Background and aims
Among chronic pain patients who are referred to participation in a multimodal rehabilitation program (MMRP), pain catastrophizing and dysfunctional pain coping is common. In many cases it may have driven the patient to a range of unsuccessful searches for biomedical explanations and pain relief. Often these efforts have left patients feeling disappointed, hopeless and misunderstood. The MMRP process can be preceded by a multimodal investigation (MMI) where an important effort is to validate the patient to create a good alliance and begin a process of change towards acceptance of the pain. However, whether the MMI has such therapeutic effect is unclear. Using a repeated single case experimental design, the purpose of this study was to investigate the therapeutic effect of MMI by studying changes in patients’ experience of validation, alliance, acceptance of pain, coping, catastrophizing, and depression before and during the MMI process.
Participants were six chronic pain patients with high levels of pain catastrophizing (>25 on the Pain Catastrophizing Scale) and risk for long term disability (>105 on the Örebro Musculoskeletal Pain Screening Questionnaire) who were subjected to MMI before planned MMRP. For each patient, weekly self-report measures of validation, alliance and acceptance of pain were obtained during a 5–10-weeks baseline, before the MMI started. Subsequently, these measures were also obtained during a 6–8 weeks MMI process in order to enable comparative analyses. Additionally, pain coping, depression and pain catastrophizing were measured using standardized questionnaires before and after the MMI.
Irrespective of experiences of validation and alliance before MMI, all six patients felt validated and experienced a good alliance during MMI. Acceptance of pain improved only in one patient during MMI. None of the patients showed clinically relevant improvement in pain coping, depression or catastrophizing after the MMI.
The patients did not change their acceptance and pain coping strategies despite of good alliance and experience of validation during the MMI process. Even if the design of this study precludes generalization to chronic pain patients in general, the results suggest that MMI may not have a therapeutic effect.
Research funding: The research was funded by MS’ employer – Region of Västmanland.
Conflict of interest: There are no conflicts of interest.
Informed consent: The participants gave informed consent before participating.
Ethical approval: The study was approved by the Regional Ethical Board in Uppsala (D-nr 2012/305).
 (SBU) Sbfmu. Metoder för behandling av långvarig smärta. En systematisk litteraturöversikt. SBU-rapport nr 177/1+2. 2006.Search in Google Scholar
 (SBU) Sbfmu. En systematisk litteraturöversikt Partiell uppdatering och fördjupning av SBU-rapport nr 177/1+2; Maj 2010. SBU-rapport nr 198. 2010.Search in Google Scholar
 Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJEM, Ostelo RWJG, Guzman J, Van Tulder, MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev 2014;9:CD000963.10.1002/14651858.CD000963.pub3Search 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 (Oxford) 2008;47:670–8.10.1093/rheumatology/ken021Search in Google Scholar PubMed
 Boersma K, Linton SJ. Expectancy, fear and pain in the prediction of chronic pain and disability: a prospective analysis. Eur J Pain (London, England) 2006;10:551–7.10.1016/j.ejpain.2005.08.004Search in Google Scholar PubMed
 De Vlieger P, Bussche EV, Eccleston C, Crombez G. Finding a solution to the problem of pain: conceptual formulation and the development of the pain solutions questionnaire (PaSol). Pain 2006;123:285–93.10.1016/j.pain.2006.03.005Search in Google Scholar PubMed
 Kazdin AE. Single-case research designs: methods for clinical and applied settings. 2. ed. New York: Oxford University Press. xi, 452 p.Search in Google Scholar
 Barlow DH. Single Case Experimental Designs, 2009.Search in Google Scholar
 Linton SJ, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Orebro musculoskeletal pain questionnaire. Clin J Pain 2003;19:80–6.10.1097/00002508-200303000-00002Search in Google Scholar PubMed
 Edlund SM, Wurm M, Hollandare F, Linton SJ, Fruzzetti AE, Tillfors M. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome. Scand J Pain 2017;17:77–86.10.1016/j.sjpain.2017.07.007Search in Google Scholar PubMed
 Linton SJ, Hallden K. Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. Clin J Pain 1998;14:209–15.10.1097/00002508-199809000-00007Search in Google Scholar
 Osman A, Barrios FX, Gutierrez PM, Kopper BA, Merrifield T, Grittmann L. The pain catastrophizing scale: further psychometric evaluation with adult samples. J Behav Med 2000;23:351–65.10.1023/A:1005548801037Search in Google Scholar
 Tremblay I, Beaulieu Y, Bernier A, Crombez G, Laliberté S, Thibault P, Velly AM, Sullivan MJL. Pain catastrophizing scale for francophone adolescents: a preliminary validation. Pain Res Manag 2008;13:19–24.10.1155/2008/845674Search in Google Scholar
 Lisspers J, Nygren A, Soderman E. Hospital anxiety and depression scale (HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 1997;96:281–6.10.1111/j.1600-0447.1997.tb10164.xSearch in Google Scholar
 Johnston M, Pollard B, Hennessey P. Construct validation of the hospital anxiety and depression scale with clinical populations. J Psychosom Res 2000;48:579–84.10.1016/S0022-3999(00)00102-1Search in Google Scholar
 Overholser J. Collaborative empiricism, guided discovery, and the socratic method: core processes for effective cognitive therapy. Clin Psychol Sci Pract 2011;18:62–6.10.1111/j.1468-2850.2011.01235.xSearch in Google Scholar
 Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991;59:12–9.10.1037/10109-042Search in Google Scholar
 Herrmann C. International experiences with the hospital anxiety and depression scale – a review of validation data and clinical results. J Psychosom Res 1997;42:17–41.10.1016/S0022-3999(96)00216-4Search in Google Scholar
 Linton SJ, Nicholas MK, MacDonald S, Boersma K, Bergbom S, Maher C, Refshaugel K. The role of depression and catastrophizing in musculoskeletal pain. Eur J Pain (London, England) 2011;15:416–22.10.1016/j.ejpain.2010.08.009Search in Google Scholar PubMed
 Svanberg M, Stalnacke BM, Enthoven P, Brodda-Jansen G, Gerdle B, Boersma K. Impact of emotional distress and pain-related fear on patients with chronic pain: subgroup analysis of patients referred to multimodal rehabilitation. J Rehabil Med 2017;49:354–61.10.2340/16501977-2212Search in Google Scholar PubMed
 Bergbom S, Boersma K, Overmeer T, Linton SJ. Relationship among pain catastrophizing, depressed mood, and outcomes across physical therapy treatments. Phys Ther 2011;91:754–64.10.2522/ptj.20100136Search in Google Scholar PubMed
 Westman AE, Boersma K, Leppert J, Linton SJ. Fear-avoidance beliefs, catastrophizing, and distress: a longitudinal subgroup analysis on patients with musculoskeletal pain. Clin J Pain 2011;27:567–77.10.1097/AJP.0b013e318219ab6cSearch in Google Scholar PubMed
 Boersma K, Linton SJ. Psychological processes underlying the development of a chronic pain problem: a prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability. Clin J Pain 2006;22:160–6.10.1097/01.ajp.0000159582.37750.39Search in Google Scholar PubMed
 Turner JA, Holtzman S, Mancl L. Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain. Pain 2007;127:276–86.10.1016/j.pain.2006.09.005Search in Google Scholar PubMed
 Finn SE, Fischer CT, Handler L. Collaborative/therapeutic assessment: a casebook and guide. Hoboken, NJ: Wiley, 2012.Search in Google Scholar
 Ackerman SJ, Hilsenroth MJ, Baity MR, Blagys MD. Interaction of therapeutic process and alliance during psychological assessment. J Pers Assess 2000;75:82–109.10.1037/e323122004-009Search in Google Scholar
 Lachapelle DL, Lavoie S, Boudreau A. The meaning and process of pain acceptance. Perceptions of women living with arthritis and fibromyalgia. Pain Res Manag 2008;13:201–10.10.1155/2008/258542Search in Google Scholar PubMed PubMed Central
 McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol 2014;69:178–87.10.1037/a0035623Search in Google Scholar PubMed
©2018 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.