The Resurrection of Interdisciplinary Pain Rehabilitation: Outcomes Across a Veterans Affairs Collaborative.

OBJECTIVE: Despite empirical support for interdisciplinary pain rehabilitation programs improving functioning and quality of life, access to this treatment approach has decreased dramatically over the last 20 years within the United States but has grown significantly in the Department of Veterans Affairs (VA). Between 2009 and 2019, VA pain rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation Facilities increased 10-fold in the VA, expanding from two to 20. The aim of this collaborative observational evaluation was to examine patient outcomes across a subset of six programs at five sites. METHODS: Outcomes were assessed using agreed-upon measures of patient-reported pain intensity, pain interference across various domains, pain catastrophizing, and sleep. RESULTS: A total of 931 patients enrolled in the selected VA interdisciplinary pain programs, with 84.1% of participants completing the full course of treatment. Overall, all programs showed significant improvements from pretreatment to posttreatment in nearly all patient-reported outcomes. The effect sizes ranged from medium to large. Notably, the results demonstrate that positive outcomes were typical despite differences in structure and resources across programs. CONCLUSIONS: The adverse impacts of opioid use have highlighted the importance of chronic pain treatment approaches that emphasize team-based care focused on functional improvements. This study represents the first and largest analysis of outcomes across chronic pain rehabilitation programs and demonstrates the need for increased access to similar comprehensive approaches to pain management across the health care system. Further, it suggests that a variety of structures may be effective, encouraging flexibility in adopting this interdisciplinary approach.

Patient-centered outcome criteria for successful treatment of facial pain and fibromyalgia.

AIMS: To define treatment success from the facial pain and fibromyalgia pain patient perspective across four domains (pain, fatigue, emotional distress, interference with daily activities) through the use of the Patient-Centered Outcomes (PCO) Questionnaire. METHODS: Participants included 53 facial pain (46 women, seven men) and 52 fibromyalgia (49 women, three men) patients who completed the PCO Questionnaire. The PCO assesses four relevant domains of chronic pain: pain, fatigue, distress, and interference in daily activities. Participants rated their usual levels, expected levels, levels they considered successful improvements, and how important improvements were in each of the four domains following treatment. Repeated-measures analyses of variance were performed to determine whether differences existed across domains and across pain groups. RESULTS: Both groups of participants defined treatment success as a substantial decrease in their pain, fatigue, distress, and interference ratings (all approximately 60%). Fibromyalgia participants reported high levels of pain (mean = 7.08, SD = 2.04), fatigue (mean = 7.82, SD = 1.71), distress (mean = 6.35, SD = 2.46), and interference (mean = 7.35, SD = 2.21). Facial pain participants' ratings of these domains were significantly lower for pain (mean = 5.62, SD = 2.38), fatigue (mean = 5.28, SD = 2.64), distress (mean = 4.34, SD = 2.78), and interference (mean = 4.10, SD = 3.06). CONCLUSION: These results demonstrate the high expectations of individuals with facial pain and fibromyalgia regarding treatment of their symptoms. Health care providers should incorporate these expectations into their treatment plans and discuss realistic treatment goals with their pain patients.

Loss of resources as mediators between interpersonal trauma and traumatic and depressive symptoms among women with cancer.

We hypothesized that loss of interpersonal, financial and work resources would mediate the relationship between physical and sexual abuse, cancer-related Posttraumatic Stress Disorder (PTSD) symptoms, noncancer-related PTSD symptoms and depressive mood among women with cancer. Participants were 64 women with heterogeneous cancers (64.1% breast cancer) seeking outpatient treatment. Structured interviews were conducted to assess for pre-cancer interpersonal trauma, recent loss of interpersonal, financial and work resources, cancer-related PTSD symptoms, noncancer-related PTSD symptoms and depressive mood. Only interpersonal loss mediated the relationship between earlier interpersonal trauma and current PTSD symptoms and depressive mood. Implications of the findings are discussed.

Validity of the Clock Drawing Test in predicting reports of driving problems in the elderly.

BACKGROUND: This study examined the use of the Folstein Mini Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) in predicting retrospective reports of driving problems among the elderly. The utility of existing scoring systems for the CDT was also examined. METHODS: Archival chart records of 325 patients of a geriatric outpatient clinic were reviewed, of which 162 had CDT results (including original clock drawings). T-test, correlation, and regression procedures were used to analyze the data. RESULTS: Both CDT and MMSE scores were significantly worse among non-drivers than individuals who were currently or recently driving. Among current or recent drivers, scores on both instruments correlated significantly with the total number of reported accidents or near misses, although the magnitude of the respective correlations was small. Only MMSE scores, however, significantly predicted whether or not any accidents or near misses were reported at all. Neither MMSE nor CDT scores predicted unique variance in the regressions. CONCLUSIONS: The overall results suggest that both the MMSE and CDT have limited utility as potential indicators of driving problems in the elderly. The demonstrated predictive power for these instruments appears to be redundant, such that both appear to assess general cognitive function versus more specific abilities. Furthermore, the lack of robust prediction suggests that neither are sufficient to serve as stand-alone instruments on which to solely base decisions of driving capacity. Rather, individuals who evidence impairment should be provided a more thorough and comprehensive assessment than can be obtained through screening tools.

Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment.

OBJECTIVES: Although the efficacy of interdisciplinary treatment for chronic noncancer pain has been well-established in the literature, there is limited research examining interdisciplinary programs that require opioid cessation. As the long-term use of opioid analgesics remains controversial, further investigation is warranted. The aim of this study was to evaluate the associations between opioid cessation and subsequent multidomain treatment outcomes among veterans admitted to a pain rehabilitation program at a large Veterans Affairs tertiary care hospital in the southeastern United States. METHODS: A retrospective design examined the medical records of 705 consecutive admissions comparing those using opioids at admission with those who were not. Participants taking opioids agreed to taper off of these medications using a "pain cocktail" approach; otherwise patients received identical treatment. Outcome measures were administered at program admission and discharge. RESULTS: Repeated measures analyses were used to compare responses across time. Those who completed the program (n=600) demonstrated improvement in all outcome measures from admission to discharge, and the opioid group improved as much or more than the nonopioid group on all measures despite opioid cessation during treatment. DISCUSSION: Results indicated that both groups experienced significant improvement on outcome measures, and that opioid analgesic use at admission had no discernible impact on treatment outcome in this large sample of veterans with moderate to severe chronic pain syndrome. The clinical implications of these findings for long-term chronic pain treatment, in light of the risks associated with opioid analgesics, are discussed.

Investigating patient expectations and treatment outcome in a chronic low back pain population.

OBJECTIVE: This study aimed to measure the outcomes that patients consider clinically meaningful across four treatment domains - (1) pain, (2) fatigue, (3) emotional distress, and (4) level of interference - and determine if patients met their own success criteria. Additionally, the role of expectations in treatment outcome was examined. This study also aimed to determine how change in levels of pain, fatigue, disability, and level of interference varied according to the type of treatment delivered to participants. PATIENTS: Forty-seven chronic low back pain patients were recruited from university-affiliated pain clinics. DESIGN: The study design was longitudinal, consisting of two randomly assigned treatment conditions. The first treatment condition used opioid medication only and the second used both opioid medication and brief cognitive behavioral therapy. Pre- and post-treatment assessments were conducted, which occurred approximately 3 months after the initiation of treatment. OUTCOME MEASURES: A patient-centered outcomes questionnaire was completed by participants at both pre- and post-treatment assessment. RESULTS: Results suggest that patients did not meet their own success criteria in treatment across any of the four domains. There was a significant main effect of time for level of pain indicating that both treatment groups had a decrease in their level of pain at post-treatment, F(1, 45) = 11.98, P < 0.001. There was a significant main effect of time for level of interference domain indicating that both groups experienced a reduction in the level of pain-related interference with daily activities, F(1, 45) = 5.46, P < 0.05. There were no significant effects of time for emotional distress or fatigue or any significant group by time interactions. Contrary to our hypothesis, no significant correlations were found between pretreatment expectations and usual level ratings at post-treatment across the four domains. CONCLUSION: Patients sought larger reductions in pain, fatigue, level of distress, and level of interference than they attained at post-treatment. Enhancing opioid treatment with brief cognitive behavioral therapy did not yield additional improvements for the four domains assessed in patients with chronic low back pain.

Measurement of patient-centered outcomes in Parkinson's disease: what do patients really want from their treatment?

BACKGROUND: Parkinson's disease (PD) impacts several domains of functioning, some of which may be neglected when designing treatment or evaluating outcome using current clinical standards. We therefore argue that taking the patients' perspectives of their condition may allow for a more in-depth assessment of patient goals and subsequent tailoring of care. METHODS: One hundred and forty-eight patients with idiopathic PD completed a modified version of the Patient-Centered Outcomes Questionnaire (PCOQ-PD), to evaluate treatment success and expectations from the patient's perspective across 10 motor and non-motor functional domains. We also examined patient subgroups based on importance of improvement in various domains. RESULTS: Patients' ratings suggested there was substantial variation in functional interference that was generally unrelated to demographic variables. On average, across all domains, patients indicated a 50.32% reduction in symptoms would be successful (range = 40.63-58.23%), regardless of treatment experience. Change scores between patients' usual levels of symptom interference and their treatment success levels suggested a greater degree of change was desired in motor versus non-motor domains (p < 0.05). Finally, cluster analyses revealed two patient subgroups based on overall importance of improvement (High vs. Low Importance Endorsement). Notably, the two groups differed in self-reported usual symptom levels despite having similar clinical severity. CONCLUSIONS: We empirically examined treatment success from the PD patient's view as opposed to clinician judgment alone, thereby broadening the set of criteria by which to evaluate outcome. Findings from this exploratory study may guide future treatment emphases and guide patient-provider communication via clarification of patient-defined success.