47
Puin, 41 (1990) 47-53 Elsevier
Three year follow-up of patients with chronic pain who were treated in a multidisciplinary pain management center Toshihiko Maruta, David W. Swanson and Mary Jane McHardy Department of Ps,vchiatry and Psychololsy, Mayo Clinic and Mqw Foundation, Rochester, MN 55905 (U.S.A.) (Received 25 April 1989, revision received 26 September 1989, accepted 15 November 1989)
Between September 1979 and October 1982,408 patients with chronic benign pain were evaluated for admission to a Summary pain management program. Of the 408 patients, 249 completed the program: the success rate at the time of dismissal was 70% among these 249 patients. Of the 239 patients who entered the follow-up study, 87% responded to either a mailed questionnaire or a follow-up telephone call by an independent reviewer at the time of 3 year follow-up; the improvement had been rn~nt~n~ by 46.6% of the successfully treated patients (or a third of the original participants). The present finding is strikingly similar to that in a previous study from this institution - an indication of the long-term efficacy of the multidisciplinary pain management program. Further search for modifications for the existing program is indicated to accommodate the needs of patients who fail initially or cannot maintain the improvement. Key words: Chronic pain; M~~idisciplina~
pain management; tong-term
Introduction In 1973, Fordyce et al. [4] initially described a multidisciplin~ treatment program for patients with chronic non-malignant pain. Since then, with multiple reports of successful outcome [3,6,7,9,12, W-21,23], this approach has achieved acceptance and support by medical care providers who were disillusioned with the traditional medieaf-surgical-psychiatric approaches to the treatment of patients with chronic pain. Now the honeymoon period of such programs is coming to an end. Patients who are skeptical of or dissatisfied with such programs [22] and thirdparty payers who are demanding cost-eff~tiveness are insisting that the medical care provider clarify
Co~es~~?&ence tu.’ Dr. T. Manna, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, U.S.A.
follow-up; Outcome study
the long-term efficacy of such programs [2,5]. The recent literature confirms that various investigators are responding to this concern [1,2,5,10,11]. The Pain Management Center (PMC) program at the Mayo Clinic was established in 1974. The efficacy of the program was established through a 1 year (1974-1975) follow-up study of the first 200 patients who enter& the program [20,21,23]. A new and larger group of patients with chronic pain of non-malignant cause who had ~~~~~~~~~ the program were entered into the present study for longer-term follow-up in order to confirm and extend the initial findings.
Methods Description of Yhe program Thk inpatient program,
specifically designed for patients with chronic pain of non-malignant
0304-3959/90/$03.50 0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
cause, is intended to help the patient and the family cope with pain more effectively, to reduce the intake of medication to a ~nimum. to teach self-treatment methods and, if possible, to reduce pain. Treatment consists of the following components: cognitive/operant conditioning approach, physical rehabilitation measures, medication management, education, group psychotherapy, biofeedback-relaxation techniques, family member participation, and supportive psychologic treatment. Each treatment component has been described in detail in previous reports [20,21,23]. Additional comments are in order for two of the treatment components, the focus of which has shifted over time. The first is the management of chemical dependency and abuse. Because of the increasing awareness of the role of chemical dependency in perpetuating or sustaining chronic pain, effort has been made to provide a definite therapeutic environment for patients with chemical abuse and dependency. More specifically, every patient with a provisional diagnosis of chemical dependency is directed to participate in a daily chemical dependency group (including, for example, audiovisual education and group discussion) led by full-time chemical dependency counselors. Individual evaluation with a chemical dependency counselor also is offered when appropriate. A second shift involved the changed focus of group therapy. Started as a discussion group, it gradually has shifted to cognitive or, at times, psychodynamically oriented group psychotherapy. Admission criteria have remained the same over the 13 years since the follow-up study in 1975: (1) complete medical and psychiatric evaluation, (2) a pain problem of 6 months’ duration or longer, (3) no related malignant disease, (4) no specific medical, surgical, or other psychiatric treatment approach applicable, (5) no known litigation, and (6) acceptance by patients of the treatment program. Patient population Between September 1979 and October 1982, 408 patients were evaluated for admission to the PMC. The PMC evaluation, which takes place after a complete medical, surgical, and psychiatric evaIuation, consists of a physician’s review of the
pain problem, structured interviews by the program coordinator (M.J.M.), occupational and physical therapy evaluations, nursing assessment, and social, family, and economic assessments by the social worker. During this day-long assessment, the patient also observes daily activities of other patients and routines of the unit. Then the results of each evaluation are reviewed at a meeting attended by all the staff involved, and consensus is reached regarding appropriateness for admission. The final decision is presented to the patient by the service physician. Of the 408 patients, 82 were rejected primarily because of lack of n~ot~vat~on to participate in the treatment program, and 44 patients rejected the program even though the staff had decided that they could benefit from the program. Of the remaining 282 patients, 249 completed the program and 33 left the program early for various reasons (mainly because of dissatisfaction with the program after the entry). The study group was composed of the 249 patients who completed the program as prescribed.
Results
Admission data Of the 249 patients, 161(65%) were women and 88 (35%) were men. Their ages ranged from 15 to 64 years (mean, 44 years). Marital status was as follows: married, 199 (80%); divorced, 14 (6%); single, 29 (11%); and widowed, 7 (3%). On adrnission, pain was often localized to the back-neckextremity area (71%); other sites were head-face (14%), abdomen-pe~neum (9%), and total body area (3%). The mean duration of pain was 6.7 of previous surgical years; the average number procedures per patient was two, and most had received treatment with some combination of medication, operation, physical therapy, traction, body casts, nerve blocks, specific neuroab~ative procedures, electrostimulation, acupuncture, hypnosis, biofeedback, and psychotherapy. The mean period away from full-time work was 24.5 months, 43% of the patients were receiving disability compensation, and 4% (10 patients) were identified as
49
L !muypto-o52 F~~~~~~
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52
52
58
67
64
66
57
46
57
56
59
55
49
Fig. 1. MMPI profiles of 160 women at admission to Pain Management Center.
being involved in active litigation, a status that was not clear at the time of admission. medication intake was reviewed carefully with the patient and validated during the first 3 days of
hospitalization, when a liberal dose of medications (based on preadmission dosage) was given on request. When the patient seemed to have requested less than the estimated dose, the staff encouraged
90 80 70 60 50 40
I
First200 patients
n = 82
t
3oL L’ stwtyptw56
I
F
I K
57
57
I
I
I
I
I
Hs
D
Hy
Pd
Mf
76
70
75
62
57
77
69
75
63
66
I
I
I
I
Pa
Pt
SC
Ma
Si
57
62
60
56
63
58
62
62
69
49
Fig. 2. MMPI profifes of 87 men at admission to Fain Meagerness
Center.
I
50
the patient to take enough medication to make himself or herself comfortable. The number of pain-related medications used ranged from 0 to 5 (mean, 1.7), and abuse or dependency (more than the recommended dose for a month or more) was noted in 104 (42%) patients. Complete medical, surgica1, and psychiatric evatuation before full participation indicated a neurologic diagnosis in 21% of the patients (for example, old radiculopathy, neuropathy, arachnoiditis), an orthopedic diagnosis in 44% (mechanical factors, pseudoarthrosis, degenerative changes, sp#ndyloiisthesisj, and a psychiatric diagnosis in 47% (depression, chemical dependency. personality disorders). On muscle and exercise testing, most patients had major limitations for their sex and age group. On admission, all 249 patients took the Shipley Institute of Living ScaIe (vocabulary and abstraction). 247 completed a valid Minnesota Multiphasic Personality Inventory (MMPI), and all 249 were rated according to the Hamilton Rating Scale for depression. Except for the Ham&on Scale, these tests were not repeated at dismissal or at follow-up. The mean Shipley Verbal IQ equivalent was 115 (S.D.. 12). The mean abstraction of IQ equivalent was 100 (SD., 19). The MMPI profiles are shown in Figs. 1 and 2. Xn the women, the mean profile was that of a mildly neurotic patient with a hysteroid personality structure, Compared with the profile obtained from the first group of 200 patients admitted to the PMC, the configuration was almost identical but had softly more morbidity overall. In the men, the mean profile indicated considerably more general personality deviation than in the women with more clear-cut elevation of the hypochondriasis and depression scales. No significant differences were observed when this group was compared with the first study population. The admission average Hamilton score, determined by a trained evaluator (M.J.M.), was 15.0, which indicates subclinical depression. Bdsmissul data Among the 249 patients
who completed
the
program, the mean duration of hospitalization was 23 days. The subjective pain level, which was rated by the patient hourly on a scale of O-10, did not change significantly (5.3 vs. 5.2). The Hamilton score at the time of dismissal was 6.3, which was significantly lower than that at admission (Y -z. 0.0001).
The criteria for evaluating improvement are based on change in 3 categories: modification of attitude, reduction in medication, and improvement in physical functioning. fn each category the patient is rated as having no, ~n~rnal, modest, moderate, or marked improvement, and a numerical rating of 0 through 4 is assigned, respectively. For better intercenter comparison, the exact criteria used are given in Appendix 1. The rating of each category is assigned at dismissal by 3 independent raters: physical functioning is assessed by the assigned physical therapist, modification of attitude is determined by the program coordinator, and reduction in medication is evaluated by the staff physician on the basis of data obtained from the daily record. Treatment success requires a rating of 3 or 4 (moderate or marked improvement) in ali 3 categories. Treatment is considered to have failed if a score of 2 or more is not achieved in any of the categories. If a score of 3 or 4 is achieved in at least 1 category or a score of 2 is achieved in all 3 categories. success of treatment is considered partial (K coefficient for overall outcome, 0.72) 1131. Of the 249 patients, 174 {70~~ achieved moderate to marked improvement (score of 3 or 4) in a113 categories, 18 (7%) had no or minimal gain in all 3 categories and were assigned the outcome rating of failure, and 57 (23%) had partial success, Outcome at 3 year follow-up On completion of the program, 10 (4%) of the patients declined to participate in a follow-up study. Of the remaining 239, 208 (87%) responded to either a mailed questionnaire or a follow-up telephone call by an independent reviewer at the time of the 3 year f&low-up. The criteria for evaluating maintenance of improvement also are based on 3 categories: attitude,
51
medication use, and physical functioning. In each category, the patient is rated as having no, minimal, modest, moderate, or marked maintenance, and a numerical rating of 0 through 4 is assigned, respectively. The requirement for the outcome categories is identical to the one used at the time of dismissal. For better intercenter comparison, the exact criteria used for the study are given in Appendix 2. Of the 208 patients who participated in the follow-up study, 81 (39%) maintained the improvement (score of 3 or 4 in all 3 categories) and treatment was classified as successful, 74 (36%) had partial success, 48 (23%) failed treatment, and 5 (2%) were deceased. Two patients who were in the failure category at the time of dismissal had improved to the success category at 3 year followup. Comparison with the initial report When the 2 sets of data (gathered 5 years apart) were compared, the 2 groups had striking similarities in demographic data (previous group vs. recent group): mean age (45 years vs. 44 years), male : female ratio (1 : 1.4 vs. 1 : 1.8), marital status, duration of pain (7 years vs. 6.7 years), work time lost (23.4 months vs. 24.5 months), neurologic and orthopedic diagnoses, admission pain level (5.4 vs. 5.3), dismissal pain level (4.3 vs. 5.2), drug use pattern, and number of operations (2.0 vs. 2.0). Outcome data were also similar. Of the 174 patients who were categorized as treatment successes when dismissed from the program, 46.6% had maintained their improvement at 3 year follow-up. Because this finding is essentially the same as that at follow-up of 1 year (43%) in the previous study, patients who manage to maintain their improvement at 1 year likely will continue to do so at 3 years.
Discussion This study provides several interesting observations. First, the patient population as a whole changed little over a 5 year period. Second, even though it is obviously no panacea, the multidisciplinary pain management program produces
long-term improvement in one-third of the patients who complete the program. Third, the outcome of treatment in this study is similar to that in our previous study and is comparable to that in reports from other centers. Two major questions remain. The first question deals with who responds to this type of program: can we differentiate partial success from failure at the time of initial evaluation? We initially thought we could do this [14] but later found that our objective predictors were unreliable [8]. Further studies in this area are clearly necessary. The second question is: how can the patient who does not benefit from this type of program be helped? Considering the fact that nearly two-thirds of the patients who completed the program either failed initially or could not maintain the improvement at the end of 3 years, it is necessary for us to continue to search for further modifications of our existing programs. Finally, recognition is given to the limitations of long-term outcome research in patients with chronic pain treated in a clinical setting. The following factors are of particular note: (1) the role of selection criteria in determining the success rate, (2) the definition and control of the treatment provided over a prolonged period of study, and (3) the correlation of clinical ratings done by the treatment team with ‘true’ improvement. These relate in part to long-term clinical research in which one cannot modify past decisions regarding research design.
Appendix 1 Categories and ratings used to evaluate patient status at dismissal from the pain management center (I) Attitude modification (0) None: rejection of program by leaving prematurely. (1) Minimal: remained prescribed time; still believed in need for invasive therapy (such as operation); frequently was critical-antagonistic. (2) Modest: remained prescribed time; generally accepted need to live with pain; needed
il
frequent support and reinforcement; was uncertain about results after leaving the program. (3) Moderate: remained prescribed time; generally accepted need to live with pain; needed minimal support and reinforcement; talked about desire and plans to cope with pain; relatives participated fully in program. (4) Marked: fully accepted need to live with pain; had concrete plans to follow through: was able to self-reinforce good behavior and enjoy being active: relatives participated fully in program. (II) Medication reduction (0) None: unsuccessful: resisted medication reduction and left program. (1) Minimal: was off medication with difficulties (such as frequent minor complaints); had drug-seeking behavior; tended to blame others (such as physicians) for use of medication; was bitter about being off medication. still had (2) Modest: was off medication; drug-seeking behavior but responded to neutral response; was unsure about results after leaving program: accepted responsibility for drug use with support. Moderate: was off medication; was moti(3) vated to stay off maintenance medication; had minimal or no drug-seeking behavior; accepted responsibilities for drug use. was strongly (4) Marked: was off medication; motivated to stay off maintenance medication and verbalized problems with drug use; appreciated drug-free status. (III)
Change in physical functioning (0) None: no change. (1) Minimal: had persistent resistance to physical therapy; had minimal increase in physical function; made frequent reference to treatment done for him or her (such as heat and massage). (2) Modest: had some increase in physical function; fully participated in physical therapy with frequent support and encouragement.
(3) Moderate: had moderate increase in physical function; performed some routine workequivalent activities; needed minimal surpervision; was motivated to continue physical therapy at home. indicated physical (4) Marked: had maximally function; was performing most routine work-equivalent activities; initiated physical activities; needed no supervision.
Appendix 2 Categories and ratings used to evaluate patient status at the time of the pain management center 3 _vear follow-up (I) Attitude modification (0) None: operation for the chronic pain problem. (1) Minimal: other invasive procedures for the chronic pain. (2) Modest: non-invasive procedures for the chronic pain (such as physical therapy). (3) Moderate: other pain management centers. (4) Marked: no further treatment for the chronic pain. (II) Medication reduction (0) None: addicted to pain medication. (1) Minimal: abusing pain medication. (2) Modest: using pain medication but no abuse. (3) Moderate: off all pain medication except a small amount of aspirin or equivalent. (4) Marked: off all pain medication. (III)
Change in physical functioning
(0) None: marked decrease in work status. (1) Minimal: slight decrease in work status. (2) Modest: no change in work status (if not working full-time before entering pain management center). (3) Moderate: slight increase in work status. (4) Marked: marked increase in work status or no change in work status if working full-time before entering pain management center and at time of follow-up, with increase of other activity.
53
References 1 Aronoff,
2 3
4
5
6
9 10
11
12
G.M., Evans, W.O. and Enders, P.L., A review of follow-up studies of multidisciplinary pain units, Pain, 16 (1983) l-11. Block, A.R., Multidisciplinary treatment of chronic low back pain: a review, Rehab. Psychiat., 27 (1982) 51-63. Cairns, D., Thomas, L., Mooney, V. and Pace, J.B., A comprehensive treatment approach to chronic low back pain, Pain, 2 (1976) 301-308. Fordyce, W.E., Fowler, Jr., R.S., Lehmann, J.F., DeLateur, B.J., Sand, P.L. and Trieschmann, R.B., Gperant conditioning in the treatment of chronic pain, Arch. Phys. Med. Rehab., 54 (1973) 399-408. Fordyce, W.E., Roberts, A.H. and Stembach, R.A., The behavioral management of chronic pain: a response to critics, Pain, 22 (1985) 113-125. Guck, T.P., Meilman, P.W., Skultetv, F.M. and Dowd. E.T., Prediction of long-term outcome of multidisciplinary pain treatment, Arch. Phys. Med. Rehab., 67 (1986) 293296. Hallett, E.C. and Pilowsky, I., The response to treatment in a multidisciplinary pain clinic, Pain, 12 (1982) 365-374. Hamburgen, M.E., Jennings, C.A., Manna, T. and Swanson, D.W., Failure of a predictive scale in identifying patients who may benefit from a pain management program: follow-up data, Pain, 23 (1985) 253-258. Ignelzi, R.J., Stembach, R.A. and Timmermans, G., The pain ward follow-up analyses, Pain, 3 (1977) 277-280. Latimer, P.R., External contingency management for chronic pain: critical review of the evidence, Am. J. Psychiat., 139 (1982) 1308-1312. Linton, S.J., A critical review of behavioural treatments for chronic benign pain other than headache, Br. J. Clin. Psychol., 21 (1982) 321-337. Malec, J., Cayner, J.J., Harvey, R.F. and Timming, R.C., Pain management: long-term follow-up of an inpatient program, Arch. Phys. Med. Rehab., 62 (1981) 369-372.
of a 13 Maruta, T. and Swanson, D.W., Outcome evaluation pain management program: correlation between staff evaluation and patient self-report (abstract). Read at the 3rd general meeting of the American Pain Society, Miami Beach, FL, October 20-31, 1982. 14 Manna, T., Swanson, D.W. and Swenson, W.M., Chronic pain: which patients may a pain-management program help?, Pain, 7 (1979) 321-329. 15 McArthur, D.L., Cohen, M.J., Gottlieb, H.J., Naliboff, B.D. and Schandler, S.L., Treating chronic low back pain. I. Admissions to initial follow-up. II. Long-term follow-up, Pain, 29 (1987) l-22; 23-38. 16 Meilman, P.W., Skultety, F.M., Guck, T.P. and Sullivan, K., Benign chronic pain: 18-month to ten-year follow-up of a multidisciplinary pain unit treatment program, Clin. J. Pain, 1 (1985) 131-137. 17 Newman, RI., Seres. J.L., Yospe, L.P. and Garlington, B., Multidisciplinary treatment of chronic pain: long-term follow-up of low-back pain patients, Pain, 4 (1977) 283-292. 18 Roberts, A.H. and Reinhardt, L., The behavioral management of chronic pain: long-term follow-up with comparison groups, Pain, 8 (1980) 151-162. 19 Sturgis, E.T., Schaefer, C.A. and Sikora, T.L., Pain center follow-up study of treated and untreated patients, Arch. Phys. Med. Rehab., 65 (1984) 301-303. 20 Swanson, D.W., Floreen, A.C. and Swenson, W.M., Program for managing chronic pain. II. Short-term results, Mayo Clin. Proc., 51 (1976) 409-411. 21 Swanson, D.W., Manna, T. and Swenson, W.M., Results of behavior modification in the treatment of chronic pain, Psychosom. Med., 41 (1979) 55-61. 22 Swanson, D.W., Swenson, W.M., Maruta, T. and Floreen, A.C., The dissatisfied patient with chronic pain, Pain, 4 (1977) 367-378. 23 Swanson, D.W., Swenson, W.M., Manna, T. and McPhee, M.C., Program for managing chronic pain. I. Program description and characteristics of patients, Mayo Clin. Proc., 51 (1976) 401-408.
Puin, 41 (1990) 47-53 Elsevier
Three year follow-up of patients with chronic pain who were treated in a multidisciplinary pain management center Toshihiko Maruta, David W. Swanson and Mary Jane McHardy Department of Ps,vchiatry and Psychololsy, Mayo Clinic and Mqw Foundation, Rochester, MN 55905 (U.S.A.) (Received 25 April 1989, revision received 26 September 1989, accepted 15 November 1989)
Between September 1979 and October 1982,408 patients with chronic benign pain were evaluated for admission to a Summary pain management program. Of the 408 patients, 249 completed the program: the success rate at the time of dismissal was 70% among these 249 patients. Of the 239 patients who entered the follow-up study, 87% responded to either a mailed questionnaire or a follow-up telephone call by an independent reviewer at the time of 3 year follow-up; the improvement had been rn~nt~n~ by 46.6% of the successfully treated patients (or a third of the original participants). The present finding is strikingly similar to that in a previous study from this institution - an indication of the long-term efficacy of the multidisciplinary pain management program. Further search for modifications for the existing program is indicated to accommodate the needs of patients who fail initially or cannot maintain the improvement. Key words: Chronic pain; M~~idisciplina~
pain management; tong-term
Introduction In 1973, Fordyce et al. [4] initially described a multidisciplin~ treatment program for patients with chronic non-malignant pain. Since then, with multiple reports of successful outcome [3,6,7,9,12, W-21,23], this approach has achieved acceptance and support by medical care providers who were disillusioned with the traditional medieaf-surgical-psychiatric approaches to the treatment of patients with chronic pain. Now the honeymoon period of such programs is coming to an end. Patients who are skeptical of or dissatisfied with such programs [22] and thirdparty payers who are demanding cost-eff~tiveness are insisting that the medical care provider clarify
Co~es~~?&ence tu.’ Dr. T. Manna, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, U.S.A.
follow-up; Outcome study
the long-term efficacy of such programs [2,5]. The recent literature confirms that various investigators are responding to this concern [1,2,5,10,11]. The Pain Management Center (PMC) program at the Mayo Clinic was established in 1974. The efficacy of the program was established through a 1 year (1974-1975) follow-up study of the first 200 patients who enter& the program [20,21,23]. A new and larger group of patients with chronic pain of non-malignant cause who had ~~~~~~~~~ the program were entered into the present study for longer-term follow-up in order to confirm and extend the initial findings.
Methods Description of Yhe program Thk inpatient program,
specifically designed for patients with chronic pain of non-malignant
0304-3959/90/$03.50 0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
cause, is intended to help the patient and the family cope with pain more effectively, to reduce the intake of medication to a ~nimum. to teach self-treatment methods and, if possible, to reduce pain. Treatment consists of the following components: cognitive/operant conditioning approach, physical rehabilitation measures, medication management, education, group psychotherapy, biofeedback-relaxation techniques, family member participation, and supportive psychologic treatment. Each treatment component has been described in detail in previous reports [20,21,23]. Additional comments are in order for two of the treatment components, the focus of which has shifted over time. The first is the management of chemical dependency and abuse. Because of the increasing awareness of the role of chemical dependency in perpetuating or sustaining chronic pain, effort has been made to provide a definite therapeutic environment for patients with chemical abuse and dependency. More specifically, every patient with a provisional diagnosis of chemical dependency is directed to participate in a daily chemical dependency group (including, for example, audiovisual education and group discussion) led by full-time chemical dependency counselors. Individual evaluation with a chemical dependency counselor also is offered when appropriate. A second shift involved the changed focus of group therapy. Started as a discussion group, it gradually has shifted to cognitive or, at times, psychodynamically oriented group psychotherapy. Admission criteria have remained the same over the 13 years since the follow-up study in 1975: (1) complete medical and psychiatric evaluation, (2) a pain problem of 6 months’ duration or longer, (3) no related malignant disease, (4) no specific medical, surgical, or other psychiatric treatment approach applicable, (5) no known litigation, and (6) acceptance by patients of the treatment program. Patient population Between September 1979 and October 1982, 408 patients were evaluated for admission to the PMC. The PMC evaluation, which takes place after a complete medical, surgical, and psychiatric evaIuation, consists of a physician’s review of the
pain problem, structured interviews by the program coordinator (M.J.M.), occupational and physical therapy evaluations, nursing assessment, and social, family, and economic assessments by the social worker. During this day-long assessment, the patient also observes daily activities of other patients and routines of the unit. Then the results of each evaluation are reviewed at a meeting attended by all the staff involved, and consensus is reached regarding appropriateness for admission. The final decision is presented to the patient by the service physician. Of the 408 patients, 82 were rejected primarily because of lack of n~ot~vat~on to participate in the treatment program, and 44 patients rejected the program even though the staff had decided that they could benefit from the program. Of the remaining 282 patients, 249 completed the program and 33 left the program early for various reasons (mainly because of dissatisfaction with the program after the entry). The study group was composed of the 249 patients who completed the program as prescribed.
Results
Admission data Of the 249 patients, 161(65%) were women and 88 (35%) were men. Their ages ranged from 15 to 64 years (mean, 44 years). Marital status was as follows: married, 199 (80%); divorced, 14 (6%); single, 29 (11%); and widowed, 7 (3%). On adrnission, pain was often localized to the back-neckextremity area (71%); other sites were head-face (14%), abdomen-pe~neum (9%), and total body area (3%). The mean duration of pain was 6.7 of previous surgical years; the average number procedures per patient was two, and most had received treatment with some combination of medication, operation, physical therapy, traction, body casts, nerve blocks, specific neuroab~ative procedures, electrostimulation, acupuncture, hypnosis, biofeedback, and psychotherapy. The mean period away from full-time work was 24.5 months, 43% of the patients were receiving disability compensation, and 4% (10 patients) were identified as
49
L !muypto-o52 F~~~~~~
51
F 54
K 58
Hs
D
Hy
Pd
Mf
Pa
Pt
SC
Ma
Si
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59
47
56
60
62
57
52
52
58
67
64
66
57
46
57
56
59
55
49
Fig. 1. MMPI profiles of 160 women at admission to Pain Management Center.
being involved in active litigation, a status that was not clear at the time of admission. medication intake was reviewed carefully with the patient and validated during the first 3 days of
hospitalization, when a liberal dose of medications (based on preadmission dosage) was given on request. When the patient seemed to have requested less than the estimated dose, the staff encouraged
90 80 70 60 50 40
I
First200 patients
n = 82
t
3oL L’ stwtyptw56
I
F
I K
57
57
I
I
I
I
I
Hs
D
Hy
Pd
Mf
76
70
75
62
57
77
69
75
63
66
I
I
I
I
Pa
Pt
SC
Ma
Si
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62
60
56
63
58
62
62
69
49
Fig. 2. MMPI profifes of 87 men at admission to Fain Meagerness
Center.
I
50
the patient to take enough medication to make himself or herself comfortable. The number of pain-related medications used ranged from 0 to 5 (mean, 1.7), and abuse or dependency (more than the recommended dose for a month or more) was noted in 104 (42%) patients. Complete medical, surgica1, and psychiatric evatuation before full participation indicated a neurologic diagnosis in 21% of the patients (for example, old radiculopathy, neuropathy, arachnoiditis), an orthopedic diagnosis in 44% (mechanical factors, pseudoarthrosis, degenerative changes, sp#ndyloiisthesisj, and a psychiatric diagnosis in 47% (depression, chemical dependency. personality disorders). On muscle and exercise testing, most patients had major limitations for their sex and age group. On admission, all 249 patients took the Shipley Institute of Living ScaIe (vocabulary and abstraction). 247 completed a valid Minnesota Multiphasic Personality Inventory (MMPI), and all 249 were rated according to the Hamilton Rating Scale for depression. Except for the Ham&on Scale, these tests were not repeated at dismissal or at follow-up. The mean Shipley Verbal IQ equivalent was 115 (S.D.. 12). The mean abstraction of IQ equivalent was 100 (SD., 19). The MMPI profiles are shown in Figs. 1 and 2. Xn the women, the mean profile was that of a mildly neurotic patient with a hysteroid personality structure, Compared with the profile obtained from the first group of 200 patients admitted to the PMC, the configuration was almost identical but had softly more morbidity overall. In the men, the mean profile indicated considerably more general personality deviation than in the women with more clear-cut elevation of the hypochondriasis and depression scales. No significant differences were observed when this group was compared with the first study population. The admission average Hamilton score, determined by a trained evaluator (M.J.M.), was 15.0, which indicates subclinical depression. Bdsmissul data Among the 249 patients
who completed
the
program, the mean duration of hospitalization was 23 days. The subjective pain level, which was rated by the patient hourly on a scale of O-10, did not change significantly (5.3 vs. 5.2). The Hamilton score at the time of dismissal was 6.3, which was significantly lower than that at admission (Y -z. 0.0001).
The criteria for evaluating improvement are based on change in 3 categories: modification of attitude, reduction in medication, and improvement in physical functioning. fn each category the patient is rated as having no, ~n~rnal, modest, moderate, or marked improvement, and a numerical rating of 0 through 4 is assigned, respectively. For better intercenter comparison, the exact criteria used are given in Appendix 1. The rating of each category is assigned at dismissal by 3 independent raters: physical functioning is assessed by the assigned physical therapist, modification of attitude is determined by the program coordinator, and reduction in medication is evaluated by the staff physician on the basis of data obtained from the daily record. Treatment success requires a rating of 3 or 4 (moderate or marked improvement) in ali 3 categories. Treatment is considered to have failed if a score of 2 or more is not achieved in any of the categories. If a score of 3 or 4 is achieved in at least 1 category or a score of 2 is achieved in all 3 categories. success of treatment is considered partial (K coefficient for overall outcome, 0.72) 1131. Of the 249 patients, 174 {70~~ achieved moderate to marked improvement (score of 3 or 4) in a113 categories, 18 (7%) had no or minimal gain in all 3 categories and were assigned the outcome rating of failure, and 57 (23%) had partial success, Outcome at 3 year follow-up On completion of the program, 10 (4%) of the patients declined to participate in a follow-up study. Of the remaining 239, 208 (87%) responded to either a mailed questionnaire or a follow-up telephone call by an independent reviewer at the time of the 3 year f&low-up. The criteria for evaluating maintenance of improvement also are based on 3 categories: attitude,
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medication use, and physical functioning. In each category, the patient is rated as having no, minimal, modest, moderate, or marked maintenance, and a numerical rating of 0 through 4 is assigned, respectively. The requirement for the outcome categories is identical to the one used at the time of dismissal. For better intercenter comparison, the exact criteria used for the study are given in Appendix 2. Of the 208 patients who participated in the follow-up study, 81 (39%) maintained the improvement (score of 3 or 4 in all 3 categories) and treatment was classified as successful, 74 (36%) had partial success, 48 (23%) failed treatment, and 5 (2%) were deceased. Two patients who were in the failure category at the time of dismissal had improved to the success category at 3 year followup. Comparison with the initial report When the 2 sets of data (gathered 5 years apart) were compared, the 2 groups had striking similarities in demographic data (previous group vs. recent group): mean age (45 years vs. 44 years), male : female ratio (1 : 1.4 vs. 1 : 1.8), marital status, duration of pain (7 years vs. 6.7 years), work time lost (23.4 months vs. 24.5 months), neurologic and orthopedic diagnoses, admission pain level (5.4 vs. 5.3), dismissal pain level (4.3 vs. 5.2), drug use pattern, and number of operations (2.0 vs. 2.0). Outcome data were also similar. Of the 174 patients who were categorized as treatment successes when dismissed from the program, 46.6% had maintained their improvement at 3 year follow-up. Because this finding is essentially the same as that at follow-up of 1 year (43%) in the previous study, patients who manage to maintain their improvement at 1 year likely will continue to do so at 3 years.
Discussion This study provides several interesting observations. First, the patient population as a whole changed little over a 5 year period. Second, even though it is obviously no panacea, the multidisciplinary pain management program produces
long-term improvement in one-third of the patients who complete the program. Third, the outcome of treatment in this study is similar to that in our previous study and is comparable to that in reports from other centers. Two major questions remain. The first question deals with who responds to this type of program: can we differentiate partial success from failure at the time of initial evaluation? We initially thought we could do this [14] but later found that our objective predictors were unreliable [8]. Further studies in this area are clearly necessary. The second question is: how can the patient who does not benefit from this type of program be helped? Considering the fact that nearly two-thirds of the patients who completed the program either failed initially or could not maintain the improvement at the end of 3 years, it is necessary for us to continue to search for further modifications of our existing programs. Finally, recognition is given to the limitations of long-term outcome research in patients with chronic pain treated in a clinical setting. The following factors are of particular note: (1) the role of selection criteria in determining the success rate, (2) the definition and control of the treatment provided over a prolonged period of study, and (3) the correlation of clinical ratings done by the treatment team with ‘true’ improvement. These relate in part to long-term clinical research in which one cannot modify past decisions regarding research design.
Appendix 1 Categories and ratings used to evaluate patient status at dismissal from the pain management center (I) Attitude modification (0) None: rejection of program by leaving prematurely. (1) Minimal: remained prescribed time; still believed in need for invasive therapy (such as operation); frequently was critical-antagonistic. (2) Modest: remained prescribed time; generally accepted need to live with pain; needed
il
frequent support and reinforcement; was uncertain about results after leaving the program. (3) Moderate: remained prescribed time; generally accepted need to live with pain; needed minimal support and reinforcement; talked about desire and plans to cope with pain; relatives participated fully in program. (4) Marked: fully accepted need to live with pain; had concrete plans to follow through: was able to self-reinforce good behavior and enjoy being active: relatives participated fully in program. (II) Medication reduction (0) None: unsuccessful: resisted medication reduction and left program. (1) Minimal: was off medication with difficulties (such as frequent minor complaints); had drug-seeking behavior; tended to blame others (such as physicians) for use of medication; was bitter about being off medication. still had (2) Modest: was off medication; drug-seeking behavior but responded to neutral response; was unsure about results after leaving program: accepted responsibility for drug use with support. Moderate: was off medication; was moti(3) vated to stay off maintenance medication; had minimal or no drug-seeking behavior; accepted responsibilities for drug use. was strongly (4) Marked: was off medication; motivated to stay off maintenance medication and verbalized problems with drug use; appreciated drug-free status. (III)
Change in physical functioning (0) None: no change. (1) Minimal: had persistent resistance to physical therapy; had minimal increase in physical function; made frequent reference to treatment done for him or her (such as heat and massage). (2) Modest: had some increase in physical function; fully participated in physical therapy with frequent support and encouragement.
(3) Moderate: had moderate increase in physical function; performed some routine workequivalent activities; needed minimal surpervision; was motivated to continue physical therapy at home. indicated physical (4) Marked: had maximally function; was performing most routine work-equivalent activities; initiated physical activities; needed no supervision.
Appendix 2 Categories and ratings used to evaluate patient status at the time of the pain management center 3 _vear follow-up (I) Attitude modification (0) None: operation for the chronic pain problem. (1) Minimal: other invasive procedures for the chronic pain. (2) Modest: non-invasive procedures for the chronic pain (such as physical therapy). (3) Moderate: other pain management centers. (4) Marked: no further treatment for the chronic pain. (II) Medication reduction (0) None: addicted to pain medication. (1) Minimal: abusing pain medication. (2) Modest: using pain medication but no abuse. (3) Moderate: off all pain medication except a small amount of aspirin or equivalent. (4) Marked: off all pain medication. (III)
Change in physical functioning
(0) None: marked decrease in work status. (1) Minimal: slight decrease in work status. (2) Modest: no change in work status (if not working full-time before entering pain management center). (3) Moderate: slight increase in work status. (4) Marked: marked increase in work status or no change in work status if working full-time before entering pain management center and at time of follow-up, with increase of other activity.
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