1. Evaluating the Immediate Effectiveness of an Outpatient Pain Management Programme on Pain Related Interference: Outcomes from a Discrete Island-Based Chronic Pain Population.
A. Agostinis, G. Purcell-Jones, C. Taylor, R. O’Doherty, J. Morris
Pain Management Centre, Overdale Hospital, States of Jersey Health and Social Services Department, St Helier, Jersey, United Kingdom Channel Islands
Aims
This study aimed to explore predictors of change in pain-related interference, immediately after a multidisciplinary Pain Management Programme (PMP) for chronic (persistent) pain patients.
Relevance
Jersey is part of the British Isles. It has a UK-independent Healthcare System offering a co-ordinated, complexity-stratified pathway leading to unidisciplinary or/and intensive multidisciplinary (MDT) chronic-pain management packages to patients. This funnel-like pathway allows to respond to demand effectively and to maximise the available resources. A PMP, is offered only to the more complex and psychosocially disabled clients, either as an individual package and/or in conjunction with additional individual or co-ordinated MDT work, following medical clearance and an introductory Pain Education day.
The PMP resource is in line with the minimum requirements of the British Pain Society (2007), but encompasses a strong component of the ‘Explain Pain’ approach (Butler and Moseley), Cognitive Behavioural Therapy (CBT), as well as a small component of mindfulness and Acceptance and Commitment Therapy (ACT).
Participants
Consecutive patients (N=72) who attended a PMP between January 2009 and November % were male, 59% were female. Mean age was 49. Pain sites included lower, upper back, legs, shoulders, arms and widespread pain.
Method
All participants completed pre and post PMP psychometric measures. Differences in scores between baseline and end of the PMP were computed utilising SPSS for all outcome measures. These included the Chronic Pain Acceptance Questionnaire (CPAQ), the Beck Depression Inventory - Fast Screen (BDI-FS), The Tampa Scale for Kinesiophobia (TSK), the Pain Self Efficacy Questionnaire (PSEQ), the Pain Catastrophising Scale (PCS) and the Brief Pain Inventory (BPI).
Analysis
Differences in patients’ matched pre and post intervention scores for each variable were analysed using Paired Samples T-tests. Direct multiple regression analysis was performed quantify the contribution made from each area of psychosocial disability and/or in/flexibility, to changes in pain-related interference, thus self-reported functioning.
Results
There were statistically significant improvements in pain interference, two specific chronic pain acceptance domains including ‘activity engagement’, and ‘pain willingness’, depression, kinesiophobia and catastrophising
Conclusions
Statistically significant improvement is observed on all measures in this study . For this population, the immediate benefits of a PMP appear to be mediated primarily by improvement in mood and self-efficacy. However, these are inconsistent with what would have been expected. In fact, it is known that chronic-pain acceptance is a mediator of enhanced functioning “…above and beyond the influence of depression, pain intensity, and coping” (McCracken, Vowels and Eccleston, 2004). In addition, there are suggestions that traditional pain management ‘ingredients’ are less predictive of functioning than more recent constructs such as psychological flexibility - which includes elements of acceptance and willingness (e.g. Vowels & McCracken, 2010), supporting the above expectation further.
It is possible that the current findings are related on the heavier reliance on knowledge/understanding is more effective in addressing pain-related interference through changes in mood and self-efficacy than it is in affecting the more recently researched constructs, such as chronic pain acceptance, but it is questionable whether these will be maintained.
As the current PMP includes only a modest component of mindfulness-based intervention, it would be interesting to increase the ‘dosage’ of this within the package. An alternative explanation is that the levels of psychological flexibility are already affected (increased) by the time patients within the specified service pathway, are selected and attend a PMP, or that the current ‘dosage’ of intensive and co-ordinated PMP does not suffice to produce the required shifts in psychological flexibility and this will be ascertained more reliably once enough follow up data is available. N
Mean Diff. t p
BPII 71
9.6
6.46
<.001
P-SEQ 70
-4.9
-4.20
CPAQ-AE 68
-5.8
-4.15
CPAQ-PW
-4.6
-3.69
BDI-FS 65
5.4
4.10
TSK
4.2
5.71
PCS
6.8
6.85
The predictors explained a significant proportion of variance in the change of pain interference scores, R2 = .35, F=4.83, p=.001, for the prediction of change in interference. Changes in depression and self-efficacy, respectively, contributed to most of the variance within the model.
Model
Standard. Coefficients t p
Collinearity Statistics
VIF
Tolerance
P-SEQ
-.238
-2.049
.045*
1.115
.897
CPAQ-pw
.057
.507
.614
1.041
.961
CPAQ-ae
-.009
-.073
.942
1.252
.799
PCS
.203
1.621
.111
1.299
.770
BDI-FS
.439
3.316
.002*
1.453
.688
TSK
.002
.012
.991
1.505
.664
References
Acknowledgements With thanks to all participants who consented to their clinical data to being used for research purposes.
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