Does validation and alliance during the multimodal investigation affect patients’ acceptance of chronic pain? An experimental single case study

1 Introduction

The bio-psycho-social model – where the illness is understood as an interaction between biological, psychological and social factors – builds the basic framework for the treatment of patients with chronic pain within multimodal rehabilitation programs (MMRPs). MMRPs are conducted by a team commonly including physicians, psychologists, physiotherapists, occupational therapists, social workers and other health professionals [1]. Based on cognitive-behavior principles it contains elements such as education, physical activity/exercise, coping skills training, and occupational therapy sessions. These programs show significant results on a group level [2], [3], [4], [5] but there is considerable variation within the chronic pain population and treatment effect sizes are moderate [4], [5]. This raises the question what part of the MMRP process is effective and for whom.

MMRP is often preceded by a multimodal assessment and, in some clinics, an extensive multimodal investigation (MMI). The purpose of the MMI is to assist the team in case formulation and patient selection, but also to motivationally prepare the patient prior to the MMRP. Specifically, the team members all individually assess the patient, and thereafter align their formulations in a patient conference, in order to assemble comprehensive biopsychosocial picture of the pain problem. An effort is made to validate the patient to create a good alliance and begin a process of change towards a greater pain acceptance. Studies have verified that patients gone through a pretreatment preparation are more likely to attend pain management workshops [6]. However, the mechanisms behind a hypothesized effect of the MMI process are unknown and to our knowledge there are no empirical studies detailing the process of change of patients going through MMI. Thus, it is unclear whether the MMI has a therapeutic effect and, if so, what the mechanisms may be. This is important to be able to improve the MMI or if not effective, explore alternatives.

Chronic pain patients often enter MMI with a long history of disappointing attempts to find satisfactory and sustained pain relief. This is accompanied by high levels of catastrophizing, disillusion and despair [7], and the development of these variables across MMI needs to be studied. The “misdirected problem solving” model provides a theoretical framework as it specifically focuses on these variables [8]. This model stipulates that worry about pain, in combination with a biomedical theory of the cause of the pain, can get patients “stuck” in unhelpful attempts to solve their pain problem (e.g. continued seeking of biomedical solutions and pain relief within the health care system). The model thus explicates how patients who enter MMI, when trying to solve their pain problem, may have unintentionally gotten stuck in a loop of failing problem solving efforts, ultimately reinforcing their despair, worry and depression [8].

In line with this model, a goal of the MMI is to assist the patient in reframing their problem away from seeking an immediate pain cure and towards acceptance of the insolubility of chronic pain. The MMI includes communication efforts such as validation and Socratic interviewing aiming to improve alliance and communicate understanding. Validation, in combination with education about the biopsychosocial model of pain, are hypothesized to enable pain acceptance and a redirection of behavioral and cognitive efforts towards relevant and attainable life goals [9].

In this study, the aim was to track how chronic pain patients change during MMI. We used the model of misdirected problem solving as a theoretical frame. Specifically, we describe changes in patients’ experience of validation, alliance, acceptance, pain coping, catastrophizing and depression. As MMI is a largely unexplored area, we use a replicated single case experimental design [10]. In this design, repeated measurement during a baseline serve the same function as a no treatment control group. If changes occur when intervention is introduced, it is assumed that this is related to the intervention. Replication is achieved via additional participants strengthening the findings and increasing generality [10], [11]. While this design provides the opportunity to draw valid inferences of change on individual basis, the requirement to collect data on large and homogeneous groups is circumvented. Thus, this type of design is well suited to explore new ideas and get a preliminary indication on changes across MMI.

2 Methods

2.2 Selection, participants and recruitment

Participants were residents in Västmanland County, Sweden who were referred for MMRP by their general practitioner (GP) to a psychosomatic rehabilitation center during the period 2012-11-15 to 2013-10-21. Selection criteria for an initial invitation to participate in the study were: 1: age between 18 and 65; 2: chronic pain (>6 months); 3: no indication of physical or mental illness that demands specific treatment.

Eighteen patients fulfilled these basic requirements and were invited by telephone to participate in the study (Fig. 1). They were informed about the study and that participation was voluntary and would not influence their health care. Sixteen patients showed interest and agreed to fill out a questionnaire screening the additional inclusion criteria. The inclusion criteria were a total score of >25 on the Pain Catastrophizing Scale (PCS) [12] and a total score of >105 on the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) [13]. These levels are established cut offs for clinically relevant levels of catastrophizing and risk for future disability for pain patients [12], [13] and were employed to ensure that only patients with high levels of pain coping problems were included in the study.

Fig. 1:

Flowchart of recruitment process.

Of the 16 patients who filled out this screening, 11 met the inclusion criteria and were invited to the rehabilitation center for further information on the study. Informed consent was obtained and the first of two standardized pretest measures were completed.

All patients completed baseline phase A but five decided to discontinue filling out weekly assessments during phase B. One participant due to discontinuation of the multimodal assessment (and referral back to the GP) and four participants were unable or unwilling to continue filling out the forms but went through MMI as planned. Six patients completed the study (see Table 1 for the characteristics of these patients).

Table 1:

Characteristics of the participating patients.

No.	Age	Female=1 male=2	Cohabitant=1 single=2	Number of children	Smoker yes=1/ number of cigarettes no=2	Working=1 non working=2 student=3	Pain distribution	Diagnosis	Pain duration (years)
1	20	1	1	0	1/10	2	Neck/shoulder	Neck/shoulder myalgia	2
2	39	1	1	5	2	3	Generalizeda	Fibramyalgia (FM)	1
3	26	1	1	1	2	1	Generalized	FM+GADb	1.5
4	45	1	2	1	1/10	2	Generalized	FM, exhaustion and depression	9
5	35	1	2	2	2	1	Generalized	FM, exhaustion	5
6	51	1	1	2	2	1	Generalized	FM	2.5

1. ^aWidespread pain; ^bgeneralized anxiety disorder.

The study was approved by the Regional Ethical Board in Uppsala (D-nr 2012/305).

3 Results

Figure 2 graphically displays participants’ weekly dairy ratings on validation, alliance and acceptance. Table 2 shows pre- to post changes on standardized measures of pain catastrophizing (PCS), depression (HADS-D) and approach to pain problem solving (PaSol).

Fig. 2:

Weekly dairy ratings.

4 Discussion

This single case experimental study aimed to explore if patients with chronic pain change in validation, alliance, pain catastrophizing, acceptance of pain and pain coping during the MMI process. Based on the theory of “misdirected problem solving” it was assumed that patients would report increased validation and alliance with the caregiver and that this would be accompanied by a positive change in pain coping style, acceptance of pain and decreased distress. This assumption could only partly be confirmed. The three of six patients who reported low baseline levels of validation and alliance indeed showed increased levels during the MMI. For these three patients the investigation process, and interaction with MMRP clinicians/team appears to have been experienced as validating and trustworthy as opposed to interactions before. However, the MMI procedure did not influence these patients’ pain coping approach, acceptance of pain and level of distress, with the exception of a trend of increasing acceptance during MMI in one of the patients. This lack of change was confirmed in the pre-post measures.

In line with the “misdirected problem solving” model we assumed that experience of validation and alliance would be a start for the patient to begin reframing their pain problem from a biomedical to a bio-psycho-social model. This broadened pain perspective would then hypothetically also have influenced acceptance of pain and distress levels. However, the results show that while validation and alliance were both already high and remained so, or did indeed improve, they were unrelated to patients’ acceptance of pain, problem framing and emotional distress. It must also be highlighted that three of the patients (P1, 4 and 6) experienced high validation and alliance already during phase A, this ceiling phenomenon did not allow for any further increase in alliance and validation, but nevertheless also in these cases acceptance of pain was almost unchanged during the MMI process. One conclusion from the results of this study may thus be that these variables were largely unaffected by the MMI procedure, opposed to what was hypothesized based on the theory. While these results are preliminary, and cannot be generalized to all chronic pain patients, they may indicate that the rather extensive MMI procedure was not exerting its assumed therapeutic effect and did not affect patients’ mood and coping approach to their pain. In fact, there were no significant improvements but in some case slight worsening with higher degree of pain catastrophizing, distress and dysfunctional pain management strategies after MMI.

One possible other explanation for lack of change is that we selected unrepresentative patients, resistant to change in attitudes. However, the patients in this study were typical pain patients with similar diagnoses, pain history and pain management approach as patients in other studies [28], [29]. While the fact that all participants were women could be viewed as a sign of unrepresentativeness, we interpret this rather as a random consequence of the consecutive recruitment procedure, as four of five patients referred to the clinic are females. Another explanation may be that we selected patients with relatively high values in pain catastrophizing and emotional distress, and that these variables are difficult to influence without specific intervention. These factors are known risk factors for the development and maintenance of chronic pain. They are also known to be stable and quite resistant to change [30], [31]. In fact, previous studies have shown that patients scoring high in both distress and catastrophizing have an elevated risk of not improving during rehabilitation as compared to other subgroups [29], [32]. Therefore, it could be that the therapeutic dose and method were insufficient to instill change in those patients. Related to this, an important reflection is that the assumption or goal of achieving therapeutic change during the MMI process on variables such as catastrophizing, pain coping and distress may not be a viable one. Indeed, the process may be too short, and lack important, more specific, cognitive and behavioral therapeutic methods that could influence these processes [33]. This is plausible, and a sufficient aim of an investigation could instead be to select and prepare patients for coming rehabilitation. This would be in line with a study of Habib et al. [6] showing that a brief motivational intervention increased engagement in pain management workshops. If so, the current form of the MMI procedure probably could be reformed to become more efficient and less time and resource consuming.

On the other hand, literature has shown changes in patients as a result of “therapeutic assessment” [34]. In contrast to traditional information-gathering psychological assessment therapeutic assessment is described as a brief intervention where the patient can get insight and change during the assessment process. Even if therapeutic assessment as described by Finn differs from multimodal assessment in pain patients, there are similarities. According to Finn the “assessors” (as in MMI) “hope to make the assessment experience a positive one and to help create positive changes in patients” [34], [35], [36] reflecting similarities regarding the goals in both therapeutic assessment and MMI. A third possibility then, could be that the MMI was in fact not therapeutic enough to bring about desired change in for example, acceptance of pain. It could be that the approach was the right one, but it was done with too little intensity or not comprehensive enough for these patients. Irrespectively, the lack of change in acceptance of pain, catastrophizing, depression, anxiety and pain coping when exploring these patients across a multimodal assessment raises important questions about the exact aim of the assessment procedure, and its subsequent form and function. This is an important issue as there are considerable resources devoted to relatively extensive MMI procedures in rehabilitation settings.

This study has some important limitations. The single case design restricts the confidence with which conclusions can be generalized to other pain patients and other clinics. The choice of the study design was based on the aim to explore the multimodal assessment, from an individual perspective. Besides there are no studies detailing the process of MMI so we considered an exploratory study with a single case design an appropriate first choice. Moreover, while we aimed to recruit patients consecutively to increase the likelihood of representativeness of typical clinic patients with chronic pain, there were several dropouts at the beginning that made the external validity uncertain. Future studies may use a group design to capture a truly representative sample. This study was conducted in a clinical setting. On the one hand this is a strength as it ensures a high degree of ecological validity, but on the other hand there was no opportunity to standardize, monitor or influence the exact content of the MMI. It therefore restricts the confidence with which these results can be generalized to other rehabilitation clinics, and opens for the possibility that the clinicians involved, while experienced and trained, may have provided a non-representative and suboptimal MMI.

In conclusion, we studied a clinically important group of pain patients with high levels of catastrophizing that underwent an evidenced based investigation method (MMI). The patients did not change their acceptance of pain nor their pain coping strategies despite their experience of good alliance and being validated during the MMI process. Since catastrophizing and distress also were unchanged we cannot conclude that the MMI of this patients were therapeutic. As seen from the theory of misdirected problem solving the results were unexpected. On the other hand, studies have shown that the acceptance of chronic pain is a process that takes time [37] and the MMI was therefore perhaps too short for change to occur. The results of this study underscore the need for specific management of the pain patients who in addition to their pain also suffer from psychological distress and catastrophizing thoughts. Specifically, the results suggest that more support than MMI in its current form is needed to alter these patients’ pain attitudes and coping models. Since the Acceptance and Commitment Therapy has shown good results as a treatment model for chronic pain [38], the principles guiding this treatment could be applied already in the investigation before MMRP. This study questions the value of MMI as a therapeutic intervention but even more so highlight the need for more research to increase knowledge of the key elements of the MMI process.