RESEARCH ARTICLE
Multidisciplinary Rehabilitation for Chronic Widespread Musculoskeletal Pain: Results from Daily Practice Robin Koele1, Gerard Volker1, Félicie van Vree1, Marc van Gestel1, Albère Köke2,3 & Theodora Vliet Vlieland1,4* 1
Rijnlands Rehabilitation Centre, Leiden, the Netherlands
2
Adelante Centre of Expertise in Rehabilitation, Hoensbroek, the Netherlands
3
Department of rehabilitation Medicine; research School of CAPHRI, Maastricht University, the Netherlands
4
Dept of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, the Netherlands
Abstract Introduction: Evidence for the efficacy of a multi-component approach for chronic widespread musculoskeletal pain (CWP) has been reported, although the effects are overall moderate and this approach has rarely been investigated in real life. Aim: The aim of the study was to describe the effects of a 15-week multidisciplinary pain rehabilitation programme on pain, activities and participation in patients with CWP. Methods: The current retrospective study used data which were routinely gathered on all consecutive patients with CWP referred to a rehabilitation programme over a 21-month period. The 15-week multidisciplinary rehabilitation programme consisted of cognitive behavioural therapy and exercise, as well as individual and group sessions with additional treatment modalities. Assessments included the Pain Disability Index (PDI), the Pain Catastrophizing Scale (PCS), the Multidimensional Pain Inventory (MPI), numerical scales for pain and fatigue, the Canadian Occupational Performance Measure (COPM), the one-minute stair-climb test and the RAND-36. Paired t-tests and Wilcoxon signed-rank tests were carried out to analyse changes over time. Results: A total of 165 patients were included [mean age 44.1 (standard deviation 12.9) years], 143 (87%) women). Discharge data were available for 154 patients (93%). All outcomes showed statistically significant improvements between admission and discharge (p < 0.05), with the largest effect sizes (>1.0) observed for the COPM. A longer duration of complaints was associated with less improvement in the PDI. Discussion and conclusion: In daily rehabilitation practice, a 15-week multidisciplinary treatment programme for patients with CWP showed statistically significant improvements in pain, activities and participation over time. Future studies are needed further to substantiate the long-term cost-effectiveness, and to identify the patients who benefit the most. Copyright © 2014 John Wiley & Sons, Ltd. Keywords Chronic widespread pain; chronic pain; multidisciplinary treatment; rehabilitation *Correspondence Theodora P.M. Vliet Vlieland, Rijnlands Rehabilitation Centre, P.O. Box 176, 2300 AD Leiden, the Netherlands. Email: [email protected] Published online 10 June 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1076
Introduction Chronic widespread pain (CWP) affecting the musculoskeletal system is a common condition, with a population prevalence of ∼ 19% (Bergman et al., 2001; 210
Breivik et al., 2006). It is common to classify chronic musculoskeletal pain according to its site(s) of origin – it may be localized to a single joint (such as a shoulder or knee), a region or a limb (the back or the legs, for example) or it may be generalized pain (often considered Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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synonymous with fibromyalgia) (Dieppe, 2013). A recent ‘paradigm shift’ in the approach to musculoskeletal diseases has been the recognition that pain should be thought of as a separate issue – the ‘fifth vital sign in medicine’ and a disease in its own right (Dieppe, 2013). There is growing consensus indicating that the best approach to treatment for CWP involves a combination of pharmacological and non-pharmacological interventions. Despite the overall favourable, yet limited, effects, systematic reviews of the literature demonstrated substantial variation regarding the content, frequency and duration of the multi-component interventions provided in randomized controlled trials (Hassett and Williams, 2011; Mannerkorpi and Henriksson, 2007; Scascighini et al., 2008). In general, a multi-component treatment approach that combines cognitive behavioural therapy (CBT) with exercise and takes into account the patient’s unique needs appears to be most effective (Hassett and Williams, 2011). In spite of the evidence resulting from randomized clinical trials, it remains to be established the extent to which similar results can be obtained in daily practice. Patients with CWP in randomized clinical trials already constitute a heterogeneous population, whereas the variety of the characteristics among patients who are actually referred to multi-component rehabilitation programmes may be even larger. Moreover, the clinical studies included in systematic reviews were in many cases published several decades ago, so that the patient characteristics may not be comparable with those of patients who are admitted in the 21st century. In addition, knowledge about patients who do and do not benefit from treatment would be important for appropriate patient selection. A recent study among 120 patients with CWP undergoing multidisciplinary treatment found that male gender; a higher level of education; less pain, fatigue and anxiety; stronger beliefs in personal control and less belief in consequences were associated with a better outcome regarding pain, depression and the general perceived effect (De Rooij et al., 2013). The purpose of the current study was therefore to assess the effectiveness of a 15-week multidisciplinary programme on pain, fatigue, physical performance, quality of life, activities and participation in a mixed population of patients with CWP and the patient characteristics associated with improvement. Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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Methods Study design A retrospective design was used. All data were routinely gathered and stored in electronic patient records in connection with a multidisciplinary team care intervention for patients with CWP. In the Netherlands, no permission from a medical ethics committee is required for the evaluation of outcomes of care based solely on data derived from the medical records and executed by the treating physician. On admission, all patients are routinely asked to sign an informed consent form, stating that the data stored in their electronic medical record can be used anonymously by their treating physician for analyses of the outcomes of care. The conduct of the current study, and in particular the handling of the data, was done in accordance with the guidelines for good research practice (World Health Organization, 2002).
Patients All consecutive patients with CWP who were admitted to the multidisciplinary programme provided at the Rijnlands Rehabilitation Centre, in Leiden, the Netherlands, between 1 March 2011 and 1 December 2012 were eligible for inclusion in the study. All patients lived within a distance of 20 kilometres from the rehabilitation centre. Inclusion criteria for the programme were: age >18 years; having CWP, with a duration of complaints >3 months; sufficient treatment of underlying somatic condition if applicable; severe limitations in daily activities and participation; being motivated and able to take part in a multidisciplinary treatment programme for 15 weeks. Exclusion criteria were: being unable to understand or speak Dutch; participation in a similar rehabilitation programme in the previous three years; involvement in legal procedures related to their chronic pain syndrome; current, intensive treatment for psychological or work-related problems, irrespective of whether or not they were connected to the chronic musculoskeletal pain. Screening for eligibility for the programme was done by a physician, psychologist and physical therapist, with the final decision on admission being based on consensus. 211
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Intervention All eligible patients took part in the same outpatient, multidisciplinary programme at the rehabilitation centre. The programme was provided by a multidisciplinary team comprising a rehabilitation physician, an occupational therapist, a social worker, a psychologist and a physical therapist. The programme was mainly based on a cognitive behavioural model that had been described and used in patients with unexplained physical symptoms (Zonneveld et al., 2009, 2010). The overall goal was to optimize the patients’ functioning with respect to activities and participation by supporting them in managing their pain. The programme employed a personalized approach within a largely standardized programme structure. This approach was employed by means of individual goal setting at the start of the programme, based on a personal consultation with two team members and the Canadian Occupational Performance Measure (COPM). The personalized goals were used for the planning of the contents of the individual treatment sessions and, to a lesser extent, to tailor the content and intensity of the activities in the group sessions. The programme involved the following treatment modalities: CBT, education, individual and group exercise, relaxation and hydrotherapy (for five to seven hours per week) (see Appendix 1 for a comprehensive overview of the general characteristics and the contents of the programme, as well as the associated home-based exercises and assignments).
questionnaire comprising: age (years), gender (m/f), living arrangements (alone/together), educational level (low = up to and including lower technical and vocational training, medium = up to and including secondary technical and vocational training, high = up to and including higher technical and vocational training and university), work status (paid job, study/school, other) and average hours of work or study per week. Disease characteristics Characteristics of CWP included: localization of complaints (12 regions), duration of chronic pain complaints (years), past treatment, number of health professionals involved before referral, use of pain medication (yes/no), and the need for formal or informal help and assistive devices including mobility aids (yes/no). Treatment credibility and expectations Patients’ thoughts and expectations of their treatment were attained by means of the Credibility/Expectancy Questionnaire (CEQ) (Devilly and Borkovec, 2000). The questionnaire consists of six questions: three on what the patient ‘thinks’, utilizing a rating scale from 1 (not at all) to 9 (very much, with higher scores indicating higher credibility and/or expectations), and three on what the patient ‘expects’, utilizing a scale from 0% (not at all) to 100% (very much), the latter linearly transformed to a scale from 1 to 9. The sum score ranges from 3–27 for each of the subscales.
Assessments
Outcome assessments
Data were gathered and entered into a central database by the treating healthcare providers as part of routine clinical care at the start of the programme and at discharge, except for the assessments of sociodemographic and disease characteristics and treatment expectations, which were only done only at admission. Assessments included both paper- and computer-based questionnaires to be completed by the patients as well as interviews performed by health professionals.
Pain
Baseline assessments Sociodemographic and disease characteristics Sociodemographic characteristics at admission were recorded by means of a patient-administered 212
• Pain was measured by using the following instruments:Two 0–10 numerical rating scales (NRS pain) (Hawker et al., 2011), one pertaining to average pain over the past seven days and one pertaining to the worst moments of pain in the past seven days (0 = no pain at all, 10 = worst pain imaginable). A reduction of 2 points or 30% was assumed to be clinically important (Farrar et al., 2001). • The Pain Disability Index (PDI) (Pollard, 1984; Soer et al., 2012) records the level of disability that patients experience for each of seven categories of life activities (0 = no disability at all, 10 = all activities are disrupted/prevented by pain), with the total score ranging from 0–70. In patients with chronic back Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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pain, the minimal clinically important change in the PDI was 8.5–9.5 points (Soer et al., 2012). • The Pain Catastrophizing Scale (PCS) (Sullivan et al., 1995) measures catastrophizing related to pain. It contains 13 items that can be divided into three subscales (rumination, magnification and helplessness). The items are rated on a 5-point scale (0 = not at all, 5 = always). • The Multidimensional Pain Inventory (MPI) (Kerns et al., 1985) assesses the impact of pain, responses by significant others and effect on general activity level. It has a total of 12 subscales; in the current study only the subscale of pain severity was used. This subscale assesses pain severity and suffering on a 7-point Likert scale (0–6), with higher values representing higher levels of pain severity.
With the one-minute stair-climbing test, the patient is asked to walk as quickly as possible up and down a flight of five steps for one minute. The total score is the total number of steps taken in one minute. In patients with chronic low back pain, the minimal clinically important change ranged from 14.5 to 23.9 steps (19–31% of the mean baseline score) (Andersson et al., 2010).
Fatigue
Statistical analysis
Fatigue over the past seven days was measured using a self-administered 0–10 numerical rating scale (NRS fatigue) (0 = no fatigue, 10 = completely exhausted). As with the NRS pain, a difference of 2 points or 30% was assumed to be relevant.
Descriptive statistics were used for the baseline characteristics of the patients. Statistical comparisons between baseline and follow-up included the calculation of change scores with the 95% confidence interval, paired t-tests or the Wilcoxon signed-rank test where appropriate and estimation of effect size (ES), computed as (Pretreatment mean – Post-treatment mean) / standard deviation of the pretreatment mean. In general, an ES of >0.80 is considered large, of >0.50 moderate and of 0.80) were seen for both NRS pain and the PDI, and a moderate ES for the PCS. The MPI showed a small ES. The ES for NRS fatigue was large. With respect to activities and participation, the change scores and ESs regarding the COPM performance (4.0 to 6.1; p = 0.000) and COPM satisfaction (3.1 to 6.3; p = 0.000) were large, and clinically important. By contrast, the one-minute stair climb test showed a small improvement only. The changes in all subscales of the RAND-36 (physical functioning, role physical functioning, mental functioning and vitality) were statistically significant, with large ESs for vitality and role 214
physical and moderate ESs for physical functioning and mental functioning. Changes in the PDI scores could be computed for 119 patients. Fifty-six of them (47%) had an improvement of ≥8.5 points and were considered as improved, whereas 63 patients (53%) had a smaller improvement, no improvement or deteriorated. There were no statistically significant differences between the baseline characteristics of patients who improved and those who did not, except for a smaller proportion of patients with a duration of complaints longer than five years in the group who were clinically significantly improved with respect to the PDI (n = 30/56, 54%) as compared with the group who were stable or deteriorated (n = 48/62, 77%; for one patient, the duration of complaints was unknown) (p = 0.007) (Fisher’s exact test).
Discussion The current observational study reflecting daily practice showed substantial improvements between admission and discharge in a mixed population of patients with CWP participating in a 15-week multidisciplinary team care programme. Improvements were in particular large with respect to individual perceived limitations in activities and participation, and to a somewhat lesser extent with respect to measures of pain, fatigue, vitality and Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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Table 1. Characteristics of 165 patients with chronic widespread musculoskeletal pain taking part in a 15-week rehabilitation programme Sociodemographic characteristics Age, years; mean (SD) (n = 165) Gender, female (n = 165) Educational level† (n = 158) Low Medium High
44.1 (12.9) 143 (87%) 52 (33%) 76 (48%) 30 (19%)
Living arrangements, living alone (n = 159) Work status (n = 159) Paid job School, study Volunteer or household work, disability pension, retired, looking for a job or other Average hours of work/study per week; mean (SD) (n = 148) Characteristics of pain complaints, healthcare usage and treatment expectancies Localization of complaints (n = 163) Head Face or throat Neck Shoulder(s) Arm(s) Hand(s) and/or finger(s) Breast and/or abdomen Back Hip(s) Upper leg(s) and/or knee(s) Ankle(s) and/or foot/feet Other Average number of pain localizations; median (range) (n = 163) Duration of complaints (n = 162) 0.5–1 year 1–2 years 2–5 years More than 5 years
20 (12%) 77 (48%) 6 (4%) 76 (48%) 2.3 (1.6)
30 (18%) 13 (8%) 84 (52%) 98 (60%) 58 (36%) 65 (40%) 13 (8%) 115 (71%) 63 (39%) 79 (48%) 58 (36%) 34 (21%) 4 (1–11) 7 (4%) 14 (9%) 36 (22%) 105 (65%)
Referring professional ( n = 162) General practitioner Rheumatologist Anaesthetist or pain specialist Rehabilitation specialist Other
86 (53%) 25 (15%) 21 (13%) 16 (10%) 14 (9%)
Average number of healthcare providers seen previously; median (range) (n = 160) Current use of pain medication (n = 158) Formal and/or informal help with daily activities (n = 155) Use of assistive devices and/or mobility aids (n = 154) Treatment expectations; Credibility Expectancy Questionnaire (CEQ) mean (SD) CEQ credibility (3–27) (n = 149) CEQ expectancy (3–27) (n = 140)
4 (1–13) 119 (75%) 121 (78%) 58 (38%) 21.5 (3.4) 15.1 (4.1)
All values are numbers (%), unless otherwise stated. SD, standard deviation. †
Educational level: low = up to and including lower technical and vocational training, medium = up to and including secondary technical and vocational training,
high = up to and including higher technical and vocational training and university.
physical functioning, which is in line with the goal of the pain rehabilitation programme – namely, to increase daily activities despite the presence of pain. Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
A longer duration of complaints was associated with fewer patients showing a clinically relevant improvement on one measure of pain (i.e. the PDI). 215
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Table 2. Admission and discharge values of measures of pain, activities and participation and quality of life of patients with chronic widespread musculoskeletal pain taking part in a multidisciplinary rehabilitation programme Baseline (n = 165) Pain Pain in past week (NRS 0–10) Pain in past week worst days (NRS 0–10) Pain Disability Index (PDI, 0–70) Pain Catastrophizing Scale (PCS, 0–52) Multidimensional Pain Inventory (MPI, 0–54) Fatigue Fatigue in past week (NRS 0–10)
6.6 (1.6) 8.2 (1.3) 37.8 (10.0) 17.5 (9.4) 3.9 (1.1)
Discharge (n = 154)
5.1 7.0 27.8 11.0 3.6
(2.0) (2.0) (12.1) (8.5) (1.1)
7.3 (1.6)
5.8 (2.2)
Activities and participation COPM performance (1–10) COPM satisfaction (1–10) One-minute stair-climb test (No. of steps)
4.0 (1.2) 3.1 (1.3) 85.2 (33.0)
6.1 (1.3) 6.3 (1.6) 95.3 (35.0)
Quality of life RAND-36 physical functioning (0–100) RAND-36 role physical (0–100) RAND-36 vitality (0–100) RAND-36 mental functioning (0–100)
46.6 14.6 36.5 61.4
57.0 38.9 51.4 71.0
(19.8) (27.0) (14.8) (18.3)
(22.5) (37.1) (17.2) (16.2)
Change in score (95% CI)†
1.3 ( 1.1 ( 9.6 ( 6.1 ( 0.20 (
1.6, 1.0) 1.4, 0.8) 11.5, 7.7) 7.8, 4.4) 0.41, 0.04)
1.5 ( 1.9,
1.1)
2.1 (2.3, 1.9) 3.1 (3.4, 2.9) 9.5 (13.4, 5.5)
9.9 25.3 15.1 9.6
(12.7, (32.4, (18.4, (12.4,
7.0) 18.2) 11.7) 6.8)
Effect size‡
0.81 0.85 0.96 0.65 0.18
0.94
1.75 2.38 0.29
0.50 0.94 1.02 0.52
†
Bold figures indicate a statistically significant difference, p < 0.05, paired t-test or Wilcoxon signed-rank test
‡
For the effect size, 0.2 is considered a small effect, 0.5 a moderate effect and 0.8 a large effect.
CI, confidence interval; COPM, Canadian Occupational Performance Measure; NRS, numerical rating scale;
Regarding the composition of our study population, they were mainly women. Although the majority of patients had back pain, the gender ratio observed in the current study was more similar to that in populations of patients with fibromyalgia than to that in chronic back pain populations. In the current study, back pain was obviously part of CWP, as reported by others (Nordeman et al., 2012). Comparisons of the characteristics of patients in clinical trials are difficult to make, as the number of studies in mixed populations of patients with CWP is limited, and individual studies were often published many years ago (Scascighini et al., 2008). The characteristics of the patients in the present study were, however, similar to those of patients included in a recent observational study performed in the Netherlands. Similarities include the age, gender distribution and baseline NRS and MPI levels (De Rooij et al., 2013). Moreover, the mean values of the NRS and MPI were in the same range as those in a large sample of >5,000 patients with chronic pain (Nicholas et al., 2008). Concerning the effect of treatment, about half of the patients showed a clinically meaningful effect. This result was in line with that found on the Global 216
Perceived Effect scale employed in the study by de Rooij et al. (2013). Whereas improvements in the MPI were in a similar range, in the latter study the change of pain score (NRS) was smaller than in the present study. By comparing the baseline characteristics of patients who did and did not show a clinically significant improvement on the PDI, it was found that a longer duration of complaints was associated with less favourable outcomes. Although more research is needed, timely referral to multidisciplinary programmes seems warranted. Unfortunately, the study by de Rooij et al. (2013) did not take into account the duration of complaints. In that study, male gender; a higher level of education; less pain, fatigue and anxiety; and stronger beliefs in personal control and less belief in consequences were associated with a better outcome (De Rooij et al., 2013). The results of both that and the present study suggest that the selection of patients for multidisciplinary treatment can be improved. The intervention as delivered in the present study was largely in line with recommendations in the literature, stating that multi-component treatment approaches combining CBT and exercise, and taking Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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into account the patient’s unique needs, appear to be most effective (Hassett and Williams, 2011). The additive value of other treatment modalities, such as the provision of occupational therapy and counselling by a social worker, remains to be established. Moreover, the optimal frequency and duration of such a multidisciplinary programme are largely unknown. The present study had several limitations. First, the design was observational, and no control group was used for comparison. Therefore, it cannot be ruled out that the improvements seen could be explained by ‘regression to the mean’. Data were gathered by healthcare providers, potentially leading to more favourable results as compared with data obtained by independent assessors. In addition, there were various selection criteria for admission to the programme, so that patients with the worst prognosis were probably excluded. Unfortunately, in the present study the reasons for exclusion were not systematically recorded. Moreover, the data were gathered in daily practice, with a relatively high proportion of missing data. Despite these limitations, the results of the present study are promising and warrant additional research into the long-term outcomes of similar interventions, as well as their cost-effectiveness, including an improved identification of patients who benefit the most. REFERENCES Andersson EI, Lin CC, Smeets RJEM (2010). Performance tests in people with chronic low back pain. Spine 35: E1559–63. Bergman S, Herrström P, Högström K, Petersson IF, Svensson B, Jacobsson LTH (2001). Chronic musculoskeletal pain, prevalence rates, and sociodemographic associations in a Swedish population study. Journal of Rheumatology 28: 1369–77. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain 10: 287–333. Cohen J (1988). Statistical Power Analysis for the Behavioral Sciences (2nd edn). Hillsdale, NJ: Erlbaum. De Rooij A, van der Leeden M, Roorda LD, Steultjens MPM, Dekker J (2013). Predictors of outcome of multidisciplinary treatment in chronic widespread pain: An observational study. BMC Musculoskeletal Disorders 14: 133. Devilly GJ, Borkovec TD (2000). Psychometric properties of the credibility/expectancy questionnaire. Journal Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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Appendix 1 Overview of a 15-week multidisciplinary team care programme for patients with chronic widespread musculoskeletal pain provided in a daycare setting a. General structure of the programme Team members
Occupational therapist, social worker, physical therapist, psychotherapist, rehabilitation physician Patient involvement The patient is considered to be the most important member of the rehabilitation team and participates actively in the development, evaluation and adjustment of the rehabilitation plan Family involvement Family members or essential others are invited to attend an appointment with the social worker at the start of the programme. When indicated, family members can attend other appointments with team members Length of team care rehabilitation 94.5 hours (in centre) over a 15-week period. Patient receives a weekly therapy schedule. Treatment days are Mondays and Fridays, therapy times: 08.00–17.00 Assessments Standardized initial assessment by all team members with individual goal setting in the first three weeks of the programme. Standardized post-assessment in the last week of treatment. These assessments take place during regular treatment sessions Management An individual rehabilitation plan is formulated in the first three weeks of treatment (goal setting phase). The rehabilitation plan is endorsed in a team meeting. After six weeks, the plan is evaluated and adjusted for the final six weeks. This adjusted plan is again acknowledged in a team meeting. In the last week of treatment, a follow-up plan is made, again endorsed by the team members. The rehabilitation physician always discusses the findings of the team meeting with the patient Education People referred to the programme receive a standardized group information session delivered by the rehabilitation specialist and one team member before admission. During the programme, patients are individually educated in line with their personal needs. Group education is also provided, by means of group sessions Theoretical framework
Cognitive model
b. Treatment goals and contents, and frequencies and durations of sessions
Rehabilitation specialist (RS) Physical therapy (PT)
Goals • Identifying individual goals and life values • Observation of (pain) behaviour • Restoring balance
Location 3 × 15 minutes at 3, 9 and 15 weeks 6 × 2 hours/week (Continues)
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(Continued) Table 0. (Continued) b. Treatment goals and contents, and frequencies and durations of sessions a. General structure of the programme Occupational therapy (OT) Psychology (PS) Social work (SW) Hydrotherapy (PT)
Physical therapy group (PT)
Relaxation group (PT)
Education group (SW and PT)
• Reducing pain behaviour • Learning new coping strategies • Increasing physical and mental capacity • Training towards independent self-support
8 × 1 hour/week 15 × 1 hour/week 12 × 1 hour/week 10 × 1 hour/week Location 10 × 1 hour/week
Content • 10 minutes’ warming up (general mobilizing exercises) • 10 minutes’ moving/swimming (personal graded activity scheme) • 10 minutes’ relaxation exercises in the water • 10 minutes’ moving/swimming (personal graded activity scheme) • 10 minutes’ relaxation exercises in the water • 10 minutes’ cooling down/group play Patients exercise twice a week during individual and group PT sessions. 12 × 1 hour/week Exercises during PT group sessions are individually tailored. All schemes are graded activity based. Although many individual differences occur, the general content of a training schedule are: • 20–30 minutes cardiovascular exercises at 60% of the age-specific maximal heart rate; • 4–6 strength exercises aimed at large muscle groups (2 × 20 repetitions, equivalent to 60–70% of one repetition maximum (1RM; the maximum amount of weight one can lift in a single repetition for a given exercise)); • Range of motion (ROM) and relaxation exercises in between (min. ten repetitions for ROM or one minute for relaxation). • 20 minutes: exercise according to lesson theme 6 × 1 hour/week (e.g. breathing exercises, mindfulness); • 20 minutes: education and sharing experiences; • 20 minutes: exercise according to lesson theme. 6 × 1.5 hour/week • Topics include e.g. Body awareness, mindfulness meditation, active listening, active speaking, connecting to others and self, closure and letting go, desire–expectation–disappointment–blame, saying no.
c. Home-based exercises
Graded activity
Relaxation/meditation
ROM exercises Other exercises and assignments
Content A graded activity plan for six weeks is made, related to a relevant goal of the patient at the level of activities (e.g. walking a distance, riding a bike, etc.). • Training starts at 70% of baseline level • Exercises are performed daily • After every three training sessions, a maximum of a 10% increase is set for the next training session • After six weeks, evaluation and adjustments are made and if necessary a plan for the next period is developed At home, the patient practises the relaxation and meditation learned during individual and group treatments. Exercises are described in a booklet and an audio-CD is provided. The patient practises twice a day for as long as needed A variety of 6–20 ROM exercises are offered, with advice to perform each exercise ten times daily Additional strength, flexibility and other physical exercises are added to the exercise plan if necessary (not standard). Patients receive assignments from the team members to work on at home. On average, the additional exercises and assignments take 1–2 hours per week
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Location 10–60 minutes/ day
2 × 5–30 min/day
5–7 × 5 min/day 1–2 hours/week
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Multidisciplinary Rehabilitation for Chronic Widespread Musculoskeletal Pain: Results from Daily Practice Robin Koele1, Gerard Volker1, Félicie van Vree1, Marc van Gestel1, Albère Köke2,3 & Theodora Vliet Vlieland1,4* 1
Rijnlands Rehabilitation Centre, Leiden, the Netherlands
2
Adelante Centre of Expertise in Rehabilitation, Hoensbroek, the Netherlands
3
Department of rehabilitation Medicine; research School of CAPHRI, Maastricht University, the Netherlands
4
Dept of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, the Netherlands
Abstract Introduction: Evidence for the efficacy of a multi-component approach for chronic widespread musculoskeletal pain (CWP) has been reported, although the effects are overall moderate and this approach has rarely been investigated in real life. Aim: The aim of the study was to describe the effects of a 15-week multidisciplinary pain rehabilitation programme on pain, activities and participation in patients with CWP. Methods: The current retrospective study used data which were routinely gathered on all consecutive patients with CWP referred to a rehabilitation programme over a 21-month period. The 15-week multidisciplinary rehabilitation programme consisted of cognitive behavioural therapy and exercise, as well as individual and group sessions with additional treatment modalities. Assessments included the Pain Disability Index (PDI), the Pain Catastrophizing Scale (PCS), the Multidimensional Pain Inventory (MPI), numerical scales for pain and fatigue, the Canadian Occupational Performance Measure (COPM), the one-minute stair-climb test and the RAND-36. Paired t-tests and Wilcoxon signed-rank tests were carried out to analyse changes over time. Results: A total of 165 patients were included [mean age 44.1 (standard deviation 12.9) years], 143 (87%) women). Discharge data were available for 154 patients (93%). All outcomes showed statistically significant improvements between admission and discharge (p < 0.05), with the largest effect sizes (>1.0) observed for the COPM. A longer duration of complaints was associated with less improvement in the PDI. Discussion and conclusion: In daily rehabilitation practice, a 15-week multidisciplinary treatment programme for patients with CWP showed statistically significant improvements in pain, activities and participation over time. Future studies are needed further to substantiate the long-term cost-effectiveness, and to identify the patients who benefit the most. Copyright © 2014 John Wiley & Sons, Ltd. Keywords Chronic widespread pain; chronic pain; multidisciplinary treatment; rehabilitation *Correspondence Theodora P.M. Vliet Vlieland, Rijnlands Rehabilitation Centre, P.O. Box 176, 2300 AD Leiden, the Netherlands. Email: [email protected] Published online 10 June 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1076
Introduction Chronic widespread pain (CWP) affecting the musculoskeletal system is a common condition, with a population prevalence of ∼ 19% (Bergman et al., 2001; 210
Breivik et al., 2006). It is common to classify chronic musculoskeletal pain according to its site(s) of origin – it may be localized to a single joint (such as a shoulder or knee), a region or a limb (the back or the legs, for example) or it may be generalized pain (often considered Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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synonymous with fibromyalgia) (Dieppe, 2013). A recent ‘paradigm shift’ in the approach to musculoskeletal diseases has been the recognition that pain should be thought of as a separate issue – the ‘fifth vital sign in medicine’ and a disease in its own right (Dieppe, 2013). There is growing consensus indicating that the best approach to treatment for CWP involves a combination of pharmacological and non-pharmacological interventions. Despite the overall favourable, yet limited, effects, systematic reviews of the literature demonstrated substantial variation regarding the content, frequency and duration of the multi-component interventions provided in randomized controlled trials (Hassett and Williams, 2011; Mannerkorpi and Henriksson, 2007; Scascighini et al., 2008). In general, a multi-component treatment approach that combines cognitive behavioural therapy (CBT) with exercise and takes into account the patient’s unique needs appears to be most effective (Hassett and Williams, 2011). In spite of the evidence resulting from randomized clinical trials, it remains to be established the extent to which similar results can be obtained in daily practice. Patients with CWP in randomized clinical trials already constitute a heterogeneous population, whereas the variety of the characteristics among patients who are actually referred to multi-component rehabilitation programmes may be even larger. Moreover, the clinical studies included in systematic reviews were in many cases published several decades ago, so that the patient characteristics may not be comparable with those of patients who are admitted in the 21st century. In addition, knowledge about patients who do and do not benefit from treatment would be important for appropriate patient selection. A recent study among 120 patients with CWP undergoing multidisciplinary treatment found that male gender; a higher level of education; less pain, fatigue and anxiety; stronger beliefs in personal control and less belief in consequences were associated with a better outcome regarding pain, depression and the general perceived effect (De Rooij et al., 2013). The purpose of the current study was therefore to assess the effectiveness of a 15-week multidisciplinary programme on pain, fatigue, physical performance, quality of life, activities and participation in a mixed population of patients with CWP and the patient characteristics associated with improvement. Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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Methods Study design A retrospective design was used. All data were routinely gathered and stored in electronic patient records in connection with a multidisciplinary team care intervention for patients with CWP. In the Netherlands, no permission from a medical ethics committee is required for the evaluation of outcomes of care based solely on data derived from the medical records and executed by the treating physician. On admission, all patients are routinely asked to sign an informed consent form, stating that the data stored in their electronic medical record can be used anonymously by their treating physician for analyses of the outcomes of care. The conduct of the current study, and in particular the handling of the data, was done in accordance with the guidelines for good research practice (World Health Organization, 2002).
Patients All consecutive patients with CWP who were admitted to the multidisciplinary programme provided at the Rijnlands Rehabilitation Centre, in Leiden, the Netherlands, between 1 March 2011 and 1 December 2012 were eligible for inclusion in the study. All patients lived within a distance of 20 kilometres from the rehabilitation centre. Inclusion criteria for the programme were: age >18 years; having CWP, with a duration of complaints >3 months; sufficient treatment of underlying somatic condition if applicable; severe limitations in daily activities and participation; being motivated and able to take part in a multidisciplinary treatment programme for 15 weeks. Exclusion criteria were: being unable to understand or speak Dutch; participation in a similar rehabilitation programme in the previous three years; involvement in legal procedures related to their chronic pain syndrome; current, intensive treatment for psychological or work-related problems, irrespective of whether or not they were connected to the chronic musculoskeletal pain. Screening for eligibility for the programme was done by a physician, psychologist and physical therapist, with the final decision on admission being based on consensus. 211
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Intervention All eligible patients took part in the same outpatient, multidisciplinary programme at the rehabilitation centre. The programme was provided by a multidisciplinary team comprising a rehabilitation physician, an occupational therapist, a social worker, a psychologist and a physical therapist. The programme was mainly based on a cognitive behavioural model that had been described and used in patients with unexplained physical symptoms (Zonneveld et al., 2009, 2010). The overall goal was to optimize the patients’ functioning with respect to activities and participation by supporting them in managing their pain. The programme employed a personalized approach within a largely standardized programme structure. This approach was employed by means of individual goal setting at the start of the programme, based on a personal consultation with two team members and the Canadian Occupational Performance Measure (COPM). The personalized goals were used for the planning of the contents of the individual treatment sessions and, to a lesser extent, to tailor the content and intensity of the activities in the group sessions. The programme involved the following treatment modalities: CBT, education, individual and group exercise, relaxation and hydrotherapy (for five to seven hours per week) (see Appendix 1 for a comprehensive overview of the general characteristics and the contents of the programme, as well as the associated home-based exercises and assignments).
questionnaire comprising: age (years), gender (m/f), living arrangements (alone/together), educational level (low = up to and including lower technical and vocational training, medium = up to and including secondary technical and vocational training, high = up to and including higher technical and vocational training and university), work status (paid job, study/school, other) and average hours of work or study per week. Disease characteristics Characteristics of CWP included: localization of complaints (12 regions), duration of chronic pain complaints (years), past treatment, number of health professionals involved before referral, use of pain medication (yes/no), and the need for formal or informal help and assistive devices including mobility aids (yes/no). Treatment credibility and expectations Patients’ thoughts and expectations of their treatment were attained by means of the Credibility/Expectancy Questionnaire (CEQ) (Devilly and Borkovec, 2000). The questionnaire consists of six questions: three on what the patient ‘thinks’, utilizing a rating scale from 1 (not at all) to 9 (very much, with higher scores indicating higher credibility and/or expectations), and three on what the patient ‘expects’, utilizing a scale from 0% (not at all) to 100% (very much), the latter linearly transformed to a scale from 1 to 9. The sum score ranges from 3–27 for each of the subscales.
Assessments
Outcome assessments
Data were gathered and entered into a central database by the treating healthcare providers as part of routine clinical care at the start of the programme and at discharge, except for the assessments of sociodemographic and disease characteristics and treatment expectations, which were only done only at admission. Assessments included both paper- and computer-based questionnaires to be completed by the patients as well as interviews performed by health professionals.
Pain
Baseline assessments Sociodemographic and disease characteristics Sociodemographic characteristics at admission were recorded by means of a patient-administered 212
• Pain was measured by using the following instruments:Two 0–10 numerical rating scales (NRS pain) (Hawker et al., 2011), one pertaining to average pain over the past seven days and one pertaining to the worst moments of pain in the past seven days (0 = no pain at all, 10 = worst pain imaginable). A reduction of 2 points or 30% was assumed to be clinically important (Farrar et al., 2001). • The Pain Disability Index (PDI) (Pollard, 1984; Soer et al., 2012) records the level of disability that patients experience for each of seven categories of life activities (0 = no disability at all, 10 = all activities are disrupted/prevented by pain), with the total score ranging from 0–70. In patients with chronic back Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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pain, the minimal clinically important change in the PDI was 8.5–9.5 points (Soer et al., 2012). • The Pain Catastrophizing Scale (PCS) (Sullivan et al., 1995) measures catastrophizing related to pain. It contains 13 items that can be divided into three subscales (rumination, magnification and helplessness). The items are rated on a 5-point scale (0 = not at all, 5 = always). • The Multidimensional Pain Inventory (MPI) (Kerns et al., 1985) assesses the impact of pain, responses by significant others and effect on general activity level. It has a total of 12 subscales; in the current study only the subscale of pain severity was used. This subscale assesses pain severity and suffering on a 7-point Likert scale (0–6), with higher values representing higher levels of pain severity.
With the one-minute stair-climbing test, the patient is asked to walk as quickly as possible up and down a flight of five steps for one minute. The total score is the total number of steps taken in one minute. In patients with chronic low back pain, the minimal clinically important change ranged from 14.5 to 23.9 steps (19–31% of the mean baseline score) (Andersson et al., 2010).
Fatigue
Statistical analysis
Fatigue over the past seven days was measured using a self-administered 0–10 numerical rating scale (NRS fatigue) (0 = no fatigue, 10 = completely exhausted). As with the NRS pain, a difference of 2 points or 30% was assumed to be relevant.
Descriptive statistics were used for the baseline characteristics of the patients. Statistical comparisons between baseline and follow-up included the calculation of change scores with the 95% confidence interval, paired t-tests or the Wilcoxon signed-rank test where appropriate and estimation of effect size (ES), computed as (Pretreatment mean – Post-treatment mean) / standard deviation of the pretreatment mean. In general, an ES of >0.80 is considered large, of >0.50 moderate and of 0.80) were seen for both NRS pain and the PDI, and a moderate ES for the PCS. The MPI showed a small ES. The ES for NRS fatigue was large. With respect to activities and participation, the change scores and ESs regarding the COPM performance (4.0 to 6.1; p = 0.000) and COPM satisfaction (3.1 to 6.3; p = 0.000) were large, and clinically important. By contrast, the one-minute stair climb test showed a small improvement only. The changes in all subscales of the RAND-36 (physical functioning, role physical functioning, mental functioning and vitality) were statistically significant, with large ESs for vitality and role 214
physical and moderate ESs for physical functioning and mental functioning. Changes in the PDI scores could be computed for 119 patients. Fifty-six of them (47%) had an improvement of ≥8.5 points and were considered as improved, whereas 63 patients (53%) had a smaller improvement, no improvement or deteriorated. There were no statistically significant differences between the baseline characteristics of patients who improved and those who did not, except for a smaller proportion of patients with a duration of complaints longer than five years in the group who were clinically significantly improved with respect to the PDI (n = 30/56, 54%) as compared with the group who were stable or deteriorated (n = 48/62, 77%; for one patient, the duration of complaints was unknown) (p = 0.007) (Fisher’s exact test).
Discussion The current observational study reflecting daily practice showed substantial improvements between admission and discharge in a mixed population of patients with CWP participating in a 15-week multidisciplinary team care programme. Improvements were in particular large with respect to individual perceived limitations in activities and participation, and to a somewhat lesser extent with respect to measures of pain, fatigue, vitality and Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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Table 1. Characteristics of 165 patients with chronic widespread musculoskeletal pain taking part in a 15-week rehabilitation programme Sociodemographic characteristics Age, years; mean (SD) (n = 165) Gender, female (n = 165) Educational level† (n = 158) Low Medium High
44.1 (12.9) 143 (87%) 52 (33%) 76 (48%) 30 (19%)
Living arrangements, living alone (n = 159) Work status (n = 159) Paid job School, study Volunteer or household work, disability pension, retired, looking for a job or other Average hours of work/study per week; mean (SD) (n = 148) Characteristics of pain complaints, healthcare usage and treatment expectancies Localization of complaints (n = 163) Head Face or throat Neck Shoulder(s) Arm(s) Hand(s) and/or finger(s) Breast and/or abdomen Back Hip(s) Upper leg(s) and/or knee(s) Ankle(s) and/or foot/feet Other Average number of pain localizations; median (range) (n = 163) Duration of complaints (n = 162) 0.5–1 year 1–2 years 2–5 years More than 5 years
20 (12%) 77 (48%) 6 (4%) 76 (48%) 2.3 (1.6)
30 (18%) 13 (8%) 84 (52%) 98 (60%) 58 (36%) 65 (40%) 13 (8%) 115 (71%) 63 (39%) 79 (48%) 58 (36%) 34 (21%) 4 (1–11) 7 (4%) 14 (9%) 36 (22%) 105 (65%)
Referring professional ( n = 162) General practitioner Rheumatologist Anaesthetist or pain specialist Rehabilitation specialist Other
86 (53%) 25 (15%) 21 (13%) 16 (10%) 14 (9%)
Average number of healthcare providers seen previously; median (range) (n = 160) Current use of pain medication (n = 158) Formal and/or informal help with daily activities (n = 155) Use of assistive devices and/or mobility aids (n = 154) Treatment expectations; Credibility Expectancy Questionnaire (CEQ) mean (SD) CEQ credibility (3–27) (n = 149) CEQ expectancy (3–27) (n = 140)
4 (1–13) 119 (75%) 121 (78%) 58 (38%) 21.5 (3.4) 15.1 (4.1)
All values are numbers (%), unless otherwise stated. SD, standard deviation. †
Educational level: low = up to and including lower technical and vocational training, medium = up to and including secondary technical and vocational training,
high = up to and including higher technical and vocational training and university.
physical functioning, which is in line with the goal of the pain rehabilitation programme – namely, to increase daily activities despite the presence of pain. Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
A longer duration of complaints was associated with fewer patients showing a clinically relevant improvement on one measure of pain (i.e. the PDI). 215
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Table 2. Admission and discharge values of measures of pain, activities and participation and quality of life of patients with chronic widespread musculoskeletal pain taking part in a multidisciplinary rehabilitation programme Baseline (n = 165) Pain Pain in past week (NRS 0–10) Pain in past week worst days (NRS 0–10) Pain Disability Index (PDI, 0–70) Pain Catastrophizing Scale (PCS, 0–52) Multidimensional Pain Inventory (MPI, 0–54) Fatigue Fatigue in past week (NRS 0–10)
6.6 (1.6) 8.2 (1.3) 37.8 (10.0) 17.5 (9.4) 3.9 (1.1)
Discharge (n = 154)
5.1 7.0 27.8 11.0 3.6
(2.0) (2.0) (12.1) (8.5) (1.1)
7.3 (1.6)
5.8 (2.2)
Activities and participation COPM performance (1–10) COPM satisfaction (1–10) One-minute stair-climb test (No. of steps)
4.0 (1.2) 3.1 (1.3) 85.2 (33.0)
6.1 (1.3) 6.3 (1.6) 95.3 (35.0)
Quality of life RAND-36 physical functioning (0–100) RAND-36 role physical (0–100) RAND-36 vitality (0–100) RAND-36 mental functioning (0–100)
46.6 14.6 36.5 61.4
57.0 38.9 51.4 71.0
(19.8) (27.0) (14.8) (18.3)
(22.5) (37.1) (17.2) (16.2)
Change in score (95% CI)†
1.3 ( 1.1 ( 9.6 ( 6.1 ( 0.20 (
1.6, 1.0) 1.4, 0.8) 11.5, 7.7) 7.8, 4.4) 0.41, 0.04)
1.5 ( 1.9,
1.1)
2.1 (2.3, 1.9) 3.1 (3.4, 2.9) 9.5 (13.4, 5.5)
9.9 25.3 15.1 9.6
(12.7, (32.4, (18.4, (12.4,
7.0) 18.2) 11.7) 6.8)
Effect size‡
0.81 0.85 0.96 0.65 0.18
0.94
1.75 2.38 0.29
0.50 0.94 1.02 0.52
†
Bold figures indicate a statistically significant difference, p < 0.05, paired t-test or Wilcoxon signed-rank test
‡
For the effect size, 0.2 is considered a small effect, 0.5 a moderate effect and 0.8 a large effect.
CI, confidence interval; COPM, Canadian Occupational Performance Measure; NRS, numerical rating scale;
Regarding the composition of our study population, they were mainly women. Although the majority of patients had back pain, the gender ratio observed in the current study was more similar to that in populations of patients with fibromyalgia than to that in chronic back pain populations. In the current study, back pain was obviously part of CWP, as reported by others (Nordeman et al., 2012). Comparisons of the characteristics of patients in clinical trials are difficult to make, as the number of studies in mixed populations of patients with CWP is limited, and individual studies were often published many years ago (Scascighini et al., 2008). The characteristics of the patients in the present study were, however, similar to those of patients included in a recent observational study performed in the Netherlands. Similarities include the age, gender distribution and baseline NRS and MPI levels (De Rooij et al., 2013). Moreover, the mean values of the NRS and MPI were in the same range as those in a large sample of >5,000 patients with chronic pain (Nicholas et al., 2008). Concerning the effect of treatment, about half of the patients showed a clinically meaningful effect. This result was in line with that found on the Global 216
Perceived Effect scale employed in the study by de Rooij et al. (2013). Whereas improvements in the MPI were in a similar range, in the latter study the change of pain score (NRS) was smaller than in the present study. By comparing the baseline characteristics of patients who did and did not show a clinically significant improvement on the PDI, it was found that a longer duration of complaints was associated with less favourable outcomes. Although more research is needed, timely referral to multidisciplinary programmes seems warranted. Unfortunately, the study by de Rooij et al. (2013) did not take into account the duration of complaints. In that study, male gender; a higher level of education; less pain, fatigue and anxiety; and stronger beliefs in personal control and less belief in consequences were associated with a better outcome (De Rooij et al., 2013). The results of both that and the present study suggest that the selection of patients for multidisciplinary treatment can be improved. The intervention as delivered in the present study was largely in line with recommendations in the literature, stating that multi-component treatment approaches combining CBT and exercise, and taking Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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into account the patient’s unique needs, appear to be most effective (Hassett and Williams, 2011). The additive value of other treatment modalities, such as the provision of occupational therapy and counselling by a social worker, remains to be established. Moreover, the optimal frequency and duration of such a multidisciplinary programme are largely unknown. The present study had several limitations. First, the design was observational, and no control group was used for comparison. Therefore, it cannot be ruled out that the improvements seen could be explained by ‘regression to the mean’. Data were gathered by healthcare providers, potentially leading to more favourable results as compared with data obtained by independent assessors. In addition, there were various selection criteria for admission to the programme, so that patients with the worst prognosis were probably excluded. Unfortunately, in the present study the reasons for exclusion were not systematically recorded. Moreover, the data were gathered in daily practice, with a relatively high proportion of missing data. Despite these limitations, the results of the present study are promising and warrant additional research into the long-term outcomes of similar interventions, as well as their cost-effectiveness, including an improved identification of patients who benefit the most. REFERENCES Andersson EI, Lin CC, Smeets RJEM (2010). Performance tests in people with chronic low back pain. Spine 35: E1559–63. Bergman S, Herrström P, Högström K, Petersson IF, Svensson B, Jacobsson LTH (2001). Chronic musculoskeletal pain, prevalence rates, and sociodemographic associations in a Swedish population study. Journal of Rheumatology 28: 1369–77. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain 10: 287–333. Cohen J (1988). Statistical Power Analysis for the Behavioral Sciences (2nd edn). Hillsdale, NJ: Erlbaum. De Rooij A, van der Leeden M, Roorda LD, Steultjens MPM, Dekker J (2013). Predictors of outcome of multidisciplinary treatment in chronic widespread pain: An observational study. BMC Musculoskeletal Disorders 14: 133. Devilly GJ, Borkovec TD (2000). Psychometric properties of the credibility/expectancy questionnaire. Journal Musculoskelet. Care 12 (2014) 210–220 © 2014 John Wiley & Sons, Ltd.
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Appendix 1 Overview of a 15-week multidisciplinary team care programme for patients with chronic widespread musculoskeletal pain provided in a daycare setting a. General structure of the programme Team members
Occupational therapist, social worker, physical therapist, psychotherapist, rehabilitation physician Patient involvement The patient is considered to be the most important member of the rehabilitation team and participates actively in the development, evaluation and adjustment of the rehabilitation plan Family involvement Family members or essential others are invited to attend an appointment with the social worker at the start of the programme. When indicated, family members can attend other appointments with team members Length of team care rehabilitation 94.5 hours (in centre) over a 15-week period. Patient receives a weekly therapy schedule. Treatment days are Mondays and Fridays, therapy times: 08.00–17.00 Assessments Standardized initial assessment by all team members with individual goal setting in the first three weeks of the programme. Standardized post-assessment in the last week of treatment. These assessments take place during regular treatment sessions Management An individual rehabilitation plan is formulated in the first three weeks of treatment (goal setting phase). The rehabilitation plan is endorsed in a team meeting. After six weeks, the plan is evaluated and adjusted for the final six weeks. This adjusted plan is again acknowledged in a team meeting. In the last week of treatment, a follow-up plan is made, again endorsed by the team members. The rehabilitation physician always discusses the findings of the team meeting with the patient Education People referred to the programme receive a standardized group information session delivered by the rehabilitation specialist and one team member before admission. During the programme, patients are individually educated in line with their personal needs. Group education is also provided, by means of group sessions Theoretical framework
Cognitive model
b. Treatment goals and contents, and frequencies and durations of sessions
Rehabilitation specialist (RS) Physical therapy (PT)
Goals • Identifying individual goals and life values • Observation of (pain) behaviour • Restoring balance
Location 3 × 15 minutes at 3, 9 and 15 weeks 6 × 2 hours/week (Continues)
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(Continued) Table 0. (Continued) b. Treatment goals and contents, and frequencies and durations of sessions a. General structure of the programme Occupational therapy (OT) Psychology (PS) Social work (SW) Hydrotherapy (PT)
Physical therapy group (PT)
Relaxation group (PT)
Education group (SW and PT)
• Reducing pain behaviour • Learning new coping strategies • Increasing physical and mental capacity • Training towards independent self-support
8 × 1 hour/week 15 × 1 hour/week 12 × 1 hour/week 10 × 1 hour/week Location 10 × 1 hour/week
Content • 10 minutes’ warming up (general mobilizing exercises) • 10 minutes’ moving/swimming (personal graded activity scheme) • 10 minutes’ relaxation exercises in the water • 10 minutes’ moving/swimming (personal graded activity scheme) • 10 minutes’ relaxation exercises in the water • 10 minutes’ cooling down/group play Patients exercise twice a week during individual and group PT sessions. 12 × 1 hour/week Exercises during PT group sessions are individually tailored. All schemes are graded activity based. Although many individual differences occur, the general content of a training schedule are: • 20–30 minutes cardiovascular exercises at 60% of the age-specific maximal heart rate; • 4–6 strength exercises aimed at large muscle groups (2 × 20 repetitions, equivalent to 60–70% of one repetition maximum (1RM; the maximum amount of weight one can lift in a single repetition for a given exercise)); • Range of motion (ROM) and relaxation exercises in between (min. ten repetitions for ROM or one minute for relaxation). • 20 minutes: exercise according to lesson theme 6 × 1 hour/week (e.g. breathing exercises, mindfulness); • 20 minutes: education and sharing experiences; • 20 minutes: exercise according to lesson theme. 6 × 1.5 hour/week • Topics include e.g. Body awareness, mindfulness meditation, active listening, active speaking, connecting to others and self, closure and letting go, desire–expectation–disappointment–blame, saying no.
c. Home-based exercises
Graded activity
Relaxation/meditation
ROM exercises Other exercises and assignments
Content A graded activity plan for six weeks is made, related to a relevant goal of the patient at the level of activities (e.g. walking a distance, riding a bike, etc.). • Training starts at 70% of baseline level • Exercises are performed daily • After every three training sessions, a maximum of a 10% increase is set for the next training session • After six weeks, evaluation and adjustments are made and if necessary a plan for the next period is developed At home, the patient practises the relaxation and meditation learned during individual and group treatments. Exercises are described in a booklet and an audio-CD is provided. The patient practises twice a day for as long as needed A variety of 6–20 ROM exercises are offered, with advice to perform each exercise ten times daily Additional strength, flexibility and other physical exercises are added to the exercise plan if necessary (not standard). Patients receive assignments from the team members to work on at home. On average, the additional exercises and assignments take 1–2 hours per week
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Location 10–60 minutes/ day
2 × 5–30 min/day
5–7 × 5 min/day 1–2 hours/week
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