Pain Rehabilitation Program Research Articles

Breaking the vicious circle: Experiences of people in chronic pain on the pain rehabilitation journey.

AimTo explore the lived experience of individuals' in chronic pain of participating in a pain rehabilitation programme in Iceland.DesignPhenomenological research.MethodThe Vancouver School of Doing Phenomenology. Eleven participants were interviewed.ResultsThe overarching theme was as follows: “the journey of breaking the vicious circle of chronic pain.” Before the programme, the participants felt they were in survival mode, trying to survive each day; they were stuck in a vicious circle of chronic pain, simultaneously trying to ease and conceal the pain. Reaching out for professional help was a turning point. While attending the programme, participants began deconstructing their old ways of dealing with chronic pain. After completing the programme, they were still reconstructing their daily lives. In conclusion, pain rehabilitation programmes can be the first step towards breaking the vicious circle of chronic pain.

Examining the effectiveness of pain rehabilitation on chronic pain and post-traumatic symptoms.

Patients with co-morbid chronic pain and post-traumatic stress disorder (PTSD) pose significant treatment challenges. This study evaluated the effectiveness of an interdisciplinary pain rehabilitation program (IPRP) in improving pain and PTSD outcomes, as well as reducing medication use. In addition, the mediating effect of pain catastrophizing, which is theorized to underlie the pain and PTSD comorbidity, was examined. Participants included 83 completers of an IPRP with chronic pain and a provisional PTSD diagnosis. Significant improvements were found for pain outcomes, PTSD symptomatology, depressive symptoms, physical performance, and medication use (i.e., opioids and benzodiazepines). At discharge, 86.7% of participants reliably improved in at least one key measure of functioning and 50.6% demonstrated reliable improvement in PTSD symptomatology. Change in pain catastrophizing mediated improvements in pain interference and PTSD symptomatology. Results support the potential utility of an interdisciplinary pain treatment approach in the treatment of patients with comorbid pain and PTSD.

Treatment Effectiveness and Medication Use Reduction for Older Adults in Interdisciplinary Pain Rehabilitation.

ObjectiveTo examine the effectiveness of an interdisciplinary pain rehabilitation program (IPRP) that incorporates medication tapering on improving pain-related and performance-based outcomes for older adults with chronic noncancer pain and determine the proportion who demonstrated reliable improvement in outcome.Patients and MethodsThis 2-year retrospective clinical cohort study examined treatment outcomes of 134 older adult patients 65 years or older with chronic noncancer pain who completed a 3-week IPRP with physician-supervised medication tapering between January 1, 2015, and December 31, 2017. Pain, pain catastrophizing, depressive symptoms, and quality of life were assessed at pretreatment, posttreatment, and follow-up. Physical performance and medication use were assessed pre- and posttreatment. Outcomes were examined using a series of repeated-measures analyses of variance, examining effect size and reliable change.ResultsSignificant treatment effects (P<.001) with large effect sizes were observed for all self-report and physical performance outcome measures at posttreatment and 6-month follow-up (42.5% response rate). There were no significant differences in outcome based on opioid use status at admission. Reliable change analyses revealed that 76.9% (n=103 of 134) evidenced improvement in at least 1 pain-related outcome measure at posttreatment, and 87.7% (n=50 of 57), at follow-up. Patients also had significant reductions (P<.01) in medications at posttreatment (opioids, benzodiazepines, sedative-hypnotics, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and anticonvulsants).ConclusionOlder adults with chronic noncancer pain demonstrated improved pain-related outcomes, physical performance, and decreased medication use following IPRP treatment. Results support the effectiveness of IPRPs in enhancing the physical and emotional functioning of older adults with chronic pain while also facilitating the reduction of medications that place them at risk for adverse events.

An interdisciplinary chronic pain rehabilitation program effectively treats impairment in sexual function, depression, alexithymia, and pain in women with chronic pelvic pain

Purpose Chronic pelvic pain (CPP) in women is often associated with marked emotional distress and disability, with particular impairments in sexual functioning. Research supports the efficacy of interdisciplinary chronic pain rehabilitation programs (ICPRPs) in treating chronic pain, however less is known about their utility in CPP. Methods This retrospective study examined pain-related sexual impairment, emotional symptoms, and pain severity in CPP patients before and after completing a 3–4 week ICPRP. Predictors of post-treatment sexual impairment were also investigated. Participants included 58 female CPP patients and 58 age-matched females with non-pelvic chronic pain (NPCP). Results All participants reported robust improvements across outcome measures. Women with CPP reported greater pre- and post-treatment impairment in sexual function than NPCP patients, despite significant treatment-related improvements. In contrast, CPP patients also reported higher levels of depression at baseline but showed greater treatment related-improvements. In participants with CPP, treatment-related improvements in depression, alexithymia, and pain severity significantly explained decreases in pain-related sexual impairment following treatment, whereas none of these variables explained sexual impairment outcomes in women with NPCP. Conclusion Results demonstrate that ICPRPs can effectively treat CPP, particularly through changes in depression and alexithymia. Future research should examine whether specific interventions can be added in ICPRPS to address CPP-related sexual impairment.

Pain Rehabilitation During Adolescence; Work in Adulthood? A Long-Term Follow-Up Study to Explore the Facilitators and Barriers for Work.

Adolescents with chronic musculoskeletal pain face different impairments in daily life. After an inpatient pain rehabilitation program, adolescents function better on several domains. The aim of this study was to explore the long-term work participation of adults who followed inpatient pain rehabilitation during adolescence because of chronic musculoskeletal pain and to identify potential facilitators and barriers regarding work in later life. A mixed-methods study with standardized questionnaires and semi-structured interviews. The questionnaires measured pain, disability, work status, and the quality and quantity of the work. The interviews contained questions about work participation. Potential participants were all patients who had participated in an inpatient pain rehabilitation program 15 to 20years previously. Analyses were performed by thematic analysis. Using the Sherbrooke model as guidance, themes were classified into 4 systems: healthcare, workplace, legislative/insurance, and personal. Fourteen patients consented to participate (12 females). Seventy-one percent of them had paid work. The mean self-reported quality of the work delivered was 9.6 (standard deviation=0.5). Eighteen facilitators and 12 barriers regarding work participation later on in life were mentioned. The inpatient pain rehabilitation program was the most frequently mentioned facilitator (n=5), while the personal system and coping-related factors were the most frequently mentioned barriers (n=5). Ten out of 14 participants are currently working, most of them despite experiencing pain. Several factors based on the 4 systems of the Sherbrooke model contribute as facilitators or barriers regarding current work participation. Pain rehabilitation is mostly regarded as a facilitator for work participation later on in life.

Post-needling soreness and trigger point dry needling for hemiplegic shoulder pain following stroke.

To determine the presence of post-needling induced pain in subjects who had suffered a stroke and received trigger point (TrP) dry needling (DN), and to investigate the effects of including TrP-DN into a rehabilitation program for shoulder pain in this population. A randomized clinical trial was conducted. Sixteen patients who had suffered a stroke and presented with shoulder pain were randomly assigned to receive rehabilitation alone or rehabilitation combined with DN. Both groups received a neurorehabilitation session including modulatory interventions targeting the central nervous system. Patients in the DN group also received a single session of DN over active TrPs in the shoulder musculature. A numerical pain rating scale (NPRS, 0-10) was used to asses post-needling induced pain at 1 min, 24 h, and 72 h after needling. Shoulder pain (NPRS, 0-10) was assessed at baseline, and 3 and 7 days after DN in both groups. Five (62%) patients receiving TrP-DN reported post-needling induced pain. Post hoc analysis found that post-needling induced pain decreased significantly at 24 and 72 h (both p < 0.001) after DN. Patients receiving TrP-DN plus rehabilitation exhibited greater decreases in shoulder pain intensity at 3 days (Δ = -4.2, 95% confidence interval (CI) = -5.8 to -2.6) and 7 days (Δ = -4.3, 95% CI = -5.9 to -2.7) after the intervention compared with those receiving rehabilitation alone (all p < 0.001). This trial found that 50% of stroke patients receiving DN experienced post-needling induced pain, a side effect that almost disappeared 72 h after the intervention without any additional therapeutic action. In addition, the inclusion of TrP-DN into a rehabilitation session was effective at decreasing shoulder pain in these patients.

An Innovative and Accessible Biofeedback Intervention for Improving Self-Regulatory Skills in Pediatric Chronic Pain: A Pilot Study.

Objectives: Although biofeedback has been considered an effective treatment component for pediatric chronic pain, little research has examined the generalizability to activities outside of the treatment setting. The current study aimed to examine the effects of a biofeedback intervention involving individual and group sessions to facilitate increased self-regulatory skills for chronic pain management and to translate these skills to meaningful activities promoting functional restoration. Methods: Participants included 104 adolescents (ages 12-18) attending an intensive interdisciplinary pain rehabilitation program for chronic pain/symptoms and completed biofeedback training as part of the program. The biofeedback protocol consisted of six sessions, including an assessment of baseline physiologic states, diaphragmatic breath training, and various biofeedback screens to reinforce self-regulatory skills within individual- and group-based formats. Results: As expected, patients showed significant reductions in respiration rates and muscle tension from admission to discharge. Ratings of perceived confidence also increased from admission to post-treatment, suggesting greater self-efficacy in patients using self-regulatory skills during their daily functional activities. Conclusions: An individual- and group-based biofeedback protocol with a focus on training skills in activities relevant to adolescents' lives has the potential to improve self-regulation skills and generalize these skills to real-world settings. Future randomized controlled trials are necessary to examine the efficacy of biofeedback interventions to improve physiologic regulation and enhance treatment outcomes for pediatric chronic pain.

Becoming flexible: Increase in parent psychological flexibility uniquely predicts better well-being following participation in a pediatric interdisciplinary pain rehabilitation program

Parents of youth with chronic pain are at risk for depression, anxiety, and poor health-related quality of life. Research indicates Acceptance and Commitment Therapy (ACT) is effective at reducing symptoms of depression and stress for parents of youth with chronic concerns such as asthma and cerebral palsy. However, it is unclear whether these interventions are effective in improving the mental health and adjustment of parents of youth with chronic pain. ObjectiveThe current study took place in a three-week interdisciplinary pediatric pain rehabilitation program. The primary aim of the study was to examine whether the change in parent psychological flexibility and pain catastrophizing from admission to follow-up uniquely predicted parent depressive symptoms and health-related quality of life at follow-up. MethodsParticipants in this single-arm pre-posttest clinical study included 268 adolescents and young adults and their parents, who completed measures assessing depressive symptoms, health-related quality of life, pain catastrophizing, and psychological flexibility. ResultsPaired t-tests with Bonferroni correction found significant improvements in parents' mental health, functioning, and psychological flexibility, as well as lower levels of parents’ pain catastrophizing from admission to follow-up, with most effect sizes in the small to medium range. Findings from multiple regression analyses suggest that when controlling for depressive symptoms, quality of life, physical symptoms, catastrophizing, and psychological flexibility at admission, change in parent psychological flexibility uniquely predicted improved parent mental health and quality of life at follow-up. Specifically, change in emotional acceptance was the strongest unique predictor of the psychological flexibility subscales when controlling for admission scores. ConclusionsInterventions that help parents of youth with chronic pain learn to accept uncomfortable emotions and engage in valued action may help support better parent mental health.

Influence of modern technologies used in rehabilitation on selected functional parameters of the spine of patients with low back pain

The aim of the study was to examine influence of modern technologies used in the DBC method (Documentation Based Care) on the selected functional parameters of the spine of patients with low back pain. The research group comprised of 196 patients randomly divided into two groups. Patients in Group I were subjected to DBC treatment with modern rehabilitation equipment, while patients in Group II underwent the traditional form of therapeutic exercise. All subjects included in the study suffered from chronic low-back pain lasting for a period of at least three months. All the symptoms were non-specific. The results presented in the article unequivocally reveal that patients who underwent DBC treatment achieved better, statistically significant improvement in spinal functionality. The modern technologies introduced to the treatment had a considerable impact on the selected functional parameters of the spine of patients with low back pain. The DBC method used as a rehabilitation program for low back pain had a statistically significant influence on the functional parameters of the spine.

Clinicians' Initial Experiences of Transition to Online Interdisciplinary Pain Rehabilitation During the Covid-19 Pandemic.

ObjectivePublic health legislation during the CO-VID-19 pandemic has resulted in forced transitioning to the use of remote care in order to continue the provision of pain rehabilitation worldwide. The objective of this study was to gain insight into clinicians’ initial experiences with the provision of interdisciplinary pain rehabilitation via videoconferencing.DesignObservational, cross-sectional design.ParticipantsTwelve team members (specialists in rehabilitation medicine -MD-, psychologists, physiotherapists and occupational therapists) from a tertiary expertise centre in pain rehabilitation.MethodsQuantitative and qualitative data were collected via a digital survey. Theme-based content analysis was performed for qualitative data.ResultsThe themes that emerged were: the compulsory context; prerequisites for proper use of videoconferencing methods, which are strongly associated with the clinicians’ experiences; changes experienced in specific components of pain rehabilitation; and overarching changes experienced, including opportunities and limitations (sub-themes: therapeutic relationship, system involvement, efficiency, hands-on possibilities, interdisciplinary teamwork, and formalities). Overall, clinicians expressed moderate agreement with the statements that the quality of the pain rehabilitation programme can be maintained using videoconferencing, and that the COVID-19 pandemic offers opportunities for growth and innovation in telehealth.ConclusionIt is feasible to provide valid and satisfactory pain rehabilitation via videoconferencing. This study identified facilitators and barriers to the use of videoconferencing, and great potential for integrating aspects of telehealth into standard care after the pandemic.LAY ABSTRACTLegislation during the COVID-19 pandemic forced transitioning to remote care to continue pain rehabilitation treatment. In this study, first experiences with interdisciplinary pain rehabilitation by videoconferencing were gathered. Both qualitative and quantitative data were collected from team members of a pain rehabilitation team via a digital survey. Overall, clinicians reported that videoconferencing is a valid way to continue care in times when legalisation does not allow for standard face-to-face care. Furthermore, clinicians see opportunities to integrate aspects of telehealth into standard care after the COVID-19 pandemic. However, several limitations and restrictions have been experienced, such as the lack of a physical examination and questions about long-term effectiveness of the treatment. In addition, further investigation is needed to investigate whether pain rehabilitation provided by videoconferencing reaches quality standards of regular care.

Prognostic factors for improved physical and emotional functioning one year after interdisciplinary rehabilitation in patients with chronic pain: Results from a national quality registry in Sweden.

To investigate prognostic factors for physical and emotional functioning following interdisciplinary multimodal pain rehabilitation, by targeting patients' baseline characteristics and health measures. A prospective cohort of 2,876 patients from 38 specialist clinics across Sweden, who were completing interdisciplinary multimodal pain rehabilitation programmes, was followed through the Swedish Quality Registry for Pain Rehabilitation, from initial assessment to 12-month follow-up. Using logistic regression, baseline data were regressed to predict improvement in Physical functioning and Emotional functioning, fused by principal component analyses using the 36-item Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS). Employment status emerged as having the largest effect sizes in both Physical functioning and Emotional functioning; Working: odds ratio (OR) 2.05 (95% confidence interval (95% CI) 1.64-2.56) and OR 1.59 (95% CI 1.27-1.98), respectively. Strong beliefs in restored health, better initial emotional health, lower levels of pain and pain interference, and younger age all predicted Physical functioning. European origin, higher levels of general activity, and sense of life control all predicted Emotional functioning. Worse initial physical and emotional health predicted the corresponding dependent outcomes. Employment was consistently found to be an important prognostic factor, suggesting the significance of avoiding delay in interdisciplinary multimodal pain rehabilitation. A positive treatment expectancy was of importance. In general, multidimensional measures indicated that better initial status was more favourable; however, inconsistency implies a complex prognostic picture.

Evaluation of a multimodal pain rehabilitation programme in primary care based on clinical register data: a feasibility study.

Investigate the feasibility of identifying a well-defined treatment group and a comparable reference group in clinical register data. There is insufficient knowledge on how to avert neck/back pain from turning chronic or to impair work ability. The Swedish Government implemented a national multimodal rehabilitation (MMR) programme in primary care intending to promote work ability, reduce sick leave and increase return to work. Since randomised control trial data for effect is lacking, it is important to evaluate existing observational data from clinical settings. We identified all unique patients with musculoskeletal pain (MSP) diagnoses undergoing the MMR programme in primary care in the Skåne Health care Register (n = 2140) during 2010-2011. A reference cohort in primary care (n = 56 300) with similar MSP diagnoses, same ages and the same level of sick leave before baseline was identified for the same period. The reference cohort received ordinary care and treatment in primary care. The final study group consisted of 603 eligible MMR patients and 2874 eligible reference patients. Socio-economic and health-related baseline data including sick leave one year before up to two years after baseline were compared between groups. There were significant socio-economic and health differences at baseline between the MMR and the reference patients, with the MMR group having lower income, higher morbidity and more sick leave days. Sick leave days per year decreased significantly in the MMR group (118-102 days, P < 0.001) and in the reference group (50-42 days, P < 0.001) from one year before baseline to two years after. It was not feasible to identify a comparable reference group based on clinical register data. Despite an ambitious attempt to limit selection bias, significant baseline differences in socio-economic and health were present. In absence of randomised trials, effects of MMR cannot be sufficiently evaluated in primary care.

Development and validation of a method to screen for co-morbid depression by non-behavioral health practitioners treating musculoskeletal pain.

BACKGROUND:Although diagnosis and treatment of depressive illness is outside the scope of practice for non-behavioral health practitioners such as occupational therapists, physical therapists, kinesiotherapists, and chiropractors, it frequently is comorbid with painful musculoskeletal disorders such as low back pain and it negatively affects outcomes, including return to work. As psychologically-informed practice becomes more widely implemented without the immediate availability of behavioral health practitioners, safe and effective methods to screen for and appropriately triage depressive illness by nonbehavioral health practitioners are necessary.OBJECTIVES:To demonstrate the efficacy and validity of a method employed by non-behavioral health practitioners to screen for and appropriately triage musculoskeletal pain patients who also are experiencing depressive illness.METHODS:As part of a previously-published psychometric research study conducted in a community-based musculoskeletal pain rehabilitation program, a method was developed for nonbehavioral health practitioners to screen for and appropriately triage patients for co-morbid depressive illness, thus providing the current opportunity to examine the effects of depressive illness on work outcomes. The first step in the two-step process involves a 22-item questionnaire, providing scores used in the second step to triage for outside consultation with behavioral health practitioners. This paper describes the screening method and its application in an observational study of the impact of depressive illness on work outcomes.RESULTS:Among 156 consecutive patients who were presenting with musculoskeletal pain disorders to an outpatient rehabilitation program, 22.3% also were identified to have co-morbid clinical depression. The screening process allowed all patients to continue in the rehabilitation program. Those who were already receiving behavioral health care were encouraged to inform care providers of their participation in the program. Those who were not receiving behavioral health care were successfully triaged to care outside of the clinic. Depressive illness was found to affect success in the program, confirming the validity of the screening process for outpatient rehabilitation program participants experiencing chronic pain.CONCLUSIONS:A simple and effective depression screening process that triages patients without interruption of musculoskeletal treatment can be employed by nonbehavioral health practitioners. Because return to work outcomes were found to be negatively affected by depressive illness, this approach has the potential to improve overall program efficacy.

A virtual reality intervention for fear of movement for Veterans with chronic pain: protocol for a feasibility study

BackgroundA key concern for people with chronic pain is experiencing increased pain and/or re-injury. Consequently, individuals with chronic pain can develop a maladaptive fear of movement that leads to adverse functional consequences. A primary goal of chronic pain rehabilitation is re-engagement in feared movements through exposure. This is often challenging since safe movement can be uncomfortable. Virtual environments provide a promising opportunity to safely and gradually expose Veterans to movements that are avoided in the real world. The current study will utilize multiple virtual reality (VR) applications (APPs) of varying the intensity levels ranging from passive distraction from pain to active exposure to feared movement. The primary aims of this pilot are to examine VR as an adjunctive nonpharmacological intervention to assist with the adoption and implementation of skills to decrease fear of movement and increase overall functioning among Veterans with chronic pain. Second, to build a hierarchy of VR APPs to assist in gradual exposure to feared movements.MethodsThis study will be conducted in the Chronic Pain Rehabilitation Program (CPRP) at the James A. Haley Veterans Hospital, a unique inpatient program within the VA system. Participants will include up to 20 Veterans who receive a VR intervention as part of their physical therapy. A rating form containing qualitative and quantitative experiences will be administered following each VR session to assess feasibility and to provide descriptive information for the proposed hierarchy. Effect sizes will be calculated from intake and discharge measures for the primary outcome fear of movement and secondary pain and functional outcomes.DiscussionThis study will inform the feasibility of a randomized controlled trial examining the clinical utility of using VR to reduce fear of movement and increase function among Veterans with chronic pain. VR has the advantage of being easily implemented both within VA healthcare settings as well as in Veterans’ own residences, where engagement in ongoing self-management approaches is often most challenging. Presumably, VR that is matched to patient needs, progresses in intensity, immerses Veterans in the applications, and is perceived positively by Veterans, will result in positive functional outcomes.

Frequency of Correct Response and Factors Associated in the Medium Term With a Multimodal Rehabilitation Program for Chronic Low Back Pain

Frequency of Correct Response and Factors Associated in the Medium Term With a Multimodal Rehabilitation Program for Chronic Low Back Pain

Cutoff scores for the 8-item version of the Chronic Pain Acceptance Questionnaire (CPAQ-8) to identify different profiles of pain acceptance patterns, levels of function and behavioral flexibility

Despite their strong evidence, group-based ACT-informed pain rehabilitation programs yield medium to low effect sizes pointing to an uneven responsiveness. This has led to the search for ways to identify differential needs and capacity to change. Previous studies found that Pain Willingness and Activity Engagement cluster into four profiles with distinct behavioral and functional patterns of psychological flexibility. Clustering could enable the creation of groups with shared rehabilitation needs and guide the tailoring of process-based rehabilitation.The statistically created clusters in previous studies are however not easily transferable to clinical practice. This study therefore aimed to create raw score cutoffs to support the clinical implementation of the profiles. The raw scores were developed by visual exploration of the distribution of the CPAQ-8 scores of 1775 patients from a Latent Class Analysis. The cutoffs’ sensitivity and specificity were tested with Operating Characteristic (ROC) and Area Under the Curve (AUC) analysis and capacity to identify the profiles and patterns of behaviors were tested with ANOVA and MANOVA, in comparison to a statistically derived clustering solution. ROC analysis showed that clinical cutoffs could mimic the statistically created clusters with excellent sensitivity and specificity. The AUC ranged between 89.3% and 96.6%. The CPAQ-8 clinical cutoffs identify the same four profiles of Behavioral Flexibility, supporting a systematic assessment, selection and allocation of patients to groups with shared rehabilitation needs. The profiles carry information that will guide the clinician to tailor ACT-informed packages for each group. Implications for triage and treatment-design are discussed.

Treatment Outcomes and Mechanisms for an ACT-Based 10-Week Interdisciplinary Chronic Pain Rehabilitation Program.

Interdisciplinary pain rehabilitation programs are an evidence-based biopsychosocial treatment approach for chronic pain. The purpose of the current study is to assess outcomes for a 10-week interdisciplinary, acceptance and commitment therapy (ACT)-based, outpatient treatment model and to evaluate the relationship between psychological process variables (ie, pain catastrophizing, pain acceptance, pain self-efficacy) and treatment outcomes. 137 adults with chronic pain completed an interdisciplinary pain rehabilitation program. Measures of pain, pain interference, health-related quality of life, anxiety, depressed mood, insomnia, pain catastrophizing, pain acceptance, and pain self-efficacy were completed at admission and discharge. Data were also collected on demographic and clinical variables, including opioid use. Results indicated significant changes in all measures at program discharge compared to admission. Opioid doses were also reduced. Results of within-subjects meditational analyses indicated that pain catastrophizing accounted for a significant portion of the treatment effect for pain severity, pain interference, and depressed mood. Pain acceptance was a mediator for change in depressed mood, whereas pain self-efficacy was a mediator for pain interference outcomes. This study supports a 10-week, ACT-based treatment model for interdisciplinary chronic pain rehabilitation. In addition, pain catastrophizing, pain acceptance, and pain self-efficacy were each found to be mechanisms by which individuals achieve successful treatment outcomes. This research provides further support for interdisciplinary rehabilitation approaches for chronic pain.

The responsiveness and interpretability of psychosocial patient-reported outcome measures in chronic musculoskeletal pain rehabilitation.

For several widely used patient-reported outcome measures (PROMs) in chronic musculoskeletal pain (CMSP) rehabilitation, it is still not known whether they are responsive to change, and what the smallest detectable change (SDC) and minimal clinically important change (MCIC) are. Knowledge of these values can be used to accurately interpret change scores in research and clinical practice. In this retrospective cohort study, the responsiveness, the SDC and the MCIC of the mental components of the Research and Development 36-Item Health Survey (RAND-36), the Pain Catastrophizing Scale (PCS) and the Tampa Scale of Kinesiophobia (TSK) were investigated in CMSP patients. Responsiveness, the SDC and MCIC were determined by using both anchor and distribution-based methods. For all outcome measures, there was a progression from smallest to largest mean change scores between participants who did not perceive change and those who reported change after treatment. However, correlations of the Global Perceived Effect (GPE) with the change scores on the outcome measures were low. For all outcome measures, the SDC was larger than the MCIC. For this population, the questionnaires were shown not to be responsive. Furthermore, the questionnaires appeared not to be able to distinguish clinically important change from measurement error in individual patients. The finding of large measurement errors of PROMs is in line with previous research in pain rehabilitation. Using generic PROMs only, to examine changes in psychosocial status due to a pain rehabilitation programme, is therefore questionable. This study shows that widely used generic psychosocial PROMs might not be responsive and not able to distinguish clinically important change from measurement error in individual chronic musculoskeletal pain patients. It therefore seems reasonable to reconsider the (compulsory) use of these PROMs for assessing the quality of pain rehabilitation programmes, and necessary to consider other, more objective, outcome measures for this purpose in this population.

Functional Neurological Disorder Responds Favorably to Interdisciplinary Rehabilitation Models

Functional neurological disorder (FND) is difficult to treat and costly. Interdisciplinary chronic painrehabilitation programs (iCPRPs) are multidimensional functional restoration interventions for pain; their impact on FND specifically has not been assessed. The purpose of this study was to assess iCPRP's impact on functioning in FND. Data were examined retrospectively from anInstitutional Review Board-approved registry capturing admission and discharge data from patients participatingin an outpatient iCPRP. Subjective measures included pain-related disability, depression, anxiety, and stress scores, whereas objective measures included physical functioning measures (timed up and go, stair climbing test, and 6-min walk test). Pre-iCPRP and post-iCPRP measures were compared using a paired t-test approach. Forty-nine FND patients completed care and showed pre-measures and postmeasures. Statistically significant reductions in subjective measures of pain-related disability (46.40-20.91; P<0.001, d=1.92), depression (20.38-4.81; P<0.001, d=1.53), anxiety (15.09-6.29; P<0.001, d=1.18), and stress (21.96-9.70; P<0.001, d=1.21) scores were observed. Statistically significant changes in objective measures of mean timed up and go scores (decreased from 15.96 to 8.87 s), stair climbing test scores (increased from 40.98 to 71.93 steps), and mean 6-minute walk test scores (increased from 0.21 to 0.30 miles) were also observed across the group. While preliminary and based on a small patient sample, these findings support the use of interdisciplinary care models for FND treatment. Clinical and investigational implications are explored.

The Mediating Effect of Pain Catastrophizing on PTSD Symptoms and Pain Outcome.

Coprevalence of chronic pain and posttraumatic stress disorder (PTSD) negatively impacts the course of both disorders. Patients diagnosed with both conditions report greater pain, affective distress, and disability when compared with those with either chronic pain or PTSD alone. While the prevalence and complexity of the comorbidity is widely acknowledged, there is a dearth of research examining potential mechanism variables that might account for the relationship between chronic pain and PTSD. The current study utilizes a series of mediation analyses to examine if pain catastrophizing mediates the relationship between PTSD symptomatology and chronic pain outcome. A total of 203 treatment-seeking participants admitted to a 3-week interdisciplinary pain rehabilitation program completed a battery of psychometrically validated measures of pain severity, pain interference, pain catastrophizing, depressive symptoms, and PTSD symptoms at program admission. A series of multiple parallel mediation analyses revealed that pain catastrophizing fully mediated the relationships between PTSD symptoms and pain outcome (ie, pain severity and pain interference) above and beyond the influence of depressive symptoms. Results suggest that pain catastrophizing may represent an important cognitive mechanism through which PTSD symptoms influence the experience of chronic pain. Psychosocial treatment approaches that directly target tendency to catastrophize in response to pain may hold the potential to have salutary effects on both chronic pain and PTSD.