Background and aims
Multimodal rehabilitation (MMR) programmes, including, physical training, educational and psychological interventions by an interdisciplinary team are found to be more successful for patients with disabling chronic pain compared with less comprehensive treatments. MMR programmes are based on the biopsychosocial model and the goal is usually to improve function, quality of life and facilitate and enable return to work. As pain clinics traditionally offer conventional medical pain treatment, there is limited knowledge about MMR given in this context. The aim of our study was to describe characteristics of patients with chronic pain, treated with a MMR programme at a conventional pain clinic, to evaluate patient-reported outcome measures (PROM) from start to one year after, and to study possibly associated factors for the improvement of health-related quality of life after one year.
A prospective, observational study with a one-year follow-up was performed.
A total of 42 individuals (38 females, age 44.0 ± 12.3 years and 4 men age 40 ± 8.5 years) with different pain diagnoses were included. After a team assessment, the patients began a programme that lasted about three months. The MMR programme contained coordinated, individually adapted treatments administered individually or in groups, and was based on cognitive behavioural principles. Questionnaires regarding health-related quality of life (HRQoL) (EQ-5D), insomnia (ISI), mental health (HADS), painrelated disability (PDI), kinesiophobia (TSK), current pain intensity (VAS) and sense of coherence (SOC) were used at the start of the MMR and at follow-up. Demographic data were collected from the patient records.
The PROM at baseline showed substantial pain problems with low HRQoL (EQ-5D index of 0.1 ± 0.282, and EQ VAS of 32.67 ± 20.1), moderate insomnia (ISI 18.95 ± 6.7), doubtful cases of depression and anxiety (HADS-depression 9.35 ± 4.1 and HADS-anxiety 9.78 ± 3.95), presence of pain-related disability (PDI 39.48 ±12.64), kinesiophobia (TSK 40.8 ± 9.8), as well as moderate current pain (VAS 61.31 ± 20.4). The sense of coherence was weak (SOC of 51.37 ± 14). At one-year follow-up, significant (p ≥ 0.05) improvement occurred on the EQ-5D index, EQ VAS, ISI, PDI and TSK. In the logistic regression analysis, no significant associations could be identified.
MMR for patients with complex pain problems can be a successful treatment alternative at conventional pain clinics.
Since access to rehabilitation clinics in Sweden may be limited, the availability of MMR can increase by providing this type of intervention in pain clinics. Increased knowledge of MMR in different settings can also contribute to increased understanding and collaboration between pain clinics and rehabilitation units.
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2015.11.001.
Conflict of interest
Conflict of interest statement: The authors have no conflict of interest.
We thank the statisticians Lina Benson and Hans Pettersson at Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm for their help, as well as the Scandinavian Association for the Study of Pain for their financial support.
 Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287–333.10.1016/j.ejpain.2005.06.009Search in Google Scholar PubMed
 Nygaard Andersen L, Kohberg M, Juul-Kristensen B, Gram Herborg L, Søgaard K, Kaya Roessler K. Psychosocial aspects of everyday life with chronic muscu-loskeletal pain: a systematic review. Scand J Pain 2014;5:131–48.10.1016/j.sjpain.2014.01.001Search in Google Scholar PubMed
 Gerdle B, Bjork J, Henriksson C, Bengtsson A. Prevalence of current and chronic pain and their influences upon work and healthcare-seeking: a population study. J. Rheumatol 2004;31:1399–406.Search in Google Scholar PubMed
 Landmark T, Romundstad P, Dale O, Borchgrevink PC, Vatten L, Kaasa S. Chronic pain: one year prevalence and associated characteristics (the HUNT pain study). ScandJ Pain 2013;4:182–7.10.1016/j.sjpain.2013.07.022Search in Google Scholar PubMed
 Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull 2007;133:581–624.10.1037/0033-2909.133.4.581Search in Google Scholar PubMed
 Fredheim OM, Kaasa S, Fayers P, Saltnes T, Jordhoy M, Borchgrevink PC. Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients. Acta Anaesthesiol Scand 2008;52:143–8.10.1111/j.1399-6576.2007.01524.xSearch in Google Scholar PubMed
 Alfoldi P, Wiklund T, Gerdle B. Comorbid insomnia in patients with chronic pain: a study based on the Swedish quality registry for pain rehabilitation (SQRP). Disabil Rehabil 2014;36:1661–9.10.3109/09638288.2013.864712Search in Google Scholar PubMed
 Linder J, Jansen GB, Ekholm KS, Ekholm J. Relationship between sleep disturbance, pain, depression and functioning in long-term sick-listed patients experiencing difficulty in resuming work. J Rehabil Med 2014;46: 798–805.10.2340/16501977-1833Search in Google Scholar PubMed
 Scascighini L, Toma V, Dober-Spielmann S, Sprott H. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology 2008;47:670–8.10.1093/rheumatology/ken021Search in Google Scholar PubMed
 SBU. The Swedish Council on Technology Assessment in Health Care, [methods of treating chronic pain. A systematic review]. Stockholm, Sweden: The Swedish Council on Health Technology Assessment; 2006. Report No 177/1.Search in Google Scholar
 SBU. The Swedish Council on Health Technology Assessment, [rehabilitation of patients with chronic pain conditions. A systematic review]. Stockholm, Sweden: SBU-The Swedish Council on Health Technology Assessment; 2010. Report No 198.Search in Google Scholar
 Merrick D, Sundelin G, Stalnacke BM. An observational study of two rehabilitation strategies for patients with chronic pain, focusing on sick leave at one-year follow-up. J Rehabil Med 2013;45:1049–57.10.2340/16501977-1218Search in Google Scholar PubMed
 Bremander AB, Holmstrom G, Bergman S. Depression and age as predictors of patient-reported outcome in a multidisciplinary rehabilitation programme for chronic musculoskeletal pain. Musculoskeletal Care 2011;9:41–8.10.1002/msc.198Search in Google Scholar
 Martin J, Torre F, Padierna A, Aguirre U, Gonzalez N, Garcia S, Matellanes B, Quintana JM. Six-and 12-month follow-up of an interdisciplinary fibromyal-gia treatment programme: results of a randomised trial. Clin Exp Rheumatol 2012;30(Suppl 74), 103–111.Search in Google Scholar PubMed
 Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2001;2: 297–307.10.1016/S1389-9457(00)00065-4Search in Google Scholar PubMed
 Morin CM, Belleville G, Belanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 2011;34:601–8.10.1093/sleep/34.5.601Search in Google Scholar PubMed
 Boonstra AM, Schiphorst Preuper HR, Balk GA, Stewart RE. Cut-off points for mild, moderate, and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain. Pain 2014;155:2545–50.10.1016/j.pain.2014.09.014Search in Google Scholar PubMed
 Mewes R, Rief W, Stenzel N, Glaesmer H, Martin A, Brahler E. What is “normal” disability? An investigation of disability in the general population. Pain 2009;142:36–41.10.1016/j.pain.2008.11.007Search in Google Scholar PubMed
 Soer R, Reneman MF, Vroomen PC, Stegeman P, Coppes MH. Responsiveness and minimal clinically important change of the Pain Disability Index in patients with chronic back pain. Spine 2012;37:711–5.10.1097/BRS.0b013e31822c8a7aSearch in Google Scholar PubMed
 Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res 2002;52:69–77.10.1016/S0022-3999(01)00296-3Search in Google Scholar
 Antonovsky A. Unraveling the mystery of health. Jossey-Bass Inc, Publishers; 1987.Search in Google Scholar
 Eriksson M, Lindstrom B. Antonovsky’s sense of coherence scale and its relation. with quality of life: a systematic review. J Epidemiol Community Health 2007;61:938–44.10.1136/jech.2006.056028Search in Google Scholar PubMed PubMed Central
 Eriksson M, Lindstrom B. Validity of Antonovsky’s sense of coherence scale: a systematic review. J Epidemiol Community Health 2005;59:460–6.10.1136/jech.2003.018085Search in Google Scholar PubMed PubMed Central
 Bunketorp L, Carlsson J, Kowalski J, Stener-Victorin E. Evaluatingthe reliability of multi-item scales: a non-parametric approach to the ordered categorical structure of data collected with the Swedish version of the Tampa Scale for Kinesiophobiaand the Self-Efficacy Scale. J Rehabil Med 2005;37:330–4.10.1080/16501970510036411Search in Google Scholar PubMed
 Luning Bergsten C, Lundberg M, Lindberg P, Elfving B. Change in kinesiophobia and its relation to activity limitation after multidisciplinary rehabilitation in patients with chronic back pain. Disabil Rehabil 2012;34:852–8.10.3109/09638288.2011.624247Search in Google Scholar PubMed
 Walters S, Brazier J. Comparison of the minimally important difference for two health state utility measures: EQ-5D and SF-6D. Qual Life Res 2005;14:1523–32.10.1007/s11136-004-7713-0Search in Google Scholar PubMed
 Merrick D, Sundelin G, Stalnacke BM. One-year follow-up of two different rehabilitation strategies for patients with chronic pain. J Rehabil Med 2012;44:764–73.10.2340/16501977-1022Search in Google Scholar PubMed
 Borsbo B, Peolsson M, Gerdle B. Catastrophizing, depression, and pain: correlation with and influence on quality of life and health—a study of chronic whiplash-associated disorders. J Rehabil Med 2008;40:562–9.10.2340/16501977-0207Search in Google Scholar PubMed
 Rothman MG, Ortendahl M, Rosenblad A, Johansson AC. Improved quality of life working ability, and patient satisfaction after a pretreatment multi-modal assessment method in patients with mixed chronic muscular pain: a randomized-controlled study. Clin J Pain 2013;29:195–204.10.1097/AJP.0b013e318250e544Search in Google Scholar PubMed
 Hallstam A, Stalnacke BM, Svensen C, Lofgren M. “Change is possible”: patients’ experience of a multimodal chronic pain rehabilitation programme. J Rehabil Med 2015;47:242–8.10.2340/16501977-1926Search in Google Scholar PubMed
 Branstrom H, Fahlstrom M. Kinesiophobia in patients with chronic musculoskeletal pain: differences between men and women. J Rehabil Med 2008;40:375–80.10.2340/16501977-0186Search in Google Scholar PubMed
 Swedish Quality Registry for Pain Rehabilitation Report 2015:2, Annual Report 2014 part 2 http://www.ucr.uu.se/nrs/index.php/arsrapportercited 13 August 2015.Search in Google Scholar
 Scascighini L, Litschi M, Walti M, Sprott H. Effect of an interdisciplinary outpatient pain management program (IOPP) for chronic pain patients with and without migration background: a prospective, observational clinical study. Pain Med 2011;12:706–16.10.1111/j.1526-4637.2011.01085.xSearch in Google Scholar PubMed
 Nitter AK, Pripp AH, Forseth KØ. Are sleep problems and non-specific health complaints risk factors for chronic pain? A prospective population-based study with 17 year follow-up. Scand J Pain 2012;3:210–7.10.1016/j.sjpain.2012.04.001Search in Google Scholar PubMed
 Gerrits MM, van Oppen P, van Marwijk HW, Penninx BW, van der Horst HE. Pain and the onset of depressive and anxiety disorders. Pain 2014;155:53–9.10.1016/j.pain.2013.09.005Search in Google Scholar PubMed
 Tang NK, Goodchild CE, Sanborn AN, Howard J, Salkovskis PM. Deciphering the temporal link between pain and sleep in a heterogeneous chronic pain patient sample: a multilevel daily process study. Sleep 2012;35:675–87.10.5665/sleep.1830Search in Google Scholar PubMed PubMed Central
 Campbell P, Tang N, McBeth J, Lewis M, Main CJ, Croft PR, Morphy H, Dunn KM. The role of sleep problems in the development of depression in those with persistent pain: a prospective cohort study. Sleep 2013;36:1693–8.10.5665/sleep.3130Search in Google Scholar PubMed PubMed Central
 Asih S, Neblett R, Mayer TG, Gatchel RJ. Does patient-reported insomnia improve in response to interdisciplinary functional restoration for chronic disabling occupational musculoskeletal disorders? Spine 2014;39:1384–92.10.1097/BRS.0000000000000420Search in Google Scholar PubMed
 Bosy D, Etlin D, Corey D, Lee JW. An interdisciplinary pain rehabilitation programme: description and evaluation of outcomes. Physiother Can 2010;62:316–26.10.3138/physio.62.4.316Search in Google Scholar PubMed PubMed Central
 Stein KF, Miclescu A. Effectiveness of multidisciplinary rehabilitation treatment for patients with chronic pain in a primary health care unit. Scand J Pain 2013;4:190–7.10.1016/j.sjpain.2013.06.003Search in Google Scholar PubMed
 Överenskommelse rehabiliteringsgarantin; 2015, http://skl.se/halsasjukvard/sjukskrivningochrehabilitering/rehabiliteringsgarantin/overenskommelsemedstaten.1035.htmlcited 1 March 2015.Search in Google Scholar
© 2015 Scandinavian Association for the Study of Pain