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MNT: RDN in Medical Team (2015)

Citation:
Burnham R, Day J, Dudley W. Multidisciplinary chronic pain management in a rural Canadian setting. Can J Rural Med. 2010; 15(1): 7-13. PubMed ID: 20070924
 
Study Design:
Non-Controlled Trial
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
To describe the development and results of a multi-disciplinary chronic pain management program established in a rural setting over its first 18 months of operation.
Inclusion Criteria:
Chronic pain.
Exclusion Criteria:
Not described.
Description of Study Protocol:

Recruitment

Physician referral.

Design

  • The Central Alberta Pain and Rehabilitation Institute (CAPRI) was a small multi-disciplinary chronic pain management program that consisted of a family physician, physiatrist, psychologist, physical therapist, kinesiologist, nurse and dietitian. All patients were assigned to either a spine or medical care assessment. Based on the findings of the assessment, the team managed the care of patients using one of four methods:
    • Consultation only
    • Interventional management
    • Supervised medication management
    • Full multi-disciplinary management.
  • This report focused on the supervised medication management and full multi-disciplinary management groups that included patients with complex chronic pain problems. Outcome measures for patients treated by consultation only are not available and the outcomes for interventional spine management have been published elsewhere.

Intervention

  • Supervised medication management: The CAPRI program primary care physician personally managed the care of the patient until the pain was deemed satisfactorily controlled and stable
  • Full multidisciplinary management: The patient attended weekly group sessions, which lasted about five hours each. The first half-hour was facilitated by the psychologist or nurse and consisted of a group meeting to troubleshoot challenges and discuss homework assignments. This was followed by a one-hour group education and psychotherapy session. A didactic presentation followed and was led by the team member with the most expertise on the topic. The physical therapist spoke on the dynamics of pain and maintaining a healthy spine; the exercise specialist discussed the adverse effects of deconditioning and the benefits and components of healthy exercise; the dietitian discussed healthy eating, weight management and constipation prevention; the psychologist explored the topics of sleep hygiene, coping strategies, stress and mood management. Over the following two hours, each patient had a one-on-one consultation with each member of the CAPRI team. During this time, the patient’s progress, treatment program adherence, concerns and goal attainment were reviewed. Team members made modifications to the treatment plan and home program and established new goals for the upcoming week. At the end of the day, patients had the opportunity for additional services, such as individual psychotherapy or an individualized exercise session. The number of weeks each patient was in the full multi-disciplinary program depended on individual progress. The mean duration of involvement was two to three months. Patients were discharged when the goals were met, progress plateaued or the patient was noncompliant.

Statistical Analysis

  • Unpaired T-test: Demographic data (except educational level) of the supervised medication management and full multi-disciplinary program groups
  • X2 analysis: Educational level
  • Two-way repeated-measures ANOVA: Initial, mid-program and discharge pain intensity and interference scores
  • Data reported as mean (SD).
Data Collection Summary:

Timing of Measurements

Initial, mid-program and discharge measures were recorded.

Dependent Variables

  • Pain intensity: Quantified using a numerical rating scale of zero to 10, where zero indicates no pain and 10 indicates worst imaginable plain
  • Pain interference (disability): Using the Pain Interference Questionnaire, patients quantified their perception of how much pain interfered in seven separate domains (zero of 10 is no interference at all, 10 of 10 is complete interference)
  • Self-reported measures were recorded for the supervised mediation management and full multi-disciplinary groups only.

Independent Variables

Supervised medication management or full multi-disciplinary program.

 

 

Description of Actual Data Sample:

Initial N

A total of 82 patients received either supervised medication management or full multi-disciplinary management:

  • Supervised medication management: N=53 (73% female)
  • Full multi-disciplinary management: N=29 (62% female).

Attrition (final N)

N=78; four patients dropped out of the full multi-disciplinary management group (14% dropout rate for full multi-disciplinary group; 5% for both groups).

Age

  • Supervised medication management: 47.9 (15.7)
  • Full multi-disciplinary management: 45.2 (10.0)

Other Relevant Demographics

Educational level: 1.1 (0.8) and 2.4 (0.9) for supervised medication management and full multi-disciplinary management respectively, P<0.05 (one = did not complete high school; two = high school graduation; three = two years or less of post-secondary education; four = more than two years of post-secondary education).

Anthropometrics

  • Beck Depression Inventory Score: 9.8 (7.0) and 14.1 (7.5) for supervised medication management and full multi-disciplinary management respectively, P<0.05
  • The two groups did not differ in pain duration, pain intensity score, pain frequency score or Pain Interference Questionnaire score.

Location

Lacombe, Alberta, Canada

Summary of Results:

Key Findings 

Measure of Pain: Program Mean (SD) Score
Initial Mid-program Discharge
Pain intensity (zero to 10)
   Supervised medication management
   Full multi-disciplinary program		  
7.8(1.5)
7.7 (1.4)		  
5.2 (2.0)
5.4 (1.6)		  
4.5 (2.0)*
4.7 (1.9)*
Pain interference (zero to 70)
   Supervised medication management
   Full multi-disciplinary program
 
47.1 (13.8)
49.3 (11.6)
  
37.1 (16.1)
36.7 (12.2)		  
30.6 (17.0)+
23.4(13.3)+
  • *Significant reductions in pain intensity occurred over the course of both the supervised medication management and full multi-disciplinary management programs (F=89.7). Not significantly different between groups.
  • +Significant reductions in pain interference occurred over the course of both the supervised medication management and full multi-disciplinary management programs (F=75.4). The reduction was significantly greater in the full multi-disciplinary management group.
Author Conclusion:
With the proper support and staff, a multi-disciplinary pain management program can function in a rural setting and offer a useful service.
Funding Source:
Government: David Thompson Health Region
Industry:
Pharmaceutical/Dietary Supplement Company:
Reviewer Comments:
  • Guidelines for enrollment in the full multi-disciplinary program were not well defined
  • A different cohort of patients were selected to enter the full multi-disciplinary program (more highly educated and higher level of psychosocial complication)
  • No P values for outcomes
  • Authors discuss four methods of treatment but only report on medication vs. full multi-disciplinary groups.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? ???
  2.2. Were criteria applied equally to all study groups? ???
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? ???
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) ???
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? ???
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) ???
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? No
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? N/A
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? No
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? ???
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes