Pain Management Programs Evidence for Efficacy Tom Perkins

A significant public health concern Chronic Pain A significant public health concern Extremely common 17.1% of men, 20% of women in Australia Prevalence peaks in ages >60 (Blyth et al., 2001) Extremely costly Estimated cost of 34 billion in Australia for year 2007 (MBF, 2007) Prevalence project to increase

Multi-dimensional problem Chronic Pain Multi-dimensional problem Distinct From Acute Pain Different neurobiological profiles (Hashmi et al., 2013) Engages more affective brain regions (Apkarian et al., 2013) Emanates from biological, psychological and social processes Maintained by complex interactions between personal circumstances and cognitions Opioid-based treatments insufficient Chronic pain not an unambiguous signal of tissue damage Taken from Hashmi et al. (2014)  different BOLD response of medial prefrontal cortex of sub-acute and chronic back pain

Pain Management Programs Multi-dimensional solution Pain management programs (PMPs) || Multidisciplinary Rehabilitation Intensive programs implementing psychological and physical therapy alongside existing medical interventions Goals Reduce negative cognitions that exacerbate pain Reduce, or better manage medication usage Types Multidisciplinary versus interdisciplinary

Evidence for Pain Programs Meta-Analyses Best evidence for short-term improvement Chipchase et al. (2012) – 6 studies Pain perceptions & self-efficacy improved at program discharge and 6 month follow-up Only pain perceptions maintained at 12 months Hoffman et al. (2007) – 22 RCTs Pain programs more effective than active-control groups for improving pain interference, but not severity Improvements not sustained beyond 3-months

Evidence for Pain Programs Cochrane Reviews Suggest PMPs typically more effective than alternative treatments Karjalainen et al. (2003) – 2 low quality RCTs Moderate evidence for improved disability for those with sub-acute lower back pain, but not shoulder/neck pain Scasghini et al. (2008) – 27 RCTs Strong evidence that 13 of 15 programs superior to waiting list or medical treatment Moderate evidence that 10 of 15 programs superior to any non-multidisciplinary treatment Long-term follow ups not available

Evidence for Pain Programs Cochrane Reviews Suggest PMPs typically more effective than alternative treatments Guzmán et al. (2001) – multi compared to non-multi treatment Strong evidence for improved function Moderate evidence for reduced pain Low intensity programs equivalent to typical care Kamper et al. (2015) – 41 RCTs Moderate evidence PMPs improve pain and function compared to usual care Low quality evidence PMPs more effective than physical treatment 35 of 41 trials show PMPs can improve pain and function

Evidence for Pain Programs Pain-related outcomes Concerning pain specifically, RCTs and meta-studies indicate PMPs are… More effective than waiting-list groups (Becker et al., 2000) Equivalent to manual therapy (Hay et al., 2005) Produce a short-term improvement (Guzman et al., 2001; Kamper et al., 2015; Karjalainen et al., 2003) That is often not identified long-term (Hoffman et al., 2007; van Green et al., 2007)

Evidence for Pain Programs Pain-related outcomes Quasi-experimental research shows PMPs… Improve pain by approximately 4 – 23% at post-program Dysvik et al. (2008) = 4.4% Fullen et al. (2014) = 10.3% Pieh et al. (2012) = 10.91% Wells-Federman et al. (2002) = 22.2% Mixed evidence for long-term improvement Robbins et al. (2003) = 38.5% improvement at 12 months Perry et al. (2010) = 12.9% improvement at 9 months Chelminski et al. (2005) = 12-15% improvement at 3 months Brown et al. (2013), Norrbrink-Budh et al. (2006), Fedoroff et al. (2014) = no improvement between post-program and 12 months

Evidence for Pain Programs Psychological-related outcomes Depression and anxiety levels improved by PMPs Meta-analysis shows depression, but not anxiety levels improved following PMP (Hoffman et al., 2007) Compared to waiting-list patients, PMPs... show greater improvement to depression and anxiety (Kames et al., 1990; Vollenbroek-Hutten et al., 2004) and anxiety only (Becker et al., 2000) Compared to GP-Care patients, PMPs… Show no difference in improvement to depression and anxiety between PMPs and GP care (Becker et al., 2000)

Evidence for Pain Programs Psychological-related outcomes Quasi-experimental research shows improvements to depression and anxiety range between 19 and 35% Depression and Anxiety Post-program (Cassidy et al., 2012) Six month follow-up (Fullen et al., 2014) Nine month follow-up (Perry et al., 2010) Twelve month follow-up (Norrbrink-Budh et al., 2006) Depression only Post-program (Wells-Federman et al., 2002) Three month follow-up (Chelminski et al., 2005) Twelve month follow up (Robbins et al., 2003)

Evidence for Pain Programs Other psychological-related outcomes Evidence for mid to long-term improvement Catastrophizing (Moss-Morris et al., 2007; Cassidy et al., 2012) Well-being (Becker et al., 2000) Mindfulness (Dysvik et al., 2010; Perry et al., 2010) Sense of control (Brown et al., 2013; Kole-Snijders et al., 1999) Social activities (Kames et al., 1990) Evidence for immediate improvement only Coping (Becker et al., 2000; Kole-Snijders et al., 1999) Self-Efficacy (van Geen et al., 2007) Control (Oslund et al., 2009)

Evidence for Pain Programs Health outcomes Weak evidence that PMPs improve physical health as measured by SF-36 RCTs Becker et al. (2000) At six-months, general health showed greater improvement in PMP compared to waiting list, but was otherwise not significantly different Perry et al. (2010) No significant difference between usual care and PMP on physical function up to 9 months follow-up  usual care greater effect size however Observational Studies Dysvik et al. (2005) Gains to physical and general health observed at 12-month post-program only Moss-Morris et al. (2007) Quadratic effect – improvements to physical health post-program, begin to taper up to 28 week follow-up

Evidence for Pain Programs Health outcomes Moderate evidence disability level can be improved through PMPs Meta-analyses (Kamper et al., 2015) Compared to typical care Moderate quality evidence PMPs are more effective at reducing disability (Cohens d = 0.23) – effects stronger in short-term Compared to physical treatment or waiting list Low quality evidence PMPs are more effective at reducing disability (Cohens d = 0.68, 0.42 respectively) No difference to surgery Observational studies Improvements to disability ranging from: 14.12% (three month follow-up, Cassidy et al., 2012) to 17.95% (post-program, Wells-Federman et al., 2002)

Evidence for Pain Programs Health outcomes Limited research to directly assess physical capabilities RCTs Compared to waiting list group, those in PMP had greater improvement to meters walked, stairs climbed and endurance (Williams et al., 1996) Observational studies Six months after completing PMP, Fullen et al. (2014) demonstrated: A 19% faster sit-to-stand test 14% faster 50 feet walking test 19% increase in how many stairs could be covered in 60 seconds Three months after completing PMP, Fedoroff et al. (2014) demonstrated: Increase in steps from 1552 to 1651 steps per day

Evidence for Pain Programs Vocational outcomes PMPs can increase return to work rates Reviews Moderate quality evidence that PMPs more effective than active-control or physical treatment from meta-analyses (Hoffman et al., 2007) and systematic reviews (Kamper et al., 2015) PMPs return patients to work faster, with fewer sick days (Karjalainen et al., 2003) RCTs Interdisciplinary PMP led to increased work-rate up to 12 month follow-up of (33% to 48.5%; Robbins et al., 2003) PMPs promote greater RTW rates (55%) than does typical treatment (37%) (Haldorsen et al., 2002)

Evidence for Pain Programs Clinical Significance An estimate of meaningful improvement Clarifies the percentage of patients to improve Using strict criteria of 30% improvement, Morley et al. (2008) report 6% improved on walk test 12% reduced pain intensity 18% improved anxiety 25% improved depression and pain interference Using scale-cut offs, Fullen et al. (2014) report 17% reduced pain intensity 22% reduced anxiety 55% reduced depression 63% improved disability 18% improved on physical function tests

Evidence for Pain Programs Clinical Significance Reliable Change Index Improvement twice the size of a samples standard error of the mean Hechler et al. (2008) 72% improved pain intensity 45% improved pain-related disability 13-26% improved on measures of emotional distress 25% improved depression and pain interference Brown et al. (2013) Examined number of patients to improve in at least one domain (pain, depression, anxiety, walk test) Effect size : 40.4% Standard error of the mean : 38.1% Reliable change index : 33.3%

Evidence for Pain Programs Final Thoughts PMPs are beneficial to those with chronic pain Effects from PMPs typically better or equivalent to other therapies such as GP care, manual therapy or surgery Pain interference, disability, depression most likely to improve Evidence for long-term efficacy weaker As time elapses after completing program, improvements commonly plateau or rescind toward baseline

Future Directions Final thoughts Patient selection critical Some patient amenable to improvement, where others are not But what factors predict improvement to PMPs? High education (de Rooij et al., 2013; Heiskanen et al., 2012) Young age (Waterschoot et al., 2014) Positive employment prospects (Heiskanen et al., 2012) Being male (de Rooij et al., 2013), presence of females in group (Waterschoot et al., 2014) High baseline pain & low baseline anxiety (de Rooij et al., 2013)

Future Directions Final Thoughts Timely referral is important, 6 month gap between injury and program commencement associated with a deterioration of symptoms (Lynch et al., 2008) Most endure long waits between injury and program admission (Howard et al., 2009) Majority of individuals suffering an injury return to work within a month, and relieved of all symptoms within 4±6 weeks (Waddell, 1987) Difficult to quantify subtle differences between programs Expertise of clinicians conducting program Rolling programs versus fixed intake programs Inpatient versus outpatient programs Degree of interdisciplinary practice Group dynamics