Evidence-based clinical practice guidelines for interdisciplinary rehabilitation of chronic nonmalignant pain syndrome patients.

This is an update to evidence-based practice guidelines for chronic nonmalignant pain syndrome patients first published in 1995 and revised in 1999. The current guidelines recommend interdisciplinary-focused rehabilitation, which is goal-directed and time-limited. Emphasis is placed on educating patients in active self-management techniques that stress maximizing function. Integrated treatment involving medical, psychological/behavioral, physical/occupational therapy, and disability/vocational interventions are recommended on an outpatient basis whenever clinically possible. Patient selection criteria are delineated. Updated references providing evidence-based support for the recommendations are provided, including the use of opioids and sedative-hypnotic medications, injection and block procedures, acupuncture, implantable spinal infusion and stimulation devices, and other invasive spinal surgery procedures such as intradiscal electrothermal therapy. Guideline integration and early detection and intervention with chronic pain syndrome patients are encouraged.

Empirically derived chronic pain patient subgroups: the utility of multidimensional clustering to identify differential treatment effects.

The current study used multidimensional clustering to delineate empirically subgroups of chronic pain patients and to compare their responses to interdisciplinary pain rehabilitation. A total of 180 chronic pain patients were used as subjects. They were administered the Sickness Impact Profile (SIP), Medical Examination and Diagnostic Information Coding System (MEDICS) and treatment outcome measures including subjective pain intensity, hours standing and walking, medication usage and work status. All subjects then participated in an outpatient interdisciplinary pain rehabilitation program, with 120 being randomly selected and 90 available for follow-up assessment. Multidimensional cluster analyses using SIP and MEDICS data identified 4 replicable subgroups: cluster A--highly dysfunctional with moderate levels of physical pathology; cluster B--moderately dysfunctional with moderate levels of physical pathology; cluster C--highly functional with low levels of physical pathology; and cluster D--highly dysfunctional with low levels of physical pathology. Cluster-A and -D patients showed significantly higher levels of depression, more medication usage, less activity and were less likely to be working at pretreatment. These 2 clusters also showed the largest improvement in subjective pain intensity, medication usage, activity level, and return to work post-treatment. Patients in cluster B exhibited the least amount of improvement across outcome measures and, unlike the other 3 clusters, failed to show any significant improvement in work status at post-treatment. Cluster differences were not primarily a function of age, sex, pain intensity, pain location, pain duration, or depression. It was concluded that useful subgroups of chronic pain patients could be reliably identified through multidimensional clustering.(ABSTRACT TRUNCATED AT 250 WORDS)

Predicting low back pain patients' response to lumbar sympathetic nerve blocks and interdisciplinary rehabilitation: the role of pretreatment overt pain behavior and cognitive coping strategies.

The current study examined the ability of overt pain behavior and cognitive coping strategies to predict low back pain patients' subsequent response to lumbar sympathetic nerve blocks and interdisciplinary pain rehabilitation. Seventeen chronic low back pain patients participated in the study. Each was assessed regarding pretreatment overt pain behavior, cognitive coping strategies and pretreatment outcome measures. They then received interdisciplinary pain rehabilitation including lumbar sympathetic blocks. Findings showed that patients exhibited significant improvement in posttreatment outcome measures and specific responses to nerve blocks. Regression analyses revealed that cognitive coping strategies failed to demonstrate any predictive utility across blocks or outcome measures. In contrast, overt pain behavior observed during the first block was highly predictive of acute and chronic subjective pain associated with initial and subsequent blocks, as well as posttreatment outcome measures for interdisciplinary pain rehabilitation. The more overt pain behavior observed during block 1, the more acute and chronic subjective pain observed across blocks and the poorer subsequent treatment outcome measures. This predictive capability was demonstrated over and above that of other pretreatment measures such as pain duration, number of surgeries, and receipt of economic compensation. Given the small sample size results were viewed with caution. It was concluded, however, that overt pain behavior might well be a significant predictor variable for specific and combined interdisciplinary pain rehabilitation techniques.

Relationship between psychopathology and graduated spinal block findings in chronic pain patients.

The current study was undertaken to investigate the relationship between response to a graduated spinal block and the presence of psychopathology. Subjects consisted of 25 chronic pain patients who had received a graduated spinal block as part of their evaluation. Each was categorized along two dimensions by independent raters based on blind review of hospital records. Dimensions were (1) response to graduated spinal block (appropriate or inappropriate) and (2) presence of clinically significant psychopathology (definitive, probable or none). Results showed that subjects were well distributed across the two dimensions. A 2 X 3 chi-square comparison failed to show a significant relationship between the two dimensions. However, females and subjects with spontaneous pain onset were found to exhibit significantly more inappropriate responses to spinal blockage. It was concluded that there was no consistent relationship between the presence of psychopathology and response to the graduated spinal block.