Outcome Assessment after
Musculoskeletal Pain
Rehabilitation
Carolyn A Arnold
Caulfield Pain
Management & Research
Centre,
Alfred Health, Melbourne,
Australia
Carolyn A Arnold
Caulfield Pain Management & Research Centre
Alfred Health Melbourne
How do we assess outcome?
We use Outcome Measures:
tools to assess change in a
patient over time
• select outcome measures
• demographic information
• pain service type
Musculoskeletal Pain RehabilitationWhat are the Goals?
• To shift the focus from curative treatments to
self management of chronic conditions
• To restore and improve function
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–
–
–
–
Personal and Domestic Activities of Daily Living (ADL)
Return to Work
Social and recreational activity
Better psychological health
Manage exacerbations of chronic condition
Physical deconditioning commonly
follows musculoskeletal pain and injury
- it has serious health
consequences
Overcoming barriers to
improve physical fitness
requires more than an
exercise prescription
What are the barriers to physical
rehabilitation?
• Fear of harm
• Fear of hurt
• Changed level of
performance after injury
• Inadequate physical
rehabilitation after injury
• Fear of social reengagement
Validity and Responsiveness of
Objective Physical Measures in a
Chronic Pain Cohort
Walk Test
J Firth et al 2011 In submission
Physical measures
• Six Minute Walk Test
(6MWT) for functional
walking tolerance,
• Ten metre Walk Test
(10mWT) for walking speed
• Timed Up And Go test
(TUAG) for general mobility
• Sit-to-Stand x 5 test (SS5)
for leg strength
• Four Square Step Test
(4SST) for balance.
Validated Self Report
Measures:
• Brief Pain Inventory
Short Form for pain
(BPIs)
• Interference Scale
(BPIi)
• Physical function
domain of the SF-36
Client sample description
• Age 49.1 years (12.3)
• Gender 63% female
• Pain duration 9.3 years (9.40)
• Pain Sites 40.65 low back pain, 22.5% widespread pain
• BPI Pain Severity: 0-10 scale: 6 (1.8)
• BPI Pain Interference: 0-10 scale: 6.7 (2)
• SF-36 Physical Functioning: % 38.5 (22.9)
• N varied from 187 to 45
Internal responsiveness of the five objective
physical measures in a chronic pain cohort.
Effect sizes (95% CI).
N
Score preprogram
Mean (SD)
Score postprogram
Mean (SD)
Mean
difference
P value
Cohen’s d
d lower limit
d upper
limit
6MWT (m)
113
433.4 (104.4)
472.6 (105.7)
39.2
<.001
.83 (large)
-18.65
20.08
10mWT
(m/min)
134
68 (16.2)
81.5 (21.9)
13.5
<.001
1.59 (large)
-4.33
2.12
TUAG (sec)
138
10.9 (4.2)
9.6 (3.1)
-1.30
<.001
-.8 (large)
-1.31
-.1
SS5 (sec)
86
21.9 (8.6)
18.7 (6.2)
-3.20
<.001
-.97 (large)
-2.28
.85
4SST (sec)
44
12 (2.7)
12.2 (4.1)
.20
.683
.07 (none)
-1.08
.93
Firth J et al 2011
Comparison of change in physical measures
between those who improved on the Brief Pain
Inventory interference scale and those who did
not.
Improved on BPIi
(n = 50)
Not improved on BPIi
(n = 63 )
p value
6MWT (metres)
36.1 (62)
33.82 (58.2)
.615
10mWT (m/min)
15.7 (15.6)
12.3 (17.3)
.137
TUAG (sec)
-1.4 (2.4)
-.8 (1.9)
.137
SSX5 (sec)
-3.6 (6.4)
-4 (8.4)
.862
4SST (sec)
-.66 (1.9)
1.2 (4.1)
.111
Self Report Measures did not correlate to objective
physical measures
Using outcome measures in managing
a patient: a case example
• Mrs PB 54 yo with chronic low back pain radiating to
her left leg, for 4 years (lumbar spondylosis)
• physiotherapy, chiropractic, injection therapies, and
medication trials without success
• Angry mood.
• Married, adult children
• Sent to the pain clinic.
Assessment Questionnaires at
commencement of treatment (Patient PB)
• High pain Scores 9/10 VAS
• Anger on VAS scale 8.2/10.
• Also high irritability and frustration
• Mood 15 on BDI II (Beck ) “mild depression”
Post CBT Review
• Checking scores on Brief Pain Inventory(BPI) and Beck
depression:
• No change in Pain Still high
• Depressed Mood BDI 26/50
• Why?
IMMPACT
Initiative on
Methods
Measurement and Pain
Assessment in Clinical
Trials
IMMPACT Recommendations:
Core domains:
• Pain (intensity NRS, rescue analgesics, categorical pain rating)
• Physical functioning, either Brief Pain Inventory (BPI) interference
items or Multidimensional Pain Inventory Pain Interference Scale
• Emotional functioning: Beck Depression Inventory or Profile of
Mood States
• Participant ratings of global improvement
• For research trials: adverse events, participant disposition, selection
etc
“Initiative on Methods, Measurement, and Pain
Assessment in Clinical Trials” www.immpact.org
( Dworkin RH et al. 2005)
Brief Pain Inventory
Domain
Tier One
Tier Two
Pain severity
BPI subscale
(MPI)
Physical functioning
BPI Interference
SF36
Emotional functioning
K10
Beck depression BDI
PSEQ
CSQ
Participants Rating
(0-7 scale)
For research
Demographics
Medication: Opioids
Treatment eg hours,
group or individual
MQS
National Pain Outcome Initiative
• To provide snapshots and audit tools for providers of chronic pain
rehabilitation programmes around Australia and New Zealand
• Select an agreed but “short and snappy” set of outcome tools to
measure at commencement of chronic pain treatment and one
follow up point.
• To give useful information to better understand service needs and
activities and allow self evaluation for improvement
• Current Pilot Project running between Caulfield (Vic, metro)and
Hunter (NSW Rural) Pain Units
Outcome measures
• Measures which demonstrate validity, reliability and
responsiveness .
• To consider the implications for future policy
• To make recommendations for further methodological
research
• To review what is currently known of the outcome
• Assist variety of perspectives (consumer, provider,
purchaser) in a scientific manner
Examples in Rehabilitation Medicine
(AROC) and Palliative Care (PCOC)
• AROC inpatient rehabilitation: data on length of stay by diagnostic
category and with Functional Independence Measures *
• PCOC: can compare pain outcomes in palliative care episodes in
hospital and community settings
* 2009 “State of The Nation” The AROC Annual Report.
http://chsd.uow.edu.au/aroc/reports/son_2009
In conclusion
• Simple outcome measures are useful in clinical practice for individual
patient management in musculoskeletal pain rehabilitation
• Our practice will be better if we evaluate our programmes’ effectiveness
• We have a shared vision and goal to establish an Australian and New
Zealand National Pain Outcome Initiative, initially for chronic pain
programmes, and supported by the Faculty of Pain Medicine
Acknowledgements:
A. Prof George Mendelson
Prof. Stephen Gibson
Dr Geoff Booth
Dr Chris Hayes
Ms Janet Firth
Thank You