health-related quality of life, and sick leave. Results Among 136 participants, 68 (mean age: 41.7 years (SD 11.8)) were randomised to standard care and 68 (mean age: 46.0 years (SD 10.8)) were randomised to the intervention group. Except for age, baseline characteristics were comparable between groups. 12-month follow-up was completed by 92.6% in the intervention group and 80.9% in the standard care group. Both groups achieved significant improvements on disability, with a reduction of −4.8 points (SD 6.1) in the intervention group compared to −3.7 points (SD 5.2), resulting in an insignificant difference between groups. No significant differences were found in the secondary outcomes. Conclusion A group-based pain management programme was no more effective than standard care for patients with persistent LBP and psychological risk factors.

Patients' experiences of occupational therapy within a multidisciplinary pain management programme: A qualitative study.

Occupational problems are common for adults experiencing chronic pain, but occupational therapists are not always accessed as part of the multidisciplinary team. Despite evidence of benefit for work-focused interventions, there is limited evidence for broader benefit from occupational therapy interventions within the context of multidisciplinary pain management. The aim of this study was to explore the experiences of programme attendees who received structured intervention from an occupational therapist as part of a multidisciplinary pain management programme, and gain an understanding as to how they felt it influenced changes they made to occupational participation. A qualitative approach was undertaken with 9 individual patients recruited from a group pain management programme for adults with chronic low back pain. Semi-structured interviews were carried out, recorded and transcribed. Thematic analysis was used to identify themes in the data. Three key themes were identified: 1) the helpfulness of activity pacing techniques 2) the value of participating in a therapeutic activity-based session and 3) an increased understanding of the importance of leisure and creative activities in the context of their lives. Participants perceived the specific occupational therapy content of the programme to be helpful in a number of different ways. The findings suggest that occupational therapy can be important in facilitating patients to apply theoretical techniques in the real world, thereby increasing the likelihood of long term benefit.

Impact of Opioid Use on Results of Interventional Back-Pain Management on Patients with Chronic Back Pain

Objectives Preoperative exposure to opiates has recently shown to be associated with poor outcomes after elective major surgery, but little is known as to how pretreatment opioid use affects results of interventional back-pain management. We investigated the impact of preoperative opioid use on outcomes after interventional pain management procedures on patients with chronic back pain. Methods A high-volume, single-center quality register analysis was performed on patients who underwent interventional pain management for chronic back pain as a part of multidisciplinary pain management program. Chronic opioid use was defined as having an opioid prescription concurrent with 90 days. Results: A total of 797 patients underwent intervention during the study period 2019-2020. Pretreatment opioid use was present in 262 patients (33%). Patients with chronic back-pain using opiates reported significantly more pain and discomfort before treatment as well as lowered working ability. Facet-joint medial branch blocks resulted for significant improvement for both groups directly after the treatment as well as at 2-hours follow-up. However, non-opiate group reported significantly more improvement at 2-days follow up as well as at one- month follow-up compared to opiate users. Opiate users reported nearly the same pain level at one-month follow-up as before treatment. Conclusions: Pretreatment opioid use is associated with greater pain discomfort, impairment and reduced functional ability, as well as poorer long-term effect of interventional back pain treatment at 1-month follow-up. In our study opiate users reported same positive effects of facet-joint nerve blocks immediately after the treatment and 2 hours after the treatment but significantly smaller effect at one-month follow-up. This could indicate that opiate use may diminish effects of pain treatments by affecting relearning, behavioral changes and central pain modulation. These findings may help to understand the impact of pretreatment opioid use on patient care, and its implications on hospital and societal cost.

Pain, Sleep, and Health-Related Quality of Life after Multidisciplinary Intervention for Chronic Pain.

Multidisciplinary pain-management programs have the potential to decrease pain intensity, improve health-related quality of life (HRQOL), and increase sleep quality. In this longitudinal prospective cohort study, the aim was to investigate the long-term effects of multidisciplinary pain rehabilitation interventions in Iceland. More precisely, we (a) explored and described how individuals with chronic pain evaluated their pain severity, sleep, and HRQOL at pre-treatment and at one-year follow-up and (b) examined what predicted the participants’ one-year follow-up HRQOL. Seventy-nine patients aged 20–68 years, most of whom were women (85%), responded. The participants scored their pain lower at one-year follow-up (p < 0.001). According to their response, most of them had disrupted sleep, mainly because of pain. One year after the treatment, more participants slept through the night (p = 0.004), and their HRQOL increased. Higher pre-treatment mental component summary (MCS) scores and having pursued higher education predicted higher MCS scores at one-year follow-up, and higher pre-treatment physical component summary (PCS) scores predicted higher PCS scores at one-year follow-up. Sleep problems, being a woman, and having children younger than 18 years of age predicted lower MCS scores at one-year follow-up. These findings are suggestive that patients should be examined with respect to their mental status, and it could be beneficial if they received some professional support after completing the intervention.

Patient and Provider Attitudes, Beliefs, and Biases That Contribute to a Marginalized Process of Care and Outcomes in Chronic Musculoskeletal Pain: A Systematic Review-Part I: Clinical Care.

Chronic musculoskeletal pain (CMP) outcomes are affected by numerous variables, including the clinical conversation. When good therapeutic/working alliances are formed, congruent clinical conversations can lead to improved CMP outcomes. Identifying patient/provider attitudes, beliefs, and biases in CMP that can influence the clinical conversation, and thus clinical management decisions, is foundationally important. The aims of this systematic review were to 1) summarize the evidence of the attitudes and beliefs of patients and health care providers (HCPs) involved in the clinical conversation about CMP, and 2) examine whether and how these perceptions impacted the process of care. A systematic search of CINAHL, PubMed, Scopus, Sociology Database in ProQuest, and Web of Science used the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Included studies were those investigating vulnerable adult populations with chronic pain. Study bias was examined with the Downs and Black tool. Seven retrospective studies were included. When making pharmaceutical management decisions, HCPs demonstrated negative implicit biases toward minorities and women. When making referrals to multidisciplinary care, HCPs demonstrated negative implicit biases toward women with lower educational attainment. Unmet patient expectations resulted in higher dropout rates at multidisciplinary pain management programs. Patients' trust was influenced by the health care setting, and patients often had limited options secondary to health insurance type/status. These findings suggest that patients with CMP may experience a marginalized process of care due to HCPs' negative implicit biases, unmet patient expectations, and the health care setting. Results suggest several factors may contribute to inequitable care and the recalcitrant nature of CMP, particularly in vulnerable populations with limited health care choices.

What is the content of virtually delivered pain management programmes for people with persistent musculoskeletal pain? A systematic review.

Virtual consultations (VC) have been embraced by healthcare organisations during the COVID-19 pandemic. VC allows continuation of patient care while adhering to government advised restrictions and social distancing measures. Multidisciplinary pain management programmes (PMPs) are a core element of many pain services and utilising virtual methods to deliver PMPs has allowed them to continue to provide care. This systematic review aimed to explore the content of existing virtually delivered PMPs and discuss if and how these findings can be used to guide clinical delivery. Eligible studies included adults (aged ⩾18 years) with persistent musculoskeletal pain and any virtually delivered intervention that was described as a PMP or that had components of PMPs. Databases were searched from inception until July 2020. We performed a content analysis comparing existing interventions with established evidence-based clinical guidelines published by the British Pain Society (BPS). Intervention reporting quality was assessed using the Template for Intervention Description and Replication (TIDieR) checklist: an established checklist developed to improve the completeness of the reporting of interventions. Eight studies were included. One intervention included six of the seven components recommended by the BPS; none included all seven. 'Skills training and activity management' was present in all eight interventions; 'education' and 'cognitive therapy methods' were present in six interventions; 'graded activation' and 'methods to enhance acceptance, mindfulness and psychological flexibility' were present in four interventions; 'physical exercise' was present in two interventions and 'graded exposure' was present in one intervention. None of the studies described all 12 items of the TIDieR checklist adequately enough for replication. Published virtual PMPs partially meet established clinical guidelines. Future virtual PMPs should be based on evidence-based clinical guidelines, and more research is needed to explore the effectiveness of virtually delivered PMPs and each recommended component.

P010 Management of fibromyalgia patients in secondary care: a retrospective audit

Background/Aims To examine the management of fibromyalgia patients referred to secondary care with respect to 2017 European Alliance of Associations for Rheumatology (EULAR) guidelines. Methods Eighty-two patients referred to the Complex Musculoskeletal Clinic in the Rheumatology Department with a resulting diagnosis of fibromyalgia were included in the audit. Data was collected retrospectively via Electronic Patient Records over the study period of December 2017 to March 2020. Variables assessed included patient demographics, clinical presentation at assessment and management. Statistical analyses were conducted using Excel 2019 and the Excel Analysis ToolPak. Results The majority of the patients were female 77/82(94%), and the mean age was 43.2yrs (SD = 12.6). Co-morbidities were common: 31/82 (38%) had a further painful musculoskeletal condition, 40/82 (49%) were obese and 46/82 (56%) had an active mental health problem. Alongside chronic widespread pain, patients reported fatigue 64/82 (78%), waking unrefreshed 69/82 (84%), and cognitive disturbance 31/82 (38%). Compared to a 2014 audit conducted in the same population and department, more patients had received pharmacological treatment (71/82 [87%] vs 34/50 [68%]; z = 2.64, p = 0.008), had received physiotherapy (28/82 [34%] vs 5/50 [10%]; z = 3.0, p = 0.002) and psychological input (16/82 [20%] vs 3/50 [6%]; z = 2.20, p = 0.03) prior to referral to secondary care. At secondary care consultation, all patients received an assessment of their pain and function, and 64/82 (78%) were assessed for psychosocial context. Fifty-three (65%) patients received information in the form of a website recommendation, leaflet or verbal education. After clinician assessment, the majority were referred to a multidisciplinary pain management programme, in a significant increase from 2014 (64/82 [78%] vs 4/50 [8%]; z = 8.04, p < 0.0001). All medication recommendations were made according to 2017 EULAR guidelines. Alongside multidisciplinary pain rehabilitation, patients were referred to physiotherapy 21/82 (26%), physical activity 26/82 (26%), sleep hygiene 9/82 (11%) and psychological 7/82 (9%) treatment options. Conclusion Multidisciplinary treatment and first-line, non-pharmacological approaches have become the standard management approach in secondary care, alongside EULAR compliant pharmacological recommendations. EULAR’s non-pharmacological recommendations of assessing not only pain, but function and psychosocial context occurs for the majority of patients. The limitation of consultation duration likely plays a role in whether psychosocial context is adequately assessed. Providing patients with information about their condition, though occurring for approximately 2/3 of patients, was recognized as an area for improvement. The high rate of co-morbidities combined with the demographics of Fibromyalgia patients emphasizes the importance of early, multimodal management. Follow-up audits are warranted to examine the effects of the COVID-19 pandemic, and the impact of the upcoming 2021 NICE guidance for chronic pain. Disclosure Y. Kang: None. R. Smith: None. A. Soni: Grants/research support; Oxford-UCB Prize Fellowship.

What Influences Outcomes From Inpatient Multidisciplinary Pain Management Programs?: A Systematic Review and Meta-analysis.

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. 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. 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. 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.