Predictors of Multidisciplinary Pain Treatment Failure.

[101N]

Predictors of Pain Rehabilitation Treatment Failure

1. Longer duration of pain
2. Chronic opioid use
3. Personality disorder (MMPI)
4. Older age
5. Non-working status
6. Extreme disability (PCS/VAS/NRS)
7. Receiving disability benefits
8. Depression (BDI, PHQ-4)
9. Negative expectations for treatment (LOT-R/PCS/MPQ-Affective)
10. Pain Self-Efficacy (PSEQ)

1. Patients with chronic disabling occupational musculoskeletal disorder failing to complete functional restoration: analysis of treatment-resistant personality characteristics. Howard KJ, Mayer TG, Theodore BR, Gatchel RJ. Arch Phys Med Rehabil. 2009 May;90(5):778-85. doi: 10.1016/j.apmr.2008.11.009.
   
2. Prediction of failure to retain work 1 year after interdisciplinary functional restoration in occupational injuries. Brede E, Mayer TG, Gatchel RJ. Arch Phys Med Rehabil. 2012 Feb;93(2):268-74. doi: 10.1016/j.apmr.2011.08.029.
   
3. Psychological predictors of recovery from low back pain: a prospective study. George SZ, Beneciuk JM. BMC Musculoskelet Disord. 2015 Mar 7;16:49. doi: 10.1186/s12891-015-0509-2.
   
4. Expectations predict chronic pain treatment outcomes. Cormier S, Lavigne GL, Choinière M, Rainville P.
5. Treatment outcome in individuals with chronic pain: is the Pain Stages of Change Questionnaire (PSOCQ) a useful tool?
   
   Strong J, Westbury K, Smith G, McKenzie I, Ryan W.
   
   Pain. 2002 May;97(1-2):65-73.
   
   

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[PainDrain]

You basically just describe 90% of my patients.

 

[epidural man]

The thing I don't like about this list - is that a good functional restoration pain program - would address many of these issues ...especially if the pain psychologists are using Acceptance-Commitment Therapy (ACT).

I suspect that has to do with how the FRPP is structured and delivered, and contact hours per week, etc.

In our FRPP, we won't take anybody already on the track to receive forever money (medical disability), or with axis II diagnosis.

 

[epidural man]

In fact, the people with depression and negative expectations need to have an intense program like a FRPP so they can change the way they think. No PCM or pill pushing, 15 min a visit - pain physician will ever effect those changes.

 

[101N]

I'm not sure I agree. If we know those characteristics result in a high rate of attrition, and
the intervention itself - multidisciplinary rehab - has such a poor success rate - wouldn't
a personalized plan exclude a program that is destine to fail?

 

[Ducttape]

are there programs in which these patients would have a reasonably higher rate of success?

 

[drusso]

Predictors of Pain Rehabilitation Treatment Failure

1. Longer duration of pain
2. Chronic opioid use
3. Personality disorder (MMPI)
4. Older age
5. Non-working status
6. Extreme disability (PCS/VAS/NRS)
7. Receiving disability benefits
8. Depression (BDI, PHQ-4)
9. Negative expectations for treatment (LOT-R)

1. Patients with chronic disabling occupational musculoskeletal disorder failing to complete functional restoration: analysis of treatment-resistant personality characteristics. Howard KJ, Mayer TG, Theodore BR, Gatchel RJ. Arch Phys Med Rehabil. 2009 May;90(5):778-85. doi: 10.1016/j.apmr.2008.11.009.
   
2. Prediction of failure to retain work 1 year after interdisciplinary functional restoration in occupational injuries. Brede E, Mayer TG, Gatchel RJ. Arch Phys Med Rehabil. 2012 Feb;93(2):268-74. doi: 10.1016/j.apmr.2011.08.029.
   
3. Psychological predictors of recovery from low back pain: a prospective study. George SZ, Beneciuk JM. BMC Musculoskelet Disord. 2015 Mar 7;16:49. doi: 10.1186/s12891-015-0509-2.
   
4. Expectations predict chronic pain treatment outcomes. Cormier S, Lavigne GL, Choinière M, Rainville P.

https://morecrows.wordpress.com/2016/05/10/unnecessariat/

 

[kstarm]

Predictors of Pain Rehabilitation Treatment Failure

1. Longer duration of pain
2. Chronic opioid use
3. Personality disorder (MMPI)
4. Older age
5. Non-working status
6. Extreme disability (PCS/VAS/NRS)
7. Receiving disability benefits
8. Depression (BDI, PHQ-4)
9. Negative expectations for treatment (LOT-R)

1. Patients with chronic disabling occupational musculoskeletal disorder failing to complete functional restoration: analysis of treatment-resistant personality characteristics. Howard KJ, Mayer TG, Theodore BR, Gatchel RJ. Arch Phys Med Rehabil. 2009 May;90(5):778-85. doi: 10.1016/j.apmr.2008.11.009.
   
2. Prediction of failure to retain work 1 year after interdisciplinary functional restoration in occupational injuries. Brede E, Mayer TG, Gatchel RJ. Arch Phys Med Rehabil. 2012 Feb;93(2):268-74. doi: 10.1016/j.apmr.2011.08.029.
   
3. Psychological predictors of recovery from low back pain: a prospective study. George SZ, Beneciuk JM. BMC Musculoskelet Disord. 2015 Mar 7;16:49. doi: 10.1186/s12891-015-0509-2.
   
4. Expectations predict chronic pain treatment outcomes. Cormier S, Lavigne GL, Choinière M, Rainville P.

What do you consider treatment failure?

 

[101N]

Maybe we need to define 'success' along this continuum

Disruptive Non-Working------------------------Neutral Non-Working ---------------------------------Fully Functional In All life roles.

are there programs in which these patients would have a reasonably higher rate of success?

http://www.cochrane.org/CD008704/DE...-other-psychological-therapies-for-depression

 

[epidural man]

I'm not sure I agree. If we know those characteristics result in a high rate of attrition, and
the intervention itself - multidisciplinary rehab - has such a poor success rate - wouldn't
a personalized plan exclude a program that is destine to fail?

101N,

Well I don't know if I agree with myself either - I just know that FRPP has the BEST chance of helping these people. What do you suggest otherwise?

Can people change? I believe yes.
How do we do it? I believe a FRPP is the best thing out there to help. I haven't seen evidence to the contrary. Certainly ESI's and RFA's aren't the answer.

People that benefit from an ESI don't need a FRPP. People that need a FRPP don't benefit from an ESI.

I get that a FRPP is very expensive - and we need to find the most exact predictors for success and let those people benefit from the limited resources. But I'm just arguing that even though there are some characteristics that make failure more likely, I still think those are the ones that NEED a FRPP the most.

 

[101N]

I guess my biggest concern - the heart of the issue for me- is: Is work-disabling chronic non-cancer pain in working-aged
adults a medical issue?[1-3] Virtually all of the severely afflicted have overwhelming combinations of psychosocial, interpersonal, financial, psychiatric, and addiction comorbidities. While these are certainly deserving of treatment, I'm not sure that it's within the
traditional medical model. We haven't done very well with it thus far.

If we take the IOM's guesstimate - 100M - at face value we would bankrupt the country by medicalizing all of this suffering.
There is a lot of money to be had in treating the many who fall into the "described in terms of such damage" by way of the
traditional medical model.[4]

This isn't meant to be an attack on you. I enjoy your posts, you seem capable of self-criticism🙂

1. http://www.pnas.org/content/112/49/15078.abstract
2. http://www.ncbi.nlm.nih.gov/pubmed/26893293
3. http://www.ncbi.nlm.nih.gov/pubmed/17881753
4. http://www.businessinsider.com/why-the-opioid-epidemic-is-so-bad-in-west-virginia-2016-4

 

[nolapsych]

How do people cope with chronic pain in countries without IPM and COT and even FRPP? Just fine. They keep moving. Medicalizing has a lot of side effects...

 

[101N]

http://www.npr.org/2016/07/04/484647073/why-back-pain-is-nearly-non-existent-in-some-populations

That & the fact that they don't catastrophize.

 

[drusso]

http://www.npr.org/2016/07/04/484647073/why-back-pain-is-nearly-non-existent-in-some-populations

That & the fact that they don't catastrophize.

Ida Rolf made the same observation more than 80 years ago.

 

[ampaphb]

I am unclear why this discussion always devolves to a zero sum game (each participant's gain (or loss) of utility is exactly balanced by the losses (or gains) of the utility of the other participant(s).)

Why is it that these folks are either candidates for FRPP or interventions? Clearly, some folks with peripheral pain generators devolve to CS. Depression makes their pain worse. Why isn't a multi-modal approach, incorporating all that we have to offer, the best of all possible worlds?

 

[drusso]

I am unclear why this discussion always devolves to a zero sum game (each participant's gain (or loss) of utility is exactly balanced by the losses (or gains) of the utility of the other participant(s).)

Why is it that these folks are either candidates for FRPP OR interventions? Clearly, some folks with peripheral pain generators devolve to CS. Depression makes their pain worse. Why isn't a multi-modal approach, incorporating all that we have to offer the best of all possible worlds?

Because, at its core, no one believes that this is really a scientific issue. Increasingly, the treatment of chronic pain is a political decision or personal choice made in the context of competing commitments and limited resources. One strategy is to "de-medicalize" the experience of pain so that its not a medical problem at all---merely a quality of life issue---thus more appropriate for other venues of care: Yoga, behavioral health, chiropractic, etc. Every dollar spent on health care is a dollar of income to someone else. In one version of the future, treating chronic pain would fall on the continuum of urgency somewhere between couples' therapy and breast augmentation.

 

[Ducttape]

is pain a definable consistently reproducible medical condition that has a definitive cause, effect, with specific pathologic changes that can be confirmed on imaging/testing?

or is it a symptom? something so variable that mood, time of day, time of season, weather can all affect the experience of pain?

 

[101N]

Ah, this is a very good question. If you take pain catastrophizing as a proxy for CNP, is it a 'trait' or a 'state'.
For example, take a person with anxiety disorder who develops an acute episode of pain. Might they not
catastrophize 'in the moment'? I think we've all seen this, fleeting catastrophizing with an acute injury
like an HNP, or sprain/strain/trauma.

But, nevertheless, most of the evidence - and there is a lot - suggests that negative affect is a stable 'trait',
developing early in life. Also, about 60% environmental (nurture) 40% genetic (nature). Not clear if it's mutable.

 

[jonnylingo]

How do people cope with chronic pain in countries without IPM and COT and even FRPP? Just fine. They keep moving. Medicalizing has a lot of side effects...

Like this:

Meanwhile in the US:

 

[101N]

Pain. 2016 May 25. [Epub ahead of print]
Cognitive behavioral therapy for chronic pain is effective, but for whom?
Broderick JE1, Keefe FJ, Schneider S, Junghaenel DU, Bruckenthal P, Schwartz JE, Kaell AT, Caldwell DS, McKee D, Gould E.
Author information

Abstract
Moderator analyses are reported for posttreatment outcomes in a large, randomized, controlled effectiveness trial for chronic pain for hip and knee osteoarthritis (N = 256). Pain Coping Skills Training, a form of cognitive behavioral therapy, was compared to usual care. Treatment was delivered by nurse practitioners in patients' community doctors' offices. Consistent with meta-analyses of pain cognitive behavioral therapy efficacy, treatment effects in this trial were significant for several primary and secondary outcomes, but tended to be small. This study was designed to examine differential response to treatment for patient subgroups to guide clinical decision-making for treatment. Based on existing literature, demographic (age, sex, race/ethnicity, and education) and clinical variables (disease severity, body mass index, patient treatment expectations, depression, and patient pain coping style) were specified a priori as potential moderators. Trial outcome variables (N = 15) included pain, fatigue, self-efficacy, quality of life, catastrophizing, and use of pain medication. Results yielded 5 significant moderators for outcomes at posttreatment😛ain coping style, patient expectation for treatment response, radiographically assessed disease severity, age, and education. Thus, sex, race/ethnicity, body mass index, and depression at baseline were not associated with level of treatment response. In contrast, patients with interpersonal problems associated with pain coping did not benefit much from the treatment. Although most patients projected positive expectations for the treatment prior to randomization, only those with moderate to high expectations benefited. Patients with moderate to high osteoarthritis disease severity showed stronger treatment effects. Finally, the oldest and most educated patients showed strong treatment effects, while younger and less educated did not.

 

[kstarm]

CBT remains a predominant treatment style for most psychologists. I see many patients that had "pain psychology" often multiple visits over a number of months and keep wondering how it suppose to help, invariably the provider is using CBT focused or CBT only model. The best psychologists that I have worked with use a variety of treatment approaches to help the patient move forward.

 

[drusso]

Our Center's LCSW uses a shame resiliency model in working with pre-contemplative chronic pain patients. The amount of low self-esteem, shame, and demoralization is unbelievable. Most feel shamed by medical providers, "victimized" by the system, etc. It's easier for the low insight/deactivated patient to connect with their shame than "their stinking thinking," or their "lizard brain," or the evolutionary basis of their disordered fight-or-flight system.

Psychol Health. 2015;30(4):495-501. doi: 10.1080/08870446.2014.991735. Epub 2015 Jan 2.
Self-conscious emotions in patients suffering from chronic musculoskeletal pain: a brief report.
Turner-Cobb JM1, Michalaki M, Osborn M.
Author information

Abstract
OBJECTIVE:
The role of self-conscious emotions (SCEs) including shame, guilt, humiliation and embarrassment are of increasing interest within health. Yet, little is known about SCEs in the experience of chronic pain. This study explored prevalence and experience of SCEs in chronic pain patients compared to controls and assessed the relationship between SCEs and disability in pain patients.

DESIGN AND MEASURES:
Questionnaire assessment comparing musculoskeletal pain patients (n=64) and pain-free control participants (n=63). Pain was assessed using the McGill Pain Questionnaire; disability, using the Roland-Morris Disability Questionnaire; and six SCEs derived from three measures (i) Test of Self-Conscious Affect-3 yielding subscales of shame, guilt, externalisation and detachment (ii) The Brief Fear of Negative Evaluation Scale and (iii) The Pain Self-Perception Scale assessing mental defeat.

RESULTS:
Significantly greater levels of shame, guilt, fear of negative evaluation and mental defeat were observed in chronic pain patients compared to controls. In the pain group, SCE variables significantly predicted affective pain intensity; only mental defeat was significantly related to disability.

CONCLUSION:
Findings highlight the prevalence of negative SCEs and their importance in assessment and management of chronic pain. The role of mood in this relationship is yet to be explored.

KEYWORDS:
chronic pain; guilt; self-conscious emotions; shame

 

[SeniorWrangler]

CBT remains a predominant treatment style for most psychologists. I see many patients that had "pain psychology" often multiple visits over a number of months and keep wondering how it suppose to help, invariably the provider is using CBT focused or CBT only model. The best psychologists that I have worked with use a variety of treatment approaches to help the patient move forward.

That's unfortunate, a lot of patients aren't able to benefit from CBT. I think Motivational Interviewing (MI) and Acceptance & Commitment Therapy (ACT) have a lot to offer as well.

 

[101N]

The behavioral options are operant conditioning, CBT, ACT, and MBSR. MI is pre-treatment.

However, it's not clear how well any of these work, particularly for the biggest risk factors.