Ò
PAIN xxx (2014) xxx–xxx
www.elsevier.com/locate/pain
Correspondence Letter to the Editor
To the Editor: The paper by Waterschoot et al. [7], ‘‘Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: A systemic review’’ is aptly titled and thought provoking. It is generally thought that multidisciplinary therapy is more effective than monotherapy for chronic low back pain [1–3]. However, the specific treatments that are the most effective singly or in combination are not clear, because the majority of the studies assessing various treatments use a heterogeneous group of treatments, patient populations, and follow-up times. In addition, other, less easily quantifiable factors such as patient compliance and motivation (influenced by disability compensation, psychiatric co-morbidities, workplace, and social factors) [4] have been shown to affect outcome and are not considered in this article, in which the focus is only on dose. The basic assumption of this article—ie, that all treatments have equal effectiveness with regard to dose per unit of time—has not been proved and is purely speculative at this time. This study looked at 18 papers, each evaluating 2 or more multidisciplinary and rehabilitation programs for chronic low back pain. Each program has a range of treatment modalities, including various physical activities and supportive psychotherapy treatments that differ from program to program. In addition, some programs include other treatment modalities such as relaxation sessions, medical therapies, hydrotherapy and unsupervised homework. These authors equate total treatment time in each program with treatment dose of that program, using the basic assumption that equal treatment time with each treatment modality is equivalent in dose to other treatment modalities (eg, 1 hour of physical therapy equals 1 hour of psychotherapy equals 1 hour of massage or hydrotherapy). However, this assumption may be problematic. In addition, the measure of pain intensity alone as the measured treatment effect may not reflect actual treatment benefit, as pain intensity varies over time in patients with chronic low back pain and is not associated with activity level [5,6]. The focus of this study is a good one, but a study of ‘‘dose’’ of treatment will be more meaningful when more high-quality and
standardized treatment studies have become available for assessment and there is more consensus on the components of the most effective treatment. Currently, given the variety of treatment options available (including their potentiating or deleterious effects when combined), the expectations and desires of the patients, and the degree of compliance and motivation of the patients, discussing the dose of treatment appears to be premature. Conflict of interest Neither of the authors have received financial gain or recognize a potential conflict of interest directly associated with this work. References [1] Buchner M, Neubauer E, Zahlten-Hinguranage A, Schiltenwolf M. The influence of the grade of chronicity on the outcome of multidisciplinary therapy for chronic low back pain. Spine (Phila Pa 1976) 2007;32:3060–6. [2] Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. PAINÒ 1992;49:221–30. [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] Hildebrandt J, Pfingsten M, Saur P, Jansen J. Prediction of success from a multidisciplinary treatment program for chronic low back pain. Spine (Phila Pa 1976) 1997;22:990–1001. [5] Huijnen IP, Verbunt JA, Roelofs J, Goossens M, Peters M. The disabling role of fluctuations in physical activity in patients with chronic low back pain. Eur J Pain 2009;13:1076–9. [6] Liszka-Hackzell JJ, Martin DP. An analysis of the relationship between activity and pain in chronic and acute low back pain. Anesth Analg 2004;99:477–81. [7] Waterschoot FP, 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. PAINÒ 2014;155:179–89.
Nicholas A. Beckmann Marcus Schiltenwolf Department of Orthopaedic Surgery, University of Heidelberg, Heidelberg, Germany E-mail address: [email protected] (N.A. Beckmann)
http://dx.doi.org/10.1016/j.pain.2014.04.003 0304-3959/Ó 2014 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
PAIN xxx (2014) xxx–xxx
www.elsevier.com/locate/pain
Correspondence Letter to the Editor
To the Editor: The paper by Waterschoot et al. [7], ‘‘Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: A systemic review’’ is aptly titled and thought provoking. It is generally thought that multidisciplinary therapy is more effective than monotherapy for chronic low back pain [1–3]. However, the specific treatments that are the most effective singly or in combination are not clear, because the majority of the studies assessing various treatments use a heterogeneous group of treatments, patient populations, and follow-up times. In addition, other, less easily quantifiable factors such as patient compliance and motivation (influenced by disability compensation, psychiatric co-morbidities, workplace, and social factors) [4] have been shown to affect outcome and are not considered in this article, in which the focus is only on dose. The basic assumption of this article—ie, that all treatments have equal effectiveness with regard to dose per unit of time—has not been proved and is purely speculative at this time. This study looked at 18 papers, each evaluating 2 or more multidisciplinary and rehabilitation programs for chronic low back pain. Each program has a range of treatment modalities, including various physical activities and supportive psychotherapy treatments that differ from program to program. In addition, some programs include other treatment modalities such as relaxation sessions, medical therapies, hydrotherapy and unsupervised homework. These authors equate total treatment time in each program with treatment dose of that program, using the basic assumption that equal treatment time with each treatment modality is equivalent in dose to other treatment modalities (eg, 1 hour of physical therapy equals 1 hour of psychotherapy equals 1 hour of massage or hydrotherapy). However, this assumption may be problematic. In addition, the measure of pain intensity alone as the measured treatment effect may not reflect actual treatment benefit, as pain intensity varies over time in patients with chronic low back pain and is not associated with activity level [5,6]. The focus of this study is a good one, but a study of ‘‘dose’’ of treatment will be more meaningful when more high-quality and
standardized treatment studies have become available for assessment and there is more consensus on the components of the most effective treatment. Currently, given the variety of treatment options available (including their potentiating or deleterious effects when combined), the expectations and desires of the patients, and the degree of compliance and motivation of the patients, discussing the dose of treatment appears to be premature. Conflict of interest Neither of the authors have received financial gain or recognize a potential conflict of interest directly associated with this work. References [1] Buchner M, Neubauer E, Zahlten-Hinguranage A, Schiltenwolf M. The influence of the grade of chronicity on the outcome of multidisciplinary therapy for chronic low back pain. Spine (Phila Pa 1976) 2007;32:3060–6. [2] Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. PAINÒ 1992;49:221–30. [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] Hildebrandt J, Pfingsten M, Saur P, Jansen J. Prediction of success from a multidisciplinary treatment program for chronic low back pain. Spine (Phila Pa 1976) 1997;22:990–1001. [5] Huijnen IP, Verbunt JA, Roelofs J, Goossens M, Peters M. The disabling role of fluctuations in physical activity in patients with chronic low back pain. Eur J Pain 2009;13:1076–9. [6] Liszka-Hackzell JJ, Martin DP. An analysis of the relationship between activity and pain in chronic and acute low back pain. Anesth Analg 2004;99:477–81. [7] Waterschoot FP, 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. PAINÒ 2014;155:179–89.
Nicholas A. Beckmann Marcus Schiltenwolf Department of Orthopaedic Surgery, University of Heidelberg, Heidelberg, Germany E-mail address: [email protected] (N.A. Beckmann)
http://dx.doi.org/10.1016/j.pain.2014.04.003 0304-3959/Ó 2014 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
