1. Pain Management Programs
Evidence for Efficacy
Tom Perkins

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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)

11. 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)

12. 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)

13. 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

14. 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)

15. 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

16. 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)

17. 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

18. 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%

19. 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

20. 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)

21. 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