Patient-focused outcomes of a multidiscilpinary pain centre : inpatient chronic pain management program

Chronic non-cancer pain and its associated impact on physical conditioning, psychological status and quality of life, social and family roles, and functional abilities are a major problem for people with pain and the communities in which they live. Since John J Bonica established the first influential multidisciplinary program to address chronic pain in 1960 at the University of Washington Pain Clinic there has been rapid and widespread development of pain management programs. In the current climate of cost containment and growing consumer demand for evidence based treatments, there is an increased need to provide evidence for the effectiveness of health services. The Faculty of Pain Medicine Australia and New Zealand College of Anaesthetists (FPMANCA) and the Australian Council of Health Care Standards (ACHS) have recommended that, for accreditation of Multidisciplinary Pain Centres (MPCs), an evaluation of outcomes including measures of the patient's pain and function needs to be made. This study evaluated the effectiveness of a MPC two week inpatient program for patients with chronic pain. It further examined whether treatment gains were maintained at three months following participation in the program. The hospital based pain management program based on cognitive-behavioural and graded activity principles had not previously implemented a systematic method of measuring patient outcomes. This study employed a repeated measures design comparing pre and post program and three-month follow-up scores on a combination of subjective and objective outcome measures.  One hundred and ten patients attending the MPC with chronic pain of non-cancer origin participated in the study conducted over a 14 month period between 24 April 2001 and 19 June 2002. Patients in this study were admitted to the MPC pain management program between 24 April 2001 and 25 February 2002. The remaining time in the study allowed for return of follow-up questionnaires from the later program participants. Subjective measures were administered on a patient's admission, at discharge, and at three-months post discharge. The measures were: the Short Form-36 Health Status Survey (SF- 36), the Pain Disability Index (PDI), the Pain Self Efficacy Questionnaire (PSEQ), the Tampa Scale for Kinesiophobia (TSK), and the McGill Pain Questionnaire (MPQ). Patients were asked to complete the Short Test of Functional Health Literacy in Adults (STOFHLA) at admission to determine if they would benefit from assistance with completing questionnaires and if they may need educational materials, other than written materials, to supplement the group verbal education program. In addition, patients were assessed on objective measures of physical functioning recommended by Harding et al. (1994), namely a five minute walk test and one minute stair climbing test, on admission and discharge. Qualitative comments on whether the program helped or not were obtained from patients at the three-month follow-up interval.               At discharge, responses to the questionnaires and performance on the objective measures of physical functioning indicated that patients had significantly improved on several constructs. Patients reported an improved perception of their physical functioning, perception of their level of functioning in everyday activities, and self-efficacy, and demonstrated improvements in observed physical functioning on the walk and stair climbing tests. Patients reported reduced bodily pain, fear of (re)injury due to movement and their evaluation of the pain experience as measured on the MPQ was also reduced.  At the three-month follow-up interval, patient response rates had reduced. Results indicated that there was a significant reduction in gains over the three month period following discharge from the MPC. Qualitative comments attested to both the positive aspects of the program and the difficulties in maintaining improvements when the patients return to their home environments.             Discussion in this thesis focuses on an exploration of the factors that may help explain the initial improvements in patient-focused measures over the course of the pain management program and the subsequent reduction in these gains at three-months post discharge. Limitations of this study include the lack of a control or comparison group and the lack of blinded therapists who are not the treating therapists. Nonetheless, it would be worthwhile advocating for resources for a study that examined whether adding a follow-up component for patients post-discharge would maintain gains made during the pain management program. Rigorous attention to obtaining follow-up data and a longer time frame for the study would improve the validity of such a study.

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