Carolyn A Arnold Caulfield Pain Management & Research Centre, Alfred Health, Melbourne, Australia Outcome Assessment after Musculoskeletal Pain Rehabilitation Carolyn A Arnold Caulfield Pain Management & Research Centre Alfred Health Melbourne

How do we assess outcome? We use Outcome Measures: tools to assess change in a patient over time select outcome measures demographic information pain service type

Musculoskeletal Pain Rehabilitation- What are the Goals? To shift the focus from curative treatments to self management of chronic conditions To restore and improve function –Personal and Domestic Activities of Daily Living (ADL) –Return to Work –Social and recreational activity –Better psychological health –Manage exacerbations of chronic condition

Physical deconditioning commonly follows musculoskeletal pain and injury -it has serious health consequences Overcoming barriers to improve physical fitness requires more than an exercise prescription

What are the barriers to physical rehabilitation? Fear of harm Fear of hurt Changed level of performance after injury Inadequate physical rehabilitation after injury Fear of social re- engagement

Validity and Responsiveness of Objective Physical Measures in a Chronic Pain Cohort Walk Test J Firth et al 2011 In submission

Physical measures Six Minute Walk Test (6MWT) for functional walking tolerance, Ten metre Walk Test (10mWT) for walking speed Timed Up And Go test (TUAG) for general mobility Sit-to-Stand x 5 test (SS5) for leg strength Four Square Step Test (4SST) for balance. Validated Self Report Measures: Brief Pain Inventory Short Form for pain (BPIs) Interference Scale (BPIi) Physical function domain of the SF-36

Client sample description Age 49.1 years (12.3) Gender 63% female Pain duration 9.3 years (9.40) Pain Sites low back pain, 22.5% widespread pain BPI Pain Severity: 0-10 scale: 6 (1.8) BPI Pain Interference: 0-10 scale: 6.7 (2) SF-36 Physical Functioning: % 38.5 (22.9) N varied from 187 to 45

Internal responsiveness of the five objective physical measures in a chronic pain cohort. Effect sizes (95% CI). NScore pre- program Mean (SD) Score post- program Mean (SD) Mean difference P valueCohen’s dd lower limitd upper limit 6MWT (m) (104.4)472.6 (105.7)39.2< (large) mWT (m/min) (16.2)81.5 (21.9)13.5< (large) TUAG (sec) (4.2)9.6 (3.1)-1.30< (large) SS5 (sec) (8.6)18.7 (6.2)-3.20< (large) SST (sec)4412 (2.7)12.2 (4.1) (none) Firth J et al 2011

Comparison of change in physical measures between those who improved on the Brief Pain Inventory interference scale and those who did not. Improved on BPIi (n = 50) Not improved on BPIi (n = 63 ) p value 6MWT (metres)36.1 (62)33.82 (58.2) mWT (m/min)15.7 (15.6)12.3 (17.3).137 TUAG (sec) -1.4 (2.4)-.8 (1.9).137 SSX5 (sec) -3.6 (6.4)-4 (8.4).862 4SST (sec) -.66 (1.9)1.2 (4.1).111 Self Report Measures did not correlate to objective physical measures

Using outcome measures in managing a patient: a case example Mrs PB 54 yo with chronic low back pain radiating to her left leg, for 4 years (lumbar spondylosis) physiotherapy, chiropractic, injection therapies, and medication trials without success Angry mood. Married, adult children Sent to the pain clinic.

Assessment Questionnaires at commencement of treatment (Patient PB) High pain Scores 9/10 VAS Anger on VAS scale 8.2/10. Also high irritability and frustration Mood 15 on BDI II (Beck ) “mild depression”

Post CBT Review Checking scores on Brief Pain Inventory(BPI) and Beck depression: No change in Pain Still high Depressed Mood BDI 26/50 Why?

IMMPACT Initiative on Methods Measurement and Pain Assessment in Clinical Trials

IMMPACT Recommendations: Core domains: Pain (intensity NRS, rescue analgesics, categorical pain rating) Physical functioning, either Brief Pain Inventory (BPI) interference items or Multidimensional Pain Inventory Pain Interference Scale Emotional functioning: Beck Depression Inventory or Profile of Mood States Participant ratings of global improvement For research trials: adverse events, participant disposition, selection etc “Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials” ( Dworkin RH et al. 2005)

Brief Pain Inventory

DomainTier OneTier Two Pain severityBPI subscale(MPI) Physical functioningBPI InterferenceSF36 Emotional functioningK10Beck depression BDI PSEQ CSQ Participants Rating(0-7 scale) For researchDemographics Medication: Opioids MQS Treatment eg hours, group or individual

National Pain Outcome Initiative To provide snapshots and audit tools for providers of chronic pain rehabilitation programmes around Australia and New Zealand Select an agreed but “short and snappy” set of outcome tools to measure at commencement of chronic pain treatment and one follow up point. To give useful information to better understand service needs and activities and allow self evaluation for improvement Current Pilot Project running between Caulfield (Vic, metro)and Hunter (NSW Rural) Pain Units

Outcome measures Measures which demonstrate validity, reliability and responsiveness. To consider the implications for future policy To make recommendations for further methodological research To review what is currently known of the outcome Assist variety of perspectives (consumer, provider, purchaser) in a scientific manner

Examples in Rehabilitation Medicine (AROC) and Palliative Care (PCOC) AROC inpatient rehabilitation: data on length of stay by diagnostic category and with Functional Independence Measures * PCOC: can compare pain outcomes in palliative care episodes in hospital and community settings * 2009 “State of The Nation” The AROC Annual Report.

In conclusion Simple outcome measures are useful in clinical practice for individual patient management in musculoskeletal pain rehabilitation Our practice will be better if we evaluate our programmes’ effectiveness We have a shared vision and goal to establish an Australian and New Zealand National Pain Outcome Initiative, initially for chronic pain programmes, and supported by the Faculty of Pain Medicine

Acknowledgements: A. Prof George Mendelson Prof. Stephen Gibson Dr Geoff Booth Dr Chris Hayes Ms Janet Firth Thank You