Accepted Manuscript Letter to the Editor Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Waterschoot et al., Pain 155 (2014) 179-189 Ulrike Kaiser, Stephanie Deckert, Christian Kopkow, Jochen Schmitt, Rainer Sabatowski PII: DOI: Reference:
S0304-3959(14)00267-X http://dx.doi.org/10.1016/j.pain.2014.06.002 PAIN 9236
To appear in:
PAIN
Received Date: Revised Date: Accepted Date:
20 May 2014 3 June 2014 3 June 2014
Please cite this article as: U. Kaiser, S. Deckert, C. Kopkow, J. Schmitt, R. Sabatowski, Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Waterschoot et al., Pain 155 (2014) 179-189, PAIN (2014), doi: http://dx.doi.org/10.1016/j.pain.2014.06.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Waterschoot et al., Pain 155 (2014) 179189 Dear Editor, Waterschoot et al. published an important systematic review on the effectiveness of multidisciplinary pain rehabilitation programs (PRPs) for patients with chronic low back pain (CLBP) with the main focus on the dose effects (e.g. treatment hours per program) [7]. The authors performed a formal systematic review using all relevant steps to guarantee extensive evidence. 18 studies investigating the effectiveness of PRPs on the predefined domains disability, work participation, or quality of life were identified and analyzed. The included studies represented a wide range of treatment hours (6.4 to 196.8h), giving evidence that programs that are less intensive, as suggested by Guzman et al. [3], might be effective as well. Even though this review supports the notion that PRPs in general are effective and superior to most other interventions in treating patients with CLBP, no conclusions could be drawn on the relationship between dose and effect in PRP alone. Since we consider the value of this review important to the ongoing discussion of dose and content in multidisciplinary pain programs (either rehabilitation or other settings), we would like to emphasize important issues concerning this matter. Please notice that we use multimodal, multidisciplinary, comprehensive and interdisciplinary synonymously when considering the bio-psycho-social dimensionality of chronic pain. There is a long history relating to the definition of “multimodal” in the therapy of chronic pain. Mayer and Gatchel [4] were pioneers in comprehensive therapy approaches such as functional restoration programs addressing chronic pain as a bio-psycho-social condition. Their treatment basically consists of a "sports medicine" approach to restore physical capacity and a cognitive "crisis intervention" technique for dealing with psychosocial issues in the patient suffering from chronic (spinal) disability. They demanded a team consisting of physical, occupational and psychological therapists, nurses and physicians. Mayer and Gatchel highlighted the importance of equal attention to physical exercise, psychological as well as occupational interventions in the treatment program and strictly excluded passive interventions from their treatment approach; only medication was left as an important medical intervention for chronic pain [4]. Over the last years this type of therapy has been established internationally in instances where the bio-psycho-social diagnosis and treatment of patients suffering from chronic pain is needed. Yet, there are some challenges in multidisciplinary pain treatment (MPT) which are evident in Waterschoots and colleagues work as well as in almost all others. There is neither a broadly accepted, international consensus on the definition of MPT nor is there a consensus on a core set of outcome measures with which to assess the effectiveness of MPT. The definition of “multimodal” is applied to any treatment consisting of at least two different interventions sometimes to the use of two different types of medication or the combination of occupational
and physical interventions only. The overlap of similar study designs in Waterschoot and colleagues review was small; the heterogeneity of the included studies had a considerable impact on the presented result. Additionally, psychological treatments used in some studies including stress management and operant behavioral components were being provided by nurses or physiotherapists only without the involvement of psychologists or psychotherapists. Furthermore, the dose of each intervention within the specific approaches varied substantially with some providing only a few hours of an intervention and others requiring equal amounts of each intervention. A systematic review as performed by Waterschoot and colleagues, which does not carefully consider such differences in concept, content, and provision of treatment most carefully, fails in informing readers about dose and the impact of dose on outcome [7]. We recognize that the heterogeneity of studies included in the review of Waterschoot and colleagues reflects the current situation in MPT. However, on this basis we believe there is no reasonable conclusion to be drawn from comparisons of dose. This leads to the conclusion that a formal consensus process involving key stakeholders such as patients, clinicians, methodologists, and regulators, should be undertaken to identify core outcome domains for assessing effectiveness in MPT. Such a consensus process could guide those wishing to conduct effectiveness studies evaluating MPT programs and could be invaluable to investigators conducting reviews of this area. To prepare such a consensus and enhance its quality we strongly need a clear definition of MPT that incorporates a consideration of chronic pain as bio-psycho-social condition. The German Pain Society has successfully conducted an interdisciplinary process for defining MPT and its contents on a broad, public basis [1,2,5,6]. They define MPT as a simultaneous, contextual, temporal and coordinated, comprehensive strategy to treat chronic pain patients integrating different somatic, physical as well as psychological treatment approaches provided by all relevant professions with identical and consensual therapeutic aims [1]. Under the supervision of a physician specialized in pain management, each of the disciplines is equally involved in assessment and treatment. Functional restoration (objective and subjective) with increased sense of control over pain (e.g. competence and performance in coping with chronic pain) of the patients is the central aim of this treatment approach [1]. Such initiatives in defining constructs can help identify relevant studies and research questions and are desirable from our point of view for further discussions and methodological efforts such as core outcome sets. Conflict of interest statement UK has received a grant from the German Federal Ministry of Education and Research (BMBF 01GY1326) RS, JS, CK, SD are co-workers of this project. References
[1] Arnold B, Brinkschmidt T, Casser HR Gralow I, Irnich D, Klimczyk K, Müller G, Nagel B, Pfingsten M, Schiltenwolf M, Sittl R, Söllner W. [Multimodal pain therapy - concepts and indication]. Schmerz 2009;23:112-20 [2] Casser HR, Arnold B, Brinkschmidt T, Gralow I, Irnich D, Klimczyk K, Nagel B, Pfingsten M, Sabatowski R, Schiltenwolf M, Sittl R, Söllner W. [Multidisciplinary assessment for multimodal pain therapy. Indications and range of performance]. Schmerz 2013;27:363-70 [3] Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001;322:1511-6 [4] Mayer TG, Gatchel RJ. Functional restoration for spinal disorders: the sports medicine approach.Philadelphia, PA: Lea & Febiger, 1988 [5] Nagel B, Pfingsten M, Brinkschmidt T, Casser HR, Gralow I, Irnich D, Klimczyk K, Sabatowski R, Schiltenwolf M, Sittl R, Söllner W, Arnold B. [Structure and process quality of multimodal pain therapy. Results of a survey of pain therapy clinics]. Schmerz 2012;26:661-9 [6] Sabatowski R, Maier C, Willweber-Strumpf A, Thomm M, Nilges P, Kayser H, Casser R. [Recommendations on classification of German pain treatment services ] Schmerz 2011;25: 368-76. [7] Waterschoot F, Dijkstra PU, Hollak N, de Vries HJ, Geertzen JH, Reneman MF. Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Pain 2014;155:179-89
Ulrike Kaiser* Comprehensive Pain Center, Technical University of Dresden, Dresden, Germany *Corresponding author. Tel.: +49 351 458 3354 Fax: +49 351 458 6391 E-mail address: [email protected] Stephanie Deckert Center for Evidence-Based Healthcare, Technical University of Dresden, Dresden, Germany
Christian Kopkow Center for Evidence-Based Healthcare, Technical University of Dresden, Dresden, Germany Jochen Schmitt Center for Evidence-Based Healthcare, Technical University of Dresden, Dresden, Germany Rainer Sabatowski Comprehensive Pain Center, University of Dresden, Dresden, Germany
S0304-3959(14)00267-X http://dx.doi.org/10.1016/j.pain.2014.06.002 PAIN 9236
To appear in:
PAIN
Received Date: Revised Date: Accepted Date:
20 May 2014 3 June 2014 3 June 2014
Please cite this article as: U. Kaiser, S. Deckert, C. Kopkow, J. Schmitt, R. Sabatowski, Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Waterschoot et al., Pain 155 (2014) 179-189, PAIN (2014), doi: http://dx.doi.org/10.1016/j.pain.2014.06.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Waterschoot et al., Pain 155 (2014) 179189 Dear Editor, Waterschoot et al. published an important systematic review on the effectiveness of multidisciplinary pain rehabilitation programs (PRPs) for patients with chronic low back pain (CLBP) with the main focus on the dose effects (e.g. treatment hours per program) [7]. The authors performed a formal systematic review using all relevant steps to guarantee extensive evidence. 18 studies investigating the effectiveness of PRPs on the predefined domains disability, work participation, or quality of life were identified and analyzed. The included studies represented a wide range of treatment hours (6.4 to 196.8h), giving evidence that programs that are less intensive, as suggested by Guzman et al. [3], might be effective as well. Even though this review supports the notion that PRPs in general are effective and superior to most other interventions in treating patients with CLBP, no conclusions could be drawn on the relationship between dose and effect in PRP alone. Since we consider the value of this review important to the ongoing discussion of dose and content in multidisciplinary pain programs (either rehabilitation or other settings), we would like to emphasize important issues concerning this matter. Please notice that we use multimodal, multidisciplinary, comprehensive and interdisciplinary synonymously when considering the bio-psycho-social dimensionality of chronic pain. There is a long history relating to the definition of “multimodal” in the therapy of chronic pain. Mayer and Gatchel [4] were pioneers in comprehensive therapy approaches such as functional restoration programs addressing chronic pain as a bio-psycho-social condition. Their treatment basically consists of a "sports medicine" approach to restore physical capacity and a cognitive "crisis intervention" technique for dealing with psychosocial issues in the patient suffering from chronic (spinal) disability. They demanded a team consisting of physical, occupational and psychological therapists, nurses and physicians. Mayer and Gatchel highlighted the importance of equal attention to physical exercise, psychological as well as occupational interventions in the treatment program and strictly excluded passive interventions from their treatment approach; only medication was left as an important medical intervention for chronic pain [4]. Over the last years this type of therapy has been established internationally in instances where the bio-psycho-social diagnosis and treatment of patients suffering from chronic pain is needed. Yet, there are some challenges in multidisciplinary pain treatment (MPT) which are evident in Waterschoots and colleagues work as well as in almost all others. There is neither a broadly accepted, international consensus on the definition of MPT nor is there a consensus on a core set of outcome measures with which to assess the effectiveness of MPT. The definition of “multimodal” is applied to any treatment consisting of at least two different interventions sometimes to the use of two different types of medication or the combination of occupational
and physical interventions only. The overlap of similar study designs in Waterschoot and colleagues review was small; the heterogeneity of the included studies had a considerable impact on the presented result. Additionally, psychological treatments used in some studies including stress management and operant behavioral components were being provided by nurses or physiotherapists only without the involvement of psychologists or psychotherapists. Furthermore, the dose of each intervention within the specific approaches varied substantially with some providing only a few hours of an intervention and others requiring equal amounts of each intervention. A systematic review as performed by Waterschoot and colleagues, which does not carefully consider such differences in concept, content, and provision of treatment most carefully, fails in informing readers about dose and the impact of dose on outcome [7]. We recognize that the heterogeneity of studies included in the review of Waterschoot and colleagues reflects the current situation in MPT. However, on this basis we believe there is no reasonable conclusion to be drawn from comparisons of dose. This leads to the conclusion that a formal consensus process involving key stakeholders such as patients, clinicians, methodologists, and regulators, should be undertaken to identify core outcome domains for assessing effectiveness in MPT. Such a consensus process could guide those wishing to conduct effectiveness studies evaluating MPT programs and could be invaluable to investigators conducting reviews of this area. To prepare such a consensus and enhance its quality we strongly need a clear definition of MPT that incorporates a consideration of chronic pain as bio-psycho-social condition. The German Pain Society has successfully conducted an interdisciplinary process for defining MPT and its contents on a broad, public basis [1,2,5,6]. They define MPT as a simultaneous, contextual, temporal and coordinated, comprehensive strategy to treat chronic pain patients integrating different somatic, physical as well as psychological treatment approaches provided by all relevant professions with identical and consensual therapeutic aims [1]. Under the supervision of a physician specialized in pain management, each of the disciplines is equally involved in assessment and treatment. Functional restoration (objective and subjective) with increased sense of control over pain (e.g. competence and performance in coping with chronic pain) of the patients is the central aim of this treatment approach [1]. Such initiatives in defining constructs can help identify relevant studies and research questions and are desirable from our point of view for further discussions and methodological efforts such as core outcome sets. Conflict of interest statement UK has received a grant from the German Federal Ministry of Education and Research (BMBF 01GY1326) RS, JS, CK, SD are co-workers of this project. References
[1] Arnold B, Brinkschmidt T, Casser HR Gralow I, Irnich D, Klimczyk K, Müller G, Nagel B, Pfingsten M, Schiltenwolf M, Sittl R, Söllner W. [Multimodal pain therapy - concepts and indication]. Schmerz 2009;23:112-20 [2] Casser HR, Arnold B, Brinkschmidt T, Gralow I, Irnich D, Klimczyk K, Nagel B, Pfingsten M, Sabatowski R, Schiltenwolf M, Sittl R, Söllner W. [Multidisciplinary assessment for multimodal pain therapy. Indications and range of performance]. Schmerz 2013;27:363-70 [3] Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001;322:1511-6 [4] Mayer TG, Gatchel RJ. Functional restoration for spinal disorders: the sports medicine approach.Philadelphia, PA: Lea & Febiger, 1988 [5] Nagel B, Pfingsten M, Brinkschmidt T, Casser HR, Gralow I, Irnich D, Klimczyk K, Sabatowski R, Schiltenwolf M, Sittl R, Söllner W, Arnold B. [Structure and process quality of multimodal pain therapy. Results of a survey of pain therapy clinics]. Schmerz 2012;26:661-9 [6] Sabatowski R, Maier C, Willweber-Strumpf A, Thomm M, Nilges P, Kayser H, Casser R. [Recommendations on classification of German pain treatment services ] Schmerz 2011;25: 368-76. [7] Waterschoot F, Dijkstra PU, Hollak N, de Vries HJ, Geertzen JH, Reneman MF. Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Pain 2014;155:179-89
Ulrike Kaiser* Comprehensive Pain Center, Technical University of Dresden, Dresden, Germany *Corresponding author. Tel.: +49 351 458 3354 Fax: +49 351 458 6391 E-mail address: [email protected] Stephanie Deckert Center for Evidence-Based Healthcare, Technical University of Dresden, Dresden, Germany
Christian Kopkow Center for Evidence-Based Healthcare, Technical University of Dresden, Dresden, Germany Jochen Schmitt Center for Evidence-Based Healthcare, Technical University of Dresden, Dresden, Germany Rainer Sabatowski Comprehensive Pain Center, University of Dresden, Dresden, Germany
