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 ≤
Chronic pain is a major health care problem. A recent review and meta-analysis including 86 studies found an average prevalence estimate of 31% [
The interaction between pain and these psychological variables as well as mental disorders like depression and anxiety [
Despite these effects of pain management treatments in controlled and clinically representative contexts, Wilson [
To further evaluate the long-term effectiveness of multidisciplinary treatments for chronic pain under the conditions of routine care, the present study investigated the effects of a multimodal day-clinic treatment for chronic pain on aspects of pain (pain intensity and affective and sensory pain) and on depression and anxiety. We hypothesized that the multidisciplinary treatment is effective up to 12 months after treatment.
The sample consisted of 183 patients (114 females and 69 males; mean age of 53.3 ± 9.8 years) who participated in the multimodal day-clinic treatment for chronic pain at the Hospital Barmherzige Brüder Regensburg (Germany) from 2010 to 2013. All patients fulfilled the criteria for the ICD-10 diagnosis of a chronic pain disorder with somatic and psychological factors (F45.41). 75.4 percent of the patients fulfilled the criteria for at least one other psychiatric disorder, with depression (57.9 percent) and anxiety disorders (22.4 percent) being the most frequently diagnosed comorbidities. The four most frequent medical diagnoses according to ICD-10 were dorsalgia (M54), other disorders of the muscle (M62), other headache syndromes (G44), and other unspecified dorsopathies (M53). The diagnoses were made by the clinic team. With regard to Von Korffs’ chronic pain grades [
The following self-rating instruments were given at pre- and posttreatment, as well as one month, six months, and twelve months after completion of the treatment. At the three-month follow-up assessment, the clinic sent a paper and pencil version of the questionnaires by post to the patients. After completing the questionnaires, the patients sent them back to the clinic.
The participants rated the average current pain intensity on a Numerical Rating Scale (NRS) from 0 (
The Pain Perception Scale (SES [
Designed for clinical populations suffering from somatic symptoms, the German version of the Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression in the past week [
At the Hospital Barmherzige Brüder Regensburg (Germany), an interdisciplinary team of psychologists, physicians, physical therapists, occupational therapists, and social workers carried out the 4-week multimodal day-clinic treatment for chronic pain. The treatment is based on cognitive-behaviour therapy for pain “
Weekly schedule of the multimodal treatment program.
SPSS 24 was used for the statistical analyses. Multilevel models for discontinuous change were performed to evaluate the progress of the outcome variables (pain intensity, affective pain, sensory pain, depression, and anxiety) between the five assessment points. According to Göllner et al. [
Sample size (
Pretreatment | End of treatment | 1-month follow-up | 6-month follow-up | 12-month follow-up | |||||||||||
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SD |
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SD |
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SD |
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SD |
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SD | |
NRS | 183 | 6.51 | 1.66 | 176 | 5.53 | 1.85 | 168 | 5.28 | 1.88 | 152 | 5.61 | 1.91 | 123 | 5.48 | 1.95 |
SES: affective | 168 | 61.04 | 24.79 | 153 | 53.79 | 25.54 | 145 | 49.39 | 27.02 | 139 | 55.11 | 29.29 | 97 | 50.17 | 27.61 |
SES: sensory | 168 | 66.90 | 26.48 | 152 | 64.65 | 26.96 | 145 | 64.37 | 26.98 | 138 | 66.20 | 28.18 | 96 | 65.15 | 26.75 |
HADS: depression | 180 | 10.34 | 4.20 | 176 | 8.13 | 4.59 | 168 | 8.42 | 4.76 | 155 | 8.45 | 4.94 | 122 | 8.76 | 5.03 |
HADS: anxiety | 180 | 10.49 | 4.24 | 176 | 8.81 | 4.34 | 168 | 8.66 | 4.49 | 156 | 9.39 | 4.67 | 118 | 9.05 | 4.05 |
Dropout rates differed between the measures. For the Numeric Rating Scale (NRS) that assessed the average current pain intensity, response rates ranged from 100% at pretreatment to 67.2% at 12-month follow-up. Response rates concerning the Pain Perception Scale (SES [
The estimates of the multilevel model with pain intensity (numeric rating scale) as outcome are presented in Table
Results of the multilevel model for discontinuous change with pain intensity as outcome
Parameter | Estimate | SE | df | T-statistic |
|
---|---|---|---|---|---|
Intercept (pretreatment) | 6.51 | 0.12 | 183.00 | 53.22 | <0.001 |
Change from pretreatment to the end of treatment | −0.97 | 0.12 | 178.66 | −7.83 | <0.001 |
Change from pretreatment to 1-month follow-up | −1.18 | 0.14 | 165.87 | −8.58 | <0.001 |
Change from pretreatment to 6-month follow-up | −0.85 | 0.15 | 168.24 | −5.74 | <0.001 |
Change from pretreatment to 1-year follow-up | −0.99 | 0.16 | 159.29 | −6.12 | <0.001 |
In addition, we calculated the percentage of patients who reached a reduction of at least two points on the NRS from pretreatment to the other assessment points. A pain reduction of 2 points or more on the NRS was reached by 34.1% at the end of the treatment, by 45.2% at 1-month follow-up, by 36.8% at 6-month follow-up, and by 36.6% at 1-year follow-up. The percentages are in relation to the sample of patients with NRS scores at both assessment points.
Table
Results of the multilevel model for discontinuous change with affective pain as outcome
Parameter | Estimate | SE | df | T-statistic |
|
---|---|---|---|---|---|
Intercept (pretreatment) | 60.93 | 1.90 | 170.14 | 32.06 | <0.001 |
Change from pretreatment to the end of treatment | −7.88 | 1.58 | 159.14 | −4.98 | <0.001 |
Change from pretreatment to 1-month follow-up | −12.08 | 1.96 | 157.33 | −6.17 | <0.001 |
Change from pretreatment to 6-month follow-up | −5.85 | 2.23 | 151.13 | −2.63 | 0.010 |
Change from pretreatment to 1-year follow-up | −7.96 | 2.30 | 148.83 | −3.46 | 0.001 |
The results of the multilevel model with sensory pain (Sensory scale of the Pain Perception Scale [
Results of the multilevel model for discontinuous change with sensory pain as outcome
Parameter | Estimate | SE | df | T-statistic |
|
---|---|---|---|---|---|
Intercept (pretreatment) | 66.58 | 2.03 | 170.00 | 32.77 | <0.001 |
Change from pretreatment to the end of treatment | −2.24 | 1.86 | 159.09 | −1.20 | 0.231 |
Change from pretreatment to 1-month follow-up | −2.26 | 1.74 | 158.28 | −1.30 | 0.195 |
Change from pretreatment to 6-month follow-up | 0.36 | 1.95 | 150.76 | 0.18 | 0.856 |
Change from pretreatment to 1-year follow-up | 2.89 | 1.96 | 134.09 | 1.48 | 0.142 |
Table
Results of the multilevel model for discontinuous change with depression as outcome
Parameter | Estimate | SE | df | T-statistic |
|
---|---|---|---|---|---|
Intercept (pretreatment) | 10.37 | 0.31 | 182.04 | 33.32 | <0.001 |
Change from pretreatment to the end of treatment | −2.14 | 0.24 | 175.39 | −8.87 | <0.001 |
Change from pretreatment to 1-month follow-up | −1.73 | 0.25 | 167.85 | −6.98 | <0.001 |
Change from pretreatment to 6-month follow-up | −1.54 | 0.30 | 157.07 | −5.12 | <0.001 |
Change from pretreatment to 1-year follow-up | −1.05 | 0.35 | 148.07 | −2.98 | 0.003 |
Results for the multilevel model with anxiety (Anxiety scale of the Hospital Anxiety and Depression Scale [
Results of the multilevel model for discontinuous change with anxiety as outcome (
Parameter | Estimate | SE | df | T-statistic |
|
---|---|---|---|---|---|
Intercept (pretreatment) | 10.52 | 0.31 | 181.62 | 33.52 | <0.001 |
Change from pretreatment to the end of treatment | −1.69 | 0.24 | 174.40 | −6.98 | <0.001 |
Change from pretreatment to 1-month follow-up | −1.73 | 0.26 | 171.19 | −6.60 | <0.001 |
Change from pretreatment to 6-month follow-up | −0.92 | 0.32 | 155.92 | −2.91 | 0.004 |
Change from pretreatment to 1-year follow-up | −0.94 | 0.30 | 151.28 | −3.09 | 0.002 |
The aim of the present study was to evaluate the long-term effects of a multimodal day-clinic treatment for chronic pain on pain characteristics (pain intensity and sensory and affective pain) and associated psychological aspects (depression and anxiety). The 4-week pain treatment significantly reduced the patients’ pain intensity, depression, and anxiety, improved the appraisal of affective qualities of pain, and remained stable over a period of 12 months after completion of the treatment. There was no effect on the Sensory Pain scale of the Pain Perception Scale.
In the following paragraphs, we embed our results in the existing literature on the effectiveness of multimodal treatments for chronic pain under clinically representative conditions. When interpreting these benchmark comparisons, it is important to consider the following aspects as possible reasons for discrepant results. Different treatment durations (4 weeks in the present study and, e.g., in [
The patients’ pain intensity improved from pre- to posttreatment with a medium effect size of
There was a positive effect on the appraisal of affective pain qualities. Although the effect directly after the treatment
In contrast to Pieh et al. [
The reduction of depressive symptoms at the end of the treatment
The data of the current study were collected in a naturalistic setting. This enhances the external validity of the results. But as the study was neither randomized nor controlled, the internal validity of the results is limited. Therefore, we cannot exclude confounders like time effects as possible causes for the found improvements. Yet, a 4-year follow-up study on the course of chronic pain in the community reported that chronic pain shows low recovery rates [
As chronic pain is most probably caused by an interaction of biopsychosocial factors, multimodal pain treatment programs seem to provide the most effective therapy. The current study supports the notion that chronic pain patients benefit from multimodal treatments under the conditions of routine care in the long term.
Mira A. Preis and Elisabeth Vögtle share the first authorship.
The authors declare that they have no conflicts of interest.