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Interdisciplinary rehabilitation in patients with chronic pain: prognostic factors and effectiveness
Karolinska Institutet.ORCID iD: 0000-0002-8307-259x
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Interdisciplinary multimodal pain rehabilitation (IMPR) is currently considered best practice for combatting chronic pain. However, it is believed that health-related outcomes could be improved with more adequately tailored treatment programs, but consensus of what grounds these adaptations should be based on is yet to be reached. Well-powered evaluations of naturalistic, real-world practices provide an evidence base for the evaluation of important characteristics that may facilitate the informed development of IMPR. The aim of the present work was to meta-synthesize existing evidence and add new data to the body of published evidence on prognostic factors for a positive outcome in patients receiving rehabilitation for chronic pain. An additional aim was to evaluate the effectiveness of different IMPR program durations on health-related quality of life in this major patient group.

Methods: Published international evidence of prognostic factors for physical functioning after IMPR was evaluated through a systematic review and meta-analyses (Study I), followed by the investigation of the inter-rater reliability of the Quality in Prognostic Studies tool (QUIPS), used in the Risk of Bias assessment (Study II). Prognostic factors (Study III) and effectiveness (Study IV) of Swedish pain specialist IMPR on physical and mental functioning and related measures of disease impact were investigated using large-scale nationwide data obtained from the Swedish Quality Registry for Pain Rehabilitation.

Results: Meta analyses showed, with moderate to low levels of evidence, that better physical functioning at follow-up was predicted by high levels of self-reported functioning, low levels of emotional distress and cognitive-behavioral risk factors, and high levels of cognitive- behavioral protective factors. Pain-related factors (intensity and chronicity) were not associated. Weak to moderate inter-rater agreement emerged for QUIPS, and suggestions for improving the inter-rater agreement and functionality were presented. Swedish registry data showed the most important prognostic factors were retaining a connection with work, having high optimistic treatment expectations, sense of control, and less interference from pain. Pain itself was of secondary significance. Also for improvement of physical functioning, better initial mental wellbeing was of importance, while for mental functioning the opposite emerged. Results on within-group effectiveness showed improvements on all outcomes, while no between-group comparison emerged on short (4-9 wks) vs. moderate (10 wks) vs. long (11-18 wks) IMPR program duration.

In summary, evidence for prognostic factors was identified, providing suggestions for the targeting of modifiable factors in clinics and in future clinical trials. Clearly, the quality assessment of published results needs systematic consensus work between assessors. Work connection, treatment expectations, levels of physical and emotional health, and coping strategies played an important prognostic role but were not consistent for physical and emotional functioning, suggesting a complex prognostic picture for the overall understanding of improvement. Finally, IMPR is effective across a biopsychosocial specter, but treatment duration seems not to play an important role.

Abstract [sv]

Multimodal smärtrehabilitering (MMR) anses vara bästa praxis för behandling av kronisk smärta. De påvisade effekterna på olika (biopsykosociala) hälsorelaterade resultat är dock suboptimala. Det antas att rehabiliteringsresultat kan förbättras med mer adekvat anpassade behandlingsprogram, men fortfarande saknas konsensus om vilka faktorer dessa anpassningar bör grundas på. Effektiva utvärderingar av reell klinisk verksamhet kan ge en grund för utvärdering av viktiga egenskaper som kan bidra till utveckling av MMR. Syftet med detta avhandlingsarbete var därför att meta-syntetisera befintlig evidens, och att komplettera med nya primärdata till kunskapsunderlaget om prognostiska faktorer för ett positivt behandlingsutfall hos patienter med kronisk smärta som genomgått rehabilitering. Syftet var vidare att utvärdera effektiviteten av MMR som genomförs med olika behandlingslängd, med avseende på hälsorelaterad livskvalitet i denna omfattande patientgrupp med kronisk smärta.

Publicerade internationella resultat vad gäller prognostiska faktorer för fysisk funktion efter MMR utvärderades genom en systematisk litteraturgranskning och meta-analyser (Studie I). Denna studie följdes av en undersökning av inter-bedömarreliabilitet (tillförlitlighet) för ett nytt kvalitetsbedömnings-instrument avsett för prognostiska studier- ”QUIPS”, ett instrument som används vid bedömning av Risk för Bias (Studie II). Prognostiska faktorer (Studie III) och effektivitet (Studie IV) vid svensk MMR (specialistnivå) med avseende på fysisk och psykisk funktion, samt konsekvenser av smärta, utvärderades med hjälp av omfattande registerdata från Nationella Registret över Smärtrehabilitering, NRS.

Metaanalyser visade, med måttlig till låg evidens, att bättre fysisk funktion vid uppföljning förutspåddes av högre nivåer av självrapporterad funktion, låga nivåer av mental ohälsa, och kognitiva beteende-riskfaktorer samt höga nivåer av skyddande kognitiva beteende-faktorer. Smärtrelaterade faktorer (intensitet och duration) var inte associerade. Överenstämmelse vid Risk för Bias-bedömningar med QUIPS var svag till måttlig, och förslag till att förbättra överrensstämmelse och funktionaliteten presenterades. Svenska registerdata visade att de viktigaste prognostiska faktorerna generellt var att vara i arbete, ha optimistiska behandlingsförväntningar, känsla av kontroll och mindre funktionsstörningar från smärta. Smärta i sig var av sekundär betydelse. För fysisk funktion specifikt var ett gott mentalt välbefinnande av betydelse medan för mental funktion var ett lägre (dåligt) utgångsvärde av betydelse. MMR som helhet var effektiv vid behandlingsuppföljning för alla utfallsvariabler. Ingen skillnad framkom dock vid jämförelse mellan grupper med olika behandlingstid.

Sammanfattningsvis identifierades evidens för att det finns viktiga prognostiska markörer, vilket pekar på modifierbara faktorer användbara i såväl klinisk verksamhet som för framtida randomiserade kliniska studier. Det är tydligt att kvalitetsbedömning av publicerade resultat kräver systematiskt konsensusarbete mellan bedömare. Att vara i arbete, ha positiva behandlingsförväntningar, samt lägre ingångsvärden på de respektive utfallen, fysisk och emotionell hälsa, samt copingstrategier, spelade en viktig roll för det framtidabehandlingsresultatet. Resultaten var dock inte konsekventa för fysisk och emotionell funktion, vilket antyder en komplex prognostisk bild för förståelsen av klinisk förbättring som helhet. MMR är en effektiv behandlingsmetod från ett biopsykosocialt perspektiv, men dess behandlingslängd verkar inte ha någon betydande roll för det framtida behandlingsresultatet.

Place, publisher, year, edition, pages
Stockholm: Karolinska Institutet , 2019.
National Category
Clinical Medicine
Identifiers
URN: urn:nbn:se:du-31740ISBN: 978-91-7831-510-9 (print)OAI: oai:DiVA.org:du-31740DiVA, id: diva2:1388961
Available from: 2020-01-28 Created: 2020-01-28 Last updated: 2020-01-28Bibliographically approved
List of papers
1. Prognostic factors for physical functioning after multidisciplinary rehabilitation in patients with chronic musculoskeletal pain: a systematic review and meta-analysis
Open this publication in new window or tab >>Prognostic factors for physical functioning after multidisciplinary rehabilitation in patients with chronic musculoskeletal pain: a systematic review and meta-analysis
Show others...
2019 (English)In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 35, no 2, p. 148-173Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: This systematic review aimed to identify and evaluate prognostic factors for long-term (≥6▒mo) physical functioning in patients with chronic musculoskeletal pain following multidisciplinary rehabilitation (MDR).

METHODS: Electronic searches conducted in MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science, and Cochrane CENTRAL revealed 25 original research reports, published 1983-2016, (n=9436). Potential prognostic factors relating to initial pain and physical and psychological functioning were synthesized qualitatively and quantitatively in random effects meta-analyses. The level of evidence (LoE) was evaluated with GRADE.

RESULTS: Pain related factors (intensity and chronicity) were not associated with function/disability at long-term follow up, OR=0.84, 95% CI: 0.65-1.07 and OR=0.97, 95% CI: 0.93-1.00 respectively (moderate LoE). A better function at follow up was predicted by Physical factors; higher levels of initial self-reported functioning, OR=1.07, 95% CI: 1.02-1.13 (low LoE), and Psychological factors; low initial levels of emotional distress, OR=0.77, 95% CI: 0.65-0.92, low levels of cognitive behavioural risk factors, OR 0.85, 95% CI: 0.77-0.93 and high levels of protective cognitive behavioural factors, OR=1.49; 95% CI: 1.17-1.90 (moderate LoE).

DISCUSSION: While pain intensity and long-term chronicity did not predict physical functioning in chronic pain patients after MDR, poor pre-treatment physical and psychological functioning influenced the prognosis negatively. Thus, treatment should further target and optimize these modifiable factors and an increased focus on positive, psychological protective factors may perhaps provide an opening for yet untapped clinical gains.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/.

Keywords
chronic musculoskeletal pain, GRADE, interdisciplinary rehabilitation, meta-analysis, prognostic factors, treatment outcome
National Category
Clinical Medicine Health Sciences
Research subject
Health and Welfare
Identifiers
urn:nbn:se:du-28867 (URN)10.1097/AJP.0000000000000669 (DOI)000458401700006 ()30371517 (PubMedID)2-s2.0-85055665160 (Scopus ID)
Available from: 2018-11-05 Created: 2018-11-05 Last updated: 2020-01-28Bibliographically approved
2. Elaborating on the assessment of the risk of bias in prognostic studies in pain rehabilitation using QUIPS-aspects of interrater agreement
Open this publication in new window or tab >>Elaborating on the assessment of the risk of bias in prognostic studies in pain rehabilitation using QUIPS-aspects of interrater agreement
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2019 (English)In: Diagnostic and Prognostic Research, ISSN 2397-7523, Vol. 3, article id 5Article in journal (Refereed) Published
Abstract [en]

Background: Many studies have been performed to identify important prognostic factors for outcomes after rehabilitation of patients with chronic pain, and there is a need to synthesize them through systematic review. In this process, it is important to assess the study quality and risk of bias. The "Quality In Prognosis Studies" (QUIPS) tool has been developed for this purpose and consists of several prompting items categorized into six domains, and each domain is judged on a three-grade scale (low, moderate or high risk of bias). The aim of the present study was to determine the interrater agreement of the risk of bias assessment in prognostic studies of patients with chronic pain using QUIPS and to elaborate on the use of this instrument.

Methods: We performed a systematic review and a meta-analysis of prognostic factors for long-term outcomes after multidisciplinary rehabilitation in patients with chronic pain. Two researchers rated the risk of bias in 43 published papers in two rounds (15 and 28 papers, respectively). The interrater agreement and Cohen's quadratic weighted kappa coefficient (κ) and 95% confidence interval (95%CI) were calculated in all domains and separately for the first and second rounds.

Results: The raters agreed in 61% of the domains (157 out of 258), with similar interrater agreement in the first (59%, 53/90) and second rounds (62%, 104/168). The overall weighted kappa coefficient (kappa for all domains and all papers) was weak: κ = 0.475 (95%CI = 0.358-0.601). A "minimal agreement" between the raters was found in the first round, κ = 0.323 (95%CI = 0.129-0.517), but increased to "weak agreement" in the second round, κ = 0.536 (95%CI = 0.390-0.682).

Conclusion: Despite a relatively low interrater agreement, QUIPS proved to be a useful tool in assessing the risk of bias when performing a meta-analysis of prognostic studies in pain rehabilitation, since it demands of raters to discuss and investigate important aspects of study quality. Some items were particularly hard to differentiate in-between, and a learning phase was required to increase the interrater agreement. This paper highlights several aspects of the tool that should be kept in mind when rating the risk of bias in prognostic studies, and provides some suggestions on common pitfalls to avoid during this process.

Trial registration: PROSPERO CRD42016025339; registered 05 February 2016.

Keywords
Chronic pain, Inter-rater agreement, Meta-analysis, Prognosis, Rehabilitation, Review, Risk of bias
National Category
Other Medical Sciences not elsewhere specified
Research subject
Health and Welfare
Identifiers
urn:nbn:se:du-30087 (URN)10.1186/s41512-019-0050-0 (DOI)31093575 (PubMedID)
Available from: 2019-05-22 Created: 2019-05-22 Last updated: 2020-01-28
3. Predictors of multidisciplinary rehabilitation outcomes in patients with chronic musculoskeletal pain: protocol for a systematic review and meta-analysis
Open this publication in new window or tab >>Predictors of multidisciplinary rehabilitation outcomes in patients with chronic musculoskeletal pain: protocol for a systematic review and meta-analysis
Show others...
2017 (English)In: Systematic Reviews, E-ISSN 2046-4053, ISSN 2046-4053, Vol. 6, no 1, article id 199Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Chronic musculoskeletal pain is a major public health problem. Early prediction for optimal treatment results has received growing attention, but there is presently a lack of evidence regarding what information such proactive management should be based on. This study protocol, therefore, presents our planned systematic review and meta-analysis on important predictive factors for health and work-related outcomes following multidisciplinary rehabilitation (MDR) in patients with chronic musculoskeletal pain.

METHODS: We aim to perform a synthesis of the available evidence together with a meta-analysis of published peer-reviewed original research that includes predictive factors preceding MDR. Included are prospective studies of adults with benign, chronic (> 3 months) musculoskeletal pain diagnoses who have taken part in MDR. In the studies, associations between personal and rehabilitation-based factors and the outcomes of interest are reported. Outcome domains are pain, physical functioning including health-related quality of life, and work ability with follow-ups of 6 months or more. We will use a broad, explorative approach to any presented predictive factors (demographic, symptoms-related, physical, psychosocial, work-related, and MDR-related) and these will be analyzed through (a) narrative synthesis for each outcome domain and (b) if sufficient studies are available, a quantitative synthesis in which variance-weighted pooled proportions will be computed using a random effects model for each outcome domain. The strength of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation.

DISCUSSION: The strength of this systematic review is that it aims for a meta-analysis of prospective cohort or randomized controlled studies by performing an extensive search of multiple databases, using an explorative study approach to predictive factors, rather than building on single predictor impact on the outcome or on predefined hypotheses. In this way, an overview of factors central to MDR outcome can be made and will help strengthen the evidence base and inform a wide readership including health care practitioners and policymakers.

SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016025339.

Keywords
Chronic musculoskeletal pain, Literature review, Meta-analysis, Multidisciplinary rehabilitation, Prognostic factors, Treatment outcome
National Category
Clinical Medicine
Research subject
Health and Welfare
Identifiers
urn:nbn:se:du-26433 (URN)10.1186/s13643-017-0598-0 (DOI)000453154500199 ()29020989 (PubMedID)2-s2.0-85030844165 (Scopus ID)
Available from: 2017-10-18 Created: 2017-10-18 Last updated: 2020-03-03Bibliographically approved

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