Predictors of multidisciplinary treatment outcome in patients with chronic musculoskeletal pain

Abstract

Purpose: The present study aimed to identify predictors of rehabilitation outcome for patients with chronic musculoskeletal pain (CMP) and psychological problems. Methods: A retrospective cohort study including 230 adult patients with CMP admitted for multidisciplinary pain rehabilitation. Potential predictors were patient characteristics, duration of complaints, baseline functioning, pain, personality, coping style, fear of movement, psychological distress and type of treatment. Outcome measures were physical functioning, mental health, pain and patient-reported effect. Multiple (logistic) regression models were used to identify predictors. Results: Patients who were more disabled and patients with more pain benefitted more from the rehabilitation treatment than less disabled patients or those with less pain. Age, work status, vitality, depression and coping style also predicted outcomes significantly. The models explained between 27 and 80% of the outcomes. There was an interaction between type of treatment, work status and the baseline pain score as regards the outcome in terms of pain. Conclusions: No strong predictors of treatment outcome were found other than the baseline scores of the respective outcome variables. More disabled patients and patients with more pain benefitted more from the rehabilitation program. Other predictors improved the prediction models slightly.

• Implications for Rehabilitation

• It remains challenging to correctly predict the outcome of treatment from patients’ baseline sociodemographic and psychological characteristics; predictors other than baseline scores of the outcome variables are only slightly associated with treatment outcome.

• Patients with chronic musculoskeletal pain and poor physical functioning or mental health benefit most from pain rehabilitation.

• Older patients benefit less from a pain rehabilitation program than younger patients in terms of physical functioning.

• Pain reduction during a pain rehabilitation program is greatest in patients with high pain intensity who are not at work at the start of the rehabilitation program.

• Coping style influences the outcome of rehabilitation of patients with chronic musculoskeletal pain.

     

Chronic pain affects the whole person – a phenomenological study

Abstract

Purpose: The aim of this qualitative study was to explore participants’ perspectives on the effects of chronic pain on the psychophysical unity. Methods: Thirty-four chronic pain outpatients were interviewed, and the transcribed interviews were analysed with Giorgi’s four-phase phenomenological method. The mean age of the participants was 48 years, and 19 of them were women. For 21 of the participants, the pain duration was more than 5 years, and most had degenerative spinal pain. Results: The results of this whole research project indicated that the phenomenon chronic pain consisted of four essential themes: Pain affects the whole person, invisibility, negativity, and dominance of pain. This study concentrates only on one theme “Chronic pain affects the whole person”, in which were found eight subthemes in the interviews. The strongest argument made by the participants was not the physical pain itself but the psychosocial consequences, such as distress, loneliness, lost identity, and low quality of life which were their main problems. Conclusions: In multidisciplinary holistic rehabilitation, it is essential to take care of the patient’s psychological distress. A potential source of psychosocial symptoms may be the subjective responses to experience of chronic pain due to the subjective meanings of pain.

• Implications for Rehabilitation

• About chronic pain

• Pain is an experience, not only an aversive sensation. Intensity of pain describes only the sensation, not the experience of pain.

• In chronic pain, the main complaint may be not the physical pain, but the distress. In rehabilitation, the patient needs to be taken as a whole person.

• Multidisciplinary rehabilitation, including patient counselling should be the fundamental part of treatment.

• In rehabilitation, the individual meaning of chronic pain needs to be disclosed.

     

Comorbid insomnia in patients with chronic pain: a study based on the Swedish quality registry for pain rehabilitation (SQRP)

Abstract

Purpose: This study investigates the prevalence of insomnia and its relationship to other symptoms and health aspects in patients with chronic pain. Methods: Patients with chronic pain conditions (n?=?845) referred to a multidisciplinary pain centre completed surveys provided by the Swedish quality registry for pain rehabilitation (SQRP). The SQRP collects data on socio-demographics, health status, symptoms of pain, mood and insomnia and life satisfaction. Results: The majority of patients (65.3%) had clinical insomnia according to the insomnia severity index (ISI). Insomnia correlated significantly but weakly with pain, depression, anxiety and coping; the strongest multivariate correlations were found with depression and anxiety followed by pain interference and pain severity. Pain intensity, depression and anxiety correlated stronger than ISI with respect to the two investigated aspects of health. Conclusions: The prevalence of insomnia is high in patients with chronic pain conditions, but the level of importance in relation to other symptoms for health aspects is low, and the associations with other important symptoms are relatively weak. One way to increase the effects of multimodal rehabilitation programs may be to provide interventions directed specifically at insomnia rather than focusing only on interventions that address pain, depression and anxiety.

• Implications for Rehabilitation

• The prevalence of insomnia is high in patients with complex chronic pain conditions.

• Relatively low correlations existed between insomnia and pain intensity, depression, anxiety and other psychological aspects.

• Pain intensity, anxiety and depression were more important for perceived health aspects than insomnia.

• One way to increase the effects of multimodal rehabilitation programs may be to also include interventions directed directly to insomnia.

     

Psychosocial coping profiles after pain rehabilitation: associations with occupational performance and patient characteristics

Purpose The aims of the present study were to assess: (i) changes in coping by use of Multidimensional Pain Inventory profiles from baseline to follow-up, (ii) associations between Adaptive Coper (AC) profiles at follow-up and improvements in occupational performance (by Canadian Occupational Performance Measure COPM) and (iii) ability to predict AC profiles at follow-up by participants’ baseline characteristics. Method Data at baseline, discharge and follow-up from 525 participants in a pain rehabilitation program were analyzed with multivariate statistics. Results AC profiles increased and Dysfunctional (DYS) profiles decreased at follow-up. Clinically relevant improvements on COPM were associated with having an AC profile at follow-up. Being Nordic born, having longer education, an AC profile and higher baseline scores on satisfaction with performance predicted an AC profile at follow-up. Conclusions Pain rehabilitation seems to result in sustainable and favourable coping strategies at follow-up, and improved occupational performance is associated with favourable coping at follow-up. Outcomes need to be measured independently of improved coping strategies and improvements of participant’s individual goals such as difficulties to perform their most meaningful occupations. Patients at risk for unfavourable coping strategies may need modified interventions.

• Implications for Rehabilitation

• More participants reported a beneficial coping, MPI profile, in a long-term perspective after a pain rehabilitation program.

• Improvements on occupational performance prioritized as meaningful by each of the participants are related to adequate coping strategies at follow-up.

• The associations between improved occupational performance and beneficial coping profiles need to be better understood.

• Patients with worse initial occupational performance may need modified pain rehabilitation interventions to improve their coping strategies.

     

Patient expectations for a multimodal pain rehabilitation programme: active participation and coping skills. A qualitative study

Purpose: To describe what patients with chronic pain expect from a multimodal pain rehabilitation programme.

Material and method: Qualitative interviews were used to uncover expectations about a multimodal rehabilitation programme offered at the Pain and Rehabilitations Centre, The University Hospital; Linköping, Sweden. Sixteen women and two men (mean age 37 years; standard deviation 10 years) with chronic benign pain participated. The interviews were analysed using qualitative content analyses.

Results: To participate actively in the multimodal pain rehabilitation programme and to learn adequate coping strategies to improve daily life emerged as a main category. It was based on the following four categories comprising expectations about: participating actively in the programme, interacting with the professionals and fellow patients, cognitive effects of the programme and tools for coping, and explicit effects from the programme.

Conclusions: Many patients expressed expectations which may reflect that the information before the programme had started rehabilitation process at the time point for this study. The results could be applied in rehabilitation programmes by acknowledging expectations to interact with professional team members and fellow patients, by early addressing of positive and negative expectations about the future pain and by incorporating and strengthen expectations of learning to cope with pain.

• Implications for Rehabilitation

• Patients' expectations to interact with professional team members and fellow patients by participating actively in the pain rehabilitation programme should be acknowledged in each rehabilitation situation.

• Patients expressed both positive and negative expectations about their future pain situation and these expectations should be addressed as early as possible in the rehabilitation screening process.

• Patients' expectations of learning to cope with pain should be incorporated and strengthened in multimodal pain rehabilitation programmes.

     

Reliability and validity study of the Finnish version of the Chronic Pain Acceptance Questionnaire (CPAQ)

Purpose: Acceptance has been discovered to be successful in improving quality of life when adjusting to chronic pain. Instead of avoiding and controlling the pain, the goal is to confront the pain and to live a value directed life. Thus far, there has not been an instrument in Finnish to assess the acceptance of chronic pain. This study aimed at translating the Chronic Pain Acceptance Questionnaire-(CPAQ)-into Finnish and assessing its reliability and validity. Method: Eighty-one persons with different types of chronic pain responded to the CPAQ, the Beck Depression Inventory (BDI), RAND-36 and questions of sociodemographic and pain-related variables. Results: The responders’ ages varied from 16 to 83 years (mean = 48.5 years) and 63% of them were women. For 55% of the participants, the pain had lasted more than 4 years and 63% from the sample had chronic pain in the low back or lower extremities. In test-retest analysis, the interclass correlation coefficient (ICC ) values were good, 0.81–0.87. Internal consistency was very good (α = 0.86). There was no floor-ceiling effect in the Finnish version of CPAQ. Correlation was found between both subscales of the CPAQ and every domain of the RAND-36 (r = 0.23; 0.68) and the BDI (r = ?0.24; ?0.62). Education, age, pain avoidance, social support and pain intensity correlated with either one of the subscales or total CPAQ. CPAQ revealed no association between fear of pain and pain duration. Conclusions: In conclusion, the Finnish version of the CPAQ is a reliable and valid method for measuring chronic pain acceptance.

Implications for Rehabilitation

Chronic Pain Acceptance Questionnaire

• There has not been an instrument in Finnish to assess the acceptance of chronic pain.

• The Finnish version of the Chronic Pain Acceptance Questionnaire (CPAQ) is a reliable and valid method for measuring chronic pain acceptance.

• In physiotherapy, CPAQ can be a useful instrument collecting background information of the chronic pain patient and assessing when to consult a psychologist. In addition in long therapies assessing the enhanced acceptance can be monitored with CPAQ.

     

Screening and assessment of chronic pain among children with cerebral palsy: a process evaluation of a pain toolbox

Abstract

Purpose: Though high numbers of children with cerebral palsy experience chronic pain, it remains under-recognized. This paper describes an evaluation of implementation supports and adoption of the Chronic Pain Assessment Toolbox for Children with Disabilities (the Toolbox) to enhance pain screening and assessment practices within a pediatric rehabilitation and complex continuing care hospital.

Methods: A multicomponent knowledge translation strategy facilitated Toolbox adoption, inclusive of a clinical practice guideline, cerebral palsy practice points and assessment tools. Across the hospital, seven ambulatory care clinics with cerebral palsy caseloads participated in a staggered roll-out (Group 1: exclusive CP caseloads, March–December; Group 2: mixed diagnostic caseloads, August–December). Evaluation measures included client electronic medical record audit, document review and healthcare provider survey and interviews.

Results: A significant change in documentation of pain screening and assessment practice from pre-Toolbox (<2%) to post-Toolbox adoption (53%) was found. Uptake in Group 2 clinics lagged behind Group 1. Opportunities to use the Toolbox consistently (based on diagnostic caseload) and frequently (based on client appointments) were noted among contextual factors identified. Overall, the Toolbox was positively received and clinically useful.

Conclusion: Findings affirm that the Toolbox, in conjunction with the application of integrated knowledge translation principles and an established knowledge translation framework, has potential to be a useful resource to enrich and standardize chronic pain screening and assessment practices among children with cerebral palsy.

• Implications for Rehabilitation

• It is important to engage healthcare providers in the conceptualization, development, implementation and evaluation of a knowledge-to-action best practice product.

• The Chronic Pain Toolbox for Children with Disabilities provides rehabilitation staff with guidance on pain screening and assessment best practice and offers a range of validated tools that can be incorporated in ambulatory clinic settings to meet varied client needs.

• Considering unique clinical contexts (i.e., opportunities for use, provider engagement, staffing absences/turnover) is required to optimize and sustain chronic pain screening and assessment practices in rehabilitation outpatient settings.

     

A case of mistaken identity? The role of injury representations in chronic musculoskeletal pain

Abstract

Purpose: To explore how patients construe bodily injury, examine how injury representations change over the course of a rehabilitation program and how injury representations influence adaptation and recovery trajectories.

Methods: A case study method was used with qualitative interviews as the primary data source. Qualitative semi-structured interviews were conducted three times over the course of a 12-week intensive interdisciplinary occupational rehabilitation program with one interview 1 month following discharge. To capture changes in rehabilitation trajectories, data analysis employed a narrative approach informed by Bury (progression, regression, and stability) and Frank’s (chaos, restitution, and quest) approaches.

Results: Sixteen patients (10 men and 6 women) were disabled as a result of persistent pain and impairment from a variety of work injuries participated. Progression/restitution narratives were characterized by the transformation of bone and nerve problems to include soft tissue elements. These participants expanded their scope of injury representations and appraisal to include neurobiological aspects of chronic pain and dimensions of psychosocial well-being, and linked diagnostic representations to self-management strategies in a functional manner.

Conclusion: Body representations of injury morphology and pain mechanisms are important objects of fear and acceptance for injury recovery. Active strategies that encourage a “hands on” understanding of diagnosis may prove most effective in treating persistent pain.

• Implications for Rehabilitation

• Patient representations of pain and body injury are windows into the personal experience of individuals with chronic musculoskeletal pain.

• When patients enter programs, practitioners need to assess what the patient believes is wrong with their body and what will be helpful in rectifying the problem.

• Based on their initial assessment, practitioners need to direct education and activity toward shifting patient beliefs to include elements of soft tissue and a broader scope of pain sensitization and psychological impact. Activity-based intervention is essential for creating coherence between injury and pain representations and coping action.

• During rehabilitation, practitioners need to monitor patient beliefs about their injury. Shifting beliefs are signs that the patient is adopting a more adaptive cognitive stance toward their injury. Lack of movement indicates that the message is not getting through and the approach needs to be modified.

• When working with patients to transform beliefs, a collaborative approach might be best to increase trust and reduce reactance.

     

Long-lasting improvements in health-related quality of life among women with chronic pain,following multidisciplinary rehabilitation

Purpose: To determine whether observed health-related quality-of-life improvements after four-week traditional multidisciplinary pain management program and additional neuroscience education and mindfulness-based cognitive therapy for chronic pain are sustained at six-month follow-up.

Method: This observational longitudinal follow-up study, with complete follow-up of 75 women, 61.5% of initial traditional approach group (treated 2001–2005) and 56 (62.2%) receiving the new approach (treated 2006–2009). Pain intensity and quality of life were measured at baseline and six months after interventions. Analysis of variance (ANOVA) and paired samples t-tests were used for statistical analysis.

Results: Both groups showed sustained improvements in pain intensity (traditional approach?=??10.6 [p?<?0.001]; new approach?=??14.5 [p?p?p?p?=?0.066]), whereas all other domains among both groups were sustained. Significant decline was observed from discharge to six month among both groups with the exception of the sleep domain among the traditional approach group, pain intensity among the new approach and financial status among both groups. No baseline differences were revealed between responders and nonresponders.

Conclusions: Multidisciplinary interventions for women with chronic pain conditions improved quality of life and pain intensity with lasting improvements observed half a year after treatment completion.

• Implications for rehabilitation

• Intensive multidisciplinary biopsychosocial rehabilitation is essential for chronic pain conditions.

• This follow-up study shows sustained improvement in health-related quality of life and pain intensity six months after such rehabilitation was completed.

• Emphasizing mindfulness-based cognitive therapy and neuroscience patient education may contribute to less decline in pain intensity from discharge to six-month follow-up compared with a more traditional approach.

     

Explaining daily functioning in young adults with obstetric brachial plexus lesion

Abstract

Purpose: To study the influence of obstetric brachial plexus lesion (OBPL) on arm–hand function and daily functioning in adults, and to investigate the relationship of arm-hand function and pain to daily functioning. Method: Adults with unilateral OBPL who consulted the brachial plexus team at the VU University Medical Center in the past were invited to participate. Daily functioning was measured with the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the SF36, pain with VAS Pain Scales and arm-hand function with the Nine Hole Peg Test (9-HP-test) and the Action Research Arm Test (ARAT). Scores of the affected arm were compared to those of the non-affected arm or norm values for healthy controls. Results: Twenty-seven persons (mean age 22, SD 4.2 years), of whom 10 men, participated. The ARAT and 9-HP-test scores for the affected arm were significantly worse than those for the non-affected arm. Moderate to severe pain in the affected arm, the non-affected arm or the back was reported by 50% of the participants. The DASH general, sports/music and SF36 physical functioning scores were significantly worse than norm values. The ARAT/9-HP-test and daily functioning showed little association. Low to moderate associations were found between pain and daily functioning. Conclusions: Many young adults with OBPL experience limitations in daily functioning. Pain, rather than arm-hand function, seems to explain these limitations.

• Implications for Rehabilitation

• Obstetric brachial plexus lesion (OBPL) is caused by traction to the brachial plexus during labour, resulting in denervation of the muscles of the arm and shoulder girdle.

• Adults with OBPL are hardly seen in rehabilitation medicine.

• This study shows that many young adults with OBPL experience limitations in daily functioning. Pain, rather than arm-hand function, seems to explain these limitations.

• Fifty percent of the participants complained about moderate or severe pain, which was located in the affected arm, the back and the non-affected arm. There seems an age-related increase in pain prevalence.

• Persons who had undergone plexus surgery had a significantly worse arm-hand function, but comparable scores on daily functioning scales compared to persons without plexus surgery.

• When limitations in daily functioning or pain occur, referral to a rehabilitation physician is indicated.

     

Improved interoceptive awareness in chronic low back pain: a comparison of Back school versus Feldenkrais method

Purpose: To determine the efficacy of the Feldenkrais method for relieving pain in patients with chronic low back pain (CLBP) and the improvement of interoceptive awareness.

Method: This study was designed as a single-blind randomized controlled trial. Fifty-three patients with a diagnosis of CLBP for at least 3 months were randomly allocated to the Feldenkrais (mean age 61.21?±?11.53 years) or Back School group (mean age 60.70?±?11.72 years). Pain was assessed using the visual analog scale (VAS) and McGill Pain Questionnaire (MPQ), disability was evaluated with the Waddel Disability Index, quality of life was measured with the Short Form-36 Health Survey (SF-36), and mind–body interactions were studied using the Multidimensional Assessment of Interoceptive Awareness Questionnaire (MAIA). Data were collected at baseline, at the end of treatment, and at the 3-month follow-up.

Results: The two groups were matched at baseline for all the computed parameters. At the end of treatment (Tend), there were no significant differences between groups regarding chronic pain reduction (p?=?0.290); VAS and MAIA-N sub scores correlated at Tend (R?=?0.296, p?=?0.037). By the Friedman analysis, both groups experienced significant changes in pain (p?p?Conclusions: The Feldenkrais method has comparable efficacy as Back School in CLBP.

• Implications for rehabilitation

• The Feldenkrais method is a mind–body therapy that is based on awareness through movement lessons, which are verbally guided explorations of movement that are conducted by a physiotherapist who is experienced and trained in this method. It aims to increase self-awareness, expand a person’s repertoire of movements, and to promote increased functioning in contexts in which the entire body cooperates in the execution of movements.

• Interoceptive awareness, which improves with rehabilitation, has a complex function in the perception of chronic pain and should be investigated further in future research.

• The efficacy of the Feldenkrais method is comparable with that of BS for nonspecific chronic low back pain. The physician can recommend a body–mind rehabilitation approach, such as the Feldenkrais method, or an educational and rehabilitation program, such as BS, to the patient, based on his individual needs. The 2 rehabilitation approaches are equally as effective in improving interoceptive awareness.

     

Health-related quality of life improvements among women with chronic pain: comparison of two multidisciplinary interventions

Purpose: To measure the effect of 4 weeks traditional multidisciplinary pain management program (TMP) versus neuroscience education and mindfulness-based cognitive therapy (NEM) on quality of life (HRQL) among women with chronic pain. Method: This observational longitudinal cohort study conducted in an Icelandic rehabilitation centre included 122 women who received TMP, 90 receiving NEM, and 57 waiting list controls. Pain intensity (visual analogue scale) and HRQL (Icelandic Quality of Life scale) were measured before and after interventions. ANOVA and linear regression were used for comparisons. Results: Compared with controls we observed statistically significant changes in pain intensity (p?p?p?=?0.008). Head to head comparison between study groups revealed that pain intensity improved more among TMP participants (21.8 versus 17.2?mm; p?=?0.013 adjusted). Women with low HRQL at baseline improved more than those with higher HRQL (mean TMP?=?13.4; NEM?=?12.9 if HRQL?≤?35 versus mean TMP?=?6.6 and NEM?=?7.8 if HQRL?>?35). Conclusions: Our non-randomized study suggests that both NEM and TMP programs improve pain and HRQL among women with chronic pain. Sleep quality showed more improvements in NEM while pain intensity in TMP. Longer-term follow-ups are needed to address whether improvements sustain.

• Implications for Rehabilitation

• Chronic pain is a debilitating condition affecting quality of life and restricting societal participation.

• Intensive multidisciplinary bio-psycho-social rehabilitation is essential for this patient group.

• This study shows improvement in health-related quality of life and pain intensity following such rehabilitation.

• Emphasizing mindfulness based cognitive therapy and neuroscience patient education improves sleep to more extend than more traditional approach.

     

What is important in transdisciplinary pain neuroscience education? A qualitative study

Purpose: The main focus of Pain Neuroscience Education is around changing patients’ pain perceptions and minimizing further medical care. Even though Pain Neuroscience Education has been studied extensively, the experiences of patients regarding the Pain Neuroscience Education process remain to be explored. Therefore, the aim of this study was to explore the experiences in patients with non-specific chronic pain.

Materials and methods: Fifteen patients with non-specific chronic pain from a transdisciplinary treatment centre were in-depth interviewed. Data collection and analysis were performed according to Grounded Theory.

Results: Five interacting topics emerged: (1) “the pre-Pain Neuroscience Education phase”, involving the primary needs to provide Pain Neuroscience Education, with subthemes containing (a) “a broad intake” and (b) “the healthcare professionals”; (2) “a comprehensible Pain Neuroscience Education” containing (a) “understandable explanation” and (b) “interaction between the physiotherapist and psychologist”; (3) “outcomes of Pain Neuroscience Education” including (a) “awareness”, b) “finding peace of mind”, and (c) “fewer symptoms”; 4) “"scepticism” containing (a) “doubt towards the diagnosis and Pain Neuroscience Education”, (b) “disagreement with the diagnosis and Pain Neuroscience Education”, and (c) “Pain Neuroscience Education can be confronting”.

Conclusion: This is the first study providing insight into the constructs contributing to the Pain Neuroscience Education experience of patients with non-specific chronic pain. The results reveal the importance of the therapeutic alliance between the patient and caregiver, taking time, listening, providing a clear explanation, and the possible outcomes when doing so. The findings from this study can be used to facilitate healthcare professionals in providing Pain Neuroscience Education to patients with non-specific chronic pain.

• Implications for Rehabilitation

• An extensive biopsychosocial patient centred intake is crucial prior to providing Pain Neuroscience Education.

• Repetitions of Pain Neuroscience Education, in different forms (verbal and written information, examples, drawings, etc.) help patients to understand the theory of neurophysiology.

• Pain Neuroscience Education induces insight into the patient’s complaints, improved coping with complaints, improved self-control, and induces in some cases peace of mind.

• Healthcare professionals providing Pain Neuroscience Education should be aware of the possible confronting nature of the contributing factors.

     

Is there a relationship between pain and psychological concerns related to falling in community dwelling older adults? A systematic review

Abstract

Purpose: To systematically review and synthesise the research evidence linking pain to psychological concerns about falling in community dwelling older adults. Methods: A systematic review was conducted in accordance with the preferred reporting items of systematic reviews and meta-analysis statement (PRISMA). Major electronic databases were searched from inception until June 2013. Two authors independently conducted the searches, extracted data and completed methodological quality assessments. Articles were included if they measured one of the psychological concerns related to falling in a sample of community dwelling older adults with pain, or explored the association between the two. Results: Of a potential 892 articles, 12 met the eligibility criteria (n?=?3398). The methodological quality of the included studies was variable and none of the included studies primary aim was to investigate the relationship between pain and psychological concerns related to falls. Two studies found significant differences in psychological concerns related to falls in older adults with pain and a control group. Nine out of 10 studies reported a significant correlation between pain and psychological concerns related to falls in their sample. Conclusion: This review provides provisional evidence that pain is associated with fear of falling (FOF), avoidance of activities due to FOF and falls efficacy in community dwelling older adults.

• Implications for Rehabilitation

• Pain is a common and pervasive problem in community dwelling older adults and can affect an individual’s mobility, levels of physical activity and increase their falls risk.

• Psychological concerns related to falls, such as fear of falling (FOF), falls efficacy and balance confidence are also common and troublesome issues in older adults, yet the association with pain has not been investigated with a systematic review.

• This review provides provisional evidence that pain may increase older adult’s risk of developing FOF, avoiding activities due to a FOF and impact their falls efficacy.

• In recognition of the findings of this review, clinicians working with older adults with pain should consider assessing psychological concerns related to falls and if necessary intervene if they identify an individual at risk.

     

Shoulder pain after stroke – experiences,consequences in daily life and effects of interventions: a qualitative study

Purpose: To describe experiences of shoulder pain after stroke, how pain affects daily life and perceived effects of interventions.

Method: A qualitative interview study including 13 community-dwelling persons (six women; median age 65?years) with persistent shoulder pain after stroke.

Results: Three categories emerged from the content analysis. In “Multiple pain characteristics” an insidious pain onset was reported. The pain existed both day and night and could be located around the shoulder girdle but also have radiation to the arm and hand. An explanation of the pain was seldom given. In “Limitations caused by the pain” it was described how the pain negatively influenced personal care, household activities and leisure, but also could lead to emotional reactions. In “Multiple pain interventions with various effects” a variety of interventions were described. Self-management interventions with gentle movements were perceived most effective. A restraint attitude to pain medication due to side effects was reported.

Conclusions: Shoulder pain after stroke can lead to a variety of pain characteristics. As the pain is complex and may affect many important areas in a person’s life, multidisciplinary rehabilitation interventions are important.

• Implications for rehabilitation

• Shoulder pain after stroke can lead to a variety of pain characteristics with radiation to the arm and hand

• Shoulder pain often influence personal care, household activities and leisure negatively, which may lead to emotional reactions

• Self-management interventions with gentle movements are perceived most effective

• As the shoulder pain after stroke is complex, interventions by a multidisciplinary team may be needed

     

Psychometric properties of the neck disability index amongst patients with chronic neck pain using item response theory

Objective: The Neck Disability Index (NDI) is commonly used for clinical and research assessment for chronic neck pain, yet the original version of this tool has not undergone significant validity testing, and in particular, there has been minimal assessment using Item Response Theory. The goal of the present study was to investigate the psychometric properties of the original version of the NDI in a large sample of individuals with chronic neck pain by defining its internal consistency, construct structure and validity, and its ability to discriminate between different degrees of functional limitation.

Methods: This is a cross-sectional cohort study of 585 consecutive patients with chronic neck pain seen in a university hospital rehabilitation clinic. Internal consistency was evaluated using Cronbach’s alpha, construct structure was evaluated by exploratory factor analysis, and discrimination ability was determined by Item Response Theory.

Results: The NDI demonstrated good internal consistency assessed by Cronbach’s alpha (0.87). The exploratory factor analysis identified only one factor with eigenvalue considered significant (cutoff 1.0). When analyzed by Item Response Theory, eight out of 10 items demonstrated almost ideal difficulty parameter estimates. In addition, eight out of 10 items showed high to perfect estimates of discrimination ability (overall range 0.8 to 2.9).

Conclusions: Amongst patients with chronic neck pain, the NDI was found to have good internal consistency, have unidimensional properties, and an excellent ability to distinguish patients with different levels of perceived disability.

• Implications for Rehabilitation

• The Neck Disability Index has good internal consistency, unidimensional properties, and an excellent ability to distinguish patients with different levels of perceived disability.

• The Neck Disability Index is recommended for use when selecting patients for rehabilitation, setting rehabilitation goals, and measuring the outcome of intervention.

     

The psychometric properties of the cervical nonorganic signs in patients with neck pain: an assessment of pain expression

Purpose: Neck pain is a common cause of disability. This study investigated the psychometric properties of the cervical nonorganic signs (CNOS), a tool for assessing abnormal illness behaviors in patients with neck pain.

Methods: The CNOS was administered on patients with neck pain. Reliability and validity analyses were used to evaluate the psychometric properties. Exploratory factor analysis was used to investigate the dimensionality. Correlations with the Short Form-36 were used to investigate the convergent validity.

Results: The results supported the reliability (inter-rater reliability intra-class correlation: 0.920), validity (correlated with body pain (|ρ|=0.31) and vitality (|ρ|?=0.30), and two-factor dimensionality (χ²=^?5.904, p=?0.66; χ²/df?=?0.738; RMSEAConclusion: The CNOS is a reliable and valid instrument for assessing pain and vitality problems. It helps patients to express severe pain and lack of vitality. The rehabilitation discipline could use the scale to understand pain expression and to design proper rehabilitation programs.

• Implications for Rehabilitation

• The cervical nonorganic signs has two domains (pain and vitality).

• The scale is reliable and valid for patients with neck pain.

• Patients with high scores on the pain domain have severe body pain that may interfere with normal social activities.

• Clinicians should understand their suffering and try to help them to alleviate the pain.

     

Ratings of pain and activity limitation on the visual analogue scale and global impression of change in multimodal rehabilitation of back pain – analyses at group and individual level

Purpose: To evaluate changes in pain intensity and activity limitation, at group and individual levels, and their associations with the global impression of change after multimodal rehabilitation in patients with back pain.

Method: Patients with long-term back pain (n?=?282) participated in a 4-week programme with a follow-up after 6 months. Visual analogue scales (VAS) were used to rate pain intensity and activity limitation. Global impression of change (GIC) was rated on a 7-category scale. The sign test, the Svensson method and the Spearman rank correlation were used for analyses.

Results: Significantly lower ratings in pain and activity limitation at follow-up were found at group level. However, a large individual variability was found by the Svensson method. The correlations between GIC and changes in pain and activity limitation were r_s??=_? 0.49 and r_s =?_?0.50, respectively. A rated GIC of at least “much better” on group level showed changes of ≥20?mm on the VAS.

Conclusions: At group level, lower VAS ratings were found in patients with back pain. However, a large individual variability in pain and activity limitation was also found resulting in low to moderate associations between GIC and the change in VAS ratings. The large individual variability might be due to the impreciseness in the ratings on the VAS. We have presented a critical discussion of statistical methods in connection with the VAS.

• Implications for Rehabilitation

• The use of VAS as a rating instrument may be questioned, especially for perceived pain intensity which is a too complex experience to be rated on a line without any visible categories.

• Single ratings of pain intensity should preferably be complemented with the ratings of activity limitation in patients with long-term back pain.

• Global impression of change is a suggested inclusive rating after rehabilitation.

• The improvement desired by the patient should preferably be determined before rehabilitation.

     

Chronic pain among community-dwelling elderly: a population-based clinical study

Objective: To present the occurrence, characteristics, etiology, interference, and medication of chronic pain among the elderly living independently at home. Design/setting: A total of 460 subjects in three cohorts aged 75, 80 and 85 years respectively received visits by communal home-care department nurses for a cross-sectional survey. Of them, 175 had chronic (duration ≥ 3 months) pain with an average intensity of ≥ 4/10 and/or ≥ moderate interference in daily life. Main outcome measures: Clinical assessment was performed for consenting subjects to define the location, intensity, etiology, type, interference and medications of chronic pain. Results: According to home visits, elderly people with chronic pain rated their health and mobility worse and felt sadder, lonelier and more tired than those without chronic pain. A geriatrician made clinical assessments for 106 patients with chronic pain in 2009–2013. Of them, 66 had three, 35 had two and 5 had one pain condition. The worst pain was musculoskeletal in 88 (83%) of patients. Pain was pure nociceptive in 61 (58%), pure neuropathic in 9 (8%), combined nociceptive and neuropathic pain in 34 (32%), and idiopathic in 2 (2%) patients. On a numerical rating scale from 0 to 10, the mean and maximal intensity of the worst pain was 5.7 and 7.7, respectively, while the mean pain interference was 5.9. Mean pain intensity and maximal pain intensity decreased by age. Duration of pain was longer than 5 years in 51 (48%) patients. Regular pain medication was used by 82 (77%) patients, most commonly paracetamol or NSAIDs. Although pain limited the lives of the elderly with chronic pain, they were as satisfied with their lives as those without chronic pain. Conclusions: Elderly people in our study often suffered from chronic pain, mostly musculoskeletal pain, and the origin of pain was neuropathic in up to 40% of these cases. However, elderly people with chronic pain rarely used the medications specifically for neuropathic pain. Based on increased loneliness, sadness and tiredness, as well as decreased subjective health and mobility, the quality of life was decreased among those with chronic pain compared with those without pain.

• Key Points

• It is known that chronic pain is one of the most common reasons for general practice consultations and is more common in women than men.

• In our study using detailed clinical examinations, up to 40% of patients with chronic pain in cohorts aged 75, 80 and 85 years suffered from neuropathic pain.

• However, only a few elderly people with chronic pain used medications specifically for chronic pain, which may be due to side effects or non-willingness to experiment with these drugs.

• Elderly people with chronic pain rated their health and mobility to be worse and felt sadder, lonelier and more tired but were not less satisfied with their lives than those without chronic pain.

     

The Norwegian versions of the Chronic Pain Acceptance Questionnaire CPAQ-20 and CPAQ-8 – validation and reliability studies

Purpose: The aim of this study was to test the validity and reliability of the translated Norwegian version of the Chronic Pain Acceptance Questionnaire (CPAQ-20) and the shorter version CPAQ-8 based on the same data.

Method: The sample consisted of 120 women with chronic widespread musculoskeletal pain (CWP). The respondents completed CPAQ-20 and visual analogue scales (pain, fatigue, sleep problems and depression), General Health Questionnaire-12, The Pain Catastrophizing Scale, Fibromyalgia Impact Questionnaire and SF-8. Confirmatory factor analyses were performed on a one-factor baseline model, the previous validated CPAQ-20 and CPAQ-8 models, as well as an exploratory generated model based on the current sample.

Results: The two-factor model of CPAQ-20 and a two-factor model of CPAQ-8 obtained adequate model fit and outperformed the baseline model. The exploratory factor, analysis-generated two-factor model obtained only a marginally better fit, supporting the two-dimensional model of CPAQ-20. CPAQ-20 and CPAQ-8 had Cronbach’s alphas between 0.75 (Pain Willingness subscales both versions) and 0.85. Both scales correlated significantly in the hypothesised direction with all the other scales.

Conclusion: The Norwegian versions of CPAQ-20 and CPAQ-8 are reliable assessment tools with good construct validity for measurement of acceptance. Future studies should validate the scales in other Norwegian samples.

• Implication for Rehabilitation

• CPAQ-20 and CPAQ-8 are valid Norwegian instruments for measuring acceptance of pain.

• Acceptance of pain is an important process in the rehabilitation of persons with chronic widespread pain.

• Treatment models supporting acceptance can now be developed and measured further in Norway.