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      Long-Term Outcomes of a Multimodal Day-Clinic Treatment for Chronic Pain under the Conditions of Routine Care

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          Abstract

          Chronic pain has high prevalence rates and is one of the top causes of years lived with disability. The aim of the present study was to evaluate the long-term effects of a multimodal day-clinic treatment for chronic pain. The sample included 183 chronic pain patients (114 females and 69 males; 53.3 ± 9.8 years) who participated in a four-week multimodal day-clinic treatment for chronic pain. The patients' average current pain intensity (NRS), sensory and affective pain (Pain Perception Scale), and depression and anxiety (HADS) were assessed at pre- and posttreatment, as well as at three follow-ups (one month, six months, and twelve months after completion of the treatment). Multilevel models for discontinuous change were performed to evaluate the change of the outcome variables. Improvements from pretreatment to posttreatment and from pretreatment to all follow-ups emerged for pain intensity (NRS; 0.54 ≤  d ≤ 0.74), affective pain (Pain Perception Scale; 0.24 ≤  d ≤ 0.47), depression (HADS; 0.38 ≤  d ≤ 0.53), and anxiety (HADS; 0.26 ≤  d ≤ 0.43) (all p < 0.05). Sensory pain as assessed with the Pain Perception Scale did not show any significant change. Patients suffering from chronic pain benefited from the multimodal pain treatment up to twelve months after completion of the treatment.

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          Grading the severity of chronic pain.

          This research develops and evaluates a simple method of grading the severity of chronic pain for use in general population surveys and studies of primary care pain patients. Measures of pain intensity, disability, persistence and recency of onset were tested for their ability to grade chronic pain severity in a longitudinal study of primary care back pain (n = 1213), headache (n = 779) and temporomandibular disorder pain (n = 397) patients. A Guttman scale analysis showed that pain intensity and disability measures formed a reliable hierarchical scale. Pain intensity measures appeared to scale the lower range of global severity while disability measures appeared to scale the upper range of global severity. Recency of onset and days in pain in the prior 6 months did not scale with pain intensity or disability. Using simple scoring rules, pain severity was graded into 4 hierarchical classes: Grade I, low disability--low intensity; Grade II, low disability--high intensity; Grade III, high disability--moderately limiting; and Grade IV, high disability--severely limiting. For each pain site, Chronic Pain Grade measured at baseline showed a highly statistically significant and monotonically increasing relationship with unemployment rate, pain-related functional limitations, depression, fair to poor self-rated health, frequent use of opioid analgesics, and frequent pain-related doctor visits both at baseline and at 1-year follow-up. Days in Pain was related to these variables, but not as strongly as Chronic Pain Grade. Recent onset cases (first onset within the prior 3 months) did not show differences in psychological and behavioral dysfunction when compared to persons with less recent onset. Using longitudinal data from a population-based study (n = 803), Chronic Pain Grade at baseline predicted the presence of pain in the prior 2 weeks. Chronic Pain Grade and pain-related functional limitations at 3-year follow-up. Grading chronic pain as a function of pain intensity and pain-related disability may be useful when a brief ordinal measure of global pain severity is required. Pain persistence, measured by days in pain in a fixed time period, provides useful additional information.
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            A literature review on the representativeness of randomized controlled trial samples and implications for the external validity of trial results

            Randomized controlled trials (RCTs) are conducted under idealized and rigorously controlled conditions that may compromise their external validity. A literature review was conducted of published English language articles that reported the findings of studies assessing external validity by a comparison of the patient sample included in RCTs reporting on pharmaceutical interventions with patients from everyday clinical practice. The review focused on publications in the fields of cardiology, mental health, and oncology. A range of databases were interrogated (MEDLINE; EMBASE; Science Citation Index; Cochrane Methodology Register). Double-abstract review and data extraction were performed as per protocol specifications. Out of 5,456 de-duplicated abstracts, 52 studies met the inclusion criteria (cardiology, n = 20; mental health, n = 17; oncology, n = 15). Studies either performed an analysis of the baseline characteristics (demographic, socioeconomic, and clinical parameters) of RCT-enrolled patients compared with a real-world population, or assessed the proportion of real-world patients who would have been eligible for RCT inclusion following the application of RCT inclusion/exclusion criteria. Many of the included studies concluded that RCT samples are highly selected and have a lower risk profile than real-world populations, with the frequent exclusion of elderly patients and patients with co-morbidities. Calculation of ineligibility rates in individual studies showed that a high proportion of the general disease population was often excluded from trials. The majority of studies (n = 37 [71.2 %]) explicitly concluded that RCT samples were not broadly representative of real-world patients and that this may limit the external validity of the RCT. Authors made a number of recommendations to improve external validity. Findings from this review indicate that there is a need to improve the external validity of RCTs such that physicians treating patients in real-world settings have the appropriate evidence on which to base their clinical decisions. This goal could be achieved by trial design modification to include a more representative patient sample and by supplementing RCT evidence with data generated from observational studies. In general, a thoughtful approach to clinical evidence generation is required in which the trade-offs between internal and external validity are considered in a holistic and balanced manner. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1023-4) contains supplementary material, which is available to authorized users.
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              Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample.

              Chronic pain and psychiatric disorders frequently co-occur. However, estimates of the magnitude of these associations have been biased by the use of select clinical samples. The present study utilized the National Comorbidity Survey [Arch. Gen. Psychiatry 51 (1994) 8-19] Part II data set to investigate the associations between a chronic pain condition (i.e. arthritis) and common mood and anxiety disorders in a sample representative of the general US civilian population. Participants (N=5877) completed the Composite International Diagnostic Interview [World Health Organization (1990)], a structured interview for trained non-clinician interviewers based on the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association (1987)], and provided self-reports of pain and disability associated with a variety of medical conditions. Significant positive associations were found between chronic pain and individual 12-month mood and anxiety disorders [odds ratios (OR) ranged from 1.92 to 4.27]. The strongest associations were observed with panic disorder (OR=4.27) and post-traumatic stress disorder (OR=3.69). The presence of one psychiatric disorder was not significantly associated with pain-related disability, but the presence of multiple psychiatric disorders was significantly associated with increased disability. The findings of the present study raise the possibility that improved efforts regarding the detection and treatment of anxiety disorders may be required in pain treatment settings.
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                Author and article information

                Contributors
                Journal
                Pain Res Manag
                Pain Res Manag
                PRM
                Pain Research & Management
                Hindawi
                1203-6765
                1918-1523
                2018
                1 April 2018
                : 2018
                : 9472104
                Affiliations
                1Georg-Elias-Müller Institute for Psychology, Georg-August University Göttingen, Göttingen, Lower Saxony, Germany
                2Institute for Psychology, Regensburg University, Regensburg, Germany
                3Hospital Barmherzige Brüder, Regensburg, Germany
                4Department for Psychotherapy and Biopsychosocial Health, Danube University Krems, Krems, Austria
                Author notes

                Academic Editor: Fletcher A. White

                Author information
                http://orcid.org/0000-0002-6113-2133
                Article
                10.1155/2018/9472104
                5901829
                29808108
                d3460e36-81c5-4617-aac6-7edc1e406ea6
                Copyright © 2018 Mira A. Preis et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 12 December 2017
                : 21 February 2018
                : 6 March 2018
                Categories
                Research Article

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