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Objective Chronic musculoskeletal pain in adults is a global health and economic problem. The aim of this paper was to systematically review and determine what proportion of multidisciplinary approaches to managing chronic musculoskeletal pain are cost-effective. Methods The EconLit, Embase and PubMed electronic databases were searched for randomised and non-randomised economic evaluation studies of non-pharmaceutical multidisciplinary chronic pain management interventions (MCPMI) published from inception through to August 2019. Results Seven studies comprising 2095 patients were included. All studies involved diverse multidisciplinary teams in one or more of the study arms. All studies involved chronic (one involved both chronic and subacute) low back pain and were economic evaluations from either a societal or healthcare perspective. Two of the three studies that reported on a multidisciplinary pain intervention compared to non-multidisciplinary intervention concluded favourable cost-effectiveness based on cost per quality adjusted life years gained, one study was not found to be cost-effective. Cost-effectiveness of the multidisciplinary intervention of interest was also not established by another 3-arm study. Two studies compared two multidisciplinary interventions; neither of these could definitively declare cost-effectiveness. The remaining study indicated the intervention by a multidisciplinary team was more effective but at a higher cost. None of the included studies used decision models to estimate long-term health outcomes and cost-effectiveness of multidisciplinary programs. Discussion There are few studies on the cost-effectiveness of multidisciplinary chronic pain management interventions. This study encourages additional rigorous economic evaluations of multidisciplinary models for chronic pain management. Economic evaluations that enable extrapolating costs and effects of multidisciplinary programs beyond the time horizon of clinical trials may be more informative for clinicians and health administrators.

Objective: To evaluate the effectiveness of a specifically modified group-based, multidisciplinary cognitive-behavioral pain management program (PMP) in comparison to usual care in a clinical sample of people with spinal cord injury (SCI)-related chronic pain. Method: Changes over time on a range of measures, including usual pain intensity, pain catastrophizing and self-efficacy, mood, SCI acceptance and self-efficacy, and interference due to pain were examined in 2 groups with SCI-related chronic pain after a multidisciplinary pain assessment. One group (n = 19) attended the PMP, and the other (n = 17) received standard care on an individualized basis in a pain management center. Results: The groups were significantly different at baseline, with the PMP group scoring more negatively on a number of the measures, including usual pain intensity. The PMP group showed an overall improvement in mood and life interference due to pain at the end of the PMP when compared with the usual care group. Within the PMP group, there was a significant improvement over time in anxiety and pain catastrophizing. No changes in SCI-related psychologic variables (acceptance and self-efficacy) were observed in either group. Discussion: This study demonstrates that a PMP may offer benefits to clinical populations with SCI-related chronic pain in a pain management center. The reported improvements were of a magnitude to be clinically significant. However, some of the initial benefits reported were not maintained at the nine month follow-up. The interventions may need to be augmented to address the effects of SCI-related psychologic variables that may impact upon the individual's ability to benefit from a PMP.

Objective Despite the growing use of opioids for persisting noncancer pain, evidence for their effectiveness is limited, especially in relation to functional outcomes. Guidelines have been developed for prescribers, but their utility is untested. This review examines the use of opioids in this population from a biopsychosocial perspective and makes a number of recommendations. Data sources Published comparison studies and reviews of oral opioids in chronic noncancer pain, as well as 5 published guidelines for the prescription of opioids and systematic reviews of cognitive-behavioral pain management programs. Methods Outcomes of the opioid comparison studies were reviewed and compared to those achieved by pain management programs. Conclusions The available evidence indicates that by themselves, oral opioids generally achieve only modest reductions in pain levels in patients with chronic noncancer pain. Functional outcomes are inconsistent across studies. There are questions about the timing of their use and patient selection. There are risks in trials of opioids only after other conservative interventions have been tried unsuccessfully. Also, in some patients, ongoing use of opioids risks repeated over-doing of pain-generating activities and reinforcing escape/avoidance responses that promote disability. These risks may be lessened by assessment of current use of pain self-management strategies among potential candidates for opioids. This offers advantages in promoting collaborative management of persisting pain as well as better pain and functional outcomes. In this view, opioids may be considered as one possible element of a management plan rather than the primary treatment.

Objectives: The ways in which people adjust to chronic pain has been partly attributed to pre-existing personality traits, but most evidence to date is from cross-sectional studies and mainly with arthritis groups. The present study examined the effects of 5 personality dimensions on measures of pain-related beliefs and catastrophizing assessed 9 months apart with a heterogeneous chronic pain sample. Method: One hundred forty-five patients with chronic pain presenting to a hospital pain center completed the NEO-Personality Inventory-Revised, 3 measures of pain related beliefs, the Catastrophizing scale of the Coping Strategy Questionnaire, and a 0 to 10 pain scale. Nine months from the initial assessment, patients completed the same measures, apart from the NEO-Personality Inventory-Revised. Results: Of the 5 personality dimensions studied, only neuroticism was related to the pain-related variables. Multiple hierarchical regression analyses revealed that neuroticism was a significant predictor of residualized change in pain self-efficacy beliefs and pain control appraisals over the time of the study, after controlling for initial values of both constructs. However, the effects were small, suggesting that other factors play a role in the determination of such beliefs, in addition to neuroticism. In contrast, neuroticism was not a significant predictor of residualized change in catastrophizing responses over the same period. The findings provide partial support for the hypothesis that pre-existing personality traits place some patients at risk for poor adjustment to chronic pain.

Optimal treatment for patients with chronic pain remains elusive. A growing international consensus advocates evidence-based practice with assessment of clinical outcomes to improve the process and outcome of care. Clinical decision making about treatment options for an individual patient should include the patient's clinical presentation, available evidence, and patient preferences. Treatment should then be monitored and outcomes of treatment assessed. Although the placement of clinical decision making on a scientific, often quantitative basis as opposed to a subjective, impressionistic approach makes intuitive sense, the question is whether we have been measuring what we need to measure to practice evidence-based practice when we consider the current available evidence on pain management? The methods of synthesis of available evidence are still in development. Much of the evidence, although having internal validity, has limited external validity and is difficult to apply to the individual patient. Patients with chronic pain are a heterogeneous group, and different interventions may be indicated for different subgroups of patients. Various methods are being developed to better match patients with treatment. Little information exists on patient preferences, or how best to measure these. Information on how health care providers make clinical decisions is also scarce. Outcome measurement has come a long way and core domains to be measured have been established. Establishing normative data is a next main goal. Important methodologic and practical challenges remain to formulate evidence that can be applied to the individual patient with chronic pain.

Objective To investigate the role of somatic items in the assessment of depression in chronic pain. Methods The Self-Rating Depression Scale was administered to 398 individuals with chronic pain, 313 psychology clinic patients with similar overall levels of depression, and a general population sample of 491. All three samples were also administered the Depression Anxiety Stress Scales. Results Confirmatory factor analysis of pooled Self-Rating Depression Scale and Depression Anxiety Stress Scales items revealed that Self-Rating Depression Scale items denoting diurnal variation, decreased appetite, weight loss and constipation failed to contribute to depression in all 3 samples. Items denoting tachycardia and irritability also failed to discriminate between depression and a combined anxiety/stress factor in all 3 samples. The chronic pain sample endorsed somatic items, in particular psychomotor retardation, sleep disturbance, constipation, and fatigue, more strongly than the other samples relative to their endorsement of nonsomatic depression items. Conclusions It was concluded that depression measures that give emphasis to somatic symptoms provide poor measures of depression severity in any individuals and in patients with chronic pain may lead to an overestimation of the severity of depression. More recently developed instruments avoid these limitations and are also better able to discriminate depression from related states such as anxiety and tension/stress.

Objectives: Cognitive-behavioral pain management programs typically achieve improvements in pain cognitions, disability, and physical performance. However, it is not known whether the neurophysiology education component of such programs contributes to these outcomes. In chronic low back pain patients, we investigated the effect of neurophysiology education on cognitions, disability, and physical performance. Methods: This study was a blinded randomized controlled trial. Individual education sessions on neurophysiology of pain (experimental group) and back anatomy and physiology (control group) were conducted by trained physical therapist educators. Cognitions were evaluated using the Survey of Pain Attitudes (revised) (SOPA(R)), and the Pain Catastrophizing Scale (PCS). Behavioral measures included the Roland Morris Disability Questionnaire (RMDQ), and 3 physical performance tasks; (1) straight leg raise (SLR), (2) forward bending range, and (3) an abdominal drawing-in task, which provides a measure of voluntary activation of the deep abdominal muscles. Methodological checks evaluated non-specific effects of intervention. Results: There was a significant treatment effect on the SOPA(R), PCS, SLR, and forward bending. There was a statistically significant effect on RMDQ; however, the size of this effect was small and probably not clinically meaningful. Discussion: Education about pain neurophysiology changes pain cognitions and physical performance but is insufficient by itself to obtain a change in perceived disability. The results suggest that pain neurophysiology education, but not back school type education, should be included in a wider pain management approach.