Brief research report 187

Differences between patients with chronic musculoskeletal pain treated in an inpatient or an outpatient multidisciplinary rehabilitation program Anne M. Boonstraa, Michiel F. Renemanb, Henrica R. Schiphorst Preuperb, Berend R. Waaksmaa and Roy E. Stewartc Multidisciplinary rehabilitation for patients with chronic musculoskeletal pain can be provided on an inpatient or on an outpatient basis, but the rationale for choosing between the two programs is unknown. The aim of the study was to identify differences between patients provided inpatient or outpatient rehabilitation. It was a cross-sectional study within usual care. The study included 415 adult rehabilitation patients with chronic musculoskeletal pain with complex psychosocial problems. The measurements used were demographics, Short Form 36 Health Survey, Dutch Personality Questionnaire, Coping with Pain Questionnaire, Tampa Scale of Kinesiophobia, Symptom Checklist 90-Revised. In the multiple logistic analysis, five variables remained significantly different between inpatients and outpatients: inpatients were less likely to have a child aged less than 12 years and to have neck pain; their physical and social functioning were poorer; and their current pain period had lasted longer. The total explained

Introduction Multidisciplinary pain rehabilitation is generally considered to be an effective treatment for chronic musculoskeletal pain (Turk, 2002), and can be offered in an inpatient or an outpatient setting. In clinical practice, patients are advised to start inpatient multidisciplinary treatment if they have severe psychosocial problems or if they are severely disabled (Angst et al., 2006), although evidence to support this practice is lacking. In view of this, psychosocial problems and disability can be expected to be more severe in inpatients than in outpatients. To our knowledge, however, no research has been carried out to ascertain whether this is indeed the case. The aim of this study was to analyze differences between the demographic and clinical characteristics of patients who took part in an inpatient or an outpatient pain rehabilitation program. Our hypothesis was that patients who participate in an inpatient program would have more severe psychosocial problems or may be more severely disabled than those participating in an outpatient program.

Patients and methods Patients

The study included adult patients with chronic musculoskeletal pain treated in a medium-size rehabilitation c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 0342-5282

variance was 26%. Five variables were identified as influencing the decision on inpatient or outpatient rehabilitation, but the explained variance was low. International Journal of Rehabilitation Research c 2014 Wolters Kluwer Health | Lippincott 37:187–191 Williams & Wilkins. International Journal of Rehabilitation Research 2014, 37:187–191 Keywords: chronic musculoskeletal pain, inpatient treatment, outpatient treatment, rehabilitation a Revalidatie Friesland, Center for Rehabilitation, Beetsterzwaag, bDepartment of Rehabilitation, Center for Rehabilitation and cDepartment of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

Correspondence to Anne M. Boonstra, MD, PhD, Revalidatie Friesland, Center for Rehabilitation, PO Box 2, 9244ZN Beetsterzwaag, The Netherlands Tel: + 31 512 389 329; fax: + 31 512 389 244; e-mail: [email protected] Received 24 February 2013 Accepted 3 December 2013

center in the Netherlands, participating in an inpatient or an outpatient program, both involving a psychologist. Exclusion criteria for both programs were current major psychiatric disorder, including alcohol and severe opioid drug abuse. Further exclusion criteria for the study were insufficient command of Dutch and unwillingness to provide data for research purposes. A specific exclusion criterion for outpatient programs was insurmountable problems of traveling to the rehabilitation center. Patient enrollment took place between September 2003 and November 2011. If patients were treated twice in the inclusion period, we used the data of the first episode for our study. Study design

The study was a retrospective cohort study within usual care. Measurements

Demographic data and pain characteristics were assessed using a self-constructed questionnaire. Physical, emotional and social functioning, and pain intensity were assessed using the Short Form 36 Health Survey (Aaronson et al., 1998), with scores ranging from 0 to 100 for each dimension; a lower score indicates more disability or more pain. Personality was assessed using the DOI: 10.1097/MRR.0000000000000047

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Dutch Personality Questionnaire (Barelds and Luteijn, 2002). Items are distributed over seven scales: neuroticism, social anxiety, rigidity, hostility, egoism, dominance, and self-esteem. Coping reactions were measured using the Coping with Pain Questionnaire (Spinhoven et al., 1994). The Coping with Pain Questionnaire assesses the use of cognitive strategies: ignoring pain sensations, coping self-statements, reinterpreting pain sensations, catastrophizing, praying or hoping, diverting attention, and ability to control pain, as well as one behavioral strategy: increasing activity level. We calculated the ‘active coping’ and ‘helplessness’ factors by summing the relevant scores. A higher score means that a patient is more likely to use this specific coping style predominantly. Pain-related fear was assessed using the Tampa Scale of Kinesiophobia (Vlaeyen et al., 1995), with higher scores indicating more fear. Psychosocial distress was assessed using the Symptom Checklist 90-Revised (Arrindell and Ettema et al., 2003), with eight dimensions reflecting various types of psychopathology: anxiety, agoraphobia, depression, somatization, insufficiency, sensitivity, hostility, and insomnia. The Symptom Checklist 90-Revised also includes a total score for ‘psychoneuroticism’, which is a global measure of distress. Higher scores indicate higher levels of distress. Procedure and rehabilitation program

Patients were referred to multidisciplinary rehabilitation for their pain-related disabilities. The rehabilitation physicians and psychologists of the pain department saw all patients with suspected psychosocial problems before the treatment started. The final choice for inpatient or outpatient treatment was a shared decision by patient, physician, and psychologist, with the physician advising the patient, taking the psychologist’s view into account. Physicians and psychologists of the pain rehabilitation ward were aware of the general view about the advantage of inpatient treatment, that is, a more intensive program or taking patients out of their own social context. Inpatient treatment always involved a psychologist, whereas outpatient treatment might or might not involve a psychologist. All patients were asked to participate in an outcome evaluation procedure, but only patients whose treatment involved a psychologist were included in this study. Both types of rehabilitation treatment, provided partly individually and partly in groups, were based on cognitive-behavioral concepts. The treatment focus depended on the patient’s characteristics in terms of complaints, activity limitations, participation problems, and psychological distress. The team always involved at least a physician, a physiotherapist, an occupational therapist, a psychologist, and, in the case of inpatient treatment, a nurse. It often also included a social worker,

music therapist, or a psychomotor therapist. Outpatient programs were mostly provided on 3 days a week for 1–4 h a day, over a period of 10–16 weeks. The inpatient program was provided Monday through Friday, with patients going home for the weekend. This program lasted 6–10 weeks. The length and intensity of the program for each patient was determined by the characteristics of the complaints and the patient’s progress during the treatment, as is usual in clinical practice. The Short Form 36 Health Survey was used as part of an outcome evaluation procedure to assess the outcome of rehabilitation in patients with chronic musculoskeletal pain. The patients filled in the Short Form 36 Health Survey just before the beginning or during the first 2 weeks of treatment in the case of outpatient treatment, or during the first week in the case of inpatient treatment. The data of the other assessments were collected as part of regular clinical procedures in the first or the second week of treatment after the decision to start inpatient or outpatient treatment had been made.

Statistical analysis

The characteristics shown in Table 1 were dichotomized. Differences between inpatients and outpatients were analyzed using logistic regression. The likelihood that a particular independent variable was associated with inpatient or outpatient treatment was first tested using logistic regression. Two multiple models were constructed. Independent variables with an unadjusted odds ratio with a P-value of 0.20 or less were included in the first multiple logistic regression. In the next step, variables with a P-value less than 0.05 in the first model were entered in the final model. As it was theoretically possible that patients with very severe psychological problems could be referred for outpatient treatment because intensive group treatment was contraindicated, we checked the distributions of the psychological data visually using histograms. The significance level was set at P-value less than 0.05.

Results The response rate of the patients eligible for this study was estimated at 78% for the outpatients and 68% for the inpatients. Psychological data were unavailable for eight patients. Five patients were excluded from the analyses because they did not provide permission to use their data for research purposes. Five patients started treatment twice during the inclusion period. Finally, data of 415 patients were analyzed, with 199 patients in the outpatient group and 216 patients in the inpatient group. Nineteen of the patients had a short outpatient treatment before being admitted to inpatient treatment. They were included in the ‘inpatient group’.

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Differences between patients with CMP Boonstra et al. 189

Demographic and clinical characteristics of patients with chronic musculoskeletal pain given outpatient or inpatient treatment, and odds ratios in univariate logistic regression

Table 1

Outpatient treatment (n = 199) Characteristics Age [mean (SD), range] (years) 42 (10), 19–75 Sex (male) (%) 31 Marital status (single) (%) 24 Educational level (low) (%) 76 Employed (no) (%) 66 Working (no) (%) 60 On benefit (no) (%) 46 Presence of a child aged r 12 years (yes) (%) 32 Pain Duration of current complaints (years) Mean (SD) 4.8 (5.2) Median (quartiles) 3 (2–6) Location of pain Low back pain (yes) (%) 28 Neck pain (yes) (%) 20 Widespread pain (including fibromyalgia) (yes) (%) 30 Other (yes) (%) 22 Functioning and pain (SF-36 scores, range of each item 0–100) [mean (SD)] Physical functioning 48 (21) Social functioning 52 (23) Physical role 9 (21) Emotional role 55 (43) Mental health 61 (17) Vitality 37 (16) Pain 35 (16) Dutch Personality Questionnaire (range of each item 0–40) [mean (SD)] Nneuroticism 13 (9) Social anxiety 13 (9) Rigidity 27 (8) Hostility 12 (9) Egoism 7 (5) Dominance 19 (7) Self-esteem 27 (8) Coping with Pain Questionnaire (score range) [mean (SD)] Ignoring pain sensations (0–60) 27 (14) Soping self-statements (0–60) 35 (13) Increasing activity level (0–60) 22 (10) Reinterpreting pain sensations (0–60) 10 (10) Catastrophizing (0–60) 23 (13) Praying or hoping (0–60) 17 (12) Diverting attention (0–60) 18 (12) Ability to control pain (0–20) 7 (6) Composite scores Active coping (0–180) 94 (34) Helplessness (0–240) 58 (27) Tampa Scale of Kinesiophobia (score range 17–61) [mean (SD)] Fear 36 (7) SCL-90-R (score range) Anxiety (10–50) 18 (6) Phobic anxiety (agoraphobia) (7–35) 9 (3) Depression (16–80) 34 (11) Somatization (12–60) 28 (7) Insufficiency (9–45) 22 (7) Sensitivity (18–90) 30 (11) Hostility (6–30) 10 (4) Insomnia (3–15) 8 (4) Psychoneuroticism (90–450) 173 (45)

Inpatient treatment (n = 216)

OR

P-value

43 (13), 18–84 20 28 82 40 84 34 12

1.00 0.58 1.27 1.44 0.35 3.48 0.61 0.30

0.58 0.02 0.28 0.13 < 0.01 < 0.01 0.01 < 0.01

6.3 (7.5) 4 (2–10)

0.96

0.02

0.95 2.26 0.60 0.75

0.81 0.01 0.40 0.30

29 10 41 20 33 40 7 45 59 31 29

(19) (26) (18) (43) (19) (18) (17)

1.04 1.02 1.01 1.00 1.01 1.02 1.02

< 0.01 < 0.01 0.24 0.98 0.25 < 0.01 < 0.01

18 14 26 13 6 18 26

(10) (10) (8) (8) (4) (8) (8)

0.99 0.99 1.01 0.99 1.01 1.02 1.01

0.24 0.20 0.55 0.44 0.55 0.16 0.45

27 36 23 10 24 18 18 6

(15) (13) (11) (10) (13) (12) (12) (5)

1.00 0.99 0.99 1.00 1.00 0.99 0.99 1.04

0.87 0.34 0.13 0.97 0.73 0.33 0.47 0.03

97 (37) 60 (25)

1.00 1.00

0.46 0.34

36 (8)

0.99

0.56

19 11 36 31 23 32 9 9 184

(7) (5) (12) (8) (7) (12) (3) (4) (48)

0.97 0.92 0.98 0.96 0.98 0.99 1.06 0.94 0.995

0.03 < 0.01 0.03 < 0.01 0.22 0.21 0.05 0.03 0.03

ORs with P r 0.20 are presented in bold. OR, odds ratio; SCL-90-R, Symptom Checklist 90-Revised; SF-36, Short Form 36 Health Survey.

Patient characteristics and the results of the univariate analysis are presented in Table 1. Most patients had low back pain (28%), fibromyalgia (24%), widespread pain (11%), or neck pain (15%). The results of the multiple logistic regression are shown in Tables 2 and 3. Nagelkerke’s R2 for the multiple logistic regression analysis of the first multiple model was 0.36 versus 0.26 for the final model.

Discussion We had hypothesized that patients in an inpatient program would have more severe psychosocial problems or may be more disabled compared with those participating in an outpatient program. Five variables remained significant in the final multiple analysis (with a total explained variance of 26%): the presence of a child aged less than 12 years at home, having neck pain,

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Table 2 Adjusted odds ratios (with 95% confidence intervals) of the variables potentially associated with being treated as an inpatient or an outpatient

Characteristics Sex Educational level Employed Work status On benefit Presence of a child aged r 12 years Pain Location of pain: neck Duration of current complaints Functioning and pain (SF-36) Physical functioning Social functioning Vitality Pain Dutch Personality Questionnaire Social anxiety Dominance Coping with Pain Questionnaire Increasing activity level Ability to control pain SCL-90-R Anxiety Phobic anxiety Depression Somatization Hostility Insomnia Psychoneuroticism

OR

95% CI

P-value

0.89 0.77 0.71 1.95 0.92 0.39

0.47–1.68 0.40–1.48 0.39–1.29 0.95–4.00 0.53–1.59 0.21–0.73

0.72 0.43 0.26 0.07 0.77 0.003

2.39 0.95

1.11–5.12 0.91–0.99

0.03 0.02

1.03 1.01 1.00 1.00

1.01–1.04 1.001–1.03 0.99–1.02 0.99–1.02

< 0.001 0.03 0.63 0.75

1.00 1.02

0.97–1.03 0.99–1.06

0.95 0.21

0.97 1.04

0.95–1.998 0.99–1.09

0.16 0.04

1.00 0.94 0.97 0.98 1.10 1.03 1.01

0.92–1.09 0.86–1.04 0.91–1.02 0.93–1.04 0.97–1.22 0.95–1.11 0.99–1.04

0.98 0.23 0.25 0.52 0.06 0.47 0.38

Independent variables with a P r 0.20 in the univariate logistic regression analysis were entered in multiple logistic regression (n = 382). The ORs with P < 0.05 are presented in bold. 95% CI, 95% confidence interval; OR, odds ratio; SCL-90-R, Symptom Checklist 90-Revised; SF-36, Short Form 36 Health Survey.

Table 3 Adjusted odds ratios (with 95% confidence intervals) of the variables potentially associated with being treated as an inpatient or an outpatient

Characteristics Presence of a child aged r 12 years Pain Duration of current complaints Location of pain: neck Functioning (SF-36) Physical functioning Social functioning Coping with Pain Questionnaire Increasing activity level

OR

95% CI

P-value

0.33

0.19–0.58

< 0.001

0.95 2.00

0.91–0.99 1.01–3.98

0.010 0.046

1.03 1.01

1.02–1.04 1.01–1.02

< 0.001 0.003

0.98

0.96–1.00

0.161

Independent variables with a P r 0.05 in the multiple logistic regression analysis of the first multiple model (see Table 2) were entered in the final model. The ORs with P < 0.05 are presented in bold. 95% CI, 95% confidence interval; OR, odds ratio; SF-36, Short Form 36 Health Survey.

self-reported physical functioning and social functioning, and the duration of the current pain period. The observation that patients with a young child at home were more likely to be treated as outpatients may not be associated with the expected outcome of either of the treatment options, but with practical and emotional reasons, as it may be difficult to find a good sitter while the parent is undergoing inpatient treatment. Inpatients

reported poorer social functioning than outpatients, which was in line with the hypothesis. Duration of complaints is a predictor of poor outcome (Michaelson et al., 2004), and may also be related to the number of treatments with insufficient effect that the patient has undergone before being referred to multidisciplinary rehabilitation. Physicians may have taken previous poor therapy outcome into account when recommending the most intensive treatment, that is, inpatient treatment. Inpatients also reported poorer physical functioning. Poor physical functioning is likely to be related to a patient’s low physical capacity, which may be too low to cope with traveling to and from the rehabilitation center as an outpatient. This is in line with the exclusion criterion for outpatient treatment of insurmountable problems of traveling to the rehabilitation center. It is striking that psychological factors were not associated with the choice to refer patients to inpatient or outpatient treatment, as we had expected beforehand, both from clinical practice and from the literature (Angst et al., 2006). The fact that psychological variables did not predict the decision on inpatient or outpatient treatment may indicate that our study did not assess the right psychological variables. However, the results of our univariate analysis suggested several psychological variables to be associated with the decision to refer to inpatient or outpatient treatment, which, however, had disappeared in the results of the multiple analysis. This may suggest that psychological variables are associated with the predictors found, but are not predictors themselves. An alternative explanation is that the instruments did not detect differences that were relevant for triage, or that social variables not assessed in the present study were more important and that those were the ones assessed by the psychologist during the interview. Our study was subjected to certain limitations, the most important being that the cross-sectional design of the study means that the direction of the associations is unknown. Conclusion

Our study showed that patients with neck pain or having a child aged 12 years or younger were more likely to be given outpatient than inpatient treatment. Longer duration of the pain, and poorer physical and social functioning predicted a higher likelihood of being given inpatient treatment.

Acknowledgements Conflicts of interest

There are no conflicts of interest.

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Differences between patients with chronic musculoskeletal pain treated in an inpatient or an outpatient multidisciplinary rehabilitation program.

Multidisciplinary rehabilitation for patients with chronic musculoskeletal pain can be provided on an inpatient or on an outpatient basis, but the rat...
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