How does patients with chronic pain experience participating in a multimodal rehabilitation program?

Malin Kokvik, ST-läkare, Nora VC, Primärvården, Region Örebro län

Introduction

Chronic pain is a persistent or intermittently recurring pain, lasting more than 3 months(1, 2).Studies suggest that 18 % of the Swedish population have a severe chronic pain condition. 20-40% of the visits at Swedish primary care centersregard pain conditions, and half of these visits are due to chronic pain (2). Chronic pain causes major socioeconomic problems, and is the most common cause of long-term disability in middle-aged people (3). This pain interacts and is influenced by a range of different physical, emotional, psychological and social factors. The literature suggests that pain is not only the sensation of pain, but has to be addressed as a whole entity when addressing the condition. The complaint may not be the physical pain, but the distress, loneliness and lost identity that exist with the condition (4). A multidisciplinary approach to the treatment of these patients has been more commonly used over the last decades(3). This approach is based on a biopsychosocial model, considering somatic, psychological, environmental and personality aspects of the pain condition (1).

Two independent groups of researchershave judged the evidence for the general positive effect of multimodal rehabilitation to be moderate to strong (1, 3). The positive effects seem to be specifically on the reduction of sick leaves and increased return to work. However, there seem to be no reduction in pain intensity, activity level or the degree of other symptoms (2).There is no evidence which suggests that a particular type of multimodal rehabilitation program is superior over another and little is known about which components of the program are the most effective and if all patients benefit from all components in the program (3). Patient with mixed chronic pain conditions seem to have less improvement then those with fibromyalgia and chronic back pain (3).

The scientific evidence of multimodal rehabilitation is weak. The aim of this literature review was therefore to investigate the personal experiences of patients participating in multimodal rehabilitation programs.

Method

The following strategies where used when searchingin the PubMed, Cochrane and Cinahl databases.

1. Search engines like PubMed, Cochrane and Cinahl: (chronic pain (MeSH)) AND (multimodal OR multidisciplinary OR interdisciplinary OR biopsychosocial rehabilitation)) AND (qualitative research(MeSH) OR focus groups (MeSH)OR nursing methodology research(MeSH)OR grounded theory OR hermeneutic OR field study OR narrative OR lived experience OR life experience) AND qualitative[Title/Abstract]) AND English[lang]) AND (experience[Title/Abstract] OR attitudes[Title/Abstract] OR perspectives[Title/Abstract]) AND (English[lang])

2. Examination of reference lists of selected articles.

Inclusion criteria: Articles describing adult patients with non-malignant, general chronic pain and their experiences of participating in a multimodal rehabilitation program.(A multimodal rehabilitation program consisting of a team of different professions with a common goal. Including at least three of the following categories of psychotherapy, physiotherapy, relaxation techniques, medical treatment or patient education. Activities should be organized in a group setting). Articles with a qualitative study design. Articles published in English and published after 2000.

Exclusion criteria: Articles describing specific pain conditions or malignant pain conditions. Articles describing a non-adult population. Articles describing a setting lacking a multimodal rehabilitation program or a multimodal rehabilitation program not meeting the criteria stated above.

Results

The first search strategyidentified 49 articles of whichfivemet the inclusion criteria. The second search strategy identified 11 articles of which five met the inclusion criteria.

Of the 60 articles found using the search strategies described above, 1 article was excluded because it described a non-adult population, 6 articles was excluded because they described the professionals perspective, 11 articles was excluded because they did not involve multimodal rehabilitation or fulfilled the multimodal rehabilitation criteria and 32 articles was excluded because they described a different condition or did not have a qualitative study design. Flow chart illustrating this is shown in Figure 1.

From the literature it can be established that a common experience from patients participating in multimodal rehabilitation programs is that it gives them a sense of personal growth. Other experiences reported were improvement in acceptance, resilience, perceived capacity and self-worth. Factors such as the mindset when entering the program, the environment and the experimental learning approach were considered to support personal growth (6). Patient participation in the rehabilitation progress was perceived to be an important factor for a successful outcome witch was enhanced by a trusting alliance with competent health professionals. Patients emphasized that being respected, trusted, confirmed and seen as a whole personal entity favored their participation (9).Patients described a supportive factor of the perception of having a personal relationship with the health professionals and to be able to find common ground guided by mutual understanding (6,9).

Patients described their life before rehabilitation as ruled by pain. Entering a chronic pain rehabilitation program started a progress of awareness of being responsible for one’s own life, starting to understand relationships between pain and attitude and actions (8). Examples of taking responsibility involved taking up social or family interests, doing physical exercise or use learned coping techniques. (8,10). Patients perceived embodied empowerment to be an important factor in the rehabilitation process. To start taking body into account, realizing that the body is not a separate part, but is connected and influenced by emotional life and involvement in activities indaily life (10). Many patients perceived getting a diagnosis or receiving a credible explanation for their pain helpful in accepting the condition. Understandingthat the pain is not dangerous and that there always will be good and bad days was perceived as an important insight (5,8,10). Strategies and new coping mechanisms was developed where moderation and reduction on demands was perceived as important. Finding balance and setting realistic long term goals was stressed as an important factor for improvement. (5,7,8)

Group dynamics was experienced to have a positive effect on most informants. Emotions of shame started to change towards respect when being member in a group.Belonging to a group also had a normalizing effect on the informants’ perceived capacity, giving a sense of safety and togetherness (5,6,10).

Patients perceive it to be important that health professionals are sensitive to the best timing of each patient and understand the patients’ readiness for change and to have various entrances to change (9,10).

The progress of participation in a chronic pain rehabilitation program can be seen as a working progress with ongoing challenges, but key perceptions include regaining hope, acceptance, increased self-confidence and self-worth (5,6,10)

Quantitative data in mixed methods studies showed a limited improvement in pain severity, pain disability, pain catastrophizing and depressive symptoms (6,7).

Discussion

There is a moderate amount of research published concerning patient perceptions of participating in multimodal rehabilitation of chronic pain conditions. Studies included in this literature review were mostly of Scandinavian origin and had a moderate scientific quality.The setting of the intervention (multimodal rehabilitation), varied with a relative even distribution between primary care settings and specialist pain clinic settings, interestingly different settings did not seem to alter the common theme of perceptions. Multimodal chronic pain rehabilitation within a primary care setting has a short history and international research is limited (5). Studies involved a mostly women population and where of small size. Informants show a similar baseline characteristic with little variation in socioeconomic status and ethnical background witch might give a skew representation of the data.

Literature shows a discrepancy between quantitative and qualitative data when measuring progress in chronic pain rehabilitation. Quantitative data in mixt-method studies showed a limited improvement in pain severity, pain disability, pain catastrophizing and depressive symptoms, while qualitative data show an experience of a positive and persisting personal growth (6,7). It is therefore important that further studies,both qualitative and mixed methods design is performed to provide a more comprehensive view of the pain experience and pain related disability otherwise there I a risk of not understanding the whole picture and components to this problem. Qualitative data important to complement quantitative data, otherwise could important progresses be undetected.

Most researchers where involved professionally in multimodal rehabilitation programs, this involves a risk of their attitudes towards the treatment to influence the data in the qualitative content analysis.

The information gained from the data can be used to give health professionals a deeper understanding of the factors that influence a successful multimodal rehabilitation in patients with chronic pain, also giving an important complementation to quantitative data when judging the need of similar programs.

Conclusion

Themes as an ongoing progress of acceptance, increases self-confidence and a strengthened sense of self-worth were central in the material.The importance of meaningful professional encounters and a sense of co-operation and equal participation were repeatedly mentioned in the literature. Learning about the complex components of pain and coping strategies was important factors perceived by participants.

References

  1. The Swedish Council on Health Technology Assessment(SBU). [Rehabilitation for longlasting pain. A literaturereview.] SBU Report 198. Stockholm: The Swedish Councilon Health Technology Assessment (SBU); 2010 (inSwedish).
  2. The Swedish Society of Medicine, The National Board of Healthand Welfare, Swedish Association of Local Authorities and Regions, The Swedish Council on Health Technology Assessment. Nationella medicinska indikationer. Indikationer för Multimodal rehabilitering vid långvarig smärta. [Indication for MMR in chronic pain]. Stockholm: Rapport; 2011, 2 (in Swedish).
  3. Scascighini L, Toma V, Dober-Spielmann S, Sprott H. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology (Oxford) 2008; 47: 670–678
  4. Ojala T, Häkkinen A, Karppinen J, Sipilä K, Suutama T, Piirainen A. Chronic pain affects the whole person--a phenomenological study.Disabil Rehabil. 2015;37(4):363-71. doi: 10.3109/09638288.2014.923522. Epub 2014 May 23.
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  6. Wideman TH, Boom A, Dell'Elce J, Bergeron K, Fugère J, Lu X, Bostick G, Lambert HC. Change Narratives That Elude Quantification: A Mixed-Methods Analysis of How People with Chronic Pain Perceive PainRehabilitation.Pain Res Manag. 2016;2016:9570581. doi: 10.1155/2016/9570581. Epub 2016 Dec 14.
  7. Craner JR, Skipper RR, Gilliam WP, Morrison EJ, Sperry JA. Patients' perceptions of a chronic painrehabilitation program: changing the conversation.Curr Med Res Opin. 2016 May;32(5):879-83. doi: 10.1185/03007995.2016.1149053. Epub 2016 Feb 26
  8. Hållstam A, Stålnacke BM, Svensen C, Löfgren M. "Change is possible": Patients' experience of a multimodalchronic painrehabilitation programme.J Rehabil Med. 2015 Mar;47(3):242-8. doi: 10.2340/16501977-1926.
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